Val Verde Regional Medical Center in need of emergency care?

October 19, 2007
By Bill Sontag
Feature Writer

Physician, heal thyself.
-- Luke 4:23

"First, do no harm." Primum non nocere. The oft-quoted physician philosophy is not – as popularly believed – stripped from the Hippocratic Oath, yet nevertheless serves as a quick reminder of the oath's basic tenets. But the factionalization of medicine in Del Rio is a microcosm of America's health care crisis: Doctors, nurses, administrators, patients and governments quibbling, often waging war to define "harm."

Val Verde Regional Medical Center Chief Executive Officer Jack Houghton proudly plugs the service record of his employer, Community Hospital Corporation (CHC), Plano, Texas, and the company's stable of "not-for-profit" hospitals in Texas, Florida and New Mexico. Houghton accepted the CEO position here in April 2006, on the heels of CHC's 2005 firing of Rick Jacobus, and followed by the turbulent interim regime of Michael Bowers, now CHC vice president for business development.

CHC is classified by the Internal Revenue Service as a 501(c)3 non-profit institution. But the local hospital takes direction at different levels of responsibility from three often-confused and –confusing sources. The hospital campus and building are owned by the taxpayers of Val Verde County, with the voter-elected Val Verde County Hospital District Board assigned as stewards of the property.

Management and day-to-day operations of the hospital are under a contract awarded eight years ago by the Hospital District Board to CHC. CHC created a local corporation – the Val Verde Hospital Corporation – to provide oversight of those operations. All the hospital employees, but one, are in the employ of that corporation. That sole exception is Houghton. His boss is CHC founder, President and Chief Executive Officer Mike Williams, Plano.

There are nine appointed, unpaid members of the local corporate board, all of whom are local business and civic leaders (attorneys, physicians, bankers and the like). A tenth seat at the table is kept vacant for Williams who has a reserve right to overturn any decision of the local corporate board. According to Houghton, that right has never been exercised.

In the eighth year of CHC's 10-year contract to manage and operate the area's only local hospital, corporate and corporate board decisions have recently run into a buzz saw of opposition from doctors and nurses, and the hospital now faces a crisis of dwindling confidence in the very community it purports to serve. But, publicly, Houghton appears undaunted. "I intend to work very diligently for progressive change at this hospital," Houghton asserted to a meeting of the Del Rio Rotary Club, Tuesday (Sept. 18).

Without addressing revenues from hospital operations and ad valorem taxes collected by the Hospital District Board that are funneled to CHC, Houghton touted the economic impact of hospital employee salaries to the Rotarians. Houghton explained that the $19,381,232 in employee compensation last year, has a ripple effect of five times that amount as the money moves through the community in purchasing power. That amounts to an annual economic impact of $96,906,160, Houghton claimed.

Dr. Noe Musquiz, family practitioner, 1004 E. 9th St., believes the emphasis on the hospital's profits and losses is misplaced and less than transparent to the patients and taxpayers. "When I came to Del Rio 14 years ago, in 1993, the thing that attracted me was that the doctors were so easy to work with, and this was a community hospital. This was the place I wanted to be because we took care of the patients, but now we take care of the corporation."

In August, Musquiz took a "leave of absence" from his privileges on the medical staff at VVRMC, effective Sept. 1. He still admits patients and sees his own patients in the emergency room, but is no longer in the loop of staff meetings and "on call" requirements for emergency department responses. "That’s the only way I could make a point to him," Musquiz said of his decision to demonstrate to Houghton what he sees as inequities in the ER "call system," i.e. that some physicians have received exemption from the call list, others have not, and none receive pay for the work.

In particular, Musquiz believes the doctors – heretofore uncompensated for middle-of-the-night and weekend calls to the ER – should be compensated with "disproportionate share" funding. With a fund Musquiz says was created by large private hospitals that eschew responsibility for indigent patients, the State of Texas compensates community hospitals that accept a greater than average number of non-paying or indigent patients.

None of these funds, Musquiz insists, go to the physicians who are providing the care for these patients. "They say ‘We built this,' or 'We're doing that,' but, no, the doctors here did it by taking care of those patients – without compensation – that the corporation is getting paid for," Musquiz contended.

Hospital officials estimate that at least 50 percent of all patients admitted to the hospital come through the emergency department, and despite that overwhelming trend, hospital admissions census – "patient days" – have steadily and dramatically declined since 2004, according to a chart displayed by Houghton. Houghton believes the decline is largely attributed to a dearth of quality physicians in a variety of specialized areas, that the key to reversing the trend is recruitment and retention of doctors.

Moreover, Houghton is convinced that the key to such recruitment is to provide spiffy, new office quarters on the hospital campus, a position strenuously opposed by many physicians in town, some of whom have vacant office space they'd like to lease to incoming doctors. "We have a critical need for new medical office space in Del Rio," Houghton said, Tuesday (Sept. 18). "With only a couple of exceptions, there’s no new space available, and nearly everything is 25 years old or older. When we go out to recruit a doctor, and the doctor comes and visits, one of the first questions they ask is 'Where will my office be?' It’s imperative that we be able to show them a quality space where they can begin their practice," Houghton said.

"I do not agree with that at all," emphasized Dr. Shamoon Doctor, urologist, 1205 Bedell Avenue. Doctor, of East Indian descent and whose family surname in a local language there translates to "doctor," is also chief of the medical staff at VVRMC, a two year assignment during which he intends to provide important leadership at a time when the hospital needs it desperately. "When I came here, I wasn’t asking where my office would be. The doctors look at the city, the housing, the schools, the things there are to do here for the spouse and family members, and the hospital facilities. Those are the important things," Doctor said. He believes that to justify building an office complex on the hospital campus – as espoused by Houghton – 50 percent occupancy must be guaranteed, up front, adding that a nearly historic slump in recruitment here does not foretell success in meeting such a standard.

But Doctor agrees wholeheartedly that a key to greater community confidence in VVRMC is recruitment of new physicians. "For the last nine months, they have had no success in recruiting. Several doctors have come for interviews, but none of them have stayed," Doctor said. Indeed, in June 2006, barely two months after Houghton arrived back in his hometown of Del Rio to take the CEO reins at VVRMC, he briefed the Hospital District Board with the news that he had "a strong candidate" in mind for a practicing nephrologist. He expected a positive response that never came.

Doctor said it's an old story that long-preceded Houghton's efforts. "For years, we have been lagging behind, but we still need more specialists. We should not look at it [a recruitment strategy] as a monumental expense, but look at it as a necessary investment. If we could do that, then our hospital would flourish." Doctor said.

Shortly after his appointment as chief of staff in February, Doctor made an impassioned Powerpoint® presentation to the Val Verde Hospital Corporation board of directors. He emphasized the need for "an aggressive recruitment policy," focusing on family practice physicians, internists, a nephrologist (kidney specialist), pulmonologist (lungs and respiratory tract specialist), ear-nose-and-throat specialist, orthopedic surgeon, and additional cardiologists. "It [this strategy] will keep patients in Del Rio, greatly increase the number of in-patients [at the hospital], and create revenue."

Doctor also urged the corporate board to consider improvements to the on-call system, much as described by Musquiz. "Physicians on call should be paid for being on call, either by the hour or by the number of patients seen," Doctor advised. Advocating a recently-discussed remedy for the call system, Doctor said, "Once we have a hospitalist or hospitalists, a general medical call system will not be needed."

Hospitalists, Doctor explained, are physicians hired to practice only in the hospital, and are available around-the-clock to address all incoming patients that don’t have personal physicians available to respond. "This would be a very good idea," Doctor said. "It would solve many of our problems, including those with the call system, because quite a few of the doctors [in the call system now] do not really want to admit new patients, because then they would have to spend time looking after them. So they send them away to San Antonio or San Angelo. And that’s how we lose many patients. And when we hire a hospitalist, it needs to be an ‘intensivist' who is highly trained to do intensive care. We don’t have that now."

Patient revenues that might be derived from Laughlin Air Force Base personnel or family members are also lost to San Antonio because of the paucity of medical specialists here. Col. Lawra Lee, 47th Medical Group commander, said Thursday (Sept. 20) that for any patients demanding the skills of a nephrologist, pulmonolgist, or neurologist – as examples – are referred to San Antonio or elsewhere.

The Laughlin Clinic, until 1998 a hospital, now provides primary and pediatric care, internal medicine, a women’s health clinic, dental care, optometry, and basic mental health care. Flight medicine and aerospace medicine include all disciplines to ensure pilots' readiness for the rigors of training for which Laughlin is famed. But working through what Lee calls a "strict referral process to send patients to town," Laughlin does rely on available Del Rio specialists and diagnostic capabilities at VVRMC.

"We have a very young, healthy population here," said Lee, explaining that VVRMC admissions are few, and that Air Force policies and actions to promote fitness are an important form of preventive medicine. Lee used the base’s impressive Losano Fitness Center as an example of institutional emphasis, saying that her last two Air Force base assignments have also had fine fitness centers. "It’s in their [Air Force] best interests to provide us good fitness centers," said Lee, explaining that wars in the Middle East have demonstrated the importance of sending fit troops into the combat theaters.

Lee has no reservations about relying on known medical care physicians, staff and facilities at VVRMC, regardless of widely publicized internal conflicts. "We are a small outpatient clinic, and when we have needs beyond our ability to care for them, we will refer them to our civilian colleagues without hesitation," Lee affirmed.

Houghton is ready to push for more than just new physicians, in the "if we build it they will come" belief that a bigger physical plant will attract needed specialists and the patients and revenues that come with them. The original plan for the hospital, Houghton explained, was for a building with four floors soaring above the campus grounds. He'd like to see three floors added to the single-story section of VVRMC, what he says would be called a "bed tower" of all-private patient rooms. "This is the industry standard today. We now have some very inefficiently designed rooms in our nursing units,” Houghton said. "This is an important mid-range goal for this hospital." Does he propose such expansion be funded with a bond issue approved by county voters? "It could be," Houghton replied.

New diagnostic technologies also interest Houghton. The hospital's 1.5 Tesla (magnetic strength) MRI machine is still up to the industry equivalent at any hospital in San Antonio, Houghton said. A CT Scan rated at 16-slice speed of imaging is deemed by Houghton to be adequate for today's needs in Del Rio, but adding a 64-slice machine (estimated cost, $1.5 million) could play an important role in attracting another cardiologist to Del Rio. In addition, Houghton wants to add digital mammography to the hospital’s inventory of diagnostic wizardry. "It’s super-fast and much less uncomfortable for the patient," Houghton said.

Doctor has striven for years to add a holmium laser machine to the hospital's array of treatment choices. The laser is useful in reducing enlarged prostate glands and in breaking stones in the kidneys and urethral tract, and Doctor believes it will add humane, in-hospital treatment for needy patients and be profitable, to boot. "They told me I had to buy it, so I'm going to, with the corporation that provides them. I'm planning to get a 100-watt machine that may cost about $120,000, and it will stay at the hospital," Doctor said, Sunday (Sept. 23).

Clearly, everyone playing on the medical field has opinions on issues of priorities of technology, staffing, administration, pay, benefits, and recruitment of new physician specialties. Some board members – from both the corporate and the district board – have confided to LIVE! their belief that the contractual relationship between CHC and VVRMC should be broken, with administration returned to local governance.

"Why not?" responded a physician, Saturday (Sept. 22), when asked if local administration is feasible. Don Griffin, now a hospital administrator in southwest Asia has offered advice through responses to a LIVE! article on the firing of RN Tamara Rattay. Explaining that he was VVRMC CEO until 1999, when the CHC contract was negotiated, Griffin believes residents here should become more active in keeping an eye on hospital governance. "Elect knowledgeable board members. Attend board meetings. Go back to an administrator that you know, and get away from for-profit companies that don’t have your interests at heart [CHC is not a for profit company, as previously stated] … Del Rio is a great place to live. You should not have trouble recruiting physicians or nurses…," Griffin wrote.

But, at least in the short run, Doctor believes good-faith communications must become the "standard of practice" in Del Rio now. "We've made mistake after mistake for the past six to eight months," Doctor said. "What triggered this [current series of problems] was the nurse aid layoff in February … it created a chain reaction, like falling dominoes. Now, the administration is trying to fix it. They'll have to get the nurse aids back, because it's so hard to recruit nurses as it is."

Doctor's prescription is nothing short of an emergency measure to halt the failing confidence of county residents in what was originally planned and once perceived as a community hospital. "To solve this problem, everybody now has to get together. No more finger pointing. We don’t need to do that. What’s done is done, and that’s the past."

Houghton hopes to dispel what he sees as pernicious and counter-productive rumors about the motives of his parent corporation. He told the Rotarians that rumors persist that CHC is deliberately "running the hospital into the ground" so it can be purchased cheaply and operated for profit. "CHC does not buy hospitals. CHC doesn't have the money to buy a hospital," Houghton protested.

At the urging of the Hospital District Board, Houghton is making preparations to find out more about what the community thinks will improve patient care and customer service. One or more public meetings will be held on neutral ground, managed by a professional facilitator, with a digest and report delivered back to the community. "I'm trying to figure out how to increase the confidence and trust of this community," Houghton said.