The Lighthouse Keeper
BY DANIEL W. DRAKE ASSOCIATE PUBLISHER
At the dump on Sunday, I overheard this conversation:

Man (with gusto): "Hi! You're back!"

Woman: "Yes." (pause) "And I have a significant other."

Man (after a longer pause and with less gusto): "The same one or a different one?"

Woman (after an even longer pause): "A new one."

The byplay was, in itself, worth repeating in the context of a new season, but it seems particularly appropriate given last week's announcement by Nantucket Cottage Hospital ("NCH") that it, too, has a new "significant other." NCH has signed an affiliation agreement with Massachusetts General Hospital ("MGH") and has become a member of Partners HealthCare, a consortium created by MGH and Brigham and Women's Hospital. Other members include community hospitals in Beverly, Wellesley and Jamaica Plain, as well as specialized hospitals like McLean and Spaulding, and now Martha's Vineyard Hospital as well.

What is the agreement really all about and why? Is it a marriage? Is it a significant relationship? Will patients benefit? Will the community benefit? Will the hospital benefit? And what's in it for the other party, the 900-bed gorilla that is now cohabitating with our 19-bed horseshoe crab?

Chuck Gifford, NCH's Director of Community Relations and Development, tried to explain the arrangements to me. Others close to the process shared their views. Most were enthusiastic.

In theory, Nantucket patients will benefit through greater accessibility to clinical specialists, both at MGH and here on the island. How this is going to play out remains to be seen as there are no implementation plan. And the agreement is nonexclusive, so the hospital - and the island's doctors, who are quick to point out that they don't work for the hospital - can continue to refer patients to whatever specialized care physician or facility they deem appropriate.

Getting specialists to visit the island is problematic. After almost seven years of making do with the traveling or electronic dermatology service offered by NCH, my wife finally decided enough was enough. In that time, she has seen several doctors and also was viewed on closed-circuit television by anonymous elves. She finally called MGH early last week to book an appointment with one of the doctors she saw here early on. She was told that she couldn't have an appointment until she had an MGH patient number. That accomplished, she was told she was a "new" patient and would have to wait more than a year for her appointment. Has anything changed in the week since the announcement? Or, will it change?

Gifford estimates that in about two years MGH's medical staff will be able to access electronically NCH's patients' complete medical records. That will be helpful when the medivac helicopter is headed towards them - but could not any doctor anywhere get those same records with the patient's consent?

Island surgeon, Dr. Tim Lepore, appreciates the effort that that NCH has made to create the liaison with MGH, and "…remains optimistic…" as to how it will play out. He points out, however, that patient referrals are made to physicians and not to hospitals.

Dr. Greg Hinson, the Chief of Staff of NCH, doesn't see any quick changes in the way things are done in patient care. He believes the medicalrelated benefits of the affiliation will evolve, and increase over time.

The community's benefit? Nantucket will continue to have an independent hospital, the fortunes of which will rise and fall in large part on the basis of local management. Four MGH representatives, including the president and the chief financial officer, will become NCH directors but they will comprise less than 20 percent of the board membership. The new director of the hospital will still be chosen by the board through a national search.

The question that may be the easiest to answer is what's in this arrangement for MGH? The answer, pure and simple, is money. Not Nantucket's money, but money received in reimbursement from the federal and state governments. It is too complicated to explain in this space, but the agreement should provide MGH access to substantial, additional reimbursement dollars. Will NCH benefit from this? Apparently not; NCH will receive no incremental operating funds under the agreement.

Finally, then, what's in the deal for NCH? Foremost, there will be one $5 million payment from MGH to be used for capital purposes. In addition, NCH will be able to save some money - Gifford didn't have any estimate - by purchasing supplies and even insurance, utilizing the gorilla's far superior purchasing power. Beyond that, it is anyone's guess. Lower cost loans? Access to capital? Perhaps, but only time will tell.

Health care is in a continuing state of financial crisis. The reasons are many and well publicized. What is clear is that NCH, perhaps, is more susceptible to these pressures than most because of its small size and isolation.

One observer says, "The affiliation is an attempt to insure the (financial) survival of the hospital." Hinson agrees with this assessment; he says that the affiliation provides NCH with a financial safety net. He points out that even the co-branding of NCH with MGH and Partners Healthcare may ultimately be helpful in retaining patients who would otherwise go off-island for primary care.

Indeed, has NCH created a blueprint for survival in this affiliation? Is it clear to the outside observer that the safety net is there? There are no assurances. There is little specificity. (The termination of the agreement requires the consent of both parties.)

Significant human relationships happen, usually without a blueprint and taking a lot on faith. It seems that the NCH- MGH affiliation is much like that. It is not a marriage, but it is much more than a casual relationship. Hopefully, the intelligent people on both sides of the relationship will make it work to the fullest.

Which brings us back to the conversation at the dump on Sunday. Unlike the woman I overheard, if this relationship doesn't work, NCH may have a very hard time casting MGH aside and finding a

new significant other. I

The "Lighthouse Keeper" reflects the views of the author and does not represent the editorial position of The Nantucket Independent. Please send any ideas or comments to drake@nantucketindependent. com.