Bozeman News

Providing Rural Health Care

Livingston, Billings Medical Merger May Affect Local Clinics

By David Nolt, 8-08-07

Health care facilities in rural locations face unique challenges, and Livingston HealthCare is no different. The small hospital provides a surprising amount of care for its size and location, but there are inevitable situations where a trauma emergency or illness requires a patient’s transfer to a larger medical facility. In Montana, this often means crossing large distances.

As Livingston HealthCare prepares to build a brand new hospital campus and complete a merger with Billings Clinic this fall, the small-town hospital begins an important transition in serving this growing community.

For many years the staff at Livingston HealthCare have had to evolve as the organization strived to keep pace with the community and advancing medical technology, all the while outgrowing the dated building in which they still operate. 

Staff at Livingston HealthCare say the new facility and partnership will provide many new opportunities for health care in Livingston, but how exactly will the merger with Billings Clinic affect Livingston HealthCare’s future, day-to-day operations and relationships with neighboring clinics?

Cardiac Conundrum

In the event of a cardiac emergency, fast medical action is absolutely crucial to save a patient and prevent long-term damage. Blocked arteries can be opened through several methods: “clot-busting” drugs like fibrinolytics and thrombolytics; cardiac catherization; balloon angioplasty; atherectomy or stent implantation.

Regardless of the method, the unclogging of arteries must happen within the very initial stages of a cardiac emergency; for every 10-minute delay there is approximately a one-minute increase in mortality, according to local physicians. Heart muscle can be damaged, potentially leading to long-term disability and death.

The American Heart Association and the American College of Cardiology formed a “D2B” Alliance, setting a national goal of 90 minutes for “Door-to-Balloon” time, or the time it takes from a patient’s arrival at the emergency room until a clogged artery is opened. The national average is 104 minutes, but physicians in the new catheterization lab at Bozeman Deaconess Hospital proudly tout a 65-minute average.

“It’s like putting a tourniquet on an arm,” Bozeman Deaconess Cardiologist Dane Sobek explains. “The longer the problem goes on the more damage will be done, so time really is of the essence.”

Four years ago, Deaconess first began taking cardiac diagnostic pictures. Then, two years ago, the cath lab began performing angioplasties and ballooning stent operations. Now, 86 percent of their patients reach the door-to-balloon time goal, which Jennifer Kack, manager of the Deaconess Cardiac Cath Lab, says is within the top five percent in the nation.

For those who suffer a cardiac emergency in Livingston or Park County, however, no such services exist at Livingston HealthCare. In the event of an emergency, patients must consult with physicians here to decide whether to go to Bozeman or Billings to receive further care. Billings Clinic and Billings St. Vincent hospitals both provide full cardiovascular services including heart surgery. Bozeman provides full cardiac intervention services (angioplasty, stents, etc.), but it does not offer cardiac surgery.

The large majority of cardiac-transfer patients at Livingston HealthCare end up in Billings, usually at Billings Clinic. Patients can go by ambulance, by fixed-wing plane or by helicopter, which is fastest. A fixed wing plane takes about two hours roundtrip, and a helicopter trip takes 70 to 80 minutes from the time it leaves Billings until it comes back with a patient from Livingston. Besides taking over an hour—as opposed to about a 30-minute ambulance drive to Bozeman—the cost of a single helicopter transfer averages about $9,000.

Ultimately, the decision of where to go is up to the individual patients and their families. Physicians provide consultation, and Livingston HealthCare Dr. Allan Supak says he is confident in referring patients to Billings in cardiac emergencies.

“I feel more comfortable as a doctor in a rural hospital sending a patient to a hospital that has a higher level of care for further intervention,” Supak says.

Supak and others at Livingston HealthCare say it is often better to get a patient to a location that could not only perform an angioplasty or stent but also have access to operating facilities for heart surgery if a patient’s condition worsened. Jennifer Kack at Bozeman Deaconess reiterates the need to get a cardiac patient to care as soon as possible, whether a heart surgeon is available or not.

“For a cardiac emergency, time is definitely of the essence,” Kack says. “We wouldn’t be doing it [performing interventions in the cath lab without backup cardiac surgery capabilities] if it wasn’t safe. We have never sent any one into cardiac surgery after intervention with complications. That isn’t to say it can’t happen, but we are not the only one in the country or state doing this.”

Kack cites a March 2006 study by the Journal of the American College of Cardiology that found less than one percent of cardiac interventions require further emergent cardiac surgery. The study compared the first 1,007 non-surgical, or PCI interventions in a smaller, community hospital without surgical facilities to a “high-volume tertiary care facility with cardiac surgical capability.”

The study’s conclusion states, “… that percutaneous coronary interventions (PCI) [angioplasties, stents, etc.] procedures can be performed safely without onsite cardiac surgery by following strict protocols for case selection and PCI program requirements.

However, Dr. Supak in Livingston says, with the use of thrombolytic drugs, physicians in Livingston are able to help stabilize cardiac patients, before getting them to another facility with surgery capabilities. Supak also says new cardiac life-support paramedic equipment and staff training allow Livingston HealthCare paramedics to perform electrocardiograms (EKGs) on-site where an emergency first occurs, which greatly reduces cardiac patient mortality.

Livingston HealthCare Patient Services Director Marsha Nanderhoff says patient health and stabilization is Livingston HealthCare’s primary priority.

“The best thing for a patient is to get that patient stabilized and find out what tests need to be done,” Nanderhoff says.

However, Nanderhoff goes on to say each case is different and should be treated as such.

“It is dependent upon the particular condition and the best way to try and fix that,” she explains. “Some require surgery and some don’t…but we can’t just indiscriminately send anybody to a cath lab.”

Billings Clinic Physician in Chief Dr. Mark Rumans says the standard of care for a rural hospital is different for facilities such as those in Billings, and getting a cardiac patient treatment with drugs like thrombolytics should be the first step before additional intervention.

Rumans also emphasizes the portion of cardiac cases that require a door-to-balloon time is very small. Rumans estimates Billings Clinic sees between five and 10 patients per quarter who meet these criteria, and he says Livingston’s smaller population should be taken into account when talking about acute cardiac emergencies.

Again, transfer decisions come down to individual cases, according to Rumans. While he says Billings Clinic has “a greater depth and breadth of cardiac services,” the decision still comes down to a case-by-case decision by physicians in the local community together with patients and their families.

“Once they receive the thrombolytics, I think it might not be better for them to come to Billings and it might be appropriate to go to Bozeman,” Rumans explains. “It depends on the situation and the physician’s assessment, but this is an independent decision made on clinical guidelines.”

Jim Duncan is the President of the Billings Clinic Foundation, and he cites a report by the American College of Cardiology and the American Heart Association. The report “strongly recommends that PCI [angioplasties, stents, etc.] should be performed in facilities that have an experienced cardiovascular surgical team on-site and available as emergency backup for all PCI procedures.”

This gray area between the best practices for initial action and stabilization techniques in cardiac emergencies has some concerned that staff at Livingston HealthCare could be indiscriminately referring patients to their partner clinic in Billings.

Sam Pleshar is the C.E.O. of Livingston HealthCare, and while he acknowledges it is a fair question, he says the reality is much different. Pleshar says management cannot dictate where a patient goes, and federal oversight would prevent such a practice anyway.

“As far as the delivery of care, we make absolutely no restrictions on where they send their patient,” Pleshar says. “There are processes in the system that would prohibit sending all our patients there.”

Pleshar says Livingston HealthCare physicians and other staff have a very cordial, working relationship with Bozeman Deaconess. Pleshar stresses the fact that any transfer is up to the physician and ultimately the patient. When asked how a cardiac surgery program at Bozeman Deaconess would affect Livingston HealthCare’s cardiac transfers, Dr. Supak says it would be a welcome addition.

“I think that would be a valuable resource to us…especially in bad weather,” Supak says. “but we would have to gain something by it, in terms of the level of care.”

For now, Bozeman Deaconess’ cardiac care remains limited to catheterization intervention, and, according to both Livingston HealthCare and Billings Clinic, transfer decisions will continue being made by patients and their families with the consultation of physicians based on each particular emergency.

“It is called evidence-based medicine,” Dr. Rumans asserts, “and it is not based on politics.”

Moving Forward

Staff at Livingston HealthCare say the partnership between Livingston and Billings will open up many new possibilities for health care in Livingston and Park County. Livingston HealthCare Community Development Director Sandy Marlowe says the partnership is a preemptive measure to deal with inevitable and unknown changes in healthcare systems in the United States.

“We know that changes are coming,” Marlowe says. “By having a partnership, it helps us in those changes.”

Sam Pleshar says, besides providing a cushion through broad and unknown changes, the partnership will help in several other ways as well.

“First, it provides stability for the organization,” Pleshar explains. “Most hospitals lose money. They are fragile organizations, yet they are vital for the community. Secondly, it allows us access to resources we wouldn’t be able to [have access to] on our own. It also lets us work with their level of expertise in many areas.”

Under the merger Livingston HealthCare will remain a Critical Access Hospital, which are Medicaid- and/or Medicare-certified hospitals designated as such by individual states. Critical-Access Hospitals (CAH) are non-profits, provide 24-hour emergency care seven days a week, are located 35 miles from other CAH facilities or is certified by the state as a “necessary provider of healthcare services to residents in the area.” Critical Access Hospitals are also limited to a certain number of beds, which is 25 in Livingston’s case.

Billings Clinic has similar partnerships with several other CAH facilities in Montana and Wyoming. Billings Clinic Foundation President Jim Duncan, says each community presents a specific set of circumstances, all of which are based on collaboration. When asked if Livingston HealthCare will lose autonomy, Duncan says the formation of the partnership and the two organization’s shared visions will ensure community-based care.

“The cornerstone of our philosophy is that we know people in Livingston are going to be better cared for if they have vibrant services in that town,” Duncan explains. “…As long as you have good shared governance in the community…we’ll develop a mutual vision of what is best for the clinic and community.”

Pleshar says he envisions more specialists coming to Livingston so fewer patients have to travel elsewhere for care. Pleshar is already a Billings Clinic employee on paper, and he will report to a board of directors made up of a majority of Livingston residents with some from Billings Clinic.

Community Development Director Sandi Marlowe says the partnership is not a merger in a legal sense, but Livingston HealthCare will essentially become a membership corporation of Billings Clinic, which will open up many new avenues to better technology and expertise.

Livingston HealthCare currently operates out of about 15 facilities around Livingston. The main hospital, built to 1950s medical standards, is too small and awkward for the current staff and modern medical equipment crammed into it today.

Also, administrative offices, the Park Clinic and other affiliated aspects of Livingston HealthCare are in adjacent houses or semi-connected trailers. Pleshar and Marlowe both say the new hospital campus will be designed specifically for Livingston HealthCare and will provide much better integration.

“The space will be designed to fit the way we deliver care today,” Marlowe says.

Livingston HealthCare doubled the volume of services provided in the last couple years, and Pleshar says he predicts levels will soon triple above what they were in 2000. Pleshar predicts the merger with Billings Clinic will help not only in the long-term, but also with the short-term construction of the new hospital. Pleshar calls the merger “a pivotal issue for moving forward.”

Pleshar says the hope is to break ground for the new hospital in summer 2008, but significant financial hurdles must be crossed before completion. The hospital will be financed through existing Livingston HealthCare assets, money in the form of a loan as well as contributions from a “capital campaign” of community fundraising.

The Livingston Watson family recently donated 20 acres of land just east of the Yellowstone River off Highway 89. The donation is conditional that the site be used for a healthcare facility and the merger between the Billings and Livingston clinics is a means to that end. The merger is scheduled to officially be complete this fall.

As Livingston HealthCare prepares for major changes, those involved in the new partnership are confident the merger will give the organization resiliency against potential larger changes within national healthcare. According to Jim Duncan at Billings Clinic, the goal is that the partnership will strengthen the quality of care in Livingston in all arenas.

“The proposed governance relationship will not change the way physicians assess the clinical needs of patients,” Duncan states. “…Healthcare is a complex and growingly complex business. You just have to stay on top of it. I think it’s a very exciting time for the people of Livingston to see that healthcare is going to be strengthened with additional partnerships and improved facilities through our partnership…to improve and enhance patient care. We share a lot of the same values as organizations.”

This article was originally published in the Livingston Weekly is Southwestern Montana’s only Alternative Newsweekly.  The Weekly is distributed Thursdays throughout Park and Gallatin Counties or online at www.livingstonweekly.com.

Like this story? Get more! Sign up for our free newsletters.