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story.lead_photo.caption St. Mary's Hospital sits on Mission Drive. SSM and MU Health announced in August 2018 they were negotiating the possible sale of SSM Health's St. Mary's Hospital in Jefferson City and Mexico (the former Audrain Medical Center) and their associated clinics, following SSM's decision to leave the Mid-Missouri marketplace. Photo by Kris Wilson / News Tribune.

If it's successful in purchasing St. Mary's Hospital, MU Health Care's vision for Jefferson City includes seeing the city as a hub for providing specialty services.

SSM Health — the St. Louis-based Catholic nonprofit health system that owns the hospital — and University of Missouri Health Care announced in August they had been in exclusive negotiations to transfer ownership of the hospital and other properties for some time.

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The two entities are in the due-diligence phase of the purchase, in which both parties are looking at the sale to see how it fits into their missions.

'One plus one is going to equal three'

Over the past few weeks, health officials have met with media and held community forums, in which Jonathan Curtright, MU Health Care chief executive officer, has explained the system's interest in the Jefferson City hospital.

Curtright says he sees the possibility of growth in specialty services in the Capital City.

"When I say specialists, I mean sub-specialists, people — you're not an (intensive care unit) doctor, you're a neuro-critical care doctor. You're not just an ICU doctor, you're a cardiac intensive care unit doctor," Curtright told the newspaper. "They're sub-specialty services that people are having to leave the area for to get their care because they don't have the right amount or the skill sets that are out there, that we haven't been able to recruit those people long-term."

If MU Health Care successfully purchases the hospital, it will merge certain St. Mary's Hospital services with those provided at Capital Region Medical Center, with which MU Health Care already has a relationship, and be more efficient, he said.

For example, Curtright said, both hospitals have small cardiovascular programs. Surgeons at St. Mary's Hospital perform about 80 cardiovascular surgeries annually. At Capital Region, surgeons perform about 50. He said it is "pretty well known" that quality and safety of the cardiovascular surgeries correlate to the number of surgeries a hospital performs. And 130 is not a large enough cardiovascular program to increase safety and quality, he said.

But, if the two combine, MU Health Care sees more than 250 people remaining in Jefferson City for their procedures rather than traveling out of town.

"If we put these things together, we believe that one plus one is going to equal three," he said.

That will allow the community to recruit enough general cardiologists to perform the work.

"It's very much going to make it so it's easier to recruit more sub-specialists because there's more population of patients to provide those services," Curtright said.

A red herring claim?

But the sub-specialist-recruitment assertion is a red herring, according to Jamie Patterson, Jefferson City Medical Group's vice president of marketing and business development.

"Specialists are being recruited to Jefferson City without this merger," she said in an email to the News Tribune.

JCMG, Urology Care, Inc. and Central Missouri Cardiology have demonstrated they can successfully recruit doctors — even sub-specialists — to the city to meet its health care demands, she said.

Leadership at JCMG is among critics of the proposed sale of St. Mary's Hospital to MU Health Care.

Opponents to the sale say the competition in Jefferson City between St. Mary's and Capital Region helps keep costs down. If the Columbia-based system were to buy St. Mary's, it will merge the Jefferson City hospitals into one system, creating a regional monopoly — putting consumers at-risk of potential price fixing.

Some of the specialties already offered, or conditions treated, at St. Mary's Hospital, according to its online provider directory, include advanced heart failure and transplant cardiology, cardiac ablation (a procedure to destroy or scar tissue in the heart that cause abnormal heart rhythms), cardiac arrhythmia (abnormal heart rhythms), pediatric pulmonary disease, pulmonary valve disease, neuroblastoma (a cancer that develops in immature nerve cells found in several areas of the body), pediatric neurosurgery and many others.

Capital Region's online provider directory shows it offers otolaryngology (a sub-specialty that deals with ears, nose and throat), audiology, orthopaedic surgery, oncology (treatment of tumors), hematology (physiology of blood) and many other specialties.

Capital Region offers several specialties, such as gastroenterology (focusing on the digestive system) and oncology.

So, between the health care providers, a number of physicians with sub-specialties already serve the Jefferson City area.

How many doctors are needed?

Hospitals' administrators answer questions about whether there are enough, too few or too many specialized physicians in any given area by using "needs assessments."

Needs assessments are done to confirm a health care facility's need for physicians in a given specialty and to justify the use of a wide range of physician recruiting incentives, according to Merritt Hawkins, a major physician recruiting firm.

The company looks at physicians-to-population ratios based on a number of formulas, such as one suggested by the Graduate Medical Education National Advisory Committee (created in 1980 is known as GMENAC), a "demand-based" ratio created at the University of Pennsylvania/Wharton School (2012 and named after its creator, Richard "Buz" Cooper), or Hicks and Glenn (which was developed in 1989 at the University of Missouri School of Medicine).

The ratios suggest how many specialists should be available for every 100,000 people in the population.

The suggested ratios vary. Where it comes to pediatrics, GMENAC suggests 15 for every 100,000 in the population; Hicks and Glenn, 12.9; and Cooper, 16.1 to 18.7, depending on demand and other factors.

Using the Cole County population as a guide — 76,708 in 2017, according to online U.S. Census estimates —the News Tribune looked at how many physicians of specific types the models suggested should serve the county. Numbers were adjusted for population. So, if the GMENAC said 15 physicians per 100,000 was correct, the newspaper took 75 percent of the total and came up with 11.25.

To serve Cole County, according to GMENAC, there should be about 2.5 physicians specializing in otolaryngology. There should be 1.8, according to Hicks and Glenn, and 2.25 to 2.6 according to Cooper.

Only Capital Region shows a physician listed in otolaryngology in its online provider directory.

GMENAC suggests there should be 2.5 physicians specializing in urology in Cole County. There should be 2.2, according to Hicks and Glenn -- and 2.5, according to Cooper.

Searches of area health care providers show four urologists are listed in the area, all at Urology Care, Inc.

GMENAC says there should be 7.5 physicians specializing in obstetrics; Hicks and Glenn, 8.3; and Cooper, 9.75 to 10.5.

Ten physicians specializing in obstetrics are listed in area health care providers' directories.

Capital Region continually evaluates the needs of the community, according to Lindsay Huhman, director of marketing and public relations. Based on its ongoing analysis, the hospital prioritizes recruiting efforts to positively affect community health.

"Over the past 10 years, we have successfully grown our physician group, Capital Region Physicians, from a group of nearly 70 providers to over 130," Huhman said in an email. "In some areas where recruitment is a challenge, we've been able to benefit from our affiliation with MU Health (Care). For example, the Missouri Orthopaedic Institute at Capital Region Medical Center provides comprehensive orthopaedic services locally, which makes access to care more convenient for patients in our service area."

But, most health care providers across the United States find for some disciplines it is difficult to recruit providers, she added.

"In areas like Mid-Missouri, where we see ample competition in our region, recruitment of specialists and sub-specialists to a community of our size has its challenges. However, by working with partners who share a common mission, we can successfully develop care delivery models to provide the right care, in the right place at the right time," she said.

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Brian Westrich, marketing and communications manager for SSM Health, released a statement from the health care provider. It said SSM Health continually evaluates how to best meet the needs of its patients while ensuring the long-term sustainability of quality health care in the communities the organization serves.

"This includes developing comprehensive short- and long-term plans and strategies to meet our physician and staffing needs across all of our ministries. However, these plans are confidential and proprietary," according to an email from Westrich.

Curtright has said the area doesn't have enough sub-specialists — such as spine surgeons or oncologists for breast, liver or colon cancers.

"There is no shortage of breast, liver or colon cancer treatment in Jefferson City," Patterson said. "Spine surgery is a line filled by Dr. Jeff Lehmen of SSM Health St. Mary's Hospital. JCMG opted not to compete with SSM Health on this service line per their request to support the hospital."

Creating a pocket of health care for specific sub-specialties (such as heart surgeries) will help MU Health Care/St. Mary's Hospital/Capital Region Medical Center recruit and retain more physicians, Curtright said.

The ratios do not include data for sub-specialties. However, Patterson said JCMG already fills needs for sub-specialties.

"JCMG is one of the largest multi-specialty groups in the state," she said in her email.

The organization provides health care for more than 30 specialty/sub-specialty lines, she said.

Reporter Phillip Sitter contributed to this report.

Correction: Capital Region Medical Center has four oncologists on staff. The original version of this article contained an incorrect reference that has since been corrected.

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