Mendocino TV Covers Coastal Obstetrics Crisis Community Forum
Citizens respond to MCHD/MCDH created OB crisis
The community forum, part of the special Mendocino Health Care District (MHCD)/Mendocino Coast District Hospital (MCDH) board meeting was well attended by about 200 people, who were clearly there to show support for keeping Obstetrics (OB) care for vulnerable women and infants local.
The poor lighting and very inadequate sound system provided by hospital staff left me recording a meeting where I could not read the entire PowerPoint and could not understand, even with headphones, what most speakers were clearly saying. (If you watched our live broadcast or video we do apologize for the poor quality)
The meeting began with CEO Bob Edwards reading a PowerPoint outlining the expenses and the problematic issues associated with providing OB care locally. There was one page that appeared to have some potential solutions and although the print was way too small for me to read, one point appeared to be that MCDH take back the OB and Pediatric services currently provided by Mendocino Coast Clinics (MCC), which I will discuss later in greater detail.
The community was then given 3 minutes each to provide input and feedback. For the next 90 minutes people of all ages, from a 15 year old to a woman over 90, from all walks of life proceeded to share their experiences and the rationale for keeping OB here on the coast. Many, including Board Member Kitty Bruning were reduced to tears, talking about how critical keeping OB here is and the serious negative impacts of trying to deliver babies in Ukiah. While I often had difficulty clearly hearing or understanding their words, their emotions were quite clear. Everyone who spoke believes this department should remain operative.
It does appear that none of the current MCDH Board Members are in favor of closing obstetrical services and also agree it serves a vital function for the community and the hospital as well. Dr. Glusker read a statement containing information from an extensive study that concludes closing core services, including OB, results in a greater economic loss to hospitals. He also included a statement from Dr. Rohr, who said a major factor in her resignation was that she did not get the financial data she requested and didn’t trust basic financial information she received. The only tense moment occurred while Dr. Glusker was reading Dr. Rohr’s statement and Chair Birdsell slammed his gavel, causing the audience to react claiming the right to hear what everyone has to say. Mr. Birdsell said that the only “remarks regarding administration should be helpful” and then let Dr. Glusker proceed. The other concerns Dr. Rohr expressed were the accuracy of data on OB, and potential risks including a 40% increase in infant mortality, pediatric risks of Emergency Department (ED) delivery, c sections, medical and legal risks. Neither of the other 3 members’ advocated closure, with Sean Hogan pointing out 2 seats will be available in the November election and Kitty Birdsell tearfully reminding the audience that she had worked in the OB Department.
MCDH did provide all OB services at their “Caring for Women” program when, in 2005, CEO Brian Ballard proposed closing both Caring for Women, which had extensive services including midwives, and allowing no births at MCDH. People again rose up distressed as the hospital attempted to rip the heart and soul of its services out of the community. That MCDH/MHCD Board also refused to close all OB operations and a compromise was reached, which transferred portions of the program to Mendocino Coast Clinics (MCC), who agreed to take on the financial loss as caring for these women and children is an integral part of its mission. Both MCDH and MCC acknowledged the fact that OB, with its unique staffing requirements (both an Obstetrician and Pediatrician on call at all times as well as trained nurses), will never be profitable and both organizations continued to assume the loss. As a result, Dr. Wright and some staff transferred to MCC, while the midwives were left out to practice on their own. MCC agreed to provide half of the on call hospital coverage. MCDH agreed to keep the hospital OB unit open and provide the other half of the on call costs.
Over the last 10 years, the MCC program has grown to include more perinatal care, a teen clinic and reproductive health classes in the schools. Additionally, the pediatric practice has merged into MCC, so they are also providing half of that hospital on call coverage, too.
If MCDH proposes to take over all the OB and Pediatric practices and coverage, it is difficult to understand how this will increase revenues and decrease expenses for the hospital. All employees of MCDH are paid considerably more money with more benefits than MCC is able to pay their staff at all levels of employment. MCDH administrative and facility costs are higher and as a nonprofit federally qualified health center, MCC does have the benefit of considerably lower insurance costs, which is a huge factor in OB expenses. People who work at MCC for lower wages are a special group of people, often taking on the difficult cases under difficult conditions because they believe in the mission of building a healthy community. Ripping OB & Pediatrics from MCC will also rip at the heart and soul of that organization, who stepped up the last time the hospital created this crisis.
If MCDH really wants to save money, they should look at all those other departments which operate at a loss, although when did we start expecting a hospital to be a profit generating business? I thought that is why we pay taxes for its operations and facilities? If they seriously want to save money and support the community look at the Physical Therapy (PT) department. It operates at a loss while competing with local private businesses! Why not limit PT to inpatient care and refer outpatients to those providers? It appears we are subsidizing this service with our tax dollars while limiting potential clients to small businesses.
For a number of years, the lack of local trust has been an obstacle to the health and well being of our hospital. Bond issues especially appear to have soured people, feeling like supporting those issues was crucial and then seeing results like the huge empty space in the admitting area. It appears that when a bond issue was recently proposed to support the Emergency Department, the public was not as supportive as was necessary to pass that measure, so it was dropped. Now it appears that staff thought shutting down OB would close that million dollar gap or perhaps stir up enough emotional distress that people will do anything to keep that care here, which feels like economic blackmail to me.
While I have thought that MCDH was really improving over the last 18 months I have been recording it, I now think they don’t quite understand the history, the needs and priorities of coastal citizens. The MCDH board needs to look at the entire health care picture, look at the realistic expenses of providing the services the community wants and needs. The poorly advertised and attended planning workshops a year ago are not enough to base decisions on either. You have people’s attention now, so use it to transparently and earnestly engage citizens and other health care providers; honestly listen to their past concerns as well as future needs without protecting any sacred cows. Build and execute a health care plan for the short and long term. This community needs a healthy hospital to rebuild a healthy economy which will not only survive, but to also thrive.
Editor’s Note: In my initial article I failed to address the fact that 43% of the MCDH 2014 births were Latino, yet there was no Spanish interpretive services available at the forum, nor did there appear to be many Latina’s offering their thoughts and experiences. While the Fort Bragg Unified School District has recently learned the value of the Hispanic Community’s participation, providing interpreters and Spanish materials, it appears that MCDH has not recognized the vital input from their constituency.
> Notes for July 12 Board Forum
> Peter Glusker, MD
> The Nicholas Petris Center on Health Care Markets and Consumer Welfare at U.C. Berkeley published a comprehensive 151 page study on the issue of OB closures in California hospitals. (“Hospital Service Changes in California: Trends, Community Impacts and Implications for Policy” by Kirby, Spetz, Maiuro, Sheffler). They looked at 389 hospitals over an eight year period and compared those which closed OB departments to those which added new services. Closing OB departments resulted in deterioration in financial position related to loss of patient relationship to the hospital and other factors. Hospitals did better financially when they added new services, instead of discontinuing them, particularly OB.
> Therefore the assumption of administration that closing OB will help finances is not supported by available data. Contrariwise, adding a new service, for example palliative care which, we could do very well here, and which could utilize both swing beds and home health would be likely to improve the financial status.
> I sent Dr. Rohr a copy of the study for her comment and she responded:
> “The absolute MOST significant finding of the study is that closing OB did NOT improve financial performance. In fact it statistically shows that closing OB had a disproportionately NEGATIVE effect on finances. That is, overall hospital business at those hospitals decreased more than could be accounted for by the loss of OB business itself. This is not a surprise to someone from the business world. If a business has a service that is part of the basic definition of its core mission, closing that service cannot possibly improve its finances. In this case labor and delivery is about as basic a core service of what it means to be a hospital. It is well known that if a core service cannot be made profitable the correct task is to streamline and make it as efficient as possible. This is the basic concept of the so called ‘loss leader’.”
> When Dr. Rohr and I joined the board, she had a plan for the finance committee to examine each hospital department, one a month. That plan was subverted by the administration, which refused to cooperate. The ED was the sole exception. The analysis of the ED, but more critically a review by the new group revealed very significant problems with undercoding and billing. We have hired the new ED group with expectations of significantly improved income, but we shall see what the actual results will be. Dr. Rohr’s frustration at being prevented from analyzing the hospital’s finances and producing real change for the hospital was a major factor in her resignation. She has publicly stated: “I cannot accept fiduciary responsibility for an organization in which I do not receive or trust the basic financial information.”
> My own attempts to obtain the financial details underlying the administration’s OB budget listing a one million deficit were thwarted and resulted in more barriers being put in my way. I managed to get OB departmental statements for Jan. and May, 2016. These reveal very disturbing inconsistencies, raising serious questions about the accuracy of the data. I suggest that this requires an independent analysis of the accounting for OB for the last year to determine accurate information, and then to plan HOW to manage OB.
> A recent study by Lorch et al, examining what happens to babies when regional OB units close, found an approximate 40% increase in infant mortality in the first three years. After that services were effectively redistributed to OB units geographically close enough to provide care. Our location does not allow OB services close enough to provide care for the kinds of problems that lead to infant mortality.
> If OB were to be closed here, besides further losing the community’s trust in the hospital, we also put patients at significantly greater risk with ER doctors trying to deal with failed home births, malpositioned or crowning babies, placenta previa or a need for an emergency C-section. These problems pose critical medical risks for mother and baby, leading to infant mortality or potentially lifelong neurologic disabilities. The distance to the nearest obstetrician and hospital does not allow transfers in most of these situations. The medico-legal risks for the hospital are also increased. ER care for OB is not good quality care. When Sean Hogan was president of the board his emphasis was on quality of care. Finally, the administration needs to cooperate with the board and not try to direct the board as they are with attempts to close OB, and the Board needs to focus on planning and strategy.