As West Penn Allegheny Health System and the University of Pittsburgh Medical Center draw battle lines over physicians and even prepare to square off in federal court, a trio of independent regional and community hospitals operate successfully in their shadows.

They do it, they say, by emphasizing quality and convenience for patients, providing a good working environment for their staffs and keeping up with the latest technology.

They do it, too, by each offering something that makes them stand out: private rooms at Jefferson Regional Medical Center in Jefferson Hills, for one example, or the greatly expanded emergency department at St. Clair Hospital in Mt. Lebanon, or the new ER and operating suites at The Washington Hospital in Washington County.

These hospitals have eked out, on average, a tidy $10 million financial profit in recent years -- until this past fiscal year that is, when the recession sent everyone's investment portfolio and possibly their total margins into negative territory.

Still, coupled with possible cuts in state and federal medical assistance programs, it wouldn't seem to be a good time to be flying solo. Indeed, the headlines across the state in recent years have regularly reported on independents being swallowed up by larger operators or even closing.

Tom Timcho, president and CEO at Jefferson, isn't hyperventilating yet. The bad economy has forced a close watch on how capital dollars are spent and the hospital has frozen some salaries.

But, he said, "We'll do OK. If everybody gets hit equally, then those who are able to scramble quickly may do a little bit better at keeping our heads above water."

Jefferson has some experience in that area. Less than 10 years ago, the hospital had yearly operating losses approaching $15 million.

A key to turning things around was the launch of an open heart program in 2002, a move that brought more patients and higher reimbursements while bestowing upon Jefferson what Mr. Timcho described as "a halo effect," burnishing the hospital's image in the community it serves.

The hospital now performs nearly 500 open heart procedures annually, compared with 620 at Allegheny General and about 1,200 performed at UPMC Shadyside and UPMC Presbyterian combined. "We've found that people take you more seriously if you can handle open heart cases," he said.

Not coincidentally, both St. Clair and Washington also have profitable open heart programs, something once considered the bastion of large, urban academic centers. The independent Ohio Valley General Hospital, which recorded a $2.3 million profit in fiscal 2008, does not do open heart procedures.

St. Clair Hospital, which began its program in 1998 and performs about 250 open heart procedures annually, this past week welcomed visitors to inspect the $2.5 million renovation of its lobby area that features cherry wood paneling and a new cafe.

The hospital has had the strongest showing financially among independents in the suburbs. President and CEO Jim Collins, who came to St. Clair from West Penn Hospital three years ago, had a $12 million-plus annual cushion in recent years before the recession hit.

The hospital has invested its money in improvements that impact the time it takes for patients to get care. With a new, enlarged emergency department dedicated in December, the average emergency room wait to see a doctor dropped from 81 minutes to 28 minutes, and patient visits have gone from 50,000 to 60,000 a year.

Medical records are fully electronic now and nurses use hand-held devices that can call up tests, medications and other critical patient information, using software developed at St. Clair.

Although St. Clair's investments -- like everyone else's -- showed losses in the recently ended fiscal year, the hospital likely will end up in the black overall.

"The hospital has been founded on quality and ultimately that is our key to being successful," Mr. Collins said. "We're going to be here for a long, long time."

Not to be outdone, The Washington Hospital, under the reins of President and CEO Telford Thomas, recently completed capital projects and now features new operating suites, critical care units and a new emergency department -- "services that will always be part of a community hospital," he said.

The larger patient rooms at Washington can better accommodate clinical teams and some medical equipment, such as respirators. The hospital is totally wireless and medical records are electronic (though some physicians still prefer paper).

Location, Mr. Thomas acknowledged, is "a little bit of an advantage."

He wants residents in Washington County and points south to see no need to drive to Pittsburgh when they can get comparable care in their community. The key, he said, is meeting the community's needs and staying up with technology to attract physicians and patients.

As for surviving in a market dominated by UPMC and West Penn Allegheny, the executives do not necessarily see the urban hospital systems as a threat. Each has a joint venture with UPMC for cancer treatment or home health care, and WPAHS assists St. Clair in neurosurgical services.

"Our perception," said Mr. Timcho, "is that it is more of a partnership with UPMC than a competition."

The bigger worries come from long-standing issues, such as lower reimbursements historically given to Western Pennsylvanian hospitals by both insurers and Medicare, and unknowns such as the impact of health care reform.

Mr. Timcho also cited recruitment of new, young physicians as a particular challenge for independent community hospitals.

Large academic centers, such as UPMC and West Penn, have resident physicians and fellows for night and weekend coverage. That is not the case at community hospitals. While medical staffs may be in more control of their destiny at community hospitals, "It's a bigger time commitment," he said.

Larger centers also offer access to more patients and resources. A few years ago, UPMC enticed two of Jefferson's six cardiac surgeons away, removing a core element of the Jefferson Hospital Heart Institute. But with a stable staff of primary care physicians onboard, Mr. Timcho said patient referrals remained steady.

"When you think of it, the primary care physician is the sort of gatekeeper who selects the cardiologist, who selects the open heart surgeon," he said.

Some experts have suggested that every hospital will have to align itself with a larger network eventually. That's what the Heritage Valley Health System did, bringing Sewickley Valley and Beaver hospitals into one organization, as did Excela Health with Jeannette and Frick hospitals in Westmoreland County.

Heritage Valley President and CEO Norm Mitry said an integrated delivery network with multiple facilities is more attractive to physicians, who are the gatekeepers of patient volume.

Heritage Valley is now taking more of a retail approach, he said, reaching out to the community through initiatives such as "convenient care" clinics being set up so people can have minor ailments treated before they get worse and require an emergency room visit.

"We're looking to thrive in this period," he said.

So, too, are the independents. But their fortunes ultimately may be decided by Congress and state legislators through Medicare and Medicaid reimbursements, and not from local competitors.

At Jefferson, slightly more than 60 percent of its net patient revenue is from Medicare, compared with 52 percent at St. Clair and 45 percent at Washington.

Washington, meanwhile, collects nearly 10 percent of its net patient revenue from Medicaid, more than double what the other two see.

"These are difficult times for the industry," said Mr. Collins. "There is cost pressure with new devices and new drugs every day. They are expensive and reimbursements from the government have not kept pace."

He said St. Clair has adopted "lean methodology," lowering the hospital's costs to its 2006 level while reducing wait times and improving patient care. "For now, our operating results have been strong. That's what we can control."

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Correction/Clarification: (Published July 21, 2009) UPMC Shadyside and UPMC Presbyterian combined to perform about 1,200 open heart procedures annually. This story in July 19, 2009 editions included an incorrect number for the procedures performed at UPMC Shadyside.