Open Letter to the Sentara Community

Sentara RMH Medical Center

by Dr. Robert H. Sease

As a lifelong resident of Harrisonburg, a retired physician and  a volunteer hospital chaplain, I feel compelled to write about the current and ongoing situation at our local hospital. My father, my two uncles, my brother and myself have a combined 180 years of medical service to this community, so I have a genuine vested interest in the welfare of our local hospital and the community it was designed to serve.

Historically, for a small community hospital, we have been blessed to have phenomenal medical care. It’s a well recognized fact that the Shenandoah Valley has some of the lowest insurance reimbursement rates in the entire state, so it’s vitally important to attract and then retain talented hospital personnel. So, it disturbs me profoundly when I hear and see what is becoming of our community hospital.

There’s always been a healthy tension between hospital administration and staff physicians and that’s been a good thing. In the past that has led to dialogue, compromise, and in the long run, improvement in healthcare delivery. There was a shared, mutual respect. Not so any longer! Healthcare locally and nationally was already on the road to becoming big business in 2011 when RMH became part of Sentara, but with that partnership really, really big business came to town with a corporate mentality that unilaterally decides and blatantly disregards input from the very people who make this hospital great.

Nationally there is already a shortage of healthcare workers and by some estimates between 2025-2030 we can expect to be short 54,000 doctors, 29,000 nurse practitioners and 500,000 nurses. Therein lies the importance of hiring and then retaining talented personnel.

RMH President Doug Moyer states in an open letter that orthopedics and urology have experienced “difficult transitions,” so let me comment on that. A simple look at the 2020 RMH physician directory lists six orthopedic surgeons in the employ of Sentara. In the last several weeks the last of the three remaining surgeons have left the area or are headed for the exit. So there is a two- story,
multimillion dollar orthopedic and rehab center and two locums providing coverage for orthopedic emergencies until full time hires come on staff in the spring and summer. How many remains to be seen.

For those unfamiliar with the term, a locum tenens is a travelling, temporary replacement for a physician, nurse, NP or PA. This temporary assignment usually occurs through an agency and, therefore, generally costs far more than a full-time employee.

Which brings me to the urology department. Mr. Moyer states that urology saw changes “primarily due to retirement” which is disingenuous at best. One urologist, highly regarded by patients and colleagues, retired two years ago because of utter physical and mental exhaustion and frustration created by the ever increasing demands of Sentara and the practice of medicine. Of the three remaining urologists, two wanted to slow down and take less call time. When their request was rebuffed by administration, one resigned and began work as a locum in Altoona, and the other two resigned and joined Blue Ridge Urology several months later. So, to provide much needed urology services here, Sentara now has a contractual arrangement with Blue Ridge Urology in Fishersville to use the same two doctors it refused to compromise with as well as the other urologists in the Blue Ridge practice.

But these aren’t isolated instances. This is a pervasive problem. Consider that there were 23 anesthesiologists on staff. Now, I understand, there are 10. Fortunately, three nurse anesthetists have recently come onboard, and two or three anesthesiologists will be added over the coming months.

At one point there were six pulmonary care/intensivists. Now there are two, and one of them has decided to resign and will be leaving in June, which means that the critical care unit is being covered most nights by PA’s instead of critical care certified specialists. And this is at the height of the COVID pandemic!

Gastroenterology was my specialty for 30 years, 18 as a solo practitioner and the last 12 with Harrisonburg Medical Associates. I chose to retire six years ago and one of my partners did likewise six months later. Locally and nationally gastroenterologists are in short supply and historically we’ve had difficulty recruiting to our area. But the hospital was able to bring onboard several locums to fill the gap after our retirements. Then, amazingly, within the last three years the hospital was able to recruit two full time GI specialists, but one of them has already left the area and the other recently served notice of her resignation.

On the cardiothoracic surgery service, four cardiac PA’s left because of a salary cap, which resulted in the loss of one of the best CT surgeons in the state because he’d have to work with locums PA’s, an unknown entity. So now that a top rated surgeon is gone, two of the original PA’s are back, hired as locums, and of course at a greatly increased cost. A second hematologist/oncologist in eight months has announced her departure at the end of April

These numbers are not consistent with attrition solely due to retirement, or a spouse wanting to move closer to family, although Sentara portrays it that way in its statistics. In fact, I know of several physicians who would have worked another two to five years before retiring but found local conditions so intolerable and the alternative of doing locum work elsewhere not worth the effort, so they threw in the towel.

As mentioned already, there is a nationwide shortage of healthcare providers of virtually every stripe. The cost of recruiting, hiring, and training new physicians is a major drain on any hospital, so says recruiting and placement firm, Merritt Hawkins, in Healthcare Finance, yet this administration keeps driving away the pool of talent that is RMH. Physicians are the key drivers of healthcare quality and revenue. I’m baffled by the administration’s intransigence to the overtures of physicians and other departments to reach a compromise on adequate staffing,
salaries, benefits and hours that might give them reason to stay.

If healthcare providers are the driving force behind quality patient care and revenue and are Sentara’s “most valuable resource,” as officials claim, then build the practice around the strengths of those providers to increase efficiency, quality and satisfaction with input from your “most valuable resource.”

As fewer healthcare providers try to maintain the same workload, burnout can worsen retention rates. But because our “departure levels are typical in modern rural markets, and the system performs better than the national average,” as Sentara tells us, I guess we should be reassured that it’s perfectly “average” to lose six of six orthopedic surgeons, four of four urologists, four cardiac PA’s, a  cardiothoracic surgeon, 13 of 23 anesthesiologists, five of six pulmonologists, two of four gastroenterologists, and two of five hematologists/oncologists over the span of two years!

A friend recently told me that in the corporate world, when good employees leave en masse, the cause is usually found at the top of the corporate ladder. I believe that is the case here. There is an arrogance born of power and business directed solely by a spreadsheet.

While money in, money out is easy to track on a spreadsheet, Sentara Corporate is sacrificing some very important intangibles such as patient continuity of care and the confidence a referring provider has in a specialist they’ve used time and again. All too often I’ve heard from colleagues the refrain, “Take it or leave it.”

The healthcare of this community has been entrusted to this hospital and its employees, but Sentara Corporate has grossly betrayed that trust. I have serious concerns about the direction this hospital is headed and what Sentara sees as the final goal. The people this hospital serves deserve and expect far better!

Dr. Robert H. Sease is a retired physician of 30 years service who lives in Harrisonburg.

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30 responses to “Open Letter to the Sentara Community”

  1. vicnicholls Avatar

    Same way down here in Hampton Roads. They’re ruthless. I protested one time at corporate about money over people. The cops approved it before hand (it was dead in front of their corporate office), and I’m sure had a good laugh when Sentara called them to get rid of me. They can’t stand or tolerate any disruption from the money coming in.

  2. LarrytheG Avatar

    This is a thoughtful post. Thank You.

    I think part of the root problem is that rural healthcare is not only not profitable, it can, and does see bankruptcy and closings and it then becomes an issue of how healthcare can or will be provided given the reality that there is no easy way to have a healthy mix of profitable and unprofitable services.

    I see what UVA is doing and I do wonder the pluses and minuses of their expansion into the rural regions about Cville, which involves, satellite offices that do not run full work weeks… In other words, they staff only some days with providers that essentially “round robin”.

    If doing that, provides services that rural needs – even if only on some days, -as opposed to no services at all… isn’t that a step in a better direction?

    I just think it’s not productive to blame or demonize the players in the economy unless they are clearly predatory and actually harm clients.

    What are the cost-effective alternatives?

    1. James C. Sherlock Avatar
      James C. Sherlock

      Larry, the financial results don’t support your concerns. The operating margins of Sentara RMH Medical Center were 13.4% in 2019 (a 2019 profit of $55 million) and 16.3% in 2018.

      Those numbers are 4 and 5 times the operating margins of such hospitals nationwide.

      1. LarrytheG Avatar

        yes,so you stop Sentara. What’s the replacement?

        re: ” Those numbers are 4 and 5 times the operating margins of such hospitals nationwide.”

        Okay, are there competitors willing to operate there for less?

        Beyond that, is it the role of government to determine what the acceptable profit margin is or should be of any company? What justifies that?

        1. James C. Sherlock Avatar
          James C. Sherlock

          In Virginia, Larry, you can’t play unless you are an incumbent. One of the truths of COPN. Outsiders need not apply.

          In the case of a tax exempt corporation such as Sentara that has its exemption because it self declares to be a public charity, you bet the government gets a vote if it wants one because it gets to withhold the tax exemptions if it finds that the “public charity” part is not getting enough love and money.

          Reasonable government questions include how much executives are paid and how much of the profit a corporation plows back into the community to improve public health. In this case, operating margin equals total margin, so not enough to matter.

          If Sentara paid taxes, no one would have a gripe about the public charity scam, but the government, acting in the name of the people, would still have an interest in abuse of a monopoly.

          If you ask me to elaborate, I won’t. Look it up.

          1. LarrytheG Avatar

            Yes, I do realize that – that Virginia govt does control who can play but they don’t decide pro/con based on how much profit the company makes or how much their CEOS make – I would hope.

            That’s a step too far in my humble opinion and I would hope way, way too far for most principled Conservatives.

            We don’t want govt deciding how much companies should make or CEOs get paid.

            So back to my original questions. Are there other potential players/competitors? And, if not, what is the role of Government at that point? Should they be letting an RFP for the state to pay (then they COULD decide pay!) ?

            The rural healthcare problem is nationwide as far as I know, no?

            It’s really not that different than say a Walamrt or an Olive Garden or Trader Joes. – the demographics just won’t support even a break-even operation.

            Most/many business don’t charge a set margin on each product or service. Some are very profitable and some almost none or they lose. Llike Walmart might sell milk at it’s cost or lower but their 2liter Diet Pepsis are very profitable.

            In rural areas, there just is not enough economic demand for the full range of services so that businesses have less flexibility to cover some costs with some more profitable services – and that’s especially true if the mix of Medicare and Medicaid reimbursements is high in comparison with other services that can be priced higher.

            Finally – I just think it is not productive to blame the companies per se if really there ae few or no companies willing to locate there to start with or if so – at such margins that services are deficient.

          2. James C. Sherlock Avatar
            James C. Sherlock

            Once again, Larry, the financial results at that hospital don’t support your concerns about “ the rural healthcare problem”. The operating margins of Sentara RMH Medical Center were 13.4% in 2019 (a 2019 profit of $55 million) and 16.3% in 2018.

            The IRS and the Virginia Tax Commissioner are in fact charged with making sure that tax exempt entities don’t overpay their executives.

            Part VI, Section B of the IRS Form 990, Question 15 asks if the organization’s process for determining the compensation of the organization’s top management official and other officers and key employees includes “a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision.”

            The IRS Reasonable compensation is defined as “the value that would ordinarily be paid for like services by like enterprises under like circumstances.”

            Corporations like Sentara are supposed to use a compensation committee and a compensation consultant in order to comply with this rule. Yet they come up with compensation packages for their executives that far exceed those of other hospital corporation of the same size.

            It is simply never reviewed by the IRS or Virginia Tax.

            Officially, paying excess compensation can subject both management employees and the board members to stiff excise taxes, as well as potentially endanger the organization’s tax-exempt status.

            Has never happened in the “not-for-profit” healthcare industry.

          3. LarrytheG Avatar

            Jim – there are different levels of non-profit. Does Sentara issue a 990?

            re:l ” Officially, paying excess compensation can subject both management employees and the board members to stiff excise taxes, as well as potentially endanger the organization’s tax-exempt status.”

            You’ll have to supply something that demonstrates WHO decides what is “excess compensation” in the government and then what actions the government would take , etc.

            what excise taxes?

            I WILL admit that the government DOES decide how much IT will pay for reimbursements but that’s not at all deciding how much the doctor or organization or it’s management is allowed to make.

            Also, I thought you were really bummed out in conversations with me on issues.

            what changed?

          4. James C. Sherlock Avatar
            James C. Sherlock

            IRS on Private Benefit and Inurement

            A public charity is prohibited from allowing more than an insubstantial accrual of private benefit to individuals or organizations. This restriction is to ensure that a tax-exempt organization serves a public interest, not a private one. If a private benefit is more than incidental, it could jeopardize the organization’s tax-exempt status.

            No part of an organization’s net earnings may inure to the benefit of an insider. An insider is a person who has a personal or private interest in the activities of the organization such as an officer, director, or a key employee. This means that an organization is prohibited from allowing its income or assets to accrue to insiders. An example of prohibited inurement would include payment of unreasonable compensation to an insider. Any amount of inurement may be grounds for loss of tax-exempt status.

          5. LarrytheG Avatar

            not there yet… need a cite

            and “jeopardize tax-exempt status” is not the same as the government determining what is acceptable profit or pay for employees.

            What standard is being used by the government to decide what is not “reasonable”?

  3. Dick Hall-Sizemore Avatar
    Dick Hall-Sizemore

    I appreciate Dr. Sease describing the situation at Sentara RMH. I also understand his frustration. Corporate medicine is a major problem in our society. It is a particular problem in a rural area in which the only hospital is part of a corporate structure whose headquarters is hundreds of miles away. The interests of the local community are secondary.

    It would be helpful to know why RMH agreed to become part of the Sentara network in 2011. I suspect the motivations were financial. Independent community hospitals, while valuable assets to a community in many ways, are becoming less and less common. I don’t know what can be done to alleviate the situation.

    1. James C. Sherlock Avatar
      James C. Sherlock

      In answer to your question about what could have been done about the Sentara acquisition of RMH, the state could have denied permission.

      1. Dick Hall-Sizemore Avatar
        Dick Hall-Sizemore

        I did not know that the state had to authorize the acquisition of a hospital by another hospital that is headquartered in another jurisdiction.

        1. James C. Sherlock Avatar
          James C. Sherlock

          It does. Specifically the Attorney General does.

  4. James C. Sherlock Avatar
    James C. Sherlock

    Dr. Sease raises significant issues of patient safety in the presence of the major physician shortfalls and turnover he details. Hospitals are required by both their state license and Medicare to maintain only those services they can properly staff.

    I have filed Dr. Sease’s column as a complaint to the VDH Office of Licensure and Certification. That office should be able to check payroll based data from RMH to identify any shortages that occurred.

  5. DJRippert Avatar

    Ever since my best friend (a long practicing doctor) sold his practice to Inova I’ve come to the conclusion that I could make a good living explaining the corporate world to doctors.

    “One urologist, highly regarded by patients and colleagues, retired two years ago because of utter physical and mental exhaustion and frustration created by the ever increasing demands of Sentara and the practice of medicine. Of the three remaining urologists, two wanted to slow down and take less call time. When their request was rebuffed by administration, one resigned and began work as a locum in Altoona, and the other two resigned and joined Blue Ridge Urology several months later.”

    “Mental exhaustion and frustration …” There is a lot of bureaucracy in many large corporations. The trick is to avoid doing the scut work yourself. You’d be surprised how easy it is to get management to fund a clerical position to offload the tedious menial work.

    ” … two wanted to slow down and take less call time.” Did they offer to take lower salaries too? Regardless, the two that joined Blue Ridge Urology did the right thing. Big companies contract with specialty organizations all the time.

    If you’re going to work for big business one of the things you have to learn how to do is go to a meeting and sleep with your eyes open.

  6. John Harvie Avatar
    John Harvie

    I was a captive patient of Sentara’s for the 40-odd years I lived in Tidewater.

    One by one, all my physicians were absorbed into Sentara’s maw except my urologist who remained loosely affiliated with Chesapeake Hospital. Each complained of the narrow window for seeing patients and other pressures by bean counters.

    My late wife and I had to apologetically ask a question during our visits because we knew we were causing our physician problems with his allotted appointment timing, of course tracked by computer. Our surfacing of a new health issue observed since our last visit cut into his allotted visit time and made him noticeably uncomfortable.

    My PCP now is in a three physician independent practice and allows so much time it’s almost embarrassing. He’s never concerned my S/O and I are overstaying. Night and day compared to The Beach.

    1. LarrytheG Avatar

      I am aware of this also – and I try to get my ducks in a row so I don’t demand too much of his limited time. For general info, I ask him to point me to a internet page…etc… and now days I gravitate to doctors who are on MyChart which allows me to communicate with the Doctor and his nurse outside of his limited office time.

      We all gotta adjust………… you can still get excellent care but not the old ways.

      1. James C. Sherlock Avatar
        James C. Sherlock

        Be well Larry.

  7. Nancy Naive Avatar
    Nancy Naive

    It may be a Not-for-Profit, but a monopoly is still a monopoly.

    1. James C. Sherlock Avatar
      James C. Sherlock

      A not-for-profit can also be extraordinarily profitable. This one is. See my reply to Larry above.

      1. Nancy Naive Avatar
        Nancy Naive

        The goal is Luxottica. You’d like them. They own something like 80% of eyewear brands, 3 or 4 of the major vision centers and the two largest vision insurance companies.

        Thank god, I can buy 125s at Ace for $5.

    2. LarrytheG Avatar

      yes, but can that entity change the reimbursements that insurance pays? Normally, the goal of a monopoly is to drive out competitors then increase prices and profits.

      Does it work that way with rural hospital monopolies?

      1. Dick Hall-Sizemore Avatar
        Dick Hall-Sizemore

        Because RMH was the only hospital in the area, it was a monopoly itself before being acquired by Sentara. Driving out competitors is only way to increase profits. Another is to cut expenses. Sentara RMH has certainly benefited from the expansion of Medicaid, which has increased its revenue.

        1. LarrytheG Avatar

          Okay. But it was said that one of the reasons RMH got out was low reimbursement rates.

          Does Sentara have any expectation to increase them?

          So Sentara is going to do what RMH would not , which is to cut costs but Medicaid and Medicare ride herd on standards and quality, and won’t reimburse if their standards are not met.

          I’m just trying to understand what government’s options are beyond getting involved in the financials of the company.

          1. James C. Sherlock Avatar
            James C. Sherlock

            First, Sentara bought RMH not because RMH was not making a profit, but because Sentara thought it could make higher profits yet, and they have.

            Reimbursement rates have been increasing faster than general inflation for decades.

            The government has carte blanche to get involved in the financials of the company because they claim to be a charity and in return get massive tax exemptions.

          2. LarrytheG Avatar

            Wait – if reimbursement rates are so great why do we read right here in BR that Medicare and Medicaid do not pay the actual cost of services?

            I’m not buying your assertion that ” The government has carte blanche to get involved in the financials of the company because they claim to be a charity and in return get massive tax exemption” because you’re not being explicit nor specific.

            The C3 401 c is NOT Virginia and I am not seeing ANY legitimate reference that says the government can determine the salaries and profit level for any company or even a charity.

            Finally, I would think that ANY self-respecting Conservative would be violently opposed to the idea that the govt could decide salaries and profit margins… except for duly-designated monopolies like Dominion but even then – only profit margins – they do not regulate the salaries of Dominion folks.

            Can you name ANY hospital in the US where the Govt – State or Federal actually regulated the salaries?

    3. DJRippert Avatar

      Can’t believe that I just “up voted” a comment from N_N.

      1. Nancy Naive Avatar
        Nancy Naive

        It happens. Probably something you ate. Oh, wait. UpVoted! Never mind.

  8. LarrytheG Avatar

    So the thing is , what is the proper role of government (local and state) when many believe that the private sector free market is better than the government at meeting market needs.

    I’d be curious how the various states deal with the rural healthcare issues.

    In most other developed countries – the government plays a more direct role in rural clinics and such, no?

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