Transcripts of Interviews

Prairie Public Television Interview with Hospital Administrator, Les Urvand, Crosby, ND

The Crosby ND hospital administrator since 1991, Les Urvand discusses the complexities of rural health care and provides insight into the myriad fee schedules and reimbursement classification structures that affect the availability and delivery of services in rural areas.

Prairie Public
Les, you've been the hospital administrator since February 1991. How have you seen things change in your ten years?

Les Urvand
Well, basically, everything has changed. The population trends are changing in North Dakota. Our reimbursements systems have all really tightened up. Medicare has cut back. They went to all fee schedules. DRGs (Diagnostic Related Groups) kicked in in about '84. The fee schedules on the out-patient side hurts us because it's volume driven, and being in a small place you don't have volume. It's determined by statistics from all over the United States. If a place does 10,000 tests in a week that figures into that computation along with our two tests. Plus we have to have staff for seven days a week, 24 hours a day, 365 days a year. Our costs are just might higher because of that.

The population trends: I think Divide and Burke county have led North Dakota in out-migration and deaths because that's why we got out of OB's. When I came here, we were doing OB's. We weren't doing a lot of 'em, but we were doing them. Once you have under ten births a year, you can't keep that service. You can't depend on keeping the quality up, and if you can't keep the quality up, then you've got to really think about not providing that service anymore.

Reimbursement: Blue Cross followed Medicare's pattern on fee schedules. They pay us much more than Medicare pays us, but it's still based on volume. I think they're starting to realize that some of the small places can't make it on those kinds of dollars. They also cut certain DRGs (Diagnostic Related Groups). That really hurt us. Take pneumonia for instance. They were paying about $8000, and they cut it in half. It's just very tough. You're kind of put in a vice, and you just kind of squeeze down.

We spend a lot of time on economic development so that we get younger people in here and more of 'em and keep our population base. We had one clinic when I came here; now we've got three outlying clinics. We go to Columbus, Lignite, and Bowbells. We have a PA that's over there, and then we try to send the second doctor when we have one so that people will get used to seeing both people out there. That's helped us, and we were profitable for a number of years. We had about seven years in a row where we made a profit, even with our small population base. But the APCs (Ambulatory Patient Classification) of Medicare really hurt us-again it was volume driven. You know you make a little bit on each APC, but you don't make enough. When we have our critical access hospital survey, I'm hoping that we'll be designated critical access and can go back to cost reimbursement.

Prairie Public
If you're designated critical access, how does that work?

Les Urvand
Okay. Let's use lab as an example. We won't be given a fee schedule anymore. It'll be based on how much cost we have in there. If we run 75% cost to our charges, that's what we'll get back from what we charge versus just a flat fee schedule. We will lose DRGs so even in-patients will be on that cost basis. We did very well on the in-patient DRGs. Our doctors took care of people, got 'em in and out fairly quickly, and we did very well but it didn't compensate for the loss on the out-patient side. It just didn't do that.

Prairie Public
Where do people go to have their babies now?

Les Urvand
Williston, and some go to Minot. If it's an emergency, we still keep our supplies. We have to redo our OB packs and keep them current and sterilized because you never know, somebody may not be able to (get to Williston). Even though we don't really want to, and our doctors probably wouldn't feel real comfortable, it's part of EMTALA (Emergency Medical Treatment and Active Labor Act) Law that you can't send somebody in active labor down the road so that's kind of where we're at. We try to do and keep prepared.

That's the one thing about a small hospital. You have to be prepared for anything that walks in the door. That kind of scares some of the younger doctors because they're trained in a certain area like internal medicine or something like that. Well, anything could walk in the door. It might be heart attacks which is in their area, but it also might be in OB which isn't in their area. We've got to try to help them get some training and keep up with the standards and tie people in. That's one thing that critical access is supposed to do. It ties you to a bigger facility that gives you a little more expertise in certain areas. We want to do that.

Prairie Public
When we interviewed Dr. Sing this morning he said he learns from the nurses on some of the things he didn't learn in medical school.

Les Urvand
Right. And that's a nice attitude. Certain doctors have a little ego attitude "I can't learn from a nurse" or from somebody that's been around, that knows the patients. When you have a doctor who's been here 20 some years, well, he knew the family, what conditions ran in the family. He knew what to look for. When you have newer doctors, you lose that kind of perspective. A doctor that can take advice from nurses and other people, that's pretty good, that's pretty flexible, so we're real happy with him.

Prairie Public
Dr. Sing is a J1 physician. Is that about the only way you can get a new doctor in here right now ?

Les Urvand
It's the easiest way. I've been in physician recruiting a long time. We used to hire recruiting firms. You didn't always get the best doctors 'cause they were recycled from somewhere else where they might have had problems. So this is the one thing I like in the J1's. You know where they've been. You know the school where they've been. You can check on 'em. You can get your references, your credentialing done, and by a pretty wide margin I would take the J1 over what was floating around in the old days of local (recruiting) 'cause they're pretty solid doctors. They don't get out of their home country and get into med school here without having some pretty good numbers and some pretty good credentials. And I think the quality of the doctors is pretty darn good. They're pretty conscientious. Yeah you may not keep 'em for more than four, five years, but the quality is a lot better. I've recruited doctors who had been through alcoholism programs, had addiction to gambling and various other things. You don't have that in this group. Yeah they may not stay a long time, but they're stable, and they're pretty good doctors.

Prairie Public
What about the learning curve?

Les Urvand
The biggest learning curve is coming into a small hospital because most of these guys are trained in a 400 or 500-bed hospital. They've got CAT scans. They've got everything right there that's available. If they meet trouble, the cardiologist is right down the hall. Well you're in Crosby, North Dakota. There's nobody right down the hall. There is no cardiologist. There is no OB. There is no internal medicine specialist. There's nothing. You're here, and some doctors can't handle that because it's a lot of pressure, and others can, and they do well with it.

Prairie Public
How about your ambulance service here?

Les Urvand
It's all volunteer. Last week they had a little blurb in the paper asking for more help. Couple times a year they've come out and said well we'd like to get more people involved. My daughter became a first responder, but we do need more people. And that's part of the downsizing 'cause there's so many more elderly people in the community, and there's less people available. That means if you're on any boards, you're middle aged. You're in Kiwanis. You went through the chairs to be a Kiwanis president. You're in the Moose, you've probably been on the board. You know you're on every kind of committee that's around so you do get a little burned out, and there are fewer and fewer people to volunteer for the ambulance. It's that much harder, and you have less and less people that want to go off to take an 80, 100-hour course to get certified as an EMT. We have to find ways to keep that up maybe through the interactive TVs and computers. Maybe we can do some of those things here and have less time that they have to actually leave the community for doing some of those things. I hope that'll help because you can't ask volunteers to go off every weekend for a course and then have to constantly go off for more courses just to keep up your certification. It's very difficult to do.

Prairie Public
How about hiring? If you've got a nurse position to fill, how difficult is it to get applicants?

Les Urvand
It would be difficult now. Some of the bigger places are short so they're offering premium dollars. We have to compete against that. When I first came here, we were fortunate that we had a couple of programs that were already in place. We had a couple nurses where we paid their tuition. They both still work here. We probably will have to start that program again at some point. I've also got one nurse and one lab person that come from Canada, so I've had to steal from up north, and that's been very fortunate, but we probably will have to stand with that because I'm not going to get somebody from Fargo who's going to come up here. They look in town and say well, there's no young people. You're not going to get a single person to come up here. You have to home grow them. They have to be a part of this community, and you have to help 'em through school, and hopefully some of 'em will come back here. Otherwise they're not going to come from somewhere else 'cause the dollars here aren't as high, and the social life for a single person is not here. Recruiting isn't the easiest thing in the world we don't always have what they're looking for.

Prairie Public
What makes people stay?

Les Urvand
I've been other places. I lived in California when I was coming out of the service, people said 'why in the heck are you going back to North Dakota?' I said, 'I want to have a family. I want to raise kids.' I've got three kids. My oldest is a senior this year. My youngest is in sixth grade. You couldn't find a better way of life for your kids. They can be involved in whatever they want to be involved in where in a bigger town you can only be involved in a few things and only if you're really good. My oldest is an FBLC, FCCLA, music. She stats for boy's basketball and girl's basketball. Kids here can be involved in as much as they want to be. They can be involved with many different things and have a wide choice. She works at the home. There's a very unique setting out here, and a lifestyle, and they can have a little freedom. We don't have to watch 'em every second of the day where if you're in a big town, you gotta know where they're at and what they're doing. It's a lot freer out here, and that's what I wanted for my kids. It's a pretty nice lifestyle.

We've tried recruiting with UND students, but generally once they're locked into Fargo, Bismarck, Grand Forks, Minot and the bigger places, they get used to those call schedules. They're only on a couple times during a month, and so coming out here it isn't the money or stuff like that usually; it's more their lifestyle. They don't want to be on call every other night and every other weekend. It's very difficult to get them out of that once they've been into it. When they're going through residency, they're on call forever. I mean they're worked to death. So when they get done with that, the last thing they want to hear is well I think I'll go to Crosby and work every other night and every other weekend. It's very difficult. The J1 has worked out fairly well for us. We'd like 'em a longer timeframe, but we get 'em five to seven years. That's not bad.

Prairie Public
How many staff did you have here in '91 compared to now?

Les Urvand
We have less because we had just opened our swing bed wing, and when I came here it was almost full. So we had a separate staff for the hospital and a separate staff for the swing bed wing. Now we run less acutes and less swing bed so we merged the staff together. But at the same time-when I came here, we weren't affiliated. We hadn't merged with the clinics yet and so our total FTEs or employees is about 65, but that's with adding the clinics. We've gone down maybe eight to ten FTEs since I came here.

Prairie Public
Does the UND Medical School help with recruitment?

Les Urvand
We used to get 'em earlier. We'd get 'em in the rotations, A third year rotation would help teach the first year rotation. I think they've changed their curriculum quite a bit so that they're getting some of that right in the school now. We don't have a board-certified family practice physician here to help teach them so it's hard to get them out here. We had the rotation for a number of years and our doctors really liked it because it challenged them to look up things and kept them on their toes a little bit. The students would ask questions, and the doctors would have to go look those kinds of things up at night. It was really a win-win situation for everybody, but UND has changed their curriculum.

Prairie Public
With all the financial and reimbursement issues you face, what's the answer to make sure this hospital is still here in 20 years?

Les Urvand
I think some of those things have to come from the federal and state level, but they can only do so much. The rest of it's got to come from here within our community. When I got here, the (nursing) home was licensed for 86 I think they're down in the low 60s now. Eventually there's a going to be a push that we're going to have to merge. And if you look at most of the medium-sized places, they're all co-mingled. They have a nursing home and a hospital that are merged together. Watford has been trying to do that for a number of years. In Harvey it's one facility, one acute care facility and the swing beds and the nursing home and the clinic are all under one management. Eventually it will come to all the small places because there are just not enough bodies out there. With reimbursements you might get a few more dollars, but you're not going to get it all fully paid for. You've got to find ways to cut costs. So a two-pronged approach-what's going on up there and what we can do in the community to achieve the same goal? And we've made overtures. But when you're profitable. When you've made money for seven years in a row, it's tougher to push things together. When there's more desperation - we've got to do something, we don't want to lose any of our facilities, then you can make it work. We'll be pushed into that. We just haven't been pushed that hard right now. So CAH - Critical Access Hospital - is the first thing for us, and then we'll see where that goes. I think moving together at some point is part of the answer for us. It doesn't have to be a full merger. Maybe they'll do our dining dietary. Maybe we'll do some of their stuff or more of a sharing arrangement before you get into the full mergers of some things.

Funding for Life Support is provided by a grant from USDA Rural Development