In the past 19 months, six health care providers have either resigned or been fired from Community Health Center of the Black Hills, including the clinic's medical director who resigned on Monday.

It's a trend that's raising questions among patients and providers about the clinic's management and long-term viability.

"I just think it's mismanaged," said Dr. Donna Smith, who worked at the clinic from October 2007 to March 2008. "Management is running it into the ground."

Medical director Dr. Mike Mathews chose not to renew his contract on Monday after serving as the director for just six months. Mathews would say only that he "can't meet the needs of the CEO."

Pediatrician Martin Spahn confirmed that after 5-1/2 years with Community Health, he was recently notified in a letter from chief executive Crystal Jordan that his contract would not be renewed. His last day is Sept. 4.

Spahn said despite repeated attempts, he was never given an explanation for his dismissal and there were never any concerns expressed about the quality of his patient care.

Dr. Kari Lund, nurse practitioner Lyn Steen and Dr. Jon Wingert round out the list of six providers who are no longer at Community Health.

Smith left Community Health over a contract dispute last year. Smith said new physicians at Community Health are expected to sign contracts giving complete control to Jordan. Smith's attorney advised her against signing it.

"I approached the staff with contract revisions, and we had a couple of meetings about it. I approached Crystal Jordan with the contract revisions, and she was unwilling to make any changes," Smith said.

Smith left the practice as a result, and says that management of Community Health has become rigid and misguided and, in the end, is hurting patient care.

She is not alone in her experience or her concerns.

Steen worked at Community Health from 2004 until April, when her contract was not renewed. She was given no reason for the non-renewal.

Steen, who now practices in Huron, said the clinic's CEO is unwilling to consider the suggestions of providers and is focused on profits to the detriment of patients. Steen said the full-time physicians who are leaving are being replaced with part-time providers, a move that hurts the continuity of care for patients.

"Her whole goal is like cattle through a chute … it's about numbers and that's what she always hammered providers about," Steen said.

Community Health was established in the 1980s to provide care for the underinsured and uninsured in Rapid City. The clinic operates a $6 million budget, receiving $80,000 from Pennington County in 2009 and about $20,000 from the city of Rapid City. It also receives money from the South Dakota Department of Health as well as federal dollars. The clinic recently received stimulus money as well.

Jordan said the management makeup at Community Health is similar to all nonprofit organizations. The board hires the CEO, who then reports to the board.

"I am responsible for this organization just like any CEO," Jordan said. "The board is my boss."

Ron Reed, a member of the Community Health Board, said that while the board consults with Jordan, "We do not get into micro-managing the facility."

"Does the CEO consult the board? Yes."

While neither Jordan nor Reed would comment on specific personnel issues, Reed said it's critical to remember that the CEO is the leader of Community Health. "His or her responsibility is not only to ensure quality patient care, but doing that within the budget," Reed said. "It's not a democracy. I don't know any business in the world that is a democracy. The physicians do not run the clinic. They are employees."

Both Reed and Roy Dishman, current president of the Community Health Board, said they were apprised of all recent personnel changes before they took place.

Smith, Steen and other local providers believe the board is allowing its CEO to rule with an iron fist that is driving away quality providers. "I think the board has a lot of apathy, and there's no action taken by the board," Smith said. "I really felt that it was Crystal's way or the highway, and she contractually can do that, and she knows it."

While Mathews served as medical director, he admits he is given very little authority over providers' dismissal or hiring. "The structure of this system does not give a lot of power to the medical director," Mathews said.

Dr. John Lassegard, who has worked at Community Health since 1995, said that while he isn't willing to speak specifically about issues, he is concerned about the loss of good medical care providers. "It's serious. It's very serious," he said. "Dr. Mathews is a tremendous asset to this community … it's a terrible loss. The same for Dr. Spahn."

The former Community Health providers say that by focusing on a rigid, profit-based approach, Jordan is making it more difficult for patients to get the care they need.

"They're draining other resources. It's so much more expensive to go to the ER to get your meds refilled than to do it at the clinic," Steen said.

Emergency department doctor Patrick Tibbles said he has begun to see the results of the loss of providers at Community Health.

"I'm starting to suspect that we are seeing a few more patients who need care for chronic illness who appear to be unable to get appointments at community health," he said.

Tibbles said community health centers and not-for-profit hospitals provide a critical safety net for the underinsured and the uninsured. Ideally, the two entities work together, with a community health center providing the outpatient follow-up care after a patient is seen in an ER, Tibbles said. But patients are reporting to Tibbles that it is becoming harder to get appointments at Community Health, possibly due to the loss of providers. "We are just beginning to see the trickle. The true fallout may come in the weeks and months ahead," he said.

That fallout could include more people without care, which will mean more people using emergency rooms for basic care.

"I think, given the recent sudden increase in the loss of health care providers, and the potential drastic fallout, that public scrutiny of this is mandatory," Tibbles said. "All of us as public citizens should be gravely concerned … these ramifications affect health care for many citizens of Rapid City."

Despite the allegations of mismanagement, Jordan insists the clinic environment is healthy. "Nothing is awry," Jordan said.

Jordan said that during her three years as CEO of Community Health Center of the Black Hills, employee retention rates have doubled. "Morale has improved tremendously," she said.

Former employees say that losing six providers in 19 months contradicts such statements.

Jordan said that because personnel issues are confidential, "there's a lot of misperceptions" out there. "We're doing well retaining employees. If there's a significant mismanagement problem, we could hardly increase like we have," she said.

Jordan and director of clinical operations Jacki Holmes said the clinic has adopted a "team-building culture" among its approximately 70 employees, with patient satisfaction at its core.

"Creativity and positive input are always valued," Holmes said.

Former employees such as Smith and Steen disagree, arguing that the loss of health care providers is an indication of a management style that discourages input from its employees. The end result, they fear, could be drastic.

"The clinic is going to implode if something doesn't change," Steen said.

Contact Lynn Taylor Rick at 394-8414 or lynn.taylorrick@rapidcityjournal.com.

About Community Health

Community Health of the Black Hills provides care to about 12,000 patients a year and employs 70 people.

The health care system has a main clinic, dental offices, an outreach clinic and the recently opened clinic at the General Beadle Community School.

The clinic accepts most insurance providers and subsidized providers. It provides care on a sliding fee scale for those who have no insurance. Homeless patients are provided free care.

Community Health operates a $6 million annual budget. It received $1.5 million in grant money, including $80,000 from Pennington County and about $20,000 from the city of Rapid City, in 2009.

The clinic was started in the 1980s to serve the uninsured in Rapid City. The clinic recently saw an increase of 1,000 more patients in March and April than it did during the same period in 2008.

Patients worry about provider loss

By Lynn Taylor Rick

Journal staff

When Jennie Smith-Thomas learned her children's pediatrician would be leaving Community Health Center of the Black Hills, she decided to speak up.

She did so by writing a letter to the health center's medical director and president of the Community Health Center board. In the letter, Smith-Thomas questions whether losing her kids' pediatrician, Dr. Martin Spahn, as well as other providers who have recently left Community Health, will affect the quality of care there.

"Please don't continue to lose the rest of your great providers," she wrote.

During a phone interview, Smith-Thomas said she's worried that the loss of several providers may start a slide in care at the community-based clinic. "I worked at the Humane Society right before everything came crashing down, and I just hope that's not what comes about at Community Health," she said.

Other patients, like Thomas, also expressed concerns in a volley of e-mails and phone calls, alleging overall mismanagement of the clinic and chaos in the facility's billing department. Community Health board members received letters as did the Rapid City Journal.

Brenna Evans of Rapid City said her children followed Spahn from his previous practice at the Rapid City Medical Center and will follow him wherever he works next.

Evens, a registered nurse, said although she's unhappy her children's doctor has been let go from Community Health, that's not her main complaint. "My biggest issue about that place is that the billing department is horrendous," she said. "I've gotten a $500 bill to remove a wart from a 4-year-old's hand. It's becoming a running joke with me and my husband … sometimes it's taken up to two years to get a billing issue resolved."

Julia Chandler of Rapid City worked in the records department of Community Health from January to July 2008 before having her temporary position terminated.

Chandler said that after filing bankruptcy two years ago, the facility assured her she had no outstanding bills to attach to the bankruptcy proceeding. Later, they sent her bills which were too late to be included. "I still get bills from them," she said. "I have asked them about it four times … they say, 'You must not have asked the right person.'"

Chandler said in addition to the billing hassles, she was surprised at the high turnover at the clinic while she worked there. She claims that during her time, she had five different co-workers due to turnover and cited a tense work environment as the reason.

Whether patients like Thomas will leave Community Health because of staffing changes is up to them, but chief executive Crystal Jordan said she hopes they reconsider. "Our plan is to provide the same level of care," she said. "We hope that they will stay with us …."

If they decide to leave, she hopes that they express concerns to her in an upfront manner.

"I'm sorry they feel that way. If they would like to write me a letter, I would like to hear from them," she said.

As for complaints about billing, Jordan said Community Health is not alone when it comes to dealing with the complexities of medical billing. "I think we have the same difficulty with billing as any other medical clinic," she said.

Contact Lynn Taylor Rick at 394-8414 or lynn.taylorrick@rapidcityjournal.com.