Brian Cabell sits down down with Brian Sinotte (rhymes with “why not”), the CEO of UP Health System Marquette.
Sinotte took the job less than a year ago after a stint as CEO at another Duke LifePoint facility in North Carolina. He arrived at time when UPHS was starting construction on its expensive new hospital here, but also when the hospital was facing some adversity: a tragic incident in the ER, layoffs, and dissension among the hospital staff. Some bad press.
There’s still some adversity out there–recent layoffs and outsourcing, murmurs of dissension–but UPHS Marquette is hoping they’ve turned the corner. Sinotte talks openly about the challenges faced by the hospital.
The interview is long.
It covers: Nurses’ union negotiations, morale problems, overworked nurses, employees choosing to leave the hospital, outsourcing, the outmigration of patients to other hospitals, Duke LifePoint’s mistakes when it came to Marquette, its interest in buying other U.P. hospitals, the hospital’s mediocre safety ratings…and a lot more.
Sinotte comes across as earnest, personable, knowledgeable, and articulate. A “charm offensive”? Or just a determination to get a true and fair story out there? Or both? You decide.
Cabell: How’s construction of the hospital going? On time? On budget?
Sinotte: It’s going very well so far. We thankfully had a pretty mild winter up here. The construction force is doing a great job. They hate it when I say they’re a little ahead of schedule, but they may be just a little ahead of schedule.
Cabell: You will open up next year?
Sinotte: We’re thinking late next year. Probably November, 2018 but things can happen. It may be a little earlier or a little later.
Cabell: A lot people wonder, since Duke LifePoint is spending all this money on the building and technology, whether this enormous expense will affect the cost for patients.
Sinotte: No. Capital funding is very different, and there’s no relationship between that and what you’re charged for patient care. They’re very distinct, different drivers. Your charges and out-of-pocket expenses for health care will largely be driven by your insurance product and what kind of coverage you have as an individual.
Cabell: Union negotiations with the nurses…How are those going?
Sinotte: They’re going fine by all accounts. Both parties are negotiating in good faith. We’ll see how things progress over the next couple of months but I’m very optimistic we’ll come to a good agreement and then hopefully we can move forward.
Cabell: We heard some rumors about replacement workers possibly coming in if negotiations break down. Any truth to that?
Sinotte: There are no thoughts of that or talk of that from my perspective. We’re negotiating in good faith and that’s really all I can say.
Cabell: The one issue we hear repeatedly that concerns the nurses is the understaffing, the overworking, the mandatory 12 and 16 hour shifts that come up unpredictably. What can be done about that?
Sinotte: That is a problem universally in health care. It’s challenging because you’ve got a number of factors that causes those things to happen. Let’s say you’re supposed to have five staff on any given shift and one of your people has a child care issue, and she can’t come into work. So then you have four. And suddenly your staffing is under what you think it should be, and because of our geographic location, we don’t have agency nurses that we can have come across town and fill shifts as quickly and easily as we could if we were in an urban area where there’s a pool to draw from. It’s more of a fixed type of labor force that we have here.
Cabell: So does that mean this problem will persist here in Marquette?
Sinotte: I’m actually hopeful that we can get to a place where we have the proper amount of staffing to handle both the seasonal increases in staffing and we’ll have enough staff that we utilize on kind of an as-needed basis. In the the industry they’re called PRN staff that don’t plan on working full time. They plan on working whenever we need them. If you get that staffing correct, that’s how you fill the shifts. We’re still working to build up that end of the work force.
Cabell: We hear a lot about heavy turnover among nurses. True?
Sinotte: Compared to the industry average, we’re actually below that. It’s a challenge everywhere. Nurses tend to move a lot, especially early in their career. They may seek more urban environments for a time, then they might have a family and settle someplace different, so it’s become a little bit of a generational piece. When they’re in the 35-40 range, they might find a place where they’re going to settle, but until then, they might be moving around. We’ve seen some of that so we’ve had turnover but we’re still below the industry average for turnover.
Cabell: What about doctors? We hear repeatedly that doctors are choosing to leave UP Health System Marquette.
Sinotte: It’s a challenge. It really is. I wouldn’t say it’s entirely unique to us, though. We’ve got a couple things that have been interesting for me coming here in the last year. The problem pre-dates Duke LifePoint coming here. You have to get the right people here that are really committed to the community, the U.P. lifestyle. That, from what I’ve heard from a lot of our folks, is one of our biggest challenges. We might get someone in and they might stay two-three-four years but then they realize, you know what? It’s not quite right for me. And in some instances, we have people choosing to leave for really impressive career opportunities. So it’s a matter of finding that person who really wants to be here for 30-plus years.
Cabell: You’ve had two recent sets of layoffs. Were any doctors or nurses laid off?
Sinotte: No nurses were impacted. Doctors are not part of this but we have looked for efficiencies and will continue to look for them on the medical staff side.
Cabell: Something else we’ve heard–Doctors are pressured to see more patients and spend less time with them, and some have been shamed or forced out because they weren’t seeing enough patients. They were spending too much time with patients. Is that part of the ethos of Duke LifePoint?
Sinotte: No. Shaming? Never. I happen to be married to a physician so I know firsthand the frustrations of how medicine has evolved in the last 15-20 years where no matter what part of the country you’re in, you’re having to see more patients and you don’t get as much time with them. It’s a universal frustration for physicians right now. We’re no different than that. The days of being able to spend more time with a patient, it’s just not there anymore. The economics don’t work.
Cabell: Two recent sets of layoffs. Thirty let go in the first one, then 19 more. Are more layoffs on the horizon?
Sinotte: No, but I will say we’re always looking for ways to become more efficient. That’s an industry mandate at this point with reimbursements continuing to be cut at levels we have not seen them be cut in the last 10 years. So will there be more layoffs somewhere down the road? I don’t have a crystal ball but I do not see any in the near future…
Cabell: Meaning the rest of the year?
Sinotte: Yes, none the rest of this year. I feel confident in saying I don’t see anything coming very soon.
Cabell: Outsourcing. You’re also doing that. Is that also part of this “efficiency” you’re talking about?
Sinotte: Partially. Outsourcing in some of these departments you’ve heard about–environmental services and food nutrition–it’s very common in the industry. There’s nothing wrong with our people. It’s just that we can contract with other people who are better at doing that thing than we are on our own. For example, food nutrition, some of these companies that I’ve worked with in the past and will be working with in the future, they’re very good at food. They can really knock out great food, they can be efficient with it, they can produce a quality product without increasing our costs. So it’s a great thing for us, also for environmental services and cleaning rooms. There are things they have learned because they’ve got this national benchmark they can use on best practices, what’s the way to do it more efficiently and safely, and empower their teams via technology. They put them through special training protocols. And we just don’t have the expertise in it.
Cabell: And the employees keep their jobs? The ones who’ve been working in those departments?
Sinotte: Every single one of those people is staying or will have the opportunity to stay here.
Cabell: But we understand they will have to change their health plans with this outsourcing. Right?
Sinotte: They will be paid by this company and their benefits will be through this company and not through us. But they’ll still wear our badge and be part of our team and go through all our training but all their packages will be with this company.
Cabell: But the benefits packages might not be as generous as they were with the hospital?
Sinotte: Could be.
Cabell: Endoscopy. We’ve been told that surgery in that department has a three month wait. Is that true?
Sinotte: There should not be a three month wait for any of our services. I know we used to have some of that for CV surgery but now we have our new CV surgeon, Dr. Brad Blakeman. There was a bit of a wait for those because we knew he was coming. That’s now better. With GI, we are now recruiting for another GI doctor–or endoscopy–so I think that will help reduce the wait. But a three month wait time, we should not have that long of a delay to get in. Anytime we have physicians that we’re recruiting and that we’re working to find more of, you want to reduce that wait time to get in as much as possible. Sometimes if you don’t have enough physicians in a specialty, a delay is inevitable. But it should not be three months.
Cabell: Is there a radiologist in house now?
Sinotte: Yes, we still employ radiologists. We are looking at different groups. We’ve looked at probably seven groups over the last year. Even before I got here, they were looking at different groups to come in and perform more of the radiology services. We still have them, we’ll always have doctors on staff. But what we do want to do and what we’re exploring is…Can we leverage one of these firms so that all of our nightime reads aren’t going out to this service commonly called Night Hawk. We could have just one firm that we get to know. It’ll lead to more consistency, higher quality, improved turnaround. So we are looking at some of those groups, but there will always be radiologists here in house.
Cabell: Revenue is down at UP Health System Marquette?
Sinotte: Compared to 2013?
Cabell: Compared to last year.
Sinotte: Yes. Largely due to outmigration (patients leaving the UP for medical care) unfortunately. We’ve had a number of things go on over the last couple of years that haven’t inspired a lot of confidence from the community in us. There’s a lot of education that needs to happen, that we are part of a larger health care industry that’s very challenging right now. You see a number of hospitals right now that are either stressed or closing, filing bankruptcy. It’s unlike anything that we’ve seen in the last ten years.
Cabell: So how do you stop the outmigration of patients to other hospitals downstate, Wisconsin, Minnesota, wherever?
Sinotte: It’s just back to basics. Provide outstanding quality of care. From the medicine side, we’re great at that. Two, outstanding service. We need to make people feel like we care about them. If you deliver on quality and service, you’ll be around for a long time in the health care world. We’ve got to do a better job of communicating the great things that are happening here every day. This area is blessed with the doctors, nurses and staff we have here. I mean, it’s extraordinary in a community this size to have a hospital like this here. Do we have things we’ve got to work on? Yes, absolutely. And so does every other hospital in the world.
Cabell: You’ve told the staff that they’ve got to do more with less. Is that a fair summation?
Sinotte: It’s an industry mantra right now that I do talk about. Nobody likes it, I don’t like it, but if you were to carve out what the Affordable Care Act mandated and what is now proposed and resting in the Senate right now, it’s essentially just that: Do more with less. Provide higher quality and higher and higher service–and you’ll get penalized if you don’t–and you’ll get paid less to do that. So that’s where a lot of the pressure in health care is coming from.
Cabell: Is there a morale problem here? Too many people criticizing the hospital, muttering under their breath about work conditions and the operation of the hospital?
Sinotte: I don’t know. I think that would be unfair to say that it’s worse here than anywhere else. I’ve been in a lot of hospitals in a lot of communities, and I think there’s an element of that wherever you go. In health care right now, that’s pretty much everywhere. There are very few people in health care now who are thinking, gosh, it’s so much better now than it was ten years ago. We’re having to do things faster, we’re having to find more efficiencies, we’re put under these pressures that we haven’t had to deal with before. And change, by and large, isn’t a pleasant experience. We’ll get through this, but it’s a hard time.
Cabell: What do you say to those who refer to Duke Lifepoint as a big chain from outside the state, and they’re in it for the money, and they don’t give a damn about the community?
Sinotte: What’s fair to say is I think there’s been a learning curve with Duke LifePoint and this hospital and the U.P. It’s the first bigger hospital that they acquired. Five years ago, they didn’t have any hospitals bigger than 200 beds. Since then, they’ve gotten some more so I think they’ve learned a lot but to think that this is a bad relationship right now, that’s overlooking what was going on here five years ago with an unfunded $90 million pension. And revenues that were going down dramatically, and those in the know understand that his hospital was under serious financial pressure. And if not for Duke LifePoint to come in and infuse some capital for the new hospital–I know it doesn’t make all the operational challenges we have today any better–but it’s still going to be a brand new facility that’s going to be here long after I’m dead and gone. It’s a tremendous asset. It’s a very good thing to fund that pension for $90 million and to put $300 million into the new hospital, plus another $60 million into other renovations. There are so many in health care right now that would love to have that relationship. And Duke LifePoint has never issued a dividend to their investors. So they aren’t one of those companies that is collecting all the revenues and then distributing it out to shareholders.
Cabell: Ultimately though, this is a business. You have to run this as a business.
Sinotte: No question. Just as I would in a non-profit. I grew up in the non-profit world. You still have to generate margins at the end of the year. No margin, no mission.
Cabell: We’ve talked about outmigration of patients. What about the competition from Aspirus? Is one hospital group going to gobble up all the others in the U.P?
Sinotte: It’s hard to say. It really is because I’m not as familiar with those hospitals that Aspirus has acquired on the west side of the U.P. or how they’re performing or what they do well. I think they’re okay but from what I hear, they have their challenges. So I don’t know what that looks like when you fast forward a few years from now especially if reform comes though. If there’s another round of Medicaid cuts and a lot of those hospitals there have a lot of Medicad patients and self-pay, I just see a very challenging future for a lot of those hospitals in another round of cuts.
Cabell: Is Duke LifePoint thinking about buying any more hospitals in the U.P?
Sinotte: Absolutely. Because a lot of these hospitals are in the same situation that we were. It’s challenging to make the margins work out. It’s not an easy business. And so they (DLP) could help with some capital, they could help with providing a new clinical service that might help their revenues and help keep jobs there. You might provide a network of care and coordinated care, so if that hospital is a couple hours away and doesn’t have open heart surgery but they have someone presenting the ED with a cardiac condition, they can flight them right here, and we’d take care of them. That’s the idea.
Cabell: Your Leapfrog safety ratings. They haven’t been very good. Mostly C’s, even a D last year. What are you doing about that?
Sinotte: You keep working very hard to understand how they’re measuring us, their criteria. Now that we know that, I feel very confident that we’ll be able to score better with time. With these agencies that have cropped up over the last five or six year years, they all have different criteria to some degree. And often times you’re not privileged to know what that criteria is until you inquire or pay to understand what it is they’re measuring you for. Leapfrog’s no different. Now that we understand them, I feel very confident that we can get back up to a B and then we’ll get to an A.
Cabell: A more general question…What would you say is the number one reason for health care costs skyrocketing here in the U.S., especially considering that our outcomes are not any better than many other countries in the world…and in many cases, are worse?
Sinotte: There are a few drivers of that. One is our demand. People don’t want to wait in the U.S. In a lot of these other countries that provide care at half the cost that we have here, they’re okay with a longer wait, whereas here we’re not. We want it right now. You know, my shoulder’s bugging me and I don’t have a good quality of life, and I’m not going to wait (to see a doctor). And a bigger question for us is this–Is health care a privilege or a right? And two, are we attempting to contain costs, to bend this cost curve, causing all this angst and stress, are we willing to bend it the other way and say, you know, you’re going to have to wait. We’re actually going to have to ration care like these other countries do.
Cabell: What about the administration of hospitals? Do we have too many administrators, and not enough doctors and nurses? Is that a problem?
Sinotte: Here it’s not. I can’t tell you about the industry in general. But here, no, this year we’ve had to reduce some of our leadership team. We’re trying to gain efficiencies so we’re seeing people take on more responsibilities, but I think in general, in the entire industry, the pie has gotten smaller so we’re seeing contraction. We’re gaining efficiencies in many forms and facets, and administration has not been left out of that equation at all.
Cabell: The Affordable Care Act…Trumpcare…Where is this going? Where should it go? What should we be doing on a national level to get a handle on health care?
Sinotte: I think there’s a lot we need to do to educate our public about how the health care system works. It’s very complicated, but, with the internet recently, it’s becoming a bit more transparent. As a country, what I’d recommend, is make your voice heard with your state representative, state senators. Find a voice because it’s really important that the people in office right now understand that what they’re proposing has a direct impact right here in Marquette. And I think some of that gets lost. I have not heard it talked about as an economic development or jobs issue and I believe it truly is. In fact, I would call it a crisis for America’s existing health care system if more cuts continue to happen because these hospitals, as they’re designed–high fixed costs that continue to escalate, the cost of the labor force, highly technical people–that’s not going to go away. The reimbursement has now reached a point where many of them (the hospitals) can’t make it. You look at some of these small towns, like where I grew up. I was just fortunate to have a hospital. But if I were in one of these small hospitals in the U.P., I’d b very concerned right now.
Cabell: So you’re saying, if there are going to be substantial cuts in health care insurance–which is what we’re hearing right now–it’s going to have a major effect on the whole industry.
Sinotte: Absolutely. No one will be immune. You’re seeing very unusual things right now that I never thought I’d see, as far as the Mayo Clinics of the world openly targeting privately insured patients and creating programs to capture those patients. And then you have all these other hospitals closing–I never thought I’d see anything like that. Yet here we are where that’s now happening, and now they’re talking about another round of cuts that’ll make it harder for hospitals to be in business long term because the economics are no longer working. It’s just going to heighten the pressure that hospitals feel to become more efficient and to keep their doors open.
Cabell: Thank you, Brian.