During a Tuesday meeting at the Kenai Peninsula Borough Assembly chambers in Soldotna billed as a health care round table, Assembly President Gary Knopp asked members of the local medical community about a perceived “divide” between Central Peninsula Hospital and area independent physicians.
Knopp said his concerns about that divide began late last year when he first heard Kahtnu Venture’s proposal to build an ambulatory surgical center in Kenai. The surgical center is currently being considered by the state for a certificate of need.
Those concerns about a divide were further amplified during discussions about two competing cancer center proposals.
“I was hoping we could say, ‘Geez, why are you guys unhappy? Why is there all this opposition with Kahtnu and building the oncology center on-site?’” Knopp said Friday.
But those answers never came and Knopp said he was discouraged more local physicians didn’t attend the round-table meeting, which other residents, assembly members, borough and hospital administration did attend.
The only physician to address Knopp’s questions about a divide at the meeting was Dr. John Halligan, an Anchorage-based radiation oncologist proposing to build a local cancer treatment facility.
“But, I don’t know that we would have ever answered (that question), you know?” Knopp said. “If I would have come out and said, ‘What is the issue here? Are you unhappy with the hospital and the way that it is being operated? Or are you just jockeying in anticipation of what reimbursement rates might do in the future?’ I’m not sure I would have ever got a true answer to that question.”
But, Knopp said he needed to give the subject he’s heard about — division of the medical community — its due diligence.
“So I invited everyone to the table, I tried to express what my concerns were, but they didn’t seem to be shared by most of the members of the assembly or the public, but at least I got my issues stated,” he said. “I feel like I’ve done all the work I can do on the issue.”
At the meeting, Halligan spoke briefly about the subject, but said he couldn’t speak for all area independent physicians.
Halligan, Knopp and the assembly spoke at length about his cancer center proposal and a competing $4.7 million CPH proposal, which the assembly unanimously approved allocating money for during its regular Tuesday night meeting. The action wasn’t binding to building the facility, and CPH officials and Halligan are still in talks about finding a common-ground solution to that issue.
Knopp asked Halligan at the meeting why he didn’t want to align with CPH and practice oncology on the hospital’s campus rather than off campus. The assembly president said Halligan previously indicated that the hospital’s offer is generous and he is having a hard time declining it.
“But you said no, because ... of encouragement from the local physicians group down here that you have to work closely with and I can understand that,” Knopp said. “Really, I don’t know and I’m curious — is it because of physician independence or are they unhappy with our hospital, or are we just jockeying for market position? I’m trying to understand that.”
Said Halligan, “I can’t answer 100 percent for all the physicians, but I am certain that there have been estranged relationships obviously in the community and that may play a part in it.”
Halligan said later in the meeting that the area’s physicians — not the hospital — would be the main source of patient referrals for his cancer center, should it be built.
“We desire to maintain our independence and that has been part of our difficulty in dealing with this,” he said. “In my dealings with the board, the question of independence was implied as being something that we would lose in my first meeting with the hospital board. I have since had other members of the board say that would not be the case. (CPH Chief Executive Officer) Mr. (Rick) Davis has come out and said that would not be the case.”
Knopp asked later in the meeting if supporting CPH’s cancer center would further divide the hospital and the independent medical community.
“The (CPH) board doesn’t appear to me to be as content just in operating the hospital for us today as it was (when it was a small rural hospital) and they think the direction they are moving is the right way to go and I don’t fault them for that,” Knopp said.
Diana Zirul, a former Central Peninsula General Hospital, Inc., Board president, attended the meeting, but said Saturday area physicians she knows were not aware Knopp called a meeting at all, or found out just before it was starting, like her husband Jim. However, she said many physicians are eager to convey CPH’s actions indicate it is trying to “aggressively monopolize” the area’s health care.
“This isn’t jockeying for position — I don’t believe that,” she said. “I think that the hospital and the assembly have chosen to do whatever they want to do ... without involving the physicians. That’s all of the physicians, that’s not just a handful of them.
“They do not appear to involve them in their discussions until they already made a decision. Then they say, ‘Why don’t you like our decision?’”
At the Tuesday meeting, Knopp asked Alyson Stogsdill, CPGH, Inc., Board secretary and treasurer, how to fix the divide. Stogsdill said it might have to do with CPH’s hiring of physicians.
“It has never been a goal of the hospital board in any meeting I’ve ever been to that, ‘We’re going to own all the docs,’” Stogsdill said. “The physicians that we do have employed came to us and asked for employment. We are not going out and ringing doorbells asking, ‘Do you want to work for us?’ or, ‘We’re going to make you work for us.’”
Stogsdill said the hospital’s communications haven’t been what they should have been.
“Some of that was that we were told what we should say and when we should say it in some circumstances,” she said during the meeting. “That came from administration, not ours but past borough administrations ... well, ‘What did we know? We’re the tenant and you’re the landlord in that case. OK, we’ll follow directions.’ We learned the hard way.”
CPGH, Inc., Board President Lore Weimer thinks much of the division comes from the hospital’s employment of physicians — a trend that’s caught on in recent years in community hospitals around the nation, she said after the meeting Friday. About 50 percent of the physicians on CPH’s medical staff are employed by the hospital, she said.
“There’s a number of physicians that have the desire to be autonomous and practice independently and so you’ve got two things — the people who have been in your community a long time and were independent and then you have all the new people and most of them want to be employed,” she said.
However, that trend seems like competition to those independent physicians, she said, adding to continuing frustrations of lowered reimbursement rates and increasing costs of maintaining a practice. The view, Weimer said, is CPH’s employment of physicians is “disrespecting” to the independents, which she said she can understand.
“If you ask some of them they’ll say we recruited some we didn’t need or we did things that seem spiteful,” she said. “But I feel pretty good about the recruits we’ve made and we’ve brought good doctors here.”
Weimer said many of the problems can be attributed to national changes to which CPH is having to adapt.
“It certainly looks divided because I can see how it plays out at the assembly all the time and how angry the independent ones feel,” she said. “I get it. But we’re not driving that anger. The (national) health care reform drives a lot of that.”
Weimer said CPH staff is working to facilitate relationships and rework its administration and governance to accommodate for the mix of physicians. She also mentioned a CPH initiative with the Coker Group, a national health care consulting firm, to listen to all of the area’s physicians and present CPH with a report about what they could be doing better.
Zirul said Saturday many physicians feel a “lack of trust” and a “lack of communication” with the hospital.
“In some ways it is a disrespect,” she said of CPH hiring its own physicians, adding some might not have been needed. “... I do know they have been less than forthright in their dealing with the physicians and there are a number of examples ... where that has created that divide with the medical community. That’s unfortunate and I think a lot of that is communication.”
Henry Krull, a Soldotna-based orthopedic surgeon associated with Kahtnu Ventures, said Saturday in an interview the issue came to a head during conversations last year about managed care contracting with self-insured entities. He said CPH administration told the independent physicians if they were not part of their decision, CPH would hire additional surgeons that would be.
“It was either, ‘You join us or we are going to beat you down,’” Krull said. “That kind of talk continued when we did our surgery center proposal and we were told straight up by the administrator, ‘If you do this, I will make your life very difficult and your reputation will be harmed in the community and furthermore we are going to hire around you if you do that.’”
Said Krull: “The hospital has expressed very overtly its desire for monopolization of health care. The examples I have to support that are their lack of interest in a surgery center, which could help save health care consumers a tremendous amount of money, and also the lack of desire on the hospital’s part to support a cancer treatment center other than on their own campus where they will be able to control it.”
Kenai Peninsula Borough Mayor Mike Navarre agreed he has seen some division among the health care community, but said it isn’t a hospital-versus-physicians division. He said he thinks many independent physicians support the hospital on a general level.
Physicians are simply anxious about where things are headed and where national health care reform impacts are going to fall, he said.
“So that leads to some apprehension about who is going to be driving these decisions and influencing decisions,” he said. “There are some independent docs who want to make sure that the hospital isn’t so strong that they get pushed along by the hospital.”
Zirul feels it would be beneficial for the assembly to sit down again, invite all of the medical community to the table, and discuss the issue of the medical divide more openly, she said.
“Nobody is sitting down and talking about it,” she said.