`Haves' vs. the `have-nots' of open-heart surgery

State weighs adding to hospitals that do it

Medicine

June 16, 2000|By M. William Salganik | M. William Salganik,SUN STAFF

Although the health regulators who control open-heart surgery programs in Maryland scrupulously avoid the terms, hospital administrators talk about the gulf between the "haves" and the "have-nots," between institutions that perform open-heart procedures and those that want to but can't.

Over more than a decade, the "haves" and "have-nots" have clashed - in administrative hearings, in court, in the legislature - over whether more programs are needed. And when health planners have decided to open new programs, the have-nots have turned around to battle each other over which should get them.

Another cycle begins today, as the Maryland Health Care Commission begins a process of updating the state health plan's section on heart surgery. The process could take as long as a year.

The stakes are high for the hospitals.

"Open-heart surgery is really the linchpin for other cardiology procedures," said John Ellis, executive vice president for finance and administration at St. Joseph Medical Center in Towson, one of five "haves" in the Baltimore area. "HMOs are moving big blocks of business to centers that can offer open heart."

Open-heart surgery along with angioplasty (the use of a balloon to open clogged arteries, generally done only where open heart backup is available), and sophisticated diagnostic heart work account for 35 to 40 percent of St. Joseph's annual revenue, which totaled $173 million last year, Ellis estimated.

In updating the health plan, the commission and its staff will be asking two different, but intertwined, questions:

Should the commission grant one or more additional "certificates of need" allowing hospitals to launch open-heart programs. If it did decide to grant another "CON," it would then invite hospitals to submit competing applications.

Is the certificate-of-need process, in place for decades, still appropriate for open heart, or should any hospital be allowed to start a program as long as it meets quality standards? Legislative action would be needed to change the certificate-of-need rules.

4 hospitals want it

Among Baltimore area have-nots, St. Agnes Health Care and Greater Baltimore Medical Center both want open-heart programs. "We're just completing our three-year strategic plan, and open heart is still right there at the top of our clinical needs," said Robert W. Adams, St. Agnes' president and chief executive officer.

In the Washington suburbs, Suburban Hospital and Holy Cross Health have indicated an interest, as well.

St. Agnes and GBMC argue that they already have large, sophisticated surgery programs that put them in good position to do open-heart procedures, most commonly bypass surgery and valve repairs.

"In our chest pain emergency room, the main activity every morning is to pack patients up and ship them to St. Joe or Sinai or University of Maryland," Adams said.

In the last year, he said, St. Agnes transferred 603 patients for open heart surgery or angioplasty.

'Having monpolies'

This issue is one of choice," said Laurence M. Merlis, GBMC's president and chief executive officer.

"Having monopolies in today's health care environment is not the best way to serve patients."

The other "haves" in the Baltimore region are Johns Hopkins Hospital and Union Memorial Hospital. Union Memorial, which was granted permission in 1992 and started its program in 1994, is the newest of the local programs.

More competition can lower prices, said Harold A. Cohen, a health economist and consultant who is helping Holy Cross in seeking an open-heart program.

Limit lowers costs

On the contrary, argue the "haves," limiting programs lowers cost.

"We are able to offer a cost-effective program because we have substantial volume," said St. Joseph's Ellis. "We have a team here of eight people 10 hours a day, and if they only do one or two cases, we still have to pay them."

Also, Ellis said, particularly with a shortage of nurses and other staff, new open heart programs would have trouble recruiting skilled people.

And, he said, open heart volumes have been leveling off as other treatments allow patients to avoid bypass surgery, so new programs will not be needed.

High-volume hones skills

The "haves" also point to studies showing that patients get better results in high-volume programs, so allowing too many programs would lead to worse outcomes.

At today's meeting, the commission will not get into those debates, explained Pamela Barclay, deputy director for health resources. Rather, the process will begin with the staff presenting alternatives on technical questions such as how to measure current capacity and project future demand.

Hearings, panels and opportunities to file written comments will continue through the fall.

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