* * Alan Fabian runs our local hospital

Ever wonder what it takes to run a hospital? I have. So I called on Alan Fabian, a newcomer to our community, who is CEO of Lewis Gale Hospital, Montgomery, whom I’ve gotten to know through his membership in my Rotary Club.

I expected it to be complex, but the more we spoke, the more complex it became. Fabian, 50, came into health care administration not through a medical education but one in computers and programming.

“We are one of four Lewis Gale hospitals,” he told me as we sat in his executive office in the ground floor of the 40-plus year old facility in south Blacksburg. “The main one is in Salem and the others are in Pulaski and Allegheny Counties. Lewis Gale has been around for over 100 years. Lewis Gale are all HCA (Hospital Corporation of America), which has 165 hospitals in 20 states. The goal with our name was to locally brand us. Our parent company is HCA Virginia which has 13 facilities. HCA is the largest hospital corporation in America.

“I grew up in Vermont and Massachusetts and got my degree in computer science. I worked around the country mostly for software companies. I worked for a hospital information systems company in Boston and a consulting company in Los Angeles that installed information systems in hospitals before I started with HCA in Dallas in 1995.”

He moved from the information technology side to the administrative side. He then worked in Louisiana but took a job here in 2013. He actively selected Blacksburg as a place he wanted to live and work. “I chose here. Having grown up (in an area) with four seasons, it’s easy to live in this area. I grew up in the mountains, the Green Mountains, doing lots of hiking, biking, and skiing. Coming here was perfect.” He had lived in large cities but felt that this was something he was more accustomed to.

The biggest challenge he had in running the hospital was keeping up with regulatory changes. “We may be half-way or three-quarters of the way through implementation of the Affordable Care Act. Regulating changes are ongoing.” For example, he said that across the country, hospitals are all required in their interventional catheterization labs to follow the same procedures and protocols. “When somebody has a heart attack, the gold standard is to catheterize and open the heart vessels within 90 minutes. The less oxygen the heart has, the more the muscle dies. These are mandated standards. and the data are put on the internet for everybody to see. We average 40-44 minutes. Our goal is the best health care the fastest.

“The challenges we have are that physicians provide care in the same manner. They feel their autonomy is being taken away from them. Historically, they did assessments and made decisions and provided treatment as they deemed appropriate. Now, diagnoses that fall under well-regulated categories are treated by mandate. We take away their ability to be doctors. It’s challenging to balance the regulation with the autonomy of the physician.”

I asked if physicians were unhappy. He chuckled and said, “Physicians don’t like change. They find things that work really well, and they stick with it and get repeatable outcomes. We’re changing the processes and that produces unrest.

“The unrest carries over to the patients, nurses, and everybody else. Patients are treated differently than in the past. Even the admission process is different. Sometimes what were overnight events are now out-patient. We have become change agents. We need to figure out how to implement the change in a consistent manner that meets everybody’s needs. That’s what we do every day.”

His customers have varying levels of coverage or none at all. The government forces the hospitals to provide coverage even for people who cannot pay. He said, “There is a base level of health care provided to anybody at any hospital across the country that will assure that any injured person can come in and be stabilized regardless of their ability to pay. Uncompensated care is higher in poorer, more rural areas where fewer people have a job that pays insurance. Uncompensated care has to be covered by patients who can pay. That’s how it evolved over decades.

“One of the biggest misconceptions is that we can do whatever we want. There are firm guidelines from the government, plus the private payers (insurance companies) adopt them. The simple act of being admitted is regulated. Insurance is phenomenally complicated, years in the making. Medicare and Medicaid don’t pay us enough to cover the expense of providing the services. The reason so many services seem so high is that the ‘sticker price’ is almost never paid by insurance or the government. Everything is negotiated.”

I said, “Almost nobody can afford medical care on their own. Has the ACA improved this? What’s gotten better and what’s gotten worse?”

“Access to insurance is better,” he claimed. “It is still too expensive. There is a focus on wellness, education, diet, and lifestyle. It’s a challenge that we’re still not meeting successfully.

“But understand that hospitals are businesses. We have to turn a profit to keep the doors open, even when faced with the mandate to serve customers who can’t pay us.

“Rural hospitals are having a particularly difficult time. We’re seeing a reduction in compensation (from the government) and we serve more uninsured people. Hospitals are really important to communities. In rural areas, they are always one of the larger employers. They provide good-paying jobs. Nurses can make $20 to $35/hour, and they can often get as much overtime as they want. We have around 500 employees and we pay $45 million in salaries and benefits annually. Those dollars are spread into the community, so there’s a magnifier. Our statewide parent company is the 4^th largest private employer in the Commonwealth.

“Medicare covers the majority of my patients. As people get older, they require more care. Medicare and Medicaid account for 60-65% of our billing. The remainder is split between commercial or private insurance, self-insurance or the exchanges, uninsured, and those who pay us nothing. We have a largely single-payer system already. The government passes on regulations and mandates and little or nothing in the way of increases. Pharmaceuticals continue to get more expensive, and we invest in better technologies like MRIs and CAT-scanners. And employees want and deserve raises.”

I asked about his best days on the job. He said, “My best day here was recently when a patient’s son and daughter came in and told me what kind and caring people we had taking care of their mother. She died within 24 hours. They came back afterwards and said the same thing again. They were so thankful their mother could pass in an environment of compassion. This happens on a regular basis. These are my best days. That’s why I do this job. We do some really tough things in health care. All of that is overshadowed when a family member comes in to tell me how thankful they are that we were able to save a loved one’s life. With the skills and technologies we have now, we can save lives that would have been lost only 10 years ago.

“This job is not a stepping stone for me. I’m finding the place that I can be happy. I’m raising my family here and my daughter is graduating from high school and looking at Virginia Tech. We’re fortunate to have a great university in our back yard. I may retire here.”