MW: First and foremost, the dominance of managed care in the health care field, because that strongly limits the control that health care professionals have, particularly the doctors, over what is done to their patients. St. Francis has always had the tradition of doing what is in the very best interest of their patients in body, mind and spirit. That is actually their mission statement and they stuck to it very strictly. There is an order of Franciscan nuns that has run this hospital for over 100 years and they felt it was their life duty. They were forced to agonize for many, many years over revenues that were being disrupted by managed care trends. Every hospital takes care of a certain number of poor. A lot is determined by how much of the original loan from the government still remains to be paid. The expenses to take care of a poor individual would be subtracted from the principal that was due on the loan. That was pretty attractive. However, most of the hospitals around here have paid back their loans so they weren’t obligated to do that, unless they took a personal mission in order to see that happen. Mercy Hospital, I believe, has a similar mission statement to help others regardless, but that really is the only hospital in the Pittsburgh area that will continue that kind of tradition now that St. Francis is gone.

MW: They had a much more indigent population, which tends to be sicker when they come to the hospital because they are less likely to participate in preventive care—they can’t afford it. They tend to be a very expensive population. St. Francis took care of the poor without reimbursement more than the average hospital. They simply could not sustain themselves. They also saw a lot of the elderly, which is that segment that uses most of the health care budget across the country.

MW: Absolutely. That is exactly what they did. They were unique in that to a fault. Physicians thought St. Francis was a caring hospital aligned with the basic tenets of the Hippocratic Oath, which says to not discharge patients until they are better. That’s always been impressive. About 15 to 20 years ago, HMOs started paying according to the patient’s diagnosis. If patients needed to stay longer than diagnosed, the hospital footed the bill.

MW: I think many people would say it is salvaged. Larger entities bought it and are turning it into a children’s mission. That’s not the idea of salvaging from the standpoint of, "Why can’t we have a hospital here, actually two hospitals here including Mercy, that have a very strong religious mission statement?" I know the administration at St. Francis struggled for years to keep it independent. They tried to salvage it by merging with hospitals throughout the country of like mission. None of that seemed to be successful. If there was a stronger sense of unity among the health care system here, instead of an extremely competitive environment, we could have salvaged St. Francis. They had the largest number of psychiatric beds in the city, and they actually had developed the very first psychiatric unit. They had done a lot over their history. It’s almost out of respect that I wish something could have been done. What physicians wanted most was just a hospital to admit their patients and be able to deliver high quality care in. I really don’t think they were too concerned with what other hospitals they might merge with. They even considered UPMC in the final phases of decision-making and that pretty much would have been in direct conflict. They probably could have done some things to postpone their demise, but unless they changed the mission statement radically, it was bound to happen at some point. It was their destiny to not be able to carry out that mission in this current environment.

MW: Unfortunately, they were on the listening end. They would make comments and had questions, but the administration was talking about a property sale. Physicians were not involved in those decisions. I think everybody was troubled by the universal fact that these situations tend to be out of our hands in the first place. I think doctors are beginning to wonder if there will be any kind of safe haven for their practice without undue influence from the economic forces. I saw a lot when I was attending medical staff meetings. Though physicians didn’t participate in administrative decision-making, they played a very key role in attempting to keep St. Francis afloat—everything from honing in on using expensive medication, to decreasing lengths of stay and tracking that. There were a lot of physicians that could have gone somewhere else where it might have been a bigger advantage to them, but they stayed on and helped keep the system a little more intact for awhile. Most were salaried physicians that worked pretty intently with the hospital. St. Francis had one physician appointed to represent us in an executive director role who was there to help mainly with communication between physician’s and administration, a figurehead. They tend to be somewhat empty positions in terms of any real power that they have. I don’t think he really had any input.

MW: I think it was very sad that they had to lay off an enormous number of personnel, hundreds and hundreds of nurses, and there were physicians also who were let go and they had most of their practices based in St. Francis. The commentary is that we as a health care body cannot rescue our own. We really need to practice our CPR when it comes to keeping our very systems alive as hospitals are really the mainstay of our system and always has been. It is threatened right now, very, very deeply. Threatened to non-existence. I heard wind of it about six months before it happened. I found it hard to believe. I was just hanging on to the idea that there would be some kind of merging with other Catholic hospitals elsewhere in the country, but for some reason they didn’t work that out. There was no paperwork, no staff notices, they didn’t really start talking about anything until about three months before it actually happened, and by that time they moved from saying that "there is going to be a major change here" to basically, "please come pick up your belongings from the hospital because we’re shutting down in a week."

MW: There has been some switching of St. Francis staff over to West Penn or Passavant. I know of whole departments en bloc just moving out, like the Internal Medicine Department. Several physicians who practiced together at St. Francis would recredential and move into another hospital as a group. It is easier to do that than it is for the individual, as it is more attractive for hospitals to get a group with their own patient population. The easiest position to transfer would be the physician with a very large inpatient practice, which would be attractive to a hospital—and they sometimes will wine and dine that position to come into a hospital. A person with a smaller practice who goes through mostly outpatient will simply have to approach the hospital and say, "Here are my credentials and they are impeccable. I don’t have many patients, but I would like to have the convenience of being able to admit up to 12 patients a year." Hospitals are reluctant to turn away physicians because they depend upon them to admit, which generates the income on which they operate.

MW: I saw a good number leave within that three-year period, but it was still a minority of physicians. In the last year there was some pretty heavy negotiating going on with these physicians to go into another hospital system, as they had no choice. Their patients are going to get sick, they will need critical care beds and admission to hospitals, and if St. Francis is not around, they absolutely had to get credentialed somewhere else, which they did with the local hospitals. Everyone is going their own way. Probably the majority will go on staff and salaried staff at some of the other hospitals. Others may choose the private practice route or may choose to work with an entirely different system. There may be some who choose to work for a managed care system, which pays well if you do what it mandates.

MW: I’m only aware of a few. I’ve had some transfer patients who have come to me and say, "Dr. so and so just left and moved to Ohio and I really didn’t know that he was leaving." More than likely it’s a pretty well planned process that the doctors let their patients know where they are going. But it’s a very complicated process for physicians to figure out where they should go. Starting up a practice is difficult, and then if you have a family, you have both factors to look at. The whole issue of moving out to an area where you don’t know anybody is not an easy one. Your practice depends on you knowing others so they can refer people to you—to network. Somebody is 55 and they have to move somewhere else—it’s extremely hard. I think the impact was pretty great on physicians here.

MW: I’m doing pretty much what I’ve done for the past 13 years with some twists to it. My private practice is really something I do when I have time. I do as much consulting work at an adolescent treatment center called Blade Run to help kids with very severe psychiatric difficulties. I do a lot of consultation at Passavant. I became involved with UPMC this past year because it was a very large hospital and I wanted to get involved in consultation. St. Francis-Cranberry really didn’t have much to offer consultation-wise, with only about 40 beds.