In Their Own Words: Q&A with Three Rivers Hospital

Last month, I had the privilege of going behind the scenes at Three Rivers Hospital in Brewster. The hospital’s COO, Jamie Boyer, gave me a tour of the facility. She also provided me with answers to questions I had submitted beforehand. They were answered by Boyer, Jennifer Munson, the hospital’s Chief Financial Officer, and Jennifer Best, Public Relations and Marketing Coordinator for the hospital.

Three Rivers Hospital opened with 12 beds on January 12, 1949. In 1951, the facility was named McKinley Memorial Hospital in honor of Dr. Charles McKinley, one of the first doctors in the area. The name held until 2011, when Three Rivers Hospital was selected from 100 entries in a contest within the hospital district.

The hospital has faced ebbs and flows over the years, including closure of its obstetrics program in 2020. A fuller history of the hospital can be found here.

Today, Three Rivers Hospital offers a family practice clinic, general surgery, gynecology and 3D mammograms, rapid laboratory tests, state of the art imaging, orthopedic services, transitional care for extended recovery, advanced wound care, IV therapy, physical therapy, and an emergency department staffed with physicians 24/7.

As you will see, the questions the hospital tackled aren’t fluff, and I want to thank Three Rivers Hospital for taking on these tough issues.

What is the state of rural health care in our area?

There will always be more need than any one organization can meet, so partnerships in rural health are invaluable. In Okanogan County, we strive to collaborate to meet the health care needs of as many people as we can. We value our relationships with all of them, too many to list. The three public hospitals in our county recently signed a new interlocal agreement to further explore collaboration opportunities, so we’re looking forward to seeing what comes out of that.

However, for all the geography and communities we cover, there are some underserved areas. We’d love to have an urgent care and/or a specialty clinic up in the Methow Valley; however, we haven’t been able to find a cost-effective solution to make that a reality. It’s a considerable investment to build a practice in a new area, especially for a non-profit hospital such as ours.

To help get around that accessibility barrier, we’re working with a company called Ingenium to expand telehealth services in our area. Okanogan County Transportation installed a bus stop outside our clinic about a year ago. We have a new partnership with Okanogan Behavioral Healthcare to welcome their patients into a virtual care room in our clinic, so they can save a trip while still getting the mental health care they need.

Jennifer Best, PR Marketing Coordinator

What is your biggest challenge as COO? 

I have found that balancing compliance, financial stewardship, quality care, and community engagement while navigating the unique challenges of a CAH [Critical Access Hospital] is central to a COO’s role. Due to our remote location and our ability to secure the latest technologies we are often in situations that require us to think outside of the box and work harder. 

Some of the challenges come in compliance with regulations. We must stay within specific regulations as directed by Medicare & Medicaid (CMS) in order to keep our doors, open. Along with this, we often face financial pressures due to the rural location and limited patient volumes. TRH understands that effective financial management, including budgeting, cost control, and revenue cycle management, is vital for sustainability. 

Quality of Care is of the utmost importance and essential for sustainability. To keep in adherence to providing quality care we have implemented and continuously monitor quality improvement initiatives, ensuring that the hospital meets or exceeds accreditation standards. 

Community relationships are vital to our hospital, we have built relationships with other stakeholders throughout the district. Through these efforts, it is our goal to build trust with our community, patients and families.  Due to our district size, we must put the effort in to travel greater distances to be a part of community events, gathering and meetings. 

Some other challenging areas that I will be focused moving forward are 

The adoption of LEAN Training, we will be working towards streamlining operations to ensure efficient use of resources, minimizing waste, and optimizing workflows can help improve overall performance and patient satisfaction.

Emergency Preparedness: Working with our Team to develop and maintain a robust emergency preparedness plan for various scenarios, including natural disasters and pandemics.

Jamie Boyer, COO

Why do you think the hospital bond issue was defeated this past fall?

For one, $72 million was too much of a burden for taxpayers who are already feeling financially strained. From the feedback we received, the price tag was the main issue. Although we proposed a reasonable facility in size and scope, on property we already own, construction costs are simply much higher than they were even five years ago. When we presented evidence of the need for a new building, the community did share overwhelming support. They recognized the need, but couldn’t justify the cost for themselves, and we understand.

There are also some district residents who would like to see one main hospital centralized in the county, and that was their reason to vote against the bond. They are supportive of the hospital but would like to see other solutions to providing health care in the county. Our administration has been having that discussion with them, but nothing conclusive has come out of it yet, aside from the interlocal agreement with Mid-Valley Hospital and North Valley Hospital.

Jennifer Best, PR Marketing Coordinator

What is your plan now?

We are still considering options. Our architect, David Franklund of Theorem Architecture, is working on a revised draft of the hospital for two possibilities:

Remaining on-site at 507 Hospital Way, but scaling down the project to replace only the oldest part of the hospital with a three-story structure for patient care departments. We’d then renovate the rest of the existing hospital. The clinic would remain in the former Hillcrest House at 415 Hospital Way. The existing part of the building would still need a new roof and some other infrastructure improvements, such as the HVAC system.

Building a single-story facility on another site in Brewster, location to be determined. The City of Brewster has been a tremendous help and support in this endeavor. The idea is that a single-story would be cheaper to build. If we can get a good deal on a parcel of land that’s big enough, it could work out to be just as good, if not better, than the above plan without costing more.

At this point, the Board of Commissioners has not determined when we might seek another bond proposition. Our original goal was this November, but we want the next proposal to be successful. We focus a lot on having a win-win mindset at Three Rivers, and this project is no different.

In the meantime, our Chief Financial Officer is working with a financial advisor to find additional options for funding that could reduce the tax burden for property owners. We’re also sending out a postcard to every district resident requesting their feedback on a new facility. 

Jennifer Best, PR Marketing Coordinator

There seems to be disconnect between hospitals’ need for money and what people see on their hospital bill, which is usually a very expensive bill. How do you explain this?

The information behind this issue can be convoluted and confusing, but there are at least a few reasons.

In our hospital district, the largest demographic of residents have either Medicare or Medicaid. Overall, reimbursement from Medicare/Medicaid is about half of the actual cost of providing the service. Private health insurance companies don’t fully reimburse for most non-preventive services, either, which is why patients still see a bill. 

Occasionally, there are also issues with delayed payments from insurers, which negatively affects our cash flow. Some of our patients who were insured with a specific private company are just now seeing bills from services we provided them a couple of years ago. Then there was the Optum and Change hack earlier this year, which did slightly impact our revenue. Those kinds of things are unfortunately out of our control.

Finally, health care costs continue to rise, and to fulfill our goal of breaking even, we raise our prices for services. We try to keep those costs around the same as what you’d find from other health care providers in the area, to be as fair as possible. We provide an online tool that patients can use to estimate how much a particular service may cost. The link is on the home page of our website, threerivershospital.net.

Jennifer Best, PR Marketing Coordinator

Drawing from an article in the Methow Valley News, Three Rivers Hospital will receive $1,145,000 in 2024 from a tax levy to support the emergency department. According to MVN this is 5% of the hospital’s total annual revenue. Doing a calculation from these figures, the annual revenue for your hospital is $22,900,000. This seems like a lot. Can you tell me a) if my calculations are correct and b) if this is sufficient to run a hospital.

It does sound like a lot of money, but running a small non-profit hospital is remarkably expensive. Three Rivers Hospital requires staffing 24/7. The base cost for the physicians in our ER begins at $1.5 million. This does not include any of the other staffing to support the ER like nursing, lab, and radiology.  It also does not include any costs for the professional staff needed to intubate patients in a code situation, or the specialized physicians who interpret radiology studies.

Our biggest fixed cost is labor – not just our own staff and providers, but the travelers we often need in patient care to maintain services, as well as contracts with staffing agencies such as ERx Group and Okeanogan Valley Anesthesia. We do manage staffing levels as best we can, and control variable expenses as much as possible.

We are beholden to all the same laws and regulations as any other hospital to ensure patient safety and the correct standards of care, and that carries with it added costs. Equipment, supplies, and infrastructure must be medical grade. Even furniture is carefully considered using infection prevention guidelines.

Jennifer Best, PR Marketing Coordinator with financial data provided by Jennifer Munson, CFO

Do any of these funds go to fund the uninsured?

The funds go into our general fund, and they offset our operational expenses.

Separately, as a hospital in Washington state, we are required to offer financial assistance to anyone. Hospitals care for everyone who comes through their doors. Often, that care is intense and expensive, but is provided regardless of a patient’s ability to pay. This helps ensure that everyone can get the care they need.

In 2023, Three Rivers provided approximately $430,000 in financial assistance. In addition to financial assistance, we allocated approximately $464,000 of an $800,000 grant to low-income patients. The remainder of the grant has been allocated in 2024.

Jennifer Munson, CFO

What percentage of your patients are uninsured or under-insured?

In 2023, 7.2 percent of our gross revenue was from uninsured patients. At year end, 40.86 percent of our outstanding accounts receivable was private pay (this would include all uninsured and any patients with a balance after insurance).

Jennifer Munson, CFO

What do people do in these situations?

Our Financial Counselor reviews the census daily and attempts contact with every private pay patient. They work with patients to sign up on the marketplace and identify patients that will qualify for Alien Emergency Medical (AEM) and other programs. The Financial Counselor also assists patients with the financial assistance applications.

We provide information to every patient upon admission regarding our financial assistance program.  We also provide contact information on all statements, as well as our website. Anyone can ask for a financial assistance application or download it from our website. It is not limited to only low-income patients. It can also be granted in times of catastrophe.

Jennifer Munson, CFO

How do people decide whether to visit your hospital or Mid-Valley Hospital? How can people make an informed decision?

We asked some Methow Valley residents for feedback at community outreach events over the last couple years. Some people told us they choose Mid-Valley because it’s a shorter drive for them over the Loup. Others said there is more shopping in Omak, so they’re able to run some errands before or after their appointment.

When it comes to deciding on a health care provider for yourself and/or your family, there is a lot to consider. Compare pricing for services. Check online reviews: Google and Facebook are where we receive most of ours. Keep in mind that some information in reviews for any hospital or clinic may be outdated, such as providers’ names, so the hospital’s website should be a good place to double-check for more current information. You can also find out more on those websites about the services offered, and how to get help with your bill or access medical records.

We also welcome questions about anything else prospective patients may want to know, via email, phone, or social media.

Jennifer Best, PR Marketing Coordinator

What are some things about your hospital that you’re proud of?

Every decision we make is guided by our organizational vision, mission, and values, which are listed on our website. They were created by a group of employees several years ago, and we still read them at the start of every meeting to keep us focused. This approach has served us well over the years.

We have a robust quality program, and a Quality Council and Medical Staff Committee that are fully invested in ensuring we provide the ideal patient experience. We’re always looking for ways to improve and innovate. 

Jennifer Best, PR Marketing Coordinator

Do you feel your staff is happy in their environment? Are there any challenges to retaining professional staff in a rural setting?

We focus a lot on fostering a positive culture as an employer, and we very much want our staff to be happy here. Not only is it healthier for them as individuals, but it’s also better for our patients. Our Human Resources department stays busy helping staff with various needs, overseeing recognition, and recruiting with a practice of “hiring well” to ensure the best fit for our organization. For instance, we share our vision, mission, and values with interviewees and chat with them about it.

We have an active employee recognition committee, and an employee wellness committee. Several employees have worked at Three Rivers for many years. At least two began working here as teenagers in entry-level positions, then worked their way up to positions in leadership and Administration after completing college.

Jennifer Best, PR Marketing Coordinator

In my circles, I know several people that travel to Wenatchee for medical services. What can you say about how people use medical services in the valley?

Confluence Health does offer services we don’t have in Brewster, or even in Okanogan County. They have a wider variety of specialty services. Critical Access Hospitals can’t offer the same variety that a larger, privately owned hospital can. Everyone has different priorities and preferences for themselves and their families, and that’s OK. We want folks to know that we’re still here if they need us. 

Jennifer Best, PR Marketing Coordinator

What can you say about patients coming from Brewster and Douglas County? What do you want valley residents to know?

Part of our hospital district includes north Douglas County, particularly Bridgeport and Mansfield. Most of our patients come from the Brewster and Bridgeport areas, in fact. Some of our Douglas County residents are lower-income, and they contend with issues like transportation access. Mansfield residents are also butting up against the “golden hour” for traumatic events like strokes and heart attacks. We know Methow Valley residents encounter the same issues. 

Many of our employees live in Brewster and Bridgeport, in fact, and they help us connect with these communities that aren’t as plugged-in as the Methow and rely on different means of getting their information. 

Jennifer Best, PR Marketing Coordinator

Last word is with you- any final thoughts about what you want people in the Methow Valley to know about Three Rivers?

First, how appreciative we are of the valley’s continuous support and partnership over the years. Aero Methow, Room One, The Cove, Methow Arts Alliance, the Winthrop and Twisp Chambers of Commerce, the farmers market, the schools, and the local businesses we’ve worked with are all comprised of phenomenal people. We’re truly grateful to have Methow, Carlton, Twisp, Winthrop, and Mazama as part of our district. We equally value the other communities we serve – Brewster, Bridgeport, Mansfield, and Pateros.

We want to understand the barriers our residents face in getting health care. Knowing our patients’ needs helps guide everything we do, from our strategic plan to new partnerships. Your involvement in your community-owned hospital district is valued and heard. You’re the driving force behind, and the reason for, our improvements. Unfortunately, we can’t meet every need in such a diverse and widespread area. That’s where our partnerships with outside organizations come into play, so we can be sure everyone who sees us gets the care they need. And if we fall short or don’t get something right, we want to know that too.

Jennifer Best, PR Marketing Coordinator