It only hurts when I LAFCO

Mammoth Hospital has essentially rejected a request by the Inyo County Local Agency Formation Commission (LAFCO) to fill out an application for permission to expand its orthopedic services outside of the Southern Mono Healthcare District with a new location on Main Street in Bishop.

Instead, Mammoth sent a letter citing a legal code in LAFCO regulations. Mammoth claims the code exempts it from the entire application process. Inyo LAFCO responded by granting the Commission’s Director permission to seek legal counsel to resolve Mammoth’s refusal to participate, including litigation, if necessary.

LAFCO’s initial decision advised the districts, Southern Mono and Northern Inyo, to work together to equitably distribute healthcare services between them.

Instead, Inyo alleges Mammoth Hospital of breaking a bond of trust between Inyo and Mono counties by expanding without asking permission and cherry picking the most lucrative procedures from Inyo without backing up those services with after hours and weekend support from  its doctors.

Mammoth Hospital has also opened a clinic (without LAFCO approval) in Southern Inyo.

Mammoth has responded by saying little other than it does not feel it has to comply with LAFCO procedures but, as Mammoth Hospital CEO Gary Myers stated in an email to The Sheet, “We remain available to civil discussion aimed at mutually acceptable resolution.”

Ironically, the LAFCO meeting was held Monday, June 1, the day the new clinic was set to open. Myers has not commented on the cost of the new clinic.

To recap, Mammoth Hospital has been operating physical therapy and orthopedic clinics in Bishop since 2011, using orthopedic surgeon Dr. John Perry since 2003. Dr. John Perry had been working at Northern Inyo Hospital (NIH) by contract as a fill in while NIH sought to replenish its services after a lapse in available specialists.

Mammoth has now remodeled the old Golden State Cycle location on Main Street as the consolidated location of the orthopedic clinic on the NIH campus and the physical therapy clinic on West Line Street.

But Mammoth didn’t ask anyone if it could expand.

Myers has stated that Mammoth Hospital needs to expand to simplify access to services and to keep up with growing demand.

The rub here is that Mammoth Hospital contends there was a contract, an agreement between the two districts to provide services, but no such document has surfaced.

Inyo has accepted Mammoth’s position that it believes it is exempt from LAFCO requirements. Inyo will hire a lawyer to try and rectify the situation.

LAFCO Commissioner and County Supervisor Jeff Griffiths said that more important is how to equitably distribute health care between the two districts, “and I believe that involves cooperation between the two districts.” Griffiths said he wanted to reiterate that he did not believe LAFCO was the appropriate forum for slicing the healthcare pie for the two districts. He encouraged the two to keep talking to resolve the issues, as LAFCO is a County entity that deals with inter-county affairs.

Northern Inyo Hospital CEO Victoria Alexander-Lane explained that Mammoth Hospital’s expansion would not necessarily have a major financial impact for NIH, but the issue is more a matter of principle. Mammoth offers services but with little to no obligation from its staff, Lane said. For example, Mammoth orthopedic doctors working in Inyo do not opt for hospital privileges because they do not want, or are told not to perform on-call duty. This means when one of Mammoth’s patients has a traumatic event or complication in Southern Inyo, if that event does not occur between 9 a.m. and 5 p.m. on weekdays, the patient must be transported to NIH or elsewhere for treatment, without reimbursement from Mammoth.

Lane pointed to an email she received from Dr. Mark Robinson, orthopedic surgeon and chief of staff at NIH, at 1:30 a.m., saying he was in the Emergency Room waiting for a trauma unit from Southern Inyo regarding a Southern Mono patient.

But Lane did call orthopedics one of the last bastions of profit at hospitals, as it is one of the only procedures people are willing to spend money on in a non-life threatening situation. If NIH has to continue to offer emergency services for Mammoth orthopedic patients without an offset in costs, the hospital could find itself unable to afford to offer orthopedic services, Lane said. The situation could get worse with a lack of work for the 10 or so orthopedic surgeons operating in both counties, forcing the doctors to seek work elsewhere.

Therefore Lane contended Mammoth’s expansion could potentially spell the end of orthopedic services in Bishop, forcing all patients to go to Mammoth or Reno.

NIH Board member Pete Watercott said Mammoth never talked to NIH about expanding its services. He said Myers tells a story of how NIH asked Mammoth to come down and help, but Myers can’t produce a written document or contract.

“They’ll further expand services as they please,” he said, taking revenue away from NIH and residents it is there to serve.

He said he was asking LAFCO to deny the request by Mammoth, even though, technically, Mammoth didn’t request anything.

Part of LAFCO’s decision was to ask the two districts to try and work together on mutually agreeable terms. “Its ironic to ask why there is not more collaboration between the two districts,” Watercott added, “because first there needs to be communicating, before there’s going to be collaboration and cooperation.”

Lane said Myers talks about wanting to consolidate the two districts, something she described as a monstrous task, and one that requires trust and communication. By moving into Inyo, Mammoth and the Southern Mono District have broken that trust, she said. She added it would be up to them to fix that breach of trust.

Follow the money

“There’s a great deal of money at stake here,” said Dr. John Ungersma, NIH Board member. He speculated as to why he thinks Mammoth is ramming the expansion through, arguing that the snow hasn’t fallen for several years and Mammoth is very dependent upon snow and tourist dollars for its operation “I’m sympathetic to that,” Robinson said.

While the discussion and debate might center on whether or not the expansion is a good idea or not, Robinson wanted to bring attention to something the public and the commission may have lost sight of: “What is it that Mammoth is doing?”

Robinson said that Mammoth takes care of all types of patients, from the indigent and uninsured to the working class, “but makes up for it with some wealthy people who enjoy dangerous sports. When Mammoth comes here or to Southern Inyo County it can do what it wants; it doesn’t have to act as a district hospital; it can take the cases it finds to its advantage, for whatever reasons those might be, probably financial reasons. It doesn’t have to provide emergency or after-hour services.

“When I came here it was required that orthopedic doctors took on-call duty. They eventually abandoned that commitment over a couple of years, slowly to the point where I was the only one left. He still is pretty much the last one left.

“If there’s a problem at night or on the weekends with one of their patients, “It’s me and my partner that come in and deal with that, not the doctor from Mammoth.”

Robinson once worked for Mammoth orthopedic at the NIH campus but, Lane explained, he was being forced to perform his surgeries in Mammoth.

Robinson told the Commissioners that, as he understood it, LAFCO is about “the orderly provision of public services and drawing a boundary so the public is benefiting. This is a situation where one district is skimming the cream off and everything else is being left to the agencies, the tax payers and various institutions in different districts to deal with. That to me is fundamentally unjust and improper.”