Last October state officials rejected the proposed Malulani Medical Center in Kihei. Now hospital proponents are asking for an appeal. Even if they get one, it's doubtful our healthcare will get any better.
January 11, 2007
The timing was beautiful. "Did you know Maui Memorial has a two-slice CT scanner?" Dr. Ronald Kwon, the chief proponent of the proposed Malulani Health and Medical Center, told me on Jan. 3. His tone was alternately incredulous and bitterly sarcastic—both understandable, given his 21 years as a medical doctor on Maui as well as his status as chief booster for the big for-profit hospital he wants to build in Kihei that would compete against Maui Memorial Medical Center (MMMC) for doctors, patients and money.
"That's 20 years old!" he said. "Triad Hospitals is buying 30—that's three-zero—64-slice CT scanners this year. They were going to put one on Maui [in Malulani]. But I guess we don't need one."
It was a well-repeated argument against relying on Maui Memorial. But the next day—Jan. 4—I unfolded my copy of The Maui News and saw the headline "Maui Memorial installs high-tech imaging system" splashed across the front page. "There isn't anything like this elsewhere in Hawaii," Maui Memorial's Dr. Chris Neal said in the paper about the hospital's new $2.5 million Axiom Artis DynaCT scanner. "There are only three in the western United States, and one is at Stanford, but it's not as good as this one."
City Editor Edwin Tanji, the story's author, described the acquisition as making "Maui Memorial a leader in stroke intervention and vascular procedures not only in Hawaii but around the Pacific and even in the U.S."
The story never mentioned Malulani or the fact that proponents like Kwon have spent years deriding Maui Memorial for lacking exactly that kind of equipment, but it's clear they deserve at least some of the credit for MMMC's new "state of the art" scanner. It was they, after all, who promised that a new hospital in Kihei would force old Maui Memorial to start improving itself rather than face extinction.
"[I]nnovative programs and technology at Malulani will serve as a catalyst for progress and innovation at Maui Memorial," states the Frequently Asked Questions page on their official website, www.malulani.org. But who would have guessed the mere threat of a new hospital might lead MMMC to go shopping?
Of course, one "high tech" scanner does not make a modern, complete American medical center, and Malulani officials and fans still want their new hospital. Though rejected by the State Health Planning and Development Agency (SHPDA) on Oct. 2, 2006, Malulani officials have requested a reconsideration hearing, which will at press time happen on Jan. 22, to ask for a formal appeal. Of course, state agencies being what they are, even if Malulani's backers win on Jan. 22, they'll have to appeal to the very same body that rejected them the first time.
"That's the way the system is set up," Kwon said. "You can make a case that they overlooked certain things. You can even bring up new things. You can appeal for any reason you want. It's a very strange statute."
Malulani has powerful friends, but it's hard to say whether they'll ever get approval—to say nothing of a chance to appeal. SHPDA officials have decreed that the reconsideration hearing will take place in Honolulu—not Maui, as Malulani backers hoped—which makes it unlikely the agency will hear from many Maui residents about the state of this island's healthcare.
In many ways, the fight over Malulani—including the recent Maui Memorial announcement concerning their super CT scanner—exemplifies what's wrong with American healthcare. Malulani's proponents have made a vivid, terrifying case how Maui's lone acute care hospital in Wailuku is woefully small and old and just not up to modern standards.
What they haven't said is that it's increasingly apparent that it's those "modern standards" that are actually making our healthcare more expensive and less rational than that found in other industrialized societies around the world. It's awful to think about, but Malulani might even make things worse.
Even attempting to make a case against Malulani seems almost sacrilegious. New, high-tech, "state-of-the-art" hospitals are supposed to do good things. When you're giving birth, or scheduling knee surgery or undergoing chemotherapy, we want the best of the best that medical knowledge and technology can offer.
In Malulani's case, the best means bringing in Plano, Texas-based Triad Hospitals, Inc.—a $5 billion health care corporation that runs 50 hospitals nationwide. If SHPDA reverses itself, Triad would own 80 percent of Malulani. The other 20 percent would go to a local non-profit entity called Malulani Health Systems, Inc., run by 11 Maui residents including Kwon and mega-developer Charlie Jencks.
According to terms of the agreement between the two companies, Malulani has to raise $42.4 million. If it can't, Triad has said it would make up the difference.
Governor Linda Lingle backs Malulani–so much so that she wants the state Legislature to grant it a special exemption from SHPDA. Mayor Charmaine Tavares, Maui District Health Officer Dr. Lorrin Pang and Joe Bertram III, the state representative for South Maui also want Malulani.
The Malulani application before SHPDA filed back in May 2006 promises a "comprehensive, state-of-the-art, fully digital healthcare campus" offering 150 private patient rooms, a full emergency department, a high risk obstetrics center as well as comprehensive cardiovascular, peripheral vascular and neurological services to Maui—programs either missing from or under great strain at Maui Memorial.
But backers insist this wouldn't be a 40-acre sterile computer center. "Holistic healing practices will not only occur within the walls of the facility," states the application. "The idea of restoration will transform and heal the surrounding landscape as restored riparian intermittent streambeds containing native biophytic vegetation run throughout the site. These features will be repeated in courtyards within the buildings in the form of natural healing gardens."
"Maui is the only major Hawaiian island without at least two acute care hospitals," states the Malulani application. "Maui has the lowest acute care bed to population ratio of any major Hawaiian island… The result is that Maui County residents must go to Oahu to receive medical care that should be provided on Maui."
Few of us wouldn't want to get well in such a place. But SHPDA rejected such a proposal, saying Malulani will fragment our medical services. They tossed out the hospital plan on the grounds that it would "undermine and weaken our community's healthcare system by duplicating and diluting services."
Kwon says that's "nonsense."
"Healthcare in Maui County is already fragmented," he said. "There are a lot of undiagnosed diseases here. People can't find access. They can't get care. It's already fragmented and broken."
Our county is hardly alone in that regard. Everywhere in the U.S., healthcare costs are exploding while access to insurance and even hospital beds is dwindling. In 2004, healthcare spending in the U.S. represented 16 percent of our gross domestic product (GDP). Contrast that with the 1960 figure, which was a mere 5.2 percent of GDP.
Healthcare costs in the U.S. are rising so high that private health insurance plans are coming apart. It's a return to the "crisis" of the early 1990's that spurred the new Clinton Administration's greatest promise and most stinging defeat—the healthcare reform effort headed by Hillary Clinton.
The Clintons tried to get every American health insurance through Health Maintenance Organizations (HMOs) and it went nowhere. That's because the U.S. has one of the strangest healthcare systems in the world. To even call it a "system" is to grant it far more rationality and legitimacy than it deserves.
In most industrial and post-industrial nations—and our own Veterans Administration, ironically enough—healthcare is government-funded. There are no HMOs. There are no private hospitals. There are no mandates on employers, requiring them to buy their employees health insurance.
We deride so-called "single-payer" systems like those in found in Europe as "socialized medicine," but there's now a huge body of evidence to indicate that they do indeed get care to all citizens and manage to keep costs down.
But here in the U.S., healthcare is a jumble of private, for-profit corporations that sell insurance, provide care and build medical equipment. Doctors earn extremely high salaries—the highest in the world, in fact. The result, according a Mar. 23, 2006 essay in The New York Journal of Books by economist and New York Times columnist Paul Krugman and co-author Robin Wells, is a mess. And the more we make it better with high technology and private health plans, the worse it gets.
"American health care tends to divide the population into insiders and outsiders," wrote Krugman and Wells. "Insiders, who have good insurance, receive everything modern medicine can provide, no matter how expensive. Outsiders, who have poor insurance or none at all, receive very little."
Technology, like the vaunted Axiom Artis DynaCT scanner, is a big part of the problem.
"In response to new medical technology, the system spends even more on insiders," wrote Krugman and Wells. "But it compensates for higher spending on insiders, in part, by consigning more people to outsider status—robbing Peter of basic care in order to pay for Paul's state-of-the-art treatment. Thus we have a cruel paradox that medical progress is bad for many Americans' health."
In a response to Krugman and Wells article, Harvard Medical School Professor Emeritus Arnold S. Relman, M.D. took it one step further.
"[O]ver the past few decades the private health care delivery system, like the private insurance system, has been converted into a huge commercialized market which in many parts is heavily influenced—if not dominated—by competing investor-owned firms," Relman wrote in the Oct. 19, 2006 New York Journal of Books. "Yes, expensive new technology and new procedures, more specialists, and an aging population are all part of the problem. But much of the impetus to expand the use of health resources surely comes from the fact that there is a lot of money to be made and the expectations of investors and physicians are high."
Investors. Given the staggering amounts of money exchanged between doctors, insurance providers, hospital administrators, medical equipment manufacturers, who wouldn't want a piece of the pie? Yes, American healthcare—like everything else that's market-driven—demands trade-offs. The rich get their super CT scanners, but the working poor lose their health insurance. Short of the federal government moving billions of dollars worth of grants to public hospitals and instituting universal, single-payer health insurance, we're trapped in a vicious cycle.
Autocratic state bureaucracies are the bane of Maui's aspirations," The Maui News editorial page sneered on Nov. 26, 2006, nearly two months after the state shot down the Malulani application. "Nowhere is that more apparent than in the ongoing struggle to build a private hospital in Kihei."
Far be it from me to defend "autocratic" anyone—especially SHPDA, which insists on holding Malulani's reconsideration hearing on Oahu instead of Maui—but even they admit that Maui healthcare is falling behind.
"Maui will need additional acute beds and associated services in the future," states the agency's Oct. 2, 2006 Malulani decision. "Maui may need: a maximum of approximately 55-85 additional acute care beds by 2010, or, a maximum of 90-130 acute care beds by 2015."
To meet that need, SHPDA recommends, "One large, well-run facility, strategically-located, would be the most efficient and effective means of addressing the acute care needs on Maui." Though it does add that since the state "may not have the capital to expand, replace or significantly upgrade MMMC to meet the future needs of Maui… a private sector provider or a private/public community joint venture may be needed."
Who knows—maybe no matter what Triad will come here after all. MTW
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