The heart of the matter

YAKIMA -- Yakima residents with heart disease could have another local treatment option under new rules to be published this month by the state Department of Health.

But that choice will come over the dead body of Yakima Regional Medical and Cardiac Center.

Dueling hospital billboards around town are only a preview of the high-stakes battle to come in the months ahead between Regional, historically considered the city's heart hospital, and Yakima Valley Memorial Hospital, which heavily promotes its heart programs.

Memorial has offered cardiology services for years but has been limited by state law to emergency procedures, diagnostic testing and rehabilitation. What the hospital is really gunning for now is a piece of the pie from doctor-advised angioplasties.

For instance, say test results show a patient has a blockage that has not yet -- but could -- lead to a heart attack. In consultation with a cardiologist, the patient elects to have angioplasty, a nonsurgical procedure to open a clogged artery.

Hospitals covet elective angioplasties because at $11,000 to $18,000 apiece, they are well reimbursed.

During the procedure, a thin tube called a catheter with a balloon on the end is inserted into an artery and threaded to the blockage. The cardiologist inflates the balloon, pushing the the blockage against the artery walls and allowing blood to flow to the heart. A tiny metal scaffold called a stent may also be inserted to keep the wall open.

State law prohibits Memorial and other hospitals from performing these elective procedures without backup, open-heart surgical capability. The thinking has always been that if something goes wrong and the chest needs to be opened for a bypass operation, the patient is better off in a fully equipped and staffed heart surgery center.

The law allows Memorial to perform the procedure in an emergency, when patients arrive at the ER complaining of chest pain. If a problem develops during the procedure and bypass is needed, the patient is taken to Regional for open-heart surgery.

But the law began to bend when the 2007 Legislature directed the Department of Health to develop rules to lift the restrictions on elective angioplasties. The department has been holding meetings with various "stakeholders," that is, hospitals that want to protect their existing angioplasty markets and those who want to expand their cardiac services.

A final version is due this month and the department is supposed to have the new rules in place by July, at which point hospitals could apply for a "certificate of need," akin to a franchise, to perform elective angioplasties.

Memorial anticipates filing its request in the fall but won't predict how long the process might take before patients can choose where they want their angioplasty performed. The certificate of need process is known for its devil-in-the-details complexity, and any decision by the state can be appealed.

Regional, which pins its survival on controlling the elective angioplasty market, can be expected to argue against Memorial's request every step of the way.

Administrators from both hospitals are suiting up.

"It promises to be a very, very contentious issue," acknowledged Memorial CEO Rick Linneweh.

Regional's Corrine Murphy-Hines, executive director of cardiovascular services, said angioplasty procedures are declining across the country as physicians and patients learn to manage heart disease with medicine and lifestyle changes.

"We have unused capacity at Regional," she said.

Although the new rules of the game aren't final yet, Memorial will have to prove a substantial need for expanded angioplasty services in Yakima and Kittitas counties and the western part of Klickitat County.

The hospital also will have to demonstrate that expansion won't result in costly duplication of services and that it can meet quality of care standards to get the best results for patients.

Through ER admissions, Memorial is already approaching the minimum volume of 200 angioplasties that would be required in the second year of a proposed three-year, phased-in expansion for elective angioplasty. Last year, the hospital performed 130 emergency angioplasties. Regional declined to release its numbers.

Obesity and diabetes are signposts to heart disease, and Linneweh said he is certain the area's at-risk population is growing among both immigrant and established residents. Heart disease in the aging baby boomer population is also rampant. Linneweh thinks the pie is big enough for both Memorial and Regional.

"We believe we could show this now," Linneweh said. "We're not playing games with this."

As the baby boomer generation ages, deaths from heart disease alone are projected to increase by 130 percent between 2000 and 2050, according to the American Heart Association.

Linneweh also points to a growing body of research showing that angioplasty is safe in hospitals that don't have open-heart, surgical backup. That backup means, among other things, the use of a heart-lung machine to keep the patient alive during what could be a five-hour bypass operation.

The most recent study, released last month, found comparable rates of success between 9,000 patients treated at community hospitals without on-site cardiac backup and 299,132 patients at 400 hospitals with the backup.

Memorial has already invested in the technology necessary for elective angioplasty. The hospital recently completed a $1.8 million expansion of its catheterization labs.

But Murphy-Hines, Regional's director of cardiovascular services, thinks Memorial is jumping the gun because the standards under which it could expand its heart services haven't been finalized.

"They would have to show need by state standards but we don't yet know these standards," she said.

Making a case for two elective angioplasty centers in Yakima at hospitals only a mile apart could be a tough sell to state health officials.

"It isn't just the angioplasty you have to look at," said Sen. Curtis King, R-Yakima. "What you have to look at is, if they both have it, is it going to be efficient?"

Before King was elected to the Senate, he sat on Regional's community advisory board. He said he resigned because he didn't think it was appropriate for a legislator to be on the board.

King said he's neutral on the question of whether Memorial should be allowed to do elective angioplasties and is waiting for the Department of Health to issue final rules, which will be followed by a comment period.

Also neutral is the Yakima County Medical Society and its president, Dr. David Krueger, a cardiologist at the independent Yakima Heart Center.

"We consistently stay in the middle ground. Legally, we take patients where we can. We don't break the law," he said.

If Memorial gets the green light, physicians will remain neutral with their patients, Linneweh said. But their conversations about where to have the angioplasty will change. "The doctor will say, 'I need to do this procedure, where do you want it done?'"

Linneweh believes most patients, given the choice, will select Memorial. He cites a telephone survey last spring conducted by Marshall Marketing & Communications, a Pittsburgh-based firm that does market research for local companies advertising on KNDO television.

When asked which hospital they would prefer if they or a family member needed angioplasty, 40 percent of 500 people chose Memorial; 24 percent picked Regional and 21 percent didn't know. Other choices were divided among hospitals in Seattle, Spokane and the Tri-Cities.

Regional said the sample is too small to mean anything and points out that it was a marketing, not a scientific, survey. Murphy-Hines said Regional's heart patients consistently rate the hospital highly, and she takes pride in the hospital's history as a fully-equipped cardiac center.

"I would not have moved across the country from my home town of 3 million people to a hospital I thought was less than excellent," said the Chicago native. "If your heart is crashing and you come to our ER, we can do everything you need."

* Leah Beth Ward can be reached at 577-7626 or lward@yakimaherald.com.