After a year and a half of work, Northwest Medical Center in Albany was one step away from becoming a level III stroke center.
For the small hospital in northwestern Missouri, this was a really big deal.
State inspectors were set to visit on July 17 to determine whether the facility met the qualifications to begin accepting and providing emergency care for local patients who’ve suffered a stroke before they are transferred to larger hospitals.
“Emergency care in a rural, underserved area is a huge part of our reason for existing,” said Jon Doolittle, president of Northwest Medical Center.
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But on July 2, the hospital got an email from the Department of Health and Senior Services saying the visit was canceled, with no plans to reschedule.
Gov. Mike Parson had vetoed money to pay the three staff members of the Time Critical Diagnosis program, or TCD, a statewide system that seeks to ensure that critically ill patients suffering from trauma, stroke and certain types of heart attack get to hospitals that have the capacity to treat them most effectively.
The veto amounted to less than $154,000 out of the state’s $28 billion budget. It was one of 21 vetoes Parson issued last month, totaling roughly $12 million.
“Due to the budget cut, there will no longer be staff to operate the TCD program,” the department’s email said. “We are sorry for any inconvenience this may have caused and truly appreciate your time and dedication to help improve stroke care in Missouri.”
Numerous hospitals got a nearly identical email, including Liberty Hospital. Its designation as a trauma center expires in September, and it was awaiting inspection. It had also applied to become a stroke center.
“This caught everybody by surprise,” said John D. Owen, vice president of emergency services at Liberty Hospital. “I haven’t talked to anyone who wasn’t blindsided by it.”
Parson’s veto set off shock waves in Missouri’s medical community. Hospitals, EMS providers and patient advocates began sounding the alarm, saying they’ve been left in the dark about the future of a program they credit with improving patient care.
Their concern is not only that hospitals seeking a new designation will be left in the lurch, they say, but also that facilities whose designations expire this year might not be able to get them renewed, a situation they fear could cause confusion and risky delays to patient care.
State law requires first responders to transport acute stroke, heart attack and trauma patients to hospitals that have been certified, rather than simply to the closest facility.
In Albany, that means bypassing Northwest Medical Center and taking stroke patients to a certified stroke center in another county. The closest is in Bethany, about 20 miles away, or in Cameron, about 43 miles away.
“When you are having a stroke, seconds matter,” said Karen Englert, government relations director for the Missouri chapter of the American Heart Association. “Every hour in which treatment fails to occur, the brain loses as many neurons as it does in almost three and a half years of aging.
“When EMS agencies don’t know where to take people, this can be the difference between life and death or long-term disability.”
Englert said her organization and others have “asked a lot of questions but have not gotten any clear answers. This change has been made and we’re not getting any clear answers about what is happening.”
There has been “very little transparency here,” said David Dillon, spokesman for the Missouri Hospital Association. “And that, as much as anything, is disturbing.”
Nearly two weeks after Parson issued the vetoes, his director of the Department of Health and Senior Services, Randall Williams, began reaching out personally to stakeholders to assure them the program wasn’t in jeopardy.
He told The Star Thursday that the governor vetoed the funding for the program in an attempt to jump-start changes he hopes will one day require participating hospitals to shoulder more of the financial burden.
“By taking away the funding,” Williams said, “it helps us move towards a system where those who benefit pay a nominal fee.”
Williams did not yet have details on how changes to the program might ultimately shake out, and he conceded that setting up a fund to collect fees from hospitals would require that the General Assembly pass legislation when lawmakers return to Jefferson City in January for the 2019 session.
But Williams insists that the veto will not affect the certification process for hospitals, despite the fact that the three employees who ran the program will transition to other open jobs within the department.
“There will be no interruption of service,” Williams said.
Jason White, EMS consultant for Mid-America Regional Council, questioned the notion that the funding cut won’t have an impact.
Inspections have been already canceled, White said, and he thinks the program was understaffed even before the veto. Now that there are no designated staff, White said, “How will they inspect hospitals? Who will handle complaints? Who will look at the national designation paperwork?”
He worries the situation could create confusion for first responders.
“In October, where are we supposed to take trauma patients that would normally go to Liberty Hospital, a wonderful level II trauma center that loses their designation in September?” White said.
“State law says ambulance services, if you’re in a certain time frame, you take them to trauma centers. So do we have to haul them further down to North Kansas City? That wouldn’t make any sense for the patient.”
Williams insisted that a situation like that will never come to pass. The governor’s veto, he said, should not be taken as a “comment on the program. It was really more a comment on the funding of the program.”
As recently as May, Williams publicly praised the TCD program for helping “a greater number of people survive and recover from trauma, stroke and heart attack.”
“People conflated our feelings about funding as a referendum on the program,” he said Thursday. “That was not our intention. If we didn’t communicate that well, that’s on us.”
To those who have followed the issue for years, Williams’ explanation fell flat.
If the goal was to overhaul a program that is “critical to patient care,” a plan should have been developed before the funding was vetoed, Dillon said, with full engagement from hospitals, EMS, patient advocates and other stakeholders.
That’s especially true if the changes envisioned by the governor will result in higher costs for hospitals.
“Many hospitals operate on a razor-thin margin,” he said. “Several Missouri hospitals have closed recently because of the enormous financial challenges. This exacerbates the already limited access to health care, especially in rural parts of the state. When Missourians need a hospital, especially when time is of the essence, it is increasingly hard to find.”
Steele Shippy, Parson’s communications director, said in an emailed statement that the veto was a “fiscally responsible decision” made to “transition to a model that reflects the varied resources of hospitals of different sizes and capabilities.”
The Star requested emails from the governor’s office pertaining to the veto and the Department of Health and Senior Services budget. Parson’s general counsel responded that it would take one month to turn over those public records.
Across Missouri there are 33 trauma centers, 62 stroke centers and 55 heart attack centers, according to figures provided to The Star by the Department of Health and Senior Services.
Of those, the state lists 17 that will see their designations expire at some point this year. That includes the trauma center designation of Liberty Hospital.
The state’s largest hospitals can bypass the state system by going through a much more expensive process of getting accredited by the federal government or a private third party. That can cost tens of thousands of dollars and typically requires a re-inspection every two years.
For example, of the 38 certified level I and II stroke centers — the highest designations — the health department says all but eight are accredited by an entity besides the state.
Of the 24 level III and IV stroke centers, all but one earned its designation solely from the state, a process that cost them about $3,000 to cover an inspector’s visit. The designation lasts up to five years for trauma, four for stroke and three for heart attack.
For smaller and mostly rural hospitals, White said, the cost of going another route besides the state system could be too much to bear.
“In a lot of rural hospitals,” he said, “they’ll never be able to get the value of getting nationally accredited to align with the cost.”
The TCD program’s funding was originally removed from the budget in January by former Gov. Eric Greitens.
Lawmakers put it back in at the urging of the medical community, and it sailed through the legislative process without controversy.
The House budget committee will meet Tuesday morning to discuss Parson’s budget vetoes and whether any should be overturned when lawmakers reconvene in September for a veto session.
House Budget Committee Chairman Scott Fitzpatrick, R-Shell Knob, said he’s already heard concerns about the TCD veto. Especially, he said, given the fact that state revenues are up and the budget is in good shape.
“If a hospital loses its status because of a veto of $154,000, that would certainly be an unwise tradeoff,” he said. “But a lot of times when something gets cut from the budget, the alarm gets sounded and generates more concern than is necessary.
“That’s what (Tuesday’s) hearing is going to be about: Determining whether it’s an imminent problem that needs to be addressed during veto session or one we should address when we begin putting together the 2020 budget.”
As for Northwest Medical Center, hospitals leaders had still heard nothing about the status their efforts to get designated as a stroke center nearly two weeks after receiving the email from the state about Parson’s veto.
“We’re very concerned about folks local to us having to have that extra time elapse before they receive care in an emergency department,” Doolittle said Thursday.
Then Friday afternoon, just hours after The Star’s story about the veto was published online, Doolittle said he got a call from Williams assuring him that the inspection would still take place.
“Although we don’t have a firm scheduled date,” Doolittle said Friday, “he did assure me that a survey team was being scheduled and would be coming out to our place in the relatively near future.”