Brittney Burns – Staff Writer

In the last five years, the number of babies delivered at Angel Medical Center has steadily increased each year. In 2012, 161 babies were born at AMC and by 2016, the Labor and Delivery Unit helped to welcome 374 new lives into this world. Despite this increase of 213 in the number of babies born at the hospital over a five-year period, Mission Health President and CEO Dr. Ron Paulus insisted that the number of births in the region has not increased.

When Mission Health announced the decision to discontinue labor and delivery services at AMC last week, one of the primary reasons for the decision was based on the claim that birth rates in the region are flat and the department wasn’t growing, while other areas, such as the demand for services for the aging population was increasing.

Dr. Paulus attributed the more than double the number of births in Franklin to a shift in “market share” saying births in the region haven’t increased, just where the babies are being born has changed. Despite Dr. Paulus’ assumption that births in the region haven’t increased, Mission Hospital, who serves the entire region also saw an increase in the number of births over the last five years. In 2012, Mission Health delivered 3,724 babies and by 2016, that number had increased by 316 births totaling 4,040 babies.

During a press conference regarding the Franklin hospital held in Asheville, more than an hour away from the community the decision was impacting, Dr. Paulus, along with Karen Gorby, president and CNO of Angel Medical Center said that the information that births were increasing provided by Mission Health over the last few years was incorrect.

In a media packet distributed last May, Mission Health announced they were expanding the women’s unit at AMC to “accommodate the growing number of births in the region.” The project was given a budget of $4.3 million and was going to completely renovate the facility. When asked what changed about the demographics in less than a year’s time, Dr. Paulus said that information distributed by Mission Health was incorrect.

In another press release sent by Mission Health announcing the resignation of then AMC President Jim Bross, Bross’ success at the hospital was touted by saying, “During Jim’s tenure at Angel Medical Center, he has been very focused on the improvement and growth of existing clinical programs and adding services, providers and specialists to the AMC-Franklin campus and surrounding communities, and he has made a remarkable impact. Under his leadership, Angel Medical Center has:

– Improved the experience for patients.

– Substantially grown the women’s and children’s program, with a 118 percent increase in newborn deliveries between 2012 and June 2015.”

Based on Mission’s information regarding the increase in births at Angel Medical Center, members of the community worked together to host a Mountains of Hope fundraiser in 2015, which raised more than $30,000 for several programs at the hospital, including the expansion of the women’s unit. During the fund-raising event, Mission Health had an AMC Labor and Delivery Nurse talk to potential donors about the increase in births at the hospital and the “importance and the comfort in knowing you are getting the highest-quality care so close to home.”

Despite multiple statements in recent years that came directly from Mission’s communications department, Dr. Paulus remains adamant that births in the region are not increasing and that was one of many reasons AMC’s labor and delivery services will be discontinued after July 14.

Elected Officials “shocked” by news of closing 

In addition to a claim of no growth in births, Dr. Paulus also said that proposed changes to the Affordable Health Care Act currently being debated in the United States House of Representatives would mean a substantial loss for Mission Health. According to Dr. Paulus, every version of the government’s health care plan that has been released would have an adverse impact on Mission Health System. Congressman Mark Meadows, who represents WNC in the House, has been the face of reform for health care in the country. When asked if Congressman Meadows was aware that the currently proposed health care changes would impact Mission Health and health care facilities in Meadows’ district, Dr. Paulus said that, “It would be impossible for him not to be aware of this.”

Congressman Mark Meadows met with Dr. Paulus and other Mission Health executives a week before the cuts to Angel Medical Center were announced and despite Dr. Paulus saying the congressman had to be aware of it, according to Congressman Meadows, he had no idea that such a decision was being made.

“While I have been in close contact with health care providers in the district, including executives with Mission Health during this process, I had no idea that a cutback of any kind was even being discussed as an option at Angel Medical Center,” said Congressman Meadows. “I had no way of knowing this was being discussed or even possible and it wasn’t addressed at any of our meetings. It came at a complete shock to me when I first learned of it when I was asked to comment on the issue by reporters in the district.”

Dr. Paulus said that the issue is largely a financial issue that most rural hospitals are facing.

“Overall, across all of our patients across all of Mission Health all of last year, our average price increase was 1.4 percent. That generated under $21 million of new revenue going forward, but our input costs rise far faster than 1.4 percent.”

Paulus added that going into the next year, there would have to be more than $30 million in cuts that Mission would have to make, in order to be even. “When it’s all said and done, when we start the very first day of the new year, compared to last year; we have to cut $37 million, just to stay even.”

While Dr. Paulus said they are facing a $37 million deficit beginning the year, he also said that Mission Health employees were given raises last year that totaled $37 million.

Because 75 percent of patients at AMC are medicaid or medicare patients, proposed changes to the Affordable Health Care act, paired with the North Carolina legislature’s decision not to expand medicaid, also contributed to labor and delivery services being cut, said Paulus.

Senator Jim Davis said that expanding medicaid would have helped able bodied men, therefore would not have had an impact on labor and delivery costs.

“Expanding Medicaid in North Carolina would have covered adult able bodied males,” said Sen. Davis. “I do not think OB coverage impacts that community. In addition, OB coverage already takes care of individuals up to 260 percent of the federal poverty level (FPL). Several years ago Medicaid was covering about 74 percent of births at AMC. I presume that figure has remained relatively stable.”

Senator Davis also said that expanding Medicaid right now wouldn’t be wise for the state.

“Healthcare reimbursement and the ACA are in a state of flux under the present administration and Congress. It would be very foolish in my opinion to expand Medicaid considering the uncertainty of the law.  And that assessment does not take into consideration that it would have cost over $1 billion more in state funding.  In spite of an improving economy North Carolina’s budget still has some holes to fill,” said Davis. “It is my understanding that Mission is in talks with Harris to take up OB services once Angel stops.  While not as convenient for Macon County residents, it will be far better than traveling to Waynesville or Asheville.”

The Macon County Community instantly started speaking out against the changes at AMC. A rally was held downtown on Sunday, where members of the community shared their birth stories as well as what AMC means to them. More than a dozen people spoke to a packed town hall on Monday, urging Franklin leaders to convince AMC and Mission to reverse the decision.

Franklin aldermen, as well as Macon County commissioners expressed their shock involving the decision and how county leaders were kept in the dark on the change to their community hospital. Macon County Manager Derek Roland attended the press conference in Asheville on Monday to which Dr. Paulus seemed surprised by saying, “I didn’t know we invited you, but welcome.”

Addressing comments regarding Macon County leaders being caught off guard with the changes to labor and delivery, Dr. Paulus said that the public wasn’t informed intentionally.

“Because of the understandable emotion and pain and challenges associated with this, the moment that there is even a single mention of the possibility, everything begins to unravel,” said Dr. Paulus of why the community wasn’t informed prior to a decision being made.

Community leaders remain shocked by the decision. 

“I did not know that the ‘Labor and Delivery’ services were in trouble and maybe, if their board feels it necessary, a commissioner liaison could attend their meetings or the liaison could be available when emergencies like this are on the horizon,” said Macon County Commissioner Gary Shields. “The last meeting I was involved in was approximately two or three months ago and I did not hear concerns about financial or other major concerns like the closing of any departments.  As the county liaison commissioner, Mr. Roland and I have attended all meetings that we have been invited to.  I have a lot of respect for the members of the AMC hospital board and have spoken to Mrs. Gordy recently and I trust they would have alerted the county leadership if they had concerns that would have been in our ‘need-to-know’ realm.”

Despite Shields and other Macon County commissioners saying they were unaware AMC was even debating such a change, Dr. Paulus said that any leader who is involved in their community had to know. Dr. Paulus also said that without revealing specific conversations, more people were aware of the change than are admitting so.

Commissioner Ronnie Beale said not only was he completely unaware of what Dr. Paulus claimed to be inevitable, Beale still doesn’t think it’s the only option.

“I don’t think this is inevitable,” said Beale. “I don’t know how we could have seen this coming when less than a year ago we were told they were expanding and investing millions of dollars to do so. I don’t see how we could have possibly known this was happening, when some of the doctors and staff there didn’t know and they are there every day.”

Macon County Commissioner Karl Gillespie said he wouldn’t have thought Labor and Delivery could be cut anymore than any other services.

“I do not think it was inevitable, no more than I suspect that surgical services, radiology or any of the other many services that Angel Medical Center provides would be considered to be eliminated,” said Gillespie. “Angel Medical Center has been a part of our community as our primary health care provider for many years with Labor and Delivery  being one of those services  While I respect Mission’s decision to terminate Labor and Delivery services, I am very concerned about the impact this will have on our community, both for residents that have lived here for years and young couples that are considering Macon County as their next home. I am hopeful Dr. Paulus will be able to attend the next Macon County Board of Commissioners meeting so he can provide additional information to help us better understand Mission’s decision.”

County prepares for potential impacts of hospital changes

Macon County is in the middle of the budget planning process, and after just learning of the closure last week, may not be able to adequately prepare for the impact it could have on county departments.

“All citizens in every community understand the need for quality Labor and Delivery services,” said Shields. “When a void like this occurs, we feel a loss and concern for the new mother and child.  Even though this service loss does not affect everyone directly there is a mourning process or psychological concerns that run the gamut from economic impact to the safety of the mothers and new babies.  Angel Medical Center, their medical staff and associates have rendered quality programs to our community with the utmost professionalism and I am sure this will continue to the best of their professional abilities.”

Macon County’s health department stands to be the most impacted by the change. Macon County Health Director Jim Bruckner shared his concerns of the closure during last week’s board of health meeting, the same day the changes were announced. The health department’s concerns include an influx in the number of patients seen at the prenatal clinic. Currently, the MCPH Department provides care to 25 percent of the prenatal clients in Macon County, around 100 women annually. Additional clients and a shift in birthing location has the health department concerned about care management and coordination of transportation. Another potential issue is regarding records transfers. The Health Department has been working to get on Mission’s Health Information Exchange.  Currently, the department is unable to upload information directly into that system.

While Mission Health says they are planning to keep prenatal and postnatal care services in Macon County, they are operating on the assumption the doctors who currently provide those services will continue to do so. AMC president Gordy said there is no guarantee they will choose to stay after July 14, and if they don’t, they the hospital will work to recruit new doctors. In the meantime, there may be a lapse in care. If there are any changes to the local Mission Medical Associates OB/GYN outpatient services (Angel OB/GYN Practice) there could be additional impact on the Health Department:

o   Fewer providers could increase the number of prenatal clients served by the Health Department prenatal program;

o   The Health Department currently contracts with the local Mission Medical Associates OB/GYN practice for provider coverage in its prenatal clinics. Loss of a provider would require new contracts/agreements be established, and could result in an increase in Prenatal Program costs, in turn, the budget, which translates to an increase in county funding to sustain the program.

o   The Health Department could also experience challenges around management  of outpatient care/services and coordination of transportation services for high risk prenatal clients wanting to connect with a provider who is from the facility where they choose to deliver their babies.

Macon County EMS shares similar concerns regarding transports of labor and delivery patients.

“While we prefer to transport to the organization that the mother has a relationship with we must also consider the well being of our patients,” said Jeremy Cabe, Training officer for Macon County EMS. “Our agency staffs trained personnel on every ambulance that are capable of performing in the event of childbirth and/or neonatal care.  Each situation will be different and we will treat them as such.  Our staff will communicate with patients and families to make the best transport decision as those events arise.”

In 2016, Mission Health delivered babies from 302 women who were specifically from Macon County. Of those 302 women, 258 delivered their babies at Angel Medical Center and 44 were delivered at Mission Hospital.

Since July 1, 2016, Macon County EMS has transported 13 patients directly to Labor and Delivery units, with 11 of those taken to Angel Medical Center’s Labor and Delivery unit. Just as the number of births have increased in the region, the number EMS transports have increased as well. In 2015, EMS transported 5 patients to Labor and Delivery at Angel. According to Emergency Services Director for Macon County, EMS is seeing an overage of eight percent increase in call volumes across the board.

“We will obviously continue to look at the data and adjust our operations accordingly as fiscally possible,” said Warren Cabe, Macon County Emergency Management Director. “Mission Hospital has increased the availability of a regional transport ambulance in Franklin and internal changes at our organization now allow us to accommodate up to two emergency transports out of town at once. We are also actually participating in a program with Mission Hospital in which transports are scheduled/arranged through one telephone call and triaged out appropriately which should allow us to better serve the needs of our most critical patients first.”

Mission planning $43 million new facility; still finalizing plans

One of the most significant increases to AMC’s labor and delivery was the increase in the number of deliveries occurring at Angel Medical Center from residents who live outside of Macon County. In 2012, AMC delivered 10 babies from women who live outside of Macon County, by 2016 that number increased to 121. Because AMC is a not-for-profit critical access hospital, AMC cannot deny care to anyone, including Medicaid patients. By comparison, Harris Regional Hospital located in Sylva, is a for-profit hospital managed by Duke Life Point. Harris Regional is not required by law to serve Medicaid patients.

Dr. Paulus said that Harris Regional is investing $6.6 million to renovate and improve their women’s unit, and will ideally help to fill the void created by AMC’s services being cut. While Dr. Paulus is working on that assumption, it doesn’t change the fact that AMC sees primary Medicaid patients, which is why Dr. Paulus said the department isn’t profitable, and Harris isn’t required to serve those patients.

While Mission Health is closing labor and delivery at AMC, they also announced plans to invest $43 million to replace Angel Medical Center’s hospital.  The new, state-of-the-art AMC facility is a key part of Mission Health’s Mission Future Ready initiative, an exceptional plan investing more than half a billion dollars region-wide to meet the future health needs of Western North Carolina.

Mission Health and AMC leadership underwent a comprehensive strategic master facility planning consultation for evaluation and assessment of Angel Medical Center where it was determined that construction of a new facility designed to meet the needs of the community for decades to come, rather than renovation of the current, outdated structure was clearly in the best interest of the community.

Both boards’ decisions were based on the outcomes of this facility assessment as well as a 10-year review of the community, based on demographics and the long-term healthcare needs of the population.

According to Dr. Paulus, it would have cost more than $50 million to repair the existing facility, which has been added onto in stages over the last half century. While Mission Health announced plans to replace AMC hospital, they did not have any details as to what those plans might include.

AMC’s President Karen Gordy said that as of right now, they don’t know if they will build the hospital on the current 11 acres where AMC is located or if the new facility will be built on nine acres near the currently facility that Mission Health already owns. Plans for what would happen to the existing hospital were also not provided. Relocating the hospital would include downsizing, as AMC has already eliminated the pathology department and with the discontinuing of labor and delivery, the facility could be downsized to fit on less acreage.

Dr. Paulus said that the plans for the new hospital are still in the works, so if labor and delivery is important to the community, than he encouraged them to find a way to fund it at the new facility. Dr. Paulus referenced AB Tech, which was able to construct a new building based on a specific sales tax. The sales tax he referred to is a specific option for counties but can only be spent for educational needs, a similar tax for a community hospital wouldn’t be possible.

The Macon County community has worked to save Angel Hospital in the past, so the move wouldn’t be unprecedented. In 1967, civic clubs, businesses, and community clubs, worked together for Operation Heartbeat, which raised the more than $1 million needed to purchase Angel Hospital and turn it into a community hospital.

Franklin Mayor Bob Scott and the board of aldermen sent a letter to Mission Health on Tuesday asking them to reconsider the decision and the Macon County Board of Commissioners have also sent a letter opposing the measure requesting someone from Mission attend next week’s county commissioners meeting to address the issue.

“This is going to have a huge impact on our entire community,” said Commissioner Ronnie Beale. “Our goal at this point is to encourage both the Mission and Angel board to at the very least postpone this decision to give us the opportunity to do something about it. The relationship between Angel Community Hospital and Mission has always been a partnership and all we are asking is for the opportunity to utilize that partnership for some dialogue and discussion, not a 60-day notice that the services desperately needed by this community are going to be ending.”

Beale said that while he may not have the answers today on how to fix the issue and save labor and delivery, he hopes Mission Health understands the need in the community and allows Macon County to at least attempt to address it.

“We have always been a creative community and we deserve the opportunity to be creative and think outside of the box on this,” said Beale. “We have always been able to find a way and this is no different. We certainly believe that OB/GYN services are important to this county and it is just the right thing to do to at least try to save it and I can guarantee it’s going to take longer than 60 days. We are hopeful that Mission will see that, and give us that opportunity.”

*Macon County News will continue investigating AMC’s operational changes in next week’s publication with a look at how Harris Regional Hospital plans to accommodate the potential increase in births as well as a look at the struggles of operating Labor and Delivery Units in rural hospitals.