By JUDE O. MARFIL
Special to the Saipan Tribune
Second part of a series
That was how the U.S. Department of the Interior's Office of Inspector General capsulized the health care condition in the insular areas, including the Commonwealth of the Northern Mariana Islands, in a scathing report last year.
The Inspector General underscored “poor record-keeping system, old equipment, very few supplies and lack of specialist-physicians” as severe problems at the Commonwealth Health Center, the only acute care facility on Saipan.
Opened in November 1986, the government-run CHC was envisioned to be a “state-of-the-art, twentieth century hospital,” said Deputy Secretary for Hospital Administration Pete U. Untalan.
More than two decades later, that promise of a modern CHC has become questionable.
The September 2008 IG report outraged the CNMI government, mainly because it was not given the chance to first review the findings. Nonetheless, CNMI Public Health Secretary Joseph Kevin P. Villagomez conceded: “Most of the facts contained in this report are probably accurate.”
A year later the perplexing issues identified in the IG report still exist, perhaps even worse. So much so that Gov. Benigno R. Fitial declared a state of emergency in September 2009 to hire non-U.S. and non-Canada-licensed doctors and to funnel funds to the hospital without having to seek approval from the Legislature.
The percolating problems at CHC did not come to the forefront until June 2009. Roughly five months before the Nov. 7, 2009, local elections, the House of Representatives, particularly the Committee on Health, Education, and Welfare, decided to conduct public hearings.
“As chairman, it is my duty to suggest any solution. I got to find out the operations, issues.mistreatment from administration [at CHC],” committee chair Ralph DLG. Torres said. Torres has since been elected to the CNMI Senate.
At a public hearing at the Garapan Elementary School cafeteria on Sept. 23, 2009, three hospital unit managers showed up: Anthony Raho, in-patient pharmacy; Maureen E. Sebangiol, respiratory care services; and Pamela Carhill, physical therapy department.
It was the first time currently employed hospital unit managers publicly voiced their frustrations, which stemmed from two things: lack of funds and mismanagement.
By coming to the hearing, the three managers were putting their jobs on the line. In the past, anyone who speaks against management could face retribution in the form of non-renewal of contracts, delay in salaries, removal of housing benefits, or perennial graveyard shifts, according to employees who spoke only on condition of anonymity.
Her intention in attending the HEW hearing, Sebangiol said, was not to disparage CHC, where she worked for 16 years, but to merely voice the sentiments of the ancillary staff. “[The hospital] is my life ... I want [CHC] to work and I will do everything in my power to make it so,” she said.
State-of-the-art hospital
Plans to build CHC began in the early 1980s. The idea was to replace the rundown Dr. Torres Hospital, where Northern Marianas College is now located, and consolidate medical services in one building.
Only a few people on Saipan knew about the intricacies of the hospital's past. Untalan, then administrator for Guam Memorial Hospital, said he advised CNMI public health officials on the hospital's blueprint. One of those Commonwealth officials was former public health director Jose T. Villagomez, the father of the current public health secretary.
With $25 million allocation from the U.S. Congress, the 86-bed hospital along Middle Road in Lower Navy Hill opened in November 1986 to serve Saipan's population of 15,000.
“What was not factored in was the explosion of businesses,” Untalan said.
Based on the 2000 U.S. census, Saipan's population ballooned to 69,221. By the time CHC began accepting patients, a handful of garment factories had already opened. These factories brought in thousands of workers from China, the Philippines and Thailand to manufacture clothes for U.S.-based brands, such as Ralph Lauren, Liz Claiborne, Gap, Levi Strauss, Calvin Klein, Tommy Hilfiger and Abercrombie & Fitch.
Not much thought was given to sustainability,” Untalan said. “[CHC] was socialized medicine at its best.”
“Running a hospital is complex. Running it in a remote location is even more daunting,” he said. Filling up positions for doctors, nurses and ancillary staff; sourcing and upgrading of equipment; procuring medical supplies; collecting and storing patient information; billing and collecting payment from patients and insurance firms; and maintaining the upkeep of the facility were among the concerns that a hospital operator needs to address.
“So for a hospital that is 100 percent supported by government and has very little island economy, can it support a complex system?” Untalan pointed out.
Money changes everything
Longtime CHC employees said the rapid downfall of CHC began in 2005. Garment factories started to close and tourist arrivals declined after Japan Airlines left. From $217.9 million in fiscal year 2004, the general fund revenues dropped to $163 million in fiscal year 2007.
Many lost their jobs. They could no longer keep their insurance. People were missing their medical checkups. Unless their condition was dire, patients would not see their doctor.
However, CHC lacked specialist-physicians and equipment to diagnose-much less treat-seriously ill patients.
This is why patients are being sent to Guam, Japan, Hawaii, or the Philippines for treatment under the CNMI's Medical Referral Services program, which has been getting a huge chunk of DPH's annual budget allocation.
Financial data showed that of the $39.45 million DPH spent in fiscal year 2008, 13 percent or $4.94 million went to medical referral. Of the $49.20 million DPH spent in fiscal year 2009, 17 percent or $8.58 million went to medical referral.
As for CHC's overall finances, expenses went up to $26.51 million in 2009 from $22.05 million in 2008. Meanwhile, allotments declined to $19.57 million in 2009 from $21 million in 2008. As a result, CHC's deficit increased to $6.93 million in 2009 from $1.05 million in 2008.
“We have been doing more with less,” Untalan said.
Compounding the hospital's financial woes is collection.
From 1986 to the present, CHC has over $118 million to collect. Of this amount, $15.8 million are from patients who have been billed but not yet referred to a collection agency. A total of $10.7 million are from patients that have been referred to a collection agency. “The patients got the bill . but [they] are not paying,” said Esther L. Muña, DPH's chief financial officer.
Muña said the government's arrears, including its share in Medicaid expenses, have reached $75 million. “The government just does not have the money. How can it prioritize paying a hospital that it is providing funding for anyway?”
Medicaid is a joint federal-local program to finance health care coverage for certain low-income individuals. The amounts are set in the law. In 2008, the CNMI got only $4.8 million. Medicaid will not match any expenditure above the spending limit it has set. “Once we reach the set amount, the CNMI is responsible for 100 percent of the amount owed to providers,” she said.
Even though Medicare has been the hospital's most reliable payer, CHC still lost money from these patients. Medicare is the federal health insurance for people 65 years old and above, the age group for CHC's Hemodialysis Center.
Latest available CHC data showed that in fiscal year 2008, the Hemodialysis Center had 1,165 visits from 137 patients. This translated to a billing of $8.16 million. But of this amount, only $6.16 million was paid, leaving almost $2 million in receivables. This happened because patients could not pay their 20 percent share of the hospital bills.
Muña said that for the monthly hemodialysis treatment, Medicare covers 80 percent of the $7,000 cost per treatment. Every month that a patient seeks dialysis, he has to pay $1,500. Most, if not all, insurance providers in the CNMI do not cover hemodialysis treatment. So a patient ends up shouldering the expense. Hemodialysis is a method of removing excess fluid, minerals and wastes from a patient suffering from kidney failure.
“How do you collect from patients if you want to make sure that they are compliant with their treatment, because if they don't they die?” Muña lamented. “I don't want the patient to die.”
Ironically CHC would occasionally only manage to collect once the patient was dead. “When we see that there is an announcement that there is a probate case going on we just present our bills,” she said.
“The patients that we serve are poor. If that's what [the Legislature] expect[s] from us, have us funded,” Muña said. “I am not a good collector. My heart goes out to the patients . Give us the money. The collection side is a difficult thing.”
Mismanagement
For months beginning February 2009, DPH, which operates CHC, did not have full-time secretary. Villagomez was in and out of the hospital. In April 2009, he finally went on medical leave to undergo surgery in California.
Untalan temporarily took over the helm of the department. Since he had to focus on the many facets of DPH operations, Untalan asked John Flores to oversee the hospital. Flores is the facility maintenance and support administrator. When Untalan was off-island, either Muña or John Tagabuel would be appointed. Tagabuel is the deputy secretary for public health administration.
“Who's making decisions and based on what information?” asked Sebangiol, a Stanford University graduate.
During his 13 years at CHC, Raho said he's had about nine hospital administrators. “It seems that there's one direction that is being taken with one administration and [when] the political situation changes, a new administration comes in and we're going 180 degrees in different direction,” Raho said during the public hearing.
Instead of being rewarded for long years of service, Carhill said, CHC removed benefits such as night deferential, on-call fees and the $600 to $800 in housing allowance. These affected nurses, physical and respiratory therapists, radiology and laboratory technicians, and in-patient pharmacists.
“We're the ones who are sticking it out. Instead, things are being pulled away,” said Carhill, who has worked at CHC since August 2002. “We are exhausted trying to make ends meet. It's frustrating.”
Echoing Carhill, Sebangiol said, “Doctors do not run the hospital. They can give instructions over the phone. As long as there is the nurse, respiratory therapist, [staff in-charge of] laboratory, radiology, in-house pharmacy and physical therapy, those patients will be taken care of.”
Another nagging problem reported is the communication gap between management and medical staff and employees.
“It's very unhealthy to not have a visible and consistent leadership presence that should be walking around the hospital once every two weeks and giving people pep talks,” Dr. Shirish Balachandra of the Emergency Medicine Department said in an interview.
“In the absence of positive feedback there is a tremendous amount of negative feedback. The leadership is more than happy to get involved to let people know when a patient complains,” Balachandra said. “But you can't just have one unopposed voice. It engenders a certain enmity among the staff and that gets directed to the patients because all [the nurses] hear is that the patients don't appreciate them,” he added.
Another issue is the pent up animosity between civil servants and off-island hires. Off-island hires get more salary and benefits whereas most of the civil servants' wages have remained stagnant since 1997, said a supervisor who only agreed to talk candidly on condition of anonymity.
Even if CHC was not in deficit, Muña said, civil servants could not get an increase until the salary freeze is lifted.
In the late 1990s, then-governor Pedro P. Tenorio issued an executive order stopping grade promotions. That order has remained in effect. Even though a hospital employee of five years could be qualified for an internal promotion, he still could not get the salary that was being offered for the vacant higher position he was applying for.
But any applicant who worked in the private sector could get the salary that was being offered for that vacant higher position. “They're going to be making more money than my employee who's already here,” Muña said. “I hate that. How can you manage a unit when you have employees that are not happy with what they are getting?”
On deaf ears
Villagomez said they have been “yelling and screaming,” asking the CNMI Legislature to increase DPH budget so they could hire more doctors and nurses and give their staff housing benefits.
“But they [lawmakers] don't listen,” he says. “As long as we continue to provide services to indigent population, we would need government subsidy.”
Responding to the charges of mismanagement, “What can I do if I get sick? I know I make mistakes but I do my best,” said Villagomez, 50, who was first appointed DPH secretary, at age 36, under the administration of former governor Pedro P. Tenorio. Villagomez finished two master's degrees: one in psychology from Washington State University and the other in public health administration from Harvard University.
“Now that I am back, I am rolling up my sleeves and working on implementing our plans for the hospital,” he said.
Meanwhile, Untalan believes the legislators behind the HEW public hearings were disingenuous and did not really mean to help the hospital. Rather, the legislators merely wanted to retaliate because Untalan refused to grant them favors.
“I question the wisdom of these people. I know they have a bone to pick,” Untalan said. “I think I am being harassed.”
Some time in June 2009, Untalan said House Speaker Arnold I. Palacios called him to ask if he could hire a “this lady.” But Untalan said he ignored Palacios because, according to the appropriations law the House passed, CHC was not supposed to hire non-medical, non-nursing employees. Efforts were made to obtain comments from Palacios but he has not responded to e-mail and phone inquiries as of press time.
Rep. David Apatang, HEW vice-chair, also called to ask why a “certain Jean Santos,” was being billed more than expected. Santos' wife was originally referred to the Philippines, where airfare is usually less than $500. But the patient preferred to go to Hawaii, where airfare is over $1,000. “By rules and regulations, if there was a change at the behest of the patient, pay the difference,” Untalan said.
“Why is Jean Santos being forced to pay extra when other people didn't?” Apatang asked. “Pete [Untalan] is just crying.”
Contrary to Untalan's claims, Apatang said it was the HEW committee's decision to conduct the public hearings following concerns about the condition of the hospital. “I don't think it's true that we just wanted to get back at him.”
Untalan said he is also being punished for rejecting Torres' request to become a member of the health department's recruitment committee.
“I don't want to micromanage but I want to see the transaction . the correspondence from the headhunters and DPH. I don't believe [DPH officials] are aggressive enough [in hiring],” Torres said.
But Untalan said it was not a legislator's job to get involved in a department's personnel selection. Besides, there were also some confidentiality issues to consider. Only DPH officials were allowed to look at personnel files. “Ralph [Torres] is jumping the gun . He should look at legislative policy and how to improve the health care system. Maybe take bigger issues, like health reform. Maybe that is something that will trigger his brain.”
“[The hospital] is a complex organization,” a fact that legislators do not understand, said Untalan. “It requires people that actually know the system.”
Untalan agreed that CHC was indeed “at the crossroads of a total breakdown.” But so is the entire CNMI. And if both the Executive and Legislative branches fail to come up with ways to increase revenue stream, then the hospital would not have the money to reverse its deteriorating condition. “I am not saying we have no faults. I am not making excuses. [But consider] the intensity of what we are operating under,” he said.
In the end, the future of the hospital, said Untalan, rests on the hands of the CNMI Legislature. After all, it “controls the purse.”
To be continued.
(Jude O. Marfil)
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