I am not sure how many inquiring minds will read this, but am compelled to weigh in regarding the upcoming property assessment ballot initiative pertaining to Cedar County Memorial Hospital (CCMH).    My name is Craig Wamsley; I serve on the medical staff at the hospital,  and have been employed for the past 14 years there.   I favor passage of the ballot initiative, and had expressed my reasons in an open letter provided last summer. 

I recently reviewed the comments and posts on Facebook of a well-numbered group identifying themselves as Citizens Against the CCMH Tax Hike.  The video posts by Mr. Peter Lee got my attention.   While there are too many comments to address in a single letter,  the video posted on May 7 appears to be at the core of the group’s ideology.   In that video, Mr. Lee advocates that the C.E.O. of Cedar County Memorial Hospital should not have received a significant salary increase in January of 2018; that her salary should have been increased only if she had achieved financial stability for the hospital; and that the proposed ballot initiative, if passed, would not sufficiently restore financial stability.    The Board at CCMH is thus taken to task for being “unwise” and deemed to be guilty of bad financial management.   This group attempts to persuade that if the Board had done their job “right”, there would be no need for a ballot initiative property tax increase. 

Our senator from Nebraska, Mr. Ben Sasse, has said:  “Among the responsibilities of each citizen in a participatory democracy is keeping ourselves sufficiently informed so that we can participate effectively, argue our positions honorably, and hopefully, forge sufficient consensus to understand each other and then to govern.”    The initial video by Mr. Lee did not get the date correct when it noted the salary increase for the C.E.O., initially broadcasting the date to be in April of 2020.   There was also no mention that three-qauarters of the hospital staff pay scales were increased at the same time as the C.E.O., which had been done in an effort to bring CCMH pay structure more in line with that of other Missouri Critical Access Hospitals.   While this might be regarded as irrelevant, the mistake appears to expose that this salary increase concern did not come to light until Mr. Lee and the “Citizens Against” group discovered it in April 2020.    In a healthy democracy, this concern would have been noted by an active and watchful electorate in January of 2018, not two years later while attempting to “dig up dirt” for a tax hike vote.   This has been noted by prior citizens in their letters on this  and cannot be overlooked: none of the “Citizens Against” group or Mr. Lee has sought to be involved in the operation of the hospital by running for the Board or attending the Board meetings as a “concerned” citizen.    The culpability for the  salary increase of the administrator, if deemed “unwise”,  rests with every voting citizen of Cedar County, and this includes every one of the 500+ members of the “Citizens Against” group.  It occurred on their watch, not on somebody else’s!   

And what about the wisdom of that salary increase for the C.E.O. in January 2018?  While Mr. Lee did his diligence with the financial numbers in discovery, he didn’t quite grasp the context right.  Cedar County Memorial Hospital has three primary members of their administrative team, the C.E.O.,  the Director of Finance, and the Chief Nursing Officer.  As of January 1 of 2018, two of those team members, the Director of Finance and the Nursing Director, had just resigned and left their positions.   The Director of Finance had been at Cedar County Memorial Hospital for decades, so the Board understandably had some significant concern with keeping the hospital functioning at that time.  Bigger hospital systems can survive two administrative team losses without much disruption; smaller hospitals do not have that luxury.   The tax hike ballot initiative didn’t come until April 2019. 

But why not pursue administrative incentives that reward achievement of objectives at Cedar County Memorial Hospital?  This concept comes under several different names, but is most commonly referred to as “merit pay”.  Do your own search online regarding merit pay, and you might be surprised to learn that merit pay doesn’t work for all situations.  Sometimes it can backfire, resulting in critical employee attrition/turnover, and decreased worker morale.  In fact, if one were to glare a bit closer at the primary causes driving the financial deficits at Cedar County Memorial Hospital, the administrative salary category would not be at the top of the list, if at all.    A much more significant force that has been unfortunate has been the loss of critical skilled employees such as lab technicians, nurses and radiology technicians.   Many of these have had to be supplied by temporary “outside” services, at a significantly higher cost.  Though this is merely speculation on my part, I believe that the introduction of the “merit pay” concept in January of 2018 would have spelled disaster for the hospital, resulting in attrition that could not be recovered from, and the system becoming non-functional.  We teeter frightfully close to that at times now, and I know this frustration all too well myself.   

And what about the argument that the “tax hike” is just a “Band-Aid”, and that it will not help the hospital long-term?   This is possible, but anybody attempting to extrapolate from previous financial numbers or gaze into their crystal ball with certainty fails to grasp the complexity of rural health care in the United States.  From an operational standpoint, Cedar County Memorial Hospital operates as efficiently as any rural hospital can, and the annual audit reviews continue to bear this out.   85% of the patients utilizing Cedar County Memorial Hospital pay for their care with Medicare, Medicaid, or on their own without insurance.  This makes the hospital much different when attempting to compare it to a private business.   Since the majority of the hospital’s reimbursement comes from government payers and at an amount less than the cost of providing those services, it makes sense to seek financial stability from a tax-based local initiative.   I feel quite strongly that a primary cause of Cedar County hospital’s financial difficulty is not mismanagement, it is owner absenteeism.   Very few people show interest in running for the Board, and this concern includes people living in El Dorado Springs where the hospital is located.   Without an active and involved citizenry at the grassroots level throughout the county, I am fearful that CCMH will not be able to attract and retain the critical employees and providers/physicians it needs to function fully as it should.

10 rural hospitals have closed in Missouri since 2014.  As mentioned in my letter last summer, Cedar County Memorial Hospital appears to be the last small hospital left in southwest Missouri with a local control mechanism.   Sac Osage hospital in Osceola closed, and serves as a model of what happens when a hospital loses its financial footing.   There appears to be some argument that a “no” vote on the tax hike measure would not “close” the hospital.  While Sac Osage and Cedar County Memorial Hospital are not “exactly” alike, they are very similar, and while there is never any certainty that a hospital will close until it actually does, I believe that any reasonable person looking at this would have to conclude that a “no” vote will lead to eventual hospital closure as the most likely outcome. 

Consequently, if one accepts that another “no” vote would adversely affect Cedar County Memorial Hospital resulting in eventual loss of ownership by the county, then a “no” vote isn’t merely about money.   It also entails the privilege of even being able to vote on this ballot initiative in the first place.   It entails the privilege of being able to assess a situation at the local level, assess blame, fight about it and then work together to find solutions.  It entails the privilege of knowing that if my present health care is obtained somewhere else, but something unexpected should arise in this unpredictable world, that I will still have some tenable health care choices downstream.   And one should remember the first rule of economics: Somebody always pays.  A “no” vote on any local initiative might make a voter feel proud to know they saved money today, but with health care, everybody needs it, and somebody always pays.  Thank you for your attention.

Craig Wamsley M.D.

Garfield, AR

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