Hospitals battle over region’s tiniest and most fragile patients

Competition between Valley Children’s Hospital and Community Regional Medical Center for the region’s youngest patients is heating up.

Community Regional now has a surgical team that is performing operations on newborns and preemies who previously had to be transferred to Valley Children’s Hospital on the San Joaquin River bluffs in Madera County.

California Children’s Services, a state program which has standards for levels of care for neonatal intensive care units, granted approval in March for Community to do major surgeries, such as for blockages of the esophagus or intestines and abdominal wall defects. And this summer, Community added a second pediatric surgeon to the team at the downtown Fresno hospital.

Through the first week in August, the two surgeons operated on 13 newborns who otherwise would have been transferred. Another 14 surgeries were done on premature infants who had conditions that developed after birth.

Newborns and infants who need complex surgeries, such as brain and open heart, will continue to be transferred to Valley Children’s, which operates the region’s highest-level neonatal intensive care unit, or NICU.

But Community now has surgeons and operating support staff, and an operating room inside its neonatal intensive care unit.

Community doctors say the ability to operate in house is good for babies and families. Moving newborns and premature infants creates unnecessary stress, they say. But Valley Children’s, which for decades had been the only hospital in the region providing neonatal surgery, says it has a specialized staff and is best equipped to operate on the tiniest and most fragile patients.

The effect of dueling NICUs on quality and cost of care remains to be seen, but what’s clear is that it’s added fuel to the ongoing feud over pediatric patients between Community and Valley Children’s Hospital.

The two hospitals have been at odds since last fall, with the children’s hospital accusing the Fresno acute-care hospital of building a pediatric specialty network, and Community accusing Valley Children’s of unwillingness to see patients in a contract dispute with a doctor’s group and of refusing to collaborate in the operation of Community’s neonatal intensive care unit.

Hospitals square off

Community executives have said they have no choice but to beef up pediatric services.

Craig Wagoner, CEO at Community Regional, said in an email statement this month that the approval to perform neonatal surgeries is in addition to the hospital’s trauma and burn-related pediatric surgeries, which the hospital has done for decades. And he said Community has more plans. “We are recruiting pediatric subspecialists and planning for necessary CRMC campus improvements to expand these services.”

On their part, Valley Children’s executives have moved to protect the institution from competition. Last year, the hospital invested in a $10 million clinic in Fowler to be operated in conjunction with Adventist Health/Central Valley Network. This year, it cut 40-year ties with the Community-based residency program operated by the University of California at San Francisco and instead joined with Stanford University to create a residency and fellowship program.

The performance of neonatal surgeries at Community has further widened the gulf between the two hospitals.

“Community has chosen to compete with Children’s, and I guess that’s what we’re going to have to live with,” said Dr. Jeffrey Pietz, Valley Children’s chief of newborn medicine.

Community’s pediatric surgeons said they don’t see themselves in competition with Valley Children’s surgeons. In July, Dr. Holly Williams, a Baltimore-based pediatric surgeon with experience in neonatal endoscopic surgery, began doing procedures at Community. She joined in practice with Dr. William Hodge, a longtime Fresno pediatric surgeon.

Hodge said the 84-bed neonatal intensive care unit at Community and Valley Children’s 88-bed unit each remain busy. “There’s plenty of business.”

It makes sense to add surgery services to Community’s neonatal intensive care because newborns in need of surgery and mothers can remain together, Hodge said. Community delivered 6,007 babies in 2014, and 930 were admitted to the NICU. And another 140 babies were brought to the downtown Fresno hospital from elsewhere. The hospital is second in the state for deliveries of babies weighing under 3 pounds, 5 ounces.

Community will continue to send babies to Valley Children’s for complex surgeries, Hodge said. Last year, before Community gained approval to perform surgeries, it transferred 41 babies, and 17 of those would still have been transferred now, he said.

Williams said Fresno is similar in size to Baltimore, which has more than one hospital for neonatal surgery. Fresno residents “deserve having more than one hospital where they can receive pediatric care,” she said.

Valley Children’s officials said they serve 1.1 million children in a 45,000-square-mile region, which is not comparable to serving a similar number of children in a dense, urban area. The hospital doesn’t deliver babies, and newborns and preemies in need of the hospital’s specialized care must be brought there. The hospital’s neonatal transport system “is the busiest neonatal transport system in California, by a lot,” Pietz said.

The Madera County hospital sees 1,100 newborns a year, and taking care of that many babies makes a difference in the health care they receive, said Beverly Hayden-Pugh, senior vice president of clinical operations and chief nursing officer.

It’s in the best interest of the children for pediatric specialists, such as surgeons, to have a large number of children to serve, she said. “In order to be skilled at something, one needs to do it a lot.”

Valley Children’s has a NICU surgery team that includes seven pediatric surgeons, Pietz said. The hospital also has doctors in 100 pediatric specialties who are available to the NICU, he said. “There’s a whole breadth and depth of specialists.”

Pietz said it looks like Community is trying to recruit doctors with the goal “to duplicate Children’s hospital and build one downtown to compete with this one.” He’s not convinced it can easily be done or will help care overall.

Hayden-Pugh said Valley Children’s has the ability to attract pediatric subspecialists because they know “that there’s not going to be one subspecialist who is going to be on call 365 days a year.”

Parents like care

Even though the hospitals remain at loggerheads, parents who have had babies in intensive care have been happy with the services they received.

Becky Parmer of Coarsegold said Valley Children’s surgeons, specialists, nurses and staff worked as a coordinated team to provide care for her son, Peyton Parmer, who weighed 15.5 ounces when he was born 6 1/2 years ago. Parmer had had triplets at Community Regional; Peyton survived, but a daughter died before she could be transferred to Valley Children’s, and a son died three days after transfer.

Within the first few weeks of his life, Peyton had several surgeries at Valley Children’s – at 10 days, 14 days and two months. “There was always a team involved in his care,” Parmer said. “I’m glad we have all of this care in one hospital because the specialists communicate.”

Amy and Aaron Snell of Porterville said Community Regional was the right place for Amy to deliver and for their daughter, Leah, to receive immediate care. Leah arrived 15 weeks early in April, weighing 20 ounces.

Their daughter did not require surgery, but spent 100 days at the Community intensive care unit. Now at home, she weighs more than 8 pounds, her father said.

The Community NICU became a second home, he said. “Not only do they have a fantastic facility and staff medically, but the people there are just very caring. It felt like a family. We got as much care as Leah did for her medical needs.”

Enough business

Experts in health planning say it’s difficult to judge whether Valley families will see much change now that neonatal operations can be performed at Community.

Neonatal intensive care units serving the same population can work together, said Valencia Walker, a neonatologist with the University of California at Los Angeles hospital system.

“The average newborn baby, the average NICU baby, even if it’s a preterm baby, doesn’t need (the highest level of care),” Walker said. “But when things go really, really bad,” they need to be at the highest level, she said.

Competition for surgery patients between Community and Valley Children’s could become intense, but Walker said she doubts “you would have two thriving NICUs if there wasn’t a genuine need.”

Paul Savage, program director for Health Care Management at Iona College in New York, said competition between two hospitals can be relatively healthy. But “you don’t want to have six or seven competitors where you’re down to around a 30-bed per hospital competition,” he said.

There is “no sort of golden ratio, sort of rule of thumb,” as to how many neonatal intensive care units a community needs or can sustain, said Charlie Cosovich, a healthcare practice director within Navigant Consulting, a global consulting company. However, the central San Joaquin Valley has a birth population and child population that is growing, he said. “The Central Valley of California has a lot of babies who need a lot of help.”

Regardless of battling hospitals, he said: “In the big scheme of things, if you have a baby who has a problem in the Central Valley, the chance that they’ll get the care they need is much greater today than 20 years ago.”

This story was originally published August 15, 2015 at 7:00 AM with the headline "Hospitals battle over region’s tiniest and most fragile patients."