Medical Subcommittee maintains a free-standing specialty hospital “is likely to fail” — according to report

Pago Pago, AMERICAN SAMOA — Doctors, nurses and medical officials who are part of the subcommittee overseeing the plans for a new hospital are voicing their opposition to the project as it stands, citing that a free-standing specialty hospital “is likely to fail” and would have “high operational costs.”

This is outlined in the executive summary from the Medical Subcommittee of the New Hospital Project, dated April 3, 2023, where the committee lays out three options, the first and second of which include a long-term acute care facility either within the current hospital facility or as a free-standing facility.

The report obtained by Samoa News, was endorsed by the medical subcommittee consisting of four senior nurses and nine medical doctors from LBJ and the DOH.

They are Dr Elizabeth Lauvao; Dr Aiga Sesega; Dr Saipale Fuimaono; Dr. Ronald Yip; Naomi Walinski-King; Aiga Mareko RN; Josephine Fuga RN; Dr Akapusi Ledua MD; Dr Joseph Shumway MD MPH ; Dr Abraham Leiato MBBS; Dr Robert Gayapa MD; Dr Olita Koria-Laititi MBBS; Dr Fiatele Porotesano-Avegalio MBBS; Simamao Tuatoo RN DON and Rosamma Finney RN.

The new hospital project, which is now overseen by the Department of Health Director is of vital importance to American Samoa, the report says.

 “It is the result of the discovery of unmet medical capacity issues unmasked by the COVID pandemic.

 “Currently the delivery of health service is challenging with many off-island referrals, late diagnosis of cancers, and inability of LBJ to provide many needed medical services.  Building the future requires the careful investment of the ARPA funds to ensure that the entire health delivery system rises and thrives. 

“The ARPA grant provided 300 million dollars to LBJ for service improvements and facility upgrades.

 “After further discussions, the ARPA Grant was split by the current Governor and $100 million was reserved to LBJ for repairs and service expansion; $200 million dollars was moved and allocated to build a new specialized acute care 40 bed specialty hospital to capture new medical services. 

 “The agreement splitting the grant was not done in consultation with a team of medical planning experts.”

According to the report the LBJ Board was excluded.

 “Critical stakeholders, including LBJ physicians and nursing staff were not consulted until very late in the process. 

“This grant was improperly left in the hands of well-meaning but inexperienced advisors. Seasoned stakeholders were specifically excluded from critical discussions.

“Most of the medical planning input was provided by two LBJ doctors with no experience or training in healthcare planning. Significant unintentional errors resulted.” 

Thus the report concludes the original proposal is flawed and unworkable. 

“It does not meet the health care needs of American Samoa — correct decisions in this matter are desperately required for the future.”

The medical committee states that the language in the initial grant proposal is very clear about what services were to be provided by the new facility.

 “Those recommendations are not supported by data. Unfortunately, most of these types of highly specialized services require extensive lab, radiology, and pharmacy services. The proposal even included ICU beds which are very expensive to build and staff.” 

Proposing a free-standing specialty hospital to perform the most complicated orthopedic, urologic, cardiac, ICU, and ophthalmologic services is likely to fail due to the high operational costs and the low clinical volumes present in American Samoa, according to the report. 

 “Such a 40-bed “mini-LBJ” facility cannot be built with the allotted funds — that fact has already been confirmed with the Hawaii architectural firm.

“It is the wrong type of facility for a population of nearly 50,000 people living hours away from any other supporting hospitals. That is a data driven conclusion.”

According to the report the Army Corp of Engineers are the experts in health care planning. 

 “They performed an all-inclusive survey and review of the unmet medical service needs of American Samoa.

 “In their comprehensive review, they never recommended to open a second specialty hospital. Such a decision is not cost effective. As professional health planners, they recognized that such a decision would squander vital health care dollars.”

A second facility would duplicate resources and have difficulty in generating revenue.  Building a second acute care hospital is nowhere to be found in their recommendations. 

 “Either we build a proper facility to meet the needs of our population or we risk wasting the $200 million dollars. In summary, the original grant proposed was not properly researched or vetted by health planning experts. 

 “It is additionally tragic that the foundational US Corp of Engineering document of 2019 was ignored in their original proposal.”

The report says the medical committee is responsible to provide the governor professional advice and recommendations. 

 “As health professionals with decades of experience, we are the most competent subject matter experts present in American Samoa. 

“We have met many times and reviewed extensive health data. For this report, we have relied extensively on the Corp of Engineers report. We have reviewed multiple years of health data from LBJ and the DOH. We have also reviewed additional data from the off-island referral program funded by Medicaid. We have consulted other stakeholders and experts in this area. The data supports our recommendations.

 “After hundreds of hours of work, this is the validated and endorsed proposal of the medical and nursing team which was assembled at the Governor’s request.”

STANDARDS IDENTIFIED AS CRITICAL REQUIREMENTS FOR A NEW MEDICAL FACILITY

These standards guided the scope and direction of our medical recommendations: 

1)        Building for the Future: The medical committee has reviewed current unmet medical needs of American Samoa. Our recommendations must address the current medical gaps and also anticipate future healthcare needs. This health planning should also enable the future expansion of our medical system capabilities within American Samoa.

2)        Financial Stewardship: Any facility must effectively capture its operational/ financial costs to be independent. It must be sufficiently profitable to not become a financial burden to the government of American Samoa in the future. It is important that any project must have a stable funding source to ensure continuous delivery of the intended care. The spending of 200 million dollars as a health care investment must be financially sound and allow for future growth.

3) Cooperation: We need to expand our acute care, chronic care, and also support our public health medical services for all of American Samoa. Any new medical investment must increase the healthcare capacity and improve the health of its people. It must do so working within our current systems. It must add to and strengthen our current healthcare systems at LBJ and DOH. This must be structured to be a complementary and cooperative relationship. Our primary health goal must be unified and aligned to promote the health of the people of American Samoa.

4) Capture New Revenue: Currently LBJ is providing medical care to nearly 50,000 people. Some of that health care is not being paid for. This is lost revenue to LBJ and (also) lost revenue to American Samoa. Any proposed healthcare project must capture previously untapped revenue sources. This will pay for services currently being supplied without payment. This will also fund additional programs in the future.

5) Provide On-island Services: With any new investment, we must have a goal to decrease the financial burdens (direct and indirect costs) of the off-island health care referral program. It is estimated that the off-island referrals would drop by 60-70% with the acceptance of our recommendations. These savings would occur with the upgrading of LBJ’s medical services, improvement of the preventive care services of the DOH, and with the new services which will be added by this new medical facility.

6) Telemedicine Capacity Building: Even with improvements throughout LBJ, DOH and with a new facility, there will still be some medical services that will need the Off-Island referral program. With the proper development of telemedicine services, only the most complex surgical or cancer patients will need Off-Island care in the future.

7) Improve health outcomes and Wellness: Providing new medical services is needed. This is the core function of this grant. Providing specific services related to outpatient cancer chemotherapy, palliative and rehabilitation services, addiction recovery and, provide a location to manage chronically ill patients who primarily need skilled nursing care is essential. These services are currently unavailable or poorly developed in American Samoa. This facility must benefit the patient and also assist the well-being of their family and community.

8) Equitable Care: Any new facility must provide care that all the residents of American Samoa can access. A private hospital is generally accessible to only the insured or the wealthy. Building a private hospital with public funds is unjust in a society that values family and community. A private hospital would [be] restrictive, expensive and fail to meet the needs of all Samoan’s due to high costs of care.

9) Avoid Duplication of Care: Any new facility must be sustainable and feasible. When expensive medical services are duplicated in a remote area like American Samoa — this is risky. The small population cannot support duplication of expensive machines and services — when this occurs the healthcare of all declines (and becomes more expensive). 50,000 people cannot financially support two acute care hospitals — in [American Samoa] or anywhere else in the Mainland U.S. Medical services are too costly to buy excess imaging machines, staff and operate costly diagnostic labs, and to have highly-paid medical professionals idle.  

10) Prevent wasteful Capital Expenditure: The ARPA grant contained a suggestion for a Helipad and to institute an emergency helicopter patient transport service. This is a very expensive idea. Air-flight medical transport services for American Samoa would be used infrequently. The operational costs are high due to helicopter maintenance and 24-hr. air-flight staffing. The inclusion of helicopter services in the original grant submission is evidence of the lack of training and experience by the original grant submitting team. They lacked fundamental understanding of the tremendous initial and on-going healthcare delivery costs to sustain a medical helicopter service.

11) Increase Medical Access: Adding capacity to the healthcare system must result in decreased waiting times in the emergency room and to obtain timely appointments.   Patient’s and families must have the ability to obtain expert health screenings for cancer, chronic disease management, and other conditions without protracted delays. This proposal must also address the ongoing problems and find solutions to provide timely healthcare. 

According to the report, the proposed medical recommendations within this long-term health care strategic plan meet these eleven requirements. 

 “Accepting our proposed recommendations would save money, generate additional revenue, improve patient and family experience and spare families the high costs and disruptions of the off-island medical referral system.”

ACUTE REHABILITATIVE & CHRONIC CARE MEDICAL CENTER

 “What remains to be done (after establishing recommended system improvements) are [sic] the creation of an acute rehabilitative & chronic care medical facility [that] would provide new and critically needed services to the people of American Samoa. 

 “Here are some of the NEW proposed services that such a facility would provide:

Long Term Rehabilitation Services & Neurologic Care; Cancer Outpatient Chemotherapy treatments; Mental Health / Dementia and Alzheimer's Programs; Addiction recovery inpatient services; Extended post-surgical care for knee and hip replacement, new amputations; Stroke and Cardiac Recovery with Occupational and Physical Therapy; Durable Medical Equipment for home use – Apnea Bipap machines, Hospital Beds; Post Op Antibiotic Infusions for Sepsis and Osteomyelitis (transfer from LBJ); Skin Graft preparation and “step down” services for prolonged post-surgical care; Chronic Apnea and COPD management services; Outpatient Dialysis to cater to the far west of the island; Chronic Pain Management Services; Palliative and End of Life care; Chronic Disability supportive services and management and Social Admission services for families unable to provide in-home medical care.”

The Medical Committee strongly recommends building a Long-Term Chronic Care/ Rehabilitative specialty hospital; America Samoa is missing an essential piece of services without the presence of an acute rehabilitation and chronic care specialty hospital. 

“Other island nations like Samoa and Fiji have outpatient cancer chemotherapy services. Why are we behind in this area? Advanced rehabilitation services and cancer care is [sic] currently not available in American Samoa. Cancer care and other medical care gaps lead to losses in revenue for American Samoa, it is a great hardship to not have these services available. 

“This is not a family friendly system. 

“The lack of these medical services results in the painful and prolonged separation of families who need follow up care of their cancers, strokes, and heart attacks.”

Furthermore the report says the acute rehabilitation/ long term chronic care facility is defined by the Center for Medicare and Medicaid Services (CMS) as a hospital that has an average Medicare inpatient length of stay greater than 25 days.

 “These hospitals typically provide extended medical and rehabilitative care for members who have multiple acute or chronic conditions with complex management.

“Services typically include comprehensive rehabilitation, respiratory therapy for ventilator management, chest tube, wound care, cancer treatment, head trauma treatment and pain management. 

“These services can also include care commonly provided in subacute care facilities, which provided rehabilitative care typically provided following an inpatient hospital admission and would include skilled personnel to assure the safety of the patient and to achieve the medically desired result. 

“The presence of a long-term acute care facility (LTACH) would allow for new revenue streams, decrease the re-admission rates, and provide a place for chronic services to be given to patients with extended lengths of stay. 

“This is not a nursing home for the aged. The average length of stay in a LTACH is approximately 25-30 days.”

According to the report, currently LBJ has significant revenue losses, as it is unable to capture payment for these provided services. 

 “A chronic care facility would be able to capture this revenue and also provide a location to meet many un-met medical needs currently faced by the people of American Samoa. 

• “With a Chronic Care Facility, those needing rehabilitation and chronic services would have a location to receive previously unavailable care for stroke, cardiac and other medical conditions.
• “When people go off island, this is a cultural, family and revenue loss to the Island of American Samoa.  A new facility to manage these services will prevent the financial and emotional costs of off-Island care. 
• “Our goal is to decrease the off-island referral systems by 60-70% from our current levels with the building of this new facility and with the upgrading of the LBJ facility.
• “Focused Rehabilitation and chronic care services are best delivered in a “purpose built” facility, LBJ hospital is an acute care hospital and not a chronic care facility.
• “This is not a nursing home or assisted living center.  It is a medical specialty hospital

“A 40-Bed Long term Chronic Care Facility is correctly sized to manage the current and future needs of American Samoa.”

 The medical professionals further noted this estimate is based on six years of admission data from LBJ.

 “This 40-bed estimate also allows for the return of some expatriate American Samoan population to return to their home and families.

 “This would allow for the respectful and appropriate care of our people, re-unite families, generate new revenues, and provide medical services previously unavailable to American Samoa.

“Based on current LBJ data, off-island referral data, and other health information, the new facility will need approximately 40 beds for cardiac and stroke rehabilitation, surgical “step-down” care, and for other chronic, disabling medical conditions. 

 “This includes services for inpatient drug rehabilitation and addiction services, treatment of serious chronic wound cases, and beds for palliative care that exceed the ability of families to provide home based care. 

“This facility will also have outpatient services with additional “day use” beds / chairs / sofas as needed to provide cancer chemotherapy and chronic antibiotic infusions. 

“These “day use” areas for these services would require an additional 20 patient cubicles. This is in addition to the 40 beds previously discussed.

“These new services are greatly needed in American Samoa.”

Also any patient admitted to this facility (either as inpatient care or “day-time ambulatory” care) who needs acute care services (such as CT or MRI imaging) would be transported to and from LBJ for these specialized services. 

“This is an efficient use of these expensive medical machines and services. It avoids duplication of LBJ services.

“This meets the US Mainland medical standard for these types of services.

“The current US standard is not being met with the absence of a chronic care facility in American Samoa.

“These are medical services that every family will need, at some point in their health care journey.

“These are services that should be provided On-Island, without the separation of those so afflicted from their families.  

“The building of a long term-chronic care specialty hospital is the final missing piece that is needed for American Samoa. 

“With this facility and the rebuilding of LBJ and with the preventative services of the Department of Public Health, patients will have all the services needed to ensure health and wellbeing at all phases of their lives.”

(Samoa News will report on the final recommendations of the Health Committee, which includes system improvements to the current medical care available at the hospital, in the Tuesday, Apr. 11, 2023 issue of Samoa News.)