Insurance revisions steal Obama-care show

This article appeared in the April 6, 2010 edition of the Springfield Business Journal.

This article appeared in the April 6, 2010 edition of the Springfield Business Journal.

The much-debated health care reform legislation is now law. Despite all the rhetoric, name calling and brick throwing, the act does very little to reform health care.

The law focuses on health insurance reform, and it is not the end game; it is little more than the end of the beginning. As the post-enactment dust begins to settle, certain hot-button topics will fade: government-run health care, Medicare cuts and abortion. Those issues were overhyped to alarm constituencies preprogrammed to react.

Two issues will dominate as the fight shifts from the U.S. Congress to the states: the mandate to purchase health insurance and the cost of expanding Medicaid.

The insurance mandate

Some states threaten legislation to block the mandate, and others threaten litigation.

Do not count on state laws and lawsuits accomplishing much more than giving talking heads ammunition (though people with no knowledge of constitutional law will begin making confident statements about the true meaning of the interstate commerce clause).

There also will be a proliferation of claims that the mandate was actually a Republican invention.

If the goal is to protect the health insurance industry, a “universal” mandate to purchase private insurance is certainly preferable to “universal” governmental insurance such as Medicare for all.

Insurance companies already are funding millions into an Enroll America campaign. The battle over the mandate will fade.

The Medicaid expansion

It does not have talking-head appeal, but it will be the real battleground as to the future of health insurance.

The act requires states to expand Medicaid to cover households earning less than $30,000.

The expansion is paid by the federal government, but the subsidy eventually drops to 90 percent. The federal subsidy only covers the “expansion” of Medicaid, but money is fungible and so are Medicaid “covered lives.”

Questions linger. How soon before the lines become blurred between existing and expanded funds and covered persons? What happens when a state cuts benefits or eligibility in its existing program while expanding its program with federal funds under the new law?

The feds will regulate the expansion, but states will prove extremely inventive in leveraging federal dollars.

For years, the federal government has attempted to rein in states which impose a “tax” on providers to increase matching funds from the federal program, but every year more states climb on the provider tax gravy train. Imagine the clever ways states will transform “existing” into “expanded.” How soon before federal regulations merge the two?

Medicaid varies not merely in eligibility criteria but also in services covered. Relocating recipients will lose certain services covered in their old states. Does the new law give rise to a federal mandate to cover a certain menu of services under Medicaid?

Medicaid also varies in what states pay for the same service. The new law requires Medicaid programs to pay primary care physicians Medicare rates.

How soon before federal regulations require Medicaid to cover the same services and pay the same as Medicare?

The new law subsidizes the mandated purchase of health insurance for households earning less than 400 percent of the federal poverty level, which is approximately $88,000. Depending on each state’s eligibility standards for Medicaid and the Children’s Health Insurance Program, the insurance subsidy could cost more than existing programs.

How soon before federal regulations transform the subsidy into coverage provided directly under Medicaid – with a sliding scale determining individual premium payment responsibility?

Pressure now exists to evolve Medicaid into a federally funded doppelganger of Medicare for persons in households under 400 percent of the federal poverty level. Everyone else would be covered under private insurance until they attain Medicare eligibility.

Paul Taylor is CEO and chief legal counsel of Springfield-based Ozarks Community Hospital. He can be reached at healthcare@OCHonline.com.

Healthy Americans must help pay for the sick

This article appeared in the March 15, 2010 edition of the Springfield Business Journal.

President Obama wants to get health care reform back on track.

The tactic he has been using did not work. He used presidential authority to “demand” a bill meeting his reform expectations.

If Congress could produce nonpartisan reform, Obama’s approach might have made sense. Unfortunately, no one in Congress seems capable of drafting legislation designed to solve the problem.

The only way this Congress designs “reform” is by benefiting certain players (the insurance industry, the hospital lobby, the pharmaceutical companies, etc.) at the expense of other players, and above all, by satisfying a particular political agenda.

The nation is in desperate need of a reformed health care system, because the current one is a complete mess. However, as urgent as the need is, the leading House and Senate bills would do little more than postpone the inevitable day when the system must be finally, fundamentally reformed.

It is possible to provide universal health care to all U.S. citizens without adding to the deficit and while promoting individual responsibility and preserving a meaningful role for the private insurance industry. All it really takes is a frank assessment of the current system and a willingness to design a reformed system with only one goal in mind: providing quality health care to everyone for the lowest possible cost. The 60/40 split in the Senate became the focus of so much national attention centered on health care reform that it might as well serve as the model of reform: a 60/40 solution, as follows.

The total cost of providing care for every U.S. citizen is calculated at Medicare rates, divided by the total number of lives and discounted to 60 percent, creating a “universal” annual premium. The cost per life would be low because the pool would cover everyone, including young healthy people. This premium would be assessed against everyone but collected in a variety of ways. Those who are covered under Medicare or Medicaid would have the premium paid under those programs. Employees would have half of the premium deducted from their wages with the other half paid by the employer.

Self-employed persons would be expected to pay the premium, and those who do not would have it assessed against them as a tax. Those covered under unemployment would have the premium paid as a benefit. There would be no tax deduction applicable to payment of the premium. The program would collect the premiums and disburse funds through a system of statewide fiscal intermediaries – insurance companies processing and paying claims much as they do now for Medicare. The Democrats will favor this part of the solution.

The total cost of care in 2009 was approximately $2.5 trillion dollars or about $8,000 per U.S. citizen, according to the Centers for Medicare and Medicaid Services. The annual premium to cover 60 percent of that cost would be $4,800 or $400 per month.

Is it fair to burden the young with the cost of caring for the old? Yes. It is more than fair: It is necessary. The U.S. Department of Health and Human Services says one-tenth of the population accounts for 63 percent of spending on health services, and one-half accounts for just more than 3 percent of spending. The healthy half must pay a premium based on helping to cover the whole.

Unlike the per capita distribution of the cost of care for the 60 percent pool, the cost of paying for the remaining 40 percent would be assessed against the pool of payers based on individual and group loss ratios and risk factors. The assessment of cost based on individual utilization of health care is a critical element in cost control. Universal health coverage in this country will collapse without it. The distribution of risk and responsibility for payment would look similar to the current hodgepodge of governmental resources, private insurance and individual payment arrangements. Legislation would prohibit loss of coverage for pre-existing conditions and other nefarious insurance practices, but individuals with higher risk factors would pay higher co-insurance premiums to cover the 40 percent share. The Republicans will favor this part of the solution.

Health care providers will say it is impossible to provide quality care at Medicare rates. It can be done, and it will be done, if there is a level playing field among all providers – and if there are payers covering all patients.

Paul Taylor is CEO and chief legal counsel of Springfield-based Ozarks Community Hospital. He can be reached at healthcare@OCHonline.com.

Charity Care at Missouri Hospitals 2004 – 2006

Prepared by the St. Louis Area Business Health Coalition for the Missouri Foundation for Health (Click here to read the full report http://www.mffh.org/mm/files/Charity%20Care%20at%20MO%20Hospitals.pdf)

In 2005, the Missouri legislature approved significant cuts to the state’s Medicaid program. While many studies have examined the effect of those cuts on the newly uninsured, there has been less research on how this loss of coverage impacted hospitals. This project examines whether hospitals suffered an increased financial burden, how hospital utilization patterns changed, and the ability of one hospital to meet the challenge with an innovative strategy to improve service to the uninsured in its area.

Hospital Utilization Pattterns Change
Greene County had the largest decline in Medicaid where patient days fell (20%).Medicaid patient days fell at all three hospitals in Greene County; Cox Health Systems (22%), St.John’s Regional Health Center (19%), and Ozarks Community Hospital (10%).Aggregate Medicaid utilization decreased in the St.Louis region, though Medicaid admissions increased at the two largest hospital systems, BJC HealthCare and SSM Health Care.Closure of Forest Park Hospital’s obstetrics practice and expansion of the Illinois Medicaid program may partially explain the increases at BJC and SSM.

Regional Snapshots
As part of the study, hospitals were asked to describe the effects of the 2005 reductions in Medicaid eligibility on their numbers Medicaid and uninsured patients.The following hospitals provided information and narrative descriptions of the impact on their hospital: Audrain Medical Center in (Mexico, MO) Audrain County, and Cox Health System, Ozarks Community Hospital, and St.John’s Regional Health Center in (Springfield, MO) Greene County.Information on St.Louis metropolitan area hospitals is supported by reports from the St.Louis Regional Health Commission (RHC).

Greene County
Cox Health Systems (CHS) reported a significant increase in the amount of care provided to the underserved.More than 65 percent of 2006 neonatal ICU discharges at CHS were Medicaid and uninsured.CHS provides access to primary care through its Federally Designated Rural Health Clinics.Although CHS’s charity care in 2006 was the second highest in Greene County at $6.5 million or, 0.95 percent of operating revenue, it was below the average for study hospitals of 1.3 percent.Bad debt was the highest in the county at $23.7 million or, 3.42 percent of operating revenue.

In a position paper from the CEO of Ozarks Community Hospital (OCH), Paul Taylor reports, “Before the Medicaid program was reformed in 2006 by reducing the number of covered beneficiaries state-wide and entirely eliminating certain benefits such as physical therapy and wound care, over 40 percent of our patients were covered by Medicaid.Following the Medicaid reforms, the percentage of our patients covered by Medicaid declined dramatically and we saw a corresponding increase in the percentage of uninsured patients.By September 2006, the percentage of uninsured patients seeking treatment in our emergency room (ER) had climbed to more than 50 percent.At OCH, given the fact that a large percentage of our ER patients were uninsured, and in need of follow-up care by a primary care provider, we created a primary care follow-up clinic.While we did not offer the care free of charge, we did not require payment at the time of service and we billed for the services provided at a substantial discount.”
St.John’s Regional Health Center (SMHS) provided the largest amount of charity care in Greene County at $9.3 million, or 1.51 percent of operating revenue, and bad debt was the second highest in the county at $21.5 million, or 3.52 percent of operating revenue.

At the time this report was written, St.John’s provided a general description of a future plan to conduct a medical management demonstration project to provide access to health care for adults (18-64 years of age) that suffer from chronic disease and have annual household incomes equal to or below 150 percent of the Federal Poverty level.The demonstration project will be limited to a maximum of 25 patients per quarter and 100 per year.Patients will be eligible for this project if they have utilized St.John’s provider network or ED in the past.Patients will be required to apply for enrollment, and make co-payments for care.Specific details on the type or amount of any additional payments required of enrollees were not provided.

Bad Debt and Charity Care – An Important Distinction
Individual hospitals and regions had higher percentages.Greene and Polk counties exceeded the aggregate percentage for study hospitals and the all Missouri hospital average for uncompensated care as a percentage of operating expense in 2006.Why is their uncompensated care so much higher? Exhibit 3 below shows the service area of hospitals located in Greene and Polk, indicated by a circle on the Missouri map.Many of the counties they serve are in the lowest per capita income category.

Greene County
Financial performance for certain hospitals in Greene County was also impacted.Charity care nearly tripled at Cox Health System (CHS) from 2005 to 2006 and bad debt increased by a third.2006 operating and profit margins were 0.90 percent and 2.47 percent respectively.Yet, in 2006 CHS had $476 million in reserves, equivalent to about eight months of operating revenue.CHS’s 2006 debt-to-equity ratio of 0.6 was slightly below the Missouri average.
Similarly, St.John’s Regional Health System provided the highest amount of charity care as a percentage of operating revenue in the county and bad debt increased 21 percent from 2005 to 2006.However, St.John’s was financially strong and, although operating results were affected, they were able to achieve a 7.3 percent operating and profit margin, well above state and national averages.Non-operating revenue was not reported by the hospital.In 2006, St.John’s had $350 million in reserves, equivalent to about five months of operating revenue, and a debt-to-equity ratio of 0.3, well below the Missouri average.

Also mentioned previously, Ozarks Community Hospital (OCH) experienced a large increase in uninsured patients resulting in a 52 percent and 7.5 percent increase in bad debt and charity care respectively from 2005 to 2006.OCH lost more than $2 million resulting in a negative (6.5%) operating margin in 2006.OCH’s low level of reserves fell to approximately $1.7 million in 2006, on average equivalent to less than one month of operating revenue.OCH had high levels of debt with a debt-to-equity ratio of 8.3, up from 3.0 in 2005, more than 13 times the state average.

Dear President Obama and guests of the President’s debate on healthcare reform

I believe it is possible to create a reformed healthcare system with the essential elements desired by both political parties. Please put aside partisan politics, pry open your hearts and minds and listen to what I am actually proposing. I say that because I have found that politicians seldom really listen. Instead, they translate what they hear into something they already planned to say.

We can provide universal healthcare to all U.S. citizens without adding to the deficit, while promoting individual responsibility and preserving a meaningful role for the private insurance industry. I call the system Americare. I know that name is already in use, but I like it.

1. At the center of Americare is a Medicare-for-all basic benefit package covering every U.S. citizen. [Please, dear Republicans, keep listening.] The total cost of providing care for every U.S. citizen for one year would be calculated at Medicare rates, divided by the total number of lives and discounted to 60%, creating a “single payer” annual premium. This premium would be the same for everyone and would thereby cover 60% of the cost of providing universal healthcare coverage. As with Medicare currently, the government would contract with insurance companies to serve as fiscal intermediaries to process and pay claims efficiently. The cost per life would be as low as possible because it would include everyone, including young healthy people who often do not pay for health insurance. This premium would be assessed against everyone but collected in a variety of ways. Those who are covered under Medicare or Medicaid would have the premium paid under those programs. Employees would have half of the premium deducted from their wages with the other half paid by the employer. Self-employed persons would be expected to pay the premium and those who do not would have it assessed against them as a tax. Those covered under unemployment would have this premium paid as a benefit. There would be no tax deduction applicable to payment of the premium.

2. The remaining 40% of the cost of covering every U.S. citizen would then be assigned to a system of payers very similar to the current hodgepodge of governmental and private insurance, and individuals. [Please, dear Democrats, keep listening.] The cost of providing coverage for this 40% “co-insurance” would be assessed based on individual and group loss ratios and risk factors depending on the nature of the coverage. Legislation would prohibit loss of coverage for pre-existing conditions and other nefarious insurance practices, but individuals with higher risk factors would pay higher premiums. If the patient will not quit smoking or lose weight, the premium goes up.

3. There would be no deductibles, but the 40% co-insurance would include mandated individual co-pays so that patients would pay something out-of-pocket each time they accessed healthcare. The individual co-pays would vary based on the underlying co-insurance. Medicaid beneficiaries might pay smaller co-pays than a patient covered under private insurance, but everybody would have to pay something. We cannot cover everyone without making everyone “feel” the cost of utilizing healthcare.

4. In addition to the basic benefit package provided through Americare, governmental and private insurance would be allowed/encouraged/required to offer additional benefits such as vision, dental, etc. A restricted, formulary-driven drug benefit would be provided through Americare and the rates paid to the pharmaceutical companies would be set by the Americare program, just as with all other healthcare providers. Expanded drug formularies would be available for additional premiums. Someone with money to pay for an expanded benefit package or “platinum” service would be allowed to find a willing partner to take his or her money.

5. Medicare would function basically as it does now, but there would be a tremendous savings over the current system because 60% of the Medicare “premium” would be based on the cost-sharing accomplished by putting everyone in the risk pool. The Medicare program would no longer be bankrupting the government. It does mean that young people would, in effect, be helping to pay for care of the elderly, but it is the fairest and most economical way of doing it. Someday those young people will be old. The state Medicaid programs would provide coverage for the 40% co-pay for covered persons—with coverage determined through a combination of federal and state mandates. Employer-funded groups would cover the co-pay through traditional commercial insurance. Self-employed persons would be required to purchase insurance through a newly created insurance exchange to cover the 40% co-pay. Individuals would also be allowed to “self-fund” the mandated insurance requirement through individual HSA investments. State Medicaid programs would be encouraged to create a virtual HSA account for Medicaid recipients to promote healthy life choices and to reduce over utilization. Those who reduced their co-insurance premiums would be allowed to choose additional benefits such as dental and vision coverage, education or child care.

6. In order to control the cost of care, it is important to include economic incentives for patients to reduce over-utilization and to maintain healthy lifestyles, which is why the premiums for the cost of covering the 40% would be based on individual rate factors. Insurers would still have financial incentives to develop innovative programs. Private insurance companies would be required to spend at least 88% of premium revenue on true medical costs (the so-called “medical loss ratio”).

7. In order to foster true competition among hospitals and doctors, Americare would mandate an “any willing provider” rule, but, since the pay would be the same for all providers, the competition would be for quality and efficiency of service. To maintain a level playing field, state and federal tax exemptions granted nonprofit providers would be phased out over four years—unless the provider was a true charity and received no money from patients for care.

8. The Americare program would create incentive payment programs to encourage quality and to create cost efficiencies. The program would encourage the creation of accountable care organizations, pooling providers into contracted affiliations rewarded for reducing the cost of care. Americare would mandate pay for performance incentives and would create economic disincentives for inefficient or poor quality care. However, instead of focusing reforms on mass-produced, “one size fits all” database-driven, mandated clinical pathways, Americare would promote the development of a nation-wide army of general practitioners, better trained and more highly compensated than specialists. Patients would be required to choose a general practice physician to supervise their care. These general practice physicians would be paid a monthly capitated rate for every patient assigned to them as the patient’s “medical home.” Chronic disease management and wellness care would be covered under the capitated rate, but acute care would be paid according to a fee schedule. The 40% co-insurance would not cover care accessed by the patient outside the medical home unless the general practice physician authorized it. Patients would be allowed to establish a medical home with any physician, but “home jumping” would be discouraged by financial disincentives.

9. There would be a four-year transition period to give private insurance companies and healthcare providers time to adjust to lower profitability.

10. Americare would be regulated by a national panel composed of representatives from all the stakeholders: patients, private insurance, governmental insurance, hospitals, physicians, CMS, etc.

Insurance and pharmaceutical companies will scream that they will go broke. The good ones won’t. They will make a rationale return for a legitimate service or product. Mega health systems will cry that they will close—that it is impossible to provide quality care on Medicare payment rates. No doubt less money will be spent on new facilities and new equipment for many years, but the healthcare delivery system will adapt and survive. Americare is one of those compromises that everyone would hate and complain about bitterly, but it would work.

Paul Taylor

Tax Advice: What To Do When Receiving An Erroneous 1099

Courtesy of Amazon.com

Springfield, MO – Though normally adverse to publicity, best selling poet and novelist, Paul Taylor, CEO of Ozarks Community Hospital, who is also one of the nation’s leading experts on healthcare reform, has decided to speak out against the conspiracy to suppress his work orchestrated by what he refers to as the dominant cultural hegemony. Mr. Taylor claims he has obtained proof by virtue of recently released official U.S. government documents that he is in fact one of Amazon’s most successful authors even though the media has refused to recognize his work.

Sarah Montgomery, one of his press agents working tirelessly to break through the official code of silence that has until now smothered his success, offered this personal insight into the drama that unfolded today in Springfield, Missouri: “Paul walked into the media room and threw down a pile of 1099s he got from Amazon in the mail yesterday. His royalties amounted to almost a million dollars last year. You know, some of us on team Paul were beginning to have doubts that the struggle was worth it. He kept telling us that his groundbreaking poetry and narrative fiction would change the world once we got the word out to the public at large, but, sometimes, when you are on the front lines fighting to promote avant-garde literature, you begin to have doubts. We all believed in Paul but it is certainly reassuring to see objective evidence validating our commitment to keep battling for him.”

Mr. Taylor spoke today at an impromptu gathering of his employed supporters: “I knew there was tremendous grass-root support for my work but I had no idea how strong the movement had grown until I received 1099 statements mailed to me directly from Amazon stating that Amazon.com and a number of its subsidiaries have paid me royalties on book sales in 2009 totaling $943,454.49. I hope to receive the checks soon because I have to pay the taxes on that income by April 15th.”

Mr. Taylor published two books in 2008: Grid, a prose poem that has been called the most important work in American poetry since Leaves of Grass by Walt Whitman, and Rehabitation, an experiment in narrative fiction that fuses novel and screenplay in an emotional thriller loosely based on Taylor family history that may soon become a major motion picture. Until he received notice of the 2009 royalties earned through sales of his work, Mr. Taylor had made less than $100 on sales of his books through Amazon.
“I am really excited that the books have begun to sell so well,” Taylor added. “I had slated Tom Hanks to star as the father in Rehabitation, to be directed by Ron Howard and produced by Steve Spielberg, but I was becoming concerned that Hollywood would lose interest if sales did not pick up.”

Janet Taylor, Taylor’s wife who is also CFO of Ozarks Community Hospital, commented: “I understood Diane Lane was supposed to play the wife in Rehabitation but I was concerned that if they didn’t start shooting the film pretty soon, they would have to go with someone younger.”

Taylor does not have much time to savor his success. “I have been contacted by one of President Obama’s people through an email I received to offer my thoughts on healthcare reform heading into the televised debate coming up next week. I have devised a comprehensive reform package that would completely solve the nation’s healthcare crisis by providing universal healthcare at no additional expense to the taxpayers while promoting individual responsibility and preserving a continuing role for private insurance in the payment system. I have to work out a few last kinks before delivering my white paper to the President.”

Paul Taylor is the CEO and general counsel for Ozarks Community Hospital. Paul Taylor’s Grid and Rehabitation are available on Amazon. His healthcare thoughts are discussed at http://ochhealthcarereform.blogspot.com/.

This Amazon tax error is widespread among authors. Read more here: http://answers.yahoo.com/question/index?qid=20100216122421AASbM8a.

What I wouldn't trade with any other CEO

(This was the speech given to employees, friends, and family at the 2009 Ozarks Community Hospital winter party)

Ten years. Part of me wants to use the occasion to follow Bilbo and make a farewell speech. I am immensely fond of you all. Ten years is too short a time to live among such excellent and admirable hobbits. I don’t know half of you half as well as I should like; and I like less than half of you half as well as you deserve. But I regret to announce that—though, as I said, ten years is far too short a time to spend among you—this is the END. I am going. I am leaving NOW. GOOD-BYE! In a few weeks, we will have been in the hospital business ten years. Of course, the history of the organization is deeper than that, but there is something special about a rebirth. On June 28, 1999, the State of Missouri granted a Certificate of Need for a 45 bed osteopathic hospital located at 2828 N. National in Springfield, Missouri. It was my birthday. We spent the next six months in labor giving birth to a hospital—believing we could do it with two million when conventional wisdom said we needed ten. While the rest of the country was obsessed with Y2K, worried that computer systems were all going to crash at midnight on December 31, 1999, we were trying to figure out how to breathe life back into a system that had been given last rites more than a decade earlier. Most of you know the numbers. We opened with fewer than 50 employees. We now employ 850. We began with two employed physicians outside the ER. We now employ 60. Gross revenue has grown from less than $8 million to more than $120 million a year. We now contribute $40 million annually in wages and benefits to the regional economy. Most of you know the mission. More than 80% of our patients have governmental insurance or are self pay. Based on hospital and physician utilization by Medicare beneficiaries, we are the lowest cost healthcare system in the nation. Most of you know the story. Years ago, during one of our many close encounters with financial ruin, I sent a memo to the physician shareholders. On the cover was a picture of the walrus and the carpenter from Alice in Wonderland by Lewis Carroll.




The time has come, the Walrus said,
To talk of many things:
Of shoes--and ships--and sealing-wax--
Of cabbages--and kings--
And why the sea is boiling hot--
And whether pigs have wings.

We rallied the troops, held the wolves at bay, kept the doors open and lived to fight another day. Janet and I used to repeat a ritual at the end of each week. We adapted it from the film, It’s a Wonderful Life. It is the scene about the run on the Bailey Building and Loan. George and Mary use their own money to keep the doors from closing. There are two dollars left at the end of the day. George does a little happy dance and says: “a toast to Momma Dollar and to Poppa Dollar, and if you want to keep this old Building and Loan in business, you better have a family real quick.” A few months later, things were looking up and I sent a second memo to the ownership group. I again referred to the walrus and carpenter poem, asking whether the pig had wings, and I answered with a picture of flying pigs under the Doctors Hospital banner:




No one really believed it would ever happen, but the swine flew. [Karla Myers claims she holds a copyright on that expression as it applies to our hospital.] We have had some years when we made money. There have been years when we lost money. At the end of ten years, the profits and losses have almost exactly balanced each other out. I have not been much of a businessman. Many other health systems have adopted a Wall Street, “greed is good” rationale. They believe the ends justify the means. Since the mission is to take care of sick people and that mission is a good thing, it does not matter how many people they have to screw to do it. I am a complete failure at being that kind of businessman. As an attorney and as your CEO, I could have been suing patients to collect money for the hospital without having to spend money on attorney’s fees. Anyone with half a brain for business would have done it. Yet, in ten years, I haven’t done it once. At OCH, our philosophy has been: do good, do it the right way, and the money is supposed to take care of itself. I would rather go broke believing that, doing it that way, than make money doing it the other way. The thing is, tonight, I don’t want to talk about the numbers, the mission or the story. I’ve got this ring of power in my pocket and the temptation to use it is hard to resist. But I’m not Bilbo. He achieved his quest. He helped slay the dragon. He found the golden treasure. He went there and came back again. He earned the right to fade away and leave the next quest to a younger generation. My successes have been limited to a series of recoveries from defeats. I shovel like a madman to fill holes—some of which I dug myself—but the best I can ever do is get back to level ground. I can’t climb the mountain. I can’t climb it but I know it is there. When the whistle blows at the end of my day, I hear a poem by Emily Dickinson. [I can hear the groans out there: “Oh my God! He is going to recite poetry at a party.” I can’t help it. Blame my liberal arts, Ivy League education. It is sad but true. This poem plays in my head like a tune that won’t stop recycling.]

Success is counted sweetest
By those who ne’er succeed.
Not one of all the purple host
Who took the flag to-day
Can tell the definition,
So clear, of victory!
As he, defeated, dying,
On whose forbidden ear
The distant strains of triumph
Burst agonized and clear!

So, I do not stand here tonight to celebrate success. I count my failures and there are many. It is the fear of failure that drives me. No, tonight is not about me or the numbers or the mission or the story. Tonight is about you. The real strength of this organization has always been the special people dedicated to service and to each other. I used to think that we had an advantage due to our small size. We felt more like family to each other than employees at the other health systems. They were just too big to feel that way. Guess what? We’re not that small anymore; yet, I still see, hear and feel the same everyday expressions of compassion, empathy, dedication and selflessness that have been and remain the unique hallmark of our corporate character. I look out here tonight and I see people I love. Yes, it has been rewarding to see the organization grow, but that pales in comparison to the pride I feel witnessing the personal growth and development of so many long time employees. We are going to recognize some of those employees tonight—those with five and ten years of continuous service time. During the first four years of our organization’s existence, we constantly faced issues that should have forced us to close. I still remember the day that the Director of the Greene County Health Department called me and said he had been told by City Utilities to arrange for the ambulance transfer of all our patients in the hospital because they were going to turn off water, gas and electric. I just laughed at the guy. He said, “What do you know that I don’t know?” I said, “This may be the easiest problem I have to solve today.” Make a difference. People use the phrase so often it has become a cliché. For those employees who worked with us five to ten years ago, it was no cliché. Almost every day, something an employee did that day made the difference between staying open and closing forever. Many organizations claim they were built by the blood, sweat and tears of their employees, but I do not know of any other hospital in the nation during the last decade that was literally built on nothing other than the blood, sweat and tears of the employees. As I like to say, anyone could have done what we did as long as they had enough money. Our employees are the only ones who have managed to do it without any money. Ozarks Community Hospital is the only organization in the world that has employees capable of breathing life back into a derelict, defunct hospital facility no one else wanted, given up for dead for two-and-a-half years, doing so without any money, facing unfair barriers to competition that would strangle a healthy, wealthy company, eventually going broke in the process… and then doing it again. Those of you who have joined us more recently will find it difficult to connect to that emotion or believe in the underlying truth of these words. You have no doubt heard similar words spoken about other organizations. I want you to hear and understand and believe this. Every day, there was one employee or another, usually someone making about eight bucks an hour, who had every reason in the world to give up on the impossible task at hand, call it a day and go home, but who, for some inexplicable reason, did not… did not give up… and because they did not give up there was just enough of something that was needed the next day, the next week, the next month, to get by, to make do. It was a nurse playing the part of a biomed technician because we didn’t have a biomed department back then or it was an ER tech performing an IT service because we didn’t have an IT department or it was a housekeeper becoming the purchasing department by making something work that another hospital had thrown away. It was an employee who, instead of saying “I can’t do my job because I need something we can’t get,” said, “I will figure something out and get it done.” I am the one who gets the pat on the back for being the miracle worker, for pulling rabbits out of my hat, but I know better than anyone who the real miracle workers were. I get to be the wizard but even Gandalf will admit that he can’t burn snow, and if it had not been for a lot of hobbits chopping wood, this fire would have gone out a long time ago. A spark here and there in the actions of a few dozen employees ignited a flame of effort and commitment that still burns today. It infects new employees like a virus. Not everyone catches it. Some are immune, but those who do seem to enjoy work and maybe even life more than those who do not. It is not going to get any easier in the years to come. I have been advocating for some kind of healthcare reform that would level the playing field for providers, insure more lives and make care more affordable, but the fact is that the people and institutions with power in this world use it mostly to hang on to power. It would be naïve to bet against them doing so again. We are not going to win the lottery, receive a large grant or suddenly get paid more for the care we provide. Unlike most health systems focused on profit (and, of course, I include billion dollar charitable organizations in that group), we do not compromise patient care by cutting staff in order to preserve a healthy bottom line. We don’t buy new if we can find it used. Our facilities don’t look like Wall Street board rooms. Our floors may not be as fancy but they are just as clean—in most cases, cleaner. I have been visiting a number of hospitals recently to talk healthcare reform with other CEOs and as I walk around the other guys’ buildings I usually say to myself: “They’re not in the same business we’re in.” We have to get it done, providing the same quality healthcare for less pay, with fewer resources and none of the advantages taken for granted by other health systems. There is not a hospital CEO in the nation who would trade financial statements with me, but I would not trade employees with any of them. Will we get it done? You will. I know you will.