Hospitals Duel Over ER Care In Arkansas

by Mark Friedman  on Monday, Mar. 24, 2008 12:00 am  

Lynn Weaks, CEO of Arkansas Surgical Hospital, said the hospital meets all the regulatory requirements by having registered nurses on-site 24 hours a day, and doctors are on call if they're not at the hospital.

Arkansas Surgical Hospital in North Little Rock has an emergency room, but the Metropolitan Emergency Medical Services ambulance service took no emergency patients to it last year.

MEMS did, however, make seven emergency runs from Arkansas Surgical Hospital to other area hospitals in 2007, according to its executive director.

While the Surgical Hospital meets all regulatory requirements, its record underscores the findings of a recent federal government report: A majority of physician-owned specialty hospitals don't have doctors on site at all times.

The report has added fuel to the long-running battle between physician-owned specialty hospitals and full-service hospitals, also referred to as community hospitals.

The report by the Office of Inspector General for the Department of Health & Human Services said only 55 percent of the nearly 110 physician-owned specialty hospitals it studied had emergency departments. And of those hospitals that had an emergency department, 58 percent had only one emergency bed.

"Most notably, 34 percent of hospitals use 9-1-1 to obtain medical assistance to stabilize a patient, a practice that may violate Medicare requirements," the report said. "Almost half of all hospitals (46 percent) use 9-1-1 to transfer patients, a practice that is permitted by Medicare."

The report didn't sit well with critics of physician-owned specialty hospitals. "Patients and consumers deserve to know what they're getting into with specialty hospitals," said Sen. Chuck Grassley, R-Iowa, in a January news release. "Most people assume that if it's called a hospital, it can handle emergencies, but this data shows that's not the case. More broadly, it's fair to ask whether taxpayers should continue to support erosion of community hospitals."

Sen. Max Baucus, D-Mont., also was shocked by the report and said in a statement that Medicare money for hospitalization shouldn't be used on facilities that most people wouldn't even call a hospital.

Lynn Weaks, CEO of Arkansas Surgical Hospital, said the hospital meets all regulatory requirements by having registered nurses on-site 24 hours a day, and doctors are on call even if they aren't at the hospital.

"We just don't meet but we exceed the expectations that are set," Weaks said. And he said all the nurses on the staff are certified with advance cardiac life-support training.

"Every nurse has been trained to individually be the lead in resuscitation efforts," Weaks said. "That is different in what you'll find in other hospitals. So we're staffed, and we're staffed very well."

The seven Surgical Hospital patients who needed emergency transfers to other hospitals last year had complications from surgeries and were stable before they left, said Surgical Hospital Chief Nursing Officer Judy Jones.

The American Hospital Association, though, doesn't believe that a hospital with one emergency room bed should be considered a hospital.

"When you only have one bed in an emergency department, the chances are pretty good that you've not got it staffed," said Ellen Pryga, director of policy for the AHA. "It's basically a room with a closed door and the lights off. And part of the problem with that is it really is holding that organization out as having a capability that they don't have."

The Arkansas Department of Health has awarded the Surgical Hospital a license to operate as a hospital.

"We believe that they meet the requirements to be licensed," said Ed Barham, a spokesman for the Department of Health. "I'm not sure what else we can legally say. It's Arkansas law."

Jon Swanson, executive director of MEMS, said his ambulance service doesn't take emergency patients to Arkansas Surgical Hospital because it doesn't have a physician on staff all the time.

And that baffles Doug Weeks, the administrator at Baptist Health.

If MEMS "is required to take patients to the most appropriate, closest facility  then I don't understand why they've never gone there," Weeks said. 

"I think that's the intent of the rules and regs of the Arkansas Department of Health. If there's a facility in town that doesn't get any patients from MEMS, something seems amiss related to the rules and regulations of the Health Department," Weeks said.

The University of Arkansas for Medical Sciences Medical Center also has a problem with hospitals that are licensed as a hospital but don't take emergency patients.

"There is a sizable task of taking care of the emergency medical needs of the citizens of central Arkansas, including those who come to us via ambulance," said R.T. Fendley, senior associate hospital director for UAMS, in an e-mail statement to Arkansas Business "This responsibility is shared by the acute care hospitals in the region. UAMS views it as unfair for any facility to be licensed as a hospital without assuming a share of this responsibility."

The Arkansas State Highway & Transportation Department doesn't consider the Arkansas Surgical Hospital to be a true hospital and refused a request to put up blue hospital signs on Interstate 430 and Interstate 40 indicating its location in North Little Rock.

"They do have what they term as an emergency room at that hospital," Highway Department spokesman Randy Ort said. "But our policy states that a hospital has to be a 24-hour emergency treatment facility with a physician on duty within the emergency department."

Ort said the Highway Department determined that the Surgical Hospital didn't meet that requirement.

Cherry-Picking Alleged

The AHA's main concern with the physician-owned specialty hospitals is that they get the best patients - the high-paying, well-insured surgical patients - without having to take in any of the 47 million uninsured Americans for whom the hospital emergency room is the primary safety net for medical care.

Federal law requires that any patient who enters an emergency room must receive initial care and be stabilized before leaving, regardless of his ability to pay. "But if you don't have an emergency department, that law doesn't apply," the hospital association's Pryga said. "And if you have an emergency department with one bed and no staff  then it isn't a portal for those patients to come through."

But Jason A. Spring, CEO of HealthPark Hospital in Hot Springs, a physician-owned specialty hospital, said the AHA was really trying to reduce competition for the full-service community hospitals that are its members.

Community hospitals "have devoted a great deal of time and money to destroying our industry," Spring said in an e-mail statement to Arkansas Business. "This is an ongoing battle between competition in the marketplace and the traditional hospital model. After numerous studies that suggest we are a business model that provides efficient, safe care to patients, they continue to work to eliminate us."

Congress has been trying to curb the expansion of physician-owned specialty hospitals for years. The House of Representatives passed a bill last year that said that if any doctor owns more than 2 percent of a hospital or if doctors own more than 40 percent of the hospital, it wouldn't qualify for Medicare payments, Rep. Pete Stark, D-Calif., said last week.

The House bill is in the Senate and might be voted on this year, he said.

History of Bad Blood

Between 2002 and 2004, the number of specialty hospitals nationwide jumped from 46 to 89, according to the American Hospital Association.

To curb the growth, in 2003 Congress approved a moratorium on Medicare payments to new physician-owned specialty hospitals. When that moratorium expired in June 2005, Congress prohibited the Centers for Medicare & Medicaid Services from approving new specialty hospitals until 2006.

The American Hospital Association has maintained that the physician-owned specialty hospitals are not more efficient and provide no better care than community hospitals. The AHA also claimed doctors who invest in specialty hospitals steered the better-paying patients and those with fewer complications to their hospitals while the sicker ones ended up at the community hospitals, often with no way to pay their bills.

On the other side of the debate, the American Medical Association - which represents doctors - insists that the specialty hospitals are good for health care. 

"They have lower infection rates, fewer medical errors, shorter turnover times, and increased cost efficiencies," according to a 2006 letter Dr. Michael Maves, executive vice president and CEO of the AMA, wrote to the Centers for Medicare & Medicaid Services. "Moreover, specialty hospitals encourage competition between and among health facilities, which has led to the delivery of higher quality, more efficient, and innovative health care in the communities where they are located."

Maves also pointed to a Medicare Payment Advisory Commission report that found no conclusive information indicating financial harm to community hospitals resulting from specialty hospitals.

In Arkansas, the battle was highlighted when a group of doctors sued Baptist Health in 2004 and accused the hospital system of canceling their privileges in an attempt to limit competition.

The six doctors were partners in the Little Rock Cardiology Clinic P.A. The doctors sued Baptist Health after the hospital's board of directors adopted a policy in 2003 that began using economic criteria as the basis for granting medical staff privileges at the state's largest hospital.

Baptist Health wouldn't comment on the lawsuit at the time, but said specialty hospitals were financially hurting community hospitals.

That trial started in Pulaski County Circuit Court on March 10 and was still going on last week.

Emergency Cases

The physician-owned specialty hospital model came under fire again in 2007 after a death of a patient who had been at a specialty hospital in Texas. In that case and another in Oregon, the patients had complications after elective surgery. Neither hospital had a physician on duty at the time, and nurses called 911 for help. The ambulance companies rushed the patients to the community hospitals, where they died.

Critics of the physician-owned specialty hospitals jumped on the news of the deaths.

"We're concerned about any hospital that relies on dialing 911 to rush a failing patient to a community hospital," Sens. Baucus and Grassley said in a joint news release.

The deaths also resulted in the study from the Office of the Inspector General.

That report came under criticism from supporters of specialty hospitals because of its conclusions.

"From start to finish, this report had a preordained conclusion," said Robert James Cimasi, the president of Health Capital Consultants of St. Louis. "It was a smear job. The number of people killed in hospitals because of medical error and the lack of response to emergency care is the largest cause of death in America.

"And to pick out and focus on these very high quality, specialty hospitals and try to infer and insinuate some sort of  ... connection because some of them don't have emergency rooms  there's no statistical validity to this report."

Many hospitals in rural Arkansas don't have emergency rooms staffed by doctors 24 hours a day, said Nate Miller, the CEO of the physician-owned Surgical Hospital of Jonesboro, in an e-mail statement to Arkansas Business.

He said if all hospitals were required to staff doctors 24 hours a day, rural hospitals would face a financial strain.

The Surgical Hospital of Jonesboro has two emergency room beds. Miller said the hospital is staffed with a registered nurse 24 hours a day, seven days a week. And the doctors are on call 24 hours a day, he said.

Transferring patients from one hospital to another happens when the patient requires it, Miller said.

"In northeast Arkansas many patients are transported from the emergency rooms to the Regional Medical Center at Memphis," Miller said. "Is it appropriate for these hospitals to transfer patients to a higher level of trauma care, yet complain that SHJ does the same thing?" 

Quality Care

Miller pointed to several studies that showed the quality of care is better at specialty hospitals than at community hospitals.

Weaks also said the Surgical Hospital has received nationwide awards for its quality of care.

Arkansas Surgical Hospital ranks among the top 5 percent of hospitals in the nation for joint replacement surgery and spine surgery, according to the 10th annual HealthGrades Hospital Quality in America Study.

The Surgical Hospital also received the HealthGrades Specialty Excellence Award for joint replacement surgery as well as the Specialty Excellence Award for spine surgery, according to a news release from the hospital in October.

The Surgical Hospital was one of only 13 hospitals in the country to receive both awards.

"This award speaks volumes about the caliber of physician and quality of staff found here at Arkansas Surgical Hospital," Weaks said in a news release at the time.

Weaks said he didn't want to get into a mud-slinging contest with the community hospitals.

"We want to have goodwill toward the community hospitals," he said. "We think they do a very good job at what they do, and we're confident that we do also."                                 



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