PPH should get out of Hospital business

Published in North County Times 2/26/08

The Palomar Pomerado Hospital facilities' master plan is in shambles. When Proposition BB was passed, voters thought it would result in major improvements to existing facilities and the construction of an additional new medical center and other facilities.

Most of the promises are no longer on the table. Instead, the only remaining part of the plan that is still firm is to build merely one new hospital, and even that on a much smaller scale than they originally promised. This determination to build in the Escondido Regional Technology Center comes from angst. Palomar Pomerado fears that if they do not build it, Kaiser Permanente will build its own hospital, providing unwelcome competition nearby.

Surely, there are better ways to spend limited taxpayer funds.

For example, why not design the new hospital that is planned for the ERTC site in Escondido in such a way that it can be turned over completely to Kaiser? That way, Kaiser will get what they need and the money saved or generated could go to the other pressing needs that are being shelved.

The obvious result of such a change would be that PPH would need to attract more of its own patients. For example, the large Penn-Elm Medical Group recently dropped its affiliation with PPH so that its patients now use other hospitals. As it stands, Kaiser is providing about a third of the Escondido hospital's patients. PPH cannot stand alone based on its own clientele.

This begs the obvious question: If customers are voting with their feet to go somewhere else, might it not be better if someone else took PPH's place?

The covert, disruptive agreement with Kaiser shows that PPH will go to great lengths to reduce competition. This despite abundant evidence that increased competition is better, not worse. Communities like northern Riverside County and the Las Vegas area are much better served because there are numerous hospitals competing for patients and doctors.

A good case can be made that PPH, with its withering amount of goodwill, should get out of the business of operating hospitals entirely. The Grossmont Hospital District came to this conclusion years ago and instead contracted with Sharp. Voters in that district overwhelmingly voted for an improvement bond and are well on their way to meeting their facility goals, without controversy.

A fresh new player stepping into the downtown Escondido facility would attract the many local patients who presently travel south to secure the quality that they demand.This would also free the feeble PPH board from dealing with its intractable operational problems. Like other publicly elected boards, it is ill-suited to compete successfully in the brutal business of health care.

PPH building new hospital to please Kaiser

Note: A severely edited version of this article was printed on 1/11/08.

Recently, the Palomar Pomerado Hospital District proudly announced an improved credit rating. A good credit rating is essential as PPH goes deeply into hock in order to construct its white elephant ERTC hospital. Projected philanthropic support has certainly stayed away. Standard & Poor, which just a few months ago had given our hospital district very low marks, changed its rating due to two key developments. First, the district finally admitted that it was drastically curtailing its construction plans and, secondly, that they were depending on Kaiser Healthcare as a key source of funds. These two developments are integrally related.

It is now clear that the motivation behind building the bizarrely located new hospital was never due to earthquake issues or other inadequacies at the existing site. Such claims were bogus from the beginning. Instead, the district is transparently pandering to Kaiser, most of whose patients will come from the west and from the north of our district. PPH has stubbornly, and some argue illegally, refused to fully disclose its agreement with Kaiser despite numerous requests for public disclosure. We can only conclude that doing so would be embarrassing, except to S&P.

Building a new hospital under the secret Kaiser plan is causing the district to go into unprecedented debt, take on incalculable risks and to abandon virtually all other promises that carried Prop BB to victory. Kaiser’s generous support of the Prop BB campaign is paying off. This may be OK with bondholders but can only leave the rest of us feeling betrayed.

For example, the $93 Million that was just recently promised for renovations to the downtown Escondido campus has shriveled down to $3 Million in the most recent plan. Escondido officials sit idly by as fervent pledges, which paved the way for rezoning the ERTC property, are cynically abandoned. Many of the promises for Pomerado hospital and various community clinics are also evaporating.

The most outrageous broken promises surround the new hospital itself. Even as it generates a huge sucking sound by absorbing all available funds, the most recent plans show that it is no longer the impressive, state of the art project originally presented. For example, there will not even be a women’s center when it opens! Presumably, emergencies involving pregnant women will not be handled by the new trauma center but instead be shuttled to the downtown location until this critical component can be funded. A half-baked, bifurcated and inefficient operation is the best we can hope for into the foreseeable future.

After the dust settles, our district will be left in a morass that the elected PPH board is entering with its eyes wide open. Our only sliver of hope lies in the fact that it is still not too late to stop this slowly moving train wreck. Construction has been delayed due to surprising and costly soil issues at the new site. This is our first taste of many inevitable setbacks. However, it gives us a brief respite before limited district funds are further squandered.

The quality of our health care system will be irreparably damaged unless an abrupt change in direction is implemented. This is the time for a public outcry led by elected officials and all those with influence. We must all appeal to the PPH board to abandon its plans for an unnecessary new hospital, live within its means and adjust their facilities plan to the current realities and pressing needs of our district rather than the narrow, private interests of Kaiser.

PPH Tapped Out

Vander Spek Commentaries re PPH Plans
http://www.nctimes.com/articles/2006/02/28/opinion/commentary/17_45_192_27_06.txt

With Palomar Pomerado Health winning control over the Escondido Research and Technology Center site for a new hospital, the tough questions can no longer be dodged.

The Escondido City Council was most persuaded by the threat that PPH would remove all acute care from Escondido and by fanciful promises for the downtown. Threats and public relations may have gotten everyone on board, but they cannot change the fact that this is a runaway train destined for a very messy train wreck.

Immediately after this victory, PPH admitted the obvious. Their plan is on financial life support. Projects in downtown Escondido, Poway, Valley Center, Ramona, San Marcos, Rancho Penasquitos and even much of the ERTC hospital will need to be "delayed" (the cruelest form of denial). When the dust settles, we could be left with a hodgepodge of hobbled facilities, crushing debt and broken promises.

Here is an update on the PPH Facilities Master Plan:


New hospital in ERTC $531,000,000

Converting Palomar Medical Center 73,000,000

Upgrading Pomerado Hospital 139,000,000

Clinics in V.C., S.M. R.P. & Ramona 10,000,000

Total as presented to voters in July, 2004 753,000,000

Admitted 30% increase estimate at 12/31/05 229,600,000

Subtotal 982,600,000

15% increase in 2006 147,390,000

15% increase in 2007 169,498,500

Total if started in Jan, 1, 2008 1,299,488,500

Additional debt (revenue bonds) (210,000,000)

Proposition BB funds (496,000,000)

Shortage of funds $593,488,500

The situation is actually much worse than this. As everyone agrees, costs are going up much faster than shown above. There is no way to start any major project until a much later date. All projects are drastically behind schedule, and large donors have been scared away.

There is no painless way to solve this crisis. Since voters will not stomach a new "oops" bond, the entire plan must to be reworked from top to bottom. Despite PPH resistance, the obvious place to start is by abandoning the ERTC project. Whether it is ever built or not, it has become a sinkhole, swallowing funds, time, promises, goodwill, trust and hope out of our district.

Of course, had PPH stuck to its original plan of expanding the existing Palomar Medical Center and Pomerado sites, we would right now be close to breaking ground and united in our focus on overcoming escalating costs.

Instead, this will be remembered as a time of lost opportunities and failed leadership.

Cumulative Articles regarding PPH hospital plans

by Jim Vander Spek- January 29, 2006

Blue Cross Controversy exposes PPH flawed planning
The Tri-City Hospital District struggle with Blue Cross underscores the economic challenges facing hospital districts. Clearly, this is a hardscrabble business and that fact makes the extravagant plans of Palomar Pomerado Healthcare especially mystifying.

It has been months since the official report was finally released showing that the repairs needed to Palomar Medical Center amount to less than $7 Million. We are still waiting for an explanation of how this relatively small cost squares with the assertion that these seismic retrofits and upgrades are the underlying rationale for a replacement hospital and the open ended, crushing costs associated with such an endeavor.

In little over a year since we passed Prop BB, the PPH facilities master plan has fallen drastically behind schedule and behind budget. Costs are up 30% already and still ballooning. The original plan assumed $210 Million in revenue bonds and $70 Million in contributions from the community and even this was a stretch. Instead of rethinking its grandiose plans, PPH is calling for more debt and greater fundraising efforts aimed at an increasingly incredulous constituency.

Why is the PPH board so quick to saddle our district with additional “revenue bonds?” Where will the excess funds from operations to pay principal and interest on such bonds come from? Will PPH become suddenly unexpectedly profitable? The whole point of passing Prop BB was to keep the district relatively debt free in order to maintain its core mission of keeping its doors open.

Hospital finances are in a permanently precarious position as the Blue Cross controversy so clearly illustrates. One reason is the hemorrhaging cost of the massive and mounting entitlement programs called Medicare and MediCal, which refuse to pay their fair share and hamstring hospital finances. There is a limit to what the private sector, including Blue Cross policyholders can kick in to cover this shortfall. Will PPH, facing tight margins, be able to issue or repay an ever-growing crop of revenue bonds? Is it doggedly pursuing a plan it cannot complete?

Why not spend the $7 Million that is required to fix Palomar Medical Center and then expand and modernize as needed? Our district is large and composed of generous citizens. We are eager to get behind a realistic plan, including a careful stewardship of existing assets and, perhaps, a community hospital in San Marcos. Let's not use the Prop BB funds as a springboard into a financial quagmire.



Hospital plan demands review
By: JIM VANDER SPEK Published 10/1/05

For the last year and a half, the people of North County have been trying to figure out what Palomar Pomerado Health is up to. Now we know.

They are fighting hard for a new hospital in the Escondido Research and Technology Center.
However, it turns out that this hospital is little more than a mechanism for leveraging taxpayer money. The real motivation is to smooth the way for private developers and their project of building 300,000 square feet of unneeded new medical office space. For this plan to work, they need to sweep up all medical professionals from the Escondido downtown district and into the ERTC.
It is noteworthy that renderings and site plans of the new ERTC project are not being pushed forward. This is because those that have been seen are grotesque, including a nine-story hospital with a heliport on top.

The happy talk about a 30-acre "healing campus" appears to have been just a ruse to lock up 30 acres for sharing with developers ----- a classic "Trojan horse."

Although it is generally not recognized, the use of Proposition BB funds is not fixed. Instead, the funds must be used for whatever capital improvements are in the most current PPH master facility plan. Unfortunately, PPH never consulted with the community when they developed their existing master plan.

There were lots of meetings with private developers but none with the cities or their staffs.

The current master plan begs many questions. Is Pomerado hospital construction on budget? Do they have enough funds to build their white elephant on the Escondido hill? Will there be any money left for upgrades in the downtown or for a clinic in Ramona?

Construction costs are going up 20 percent a year, but they have budgeted only 5 percent. How will they make up the difference? Renderings and site plans along with fully adjusted budgets need to be brought current and carefully examined. No one project should go forward until an updated master facility plan ---- which accounts for all Prop. BB funds ---- is agreed upon.

PPH has been deftly playing San Marcos against Escondido. The crucial question is: Why should San Marcos and Escondido get less than what Poway is getting? All citizens in the PPH district are paying dearly and deserve quality, accessible acute care.

The solution is obvious: San Marcos needs a new community hospital and Escondido needs its existing hospital upgraded, pure and simple. If PPH is not able to operate all three, that is even better. Wouldn't it be great to see some fresh blood operating a North County hospital?

Prop. BB funds are there and should be spent properly. Escondido should take the lead and create a joint task force with the leaders of San Marcos so that a mutually beneficial master facility plan can be developed. Better late than never.

Sadly, PPH has let us all down. They can and must become more transparent and cooperative. This is a time for leadership and for standing up to greedy, dangerous developers. Let's not be suckered into a bad plan.

Jim Vander Spek lives in Escondido.

Published 7/21/05: Secret Kaiser-PPH deal raises questions

Kaiser Healthcare’s requirements are trumping what’s best for the citizens in the Palomar Pomerado Hospital district. Kaiser was a heavy contributor to Prop BB and has a no-bid, secret deal with PPH in its back pocket. Most of Kaiser’s patient base lies far to the west and north to that of the PPH district, yet it is poised to prosper from a hospital site tailored to its needs.

What promises were made to Kaiser? Does their deal with PPH hinge on the new hospital being far west of the superlative, historical site in downtown Escondido? With new beds costing us a $million apiece, are we receiving a fair return on our investment? PPH needs to come clean. That this one private company is being given favored treatment should concern all taxpayers.

PPH readily admits to its peers that it is a “second tier” provider. They know that discerning consumers have always fled the district for superior medical care. Sharp and Scripps, among others, have been the way to go. Everyone also knows that traffic gridlock is making the trek to quality much less feasible and palatable.

Generous taxpayers are piling up a mountain of money for facilities, but no level of taxpayer funding will overcome the plodding mediocrity of this monopolistic provider. New, taxpayer provided facilities will not solve the problems created by heavy-handed cronyism and arbitrary favoritism.

However, there is a way to break from special interests and failed management: PPH must be nudged out of the health care business. We need to elect a board that is determined to attract competitive health care providers into our market, while remaining a manager and provider of facilities only.

These moves would attract new and innovative players who could thrive once we are freed from the stultifying control that PPH exercises. Patients and medical professionals could choose between the competing operators of Palomar, Pomerado or some new specialty hospital (housed in the existing Palomar site?) as to best place to invest their time and money. A wide-open private sector is preferable to a government run operation every time.

A level playing field would work wonders. Why should Kaiser be the only non-public player to profit from the passage of Prop BB and the generations of hard work that have built up PPH?

Who knows? By encouraging entrepreneurship, North County may actually become a net importer instead of a net exporter of patients.




Here is a column printed 5/4/05: Hospital Site Reflects Board Blunders

It is no surprise that Palomar Pomerado Hospital district wants to co-opt the ERTC site for their new hospital. This latest assault against Escondido is a pathetic attempt to mask an obvious blunder.

The Proposition BB strategy was flawed from the beginning. Creating a budget and passing a bond before having selected a site, developing a plan or fixing a timetable has placed the cart squarely before the horse. Skyrocketing construction costs virtually guarantee that we will not get the state of the art complex we were promised. The fervent pledge of improved access has already been thrown overboard.

Crowding themselves into the industrial area is a desperate shot at going cheap. Instead of playing by the rules and choosing a site with appropriate zoning and infrastructure, their ploy is to snag entirely unsuitable, inexpensive property.

Any other developer attempting such a massive upgrade in zoning would produce a comprehensive funded plan to overcome every objection. Instead, we get slapped with the prospect of horrendous traffic congestion, lost property taxes, stunning lost opportunities from new businesses, mangled access to acute care and a calculated obsolescence for existing medical facilities surrounding the downtown hospital.

PPH hopes to make Escondido taxpayers absorb all these costs while also pitching in for better planned facilities elsewhere.

The portion of the ERTC not gobbled up by the hospital would necessarily be transformed into ancillary medical offices, completing the blatant switch-a-roo. This would only compound the error. Although Escondido has a dismal history of caving in to real estate sharpies, there is nothing in this deal to commend it. It should be rejected outright.

Of course, PPH could follow through on its threat to waltz over to San Marcos. No doubt they will be rebuffed there also. Why should anyone accommodate this feckless agency and sacrifice a vast tract of land to a facility that will not generate tax income while straining infrastructure? Think of the traffic, the helicopters and the sirens.

But, if such a move does occur, a future, more sensible PPH board will be able to revisit the issue of whether it is wise to obliterate accessible acute care from the historic Palomar site. The aptly named “Covert era” is not permanent and current decisions are not final. Obviously, the present site can be modified to retain its historical role as an acute hospital. It could even become a much improved asset if it were freed from the burden of serving an outsized area.




Here is a column printed 1/26/05: Downtown Site Best for Escondido

Are you ready to take a trip to the new Palomar Medical Center West?

PPH seems determined to place our new and only acute hospital in the remote bowels of the Escondido industrial district. To get there you will need to navigate the 78 freeway, work yourself through the Nordahl interchange, cross a busy Mission Avenue and then, avoid a hyperactive Sprinter train road crossing.

If you think that this is a harrowing route now, wait until the traffic from a teeming 453 bed hospital and a fully developed research and technology center are added to the mix.

One can only conclude that this outrageous choice for the new hospital site is being vetted as a red herring. They cannot be serious. When will they reveal their real plan? Will we start repaying the Proposition BB bond funds before we even know where the new hospital will be built? Did their $million campaign, waged with special interest money, leave them no time to figure out how to keep their promise of staying in Escondido?

Although the existing facility will be used for other purposes, downtown Escondido must remain at the top of any list as a location for the new hospital. It is the optimum spot because it is central for the area serviced with access available from many directions. The infrastructure, including roads, public transportation, doctors’ offices and medical support facilities are all in place. On top of that, local officials are eager to help pull it off.

This may disappoint developers and other sharpies eager to piggy-back on a “fresh start” hospital location, but it is obviously better for everyone else. Why should all the existing investments be made obsolete?

Only one objection is raised against locating the new hospital in downtown Escondido. PPH claims to be a gentle giant that is opposed to using its eminent domain powers for this purpose. This is truly a weak argument! There are huge tax advantages available to property owners targeted for condemnation. In fact, there is virtually no objection to a downtown location, least of all from property owners.

Having Proposition BB funds in their pocket, PPH management is acting as though it can do whatever it wants without accountability. It is urgent that all citizens, organizations and elected officials apply as much pressure as possible on the elected PPHS board to act responsibly. Let’s hope they end up doing the right thing.

This was published 8/28/04


Is it really necessary to replace Palomar Hospital?

Voters are being asked to approve a bond measure proposed by the hospital district for close to $500 million. This massive debt will provide funds to replace Palomar hospital with a new facility somewhere else.Palomar hospital is deemed to be unsafe based on the latest state earthquake standards. Complying with these standards, we are told, forces us to abandon and mostly mothball a perfectly fine facility.

If these new earthquake rules were based on practical concerns for public safety and a convincing scientific argument, this could be understandable. This is not the case. Escondido is not Coachella, Sylmar or San Francisco. Escondido and much of North County sit on a huge granite rock. When major earthquakes hit, this granite formation buffers the shock and limits the risk of damage. This is undisputed.There is another central consideration. Palomar hospital is a vital component for the continued economic health of downtown Escondido. We have invested a huge amount into this facility, related infrastructure and surrounding private development. The hospital alone is our largest employer.

With the hospital leaving, we can expect that the area surrounding the site, which is largely occupied by supporting services, will go into long-term decline. In fact, we are being given no guarantee that any new facility would be located within Escondido.Until just recently, the plan was to retrofit and expand the existing facility. This is now being rejected because it is deemed to be too expensive. I doubt that the economic cost to Escondido was factored into this decision.The discussion about converting some of the space for rehab or psychological uses shows that there is no real plan for this facility.

Perhaps, if they leave, the district should be required to tear down the existing hospital or to fully convert it to productive use. Why leave that problem to future generations? The hospital board is aware of the earthquake argument. They claim that the state has turned a deaf ear to their requests to provide relief from the new seismic rules as they affect Palomar Medical Center and our seismically protected community.What needs to happen before approving the district's plan? First, we need to turn up the heat on Sacramento. With enough pressure, wasteful, unneeded expense could be avoided. Second, we must make sure that there is a comprehensive plan in place for the current hospital site.

Jim Vander Spek is an accountant in Escondido and a regular contributor to the North County Times Business pages

This was printed on 11/1/04 just before the Prop BB election:

The "over the top" campaign to pass Proposition BB shows how eager the health establishment is to maintain their situation. They are spending more than $1.2 million to get your vote.A growing number of critics urge you to see past this special-interest spending spree.

Consider these reasons to vote "no" on Prop. BB: - Prop. BB calls for one new megahospital, or "Mystery Ship," to replace the existing Palomar Hospital in Escondido. This acute hospital and emergency room would serve everyone from Palomar Mountain to San Marcos.

Such centralization will maintain the Palomar Pomerado Health district monopoly but severely restrict access for many, who will be far from the new site.

- The 30 acres of prime land that PPH plans to grab for the Mystery Ship will be removed from the tax rolls and be exempt from building fees. This will demolish tax receipts while simultaneously placing great strain on public services and infrastructure.
- Despite plenty of time to do so, the district has not disclosed its site for the Mystery Ship. There are no appropriate sites, and the failure to pick one makes this proposition the ultimate "pig in a poke."
- Downtown Escondido will lose its only acute hospital, breaking faith with generations of taxpayers and volunteers. Passing Prop. BB also will result in permanent damage to historic Escondido medical office districts and to other downtown businesses. Thousands of jobs will be lost in the downtown area.
- Kaiser Permanente, which will share use of the Mystery Ship, is a major supporter. The bulk of their patients live outside of the PPH district and get a free ride.
- Our freeways, alongside of which the district is determined to place the Mystery Ship, are a mess and getting worse. Such a site is optimum for Kaiser.
- The dollars are huge, increasing property taxes for 30 years and budgeting over $1 million per new hospital bed. After Prop. BB fails, we can demand a better plan that would improve accessibility of acute care for all of us. Such a plan could:
- Provide for a community hospital in San Marcos so that the citizens of that growing city will not need to get on a crowded freeway to obtain service.
- Provide for an improved and enlarged Pomerado hospital in Poway.
- Provide for the expansion and modernization of the present Escondido hospital, using eminent domain powers if needed.

Reasons you should support the North County Healthcare Coalition (NCHC)

Recently, North County Healthcare Coalition, a new citizen group, has sprung up in North County. Go to the website at www.NCHealthcareCoalition.org to find out more. Its purpose is to provide a voice for residents in the Palomar Pomerado Health (PPH) district and to allow input regarding the direction our district is going. Together we can urge the district to adjust its vision for Hospital construction in North County and more wisely spend Proposition BB funds.

The recommendations promoted by NCHC call for the upgrading of Palomar Medical Center (PMC) in Escondido and the construction of a new hospital in San Marcos. This is a compelling alternative approach and deserves careful consideration in light of the latest information available.

Supporters of NCHC are stepping forward with a broad range of motivations. Here are some of the many reasons that have been clearly articulated for supporting the NCHC goals:

PPH has not provided a reasonable explanation for abandoning Palomar Medical Center (PMC) Initially we were told that it was prohibitively expensive to retrofit PMC. However, just recently reports were released which show that it would require less than $7 million to bring the existing non-seismic compliant portion of the hospital up to 2030 earthquake standards. We have also been told that PMC is 50 years old and much too small. Again, recently extracted information shows that over half of the facility is seismically compliant and that the hospital space is 31% larger than officially admitted. Over half of the facility is less than 20 years old and in fine shape. Decommissioning the hospital and downgrading it to other uses is a huge misuse of resources and seems to be primarily motivated by a desire to help private developers lure professionals from the downtown.

The plan to build in the ERTC is flawed. The ERTC mega hospital proposal is not what we were told it would be. Instead of a spacious healing campus, the actual plan calls for a beehive of government and private enterprise. Most of this will likely be exempt from building fees, property taxes and infrastructure improvement costs. Specifically, the hospital is shown to be nine stories high and topped by a heliport. It will take up about half of the site demanded, with the remainder of the site scheduled for up to 300,000 square feet of medical office space. Moving the location of community hospitals does not generate jobs. The only result will be siphoning these jobs out of the downtown area. All indications are that this project is uneconomic, inaccessible and unwelcome. Developers will be the winners. The citizens of North County will be the losers.

Although generally not understood, the small print in Proposition BB allows funds to be used for virtually any capital improvement PPH lays out in its FMP. Changing the FMP can change any and all promises relating to the downtown site or even the new hospital and can be done by a simple vote of the PPH board.

Proposition BB funds are not adequate to do all that was initially promised. In creating its budget, costs were expected to go up by only 5% a year. Actual costs have gone up about 30% in the first year and are still ballooning. Because the project is way behind schedule and costs are so far above original estimates, something will need to give. The district is claiming that additional revenue bonds and contributions will make up the shortfall, but it is not at all clear that this is possible. There is already talk about phasing in certain portion of the ERTC project. Expected shortfalls will force the FMP to be adjusted and certain projects curtailed or eliminated. Delays and overruns are a direct result of PPH failure to hit the deck with plans in place. A constantly updated FMP including all projects and adjusted to current costs is needed as decisions are being made. This is the only way to assure that Prop BB funds are spent wisely.

The promised conversion of PMC into a first class center after acute services have been removed is becoming unlikely. Initially we were promised that PPH administration offices would move downtown. This is unlikely for both operational and functional reasons. The obtained plans reveal an excessive amount of new office space in the new hospital and related development. Recently we were shown elaborate drawings for other conversion ideas. However, nothing binds PPH to the promises made about the downtown, especially not for the long-term. In fact, there likely will be little if any money left to make any improvements to the PMC site. A recent public statement has already claimed that the original $73 million dollars promised for this is looking more like $40 million now, and the PMC site has lowest priority.

The goal of having up to date medical centers in each of the three major communities is compelling. It is also a practical, effective use for Prop BB funds. It would make acute healthcare accessible and manageable without pitting San Marcos against Escondido in a “winner takes all” battle. It would also spare Escondido from making unsavory land use and zoning decisions. Less confrontation and more enthusiasm across the board will inevitably result from such a “win, win” strategy.

Four of seven PPH board members are up for election in November 2006. We hope citizen activism will serve as a motivation to provoke adjustment on these important issues. This board or one made up of new members should abandon the mega hospital strategy. A “three hospital” solution is optimum and most cost effective. Since they are authorized to make this change, why not decide this right now?

Decisions made now will have a deep permanent affect on North County. We must proceed with all due speed in creating additional facilities. However, we must make sure that the right decisions are made. Key decisions concerning hospital locations, size and function, should be based on the public interest, not for private profit.