Budget Battles Providers Try To Minimize Further Financial Strain

Room To Grow
CDH Plans $45 Million Expansion


When asked when the $45 million expansion project planned by Cooley Dickinson Hospital first went on the drawing board, Craig Melin, the facility’s president, said he’s known since the day he arrived at the hospital in 1988 that its “core” needed some attention, as he put it.

That’s a word he used repeatedly to describe the heart of the hospital’s care-delivery facilities — operating rooms, the central laboratory, and inpatient beds. Melin said the hospital has known for some time that these facilities must be expanded and modernized to accommodate advances in technology and overall patient care. But until very recently, CDH, which was on fiscal life support just over a decade ago, simply couldn’t afford to move forward.

Now, as one of the few hospitals in the Commonwealth reporting surpluses over the past several years, Cooley Dickinson can match its need with the wherewithal to meet it, said Melin, noting that ground will be broken on the first phase of the ambitious plan — a 660-space, four-story parking garage — early next month.

“The time is right to begin one of the most important initiatives of Cooley Dickinson’s 118-year history,” said Melin, noting that the far-reaching initiative is part of the hospital’s ongoing effort to move from “good care to really great care.”

Healthcare News in his office, Melin said he wouldn’t be in that space much longer. He was being moved as part of a chain-reaction-style series of steps designed to give departments and individuals needed room and convenience during the expansion construction process. When the new facility is ready, Melin will move back.

He described his move and others — some offices are being moved into modular facilities being placed in the parking lot — as minor inconveniences, necessary steps being taken in an effort to provide more space and efficiency for both those receiving care and those administering it — and, in the process, perhaps create a model that can be incorporated by other community hospitals facing the same issues and challenges.

“Nationally, more care is being delivered in community hospitals than in teaching hospitals,” he said. “But most of the research on how to provide care and how to do it best is being done in teaching hospitals. We have a sense that some community hospitals should be moving toward setting a standard, and we’re on that path.”
The Healthcare News looks this month at CDH’s expansion plans — and the process for piecing them together — and what they will mean for the future of the hospital and the population it serves.

Space Exploration

Melin told The Healthcare News that many of the services provided by health care providers could be — and often are — administered in remote locations. This list includes laboratory services, rehabilitation, and many types of outpatient care.

But those core services that he talked about — the emergency room, the operating rooms, and inpatient beds — must be at the hospital, and they should be designed and built to permit full use of today’s ever-improving technology and to maximize patient comfort.

These are the main goals behind CDH’s expansion plans, which were announced to the public in late June. Plans call for:

• Eight new operating rooms. Currently, CDH has five operating rooms that were built in the 1960s, said Melin, adding that in the intervening years, the number and type of surgeries have changed. “As we have continued to update our technology and services, we now have the highly trained staff and cutting-edge equipment, but the operating rooms are too small to accommodate the staff, equipment, and patient.”
• A new central sterile laboratory. The current laboratory is housed in 10 small rooms joined by an L-shaped corridor in a building 100 years old, Melin explained. “The increased capacity of the new operating rooms will require an expanded, efficiently designed, and streamlined central laboratory.”
• More private patient rooms. The immediate addition of 32 patient rooms and reducing occupancy of existing triples to single- and double-occupancy rooms will create more privacy, said Melin, adding that with the new rooms, CDH will be able to meet new space-per-patient requirements and create an environment that is conducive to rest and recovery.
• A new central sterile supply department. All equipment and instrument sterilization services will be located on the ground floor of the addition, beneath the operating rooms, to offer easy access to surgical staff.
• A parking garage. The facility will be built on the site of an existing parking lot on the southeast corner of the hospital grounds.

To pay for the expansion, CDH will borrow $12 million, a task made simpler and less expensive by both its current fiscal health and its affiliation with the Dartmouth-Hitchcock Alliance. The balance will be derived from a combination of funding from operations as well as a capital campaign that will commence sometime later this year.
Both Melin and Richard Corder, CDH’s director of guest services, said the expansion, as well as moves being made in advance of the actual construction of that facility, have been designed in response to a variety of changes that have been taking place in health care.

Citing operating rooms as one example, Corder, a longtime veteran of the hospitality industry who was brought to CDH to improve service to both internal and external customers of the hospital, said the current 420-square-foot rooms do not provide the flexibility needed today.

“The rooms were simply not designed for many of the surgical procedures being performed today,” he said, adding that the new 600-square-foot models can accommodate more — and larger — equipment.

Melin agreed, noting that while physicians gain much needed space and flexibility with the new rooms, they also gain something even more precious — time.

“What the new, larger rooms will allow us to do is perform any surgical procedure in any room,” Melin explained, noting that this saves precious time for physicians because it improves the individual rooms’ turnover rates. “If you have enough ORs that are designed to accommodate the full range of surgeries, then that reduces the need to take equipment out of a room, sterilize it, and then move it back in again. Instead, the surgeon can gown down, clean up, get ready for the next case, and move into the next room.”

Improvement — by Design

The addition of more private patient rooms is also being taken in response to changes sweeping the industry. Melin explained that while all hospitals went through a period of downsizing with regard to capacity — CDH itself went from 237 rooms to 125 in less than a decade — the pendulum has in some ways swung in the other direction.
Like schools, hospitals see their populations change as successive generations move through them, Melin explained. As the Baby Boom population nears retirement, hospitals can see growing demand for inpatient care, and this will only increase in the years to come.

“It’s like an accordion … needs change with the population; for the inpatient beds, what we know is that there is more demand,” he said. “In addition, the diseases that we’re treating and the intensity of the illnesses are different than they were years ago; it is the least healthy people who are now in the hospitals.

“A higher percentage of these people are going to be immune-suppressed or infectious,” he continued. “By adding 32 private rooms, we won’t be adding 32 beds, necessarily, but instead decompressing the two-, three-, or four-bed rooms that we have, and that will have a positive impact on all the patient care in the hospital.”

And the impact will be felt by staff members as well as patients, said Melin, noting that care providers spend a good deal of time and energy moving patients from one room to another because they are incompatible, for various reasons, with other patients. “With more private rooms, staff can focus on taking care of patients and not moving them around.”
Corder told The Healthcare News that all aspects of the expansion project are what he called “user-driven.” By that, he meant that input has been gathered from those who will be using the facilities, and this input was carefully considered as designs for the various facilities came together — a process that is ongoing.

The hospital engaged the services of Newton-based TRO (The Ritchie Organization), a group that specializes in design of health care facilities, to modernize and streamline its core services. Corder said the hospital had conducted a number of master facility-planning efforts over the years, and many of them were merely taking up space on shelves. Instead of doing another one, the hospital decided to work with an architect to design new space and renovate old space to achieve long-recognized goals.

“We didn’t need anyone telling us what we already knew; no one needed to come in here and do six months of research to tell us that we needed bigger ORs,” he said. “What we needed was for someone to tie it all in together and create a model for growth that can be used here and elsewhere.”

Using an approach known as the Charette process — a highly intensive effort whereby ideas are generated and exchanged — CDH officials, working with TRO, fast-tracked the expansion design process, said Corder. After working with senior management to forge initial blueprints for new facilities, the architects sought input from a much larger audience about what they wanted and needed in their work environments.

“They would set up a day in a conference room and absorb input from individuals who would take the opportunity to say what they liked and didn’t like about their current space,” said Corder, adding that with this data, the TRO was able to fine-tune designs and put several options before CDH officials.

Taking the process a step further, CDH and TRO then worked with chosen general contractor Barr & Barr in an effort to balance need with practicality and affordability.
“Involving the builders has allowed us to balance out owner need and architect’s design with economic reality,” he explained. “It was an effective planning process for us, one that enabled us to fast-track the process and get a design we could work with — and afford.”

The Bottom Line

Melin described a hospital’s core services as its primary reason for being; “it’s why it is that we’re here.”

Taking those facilities to a new level of efficiency and flexibility is the goal at the heart of the CDH’s expansion plans and the next major step in its multi-faceted approach to moving from good to really great care.

“We’ve made a number of important strides in that direction involving staffing and patient satisfaction,” he said. “But you must have a facility that supports the care, and that’s why we’re taking on this project.”

Course Of Action
Medical Crews At The Open Were Ready For Anything


Dr. John Santoro says the crowds gathered at the Orchards Golf Club in South Hadley earlier this month for the U.S. Women’s Open — a diverse group that included players, caddies, volunteers, spectators, and the media — was comparable to the population of a small city, with perhaps 30,000 people on the property any given day.

And like the inhabitants of any community, this constituency needed medical facilities, said Santoro, chief of Emergency Medicine at Baystate Medical Center and the director of what was called a “virtual emergency room” for the Women’s Open.

He told The Healthcare News that over the course of Open week, he and a small army of volunteer nurses, doctors, and EMTs treated mostly routine cases — cuts, scrapes, a few instances of dehydration, and a small number of fainting episodes. But if the recorded instances were not extraordinary, the level of preparation for this event certainly was, noted Santoro, who said the assignment proved to be a tremendous learning experience, not only for the Baystate employees who took part, but also for the team that will be charged with handling medical services at next year’s Women’s Open at Cherry Hills Country Club outside Denver.

Indeed, while the Baystate crew had little direction and no models to work with as it took on the Orchards assignment, next year’s crew will have detailed logs and a thorough report of the week’s events as a base for their work.

“We learned a ton,” said Santoro. “We put together two big medical books of all the procedures that we went through, which the people who will handle Cherry Hills asked us for. We briefed them before they left about the medical staff and operations, and I think that in a lot of ways, they’d like to duplicate what we did.”

As Santoro talked with The Healthcare News about the Open experience, he described it as a “good week,” not only because there were no serious incidents, but because those who participated took away a good deal from the experience — and even managed to catch a little of the action during a very exciting tournament.

Rough Assignment

Santoro brought an intriguing mix of experience to his assignment as director of the Open’s virtual emergency room, including work handling medical services at the Friendly’s Classic, an LPGA event staged for several years at Crestview Country Club in Agawam.

Also, for several years now, he has been one of the physicians working for the Springfield Falcons to handle the players’ various minor injuries — cuts, bruises, sprains, and strains. Meanwhile, he has served many times as ship’s physician for the cruise line Holland America. Describing the arrangement, Santoro said he and others who participate are given a ticket for a particular cruise and a small stipend. In exchange, he handles whatever medical needs arise during a voyage, helped by full-time critical care nurses hired by the cruise line.

“Sometimes, it’s very quiet, but other cruises are real horror shows, and there’s no way to know what you’re going to get,” he said, noting that a lengthy cruise’s worth of eating and drinking can take its toll on passengers, especially older individuals. “By the end of the week, you know what you’re going to get — heart failure, people overtaxing their ulcers, and dietary indiscretions that run the gamut.”

While Santoro said the work on his resume was a benefit in helping him prepare an emergency facility for the Open, the tournament — or championship, as the U.S. Golf Assoc. prefers to call it — presented a unique set of challenges.

For starters, there was the size of the constituency being served. While a cruise ship might accommodate close to 2,000 passengers, the Open would host more than 25,000 spectators during each of its four rounds, and a smaller but still significant audience during the three preceding practice rounds. Meanwhile, there were also players, caddies, and a small army of volunteers (an estimated 1,500 a day) that might also need medical attention.

There were also logistical concerns. The Orchards is spread over several hundred acres, making rapid response to a specific location a challenge. And then, there are all the various contingencies that must be prepared for. The list included everything from a lightning strike to widespread food poisoning.

“I even took some time looking at the grandstand behind one of the greens,” said Santoro, “and wondering what would happen if it collapsed. We had to look at everything — and be prepared for everything.”

That was the broad assignment given to Baystate, which has the region’s largest emergency department, by the Bruno Event Team, the Atlanta-based company awarded the contract for running the Open. Bruno executives didn’t offer any instruction or provide much input, Santoro recalls. “They basically said, ‘cover anything that can happen.’ They had a few ideas on how we should go about that, but not a lot.”

The first step in the process was to put together a committee that would spend several meetings coming up with ‘what ifs?’ and then answering those questions.
“It was a fun, challenging exercise,” Santoro recalled. “We started by saying, ‘we’re going to have 100,000 people here over the course of a week — what kind of medical services do we have to provide?’

“As one of the biggest emergency departments in the state, we’re prepared to handle a large number of patients; every day, we’ll see 260 patients in our emergency department,” he said. “Over the course of a year, we’ll see perhaps 100,000 people, and that gives us a certain amount of expertise in handling large numbers of people.”

After several meetings, it was decided that the Open’s population could be served with two trailers equipped with both medical and communications equipment — including a small television set for watching the tournament. Meanwhile, there would be five roaming golf carts, equipped with various equipment — including portable defibrillators — and staffed with two EMTs, and two ambulances at the ready should any patients need transport to an area hospital.

The key to the operation was the volunteers — some 250 of them — who staffed the trailers and the golf carts, said Santoro, noting that volunteers worked shifts that ranged from five to eight hours, with one doctor and two nurses in each trailer at all times. “It really was a total team effort.”

Par for the Course

Looking back over the week, Santoro said most all the cases handled by the crews were routine, or non-life-threatening. Heavy rains during the tournament’s first day created some slick conditions, contributing to several slips and falls, he said. Meanwhile, the early summer heat contributed to several cases of dehydration.
In all, there were six incidents where individuals had to be transported to area hospitals. A few of the cases involved dehydration, but there were a few individuals experiencing chest pains. All other patients were treated at the trailers.

So it was a relatively quiet week, one that was good in a number of respects. “We were prepared for the least — cuts and scrapes — and the worst, cardiac arrest,” said Santoro. “Thankfully, we didn’t have any of those ‘worst’ cases, but we were ready for them, and that’s what we were there for.”

Budget Battles
Providers Try To Minimize Further Financial Strain


As this year’s state budget process is played out, Gov. Mitt Romney has found himself at odds with health care providers in multiple skirmishes — some of which the providers are winning.

But in an environment that still presents numerous financial challenges to practicing medicine in Massachusetts, it’s difficult for anyone to claim victory.

Still, hospitals struggling to stay in the black avoided a crisis last month when legislators overturned a Romney amendment that would have removed the earmarks from a vehicle known as the Essential Community Provider Fund — earmarks that included emergency funding to several Western Mass. hospitals that provide copious amounts of free care in their communities.
The free care situation, in fact, is one that worries hospitals and other providers throughout the state, especially since the number of uninsured patients seeking care has increased over the past year, severely cutting into already-strained resources.

To make matters worse, administrators complain, Romney attempted to cut by $25 million the state’s contribution to the uncompensated care pool, a move also overturned by the state House and Senate, forcing the governor to either sign or veto the entire appropriation.

As letters and E-mails fly back and forth between lawmakers, provider groups, and industry advocacy organizations, health care has emerged as one of the key battlegrounds during yet another budget season marked by hard decisions and harder feelings.

Taking a Stand

Hospitals are breathing easier in at least one regard. Some facilities that provide significant amounts of free care hailed the Legislature’s action to restore the legislatively approved earmarks of the Essential Community Provider Fund. Robert Simpson, COO of Providence Behavioral Health Hospital, called the rejection of Romney’s veto “a courageous stand.”
Simpson said Romney has already contributed to a severely strained free-care situation by cutting off basic Medicaid coverage for 50,000 residents last year — many of whom essentially went into the free-care pool. Providence’s own free-care burden shot up from $1.5 million in 2002 to more than $4 million in 2003, while other providers tell similar stories.

“We cannot afford to do that, which is why we prevailed upon our local delegation to put us in for $4 million,” Simpson said. “When the governor vetoed it, he basically said he doesn’t like the earmarks and would rather have the money dispersed by the secretary of Health and Human Services.”

Other hospitals in Western Mass. set to receive earmarked funds include Holyoke Medical Center ($2.5 million), Baystate Medical Center ($1.2 million), Wing Memorial Hospital ($1 million), Mary Lane Hospital ($1 million), and Noble Hospital ($500,000).

The struggles that hospitals face today stem largely from what has happened to the uncompensated care pool — specifically, how the state has continually underfunded it and placed increasing burdens on hospitals to pay for free care, said Charles Cavagnaro, president and CEO of Wing Memorial Hospital.

“What Mitt Romney has accomplished is a massive transfer of funds out of the endowments and operating budgets of hospitals essentially to the state,” he said. “We have taken on funding a program the state was supposed to fund, and now there’s nothing left.”

Western Mass. hospitals, he continued, have been hit with a double whammy. There’s the spike in demand for free care — Wing’s own free care costs have risen 250{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} over last year — coupled with the Medicare wage area index, which pays Western Mass. hospitals a smaller percentage than it does facilities near Boston.

“Our Medicare margins are dropping,” Cavagnaro said. “The amount of money we can make from Medicare — well, it’s probably negative at this point because of the hits we’ve taken from the wage area index and just the way Medicare does business.

“That’s why we in Western Mass. need these earmarks. We need to make up how much free care we give out, and we’re the last in line when it comes to getting help.”
Free Care Isn’t Free

Still, the free-care situation is one that troubles hospitals statewide, and the Mass. Hospital Assoc. (MHA) lashed out at Romney when he attempted to reduce available state funding by $25 million — while at the same time proposing budget amendments that would not restore MassHealth coverage for elderly and disabled legal immigrants, while capping coverage for certain programs, moves that would increase the number of people seeking free care.

“Hospitals were already faced with a near-untenable situation with an anticipated FY ’05 uncompensated care pool shortfall of approximately $140 million — this on top of a similar projected amount in FY ’04 and woefully inadequate MassHealth provider reimbursement rates in both years,” MHA President Ronald Hollander wrote in a letter to Romney before legislators voted to override the $25 million cut.

“The legislature also acted to prevent a further decline in these rates, but your vetoes allow for the possibility of deep rate cuts that your administration proposed earlier this year. These actions would worsen the situation and precipitate a decline of our world-class hospitals and health systems.”

Further, Cavagnaro said, the state is now looking at changes in the way free care is compensated — specifically, a move away from paying hospitals for outpatient clinic visits by people receiving free care. He said such a move could dissuade some people from receiving needed health screenings at all, and down the road, a $50 visit for, say, a blood-pressure screening could turn into $5,000 in treatments after a heart attack.

Simpson said he understands Romney’s general emphasis on pushing patients from hospital care to clinic care, but says the change must be gradual.

“He wants the hospitals to work in partnership with the community health centers, which isn’t a bad concept,” Simpson said. “But patients have established relationships with doctors, and they want to get care at a hospital where more technology is available, and doctors don’t want to give up their patients.

“It’s kind of a conundrum for the state, and I think it’s a process that must take place over time,” he continued. “The processes are not in place to make it happen that quickly.”
In the meantime, Simpson continues to worry about skirmishes like the one surrounding the Essential Community Provider Trust Fund, as they illustrate how tenuous state aid can be.
“We’re an enormous provider of behavioral health services, with 400,000 patient-days per year and 10,000 patients annually,” he said. “If we lose those funds, those services are in jeopardy for the community, and no one will step in and provide them. What hospital in its right mind would pick up services that lose money?”

Cavagnaro said that if the state simply kept last year’s promise to move Medicaid reimbursements to 78 cents on the dollar — they currently average around 71 cents — that would immediately eliminate much of the strain, making the free-care costs less burdensome.

“We don’t want anything special from the state,” he said. “We just want them to pay their bills.”