Cradling a Market : Hospitals Update to Woo Women--and Their Families


The Women’s Center at Grossmont Hospital was hardly born this month and already it was facing the prospect of a new kid on the block: Alvarado Hospital’s new childbirth unit.

In the heavily populated Interstate 8 corridor east of San Diego, an area which for two years has had only one hospital delivering babies, there will be two when Alvarado’s center opens June 4.

The new facilities provide a milepost in the drive by San Diego County hospitals to create specialty centers that ensure a steady supply of patients in a competitive marketplace.

Women are being pursued as customers because they usually serve as the primary health care decision-makers in families. A woman who has a pleasant hospital stay after childbirth or surgery is likelier to bring other family members to that hospital, the reasoning goes.


The women’s centers also are creating a dilemma among East County obstetricians and gynecologists, who have to decide whether to practice at both hospitals--an inconvenience--or to restrict their practice to just one facility.

Alvarado officials are also trying to lure physicians from Grossmont by offering to relieve them of the need to be on call for emergency deliveries by patients who have no money and no doctors.

“So far, I’ve said to myself, '(Alvarado’s) not open yet. When it opens, I’ll worry about it,’ ” said Dr. Carolle Jean-Murat. Jean-Murat lives near Grossmont but has an office near Alvarado.

Significant income for the hospital is attached to physicians’ decisions about the hospital at which to practice. In the United States, one obstetrician brings an average of $356,000 into a hospital each year, according to a 1988 survey done by Jackson & Coker of Atlanta and Ernst & Young of New York.

In the case of Grossmont and Alvarado, the birthing battle is a David and Goliath encounter, in which the participants can play either role:

With 425 beds before the expansion, La Mesa’s Grossmont is the leading hospital in the East County area. The hospital delivers 375 to 400 babies a month.

Grossmont is a nonprofit, district hospital whose service area covers 750 square miles stretching to the Imperial County and Mexican borders. Tax revenue provides less than 2% of its annual operating budget.

It became the only hospital offering maternity services in East County in 1988, when Valley Medical Center in El Cajon closed its unit because of a lack of obstetricians willing to care for poor women who arrive at the emergency room for delivery.

Alvarado, a for-profit hospital with 214 beds, opened in 1972 as a small specialty facility that didn’t try to be a full-service hospital.

But it now is adding a 12-bed maternity unit and an 80-bed rehabilitation hospital to broaden its scope. The efforts are backed by the strength of Alvarado’s owner, National Medical Enterprises, one of the largest hospital firms in the country.

The Grossmont and Alvarado women’s centers are the next step in the evolution of childbirth facilities: beyond homelike, to luxurious.

A woman who goes there stays in a single, spacious, carefully decorated room, from labor until she leaves the hospital.

“The idea is that birth becomes a pleasant experience. It’s very important for a woman to be as comfortable as possible,” said Dr. John Missanelli, a doctor who practices at Grossmont. “And that’s what we see in a facility like this. It really is different from the old hospital environment. It will be the standard of care in the next century.”

A walk down the wide hallways of the 62,000-square-foot Grossmont Women’s Center, which opened May 9, is more like a stroll through a grand hotel. Soothing colors, indirect lighting, high ceilings and plenty of rosewood trim set a tone that makes rude interlopers out of the trash carts distributed along the curving hallway.

The 24 “LDRP” rooms--for labor, delivery, recovery and postpartum--could pass for hotel rooms.

Floors are hardwood, not tile. The bed is covered by a bedspread, color coordinated with the drapes and wallpaper. A door opens onto an outdoor patio. The bathtub is a hydrotherapy pool.

Buttressing the illusion, all medical equipment is secreted inside wooden cabinets. Trash, dirty linen and mobile medical equipment are tucked into a closet that has a back door into the hallway, so the room’s occupant needn’t be disturbed.

“My staff feels like they’re coming to work in a resort,” observes Barbara Gutshall, nurse manager of the women’s surgical unit. That unit has 24 equally posh rooms, situated downstairs from the birth rooms.

What also distinguishes the Grossmont facility is that it is intended as a hospital within a hospital, said center director Lisa Branciforte.

So far its services are restricted to childbirth, gynecological surgeries and a neonatal intensive care unit, but it also has meeting rooms for classes and special events. Eventually it also will have a library on women’s health issues and will serve as a central spot for coordinating other women’s services at the hospital, Branciforte said.

“If the female component of the family is satisfied with the services that a hospital offers, then that family will come back again,” said Branciforte. “Not just the patient, but the entire family will be serviced by the hospital . . . for a broken foot, gallbladder surgery, and so on.”

Just down the freeway from Grossmont, Alvarado is in the final stages of decorating a dozen LDRP rooms that try for the same goal in a different way.

Those rooms, 320 to 400 square feet in size, also will aim for an illusion of hotel-like luxury. Women can choose their favorite decor--among them, contemporary, Southwestern, Polynesian and colonial. Each room has a hide-a-bed couch so fathers can stay over with mom and baby after delivery.

Rather than the long promenade-like hallway at Grossmont, here the halls feel more hospital-like and are laid out to make the unit seem smaller than it is.

The birth unit also is the only visible part of what Alvarado is calling the Center for Women’s Health. Gynecological surgeries and other women’s services will still be performed elsewhere in the hospital.

Alvarado hopes to be delivering 100 babies a month by the end of the year and double that within four years. It expects the patients to come not only from Grossmont’s East County service area but also from Sharp and Mercy hospitals, neither of which has birth facilities as attractive as Alvarado’s.

Fees at the Alvarado and Grossmont units are comparable to those of other hospitals: $2,470 for everything except doctors’ fees for a normal delivery at Grossmont, $2,400 at Alvarado and $2,500 to $2,800 at Mercy Hospital.

Alvarado officials are acutely aware that their maternity unit will be compared to Grossmont--and are quick to point out what they see as their own strengths.

“This is a warmer, smaller facility,” said administrator Gary Sloan. “It gives people a choice. There are people who like the Las Vegas look and people who like the bed-and-breakfast look.”

Sloan believes the unit not only will be attractive to patients because of its intimate atmosphere but also to doctors because of special features built in for them.

To improve the lighting during deliveries without lighting up the whole room, Alvarado installed special ceiling lights, controlled by a hand-held wand, that the doctor can focus during delivery.

Also, even though baby stealing isn’t common, doctors worry about it, Sloan said, so the nursery was designed with a circuitous access route.

“It only has to happen once,” he explained.

The physical detail about which Sloan almost crows is the doctors’ dressing areas and lounge. Women doctors have their own dressing room, separate from the nurses’ area, he said.

This is significant mainly because, after the Grossmont women’s center opened, women physicians were disgruntled to find that they had been given no place of their own.

Jean-Murat recalls that, when she first started doing surgeries at Grossmont in 1982, she had to leave her purse with the head nurse and stack her street clothes on a bench because there was no locker room for women doctors. After a day when she couldn’t find a nurse to retrieve her purse, she began crashing the male doctors’ dressing room.

“So I became very famous,” Jean-Murat recalls with a laugh. “I would go to parties, and their wives would come to me and say, ‘Oh, we have to meet you.’ Their husbands would come home blushing and everything because ‘that woman’ just walked in there.”

So, when the new women’s center at Grossmont also had no facilities for women physicians, it was doubly distressing because more than half of all obstetrical residents today are women, Jean-Murat said.

“There are a lot of women coming into medicine that you have to account for,” Jean-Murat said she told Grossmont officials. “But they are trying to remedy it. They are taking one call room and making it into a (women’s) locker room.”

Another incentive Alvarado is offering obstetricians speaks to the biggest issue in obstetrical care in San Diego County: poor women who show up in labor in the emergency room, with no prenatal care.

There were 242 such deliveries at Grossmont last year. Grossmont requires every obstetrician on staff to be on call regularly for such emergency deliveries.

Doctors complain because they often go uncompensated or poorly compensated for these deliveries, yet could face malpractice suits because babies whose mothers have had no prenatal care are more likely to be born with problems.

Alvarado has arranged for a group of doctors to handle all of the no-prenatal-care mothers who show up in its emergency room. Thus, an obstetrician who switches to Alvarado from Grossmont would no longer have to be on call for those deliveries.

“That’s one of the things that Alvarado is promoting,” said Dr. James R. Schaefer, an obstetrician with an office near Alvarado. “We’ve requested that from Grossmont as well, and they are unable to do that at this time. At Grossmont that’s a real problem. It represents a real albatross for us.”

Pam Parmelee, chief operating officer at Grossmont, said a few physicians have told the hospital they will move completely to Alvarado if Grossmont doesn’t solve the problem.

“The physicians have a valid concern, and we are looking at ways to alleviate those problems or assist where we can,” Parmelee said. “But, as a district hospital and as a Medi-Cal facility, we have a duty to care for those patients.”

Nonetheless, Schaefer predicts that Alvarado’s incentive won’t lure most of his colleagues to practice solely there.

“I think that people are not just going to drop everything for Alvarado Hospital,” he said. “I feel that, just because you’re comfortable with what you’ve been doing for years, you’ll remain with that unless something just makes it untenable to cover two places.”

“Ideally, everybody would like to practice in just one place. You don’t want to be caught in the dilemma of having two patients delivering at different places at the same time,” said Dr. Frank Goicoechea, chief of obstetrics and gynecology at Grossmont.

In such cases, a woman would have to have a backup doctor at her delivery.

But many doctors won’t have any choice, Goicoechea said.

Health insurers increasingly contract with specific hospitals, requiring their patients to go to those facilities. So an East County obstetrician who ruled out deliveries at one of the hospitals could be limiting his pool of patients, he said.

In another two years, the choices among the new generation of maternity units will be even more complex, when Sharp Memorial Hospital opens a $46-million Mary Birch Women’s Hospital.