By Malia Zimmerman for the Grassroot Institute of Hawaii

Ellen Bellerose rushed to Maui Memorial Medical Center's emergency room at her cardiologist's direction after she felt severe pain and pressure in her neck, chest and arms. As the pain intensified over the next two hours, she walked up to the counter three times to report difficulty breathing. She was told there were no beds available. "I was becoming terrified that I could die, unattended, in the emergency room." Although registered as a patient for 27 hours, she never entered the main hospital that February 7, 2006, but was billed as if she had.

Bellerose is one of many Maui residents with complaints about Maui Memorial, the island's only acute care hospital. She along with several dozen other Maui residents and medical professionals shared their agonizing stories in 2006 with the Hawaii State Health Planning and Development Agency (SHPDA), a division of the state Health Department, in hopes the agency board would agree to allow competition for the island's only hospital. But SHPDA blocked the plan to open Malulani Health and Medical Center, a 150-bed acute hospital facility, largely at Maui Memorial's insistence, because Maui Memorial claimed competition would put the state hospital out of business.

Today, as debate rages nationally on whether healthcare should be controlled by government or the free market, the battle continues over what healthcare should encompass on Maui - an island with a growing population of about 140,000 people and another 2 million visitors annually. Should there be just one acute care hospital to service an island with 727 square miles, much of the land remote and accessible through just one road?

The current hospital system's supporters say yes, including many of its more than 1,000 workers, as well as Maui lawmakers, such as union-backed Democratic Senators Roz Baker and Kalani English and Senate Health Committee Chair David Ige.

However, many Maui residents are deeply troubled by the conditions at the 231-bed, government-owned hospital, which is overseen by the state Department of Health and managed by the Hawaii Health Systems Corporation (HHCS), an entity created in 1998 by the state Legislature to manage a dozen state-owned hospitals.

While most in the community don't disparage the hospital's doctors and nurses, they are critical of the old facilities, outdated and broken medical equipment and mediocre management.   Whether it's the smell from the morgue contained by a towel stuffed under the door; the "old building syndrome," meaning battles with mold and potential asbestos problems in the hospital's older section; the aged, out-of-date medical equipment; or the archaic record-keeping computer system, several medical personnel interviewed for this story question whether the facility is "safe" for its staff and patients.

POOR MANAGEMENT PLAGUES HOSPITAL, CRITICS SAY, BUT CEO DEFENDS SYSTEM

Wes Lo, CEO of Maui Memorial, maintains his hospital is safe, that national benchmarks are met, that his staff does its best to provide quality care and that the hospital has passed quality and accreditation tests. In addition, Lo says Maui Memorial is one of about 500 hospitals nationwide to receive an award from the American Heart Association.

But that doesn't stop patients and doctors from criticizing Maui Memorial for poor fiscal and patient management, overcrowding, and its hard fought battle to keep private competition out.

Jane Kocivar, an MD in private practice who also was on call at Maui Memorial, says she is frustrated by the lax management and an unwillingness to work with doctors for the betterment of the patients.

Jeffrey M. Drood, M.D., cardiologist and electrophysiologist on staff in the Maui Memorial Medical Center Department of Cardiology since 1999 and private practitioner in Wailuku, says every hospital makes errors, but at Maui Memorial, there are an inordinate number. "I am concerned there does not seem to be any effort to change that. There is no accountability or constructive education, or a change from the bad practices going on that seem to be very ingrained in the system in Maui Memorial."

Doctors note that at a cost of millions of dollars, a new cardiac unit was established this year with a salaried staff to include two open-heart surgeons, a perfusionist and some attending nurses, when patients can be flown to Oahu for better care.

In addition, while these doctors are being paid as staff rather than contractors, at the cost of hundreds of thousands of dollars per year, medical staff say the hospital regularly runs out of basic supplies. "Cardiac surgeons are hired and are not doing any work, yet we don't have basic services and supplies like beds that work, oxygen monitors, blood pressure cuffs, recliner chairs, utensils, napkins, and paper towels for the nurses," says Kocivar.

Drood says Maui County needs local availability of cardiac interventional procedures and not just diagnostic capability; however, Maui Memorial's proposal to launch a high-end tertiary-care cardiac program is premature until the hospital administration addresses the deficiencies in the quality of basic hospital care.

Maui Memorial CEO Wes Lo defends his decision to make Cardiac Surgery or Interventional Cardiology services available on Maui for the first time, calling it a critically needed service for people who have Heart Attacks and Acute Myocardial Infarctions (AMI's).

Lo says Maui Memorial is now ready to start open-heart surgery on an elective basis with additional staffing he says is required, including specialty-trained nurses, physician assistants and perfusionists.

"Approximately 50 percent of all our off-island transports per month are cardiac related cases. I believe that we probably transfer more than 350 cardiac cases per year off-island due to lack of available services," Lo says.

FACILITIES SUFFER FROM 'OLD BUILDING SYNDROME'

Medical staff have complained about working conditions, particularly in the old wing of the hospital constructed in 1952, where a perpetual battle with mold continues. Some staff have been reassigned to other hospital areas because of health issues that have arisen likely due to exposure to mold.  They are also being treated by physicians for respiratory symptoms similar to what a patient would experience if they breathed in black mold spores.  These patients said the hospital has not investigated this possibility despite their requests, further jeopardizing their health by delaying targeted treatment.

Lo agrees Maui Memorial does encounter mold issues from time to time, but makes its best effort to validate and mitigate concerns immediately. "We have a full-time infection control person, and our facilities staff is fully trained in remediating any mold issues. We have not recently had any mold issues that are 'extraordinary', however, there was recently a report of some mold in one of our buildings.  We did have an independent mechanical engineer test the air in the area, and identify any concerns, and his test did not indicate any air quality issues in the hospital."

However, two independent mold tests taken for this report in mid-August 2009, found traces of multiple kinds of mold, including those that could cause health problems.

Maui resident and former county police officer Marc Hodges, who volunteered to help facilitate the mold testing, says observations at Maui Memorial found an interior wall on the fifth floor with water running down it, which appeared to be a result of a persistent leak from the ceiling area.

Pro Lab, a professional mainland lab that analyzed the wall swab sample, detected "Fusarium" and "Coelomycetes." "Symptoms from Fusarium may occur either through ingestion of contaminated foods or inhalation of spores. In severe cases, the fungus can produce hemorrhagic syndrome in humans characterized by nausea, vomiting, diarrhea, dermatitis, and extensive internal bleeding and is frequently involved in eye, skin and nail infections."

Enviro-Cure Services Inc., says Fusarium causes "extremely dangerous skin infections with symptoms similar in appearance to Strep A, 'the flesh eating' bacteria" with many experts comparing the symptoms to that of leprosy."  The web site adds: "Ulcerations or infections of the face, hands, and body are very graphic, and once infected, most persons stay bed ridden for a considerable period. Further debilitates the immune system of already suppressed persons.. Preliminary analysis reveals that Fusarium has been linked to impotence."

Pro-Lab also reports finding "Coelomycetes," which "cause hay fever and asthma."

Hodges says in order to protect the health and safety of the Maui Memorial staff and patients, a dedicated expert mold inspection followed by appropriate remediation should be implemented as soon as possible.

FINANCIAL, AUTONOMY AND CAPACITY CHALLENGES PLAGUE HOSPITAL SYSTEM

Recent legislation allows Maui Memorial to have control over its decision-making and finances and to pursue private financing to reduce financial support from the State of Hawaii.

FY 2009 was "extremely tough," for Maui Memorial, which had operating income of $142 million and operating expenses of $172 million. The State contributed $20.8 Million in appropriated assistance and also provided a $10 million loan when previously arranged credit facilities were frozen.

Salaries and benefits comprise about 60 percent of hospital operating costs, which Lo says is slightly high based on national averages, but "typical" for the industry locally. To lower labor costs in the future, Lo says: "One area that we would like to explore in our labor area is work rules and some of the benefits, as we think that these could have a significant impact on our costs in the future." As for himself as CEO, Lo is the highest paid administrative employee at $234,000 a year.

Several physicians cited patient capacity as an issue, saying the hospital is often overflowing with patients into the emergency room, the hallways and elsewhere. Physician George Martin says Maui will require a maximum of 55 to 85 additional acute care hospitals beds by the year 2010, and by 2015 an additional 90 to 130 acute beds.

Maui Memorial is looking at other options for continued expansion plans, including private, not-for-profit partnerships.  Lo says the hospital is being upgraded including re-roofing, exterior repair, plumbing and air-conditioning upgrades and a generator upgrade.

There is a neighboring building that is also sitting empty, which Maui Memorial is leasing for $51,000 a month - something that has doctors critical of Maui Memorial's financial management.

Lo says this building will be used for the expansion of medical services and make for a 'virtual medical campus.' "We are currently in final stages of negotiations with an independent company who is a medical provider for the sublease of the building."

ATTRACTING AND KEEPING MEDICAL PROFESSIONALS IS A CHALLENGE

Doctors say they are leaving Hawaii because of business unfriendly laws that make it expensive and prohibitive to practice. The neighbor islands, especially Maui, are most greatly impacted.

Drood says there will soon be a real, tangible physician shortage at the hospital and eventually on Maui, because in the next three to five years a significant number of the current Maui physicians will retire from practice. Physicians are resigning, he says, "because they can no longer work within this system that for years has been unresponsive to their needs as clinicians, that has strived to maintain mediocrity and that has placed self-preservation above the welfare of our community."

PATIENTS LEAVING MAUI TOO, INCLUDING MAUI'S YOUNGEST

Jan Shields L.V.T., B.S.N., R.N.C.-NIC, the Executive Director for the Association for Improved Healthcare on Maui, and Vice President of Malulani Foundation, used to work at Maui Memorial in its well baby nursery.

She says Maui's youngest must leave the hospital if there is a complicated birth, or complication with a newborn, because there is no neonatal ICU. That has a great impact on Maui parents, because at least one parent usually stays with the baby, and loses time at work, putting their livelihood in jeopardy.

"There is an average of 12 sick or premature Maui infants in Oahu hospitals every day, and sometimes, many more. There have been several cases where babies could face lifelong damage because they did not have the proper immediate care after being born at Maui Memorial," Shields says.

When Shields worked in an Oahu Neonatal Intensive Care Unit, her manager told her that the infants transported from Maui Memorial were always in the worst shape due to poor initial care, in comparison to the other islands.

"There are babies who have died because they were born at Maui Memorial. Where is the outrage about our Maui babies?  We need a real hospital that will give these infants the care that they need and send home healthy babies to our Maui families," says Shields, who is still working to bring additional competition to Maui.

COMPETITION: A FRIGHTENING PROSPECT FOR MAUI MEMORIAL MANAGEMENT

When there was a chance in 2006 for a competitor to Maui Memorial, Maui Memorial and its contractors mobilized against Malulani Health and Medical Center through the anti-competitive Certificate of Need process.

"I got mad because I saw how corrupt it is and how they squashed what the public wanted," says Jane Kocivar MD. She adds that there are only a handful of physicians who will speak out on Maui about the problems with healthcare there, because nearly every medical professional is financially or professionally tied to the system in some way.

Ron Kwon, MD, a Maui-born, Harvard-educated physician, spent 10 years working to build Malulani, the private alternative, which he says would have solved many of the most pressing healthcare needs.

In Hawaii, private companies must apply to the SHPDA Board for a Certificate of Need before they are allowed to build a hospital.  CON state and federal laws were passed around the country in the 1960s, and were repealed federally in 1987, but Hawaii did not follow suit.

"Under the guise of controlling health-care costs, Certificate of Need laws allow established market players to game the system by convincing regulators that competition would force them to charge more or to cut politically popular but money-losing services such as substance-abuse counseling. This CON job is even easier to pull when the established market player is a state-run hospital, such as Maui Memorial," says a recent article in the National Review.

When denying Malulani's CON application, National Review and others point out that SHPDA relied almost entirely on the testimony of interested parties, primarily officials from Maui Memorial who claimed the competition would hurt them financially.

Kwon, who raised $1.3 million to get Malulani off the ground, says SHPDA ensured that no outside sources of funding for new medical facilities in Maui County will be available for years to come.

In a 2008 farewell letter to Maui, Kwon said "the healthcare crisis in Maui County is doomed to get worse before it can get better." Kwon left Hawaii in 2008, and now works with a community hospital in Concord, Massachusetts.

Celeste M. Baldwin, Ph.D., APRN, a lecturer at the University of Hawaii, says as a prior staff nurse, administrator, tenured professor of nursing, nurse researcher, and patient advocate:  "At present, we have a one hospital show in town.  Every attempt is being made to make it the best.  However, due to the economics, bad luck in decision making, and unforeseen circumstances, the current hospital system is failing."

RECOMMENDATIONS FROM THE MEDICAL AND BUSINESS COMMUNITIES TO IMPROVE

• The Certificate of Need process should be eliminated in Hawaii, so healthcare competition is not unfairly kept out of state by people and businesses with conflicts of interest.

• With more competition in healthcare introduced to Maui, patients will have more choices, services and options at a lower price. Residents and their families will also potentially have a better quality of life and less expense if they can stay on the island for medical care.

• The Association for Improved Healthcare on Maui and the Malulani Foundation are still working to bring a private medical center to Maui. Whether it is the Malulani or other private medical groups opening a competing hospital, this would increase health care options, add well-paying construction, medical and administrative jobs during a down economy, help small businesses servicing the hospital on island and diversification of Maui's economy.

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Malia Zimmerman is the president of Hawaii Reporter, and has worked for the Wall Street Journal, ABC 20/20, Fox News and the Washington Times. She wrote this report for the Grassroot Institute of Hawaii, a non-profit public policy institute on Oahu. For more information, log onto www.grassrootinstitute.org

Reprinted with permission, GRIH.