People Behaving Badly, Or Why There Is a Medical Crisis in Guam

Originally published in The Guam Daily Post, Letter to the Editor (Part 1/Part 2)

Oh, the poor folks hate the rich folks

And the rich folks hate the poor folks.

All of my folks hate all of your folks

It’s American as apple pie.

Tom Lehrer – National Brotherhood Week lyrics

Guam has so many positive aspects… a beautiful island, tropical splendor and climate, friendly and generous people, clean major industry (tourism and military), a part of the American dream without the attendant part of the American nightmare of insanely divisive politics, racial problems, overbearing government and police, violent crime, areas of urban blight and over population, etc. So, it is difficult to understand why we have our mini-divisiveness here over a chronic problem that affects all the residents and has been resistant to significant improvements; medical care on Guam and the fate of Guam Memorial Hospital Authority.

As a self-professed curmudgeon, with no deep connections to so many divisive entities that may cause discourse…. politics, religion, medical insurance and industry, medical associations, hospital affiliations, nationality, ethnicity, I may be able to elucidate without prejudice, some factors responsible for this chronic problem, although the solutions are not easy, nor do I have all the answers.  It is interesting to note in the upcoming gubernatorial race, three candidates from one party who profess the knowledge to correct the problem, have had significant opportunity  to positively affect health care in the past, and all have either failed through inaction or more ominously by worsening the problem; while from the other party, we hear if anything, ”What problem?” 

Rather than join the ongoing current debate limited to incompetence of GMHA management vs. lack of adequate GMHA funding, let me expand to blame all the players: GMHA management, the GMHA Board of Trustees, the Senators, the Governor, the doctors, the insurance companies, and finally the patients and potential patients.

GMHA management

I will not go into allegations of corruption, rule by a medical oligarchy to maintain power and enrich themselves, political assassinations of staff wishing to change this chronic management disease and improve patient care, all of which were referenced in senate hearings and will hopefully be fully exposed in the upcoming senatorial investigations.  But, at the very least, would any rational person seeing the pathetic exhibition and incredible incompetence of some of the GMHA management under piercing questions by some Senators, believe that these people are capable of running a modern hospital? Enough said on this subject.

GMHA Board of Trustees

We also heard really few people on the Board consider it an honor to be appointed and really do not wish to commit the time and effort, let alone have the pertinent knowledge, to be essentially the effective motor that runs the GMHA. You are ultimately the ones is charge. Yet, you let the CEO and his staff run wild, commit funds and critical actions without your approval or even knowledge, and acquiesce to the (often) faulty narrative you are fed without question.  If you cannot or do not wish to commit the necessary time to do a decent job, resign rather than continue this farce.

The Senate

We are seeing a flurry of recent, long overdue action by this body, with five Senators distinguishing themselves with very well researched and intelligent questions to the hapless GMHA management.  But as we all know, the GMHA and medical problems have been ongoing for decades. Only a cynic (or curmudgeon) would suggest the current energy may have something to do with upcoming aims for higher office, but whatever the case, it is long overdue and most welcome. However, would it be depressing to point out the five animated and perceptive senators, for diverse reasons, are all leaving at the end of the session? We certainly do not hear much from the other 10 senators, apart from one who woke up at the end of one hearing that devastated the GMHA management to congratulate this management for a job well done!  

Governors

We all are aware of inactions, or misdirected actions of former governors regarding GMHA and medical problems, but let’s deal with the current situation. I firmly believe Governor Calvo came into office with a genuine will to improve GMHA and some of the medical problems. He wisely declared an emergency at GMHA and assumed Organic Powers to drain the GMHA swamp by firing the then CEO (who ironically has been resurrected as current CEO) and most of the Board of Trustees who did not resign (including a current prospective governor who, not content with the mess which was then ongoing, insisted on staying on to make it worse and had to be almost physically ousted).  But, Governor Calvo thought in his naivety and good will the appointment of anyone to management could improve the inherited mess, and the information he was being fed by some of these people was accurate and devoid of selfish interest. Also, like so many people untrained in medicine, hearing diverse stories from medical professionals about how to run medical care can be downright confusing if potential benefits acquired by the people making the recommendations are not assessed. Well, there have now been five CEO’s during his terms, and I don’t know how many CFO’s, which should tell most people there was not only smoke but a conflagration of massive proportions long before it became a crisis over closure of GMH. We understand Governor, the medical profession must shoulder much of the blame for your confusion, but honestly to insist that money will solve the problems is to live in a Trump-like world of denial, when 32 or 41 defects outlined by the CMS report pointed to managerial incompetence and not financial matters. I have not heard one critic of GMH say more money was not needed, but that first the incompetence that created the situation had to be corrected and other sources of funds identified and made available before yet more burden was placed on the people of Guam.  And Governor, I know you have many important matters which occupy your time, but you cannot honestly plead complete ignorance to the political/professional assassinations ongoing at GMHA. You recognized that Dr. George Macris was so treated by the entrenched cabal of physicians running GMHA under the previous comatose administration, and you most laudably reversed his biased ‘conviction’ when you assumed power.  But where were you when an equally egregious action was and is ongoing against Dr. Kozue Shimabukuro? It is interesting how she was the darling of GMHA when she was genuinely and tearfully pleading to the senators for more funding to save lives at GMHA, but suddenly became the ugly villain when she started to pressure GMHA management to change some of their corrupt, outdated and costly policies. 

Doctors

Let me say first that despite some justified criticism of delayed or denied payments on Guam by public health (MIP, Medicaid), the majority of physicians on Guam are very well paid compared to most of their mainland colleagues with expenditures usually being less, and they have an easier time professionally with bureaucratic chores, which we all hate. There are considerable numbers of well trained and dedicated medical professionals available to serve the people of Guam. However, there is a dearth of cohesive action to address and solve problems with factions who for reasons of self aggrandizement or apathy continue to be divisive, and none more so than some of the entrenched physicians who make policy at GMHA and face no opposition from an ignorant and inept management. Nowhere does one see committees to address questions of professional competence or malfeasance (also cited by CMS report) and hence we have physicians practicing at or actually employed by GMHA who repeatedly commit medical malfeasance or malpractice and actually harm patients, never to be held to account. I am aware of many of these malfeasances and even deaths at GMH which were totally avoidable if proper medical care had been provided in a timely fashion provided.  We all make mistakes, certainly myself included, some more serious than others, but if our actions are not realized by ourselves, or we are not educated to prevent the recurrence of such actions, these will continue to occur. Instead, the medical oligarchy at GMH passes, on its incompetent friends, and attacks any physician with the temerity to questions their entrenched own competence in their positions of power. Then there are physicians at GMHA well compensated by the Hospital but who undertake almost no action to justify their generous stipend (the inactions of some also cited in CMS report). In fact, I am told on good authority, that instead of trying to improve care to meet the CMS deadline, they are with the administration, pulling a plethora of charts of a recently assassinated (at their hands) highly competent physician to try to find any malfeasance to defend their outrageous behavior against the legal actions that will be forthcoming against GMHA. Then there is a group, most in the mentioned power structure of GMHA who have been chronically deficient in completing and signing off charts so that they can be billed; completely uncaring that their delays are looked at by the insurance companies like vultures over a dying animal, knowing they will avoid paying the entire hospitalization if the claim in not submitted on time. Finally, I have never seen such a paucity of programs for continued medical education, necessary annually for all physicians, as on Guam; or when a commendable program is available, it is mostly attended by non-physicians. And how about the hypocrisy of some very vocal self-professed philanthropic and altruistic physicians who refuse to see Medicaid and MIP patients!!

Insurance Companies

One has to be a bit kind to insurance companies facing the incredible cost of some medical care and especially newer drugs. And to their credit, most, not all, have been less onerous than mainland contemporaries in approving necessary drugs and procedures. However, trying to short change GMHA by nefarious actions may improve their bottom line, quite plump in any case, but ultimately cause GMHA to be perennially underfunded. They have all basked, some more than others, in the incompetence of GMHA to properly bill on time or answer professional questions, sometimes contrived, so that the entire claim can be denied. Instead, now they are faced with a new hospital where the cost is a multiple of GMH and the care certainly no better despite this hospital’s self-inflated advertising. So, one insurance company refuses to have patients seen there, although they are infamous as the most dishonest with regards to denying GMH payments on technicalities; and another insurance company charges an additional policy premium if any care is to be covered for the patient at GRMC. Then there is the con job all the insurances pull on patients by sending them off island, not to a superior facility of the mainland, but to third world Philippines, knowing full well, that notwithstanding some reasonably good care provided by some medical professionals there, a large portion of the care, to say nothing of the lack of information provided to Guam physicians for follow up, is sub standard.  I know that some patients, because of family ties, etc., wish to go there, but what about the better informed or ignorant patient who trusts their insurer to decide their fate, when the latter only considers cost?  

Patients and potential patients

So, I’m sick, why am I at fault? Well, most of you are totally blameless and deserve the best care available, not always the case on Guam. But, the majority of the illnesses seen now in most advanced countries are self induced by obesity, poor diet, lack of exercise and especially, smoking. I know, we like to blame the government for their inaction or even their opposition to raising tobacco taxes to the point that smoking becomes a financial disincentive to smokers and young potential smokers, but despite smokers’ protestations that they cannot give up the self destructive habit, it is amazing how many do after the fact of life altering, and frequently life ending, heart, lung and malignant diseases. The heaviest smokers worldwide are usually the lower economic classes; on Guam, translated to people on public assistance and MIP/Medicaid. So, the government/tax payer, in lieu of raising taxes to curtail tobacco use, has the irony of partially subsidizing their habit and then paying for the horrendously expensive care that will entail. The more progressive state and foreign governments have raised cigarette costs to realistic levels… Australia $24 (US funds), NY state $14, most western European countries $15-20 (US funds), vs. Guam $6. And does one need government action to push oneself away from the table, avoid fast foods, food high in fat and sugars, or to exercise on a schedule?  OK, so you are a model patient, take care of yourself and still have the problems of poor medical care at GMH. Well, how about the concept of holding your elected officials accountable?  I keep hearing serious complaints from patients about care received, but when told to complain to their elected officials, there is a stunning silence.

Well, I started off by saying I don’t have all the answers, but do have some suggestions and directions that can be followed both short and long term. Firstly, medicine and politics do not and should not mix. Drain the current septic tank at GMHA (septic tanks need to be drained every seven years or so), pay a decent wage to get qualified professionals running the place and get the hell out of the way! Government should have no influence on the running of GMHA other than having some overseeing non partisan body (like an off island advisory) to be sure everything is running well and intervene only when this advisory indicates action is necessary. This includes not hiring friends, family of friends and Adelup staff, etc., including appointments to the Board of Trustees, but hiring or purchasing based on demonstrated ability and by competitive bidding!  

Guam is bleeding some of its best and brightest to the mainland because of lack of opportunities on Guam both medical and non medical. That should not be difficult to change.

Attract a competent staff, which would be much easier once the professional mafia is ousted,  and improve facilities so patients need not go off island for care…this will have a multiplying effect on Guam’s and GMH’s bottom line by keeping funds on island to expand medical care. Raise tobacco taxes to a realistic level to discourage the start or continuation of smoking and mandate and subsidize HPV (human papilloma virus) inoculations (to eradicate cervical and many other HPV caused cancers) to grade school children along with the other inoculations. A tax on sugared beverages would also notify consumers that there is something amiss with the prolific use of these beverages.

Encourage constructive criticism of the established powers instead of victimizing the visionaries, or be left with the cynical utterance of a local attorney (non Chamorro, who works for one of the insurance companies), “Just smile and make money”. If we would see the same outrage engendered by the Guam population against a navy person who innocently had her photo taken atop an artificial latte stone, directed against the numerous persons responsible for the GMHA disaster, perhaps we would be on the way to mending the situation.