Reforming the CNMI healthcare system

By GRANT E. WALKER, M.D.
Special to the Saipan Tribune

Editor’s Note: The following is the testimony offered by orthopedic surgeon Dr. Grant E. Walker in reference to Senate Bill 19-04, which proposes to transform the Commonwealth Healthcare Corp. advisory board into a governing body.

Fourth part of a series

When I began to look at the hospital bylaws, the hospital operations manual for the process of credentialing physicians and Public Law 16-51 I found that PL 16-51 set up the Commonwealth Healthcare Corp. for failure. It created enclaves of power without any oversight. There was no process for the people to elect officials to oversee CHCC. In some wacky move, someone decided to put a CEO in charge of medicine at the CNMI’s only hospital? What training does a CEO have to make such doctor-patient related decisions? What previous hospital CEO training did this CEO even have at all? Under PL 16-51 the CEO’s power was ultimate and unchecked. The board of trustees was impotent under PL 16-51.

Why did I write previous newspaper articles entitled, “The History of Healthcare in America” and letters to the editor on “Oversight”? Remember those 28 years in American healthcare? I wanted to tell you that the rules of CMS Medicare are born out of the Social Security Act. Here are a couple of them:

– 42 C.F.R. §§ 422.503(b)(4)(vi)(B), 423.504(b)(4)(vi)(B). The sponsor’s governing body (e.g., board of directors or board of trustees) must exercise reasonable oversight with respect to the implementation and effectiveness of the sponsor’s compliance program.

– 42 C.F.R. §§ 422.503(b)(4)(vi)(A), 423.504(b)(4)(vi)(A). Standards of Conduct, also known in some organizations as the “Code of Conduct” or by other similar names, state the overarching principles and values by which the company operates, and define the underlying framework for the compliance policies and procedures. Standards of Conduct should describe the sponsor’s expectations that all employees conduct themselves in an ethical manner; that issues of noncompliance and potential FWA are reported through appropriate mechanisms; and that reported issues will be addressed and corrected.

-42 C.F.R. §§ 422.503(b)(4)(vi)(B), 423.504(b)(4)(vi)(B). Sponsors must have a compliance committee in place that oversees the Medicare compliance program. The sponsor need not have a separate Medicare compliance committee, as long as the committee addresses Medicare compliance issues. In many organizations, the compliance committee is chaired by the compliance officer. The compliance committee serves to advise the compliance officer. The compliance committee is accountable to, and must provide regular compliance reports…

After reading just these three laws, is it any wonder why CHC is in trouble with Medicare? For the longest time there was no compliance officer. An experienced CEO just plainly knows these laws and they play by the rules of society. The position of CEO is short and not a lifelong appointment. No one person can ever be above the interest of a corporation, whether it be public or private, an employee or an owner.

My many thanks go out to the board of trustees. A resolution, CHC 14-02, was issued in February 2014 granting me privileges and the basic message was that due process was not followed and found that, as investigated by the board, the accusations made lacked validity or merit. In plain language, they were false. This was swiftly followed by a second board resolution, a non-confidence vote censuring the CEO.

What did the CEO have to say? She snubbed her nose at the board and implied that they were powerless to do anything about it. Who were they? She had all of the unchecked power.

Now I like a good debate and I have pretty thick skin that can withstand an attack. But this problem was no longer about Dr. Walker; it was about you as citizens. Patients were hurt. Former representative Ana Teregeyo (with permission) lost her leg. I know because I participated in her sixth and final reconstructive surgery at the Las Vegas Trauma Center. This was no longer about pointing fingers. No one can say, “We never had a problem.” This is your world on those tiny islands in the middle of the Pacific. You are the owners of the fix for this problem and you can do it!

Great ideas are developed. I thought, why not put the tools in place whereby a strategic organizational chart, with oversight, could set the stage for growth and expansion of services and facilities? Why not attract more private doctors? Why not get their Medicaid payments out of the control of the CHCC CEO? Why not create partnerships between the private and public sectors to build $1.5 million to $2 million surgical centers /mini hospitals in underserved areas like Tinian and Rota where patients such as that elderly Japanese man don’t have to travel so far and risk a fracture fat embolism or blood clot going to his lungs and killing him because of the transport?

Why not put some of this, say, back in the hands of the mayors, elected by the people of Tinian and Rota? Hey, why not put the direction of healthcare back in the hands of the elected Senate and House Healthcare Committees who could then neatly provide the oversight that the people need to the board of trustees, who would not run the day-to-day CEO show but could also provide the necessary CEO oversight?

Why not restructure CHCC into two parallel functioning arms: the administrative side headed by the CEO who runs day to day operations and the medical professional arm headed by physician peer review committees who oversee and are educated to oversee the doctors? No patient would have the doctor-patient relationship decision making severed. Anything that falls too far out of the standards of care and caused a problem could swiftly be heard by the peer review committees made up of all, I repeat, all of the physicians themselves. Any recommendation for reprimand, suspension, or dismissal of privileges would ultimately be carried out by the board of trustees in the same way a malpractice judge or jury adjudicates a court case. I cannot take credit for making this stuff up, I was taught.

To be continued.