The Juan F. Luis Hospital and Medical Center. By. V.I. CONSORTIUM
Editor's Note: This opinion was submitted to the Consortium by Dr. Gerard Abate on Fri. Aug. 12, 2022. Dr. Abate works at the Juan F. Luis Hospital and in private practice, and he expressed to the Consortium his desire for a better healthcare system in the territory, one he says cannot be realized without major changes.
I have been on St. Croix for the better part of three years, working at the Juan Luis Hospital as well as in private practice. After a career in practice and industry on the mainland, I came here because I thought I could make a difference. I am writing this in hopes that you would be interested in exposing the issues that exist. Being that it is an election year I feel the state of healthcare on the islands should be a top priority and be more than talk by the governor. I have copied two men I know take this seriously and I hope we can finally provide the people of the USVI, particularly St. Croix where I have spent my time more than hope for a better healthcare system.
Over the last three years I have found that the medical system is broken beyond just the tragedy of JFL. I have found a medical community that is not collegial, but adversarial to their colleagues. I see the ineptitude of the governing board of the hospitals. I see the lack of services to those that need it most and the inability of the government to recognize that they cannot run healthcare any better than they can manage WAPA.
When I first came to the island it was to work as a hospitalist at JFL. I found a hospital whose facility has been and remains in a shambles, with some of the issues already discussed over and over — mold, lack of functional plumbing, basic needs of the Medical Examiner etc. What no one looks into or cares to look into is that the people of St. Croix deserve not just a functioning facility but adequate healthcare that we cannot even provide.
From the emergency room to the ICU deficiencies abound ranging from equipment to incompetent leadership both by hospital and medical leadership. My question is what will it take for the government to pay more than lip service to these deficiencies? When will the patronage system that has become ingrained in our island culture change to have leadership and even day-to-day jobs be based on resume not DNA?
The governor has always had the ability to make change but has done nothing but talk. Every day I see over 20 patients in clinic from all walks of life, and there isn’t one single patient I’ve seen on St. Croix that feels the government has done its best to provide basic health services. On St. Croix alone we have invested over 150 million dollars in a temporary hospital that is insufficient to meet the long-term needs of the island and yet over 5 years after Maria, still is not opened. We are told this is a temporary hospital, but we also know it will be years before a new facility is built. We read of reports of bad accounting, millions of dollars missing, excuses for delays but in the end who has been held accountable?
It’s a given that the old hospital JFL has been plagued with problems from when it was built, and we have seen a hospital that offered so many services 10 years ago to one that can barely offer basic care. Just be put on hold and listen to the message about a cardiac catheterization lab, surgical services, dialysis etc., etc. There needs to be the immediate hiring of a consulting firm to come from the states to do a forensic accounting of both hospitals to find all moneys spent, review and set up systems for all areas of finance and create a structured oversight program with regular audits. A new professional board that is not chosen based on patronage but by credentials and skills must happen immediately.
Being a cardiologist, I had been told that the catheterization lab was flourishing under Dr. Kendall Griffiths and after he left the island not only has it not been used but will never be used again. First, to have a certified catheterization lab, a hospital must do 250 cardiac catheterizationa a year, not just total procedures. Statistically, the number of cardiac catheterizations done per year are 405/100,000 people. The population of St. Croix as of 2021 is 50,000, and 70 percent of the people are over the age of 25, therefore that’s 35,000 potential people. That means a potential 140 cardiac catheterizations per year. You need 50 angioplasties a year to maintain competence. The number of angioplasties are180/100,000 people in the US. Therefore in St. Croix that would be 63 per year best case scenario.
The island doesn’t have the volume to attract a full-time interventional cardiologist. So reopening the catheterization lab is a pipe dream. The nuclear medicine department is closed since like most vendors, JFL didn’t pay the bills for isotopes and maintenance. They have lost their nuclear license and it is highly doubtful they will get that back. Nuclear medicine plays a role in cardiology, oncology, orthopedics, pulmonary and other areas yet a basic service doesn’t exist at JFL. From a cardiac standpoint, we have no ability to do cardiac screening — there is no stress test lab, no Holter monitors and over the past year having echocardiograms done has been part time at best.
Aside from those areas in cardiology, there is no ability for central monitoring of cardiac patients. The equipment in the ER doesn’t work, and there is no ability for monitoring in progressive care outside of the ICU where even those monitors are substandard. In three years I never saw invasive hemodynamic monitoring at JFL, a standard in most hospitals for monitoring critically ill and cardiac compromised patients.
Beyond cardiology, JFL lost its out patient dialysis that is a guaranteed money maker since medicare /MAP and private insurers pay for all dialysis, to out-patient centers and a new non-profit will be opening to take the remainder of out- patient dialysis shortly. This happened due to the hospital having no long range plan for providing services and medicare only granting a temporary use certification for the trailers that have been in the parking lot for the last few years since Maria.
Surgery: There is one functioning OR and only one anesthesiologist at JFL. There are rare elective cases since OR time is at a premium and in-patients have to be prioritized based on severity to have their surgeries done. This results in prolonged hospital stays as well as potential complications. Again, there has been no solution brought by leadership of JFL, just excuses. Medicare patients in particular are billed by a global diagnosis code that has an established length of stay, therefore again, JFL loses money. Additionally, the lack of ORs and OR time over the last few years has resulted in the development of private out-patient surgical centers syphoning off more paying patients that would generate revenue for JFL.
The hospital staff at JFL is not an open staff to all doctors on the island. They make it difficult to get on staff because the handful of doctors that are on staff control what happens medically and don’t want new doctors to become part of committees or leadership because that would jeopardize their ability to control their departments.
As for the nursing crisis, the issues are serious but money isn’t the only issue. The government made this crisis by bringing in temporary nurses with Pafford and paying them more than double what our own staff is paid as well as having housing and a car. Pafford has made millions of dollars off of this contract. The leadership of Pafford has been living large and has taken advantage of the situation. Again, no investigation into contracting and the government has to take responsibility for this. Additionally, there are no opportunities for the nurses to enhance their skills. The majority are trained at UVI but there are few mentors.
One way to enhance job satisfaction as well as improve patient care is to create a relationship with a hospital network on the mainland. This would benefit two fold:
- Create clinical internships for the nurses that are paid for by the government to rotate through these hospitals for a specific area of expertise. This will not just enhance individual skills but also have them return to the islands to share their knowledge with their peers.
- We badly are in need of a network for ready transport of critical patients without delay to the mainland. I have first-hand experience over my time at JFL that patients in need of transfer and may wait days instead of hours to be transferred into tertiary care.
We need a transfer system that will take patients into care regardless of means or insurance. It is unacceptable that hospitals refuse patients or drag their feet on a transfer based on means. ALL hospitals that accept government insurance, ( medicare/Medicaid) participate in an indigent care pool and by law cannot refuse patients based on means. The issue with the USVI is that we have no one overseeing this process, creating a network for our citizens.
Additional issues with healthcare on the islands are that:
- There is no oversight of the practicing physicians. Unlike in the states where you are subject to audit, here, fraud goes on regularly and nothing happens. I can name several physicians that it’s common knowledge of how they run their practices.
- Quality of care: hospitals, JFL from which I have first-hand experience, has no true QA ( quality assurance) and physician care is only looked at for those that leadership has a grudge against. I saw this happen first-hand with a surgeon that was doing procedures and cases were being reviewed by the chief of staff who was also doing the same procedures. But who was reviewing his cases? There is a double standard here for sure and that is not an isolated instance.
- General quality of licensed physicians: We are not attracting quality physicians to come work here. What do we have to offer aside from the beauty of the islands and weather? So aside from the required CME to maintain our license, what is done to assure that we are all providing quality care? There is no oversight or peer pressure for physicians to improve unlike in the states. I was president of my medical society back in the day and we had a community of doctors that helped each other and policed our colleagues because it is a reflection on our profession. That isn’t the case here.
We can go on about the issues that exist but at what point will every Virgin Islander say enough is enough and demand that at least basic healthcare is improved. It is time to stop passing the blame and to start finding solutions today and not years down the road.
Many of the issues I listed have easy fixes but until the government and the community leaders in general step up we will continue to have the same issues that have gone on for perpetuity. Until changes in board oversight, medical leadership and all levels of management occur we will see no improvement in our hospitals.
If we don’t have a board of medicine and commissioner of health that are run by professionals instead of political appointees, we will not develop a comprehensive long-term plan for providing and improving healthcare for the USVI. I focus on healthcare but we all know these same issues are entrenched in every aspect of USVI politics. Holding office is a privilege and one should not use their positions to promote cronyism. So the question is when are the people and leaders of the USVI ready to step up and bring real change?
Submitted to the Consortium on Friday, Aug. 12 by Gerard Abate, MD
