When he was in private practice at Rodeo Family Medicine, Dr. Gerzain Chavez barely had time to see his patients.

There was the mounting paperwork, the struggles with the increasingly Byzantine medical insurance system. And as for his patient base, that too had changed over the last decade, as he was able to treat fewer and fewer low-income patients on programs such as Medicaid and Medicare, due to the dropping reimbursements from the government.

By selling his practice to CHRISTUS St. Vincent Regional Medical Center approximately two years ago, Chavez says, he’s been able to go back to being a doctor.

He’s not alone. The hospital purchased five doctors and nurses from Rodeo Family Medicine, as well as another four from St. Michael’s Family Medicine. St. Vincent also owns Harkle Road Family Medicine and Pojoaque Primary Care. In total, according to CHRISTUS St. Vincent spokesman Arturo Delgado, the hospital has hired more than 50 physicians in the past three years, as well as a new neurosurgeon who began work this month and a pulmonary critical care physician who starts in October.

Hospital officials say expanding its physician ranks is one way in which the growing institution will be able to serve its expanding customer base.

“Some might kick around the term ‘monopoly,’” CEO Alex Valdez says. “Through my eyes, we need to be as strong as we can be, because that’s what the community is expecting of us.”

But others worry the hospital’s growth is leaving patients with fewer options. It’s of particular concern in some sectors following St. Vincent’s April 8 merger with CHRISTUS Health, an organization that follows religious doctrine from the Catholic Church.

“One of the problems with St. Vincent is the fact that they are truly the only game in town,” medical legal consultant Elliott Oppenheim says. He, like others, believes “women’s health services will be greatly impacted here” due to the merger. “No question about it.”

There also is no question that the merger, the growth and doctors’ migration to St. Vincent reflects a larger health-care trend. Increasing numbers of clinics and smaller hospitals, over the past few years, have become part of large medical corporations, as the cost of doing business on their own grows.

In fact, in New Mexico only 30 percent of doctors work in private practices and 17 New Mexico hospitals are owned by just three health systems.

New Mexico Department of Health Secretary Alfredo Vigil says that hospitals and clinics are no different than any other American business in this regard—small mom-and-pops are joining franchises. To put it another way, he says, “you don’t see solo hamburger stands anymore.”

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Joining CHRISTUS St. Vincent gives doctors “the opportunity to be where we were 10 years ago,” Chavez says.

Ten years ago, doctors in private practices could treat Medicaid/Medicare patients with some confidence they would be reimbursed. Without that confidence, running a private practice becomes less financially viable. In New Mexico, such patients comprise a significant portion of the population.

“Look at [New Mexico’s] population,” Randy Marshall, executive director of the New Mexico Medical Society, says. “Twenty-one percent are uninsured…we’re one of the highest populations in the nation for Medicaid and Medicare.”
Marshall runs the professional association for physicians in the state, conducting legislative work on behalf of doctors and trying to increase their Medicare reimbursements. He says that every year, when Medicaid/Medicare payouts to doctors decrease, he has to fight to convince lawmakers to continue providing reasonable reimbursements for physicians. The inability to do so not only drives private doctors out of their practices, it also makes it more difficult for the state to attract doctors in general.
alfredo-vigil-l
But going to a hospital also allows doctors to concentrate on being doctors, rather than businessmen.

There are more pitfalls in running a doctor’s office now than there used to be, according to Vigil, a 54-year-old Taoseño who, since being appointed to Department of Health secretary in June 2007, is no longer in private practice.

“[Doctors] have to balance all the revenue streams at the same time,” Vigil says, speaking from his office on St. Francis Drive. “There are particular types of Medicare and a lot of different insurance companies. There are doctors who do extremely well from a business perspective, and those who figure it out make very comfortable incomes. If you don’t manage any of those things exactly right…it gets extremely complicated.”

And docs like Chavez who join a large hospital have fewer strings attached. They can move from one hospital to another. They don’t have employees or offices to worry about.
But sometimes that benefit for docs—mobility—means that patients lose out. A sense of connectivity is lost when their doctors move away.

“The way a lot of us were brought up, television always shows the private doctor as the model of health care—like Marcus Welby, MD,” Vigil says. “If you ask a typical patient, they’d prefer their doctors hold still, and stay by them and get to know them.”

Furthermore, when hospitals like CHRISTUS St. Vincent become the go-to hospital for such a large region, Vigil says, patients who need specialized care become far more likely to go there than stay close to home. And that is hard on loved ones because of the practicalities of travel.

Vigil says, “If your family member has a serious problem and the doctor says they’ll have to send them to Denver or Albuquerque or something, hundreds of miles away, your reaction isn’t, ‘Oh goody!’”

It also is hard on the small, local hospitals because they lose revenue. “If you have to send a patient away to another hospital, you’ve lost that revenue flow,” he says. This is one reason smaller hospitals like St. Vincent have been merging with bigger companies. Another reason is that running a hospital, like running a private practice, has become markedly more difficult than in years past.

“Now, you need a legal department, you need specialists, people in recruitment and retention, contracting with outside agencies…. Even the smallest issue in a hospital, an administrator would find daunting,” Vigil says. Bigger health care systems, with added infrastructure, are an attractive option.

“Whether it’s good or bad, I don’t know,” he adds. “But it’s happening everywhere.”

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It’s certainly happening in New Mexico. Currently, the Tennessee-based Community Health Systems owns 116 hospitals, including those in Las Vegas, Deming, Roswell, Las Cruces, Hobbs and Carlsbad. Quorum Health Resources manages hospitals in Taos, Alamogordo, Grants and Silver City. Presbyterian Medical Group, which owns hospitals in Albuquerque, Española, Springer, Socorro, Ruidoso, Clovis and Tucumcari, has seen its physician roster grow by 200 in the last five years.?

Brentwood, Tenn.-based LifePoint Hospitals, Inc. has owned Los Alamos Medical Center (LAMC) since 2005. CEO Sandra Podley, via e-mail, describes LAMC’s reason for joining a big health-care provider: “Because of industry-wide challenges, stand-alone community hospitals are finding it increasingly difficult to grow and be successful on their own.” The buyout has helped the hospital buy $10 million in equipment and facilities in the last three years.

St. Vincent’s merger with CHRISTUS allowed it to wipe out $38 million of annual debt. Its growth is evidenced not only in its growing ranks, but in ongoing construction to expand and improve facilities.

It’s also expanded its coverage area. Valdez tells SFR that CHRISTUS St. Vincent recently did an analysis of its market service area, which revealed that two counties previously outside the hospital’s coverage area—San Miguel and Los Alamos—now fall into its service zone.

“Whether we want to debate it or not, whether we like it or not, CHRISTUS St. Vincent is the regional medical center for north-central New Mexico,” Valdez says. Therefore, he adds, “we want to be as strong as we can possibly be.”

But that strength, some say, does not necessarily benefit the public. Cardiothoracic surgeon Richard Gerety moved to Santa Fe two years ago from Albuquerque. While there, Gerety worked to get the privately owned Heart Hospital of New Mexico up and running. It is a good example, he says, of how beneficial competition in the medical field can be.

“It was a tough go,” Gerety says of the Heart Hospital’s establishment in 1999, “because the current competitors didn’t want anyone else in town to add to the mix. My experience is in cardiac, and that’s a fairly lucrative business for the hospital. I think the hospitals in town saw their share of the pie being diluted.”

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Ultimately, however, Gerety says Heart Hospital actually raised the level of care at another facility.

“It persuaded Presbyterian to upgrade its cath labs, which it had needed done for 10 years,” he says.

In that instance, Gerety claims, one hospital’s founding caused another to upgrade. Patients at Presbyterian were better served as a result and “the people who benefit are the consumers.”
Presbyterian spokesman Todd Sandman admits as much.


"It is true, if you look at the history of the New Mexico Heart Hospital and the establishment of the Presbyterian Heart Group," he tells SFR. "Some of the cardiac equipment in the cath labs did follow that development."

Gerety also believes that when hospitals such as St. Vincent buy a private practice, it squeezes doctors outside the hospital fold by encouraging those new hires to only refer patients to specialists and other doctors also within the hospital's employment.

"If you were a hospital, and you saw that another hospital was coming to town—and you wanted to thwart that effort—what would you do? Would you make it so that the physicians' community only referred [patients] to you? I think you would," he says.

Dr. Mario Pacheco disagrees. "But then," he says, laughing, "I'm biased."

The family doctor works at Pojoaque Primary Care, a formerly private practice that St. Vincent bought six years ago.

Pacheco tells SFR, "There's never been a requirement that I send my patients to St. Vincent, and indeed some of my patients went to Española [Hospital]. I choose to use St. Vincent because I get results back quicker."

CHRISTUS St. Vincent spokesman Delgado says referrals are never a consideration when the hospital considers buying private practices. CEO Valdez agrees, adding that his main reason for hiring more doctors is to keep them in Santa Fe—outcasting a doctor by not referring patients to him or her is counterintuitive to that.

"We are challenged enough in this community to have the vast array of physicians we have," Valdez says.

But former St. Vincent crisis counselor Amy Bloom believes she and her husband were outcast for working outside the hospital's sphere of influence. Bloom moved to Olympia, Wash., in June, along with her husband, medical oncologist Maury Blitman. They came to Santa Fe from New Jersey five years ago to work at St. Vincent.

The hospital, Bloom says, "promised us the moon, stars and the sky. We got here and [Blitman] was the only medical oncologist on staff," which means he was overworked and constantly on call.

Blitman left St. Vincent and joined The Cancer Institute in early 2006. When The Cancer Institute's doctors decided to partner with St. Vincent in June 2006, Blitman and Bloom did not want to return to the hospital. So they began a private practice. That venture failed, Bloom says, because doctors at St. Vincent wouldn't refer patients to them. Their current situation, Bloom says, "is 9,000 times better" than it was at St. Vincent.

Nonetheless, Chavez doesn't think the hospital blocks outside referrals. He doesn't think it's even possible.  "If there were two hospitals in town, I could see that being the case. But there's nowhere else in town I'm going to refer someone for neurosurgery—St. Vincent is the only place."
For now.

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There is the specter of another hospital on the horizon. Presbyterian Healthcare Services has increased its roster of physicians to more than 500, and it is looking to expand even more—into Santa Fe.
The state’s largest health-care provider purchased 40 acres of land on the city’s south side in late June, a plan that Presbyterian spokesman Sandman says has been in the works for years.
But don’t expect a ribbon-cutting ceremony any time soon. “We look ahead to communities that need additional health care in years to come,” Sandman says. “We try and anticipate future health-care uses.”
He points to a land purchase Presbyterian made in Rio Rancho three years ago for a hospital not slated to open until 2010.
“We had been building up services in Rio Rancho since the late ’80s, early ’90s,” Sandman says. “We got to a point where the community has grown enough and we have a good foundation of the kinds of doctors who’ll be working there in the future hospital.” When Presbyterian bought the land, he says, the doctors were already there.
CHRISTUS St. Vincent spokesman Delgado declined comment on the land purchase. However, the hospital did mount an offensive when doctor-owned Physicians Medical Center announced its plans to open, with former St. Vincent CEO John Lucas calling the facility a “boutique hospital” that would siphon off St. Vincent’s patients.
Physicians Medical Center opened last year and specializes in fields such as radiology, orthopedics, urology and pulmonary care. St. Vincent’s hold on the general market seems secure. And that, critics say, is the problem.
“St. Vincent has an institutional monopoly on federal and county money that supports care in that area,” ACLU Executive Director Peter Simonson says, referring to the millions of dollars CHRISTUS St. Vincent receives for being the only hospital in the area.
The fact that CHRISTUS is a Catholic organization with conservative views is another one of Simonson’s concerns. “They can choose how they spend their money based on a religious doctrine others might not share,” he says.
Indeed, another hospital would be a welcome sight for women’s-health advocates. NARAL Pro-Choice Executive Director Heather Brewer has been an outspoken opponent of Santa Fe’s only hospital’s merger with CHRISTUS. It limits patients’ options, she says.
“The problem is that they can’t
sacrifice quality services for all the people in northern New Mexico for the sake of what they see as financial gain,” Brewer says. “Their job as a community hospital is to serve the community,
not to exclude reproductive health-care services.”
According to an April 1 letter to the state’s Human Services and Health departments, St. Vincent administrators say that one service—elective abortion—was never offered at the hospital anyway. As for services such as elective sterilizations, the letter states they will be
provided.
CHRISTUS St. Vincent also set up SupportCo, a separate organization from the hospital that will provide services the Catholic Church opposes. Although there have yet to be documented instances of services being denied, the concern of what might happen down the road is still there.
“If people in northern New Mexico need major medical care, they have to be prepared for their medical choices to conform with religious faiths that may or may not be their own,” Simonson says.
The ACLU is sponsoring an online petition program that asks the newly merged hospital to promise it will not change any of its services.
Regardless, Simonson and others believe the hospital has simply grown too large to be accountable. He points to the hospital’s Sole Community Provider funds, which Medicare provides to rural hospitals in order to keep their doors open. Last year, St. Vincent received $25.6 million in sole community funding. According to Santa Fe County Commissioner Jack Sullivan, approximately $10 million of that money came from county taxpayers.
“They have a cash cow,” Simonson says.
Incoming County Commissioner Liz Stefanics, agency director of the New Mexico Health Policy Commission, believes the county should have a representative on St. Vincent’s board.
“We are involved with a hefty amount of money going to St. Vincent,” Stefanics says. “It’s almost like the county is a business partner. The county needs to hold them more accountable. We should also put into place some standardized reporting form.”
Outgoing Commissioner Sullivan also has been an outspoken critic of CHRISTUS St. Vincent’s financial practices [Outtakes, June 3: “Funding Fallout”]. He wonders if the hospital’s attitude may result in a backlash.
 “[Presbyterian Medical Services]
is poised to move into town with a
new hospital, and I suspect that it will be sooner rather than later if [CHRISTUS St. Vincent] does not embrace a new paradigm in management and an open community
attitude,” Sullivan says.

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Nancy Schreiber certainly wishes she had more options. When the College of Santa Fe graduate school student had an asthma attack in early June, it was not life threatening, though it was bad enough to send her to CHRISTUS St. Vincent’s emergency room. Schreiber says she walked in, asked to see a doctor, was told by staff that they were short on doctors and then waited for two hours before leaving.
The next day Schreiber went to see her pulmonary critical care doctor, Vivian Leigh. Again, Schreiber waited hours before getting treatment. When she saw Leigh, Schreiber says, the doctor appeared worn out and overworked.
“What’s going to happen to her?” Schreiber asks rhetorically. “She’s going to get run off.”
Schreiber says she would rather have gone somewhere other than CHRISTUS St. Vincent’s ER, but her choice was limited to Albuquerque. Which, if she had had a serious attack, would have put Schreiber in danger.
Leigh agrees she is short-staffed, despite the hospital’s push to hire new medical personnel. She is one of three pulmonary critical care doctors presently employed at CHRISTUS St. Vincent, but the only one accepting new patients. When Leigh started working at the hospital, she asked for a commitment from St. Vincent that the hospital would hire more pulmonary care doctors, “because I wanted a normal life.”
But better days are ahead, Leigh hopes—another pulmonary critical care doctor is starting in the next couple of months, which means that patients like Schreiber hopefully will not wait so long to get help.

“I do think this place has the potential to be very, very good,” Leigh says. “That’s what I keep telling myself.”  SFR