Local hospitals get to the heart of the matter

YAKIMA, Wash. -- Yakima Valley Memorial Hospital is battling for your heart again, and it's set off a war of words between the chief executives of the city's two hospitals.

For the second time in four years, Memorial is seeking state permission to perform nonemergency procedures to unclog arteries. In a direct slap to its competitor, the hospital argues the community has a "preference for Memorial as a provider of cardiac procedures."

Memorial CEO Rick Linneweh also said hospitals across the state, including Yakima Regional Medical and Cardiac Center, may not be correcting data that underreports certain heart procedures, giving them an advantage over competitor hospitals.

Responding swiftly was Regional chief executive Rich Robinson, who said he can document every case reported under state rules, adding that Linneweh has told physicians he intends to drive Regional out of business. Linneweh said he's made no such statements.

Competition between Memorial and Regional is nothing new, but the stakes are higher than ever because of ongoing financial pressure on hospitals and federal directives to deliver services more efficiently.

Cardiac services are easily among the most lucrative a hospital can offer.

For area residents, particularly aging baby boomers who are the most likely candidates for cardiac care, the issue comes down to which hospital they trust with their hearts -- a decision heavily influenced by their physicians.

Regional's bread-and-butter is cardiology and stroke treatment and rehabilitation. Only Regional, a for-profit, 214-bed facility, has the capability for open-heart surgery, and recently invested $6 million in an advanced cardiac single-stay unit. Regional says it's only the second such unit in the state and speeds recovery by eliminating patient transfers between critical care and other parts of the hospital.

Meanwhile, Memorial provides considerable nonsurgical cardiac care, from diagnosing irregular heartbeats and detecting artery-clogging clots to treating people who arrive at the emergency room with heart-attack symptoms.

Linneweh said patients are inconvenienced now when they are diagnosed with a blocked artery at Memorial but are stable and not in immediate danger of a heart attack. The inconvenience and duplication comes, he said, because under current rules those patients must schedule the angioplasty at Regional.

Memorial cannot treat stable patients unless it demonstrates to the state that the region is underserved by just Regional.

So far, that's been hard to prove.

To sway the state Department of Health, Memorial is conducting a media campaign aimed at getting the public to contact the agency and request approval for a new certificate of need.

Meanwhile Regional board member Maureen Adkison -- whose husband, physician Dr. John Adkison, is also on the Regional board -- asked Yakima county commissioners and Yakima City Council members to stay neutral on the question. Commission Chairman Kevin Bouchey said they would not ordinarily take a position in any event.

Adkison, a Yakima City Council member, said she was acting as a private citizen seeking to caution both bodies that elected officials shouldn't express an opinion on an issue that is between the hospitals and the state.

"I don't want this to become a political issue. It's a contentious enough issue already. And it has been," she said.

'Vitally important'

Memorial, a 226-bed nonprofit hospital, says it's "vitally important" that it be allowed to add the service, which it says would come at no extra cost to the hospital. Additional total operating revenue for Memorial from angioplasties would be $28 million by 2014, with net revenue of $15 million, according to projections by Memorial in its application. Memorial's total revenue in last year was $262 million.

Angioplasty, or percutaneous coronary intervention (PCI), is the unblocking of arteries with a balloon-tipped catheter, often followed by the placement of a stent, or tiny scaffold, to keep the vessel open.

The state Department of Health, which regulates new hospital programs through its certificate of need process, decided in 2007 that the market served by Memorial and Regional doesn't need another angioplasty service. Adding one would lead to a costly duplication of services, the state has concluded.

Memorial sued the Health Department over its decision, arguing that the state has improperly given Regional a monopoly on elective angioplasty. Memorial lost in U.S. District Court and has appealed to the U.S. Ninth Circuit Court of Appeals, where a decision is pending.

Memorial's latest application takes a new approach. The hospital argues that the state has significantly undercounted the number of inpatient and outpatient procedures, and as a result has underestimated the need.

Memorial said it missed many of its own cases which could have bolstered its numbers. But the hospital also specifically casts doubt on the way the state counts outpatient procedures -- when the angioplasty is performed without an overnight stay.

Linneweh said hospitals may have an incentive not to report all their outpatient numbers, making the market look smaller than it really is.

"If you are a facility doing a procedure in an outpatient setting, sometimes it's beneficial for you not to report and sometimes its beneficial to report," Linneweh said in a telephone interview. "There's a built-in opportunity for controlling the market on outpatient. A lot of this has to do with, 'I've got my service and I don't want anyone else to do it so I can report what I want.'"

Memorial spokeswoman Nicole Donegan subsequently attempted to clarify Linneweh's statement, saying the problem is more a question of hospitals not correcting data that is missing because doing so is voluntary.

"We're not saying it's intentional, but there's not an incentive for some hospitals to report data that hasn't been counted," Donegan said.

In any case, Memorial argues that data compiled by the health-care arm of information-services company Thomson Reuters shows that outpatient angioplasties across the state may be underreported by as much as 40 percent.

But Robinson said Regional has no reason to allow any underreporting because that would mean the hospital would get reimbursed for fewer procedures or at a lower rate, which would be counterproductive.

"If you don't count, you don't get paid and that would be eroding our own revenues," he said.

Volume and quality

Robinson also disputes Linneweh's argument that choice for heart procedures is good for patients. What matters, he said, is how many procedures a hospital does, not how many hospitals can do a procedure.

"It's not competition that creates quality, it's volume. Adding another program could erode volume and quality," Robinson said.

In 2009, Regional reported performing 339 elective and emergency angioplasties; Memorial reported 151 emergency procedures.

Some 150 patients a year leave town for their angioplasties. Linneweh argues those patients would stay in town if they could go to Memorial.

Both hospitals report excellent records for the time between a patient arriving at the emergency room and getting to the cath lab for the life-saving procedure. During a heart attack, the quicker blood flow is restored to the heart the less damage.

Regional reports 57 minutes, while Memorial clocks 65 minutes. The statewide median is 67 minutes, with times varying from 53 to 91 minutes, according to the Foundation for Health Care Quality, a Seattle-based nonprofit that researches health outcomes and quality standards.

The state has set a threshold of 300 procedures as the projected demand that could justify a new angioplasty program. In other words, if population growth and historical trends forecast a need for 300 or more procedures in a year, the case can be made for another hospital program.

Memorial now argues that when all the cases are counted, the local market exceeds that threshold. For the state's purposes, the local service area includes all of Yakima and Kittitas counties and the eastern part of Klickitat County.

To back up its assertion that patients prefer Memorial, the hospital says it operates the third busiest emergency room in the state and dominates the market for treating heart failure, heart attacks and managing irregular heartbeats.

Robinson concedes that Memorial may boast a higher market share for some cardiac services, but says that's a reflection of where Memorial-employed doctors send their patients, not of preference or quality. Memorial has owned the largest internal medicine clinic in town for years -- Cornerstone -- where many patients get their referrals for cardiac testing.

What's more, the independent Heart Center of Yakima happens to be on Memorial's campus, which for patients may link the hospital with cardiac care, he said.

Playing by the rules

Robinson said Memorial is not only trying to confuse the state by "redoing the math" on the market for angioplasties but is attempting to scare physicians away from working for Regional.

"For example, you reportedly told a group of physicians they should not consider employment by our hospital because you intend to use the certificate of need for PCI services to put Yakima Regional out of business," Robinson wrote in a letter to Linneweh this week.

Said Linneweh: "I have never made that statement at all."

Robinson said in an interview that he is puzzled by Memorial's persistence in seeking approval for elective angioplasties.

"I don't want to make any disparaging assumptions. When I'm dealing with patients' lives, it's highly inappropriate for health-care providers to battle over revenue-producing services that might help us financially."

Linneweh said he is simply seeking fair treatment from the state. He said the state has shown a bias against the hospital ever since it first proposed changing the angioplasty rules many years ago.

"They went into the rule making in a very biased position. I believe we're facing that bias now. We've been swimming upstream in this program."

For its part, the state stands by its process. Bart Eggen of the Health Department, who evaluates hospital expansion plans, said Memorial will get a fair shake.

"We will thoroughly scrub and try to understand their argument and get that number right," he said.

Public comments

Should the state give Yakima Valley Memorial Hospital a certificate of need to perform elective angioplasties?

* To comment: Written comments must be mailed, not faxed, to the state Department of Health by Aug. 24.

* Address: Certificate of Need Program, Mail Stop 47852, Olympia, WA 98504

* Decision: Expected by Oct. 24