Providence St. Patrick Hospital in Missoula unveiled its brand-new, state-of-the-art Level II Neonatal Intensive Care Unit on Wednesday, the hospital’s latest foray into territory that previously was the sole domain of its cross-town competitor Community Medical Center, which has a more complex Level IIIB NICU.
It's a decision that the CEO of Community Medical Center, Dr. Dean French, says creates "unnecessary and potentially catastrophic competition" that he tried to quietly avert, but was rebuffed. Officials at CMC believe that having two NICUs in town will essentially dilute that talent pool for the highly specialized staff that is required, which might reduce the quality and safety of care that patients receive.
The new unit at St. Pat's is slated to “go live” on March 11 and will allow the hospital’s specialized staff to care for premature babies. Babies born before 35 weeks of gestation were previously transported to CMC’s NICU, but now St. Pat’s can care for babies born as early as 32 weeks of gestation.
St. Pat’s opened its $5 million, seven-bed Family Maternity Center in August 2015 and has since delivered more than 1,200 babies. Before that, CMC was the only hospital in town with a maternity ward and a NICU. Community switched from a nonprofit to a for-profit model in 2014, and St. Pat’s began delving into the market of delivering and caring for babies shortly thereafter.
Joyce Dombrouski, the chief executive of Providence Health & Services Montana, said the opening of the NICU was a strategic program goal since the maternity ward’s inception. Through a partnership with Western Montana Clinic, the Maternity Center contains a three-bed Special Care Nursery staffed by pediatric hospitalists, which has now been elevated to the Level II NICU.
“Since we opened the Maternity Center, we’ve been transferring about 15 babies a year to Community, as they have a well-established Level III NICU,” Dombrouski said. “But it made sense to start a program here and one of the many benefits is we’ll be able to keep new moms and their babies together.”
St. Pat's did not respond to a late-afternoon request for specific comment on French's remarks.
French said that St. Pat's decision to pursue opening the NICU "unfortunately puts at risk a fragile resource that is unusually robust and advanced for a community the size of Missoula."
"The depth of resources required to maintain a Level IIIB NICU typically requires a population in excess of 250,000 to generate the volumes necessary to maintain the skill and competency of the medical staff," he said. "Because the NICU at CMC is a regional referral center, we are able to achieve the volumes necessary to maintain competence, but by a narrow margin."
French said he tried in vain to express his deep concerns to executives at Providence.
"Early in the process of Providence St. Patrick Hospital announcing their intent, CMC quietly communicated and offered multiple avenues to avert unnecessary and potentially catastrophic competition," he said. "Unfortunately, these were ultimately rebuffed. St. Pat’s decision may result in Missoula no longer being able to provide the state’s highest level NICU to care for the most vulnerable neonates.”
Dr. Bonnie Stephens, the medical director of the NICU services at CMC, said many people might believe that having multiple NICUs in a single location is a good thing, but that it actually can reduce the level of care for patients.
"In a high-volume medical specialty, such as orthopedic surgery or cardiology, where it is easier to gain and maintain expertise, competition can result in improved quality and lower cost," she said. "But in a low-volume, highly specialized field such as neonatal intensive care, it is more difficult for neonatal physicians, nurses and respiratory therapists to maintain their skills. Having two hospitals providing NICU services will reduce the capabilities of the providers at both facilities. The quality and safety of neonatal care in western Montana will decrease."
St. Pat’s recruited neonatologist Deborah Reed-Thurston, M.D., to supervise the new NICU. She said that of the roughly 30 babies that have been transferred from St. Pat’s to Community since 2015, only about three were so premature that the new Level II NICU at St. Pat’s would not have been able to care for them.
Full term is considered 40 weeks, Reed-Thurston said, and many infants born under 37 weeks have respiratory issues, feeding issues and hypoglycemia. Many of the smaller infants also have trouble regulating their own body temperature, which requires special incubators. Level II NICUs can provide care to these infants, who are considered moderately ill, and most are expected to heal quickly. At Community Medical Center, infants with much more serious complications can be cared for. The industry-wide standard is that babies born after 23 weeks are expected to have a chance at survival.
Reed-Thurston said technology has evolved in the past decade to the point where many babies who previously would not have been resuscitated can now survive and lead healthy lives. Many of the staff at St. Pat’s have been training in Spokane for the new NICU to open.
“We have a wonderful staff here, and Providence has been actually really forward-thinking to send nurses to Spokane,” Reed-Thurston said.
Dombrouski said securing Reed-Thurston and conducting NICU nurse training were the final components to open the NICU. She said that the Maternity Ward has proven to be successful for the nonprofit hospital.
“We’re really busy,” she said.
The birth rate in the hospital’s service area has been fairly flat the past few years, she said, despite a growing population. That’s why she also sits on local economic development boards.
“If we can grow the economy and create more jobs here, hopefully that birth rate will begin to climb again,” she said.
Sherry Glied, Ph.D., is a Harvard-trained economist, the dean of the Graduate School of Public Service at New York University and an expert in health care policy. She told the Missoulian that her research indicates that competition in health care is usually good unless hospitals use fancy technology to woo patients even though it may not be better for them.
“In general, the literature suggests more pros than cons to competition if it’s robust,” she said, “although, it’s not really clear with two competitors in the same market. But competition can drive down prices and drive up quality, just as in any market. Competitors are looking over their shoulder and that might lead you to up your game. And evidence suggests that as quality improves, that might lead insurance companies to choose to send patients where they think the quality is better.”
However, Glied said that sometimes hospitals can try to attract “lucrative patients” by marketing slick new technologies, even if they are just more expensive and provide the same or worse quality of treatment than the old technology.
“It’s called the medical care arms race,” she said. “Hospitals try to outdo each other. Especially in small markets, it’s sometimes that way. They try to get the latest fancy technology and try to outdo the other hospital, but it’s not necessarily good for the patient but it drives up the cost. They offer fancy new machines or whatever that looks exciting.”
Glied said that in an era where profit margins for health care providers are getting slimmer, there is a lot of “churning” in business models. That may be one explanation for why Community Medical Center in Missoula switched from nonprofit status to a for-profit model in 2014.
“We see a lot of churning in organizations form where margins get thin,” she said. “People feel like the grass must be greener on some other side of the street.”