The first shoe has dropped in the long-winded debate over a new hospital for Des Moines’ western suburbs. The trouble is that we are no closer to knowing where and when the other will fall.

Last week’s decision by the U.S. Justice Department to kill any joint management of the facility eliminates one option for Mercy Medical Center and Central Iowa Health System. Many questions remain.

First among them: What now? The short answer: Everything or nothing.  In the effort to build a hospital, CIHS leads the race. It spent the better part of 2002 pulling its plans together for a $78 million facility on land it owns off 60th Street in West Des Moines.   It has architectural plans and has filed a thick application for a license with state regulators. This isn’t to say that Mercy should be counted out. It owns land across the street from the CIHS site. Its leader, David Vellinga, has asked his board of directors to study building a facility there.

Though Mercy hasn’t made any public announcements, it would be surprising if plans don’t exist in hard copy someplace.

So Vellinga and his counterpart at CIHS, Eric Crowell, face some tough choices. None will satisfy everyone, and whatever they choose will have large consequences for dmany constituencies, including patients, doctors, insurers and politicians.  Crowell could go forward with CIHS’s plans. Vellinga may respond.

Or the two could decide to not build at all. Though this is clearly the desire of Wellmark Blue Cross and Blue Shield of Iowa and other foes of rising health-care costs, it’s unlikely. CIHS and Mercy have 18 months of effort invested.

Why did it fail in Washington, D.C.?

Selling the plan to antitrust regulators was always the most difficult part of the proposal. Mercy and CIHS are the biggest health-care providers in the state, and there were difficult concerns to overcome. How would costs be shared? Who would set prices? How would management and ownership of future Des Moines hospitals be set up?

Talks between the two hospital groups collapsed just over a year ago because of these issues. Political pressure forced them back to the bargaining table, though neither Vellinga nor Crowell was overly optimistic that their proposal would pass regulatory muster. To their credit, they gave it a second chance.

Still, coming as it did under duress, it’s worth asking how sincere the effort was. There is no doubt that Vellinga and Crowell want to provide the best health care possible to Central Iowans. That is not in contention.

But what exactly did they propose to Justice? There is a possibility, however slight, that the two paid cooperation just enough lip service to score political points and then scuttled the ship in deliberations with Washington, D.C., bureaucrats.

Why build a hospital at all?

The issue is being sold to residents as a matter of improving access to health care. This is misleading. It takes 15 minutes to drive from Waukee to Mercy’s downtown campus – a trip needed for only the most serious of emergencies. Is saving five minutes worth $78 million (twice that for two hospitals)? It’s politically incorrect to ask the question, but it must be asked all the same.

Mercy and CIHS say capital expenses account for a small percentage of total health-care costs. They also argue a need for more capacity; Des Moines’ hospitals are often full. Yet this, too, is misleading. Empty rooms don’t generate cash. More important, the drop in capacity was a matter of choice, though health care executives aren’t totally at fault.

Customers have increasingly demanded private rooms. New technology has required more space. Hospital executives years ago decided to let some rooms fall behind on code requirements, betting (incorrectly) that technology would pare utilization. As we now know, the opposite has happened.

West Des Moines politicians are eager to show that their city has arrived as a true power in the state. They have Iowa’s biggest retail mall under construction. If one hospital is good – and they believe that it is – two must be better.

Then there are the physicians, a good number of whom live in the western suburbs. Many have their offices in West Des Moines and wouldn’t mind a hospital or two close by, as long as their salaries don’t drop to pay for it.       All of these issues are worth considering.     Des Moines Business Record staff writer Michael Lovell writes a weekly column on business issues affecting Greater Des Moines. He appears on Sunday mornings to talk about business trends on WHO-TV. Contact him at 288-3336 or by e-mail at michaellovell@bpcdm.com.