TULARE REGIONAL MEDICAL CENTER
Comprehensive, Quality and Innovative Care in your backyard…
Background 112 Bed Acute
Care Hospital Serving
approximately 170,000 people in the Tulare County and its surrounding area
Provides emergency, diagnostic, elective and surgical care
Operates 4 rural health clinics, 1 wellness center
Future expansion will include a new medical tower, an FQHC, and an additional rural health clinic
TRMC's Current Situation: SWOT Analysis
-Low market share in desirable service
lines and payer categories
-Loss of insured patients to other
hospitals-Dependency on Medi-Cal patient
base-Difficulty
attracting and retaining
physicians-High cost
structure; low revenue
-Financial burden of the uninsured and
underinsured
-Physician recruitment and
retention-Quality
improvement of health care
services-Performance improvement initiatives for
improved -charge capture, reduced
readmissions rates, and
reduced bad debt-Improve hospital
reputation and image
-Improve market share in specific
service lines
-Competition from surrounding
facilities and hospitals
-Defection of key physicians,
unsuccessful recruitment-Potential
resistance of medical staff to
change-Potential for poor financial performance threatening expansion
-Continuation of negative public
image
STRENGTHS
OPPORTUNITIES
WEAKNESSES
THREATS
Financial Snapshot
2006-2007 2007-2008 2008-2009 2009-2010 2010-2011Gross patient Revenue 147,933,171$ 169,524,455$ 237,528,661$ 253,412,890$ 267,526,211$
Provision for bad debt 5,797,842$ 7,242,659$ 9,767,597$ 13,156,331$ $16,851,090Total contractual adj. 84,929,348$ 99,371,655$ 142,437,679$ 155,440,984$ 159,627,809$
DSH funds ($985,965) ($5,291,579)Charity other 900,995$ 1,391,501$ 1,366,276$ 5,468,836$ 6,754,192$
All other deductions 13,550,074$ 7,438,460$ 10,352,541$ Total deductions from
revenue 91,628,185$ 108,005,815$ 166,135,661$ 181,504,611$ $188,294,053Capitation premium revenue $112,004Net Patient Revenue 56,304,986$ 61,518,640$ 71,393,000$ 71,908,279$ 79,344,162$ Other operating revenue 617,025$ 766,842$ 673,721$ 2,744,238$ 1,878,170$
Total operating expenses 60,696,426$ 65,062,641$ 72,634,498$ 72,849,437$ 78,074,747$ Net from operations ($3,774,415) ($2,777,159) ($567,777) 1,803,080$ 3,147,585$ Non-operating revenue 4,874,867$ 4,566,523$ 9,640,063$ 12,790,190$ 13,897,152$
Non-operating expenses 604,776$ 48,748$ 3,933,781$ 4,477,770$ 3,872,312$ Net Income 495,676$ 1,740,616$ 5,138,505$ 10,115,500$ 13,172,425$
Source: CA OSHPD
Strategic Plan Overview
• Performance Improvement Initiativeso Clinical processeso Financial processes
• Physician Recruitment and Community Development
• “Be Healthy Tulare” Marketing Campaign
Performance Improvement Initiative
Performance Improvement Initiatives Two performance improvement initiatives
for both clinical and financial processes Focus clinical QI initiative on the following
areas: Readmissions:
Heart attack- 19.8% Heart failure- 27.3% Pneumonia- 21.8%
TRMC is not be paid for episodes of care resulting from readmission within 30 days
Performance Improvement Initiatives Poor quality of care scores will soon have
a financial impact on TRMC Starting in October 2012, Medicare’s
Value-Base Purchasing will withhold 1-2% of TRMC payment
Will track and reward performance based on: 12 process of care measurements 8 patient satisfaction scores from HCAHPS 30-day mortality rates 8 hospital acquired conditions
Financial Process Improvement Critically important to address weakness in
financial processes now before the payment environment changes Disproportionate Share Hospital(DSH) fund
payments will be gradually decreasing due to ACA from 2014-2020 need to ensure financial viability without additional payments
Three areas of financial management that need to be closely monitored and actively improved in order to retain financial stability: Occupancy Rate Bad Debt Rate Days in Accounts Receivable
Change due to increased number of licensed acute beds
Financial Process Improvement
Financial Process Improvement
Fiscal Year
Financial Process Improvement
Physician Recruitment & Community Development
Physician Recruitment and Community Development Challenges:
• TRMC in rural, lower income area - presents challenge to physician recruitment
• 25 admitters account for 87% of all referrals, leaving TRMC vulnerable to change
o Areas of particular concern - Cardiology, Ob/Gyn, Family Practice, Orthopedic Surgery
o Revenue at risk at minimum $16 million• In Summary - Physician recruitment needs to be
addressed and relationships with referring physicians need to be fostered
Solution: Immediate - Use NHSC loan forgiveness
programs as a draw for primary care providers
Long Term - Reorient physician recruiting efforts towards a community development approach
Physician Recruitment and Community Development
1) Immediate - Use NHSC loan forgiveness programs as a draw for primary care providers
• 4 Rural Health Centers and Future FQHC are eligible under National Health Services Corps Loan Forgiveness Program
• Notify current staff of eligiblity to apply for loan repayment assistance.
• Inform primary care providers when interviewing them for positions that TRMC site is NHSC-approved and therefore they may be eligible to apply for loan repayment if they accept your open position.
• Utilize NHSC Recruitment Site to alert prospective and current Corps members to TRMC open positions.
• ACA expands funding for FQHCs and the NHSC program - this opportunity is growing
Physician Recruitment and Community Development
2) Long Term - Reorient physician recruiting efforts towards a community development approach
• Modeled after a successful rural recruitment program in Arkansas funded by RWJF
• Combines traditional recruiting/retention and community developmento Mobilize community members; with long-term
goal to develop community into more attractive place for providers
• In RWJF funded pilot, average recruitment fees with this approach were $18,750 per provider – our projection is approximately $30,000 per provider due to CA labor costs
Physician Recruitment and Community Development
Physician Recruitment and Community Development Recruiter Position:• Works with residents/primary care providers/health care facilities
to design and implement community improvements that make the area more attractive to new and existing providers
• Builds relationships with local health care providers and residents and works to unite them into action groups
• Provides technical assistance to enhance local capacity to self-assess needs and map resources
• Informs community about alternative solutions to increasing access to primary care, such as use of nonphysician professionals (nurse practitioners and physician assistants)
• Assists in developing grant proposals to bring needed resources to the community
• Nurtures new providers to ease their transition into their new community
• Links new providers with resources to improve practice retention.
One more thing… Marketing
A reminder of what we are facing…• Hospital’s historical reputation and public
perception and the continuation of that negative public image
• Low market share in desirable service lines and payer categories
• Growing competition with other regional providers and the need to differentiate
• Little philanthropic support from the community
• Growing need for chronic disease management and strategies to address obesity
Marketing Campaign
Be Healthy Tulare!
The Campaign AIMS to… Revitalize TRMC’s public image as a leader in
the delivery of healthcare in the community by highlighting recent performance improvement work and addressing drivers of health in the Tulare community
Advance re-branding of TRMC’s approach to healthcare (Emphasis on Prevention/Wellness and Quality)
Enhance TRMC’s visibility within and outside of the county
Improve community goodwill/customer loyalty Position TRMC as the principal partner in
advancing the total health of the communities it serves
“Be Healthy Tulare!” Marketing Campaign
Identifying our approach…
“Be Healthy Tulare!” Marketing Campaign
Strategic Focus Areas
“Be Healthy Tulare!” Marketing Campaign
CareDeliveryWorkforce WellnessCommunity Wellness
Care Delivery “Comprehensive, Quality and Innovative
Care in your backyard…” is the key message Heavily market Maternal and Child Health
services Focus on pregnant women Aggressively capture stories and share
Highlight recent performance improvement initiatives Cardiac and Respiratory care
Share patient stories- videos are extremely effective
Key Message: Show the community we are the leading healthcare provider in the region
“Be Healthy Tulare!” Marketing Campaign
Workforce Wellness Internally-focused campaign to motivate TRMC
employees and physicians to be “healthy eating, acting living” role models in their community
Explore possibilities of extending Evolution Fitness and Wellness Center membership to TRMC staff, if not done already
Quarterly wellness event – “Get-Fit Challenge” Capture the experience and share
Key Message: TRMC’s commitment to health care is not limited only to its patients
“Be Healthy Tulare!” Marketing Campaign
Community Wellness Campaign: Investment and/or development of local healthy
eating, active living initiatives ID and collaborate with local community partners (e.g.
schools) Targeted Employee and Community
Engagement Targeted community service activities with
TRMC Senior Leadership and community partners (year-long projects)
Employee-driven community service projects Retired Physician Program (Transition to Public
Health Wellness Advocates) Key Message: Demonstrate TRMC’s
commitment to the total health of the communities it serves
“Be Healthy Tulare!” Marketing Campaign
Graphic depicting Marketing Strategy Overview
“Be Healthy Tulare!” Marketing Campaign
Strategic Plan Summary
Ongoing Main Issues Tackled BenefitsPerformance Improvement
Quality; Financial Stability
Increased Net Income; Financial Stability
Marketing Campaign Public Image; Visibility Improved reputation; customer loyalty; community presence
Long-Term Main Issues Tackled BenefitsReorient physician recruiting efforts towards a community development approach
Physician Recruitment and Retention
Strengthened referral network; community capacity development
Short-Term Main Issues Tackled BenefitsNHSC loan forgiveness programs
Sustainable Physician Recruitment
Strong physician recruiting tool
Appendix 1: Value-Based Purchasing
Appendix 2: Revenue at Risk Revenue at Risk
Net Patient Revenue
High Estimate (87% referrals)
Low Estimate (21% referrals)
$79,344,162.00 $69,029,420.94 $16,662,274.02
Appendix 3: Recruiting BudgetProjected Program Budget