Rise in Hospital Neonatal Units Questioned

First there were 30 neonatal beds at Ventura County Medical Center, rows of tiny little cribs in a nursery equipped to care for infants born too young, too sick, too delicate.

Then in January 1994, St. John’s in Oxnard added eight beds for infant intensive care. Before that year was out, Los Robles Regional Medical Center in Thousand Oaks was also able to boast that it was equipped to care for needy newborns, with 10 beds open and ready for fragile cargo.

Now Community Memorial Hospital in Ventura, amid a flurry of criticism, is embarking on a plan to add 13 more slots to Ventura County’s growing supply of neonatal care units.

The expansion move by the private, nonprofit hospital brings the county’s grand total of neonatal beds to 61 and begs the question: Just how many of these specialized care centers does Ventura County need?

Neonatology experts from outside the county suggest the county already has enough beds for the number of babies born here. If anything, the quality of health care may be diluted by spreading resources across a wider area.

A recent statewide study indicates that infants at regional centers--such as UCLA or Children’s Hospital--have a 30% better chance of surviving than infants at smaller centers like the one Community is planning. Better to concentrate the babies and the staff at one center of excellence, than spread them among several hospitals, the study concludes.

There might be sound business reasons behind building a new intensive care unit for infants, but there aren’t medical reasons, experts say.

“You need about 30 [neonatal] beds for the entire county’s deliveries from a strictly medical viewpoint,” said Dr. Robert de Lemos, director of the Division of Newborn Medicine at the University of Southern California. “But the business arguments are different.”

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Within Ventura County--where business, medicine and politics are hopelessly intertwined--the neonatal question has done nothing to dampen the long-standing antagonism between the county hospital and its private neighbor, Community Memorial.

Defending their own niche, doctors at the county hospital say the 48 neonatal beds already in place are more than sufficient; in fact they are on average only two-thirds occupied.

The neonatology unit at Ventura County Medical Center is considered top-notch and is classified as a Level III, the highest rating the state gives to smaller centers.

“Why do they want to build a replica of the unit at county?” said Dr. David Kastings, head of the neonatology unit at the county hospital. “Here is a center of excellence that is already in existence two blocks away.”

Simple, say doctors at Community Memorial. Their patients are clamoring for a neonatal unit at the private hospital and in the increasingly competitive medical market, they want to make their patients happy. As it stands now, a mother who has to deliver her child at 35 weeks or earlier is diverted to the county hospital.

“They are very unhappy when we tell them we have to divert them to county,” said Dr. Richard Reisman. “It’s almost like a threat we use in our office, if you don’t get to 35 weeks you’ll have to go to county. It’s kind of funny but not really.”

Ingrid Giammichele was one of Reisman’s patients who ended up at the county hospital, against her will. While she praised the care her newborn twin boys--born at 35 weeks and each weighing less than 5 pounds--received as “fantastic,” she was unhappy with her experience at the county hospital.

She didn’t like her nurse; supplies ran short. And she said the hospital lost her placentas, which she said she wanted to have tested to determine if the twins were fraternal or identical.

Reisman also justifies the expansion by pointing to the increasing numbers of women giving birth at Community Memorial Hospital.

“As our service has gotten much larger, we have reached a threshold where we in the obstetrics department feel very strongly that we want to be able to safely deliver all our moms at Community Memorial,” he said.

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According to Community Memorial administrators, the number of women delivering at the private hospital was up about 30% in 1995. They estimate about 2,500 women gave birth there in 1995 and expect 3,000 births in 1996. The boost in numbers is largely attributable to Community Memorial having signed a contract in 1994 to accept Medi-Cal recipients and its campaign pursuing them.

In 1994, the most recent year for which solid data is available, 11,988 Ventura County women gave birth, according to the Ventura County Center for Health Outcomes Research & Evaluation. About 20% of them chose to go outside the county lines, many to Santa Barbara or the San Fernando Valley. The rest were divided among eight hospitals, all eagerly vying for the business.

The lion’s share--23%--went to the county hospital, while 17% went to Community Memorial. But the county’s share has dwindled substantially since 1992, when it handled 35% of the births. In 1992, Community Memorial had one birth paid for by Medi-Cal, compared to 293 in 1994.

Those numbers are still rising, Reisman said. Out of the 222 babies born in March at the private hospital, 64 were paid for by Medi-Cal, or nearly 29%, he said.

That means good, steady business, with substantial payouts from the state. But more Medi-Cal babies means more high-risk pregnancies, doctors said, hence the need for the neonatal unit. Lower economic status is linked with inadequate nutrition and other factors that can diminish chances of giving birth to a healthy, full-term baby.

But Community Memorial’s quest for a neonatal unit has met with resistance from other hospitals, which have refused to let their contract physicians work with the private hospital.

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Community Memorial administrator Michael Bakst attributes the contract problems to rivals trying to “freeze us out” of the market. Kastings, the first neonatologist Bakst approached with a contract, said his decision not to work with Community was much more complicated than that.

“There are multiple reasons, the most important of which is that we believed patient care would suffer as a result,” Kastings said.

He cited a talk by Stanford researcher Dr. Ciaran Phibbs given in February at a meeting of the Western Society for Pediatric Research. Using data from 1990 births, Phibbs concluded that the increase in neonatal intensive care units throughout California in the 1980s has actually been damaging to health care.

The study, titled “The Effects of Patient Volume and Level of Care on Neonatal Mortality: Is Competition Killing Babies?” says that regional centers have much lower mortality risks than the smaller centers. The study dismisses Level II neonatal centers as no better than average hospital care. It also correlates patient volume with quality of health care.

Phibbs’ findings echo the thoughts of other neonatologists, who say doctors who work with higher volumes of patients end up with better skill levels and exposure to the latest techniques and technology.

“Most of us who have been doing this for a while believe in regionalization,” said Dr. Ron Ariagno, associate chief of the newborn nursery at Stanford University Medical Center, which is a regional center, rated above Level II and Level III hospitals.

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But even the doctors who said the new neonatal unit is not medically needed reluctantly admit that medicine has as much to do with business as it does health in this era.

“We are a free enterprise,” said de Lemos, the USC doctor.

That’s what brought Community Memorial into the neonatal business.

Bakst said his hospital is diverting about 100 patients each year to the neonatal unit at the county hospital, or to St. John’s, which is also run by Kastings’ group. But those are just the emergency cases where problems were not anticipated in the pregnancies; he believes Community is losing more potential high-risk patients who private physicians automatically send to the county.

After seeing a cost analysis, Bakst said, his board of directors was convinced that building a separate neonatal unit at Community Memorial was a good idea. Bakst said he went to the obstetricians, including Reisman, last June and asked who they felt comfortable working with.

“They said we’ve got the guys down the street,” Bakst remembered. “They said we would be happy to work with them.”

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Any Ventura County resident who voted March 26 knows that the relationship with the guys down the street isn’t exactly blossoming. In the latest chapter of the saga between the two hospitals, Community Memorial forced a public vote on a new wing at the county hospital and spent at least $1.3 million to successfully defeat the project.

Bakst and Reisman said they approached Kastings last June about planning and staffing a new neonatal unit at Community. They described him as receptive and enthusiastic. Negotiations went well, they said. According to Reisman, Kastings pulled out at the last minute, saying he had been told he would lose his contract with the county hospital and at St. John’s if he worked with the rival hospital.

Rita Schumacher, spokeswoman for St. John’s, confirmed that Kastings was indeed threatened with losing his contract.

Eventually, Community Memorial contracted with a physician at Tarzana-Encino Regional Medical Center to set up the 13-bed unit, train nurses and serve as interim medical director until a permanent staff can be hired. Until Community’s neonatal unit is established--sometime late this summer--Bakst said babies will continue to be transported to the county hospital.

Kastings said he entered into the discussion believing that a solution could be worked out that didn’t include a completely separate, free-standing neonatal center at Community.

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And so on Loma Vista Avenue, where the battle lines have been drawn so many times, there ought to be a trench down the middle instead of a yellow line. The war over babies will continue and the number of neonatal beds--including empty ones--will rise.

“They probably won’t even fill those beds,” said California Healthcare Assn. spokeswoman Susan Harris.

“When you are getting pressure from patients, it does come down to being a political decision,” Harris said. “But you have to trust that the facility is making the right decision to serve the population. While it somewhat seems odd, I think they [Community Memorial] have probably spent a lot of time investigating the need.”