Public discussion about our hospitals often moves quickly from one challenge to the conclusion that the entire system is failing. A shortage becomes a crisis. A delayed payment becomes mismanagement. A regulatory finding becomes evidence that nothing is working.
Our hospitals certainly have problems. Some are longstanding, some are self-inflicted, and some require urgent correction. We should neither minimize nor excuse them.
But we cannot improve healthcare in the Virgin Islands if our understanding of its problems is based on misinformation.
Recent public comments provide an example. It was suggested that Schneider Regional Medical Center (SRMC) is experiencing supply shortages because it sent supplies to the Governor Juan F. Luis Hospital and Medical Center (JFL), leaving St. Thomas without adequate supplies.
That assertion is false.
For many years, our hospitals have shared supplies and other resources when circumstances required it, and that assistance has flowed in both directions. JFL has assisted SRMC just as SRMC has assisted JFL.
We should want that cooperation. If a patient on one island urgently needs something available at the other hospital, our priority should be getting it to the patient who needs it. That is what a territorial healthcare system should do.
The actual causes of hospital supply pressures are more complicated and include cash flow, vendor obligations, reimbursement and the overall financial condition of the hospitals.
A Complicated Financial Picture
One of the least understood realities of hospital finance is that providing care does not necessarily mean getting paid for that care—or getting paid when the money is needed.
The pressures come from many directions.
Uncompensated care is measured in tens of millions of dollars. Some patients who have a responsibility to pay their bills do not pay them. More than 30 percent of the patients seen by our hospitals are Medicaid beneficiaries, while Medicaid payments are presently behind by tens of millions of dollars.
Hospital allotments have not always arrived during the periods for which they were budgeted. Government agencies also have outstanding invoices for hospital services ranging from hundreds of thousands to millions of dollars. Portions of current allotments are additionally being applied to historical WAPA, Cigna, GERS and tax obligations.
Meanwhile, payroll, medications, supplies and other operating expenses must be paid today.
Against that backdrop, something important has changed.
In August 2025, JFL and SRMC began working with Firstsource as a revenue-cycle management partner. Since then, cash collections from commercial insurance and patient billing have improved significantly and are reaching levels higher than at any time in recent history. That improvement has helped the hospitals continue meeting payroll and making basic purchases from critical vendors despite extraordinary pressure on available cash.
This creates an important reality:
The hospitals can be collecting more successfully and still have less cash available.
That does not mean the hospitals’ work is finished. Further improvement is needed in staff and clinical documentation, billing practices and technology, including modernization of the electronic medical record system. Every legitimate dollar earned must be properly documented, billed and pursued, while expenses must be responsibly managed.
But responsibility extends beyond the hospitals. Patients who can pay their bills must do so. Insurers must process legitimate claims timely. Government agencies must pay for services received. Medicaid must reimburse appropriately and predictably. And appropriated operating funds must reach the hospital system with sufficient regularity to support the services they were intended to fund.
Medicaid Must Change
Medicaid presents an especially important structural problem. The issue is not simply when Medicaid pays, but how it pays.
Some Virgin Islands reimbursement methodologies are antiquated and poorly aligned with the actual cost of modern hospital care. In some circumstances, flat daily rates can be so low that reimbursement does not cover even the cost of materials required for procedures performed during a hospitalization.
Current rules also prevent the hospitals from billing certain professional fees for services provided by fully employed physicians and locum physicians (temporary physicians). The hospital pays the physician and provides the care, yet may be unable to collect the corresponding professional fee.
When Medicaid beneficiaries represent more than 30 percent of our patients, these are not minor billing issues. Medicaid modernization must be part of any serious plan for sustainable healthcare in the Virgin Islands.
Approximately 10 Percent of Our Beds
There is another serious problem largely invisible outside our hospitals.
Today, 20 boarder patients—15 at SRMC and five at JFL—remain hospitalized despite being medically stabilized and cleared for discharge.
With 169 licensed beds at SRMC and 52 beds at the temporary JFL facility, those patients represent the equivalent of approximately 10 percent of our combined hospital bed capacity.
Some remain because families are unable or unwilling to receive them. Others require long-term placement that has not been secured. Some patients can remain in this situation for months or even years.
Once a patient no longer requires acute hospital care, responsibility for appropriate long-term placement and care ultimately rests with the Virgin Islands Department of Human Services.
Families who can safely receive their loved ones must also do their part. But where home discharge is not possible, an acute-care hospital cannot become a substitute for long-term care.
Our hospitals must remain focused on what they were designed to do: provide acute medical care.
One Territory, One Healthcare System
The challenges we face also demonstrate why greater territorial integration is necessary.
Integration does not mean St. Croix losing something to St. Thomas or St. Thomas giving something up for St. Croix. It means recognizing that a patient on either island is a Virgin Islands patient and using our collective purchasing power, personnel, expertise and resources intelligently.
And St. John must be explicitly included in that vision.
The Myrah Keating Smith Community Health Center is administratively part of SRMC, but St. John must never become a footnote in discussions about the future of Virgin Islands healthcare.
There is genuine reason for optimism. The redevelopment of the Roy Lester Schneider Hospital is advancing. JFL is moving from its temporary facility toward a permanent replacement hospital. And the rebuilding of the Myrah Keating Smith Community Health Center is advancing for the people of St. John.
After years of operating in the aftermath of Hurricanes Irma and Maria, this progress matters.
But new buildings alone will not solve old problems.
We must modernize Medicaid, improve technology and the EMR, strengthen billing and documentation, control expenses, ensure reliable funding, expand long-term-care capacity and continue integrating our hospital system.
We should also examine whether our statutory funding framework needs modernization so that funds appropriated for hospital operations reach the system during the periods for which they were budgeted. Healthcare obligations occur in real time. Our funding structure should recognize that reality.
Progress and Accountability
None of this absolves our hospitals of responsibility.
Hospital leadership must be accountable. The governing board must demand measurable performance. Billing must improve. Expenses must be controlled. Procurement must be disciplined. Quality and patient safety must remain paramount.
Where our hospitals have made mistakes, we should say so. Where they are improving, we should be equally willing to say that.
But accountability cannot stop at the hospital doors.
Healthcare is an ecosystem. Patients, families, insurers, Medicaid, government agencies, Human Services, policymakers and the hospitals themselves all have responsibilities. When one part fails to perform its role, the consequences frequently arrive at the hospital.
There is a tendency to speak about our hospitals primarily when something goes wrong. That creates an incomplete picture.
Every day, Virgin Islanders receive emergency treatment, undergo surgery, deliver babies, receive dialysis, obtain diagnostic testing and receive countless other services within this system. Much of that work never becomes a headline.
At the same time, significant transformation is underway. Both hospitals now operate under one territorial Chief Executive Officer. JFL and SRMC are increasingly coordinating resources. Collections are improving. And healthcare infrastructure is moving toward rebuilding on St. Thomas, St. Croix and St. John.
There is much more work to do.
Our hospitals are not without problems.
But neither are they without progress.
We have an opportunity before us that is greater than rebuilding hospitals. We can rethink how healthcare is financed, organized and delivered throughout the Virgin Islands.
Doing that will require accountability, partnership and, above all, an honest understanding of the facts.
If we get it right, we will leave the next generation something far more valuable than new buildings.
We will leave them a healthcare system built to last.
This is an opinion piece from the author, not a news report. It does not reflect the views of the station.