How to win a war

Years ago, when the institution I was associated with was starting a helicopter program, my mentor informed me that to start an air medical program was to immediately go to war with every other ho+ pital in the area. In my naivete I thought he was overstating the problem and given to melodrama. However, as with other principles advanced by those older and more learned than myself, I have come to appreciate the wisdom of his po sition. Our history is replete with bitter interhospital rivalries that have occurred in cities with multiple programs and unnecessary duplication of services. Not only do we squabble between hospitals but also among our own associations. Periodically we show fitful signs of maturation, albeit often in a seemingly re luctant fashion. Multiple programs have merged into consortia and other models. We have begun to achieve integration with ground-based EMS, one of the necessities of survival espoused in the original government analysis of the early foray into civilian air medical programs. We have learned to work collaboratively with governmental bodies instead of ap proaching all situations in an adversarial fashion. Despite intermittent self-destnmtive outbursts, our associations are learning to work together in joint ventures and other standard business models. Our maturation is not yet complete. Like the adolescent wild animal that has outgrown its parental protection but is not yet fully capable of withstanding or outrunning the onslaught of nature, we move into a time of increasing peril. Our peril comes from society’s perception, be it true or otherwise, of the need to reduce expenditures in virtually every area of our existence. As the economic pasture in which our society grazes becomes smaller, competition for the available nourishment will become more intense. This is not a forecast of doom and gloom, but simply a reasonable analysis of the current state of affairs that would probably be accepted by most who do not consider long-term planning the purchase of a lottery ticket. This competition will manifest itself in various ways. Areas of pasture once ceded to us will again be challenged by those who begin to feel hungry, or even see a future drought. Control of resources is one of the key issues over which wars are fought both by humans and in the animal world. One need only look at recent conflicts to see that the “have nots” have become increasingly bold in their attack on the “haves,” whether the commodity in question is oil, land, food, or water in the Middle East. As our attackers become more bold and more sophisticated in their attack, new alliances will be forged, and strategies will advance. Early this year, the Vermont Health Policy Council voted to recommend to the Vermont Health Care Authority that the Dartmouth-Hitchcock Air Response Team @HART), based in neighboring New Hampshire, be denied a Vermont Certificate of Need (CON). Vermont has no air medical programs of its own listed in the 1995 AAMS Program Directory. The chief opponent to granting the CON appears to have been Fletcher Allen Health Care, a hospital and health system in Vermont that may stand to lose patients. Without analyzing the relative merits of the arguments pre sented by the protagonists, I will not accept that the opposing hospital is motivated purely by a sense of concern for the well-being of the patients involved, any more than any sane person would accept that the liberation of Kuwait had everything to do with democracy and nothing to do with oil. Even in this time of shifting from profit-centered to costcentered strategy, patients are the livelihood of a health care system. If the transfer of a few hundred patients from one system to a competing system takes place in a highly visible and spectacular fashion, it is likely to carry other patients with it. Thus a hospital will see its available grazing land threatened. In reading the press releases and ana lyzing the apparent “battle plans” of both hospitals, I am struck by the use of the same old weaponry. Both have appealed in various fashions to the emotional side-grass roots campaigns, personal testimonies, endorsements (negative and positive) from nationally recognized experts, and biting rhetoric in editorial columns. I personally wrote several key politicians, emphasizing among other points the cost of not granting the CON in terms of lost wages, taxes, and the cost of litigation by those denied a service available in all other states and most countries in the world. DHARTs experts cited a small internal study showing the effectiveness of their program. The Fletcher Allen expert attacked DHARTs analysis on the basis that it was performed in house and by a physician in a particular medical specialty different (and therefore, inferior) from that of the Fletcher Allen expert He also wrongly alleged support of one of the grand old