Pago Pago, AMERICAN SAMOA — Senator Togiola T.A. Tulafono was the only one who defended the Hope Dialysis Center(HDC) when its closure was first discussed, and he went as far as accusing the LBJ Dialysis Unit management of doing all it could to stifle and kill the private dialysis center since its inception.

Togiola made the allegation on the first day the Senate convened after the opening of the Fourth Regular Session last Monday, when the chairman of the Health Committee, Senator Tuiasina Salamo Laumoli updated senators on the latest development of the issue, saying LBJ CEO Dr. Akapusi Ledua had confirmed to him that HDC had indeed closed its operations.

On Monday, Senator Togiola told the Senate that he had heard rumors that negotiations were underway between LBJ and the Hope Dialysis Center to help carry out treatment for patients at LBJ.

He requested the Health Committee to investigate these rumors.

Togiola revealed that he had been heavily involved in setting up Hope Dialysis in the early stages of its inception and that from the start, LBJ had been strongly opposed to the private dialysis center.

He said LBJ did not want patients to transfer treatment to Hope Dialysis Center using their Medicare and Medicaid benefits and did all it could to shut down HDC's operations.

"And now that Hope Dialysis has closed its doors, LBJ is now whining about the added cost and workload," Togiola said.

During the Senate Health Committee hearing last Thursday, Senator Magalei Logovi'i was of the opinion that the HDC was established as a private business venture with the financial assistance of investors, in anticipation of a profit.

However, he claimed that not enough research was carried out on the logistics of running such an operation — if it was feasible or sustainable as federal funds were involved, and especially since dialysis treatment was already provided by LBJ.

Magalei pointed out that consequently, HDC found itself without the funding it needed to operate and the investors could not afford to continue their assistance, "so now you're running back to the government for help."

The Senate Vice President said that the government was not prepared to facilitate the HDC request because the budget had already been passed.

The only exception was during the COVID-19 pandemic when the usual requirements for government procedures were waived so that HDC could be a temporary Medicaid provider.

After the pandemic, the private dialysis clinic continued its services until Medicaid payments that covered 20% of the dialysis cost were stopped in November last year because no local match funds could be found.

HDC ultimately closed its doors on June 30, 2024, because it could no longer afford the cost of dialysis treatment with the suspension of Medicaid funds.

"This is a serious matter because the lives of patients are in danger if they don't get dialysis treatment," Magalei said. "Fortunately, LBJ was kind enough to bring them in and treat them but now they need $1.5 million in additional costs. I hope you are not complaining because we can't come up with the money you requested.

Magalei's criticism did not sit well with HDC Facility Administrator Saluafata Talili who reminded the Senate that the government through DoH and the Medicaid Office, had reached out to HDC to assist in treating repatriated dialysis patients during the COVID-19 pandemic.

"We're not complaining about not getting any money, we're just asking for assistance," Talili clarified. "When the repatriation process started, LBJ did not want to take on the patients.

“When we met with LBJ, DoH and Medicaid to discuss the best course of action, LBJ did not want to take the dialysis patients.

“Who took them? We did!" she stated.

This however was explained by Medicaid Director Sandra King-Young who recounted that in 2021 when Governor Lemanu P.S Mauga initiated the repatriation of off-island patients, the issue was that dialysis patients could not be brought home because they had to be quarantined.

"So we met and it was all agreed that they could not be treated at LBJ because of the risk of exposure," she clarified. "That is the reason why LBJ could not treat any of the repatriated dialysis patients. Because they had to be separated from the rest of the population and the risk of taking them to the hospital was too high."

King-Young said that the DoH director had asked her if there was anything that the Medicaid Office could do to help bring dialysis patients home.

"So the only solution was that we needed to work with HDC," Director King-Young said. "So we submitted a disaster response state plan amendment under the Public Health Emergency Act, that waived all the licensing and requirements for facilities so that we could immediately bring them on board to address the disaster response. The only problem was, it was temporary."

She emphasized that her office had clearly articulated to HDC staff and management that their Medicaid provider status would only be temporary during the Public Health emergency.

She also told them that her office was very open to making them a permanent Medicaid provider; however, there has to be a local match appropriated specifically for them.

Subsequently, the Public Health emergency time frame ended in November last year and HDC was informed that their Medicaid provider status had also come to an end.

The director also informed them that they could not be made permanent Medicaid providers at this time because the budget for the current fiscal year had already been passed.

However, she revealed that this could be accomplished at the beginning of FY 2025 which begins in October and the governor has given the green light to allow this to happen.

"Governor Lemanu has already instructed me to move forward with amending the State Plan to allow this to happen for any private dialysis institution, so long as we have the local match increase for the year, and it would be up to me to look at the financial data and set aside an amount to ensure that we provide them with local match," the Medicaid director said.

Later in the hearing when Senator Alo Paul Stevenson asked what was to be done to resolve the situation, the Medicaid Director replied, "Firstly, all 41 patients who were at HDC have been absorbed by LBJ and are currently receiving treatment there.

"Secondly, the financial sustainability of HDC as a private business. Medicaid cannot interfere with that. It is not our job to financially sustain a Medicaid provider. In fact, we have the authority to close down a Medicaid provider if they are not complying with federal laws."

However, she reiterated that Governor Lemanu has already approved the necessary action that will allow HDC to become a permanent Medicaid provider as soon as FY 2025 starts on October 1st, 2024.

"So it is up to them to sustain themselves until that time," Director King-Young concluded.

Senator Togiola finally got his chance to question the witnesses and he began by asking where the 41 HDC patients came from, to which HDC Facility Administrator Talili answered that only two were transiting in American Samoa and the other 39 were all local residents.

"So let's not talk about them as if they were foreigners," said Togiola. "That's the insulting part of that presentation because these are not different people, they are our people.

"So the two transients are from outside request treatment. Now if HDC did not exist, where would they request treatment when they travel back to American Samoa?"

Talili replied, "LBJ of course!"

"So LBJ is on the hook for everything right?" Togiola asked. "So there's nothing additional to the responsibilities of the hospital because if those 39 patients were not at HDC, they would be seeking treatment at LBJ."

Togiola referred to the allegations of misconduct he made the day before against LBJ staff and stated that it was during the early days when they were in the process of setting up HDC.

He said many of their patients would have to go to the hospital to have their vascular access done and they had a problem with that because LBJ refused to treat them unless they transferred to LBJ.

"But these patients preferred to be treated at HDC," Togiola said. "So LBJ was discouraging the patients from going to HDC and they would not give them treatment for these other services unless they transferred. And that deprived HDC the ability to keep its own patients."

He asked Talili, if to her knowledge, how many times did this happen and she answered, "more than ten times."

"So LBJ was responsible for the reduction of the number of patients who chose HDC as their treatment center?" Senator Togiola asked. Again, Talili answered in the affirmative.

"Now why are they complaining about transferring these patients back to them when that's what they wanted in the first place?" Togiola asked.

LBJ Acting CEO Dr. Maria Guyapa answered in the present tense saying that LBJ doesn't refuse patients, but Togiola intervened saying he knows that LBJ refused to treat some patients because he was there and had witnessed the whole thing!

Dr. Guyapa explained that there had been patients with complications who were not referred properly but just showed up in the emergency room, and she stated that they had not been refused treatment directly.

"Why?" Togiola asked, "Do you prefer them to die instead of being treated? Is that the deal?"

Dr. Guyapa explained that they were not stopping the patients from entering LBJ when they were experiencing complications.

She clarified that they were discouraging the patients from doing procedures like vascular access or allowing their physicians access to LBJ facilities because they did not want to be liable for their complications.

"We want LBJ to deal with our sick patients directly and complications of our own," Dr. Guyapa said. "They have their problems and they have to fix them.

“However, we never refuse a patient to be treated for complications they acquired from HDC."

Togiola asked, “So is that the legal position of LBJ?

"If they were treated at HDC, you wouldn't accept them if they had an emergency because you might be liable for any complication?"

Dr. Guyapa repeated her last statement but changed the last sentence to, "But if they have complications, we will never refuse a patient who enters the facility."

Senator Togiola stated that her answers were adding more confusion to his mind.

LBJ COO Dr. Jean Anderson then intervened and clarified Acting CEO Dr. Guyapa's statement.

"We do not refuse... there is never a 'no' — our concern is that there have been cases where HDC was not equipped to deal with the complications of the patients that they were providing dialysis for," Dr. Anderson explained.

"And when those patients come to LBJ with those complications, we encourage them to consider remaining at LBJ for their Dialysis treatment.

“That way, if there are complications on the spot, we can address them immediately.

"That drive time just from HDC to LBJ with the complication could result in something fatal, and that was the reason why we were encouraging those patients to come to LBJ for dialysis.

“We can take care of your dialysis and any other complications you may have, and remain with LBJ permanently."

 Senator Togiola then turned to the two HDC officials and said, "There you have it, your reason for failing.

“They were taking your patients away from you, purposely I might say."

Talili then informed Togiola that LBJ was still doing it.

"They're still not accepting patients," she said. "Patients will call LBJ to come and take a patient to do treatment and they will not accept them."

Togiola then turned to Dr. Anderson and accused her of lying, which she vehemently denied.

"You guys are lying to me aren't you," Togiola accused. "I don't appreciate being lied to."

Dr. Anderson argued,” I find that difficult to understand when we took the initiative to take in all 41 patients.”

But Senator Togiola ignored her and instead focused his attention on Medicaid Director Sandra King-Young whom he asked for certain details of the Medicaid program.

He then turned to Talili and asked her if HDC was treating patients today, to which she replied no.

"What are you doing with your machines?" he enquired.

"We're packing them up and we're going to be sending them to a buyer off-island," she said.

"So the business is done," Togiola wanted to know. "And how many machines did you have?"

"We had 14 machines altogether," Talili revealed.

"And how many shifts did you have," he asked.

"We had four shifts," she replied.

Wow! That's a terrible loss to the Territory and to the people who are entitled to the service.

“Terrible!" Senator Togiola concluded.

BACKGROUND

In the email the LBJ CEO sent to Faipule Larry Sanitoa in response to his email about HDC patients’ concerns about the facility closing, Dr. Ledua wrote, “…our hospital senior leaders and I have been having discussions and plans on the Hope Dialysis closure and our dialysis service to accommodate all Hope Dialysis patients.”

He said the short -term solution to the closure of Hope Dialysis was outlined in a press release they was sent out last Friday to the media and it’s also on the LBJ website.

Samoa News and KHJ posted the press release over the weekend, as well as reported on it.

Dr. Ledua further noted that “our dialysis unit has scheduled shifts to accommodate all the patients that were using Hope Dialysis.

“We have also prepared supplies to meet this need.”

The LBJ CEO in his email also gave a brief outline of the hospital’s long term plan for dialysis treatment in the territory.

He said that the hospital plans “to decentralize the dialysis service and bring this service out to the community rather than the hospital.”

This plan, Dr. Ledua said, includes acquiring Hope Dialysis and building dialysis units — in the East and in the West “as our satellite dialysis units”.

“The plan includes home dialysis service which about 20% of our dialysis population can have,” he added in his email.

Samoa News should point out that Senator Togiola’s past relationship with HDC, also included representing Chris Fisher, who was the president of the HDC. In 2022, Fisher was taken to court by the HDC board, seeking a a preliminary injunction; to stop Fisher from doing business on behalf of the center and from interfering in its operations.

The application for a preliminary injunction was filed by members of the HDC board, Dr. Jean Letarte and John Wasko, represented by attorney Thomas Jones against Fisher.

At the time, Fisher was seeking to close HDC’s doors, saying it was no longer a viable entity due to Medicaid no longer supporting it as a provider. At the heart of the issue was the lack of funding from Medicaid going forward.