Saving D.C. General Hospital Part 2

II. CLOSING D.C. GENERAL HOSPITAL IS NOT SAFE But those who say “anything has got to be better” can easily find ways to make things worse. That is because they are so convinced that anything else must be better that they fail to scrutinize carefully the different alternatives. In this section, we consider the evidence indicating that closing D.C. General Hospital is not safe. This is important to do because the hospital could very easily be closed within the next six to eighteen months. It is important because it appears that some individuals would privately prefer that the hospital close, though few people publicly advocate an outright closing imminently. It is important because of the very high likelihood that pursuing the Community Access Hospital Proposal will quickly lead to a complete closing of the D.C. General Hospital. Closing D.C. General is not safe: • because it would leave many citizens too far from care. The hospital is strategically located in the eastern half of the District, an area that has already suffered the closing and relocation of other acute care hospitals—closings and relocations that are closely linked to the racial characteristics of the residents of the eastern half of the District; • because it would risk shortages of many types of care today. The hospital’s closing would substantially reduce the volume of care available today in the eastern half of the District—emergency room care, inpatient care, outpatient care—and back-up for clinics and health centers that offer primary care to the residents of the eastern half of the District; and • because it would mean worse shortages in the future. The need for hospital care in the District will grow in years to come, so closing D.C. General will deprive the District of the right hospital in the right place, worsening the looming shortage of hospital beds to serve the people of the eastern half of the District. The future of D.C. General Hospital must be decided in light of what is best for the health of the people of the District of Columbia. Those who decide must consider: ‰ the current availability of alternative hospitals, trauma centers, and ambulatory care; ‰ the hospital’s location in relation to the patients who depend on the hospital, and ‰ the need for the hospital in the years to come. Closing the hospital is discriminatory. It is dangerous to the health of the public by all three criteria. Examining this evidence requires considering both space and time. Let’s first examine space—where the hospital is located today, the communities it serves, the services it provides, and the locations and survival prospects of other hospitals. It is important to retain needed hospitals and emergency rooms near where people live today, and also where they will be needed tomorrow. -6- A look at a map helps to show D.C. General Hospital’s current importance in the city. Doing so requires considering the past six decades’ legacy of closing or relocating hospitals from African-American neighborhoods of the District. Please refer to the attached series of maps. These are included at the end of this report, following the notes. A. The Loss of Hospitals in the Eastern Half of Washington, D.C. The first map identifies hospitals locations. D.C. General Hospital is number 7, as shown in the “Key to Washington, D.C. Hospitals” following the first map. This map shows that D.C. General Hospital is the only surviving institution in the eastern half of Washington, with the exceptions of the Greater Southeast-Hadley hospitals, now run forprofit by Doctors Community Healthcare Corporation, and of Providence Hospital. This map displays the loss of hospitals from the eastern half of the district.21 • Central Dispensary/Emergency on New York Avenue closed in the 1950s, removing 310 beds. • Providence relocated from near Capitol Hill in the 1950s, moving 297 beds. • Sibley relocated from North Capitol Street in the 1960s, moving 248 beds. Several other smaller hospitals closed or converted to other uses. As a result, some 1100 beds in five hospitals were removed from the heart of the eastern half of the district. This map shows the importance of D.C. General Hospital as a surviving caregiver for a large expanse of the District and its citizens. The map shows that Greater Southeast and Howard University hospitals are both about three miles from D.C. General Hospital. D.C. General Hospital would be even more important if, for example, Greater Southeast were to close. And if D.C. General Hospital were converted into a CAH, the most time-sensitive services—those of a Level I trauma center—would be the farthest away from the citizens of the eastern half of the District. Without D.C. General Hospital, only four Level I trauma centers would remain to serve residents of the District—those of Washington Hospital Center, George Washington, Georgetown, and Howard.22 As a public hospital, D.C. General has been able to remain open in the face of trends that have removed most of the other hospitals in the eastern half of the District. As a public hospital, D.C. General has claims on public dollars that other hospitals do not and would not. -7- The second map shows hospital closings against the background of the race of the residents who were living nearby when the 1990 census was conducted.23 The racial data indicated are the African-American share of each census tract’s population in 1990. (The third map combines ethnicity with race; it indicates the African-American plus Hispanic shares of each census tract’s population in 1990.) Visual inspection of the second map shows the close association between community race in 1990 and closing or relocation of hospitals in earlier decades. This association is not restricted to Washington, D.C. One long-standing reality, which I have found in 52 U.S. cities—decade after decade since the first data were available in 1936—is that hospitals located in AfricanAmerican neighborhoods, are significantly more likely to close, even after controlling for other factors—such as efficiency, teaching status, and the like. Exhibit 1 Acute Hospitals in 52 U.S. Cities: Shares of Hospital Surviving to 1997 Grouped by 1990 Area Percent Minority % of the 701 hospitals open in 1936 that survived Area % minority, 1990 % survived total % of the 1,170 hospitals ever open between 1936 and 1997 that survived % survived total % of the 706 hospitals open in 1980 that survived % survived total 0 - 19.9 percent 20 - 39.9 40 - 59.9 60 - 79.9 80 - 100 48.5% 50.5% 53.9% 39.7% 30.5% 171 107 102 121 200 53.8% 56.1% 57.4% 45.4% 32.6% 320 180 188 194 288 79.1% 74.8% 74.4% 69.3% 63.6% 196 123 133 114 140 All areas 42.9% 701 48.1% 1,170 72.8% 706 • As shown in Exhibit 1, on the preceding page, residents of neighborhoods with high minority (African-American plus Hispanic) population shares in 1990 were much more likely to have lost hospitals located in those neighborhoods. We found a fairly regular and consistent relation between the 1990 minority share of the people residing around a 1936 hospital’s location and its chances of survival. For example, as the following table displays, while almost half of the 171 hospitals open in 1936 in neighborhoods under 20 percent African-American or Latino in 1990 remained open in 1997, only about 30 percent of hospitals located in neighborhoods 80 percent or more minority remained open in 1997. We found the same general pattern for hospitals ever open at any time between 1936 and 1997. And we found the same for hospitals open in 1980. -8- B. Hospital Use Data Show the Value of D.C. General Hospital The evidence on the high level of use of the hospital suggest that it is needed. • D. C. General Hospital is the second most important trauma center in the District. In calendar year 1999, 51,596 ER visits were made to D.C. General Hospital. This was the second-highest figure in the city, just 3,500 visits behind Washington Hospital Center.24 • In 1999, this meant that D.C. General Hospital provided 14 percent of the District’s ER visits. • Total uncompensated care in the District declined between 1991 and 1996—by 12.4 percent in real or constant dollars. But D.C. General Hospital provided more of that uncompensated care—with its share rising from 32.6 percent of uncompensated care in 1991 to 35.6 percent in 1996.25 And D.C. General Hospital’s share of total uncompensated care for rose to 37.5 percent in 1998.26 To summarize: year D.C.G.H. percent of uncompensated care 32.6% 35.6% 37.5% 1991 1996 1998 Further, D.C. General Hospital’s share of the actual cost of uncompensated care is substantially greater than these data would suggest. If we assume that each hospital measures uncompensated care costs at average cost, then D.C. General’s costs accurate the actual burden of that cost on the hospital. But at hospitals that provide relatively small amounts of uncompensated care, it is much more appropriate to measure the cost of uncompensated care at marginal or incremental cost, which is substantially lower than average cost. • Use of the hospital’s inpatient beds rose substantially between 1995 and 1999. So the hospital seems to be becoming more useful, not less useful. Admissions rose by 5.7 percent, to just over 10,000 admissions. This was the largest rise among all of the District’s hospitals. • This increase contrasts with drops at some other nearby hospitals. Greater Southeast lost 12.3 percent of its admissions; Hadley Memorial lost 5.7 percent, and Howard University lost 2.5 percent. • Amidst all of the turmoil surrounding the hospital, it is reassuring to learn that the hospital’s annualized inpatient days for 2000 will be almost exactly equal to those for 1999 (59,600 expected for 2000 versus 59,782 for 1999).27 -9- These use data show the importance of the hospital. It is helpful to appreciate that hospitals are not inter-changeable parts in some health care machine. Patients make the best choices they can in today’s world. Patients go to D.C. General Hospital today for good reasons of their own. Many of the District’s estimated 80,000 uninsured patients have particularly strong reasons. And the number of uninsured citizens of the District has remained high, even during very good economic times..28 While it is decent and proper to talk about expanding Medicaid eligibility and designing new insurance options, doing so can be difficult. If one hospital is closed, and its patients are obliged to go elsewhere, they can suffer harm. Shepard has found, for example, that almost one-third of a hospital’s patients cease to seek inpatient care for some time after their hospital is closed.29 More than inpatient care is involved. Nationally, in 1996, African-American citizens depended twice as heavily on hospitals to organize and deliver ambulatory care (32 percent of their ambulatory care visits were in hospital ERs or OPDs) as did white citizens (15 percent).30 Washington, D.C. may or may not have too many hospital beds (much depends on whether we count licensed beds or beds actually set up and staffed, as discussed elsewhere), but African-Americans’ heavy reliance on hospitals for ambulatory care obliges caution before disrupting existing arrangements. Heavy reliance on hospital clinics and ERs for routine primary care services is seldom optimal, but it is much better than no care at all. More satisfactory alternative arrangements should be put in place and tested and stabilized before existing patterns of care are dismantled or forced to undergo hasty reorganization. And would nearby hospitals have the physical capacity and the practical willingness to serve the patients who would be displaced if D.C. General Hospital were to be closed or reshaped into a CAH? Would nearby hospitals be willing and able to provide the emergency room capacity, the inpatient care, the ambulatory care, and the specialized services (such as dental, orthopedics, burn, or trauma care) required by displaced patients? Would nearby hospitals have the financial capacity to serve patients displaced from D.C. General Hospital? Ormond and Bovbjerg have reported that “Even unburdened by uncompensated care, the academic medical centers are financially insecure….”31 They describe private hospitals’ efforts to transfer uninsured patients to D.C. General Hospital.32 Were D.C. General Hospital to close, the financial stress on many—and perhaps most— remaining District hospitals would almost certainly grow. One reason is that, as shown elsewhere, only 39.6 percent of D.C. General Hospital’s inpatients—only two patients in five—are covered by either public or private insurance. A second reason is that the added costs of uncompensated care are likely to exceed added revenue from the District government (to provide services under contract) or from private third parties (owing to - 10 - surviving hospitals’ stronger bargaining positions). Some of the District’s other hospitals could close as a result. A third reason why removing D.C. General as a provider of considerable inpatient care to uninsured patients would destabilize other hospitals is that many are already in weak financial condition. Many—though certainly not all—District hospitals again lost money in fiscal year 1999, the latest for which data are now available, as shown in Exhibit 2.33 Exhibit 2 Operating Margins, Fiscal Year 1998, Selected District Hospitals Operating Margin Hospital George Washington University Georgetown University Greater Southeast Community Howard University Providence Sibley Washington Hospital Center Aggregate, Washington hospitals 1997 1998 1999 1.1% -14.6% 1.7% -3.2% 3.5% 5.4% 5.1% -2.5% -14.2% -51.9% -23.2% 3.3% 5.3% 3.0% -1.4% -14.8% -28.6% -23.4% 2.6% 3.3% 4.4% -0.3% -5.0% -6.5% Source: District of Columbia Hospital Association, 1999 DCHA Annual Survey. * Note: Howard University Hospital was originally reported to gain 1.1 percent on operations in 1998, but new data from the 1999 D.C. Hospital Association show a loss of 23.2 percent in 1998. The finances of some hospitals in the District may have improved since 1999, particularly those of Greater Southeast Community Hospital, while others’ may have deteriorated. Additionally, George Washington University and Greater Southeast Community/Hadley hospitals have been bought by for-profit hospital corporations. If those corporations are unable to earn substantial rates of return on their invested equity, they should be expected to sell, convert, or even close hospitals they own. Looking beyond the hospital-to-hospital variation, it is important to note that the District’s acute care hospitals, taken as a group, were not in good financial condition in 1999. According to the District of Columbia Hospital Association, private non-profit hospitals in the District suffered an overall operating margin of – 6.5 percent in fiscal year 1999.34 - 11 - When we consider all the acute care hospitals of the District, and compare their finances with those of hospitals in Maryland and Virginia, a similarly bleak picture emerges, as shown in Exhibit 3. Here, total margins for 1998, the latest available, are reported. These include non-operating revenues, such as income on endowment. The District’s acute care hospitals’ financial margins were only 29 percent as high as Maryland’s, and only 14 percent as high as Virginia’s. Exhibit 3 Total Hospital Financial Margins, Fiscal Year 1998, D.C., Maryland, and Virginia Jurisdiction D.C. Maryland Virginia Total Net Revenue Total Expenses Total Margin $1,828,063,922 $5,441,766,935 $6,874,805,160 $1,804,493,901 $5,198,032,054 $6,233,864,195 1.3% 4.5% 9.3% Some have said that a great deal of money could be saved by closing D.C. General Hospital, or by re-shaping it into a CAH. They have suggested that the savings could be devoted to insuring people who are currently uninsured, so they could use other hospitals. But this raises several questions. • First, how much money would be saved by closing D.C. General Hospital or by reshaping it into a CAH? • Second, would the savings be adequate to insure all the patients now served by D.C. General Hospital, or to finance their care at a CAH—and also to pay for needed contracted emergency room and specialist physician and inpatient care services at other hospitals and facilities? • Third, the draft proposal approved by the PBC “anticipates being able to provide the equivalent of health insurance for the current uninsured population served by D.C. General.”35 This language appears to exclude both currently uninsured people who are not served (or who are not acknowledged to be served) by D.C. General Hospital, and people who lose their insurance in the years ahead. • Fourth, where would uninsured patients obtain needed inpatient and outpatient care once D.C. General Hospital was closed or re-shaped into a CAH? What are the assurances that care at other hospitals would continue to be paid for—or even that those other hospitals would remain open? • Fifth, maintaining D.C. General Hospital as a full-service acute care hospital constitutes a political mortgage on the District government—a claim for money with which to serve uninsured patients and other patients who are vulnerable to deprivation of needed care. Any government that is short of money might - 12 - resent such a mortgage, and try to pay it off. Today, the District might promise to pay other hospitals for services now provided at D.C. General, but the District might not be able to willing to keep that promise. So tomorrow, it could blame private hospitals for failing to spend the District’s money well, or for failing to provide good care. The complexity of the CAH proposal—with its difficult demands for negotiating contracts, enforcing contracts, maintaining accurate records of referrals, and billing and paying for services provided—offers many reasons or opportunities for cutting District payments to contracting private hospitals. • Sixth, even if citizens were given insurance cards, would the rates of payment be adequate to persuade doctors and hospitals to provide care? It is one thing to put in place contractual provisions; it is another thing to enforce them. • Seventh, if the new insurance were cancelled—or if eligibility or payment rates were cut back—during the next recession and resulting District fiscal crisis, where would patients get care? Providing insurance for all is a decent and worthy goal. But the rhetoric of offering insurance tomorrow (like the rhetoric of prevention) should not be used, even unintentionally, as a smokescreen behind which needed care is withdrawn today. It should not be used, even unintentionally, to grease the skids for closing D.C. General Hospital. Uninsured patients need guarantees and carefully designed reforms, not promises or hastily sketched proposals. • Eighth, it is vital to provide all residents of the District with first class ambulatory care and in-hospital care. Ambulatory care should include primary care by physicians, nurse practitioners, and other clinicians. It should include specialty care by board-certified or board-eligible physicians. In-hospital care should include routine secondary inpatient care for the ordinary problems—such as appendicitis, a broken leg, or pneumonia—and the specialized tertiary problems— such as open heart surgery, organ transplantation, or radiation therapy for a brain tumor—that require admission to a hospital. When health care works well, ambulatory care and in-hospital care are not enemies of one another. They are allies. First class health care requires good primary care. But it also requires easy referral to specialists, easy access to lab work and radiology, and easy access to in-hospital care when needed. Smoothly-working health care ensures coordination of care across different kinds of doctors, and across different sites of care. And it ensures continuity of care over time. In practice, coordination and continuity require smooth relations among all clinicians and organizations involved, adequate financing for all needed services, easily integrated medical records, and appropriate hospital admitting privileges for qualified physicians. Primary care is not the enemy of specialized care. Ambulatory care is not the enemy of hospital care. All are needed if lives are to be saved. The painful, heartbreaking, and frustrating case of a Washington, D.C. resident who was denied timely and appropriate care was described vividly in the September 2000 issue of Consumer Reports.36 This case shows the importance of improving coordination and continuity of care for uninsured patients. And it shows the importance of retaining D.C. - 13 - General Hospital as the hub of a network of primary care practices. For if this hospital were to close, which other hospitals would be willing and able to forge the links of care with the District’s clinics and health centers? Having a hospital is a guarantee of care. It is there. It is available to serve. It has to serve emergency patients even if they cannot pay. Its future depends on serving people in need. This guarantee can’t be exchanged for mere promises. The challenge is to make this a superb hospital. C. Looking Forward: The Growing Need for Hospital Care In recent decades, some experts have argued that the U.S. had built too many hospital beds, and that closing beds was a sensible way to save money. Indeed, some hospitals had built too many beds. But my evidence indicates that urban hospitals that closed were, on average, somewhat less expensive and more efficient than the survivors. Survivors tended to be larger teaching hospitals, hospitals with more money in the bank, and hospitals located in non-minority communities. Someone called this “survival of the fattest,” not survival of the fittest. Closing hospitals has been over-sold as a method of saving money in health care. Some might assert that the District has too many hospital beds today. But this may depend largely on whether licensed beds or beds actually set up and staffed are counted. In calendar year 1999, an 2,117 patients occupied beds at the District’s 11 acute care hospitals on an average day.37 Few hospitals today set up and staff beds that are likely to be empty. If the District’s hospitals set up and staff beds to achieve an average occupancy rate of 85 percent—a reasonable safety margin—they actually set up and staffed some 2,490 beds on an average day in 1999.38 Dividing that figure by an estimated District population of 519,000 in 199939 yields an average of 4.8 set up and staffed beds per 1,000 District residents. When we allow for the substantial number of patients who live outside the District but obtain inpatient care within the District, this is not an unreasonable number. Looking forward, the need for hospital beds is likely to rise again, we predict, as the number of older citizens rises. The baby boomers will start turning age 55 next year, and 65 in eleven years. People over age 55 need and use hospital beds much more frequently than do younger citizens. It is important to retain enough hospitals and beds to serve them.40 The first signs of hospital crowding are becoming very visible in many cities. Hospitals from coast-to-coast have complained of ER gridlock during the past few flu seasons. And this year, some hospitals are voicing similar complaints even in warm weather. Once a hospital is closed, it is usually impossible to re-open it. That is partly because it would be too costly to reassemble and reorganize an adequate staff, and partly because re-opening a hospital usually requires very costly capital investment to meet the current - 14 - building and life safety codes. Closing too many hospitals and beds today will therefore require costly building projects tomorrow. If the nation liked bailing out the S&Ls for $500 billion, it will love replacing a thousand or so closed hospitals at a cost of $1 million per bed. As mentioned earlier, D.C. General Hospital’s importance would be even greater if one or more of the remaining nearby hospitals were forced to close, or to restrict services, in coming years. Some would argue that closing or substantially down-sizing D.C. General Hospital would tend to financially buttress other nearby hospitals. Right now, that is only an interesting theory about the future. The reality would depend on the numbers and types of patients who actually went to surviving hospitals, the costs of treating them, and the public and private revenues they provided. A competing interesting theory about the future is that closing D.C. General Hospital would tend to financially stress other nearby hospitals, resulting in a domino effect. Health care for the citizens of the District is too important to rest on theoretical arguments. Citizens and patients need assurances, guarantees, and commitments, not theory and promises. Guaranteeing health care to District patients who are vulnerable to denial of needed services means stabilizing, renewing, and reforming a hospital like D.C. General Hospital—a hospital that is located where it is needed, that will be needed even more in the future—when the population ages and if other hospitals in the District close. An enormous number of urban hospitals have closed throughout the nation in recent , I have found. So many hospitals—particularly those located in African American neighborhoods—have closed that hospital should be considered valuable unless demonstrated otherwise. Consider the closing of Detroit Mercy hospital this summer to see what happens when one of these surviving hospitals closes.41 That is, the burden of proof should be on those who would close a hospital. - 15 - III. THE PLAN FOR A COMMUNITY ACCESS HOSPITAL (CAH) After considering the problems of D.C. General Hospital, the dangers of closing D.C. General, and other matters, the Public Benefit Corporation (PBC) voted in midSeptember 2000 to convert the D.C. General Hospital into a new “Community Access Hospital” (CAH).42 This was a hurried and radical departure from the directions that were being pursued earlier in the year. Then, Cambio Health Solutions, which has been responsible for managing the hospital, was identifying hospital problems and devising ways to overcome them. The reasons for this departure have not been presented before the public in a comprehensive, clear, and convincing way. It is possible that the departure stems from a sense of financial panic—driven by a belief that the hospital will run out of money early in the spring of 2001 if something was not done.43 That CAH would offer selected services: • minor ER services, but not Level I trauma—which would be re-directed to other hospitals • short-term observation and stabilization (for up to 36 hours), but not acute inpatient care, which would be provided under contract at other hospitals • basic laboratory, limited radiology, and a pharmacy • a DC Qualified Health Center (DCQHC), with primary care, with disease management and prevention for diabetes and cardiovascular problems, with preventive dentistry, and possibly with certain specialty clinics; but other “chronic and specialty care will be provided through contracts with other providers and facilities.” The PBC proposal promises to direct resources to “community-based primary care” health facilities. It notes the previous commitment of $14.5 million in capital for clinics. It asserts that “The dollars must follow the patients.”44 The PBC’s proposal “anticipates being able to provide the equivalent of health insurance for the current uninsured populations served by D.C. General.” This would be done by giving cards to people lacking insurance—cards that would entitle them to services at the proposed CAH and at contracting providers. The PBC’s proposal also mentions the District’s hope of expanding Medicaid. The PBC asserts that its proposal is “manageable within the current PBC subsidy.” But it does expect that unquantified transition funding will be required. The PBC expects that aligning the current D.C. General Hospital into the CAH and the DCQHC, preparing referral and contracting arrangements, preparing eligibility- - 16 - determination systems, designing and testing needed payment systems, and obtaining needed regulatory approvals can all be accomplished by 1 January 2001. - 17 - IV. WHY THE CAH IS NOT FEASIBLE To some, the CAH proposal may appear feasible and desirable. It may appear to be a medically, financially, and politically palatable alternative to closing D.C. General Hospital. It would seem to avoid the hard, slogging work of renewing and reforming D.C. General Hospital. But the evidence supporting the feasibility of the CAH is grossly insubstantial. • Despite assertions to the contrary, no such method of care has been implemented in the United States. • The proposed timetable for implementing the CAH is so short that it constitutes a recipe for financial, administrative, and possibly medical disasters—disasters that would discredit all those responsible for them. • Further, it appears that the staff time and expertise needed to design and test the CAH—and get it up and running on schedule—are simply not available. The PBC Board apparently voted to support the CAH proposal without first securing evidence on its medical safety, its financial feasibility, or its capacity to meet the medical needs of the uninsured and patients currently served at D.C. General Hospital. If this is so, the PBC’s vote is premature at best and reckless at worst. The PBC’s Board seems to have ratified a top-down planning process, one that appears to have sought little participation from other stakeholders—such as patients, employees, and the communities served by D.C. General Hospital. A. High Complexity—but Low Resources It will not be easy to implement the CAH proposal responsibly. Doing so would require at least the following eleven elements of detailed design, testing, and preparation of clinical, administrative, medical records, legal, and financial systems: 1. estimating the volumes of patients to be served in the CAH’s emergency room, its observation beds, or its ambulatory care programs; 2. estimating with reasonable confidence the volumes of emergency room patients, hospital inpatients, ambulatory patients requiring specialized services, and other patients to be served under contract at other hospitals and facilities in the District; 3. estimating with reasonable confidence the costs of patients served at the CAH and at contracting caregivers; 4. estimating with reasonable confidence revenues generated by serving patients at the CAH and at contracting caregivers; 5. developing a practical and comprehensive work plan for designing and managing the conversion of D.C. General Hospital into the CAH; - 18 - 6. developing a practical and comprehensive work plan for addressing the reductions in force, retraining, and associated issues involving D.C. General Hospital’s employees; 7. designing, negotiating, and signing a set of contracts to ensure that other hospitals deliver specified services to former patients of D.C. General Hospital; 8. putting in place fall-back or contingency plans to deliver care to uninsured, Medicaidsponsored, and other vulnerable patients formerly served by D.C. General Hospital in the event that contracting hospitals themselves suffer financial distress or are forced to close; 9. designing and implementing procedures to coordinate care (including referral methods, and methods coordinating medical records) by D.C. General Hospital or health center physicians with care by specialists at hospitals that do accept referrals; 10. designing methods to assess and certify patient eligibility for services at D.C. General Hospital and at contracting hospitals and other caregivers; and 11. designing methods of paying contracting hospitals and other caregivers for services performed.45 Performing these eleven steps quickly, competently, and safely is enormously difficult. I am surprised that anyone could expect them to be accomplished in anything like the time contemplated with the human, financial, software, information systems and other resources likely to be available. Consider the statements by Dr. Ivan Walks, D.C. Commissioner of Health, mentioned during the City Council’s hearing on 18 September 2000 that he and his staff “worked all-nighters and on Labor Day” to get the CAH proposal ready, and that “we have a complete lack of resources” to prepare the CAH.46 B. Inaccurate Representation of Evidence on Precedents for the CAH The evidence base for the proposal is very weak. For example, the proposal claims that Careful research was conducted to determine the feasibility of offering a freestanding emergency room with primary care and resources services together on one campus. The research revealed that there are freestanding emergency facilities currently operating in urban metropolitan areas and in dense suburban areas including Philadelphia, Fairfax, 47 and a statewide system in Illinois. This language is confusing at best and positively misleading at worst. The research is called “careful” in the first sentence. And it is true that the Fairfax, Philadelphia, and Illinois examples involve freestanding emergency rooms, as stated in the second sentence. But no research was able to demonstrate the feasibility of a freestanding emergency room like the CAH proposal envisages. That is because the - 19 - Philadelphia, Fairfax, and Illinois cases bear virtually no important resemblance to what is proposed for the CAH.48 Therefore, while each of the two sentences may be true, individually, they are simply not connected, either logically or substantively. Joining them in the same paragraph leaves the false impression that research into the Philadelphia, Fairfax, and Illinois cases support the feasibility of a freestanding ER. Any investigations in these three jurisdictions should have revealed striking differences from what is proposed for D.C. General Hospital. These differences are so striking that the Fairfax, Philadelphia, and Illinois examples should not be considered to offer relevant evidence regarding the medical safety, financial feasibility, or managerial feasibility of the CAH plan for D.C. General Hospital. Perhaps most important, the Philadelphia and Fairfax emergency rooms, and the two Illinois emergency rooms, while physically freestanding, are actually owned by and fully integrated with large and strong hospital systems. They are not organizationally freestanding, as the CAH would be. Further, three of the four facilities are located in relatively affluent suburban areas, while the fourth serves a wide cross-section of an urban community. • INOVA, the umbrella for hospitals in Fairfax County, Virginia, operates its two physically freestanding ER/urgent care facilities in close coordination with its major hospital and its three smaller hospitals.49 The four INOVA hospitals operate a total of some 800 beds.50 Patients are transported by ambulance from the freestanding ER to other sites of care when appropriate, and clinical services and information are integrated throughout the system. Because services, information, and transportation are integrated, this system does not depend on contracts and referrals among entities that are legally and financially independent. INOVA has strong financial resources, and is located in a fairly affluent set of communities. Estimated per capita income in Fairfax County in 1997 was 53.0 percent above the statewide Virginia average.51 • Germantown Hospital, formerly an acute hospital in Philadelphia, was converted into a freestanding ER. But it is owned by and part of the Albert Einstein Medical Center, a 700-bed major tertiary teaching hospital. Again, the ER is physically freestanding but it is integrated with physician, inpatient, and other services. Albert Einstein Medical Center serves a wide cross-section of the community.52 • The Adventist hospital system in Hinsdale, Illinois, owns a freestanding ER in nearby Bolling Brook. That facility is completely integrated into the Adventist system. The system supports the ER, which is located in an affluent community. The ER was to have been a full-service acute care hospital, but the state denied a certificate of need for that facility. The Adventist system fought successfully to overcome state Department of Health opposition to licensing a freestanding ER, eventually persuading the legislature to over-ride the Department’s position.53 • Similarly, the Trinity hospital system in Moline/Rock Island, Illinois runs a Recovery Center, which includes a freestanding ER along with a wide range of specialty services. The facility, which is completely integrated into the Trinity system, is also - 20 - located in an area whose residents’ incomes are above the regional average. Trinity is now trying to convert and designate the Recovery Center as a hospital because the present reimbursement rate is not adequate to pay for care.54 All four of these examples are incorrectly cited as precedents for the CAH proposal because all four are fully integrated into large and relatively strong hospital systems. The challenges that the CAH will face—in arranging referrals, in coordinating among physician, ER, and inpatient care, in billing, in payments, in coordinating medical records, and the like—are much smaller in a fully integrated system. Three of the four freestanding ERs serve affluent suburban areas, and one is a large teaching hospital that serves a broad cross-section of city residents and suburbanites. Recently, the state of New Jersey has offered some support for free-standing emergency rooms, but these “must be part of a system with nearby acute care hospitals.” The emphasis would be on rural areas.55 The plans under consideration in New Jersey also fail to provide support for the CAH proposal. The CAH proposal, therefore, is without precedent. It is not right to ask that vital services for people vulnerable to denial of needed care by the objects of risky experiments. A hospital for under-served low-income urban citizens should not be one of the nation’s institutional guinea pigs. One of the many benefits of operating a freestanding ER as part of a strong, wellfinanced, reasonably well-functioning, and integrated system of care serving a wide cross-section of the community is that many of the fixed costs of operating a freestanding ER— particularly all of the administrative functions of billing, central administration, payroll, ordering supplies, and the rest—can be spread among the entire system. Expertise is at-hand in all areas. Unit costs are reduced when these fixed costs can be spread over a variety of needed services, such as acute inpatient care, and ambulatory care. By contrast, in the CAH proposal for the District, the high fixed costs that must be incurred to provide emergency care—laboratories, radiology, critical care unit, and the like—will have to borne entirely by the CAH. They could not be shared across a genuine inpatient services. This can make a CAH very costly. Further, when a freestanding ER does operate under the license of a strong hospital, legal and reimbursement issues—those that must be settled before a freestanding ER can be paid for services—might be easier to resolve. Despite this advantage, those who would try to imitate any aspect of the Germantown – Albert Einstein experience should note that Germantown apparently suffers ongoing licensure problems with the Pennsylvania Department of Health. And the Bolling Brook facility required a legislative over-ride of Illinois Department of Health opposition to a freestanding ER. The CAH proposal for D.C. General, would not make for an integrated system under one ownership and management. Instead, the CAH proposal calls for complicated referrals of patients among different hospitals and other facilities. The CAH would serve many low-income patients, many of whom are vulnerable to deprivation of needed care and some of whom suffer from more than one medical problem. All of the costs of the CAH - 21 - would have to be borne by the CAH. There would be little opportunity to spread fixed costs. How will clinical care be coordinated when a patient receives some services at the CAH, other services at another hospital’s ER and inpatient facilities, and still other services from specialist physicians—possibly located elsewhere? Coordination of care and continuity of care are likely to suffer. Patients and their problems could fall through the cracks in the system, or be caught in webs of incomplete or inaccurate eligibility, medical records, or other information. Billing, eligibility determination, and medical records will be difficult to coordinate. And many other hospitals in the District suffer substantial financial problems, as discussed elsewhere in this report. The Fairfax County, Philadelphia, and Illinois arrangements are so different from the CAH that is proposed for D.C. General Hospital that it is very surprising that they are presented as support for the CAH proposal. C. Too Much, Too Fast, with Too Weak a Foundation The CAH proposal approved by the PBC is very ambitious, untested, complicated, hasty, and rushed. I can recall nothing like it. I find it inconceivable that the necessary elements and systems could be designed, tested, and implemented in the few months remaining before 1 January 2001. The proposal’s haste is demonstrated even in the words of the Medimetrix consulting group that prepared a presentation on two models, including an “emergency stabilization and access center” that closely resembles the CAH. According to Medimetrix, “10 days ago, these two models were just terms.” 56 If the CAH idea was only a term in the middle of August of this year, what is it today? Even on the 25th of August, according to Medimetrix, the CAH idea is “only at a level of refinement that allows for a choice of direction to pursue. . . further research and evaluation.”57 There has been little time to flesh out the idea. There has been little time to address, in detail, the eleven sets of tasks just listed. The Commissioner of Health has said, as noted earlier, that he and his staff have been working under very serious stresses of time and resources. And there has been almost no time to test them to see how they work in practice. Even if the CAH idea is the right one for this hospital—and it does not seem to be—it is being pursued too quickly to do it right. Perceived unreliability. And it is being pursued by an entity closely linked to the District’s government. Given “the historical unreliability of the District government as a payer or partner”, 58 it is hard to see how the hospitals, health centers, and physicians of the District will be comfortable in investing in or committing to doing all the work needed at their end to make the CAH work. The PBC and the District would need to make a durable commitment to the CAH’s partners in order to overcome the District government’s perceived unreliability. Cost. The PBC asserts that its proposal for a CAH is “manageable within the current PBC subsidy.” But it does expect that unquantified transition funding will be required. - 22 - This is a very troubling set of assertions. It does not seem possible to estimate the cost of subsidizing the CAH without much more detailed plans than were available in midSeptember when the PBC Board voted for the CAH. Without detailed plans, the claim that the current subsidy is adequate can be dismissed as unsubstantiated. The failure to quantify the transition costs is equally troubling. Disruption of emergency care. In written testimony submitted to District of Columbia City Council’s Subcommittee on Health and Human Services on Monday 18 September 2000, the District of Columbia Hospital Association’s president, Robert A. Malson, asserted that “Hospitals have already experienced problems with ambulance rerouting, not only because of emergency room overcrowding, but also because of clogged operating rooms and intensive care units.”59 Mr. Malson said that from November 1999 to March 2000, there were frequently no empty medical-surgical beds set up and staffed in District hospitals. For all of these reasons, the CAH proposal violates the long-respected injunction on doctors to “First, do no harm.” This injunction makes enormous sense even when applied to a doctor who is treating one patient at a time. It makes even more sense to apply it to governmental agencies that are treating a hospital that serves 50,000 ER patients, 10,000 inpatients, and even more ambulatory clinic and health center patients annually. Even to contemplate moving to a CAH in a few months is surprising. To vote for it is shocking. What might explain such a vote? Without an adequate public record, we can only speculate. Here are four possible explanations: • To those who believe that renewing D.C. General is too costly, too difficult, or simply impossible, the CAH offers a new and cosmetically attractive alternative. As a new and vague idea, the CAH’s costs are hard to quantify. The difficulties of implementing it hard to appreciate. • To those anxious to save money for the District, the CAH promises to save money but avoids the appearance of an outright closing of D.C. General Hospital. • To those seeking increased funding of primary care services, the CAH promises that the dollars will follow the patients. • To those who believe that anything has got to be better than D.C. General Hospital, the CAH proposal offers the cover of an “anything.” But there is great risk that the CAH will serve unintentionally as a Trojan Horse for closing D.C. General Hospital. As this is written, only six months remain before the hospital runs out of money unless additional funds are obtained.60 - 23 - Because the CAH cannot work, in my judgment, every day that focuses on it as the main solution or as a serious possibility wastes a day of the limited time, staff resources, and political capital that are available to renew D.C. General Hospital. Money is wasted as well. The result will be need for a greater public subsidy to renew D.C. General Hospital. As the price tag for renewing the hospital rises, the political ability to secure it falls. - 24 -