Low morale, low wages, poor work conditions

Haidee V. Eugenio

NOVEMBER 2009

After suffering from frequent sore throats, Verena T. Cabrera went to the only hospital in the Commonwealth of the Northern Mariana Islands (CNMI) on March 10 this year to have her tonsils removed.
Prior to the hospital visit, she was assured by the doctor who later operated on her that “the procedure (would be) very minor, that she would spend the night in the hospital to be observed, and eat ice cream.”
But what was supposed to be a simple and safe procedure to remove the tonsils that might lessen the frequency of her sore throats became the cause of her untimely death a day after she went into cardiac arrest on the operating table. She was only 18.
Now her family is suing the government-run Commonwealth Health Center (CHC), two doctors, and nine others for her death. Out-of-court settlements and lawsuits have not only taken away millions in dollars from actual patient care, but also discourage patients from seeking treatment at the hospital for fear of aggravating their illness or, worse, die on the operating table.
Concerns about medical malpractice at CHC come at a time when there is a shortage of physicians, from emergency room doctors to nephrologists and cardiologists, and a high turnover among those on board for a host of reasons including working condition such as low employee morale, much lower salaries than what they used to earn on the U.S. mainland or Canada, and lifestyle.
There are only a little over 25 doctors at CHC for a CNMI population of 50,000, and the number keeps on changing with the recruitment and resignation of doctors. To be effective, the hospital must have at least 45 doctors, health officials said.
Health officials also told lawmakers that the $85 an hour that doctors get should be raised to at least $120 an hour to make the CNMI competitive in hiring physicians. Officials also said Canadian doctors find the $85 hourly rate “ridiculous” compared to the $200 an hour in their own country.
Even the doctor who operated on the patient in the most recent medical malpractice case has already quit the government hospital for greener pastures.
Just two weeks prior to the filing of the case, another patient sued CHC after his face was allegedly set on fire while undergoing operation in April this year.
Mismanagement
A survey conducted by the CNMI House of Representatives’ Health, Education and Welfare Committee also identified mismanagement, inadequate procurement practices and poor records and billing systems as among the major problems at CHC.
The survey result, coupled with the continuous exodus of the few remaining doctors and the lack of a stable management, led the House of Representatives’ oversight hearing on the CNMI Department of Public Health. CHC is one of the component units of DPH.
Prior to the oversight hearings, lawmakers subpoenaed dozens of documents from DPH. Lawmakers also asked DPH to answer over 230 questions about its management, hiring practices, medical supplies and equipment, hospital billing and collections, medical records, customer service, medical referral, and the long-delayed opening of the bloated $22 million dialysis center which began as a $5 million project.
The government hospital has over $118 million in uncollected billings for the services it rendered to patients. The opening of the dialysis wing is still uncertain because Medicare would not certify the facility due to a lack of a medical director and other medical professionals, design flaws, a non-U.S. Food and Drug Administration-approved reverse osmosis system, and problematic water treatment system, among other things.
DPH fires back
But because the oversight hearing was scheduled only weeks away from the Nov. 7 general elections, DPH officials accused lawmakers of electioneering, grandstanding and using health issues to gain media mileage and earn votes.
Acting Health Secretary Esther Muna said if lawmakers had really wanted to help DPH, it should have done so from the time they were elected into office and not only when their re-election is coming up. DPH also accused lawmakers of witch-hunting.
During the oversight hearing, Rep. David Apatang (R-Saipan) brandished a letter he received complaining about the lack of sensitivity of nurses at the psychiatric ward towards patients.
When DPH officials asked for a copy of the complaint so they can investigate and help address the specific complaints in the letter, the lawmaker refused to release such letter, saying it’s “confidential.”
This disappointed DPH officials. “We are the ones who should be given those complaints. They’re saying they’re confidential. If you want us to take care of the problems, give it to us so we can take care of the problems. But they’re keeping it and collecting it for this hearing. I just don’t understand that,” Muna told reporters.
One of the lawmakers who have been consistent in her quest for efficiency and transparency, Rep. Tina Sablan, said CHC’s “crisis is so acute, so severe, and far reaching that the timing is irrelevant.”
 “We can spend our time speculating about motives or we can try to do the right thing,” she said.
The speaker of the House of Representatives, Arnold I. Palacios, said lawmakers are not expected to stop what they are doing to address concerns at DPH and any other CNMI concerns just because it’s an election year.
Other lawmakers said one of the root causes of the problems at DPH is the absence of a stable management. For seven months, CNMI health secretary had been on medical leave. He returned only a week after lawmakers held the oversight hearings on DPH.
The DPH officials who were temporarily assigned to hold the health secretary’s post had also gone off island for medical treatment or had to go back to their actual duties and responsibilities, and they held the post alternately, making it hard to implement and follow through policies and hurting employee morale.
Adding to the toxic mix is the system of promotion and salary at DPH which makes it difficult for employees to pole vault into positions commensurate to their qualification and instead have to move up the ladder one step at a time.
The lawmakers have yet to issue formal recommendations to DPH after conducting the oversight hearing, although committee chairman Ralph Torres (R-Saipan) said they want immediate hiring of needed physicians, appointment of permanent managers, and regular dialogue between the committee and DPH managers.
Health emergency
On Oct. 20, CNMI Governor Benigno R. Fitial took control of DPH after declaring a state of health emergency for the CNMI. This paved the way for the government to hire physicians from the Philippines and other countries outside the U.S. and Canada to help address the shortage of specialists on the islands.
The governor directed DPH to immediately adopt appropriate recruitment strategies to restore an adequate level of medical services to the client population.
 “The Commonwealth is experiencing an increasing rate of deaths among community members that can be attributed to lack of health care,” Fitial said in his one-page declaration, which underwent extensive legal review weeks after he announced his plan to address doctor shortage at the government hospital.
He said the current systems of healthcare delivery are overtaxed with less than needed numbers of physicians and nurses available to serve medical needs, and the rate of of-island referrals has increased to the point where it poses a fiscal threat to the economic stability of the Executive Branch.
CNMI’s medical referral costs reached $7.4 million in Fiscal Year 2009, a 17 percent increase over FY 2008’s $6.3 million, even as appropriations totalled only $5000.
The $7.4 million includes the actual costs of treatment and other medical care, as well as expenses related to transporting and accommodating patients and their family and medical escorts to health care facilities in Guam, the Philippines, Hawaii, and the US mainland.
 “The Department of Public Health is unable to address this situation within the existing regulatory structure,” the governor said.
Health secretary, Joseph Kevin Villagomez, who came back from months of medical leave, met with key DPH personnel a day after the emergency declaration, to discuss and begin work required by the declaration.
DPH has yet to provide details on the number and types of doctors that needed to be hired, the countries where they will be hired from, the salary levels, the start of the hiring process, whether it would involve direct hiring or the use of manpower agencies, and reprogramming of funds, among other things.
The governor, however, earlier said the CNMI needs to immediately hire, among other specialists, nephrologists or kidney doctors who are needed for the $22 million dialysis wing.
Press secretary Charles Reyes said details will be addressed shortly.
He said the Fitial administration expects DPH to recruit or use qualified and proficient foreign doctors, preferably with US training.
Lawmakers, along with the governor, have said that “it doesn’t make sense” to be restricted from hiring qualified, including US-certified, doctors from the Philippines when the CNMI sends hundreds of patients to the Philippines every year to undergo treatment.
Of the 2188 referrals made in the last three fiscal years, almost 63 percent or 1,373 were to Guam, followed by the Philippines, 420; Honolulu, 357; and 38 to the US mainland.
In FY 2009 alone, 192 patients were referred to Guam for radiology, followed by 128 patients referred also to Guam for oncology, and 56 patients referred to Manila for cardiology.
Currently, DPH is restricted from hiring doctors that are not from the U.S. mainland or Canada due to the CNMI Medical Profession Licensing Board regulations.
CNMI also cannot hire doctors from foreign countries due to the standards and requirements mandated by the federal government. CHC, which receives Medicare and Medicaid funding, is required to hire US-trained doctors.
The governor directed the CNMI Medical Profession Licensing Board “to review and revise regulations so that expanded medical services may be provided to the client population of the Commonwealth” within 15 days of the declaration.
Lawmakers who held the oversight hearing on DPH also raised concern about the costly arrangement between DPH and a US-based headhunting firm in which the firm is paid $25,000 per doctor from the US and Canada hired to work in the CNMI’s hospital.
The chairman of the House committee on health earlier asked the CNMI’s nonvoting delegate to the US Congress, Gregorio Kilili C. Sablan (D-MP), to seek help from the federal government to address DPH woes.
But Sablan said the federal government is not the answer to all of the problems at CHC as identified by the committee.
 “We in the Commonwealth have to take the initiative,” Sablan said, citing as an example a step he initiated in August asking a Guam company that currently provides imaging services to CNMI patients to set up operation at CHC.
“This would make it unnecessary to send patients to Guam for these services. The company is more than capable and willing to make the move.
“Now it is up to our CHC officials to take advantage of this opportunity to improve service and save money,” he added. This suggestion has yet to be taken by DPH itself.