Access to quality health care is something most of us take for granted. Even the 44 million Americans without insurance, and the other 40 to 50 million with minimal coverage, rest easy with the knowledge that if they walk into an emergency room, they won't be denied care. But conflict over who foots the bill and shares the burden of caring for the uninsured has hospitals warring in Collier County, and consolidating and moving beds in Lee.

Conflict in Collier

Over the past couple of years, the local press has been filled with reports about the public feud between NCH Healthcare System-which for decades ran Naples' only hospital-and Health Management Associates, the Naples-based national hospital chain intent on building a 100-bed Collier Regional Medical Center in east Naples. NCH has waged a very public PR battle opposing HMA's first hospital in Collier, and has challenged the plan in court.

What's the problem? That depends on whom you ask; and, understandably, all parties involved mount pretty solid arguments. According to Edward Morton, CEO of NCH, the issue boils down to indigent care and conflicts of interest that arise from the for-profit hospital model.

By state law, hospitals are required to offer emergency care to indigent or uninsured patients unable to pay for health care-they can't walk through the door of an ER and be turned away. Florida law also mandates that every hospital assumes a certain percentage of indigent care, so that one hospital doesn't shoulder the full burden of treating the poor.

But Morton says that if a hospital makes a business decision not to offer big-ticket services that many indigent patients need, it eliminates a lot of that walk-in traffic. "If you're a migrant worker and you fall and hit your head at work," says Morton, "where will you be sent? You'll go where there's a neurosurgery department, and that's NCH."

This is no accident, says Morton. Hospitals know they'll foot the bill for that uninsured migrant-tens of thousands of dollars, if not more. So instead of turning away the poor, which by law they cannot do, they simply don't offer the services that the poor may seek.

Morton adds that not everyone who walks into an emergency room is in a critical state. The majority of uninsured (40,000 to 50,000 people in Collier County alone) rely on emergency rooms for conditions like headaches, the flu, a sick child or even a pregnancy-routine medical care for which someone with insurance or financial means would visit a family doctor. But if your hospital doesn't offer OB, pediatrics or neonatal care, or closes its ER doors to non-emergency patients, problem solved. They'll go elsewhere. In Naples, says Morton, elsewhere is NCH.

Morton cites the indigent-care issue as part of a larger conflict, that of nonprofit versus for-profit hospitals. NCH is a nonprofit hospital governed by a board of directors who are members of the community. Any profits the hospital makes, it spends, through expanding programs, hiring more staff, offering more services. A for-profit model such as HMA has stockholders expecting to see a return on their investment; the business model requires that for-profit hospitals make money. When they make money, their stock price goes up, and their shareholders are happy.

Nonetheless, Morton doesn't knock the caliber of service available from HMA hospitals. "HMA delivers wonderful care," he says. "It uses great physicians, fine people. But their business model is what we take fault with. If they don't make a big profit, their stock price goes down. So they have to figure out the best way to make a lot of money off sick people."

To keep investors happy, he adds, for-profit hospitals have to make more and more money each year. "You can't run a for-profit hospital without running smack-dab into a bioethical wall of legal difficulty."

Morton refutes claims that NCH just doesn't want competition in Collier. "We welcome competition," says Morton. "We just want HMA to agree to take care of its fair share of the poor, and we want that agreement in writing."

Competing Claims

HMA sees the situation differently, of course. John Merriwether, vice president of financial relations for HMA, says the issue does boil down to competition, and that NCH has neglected the needs of east Naples. "We're coming to east Naples because we were asked to come," says Merriwether. He points to meetings with east Naples civic leaders, the unanimous support of the Collier County Commission and, perhaps most important, the certificate of need, or CON, granted by the state that green-lighted plans for HMA to build its 100-bed hospital in east Naples. The CON is awarded after the Agency of Health Care Administration determines that the proposed services are needed and won't be a duplication of existing resources.

What HMA brings to the table, according to Merriwether, is another health-care choice, particularly for the people of east Naples, Golden Gate, Marco Island, Goodland and Everglades City, who currently have to drive to NCH's downtown Naples location for care. HMA, he says, is more than willing to honor its obligation to the state and the community, and to take on its fair share of indigent patients.

In fact, he predicts the new hospital's presence will take the burden off NCH, because the majority of uninsured and low-income patients come from the east county. "Do you think they're going to drive past our 100-bed hospital and 24-hour emergency room and go to NCH?" says Merriwether. "I don't think so." Plus, the new Collier Regional Medical Center will have a 14-bed women's health center that will offer OB service. It's not exactly NCH's 52-bed birthing center at the north Collier branch, but it's 14 more OB beds than are currently available in east Naples. Of signing an agreement with NCH, Merriwether says, "We were asked to come here. We see no need to cut a deal with NCH."

The Cleveland Connection

The third player in the Collier hospital scene is steering clear of the finger-pointing fracas. Cleveland Clinic Naples, which opened its doors in 2001, offers an 82-bed hospital and 24-hour ER at its location off Pine Ridge Road, just east of I-75. According to Dr. Robert J. Zehr, executive director of the Cleveland Clinic Florida Naples, when the Ohio-based hospital decided to open a location in Naples (Cleveland Clinic also has a large facility in Fort Lauderdale), it was responding to consumer demand. "We saw such a high number of patients driving from this area to the other coast for care from Cleveland Clinic doctors," says Zehr. "That told us there was a need for another option in Collier County."

The Cleveland Clinic model is what attracts patients to the facility, says Zehr. All the physicians here are employees of the hospital, unlike the traditional arrangement in which physicians in private practice have hospital privileges. Every aspect of a patient's medical care can be handled under one roof. That means one-stop shopping, with one patient chart; and the system enables patients to get more of their health-care services provided in a single day.

A nonprofit hospital, Cleveland Clinic is also obligated by the state to take on its fair share of the indigent. But what if the indigent don't show up? According to Zehr, Collier residents used to availing themselves of NCH's emergency facilities aren't going to start heading to Cleveland Clinic overnight. And while Cleveland Clinic's charity care numbers turned up short for both 2001 and 2002, Zehr says that will change as more people learn about the hospital's presence. "We don't have any means of controlling flow of traffic to the hospital, but we fully intend to be good community citizens," says Zehr. "We are open 24 hours a day, seven days a week, and we've never turned anybody away. We take everyone who comes in the door."

Zehr also makes it clear that Cleveland Clinic never opposed HMA's move to Collier. Though he shares many of Morton's views regarding the inherent conflicts in a for-pro-fit hospital system, he welcomes competition. "More competition encourages superior health care," he says. "Sure, dozens of hospitals in an area would seem foolish. But America is not based on monopolies; people want the ability to choose. Growth is good, and competition is good."

Trauma in Lee

In Lee County, indigent care is still a buzz phrase, but it doesn't seem to generate the contentious debate that it does in Collier.

The health-care giant in Lee is Lee Memorial Health System. Once dominated by the old Lee Memorial Hospital on U.S. 41 near downtown Fort Myers, the focus of LMHS is now at HealthPark, its 403-acre campus in south Fort Myers. HealthPark houses 240 hospital beds, along with the only children's hospital in the region, including a renowned children's oncology unit, and one of only 11 high-risk OB wards in the state.

Recent news from LMHS hasn't been all positive. The hospital is struggling to keep the region's only trauma center open for business. The center takes in seriously injured emergency patients, many of whom are uninsured or under-insured. And it hemorrhages money-in 2004 alone it's already lost nearly $6 million. In 2002, Lee County voters rejected a half-cent sales tax that would have funded the center. Although the rebuke was stinging, the ballot measure raised local awareness of the issue. Short-term funding is keeping the trauma center open for now.

Net Losses-and Gains

But LMHS is not without competition, and the musical beds might reflect an awareness of that. HCA, a Nashville, Tenn.-based corporation that owns 191 hospitals across the country, plans to consolidate its two Lee County hospitals by moving Southwest Florida Regional Medical Center from its present location in downtown Fort Myers to the campus of Gulf Coast Hospital in south Fort Myers, right in HealthPark's back yard.

Though this is a net loss of 200 beds, Mark F. Weber, president and CEO of Southwest Florida Regional Medical Center and Gulf Coast Hospital, boasts that the new facility will be "the only full-service hospital providing services ranging from obstetrics and pediatrics to open-heart surgery, neurosurgery and organ transplantation." (Currently, Southwest Florida Regional Med-ical Center has the region's only organ-transplant center).

Despite dueling strategies, LMHS and HCA do appear to be on much more civil terms than NCH and HMA. John Wiest, chief financial officer, and Jim Nathan, president of LMHS, both agree that the region is "blessed" with excellent health-care choices. If there are tensions between the nonprofit (LMHS) and for-profit (HCA) models, they're handled politely.

HCA's Weber explains that "both not-for-profit and for-profit hospitals provide charity care, and are incurring increasing bad debts." Employers and insurance companies are requiring patients and family members to spend more out of pocket, which in many cases, they're unable to pay.

According to both hospital groups, the problem is not greedy hospitals that don't want to serve the poor, but a failing health-insurance system.

"Insurance costs are on the rise for a variety of reasons, from the rising costs of drugs and other medical supplies and devices, to the rising costs associated with providing care to the uninsured," says Weber. And, he notes, "Health-insurance companies are more profitable today than they have been in the past 20 years."

Wiest agrees. Medical malpractice costs, he says, have put pressure on physicians to shift to outpatient and less risky business options. That search for the safe dollar, from sources like elective orthopedics (think rotator-cuff repair from a tennis or golf injury), for example, "has forced hospitals to compete more vigorously for patients."

Still, increased competition may not be altogether a bad thing for the public. Both institutions cite big plans to offer more and better services. Dr. CB Rebsamen, LMHS' chief medical officer, rattles off a list of innovative techniques and services not available even a few years ago that have improved patients' survival rates and quality of life, including "clot-buster" drugs, "space-age" implants and prosthetics, and greater safety measures.

Weber concurs. "We talk a lot about the rising costs of health care," he says. "However, if you look at the benefits we have delivered for a dollar invested in health care over the past few decades, they are tremendous."