January 26, 2018


Ms. Werner,

The following letter is in response to the inquiries you have made with regard to the Sublette County Rural Health Care District USDA Rural Development application.  It is our understanding you will be in Pinedale on Wednesday, February 7th.  Our board is planning on attending this meeting and many of us may be available to meet with you separately if that would be of value.

We welcome the opportunity to be involved in the dialog related to the Critical Access Hospital (CAH) as proposed by the Sublette County Rural Health Care District (SCRHCD).  Unfortunately, a current study indicates the CAH will negatively impact, to the point of insolvency, the Sublette Center and the much needed services we provide for our local and surrounding communities.  Given that our facility is a key component to providing a continuum of care to the residents of Sublette (and surrounding) counties, we believe that the viability of the Center is congruent with city, local, and state government goals.  In addition to the loss of services, our closure would disrupt the economic base through the loss of employment and our purchasing power with other businesses; it would also leave a number of vacant empty buildings within the Town of Pinedale.

Below we have outlined additional information and concerns and welcome your questions.


The Sublette Center was founded in 1978 by civic-minded citizens of Sublette County acting upon the wishes of the community at large to provide skilled nursing services.  We find that most of our clients are senior citizens but the facility services all age groups.  As the only skilled nursing facility within a 100-mile radius, the Sublette Center is key to providing a continuum of care for our citizens.  A few of the services we provide are:

  • Full Skilled Nursing
  • Long-term Care
  • Respite Care
  • Medicare Swing Beds
  • Independent Living
  • Short-term and Long-term Recovery

Today these services are in even greater need than when the Sublette Center was founded and this demand continues to increase as local demographics show an aging population.

The Sublette Center provides both long-term care and Independent living environments within close proximity to our skilled nursing facility and is an important component of the Sublette County extended-family structure.  Our services allow families to keep their aging family members closer to home rather than having to consider relocation to out-of-state out-of-county facilities where contact is difficult.  A move often leads to the loss of friendships and decreased family contact at a time when this contact is needed more than ever.

Employment and Contracted Services

The Sublette Center employs 65 individuals from Sublette County, including many industry specific positions, such as, Dietary Workers, Activities Professionals, and C.N.A’s.  In addition the Center has contractual arrangements with many businesses to provide services for our residents, as well as maintenance for our facilities.

The insolvency of the Sublette Center would have a major impact on our employees and these businesses.  Our displaced employees may find it difficult or impossible to to find other gainful employment within the our community and the local economy would also be impacted by the loss of a major employer.  Currently, the Sublette Center has an annual payroll of 2 million dollars.

The county would lose the economic boost the Sublette Center provides through our buying power of supplies and services.  This would negatively impact other local businesses; specifically, those that provide services for the Sublette Center and its residents.  For example, businesses and professionals related to occupational and physical therapy, social work, dental and ophthalmic services, as well as contracted facility maintenance such as IT, plumbing/HVAC, and electrical services to name a few.  These businesses would experience a loss of revenue and a reduced need for employees who provide services to the Center today.

The Sublette Center and our Local Government

While the Sublette Center is an independent not-for-profit organization, we work closely with all levels of government including city, county and state.  As the only only skilled nursing facility within a 100 mile radius, our mission is to serve the residents of Sublette County and provide much needed services required for a full continuum of care.

Sublette County currently provides $480K annually to the Sublette Center to support operational expenses and has a history of advocating and providing support to the Center.  Furthermore, the county recently completed a survey related to the proposed Critical Access Hospital (CAH); it is our understanding that the majority of respondents expressed a wish to ensure the Sublette Center would not be harmed financially or otherwise by the proposed CAH.

Of note, Sublette County has also invested in providing independent living facility nextdoor to the Sublette Center.  This provides many benefits to residents including food service, housekeeping, and other ancillary services provided by the Sublette Center.

We believe our services are important to our governing bodies and fall well within their purview and goals, especially as those goals relate to the health and care of our community members who require either a Skilled Nursing Facility or the security of an Independent Living Facility.

The CAH, as detailed below, will immediately negatively impact our Medicare swing bed revenue, we do not believe this is a loss the County would be able to offset.  And if additional funds were available, the board believes these funds would better serve capital improvements and adding to our service base.

Our Unique Demographics

Most of the Sublette Center residents are between the ages of 70 to 100 years old with a mix of approximately 60% female and 40% male residents and over 80% of our residents enjoy long-term care services.  While the majority of our residents are seniors the facility provides services to all age groups.  A unique demographic that makes the Sublette Center a truly special facility and gem for our community is the fact that many of our current and past residents have lived all, if not most, of their lives in Sublette County.  The loss of these citizen in our midst would be irreplaceable.  

Below is census data for the past ten years.  The 2017 data is current through December and as such only represents a partial fiscal year.  This data shows that our high-risk residents who qualify for Medicaid (over 70% in our last complete year) continue to trend up.  This is of grave concern as it places additional financial reliance on revenue streams that are trending down but traditionally pay at higher contractual rates.

<Graph omitted, see Census Data Graph>

Of note, the Sublette Center is currently receiving residents who are transferring from surrounding areas, including Teton County, due to census caps at other facilities related to financial status, such as Medicaid, or increasing rates.

The Sublette Center also provides peace of mind to those who live within proximity to Pinedale.

For those seniors who do not currently need our services, we believe knowing the Sublette Center is available, if needed, provides peace of mind and alleviates the stress of worrying about potential relocation far from loving family members, friends, and long established community relationships.  As we provide short-term stays as well as long-term care our services keep our seniors in their own homes, and help stretch their financial means, as long as possible.

This makes our mission to continue to serve all the more poignant, especially given the current economic environment and the stress on our overall healthcare system.

The Harm of the CAH to the Sublette Center

The Sublette County Rural Health Care District (SCRHCD) had previously stated their intention was to “Do No Harm” to the Sublette Center and our services.

Unfortunately, the Sublette Center Board has information that concludes the current CAH proposal would not only be harmful, but would lead to the Sublette Center facing insolvency within 5 years, leaving the town of Pinedale with an empty facility, and the loss of employment for up to 65 individuals, and more importantly the loss of services for our elderly population as well as potential displacement of a low-income population. 

We would like to state our hope is for all of the healthcare providers and services within Sublette County to work together synergistically for the benefit of all of our citizens, especially our elder population and those who face financial difficulties.  We welcome the idea of an in-depth study of the services currently available, as well as services being sought after outside of the county that could be brought closer to home if feasible.  Perhaps a solution that would not only broaden services but lead to growth of healthcare professionals and staff in our area.

Financial Impact of the CAH to the Sublette Center

As stated above, the CAH would negatively impact the financial viability of the Sublette Center in Pinedale.  The Eide Bailly study completed on May 16, 2016 and paid equally for by the Sublette County Commissioners, SCRHCD, and The Sublette Center concluded that the CAH would lead to the insolvency of the Sublette Center within 5 years of the upstart of the CAH.

In addition, this report also indicated that the SCRHCD with The Sublette Center as a Critical Access Hospital would show an Operating Loss of $3,073,000 year 2020 based on an initial $6.2 million capital investment.  This loss was based on a significantly lower capital investment than the current estimate of $26 million.  

In addition, a cursory analysis based upon our 5 year average Profit and Loss indicates that the Sublette Center would immediately lose approximately $350K in annual swing bed Medicare revenue, which currently equates to ~11% of our total operating revenue.

Negative Economic Impact for the State of Wyoming

We anticipate duplication of services both immediately and in the future.  Given the State of Wyoming continues to struggle with revenue and noting that Medicaid is a shared cost program with the Federal Government, we believe services currently provided by the Sublette Center would be redirected to the CAH at a higher reimbursement rate for identical services.  This would result in higher expenditures for the State and a negative economic impact.  A potential downstream result could be a reduction of overall State funding for health care related grants, including grants for Sublette County.

We also believe that many of our current residents would opt for services outside of the state of Wyoming, leading to additional reduction in revenue.

Impact to Human Environment

Given the anticipated insolvency of the Sublette Center, the board is gravely concerned about the displacement of all of our residents, but especially those who are high-risk, indigent and our low-income Medicaid residents.  Of note many of these individuals are also minorities.  Over 70% of the Sublette Center’s residents qualify for Medicaid.  Without the Sublette Center, these low-income Medicaid patients, some as young as their early 20’s, would be displaced to other facilities far from their families and home communities.  As the care we provide is not limited by patient resources, these individuals may also not receive equivalent services in a new facility.

The loss of these individuals from our community has a non-financial component as well; the community would lose much valued cultural diversity, as well as the community connection and cohesion each of these individuals and their families bring every day.


If a CAH is pursued, we are concerned about the lack of public input and discussion, as well as collaboration with all healthcare providers in Sublette County.  We welcome additional information to ensure that a CAH would be an asset to our community, and be collaborative and supportive of all of our population, especially our vulnerable seniors— many of whom have limited financial resources.

We hope that the anticipated negative impact to the Sublette Center will be seriously considered and steps taken to not only mitigate, but assist with supporting and growing our services.

To reiterate, the Sublette Center Board members are not saying we definitively oppose a CAH; we are saying that we are opposed to the current plan as it stands today.  Any health care services within Sublette County’s continuum of care should be considered with the participation of all parties and a goal to preserve and improve the health care available to all of our citizens.

To gain our support, the Sublette Center would need to be assured of the preservation of our services and be an active, collaborative partner in forming a strategy for a CAH.  Our purpose is to advocate for our elderly population and to do that effectively we must be included and allowed to closely examine all outcomes, including positive and negative.

We would greatly appreciate more information and dialog before a final decision, one that will impact many long-term goals and all of our residents, be made.

Our final hope is that if the Critical Access Hospital is developed, it would be beneficial to our entire population and all of our citizens.

Thank you for your consideration.




Jay Majhanovich

Sublette Center

Board of Directors - Chairman