Coaltrains a mile long rumble daily through this little Appalachian town, their lonesome whistles echoing down the hollows of the Clinch River Valley.
These are boom times in the mountains of southwest Virginia; the nation wants more coal. Employment is up, housing starts are rising, paychecks are fatter.Richlands, an island of relative flatness in a sea of slopes, is anticipating growth.
Yet, in true coalfield tradition, there is feuding here these days-- bitter, emotional and colorful. But unlike past battles, the two sides this time are the unlikeliest of opponents.
After years of peaceful coexistence, Richlands has dueling hospitals.
"It is bitter," says T. Patrick Cavanaugh, publisher of theRichlands News-Press, the local weekly. "It's split the community. And the bitterness isn't going to go away, whoever wins."
The controversy has engulfed the town in a six-month ruckus over medical ethics, free enterprise and fair play, played out with pickets, demonstrations, raucous meetings, angry letters to theeditor, protests to state officials and cries of foul from both sides.
It is a situation that mirrors, in microcosm, a growing national debate as large, private hospital concerns muscle their way into the health care field, often over the protests of doctors and others critical of their cash-on-the-barrelhead approach to patients. It also illustrates the obstacles that health planners say they face when they attempt to cut the number of hospital beds in any area as excessive.
Tiny Richlands, which leans heavily in its local color to gun racks and "We Dig Coal" T-shirts, has never seen the likes of the hospital feud. "It's a phenomenon," says one Virginia health planning official in awe.
On one side is Humana Inc., a gigantic, Louisville-based corporation that owns and operates some 90 hospitals -- including, since 1978, the Clinch Valley Community Hospital in Richlands-- on an aggressively for-profit basis. To lobby its case through the Virginia health bureaucracy, it has hired the Richmond law firm that Gov. John N. Dalton will join on leaving office, causing some Humana opponents to claim that their case won't get a fair hearing from health officials whoseallegiance is to the governor.
Across an ever-widening chasm of public opinion -- but less than a mile away -- is theRichlands Medical Association, a small group of doctors who for 16 years have operated, but never owned, Mattie Williams Hospital, an aging former hotel they are leasing until 1986 from a locally prominent family.
The surgical gloves have been off since March, when Humana bought up Mattie Williams -- to the dismay of hundreds of longtime residents who argue that the firm is positioning itself to drive the Richlands Medical Association out of business and monopolize hospital care in the coal-rich (and health insurance-rich) district around rural Tazewell County.
Both hospitals have turned a profit in recent years. The area, according to state figures, has an unusually high admission rate, in part because of a lack of preventive medicine among many miners and mountain folk.
"You wouldn't believe how many OB obstetrics cases we handle where there has been absolutely no prenatal care," says one Clinch Valley Hospital executive.
While Mattie Williams posted a profit for 1980 of $76,000, Humana-owned Clinch Valley outstripped its neighbor 14 times over, clearing more than $1 million.
"Don't let these little houses on the mountainsides fool you," says Clinch Valley administrator William Gillespie, who was born in the hospital he now heads. "The average coal miner here makes $25,000 a year straight time -- $30,000 with overtime. There's a lot of money in this area."
Foes of Clinch Valley claim that Humana's success has had its price. Dozens of local residents say they are offended by the hospital's policy --which hospital officials confirm -- of verifying nonemergency patients' insurance coverage ordemanding a cash deposit of up to $500 before a patient is admitted.
There also have been dozens of unconfirmed allegations -- front-page news in the local weekly-- of people in need of immediate hospitalization being turned away from Clinch Valley because they could not pay in advance.
The poor, said one letter published by the News-Press, "will just have to stay home and die because that will probably be cheaper than going to Humana for treatment." Said another: "You Humana belong in the business market alone, where people's lives are not at stake . . . . IfHumana had a slogan it would be 'Money first, patient last.' "
The hospital denies this.
"We have never, and will never, turn awaypatients in need of acute care," says Clinch Valley's Gillespie. The furor over admissions, he maintains, is rooted in misunderstandings among the rural poor.
His chief competitor, Dr. Emile Khurie, chief of staff at Mattie Williams, scoffs at that claim. Khurie says that his 76-bed facility has been "flooded" with acute cases turned away by theHumana staff.
"Their main concern is making money, and making it in a hurry," says the 37-year-oldPalestinian-born physician, who has practiced in Richlands for almost eight years.
Unfortunately, from Khurie's point of view, there eventually may be no alternative to Humana. The wealthy corporation bought Khurie's hospital out from under him, outbidding theRichlands Medical Association and agreeing to pay the Williams family $3.5 million for the 74-year-old Victorian structure -- a building so small that the laboratory is in a house trailer.
Then, late last month, in a decision that outraged Mattie Williams supporters, Virginia Health Commissioner James Kenley granted Humana permission to build a new, $48 million Clinch Valley hospital and eventually shut down both existing facilities.
Again, say officials, there were misunderstandings. Humana's foes pointed out that beds in the two hospitals now total 211; the new hospital will house only 200. The paradox of permitting fewer beds for a growing area is explained by the current 82 percent occupancy rate, says Scott Malbon, a state health planning official in Blacksburg.
In hospital planning jargon the Richlands area is "overbedded," according to the state.
"The state never had to lie out in the corridor," snaps Clara Griffith, a Richlands resident whose son was born in Mattie Williams and whose father died there.
"Humana has played right into the hands of the health bureaucracy," agrees Richard Farthing, one of many local business executives who have joined the fight and/or written letters to Kenley endorsing Mattie Williams. "I get all upset with thebureaucrats telling me I'd be better off with onehospital."
Service and the general level of concern at Clinch Valley, says Farthing, are "lousy."
Meanwhile, the intense, competitive Khurie and his colleagues have determined that Mattie Williams will not disappear without a fight.
The Richlands Medical Association has filed its own application with the state, asking permission to build a new 76-bed facility on a hill on the outskirts of town. That request was approved by lower-level health planning panels in Richlands and Blacksburg after hearings packed with outspoken Mattie Williams supporters.
Last Tuesday, at a hearing in Richmond attended by about 250 Williams loyalists who chartered buses for the seven-hour ride, the association's filing hit a solid wall of opposition.
The health facilities and services review committee, part of Virginia's state-funded health planning apparatus, voted overwhelmingly to recommend that Commissioner Kenley deny the petition on grounds of overbedding. Kenley, who has referred favorably to Humana in earlier public statements, has until Sept. 8 to issue his decision.
Khurie refuses to say how much money he and his colleagues have spent on their battle. The group hired a lawyer and a public relations specialist to represent them, and a health planning consultant from the University of Delaware to contest official state estimates of projected hospital needs through 1984.
But Humana, which has been through this kind of fight before, seems always one step ahead. After association lawyer David Barbe said publicly that his clients will go to court if Kenley's decision is unfavorable, Humana officials promptly moved up the date for groundbreaking in Richlands from next spring to Oct. 1.
After last week's hearing went against theRichlands doctors, Humana attorney Thomas McCandlish walked up to Khurie and offered his hand. The scowling physician refused to shake it.
"The good people of this town deserve better," Khurie said a few days later, sitting in a Richlands cafe. "I owed them that much, just to stand up and say so."