Money Battles at UCSD Spur Prenatal Flap : Medicine: Doctors’ fees led to a decision--now apparently rescinded--to drop a program that uses nurse-midwives to give prenatal care and delivery services to poor women.
To the outside eye, UC San Diego’s Medical School, Medical Center, Department of Reproductive Medicine and doctors and nurses are one and the same. But divisions between competing interests--particularly financial ones--in the institution can run deep.
Nowhere was that more apparent than in the recent fiasco over whether UCSD was going to shut down its pioneering program that uses nurse-midwives to give prenatal care and delivery services to poor women.
At least in part, you could call it a case of the right hand not having access to $961 that was in the left pocket.
First, the Department of Reproductive Medicine, a division within the medical school, issued an Oct. 16 memo saying the program would end because of financial difficulties. Chiefly blamed for the shutdown were anticipated losses of $250,000 to $350,000 a year in physicians’ fees.
These are fees that wouldn’t be paid to faculty obstetricians for their help with Caesarean section and other problem deliveries of women in the perinatal program, said the former director of the Comprehensive Perinatal Program (CPP), Ann Bush-Sheresh. Instead, under a standing agreement between the CPP and the medical school’s Reproductive Medicine Department, such fees have long gone to the perinatal program to help it operate.
But if the women were not receiving prenatal care through the CPP, the faculty obstetricians would receive up to $961.20 from Medi-Cal for each woman who walked into the emergency room in labor.
Bush-Sheresh left CPP in April because, she said, she couldn’t bear to see the program she spent 10 years building dismantled.
Suspicions about this potential financial incentive for killing CPP was one of several reasons that the shutdown plan brought a storm of anger and disbelief when it was revealed publicly last Tuesday.
How, critics asked, could a state-funded institution deliberately add 1,000 babies a year to the 4,000 in San Diego County whose mothers get no medical care at all during their pregnancies? Fragile premature babies, hooked to tubes and wires instead of safe inside their mothers’ wombs, are often the result of the lack of prenatal care.
The end of the Comprehensive Perinatal Program also surprised key parts of the hospital’s bureaucracy--emphasizing the separate roads that different parts of the UCSD medical establishment can choose to travel on the same issue.
Not only did the action make the hospital look like it was backing away from caring for the poor (an issue on which administrators are particularly sensitive) but it also came when the hospital was trying to work out agreements to get more--not less--prenatal care for poor women.
Two days later, the administrators’ “damage control” messages had intensified: The decision to close the perinatal program hadn’t ever really been made, UCSD spokeswomen contended. It was a departmental move, not an administrative decision, they said.
All this backtracking made it apparent that there had been little coordination in making the decision between the Reproductive Medicine Department and hospital administrators.
Contacts also were lacking with county officials and other university departments, such as the joint UCSD-UC San Francisco master’s program that trains nurse-midwives as part of the CPP program.
“I have already gotten calls from across the country asking, ‘Is your program closing?’ ” said Judith Fullerton, director of graduate nursing programs at UCSD.
The midwives can be trained at other area hospitals, but Fullerton said she is concerned that in the meanwhile, the CPP crisis will scare away potential students.
“I think it was a decision that was made in a vacuum,” said County Supervisor Brian Bilbray of the CPP closure.
Bilbray and other county officials were particularly upset because the county subsidizes UCSD Medical Center every year for care to poor people. That amounted to $8.5 million in 1989-90. The county also helped make the hospital eligible for $2.6 million in state aid under AB-75, the tobacco tax bill.
“We backfilled millions of dollars by being willing to bite the bullet in other areas and provide for (UCSD) programs that had been funded in the past,” Bilbray said.
But this money for uncompensated care--$11.1 million total last fiscal year--goes to the medical center, not necessarily to the medical school departments or doctors. So state Medi-Cal reforms that helped hospitals didn’t end UCSD obstetricians’ continuing complaints that they weren’t being paid for individual medical procedures.
On the other hand, Bush-Sheresh points out, the physicians can expect little sympathy from the public. They are state-paid faculty at an academic institution, complete with the research opportunities, prestige and job protection of tenure.
“These are faculty physicians at a university, and their base salary is being paid by the university,” she said. “They’re public employees. These people are being paid regardless.”
In addition, there are questions about another reason given for shutting down CPP, that the hospital’s obstetrical facilities are too crowded. But at the same time, the university has been actively pursuing arrangements to deliver babies for private practices or community clinics whose patients would come with their own doctors and insurance or Medi-Cal funding.
Any public perception of UCSD’s hospital or doctors as greedy or insensitive to the community’s needs comes at a particularly inopportune time for the university.
UCSD is building a luxurious new hospital in La Jolla that critics had feared symbolized a lessening of UCSD’s commitment to the poor. The lavishly decorated rooms at the new hospital will feature large picture windows, polished wood floors and other amenities that make them look like comfortable hotel rooms.
In that context, those concerned with medical care for the poor ask, how much commitment to the poor is enough? Hospital officials say that, through their emergency room and clinics, they provide a great deal of free care already.
But more than free care, the university has to provide responsibility and leadership in finding solutions to the poor’s medical care problems, Supervisor Bilbray and others said. Killing CPP did the opposite, they said.
“The UC system can’t expect to be an ivory tower set aside from the realities of the people and the communities that they serve,” Bilbray said. “The taxpayers, rich and poor, pay the bills for that operation, so the taxpayer should gain a cross-section benefit of those expenses.”
By the end of the week, high-level UCSD hospital and medical school officials were behaving as though they agreed. Discussions on how to save CPP, with fiscal responsibility outside of the medical school, were continuing.
But university officials did not return repeated phone calls and spokeswomen refused to release any details of the financial underpinnings of the initial decision to close CPP.
“There’s nothing in the discussions that indicates that the service that has been provided is going to change, but to restructure it so that the fiscal responsibility for it lies elsewhere, outside the department of medicine,” public information chief Leslie Franz said.
She denied that physicians had any financial incentive to shut CPP down, but did not provide any details. More information won’t be released until an agreement is reached, she said.
“This whole thing has been turned into mass confusion because of the bits and pieces coming out in the press,” Franz said. “If there’s egg on our face, that’s the point at which it will be wiped off.”
