FW: Grady pt2

[Robert F. Smith]

Many similarities to the situation County Hospital in Chicago is in. We seem
headed for a time when there may be no large public hospitals in our
country.

 

Rob Smith 


A Safety-Net Hospital Falls Into Financial Crisis 


By SHAILA DEWAN
<http://topics.nytimes.com/top/reference/timestopics/people/d/shaila_dewan/i
ndex.html?inline=nyt-per>  and KEVIN SACK
<http://topics.nytimes.com/top/reference/timestopics/people/s/kevin_sack/ind
ex.html?inline=nyt-per> 

ATLANTA — Pamela Vaughn is a Grady baby.

Like tens of thousands of Atlantans over the last 115 years — like Gladys
Knight, the soul singer, and Vernon Jordan Jr., the presidential confidante;
like more than one in three babies born here in the last decade — Ms. Vaughn
entered the world at Grady Memorial Hospital, one of the nation’s largest
safety-net hospitals
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics
/hospitals/index.html?inline=nyt-classifier> . 

Ms. Vaughn was not only born at Grady, she also works there, as a senior
nurse in the diabetes
<http://health.nytimes.com/health/guides/disease/diabetes/overview.html?inli
ne=nyt-classifier>  clinic, where many of her patients are Grady babies,
too. And now, like thousands of other Atlantans, she is hoping to save the
teeming charity hospital that has provided her with both life and
livelihood.

To generations of Georgians, this city is unimaginable without Grady. Yet
that has been the prospect facing the region for the last year, the result
of a multimillion-dollar shortfall in the cost of providing charity and
emergency care that no one — not the counties, the state nor the federal
government — has been willing to cover, though Grady provides vital services
to the entire region. 

Once admired for its skill in treating a population afflicted by both social
and physical ills, Grady, a teaching hospital, now faces the prospect of
losing its accreditation. Only short-term financial transfusions have kept
it from closing its doors, as Martin Luther King Jr.-Harbor Hospital in Los
Angeles County did last year. That scenario would flood the region’s other
hospitals with uninsured patients and eliminate the training ground for one
of every four Georgia doctors.

Ms. Vaughn feels the strain when she has to counsel 20 patients in a day,
twice as many as she did only five years ago. Or when she has to tell
diabetics at risk of blindness
<http://health.nytimes.com/health/guides/symptoms/blindness/overview.html?in
line=nyt-classifier>  that it might take four months to get an eye
appointment. “It makes me sad,” she says, “that I’m a Grady baby and we have
to go through all of this.”

Although the hospital is unique in many ways, the code red at Grady is
emblematic of the crippling effect America’s health care crisis has had on
public hospitals around the nation. Though Grady is among the most
distressed of the country’s 1,300 public hospitals, others have faced
similar challenges in recent years, including those in Miami, Memphis and
Chicago, said Larry S. Gage, president of the National Association of Public
Hospitals and Health Systems. There are 300 fewer public hospitals today
than 15 years ago, with hospitals having closed in Los Angeles, Washington,
St. Louis and Milwaukee, Mr. Gage said.

Dr. Carlos Del Rio, Grady’s chief of medicine, calls the hospital “the
canary in the coal mine.”

Like other public hospitals, Grady is operating on a business model that is
no longer sustainable. A third of the hospital’s patients, including those
treated as outpatients, are uninsured, among them a rapidly growing group of
immigrants. Another third are covered by Medicaid
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics
/medicaid/index.html?inline=nyt-classifier> , which reimburses at rates well
below Grady’s actual costs. Many hospitals use their privately insured
patients to subsidize indigent care, but at Grady, only 8 percent of
inpatients fit the privately insured category.

In large part, that is because in Atlanta, as in most other cities,
better-financed private and nonprofit hospitals are able to market their
services and high-tech equipment to patients with good insurance coverage,
including those on Medicare
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics
/medicare/index.html?inline=nyt-classifier> , leaving Grady with little but
those it was intended to help: the under-insured and those without insurance
at all. The National Association of Public Hospitals says its members
account for 2 percent of all hospitals, but provide 25 percent of the
nation’s uncompensated care.

Over the years, the cost of caring for the uninsured and underinsured has
grown while taxpayer support has stagnated. Suburban counties have declined
to pay a share of those costs, though their residents regularly wind up in
Grady’s emergency room and its highly regarded centers for burn and poison
treatment. Management problems within the hospital have played a role, and
community pressure has kept Grady’s politically appointed board from making
deep cuts. As a result, the hospital has faced deficits for 10 of the last
11 years.

It can no longer do so. This fiscal year’s budget gap is projected to hit
$53 million. Emory University
<http://topics.nytimes.com/top/reference/timestopics/organizations/e/emory_u
niversity/index.html?inline=nyt-org>  and Morehouse College, whose medical
schools
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics
/medical_schools/index.html?inline=nyt-classifier>  supply the hospital’s
doctors and are its biggest creditors, are owed an accumulated $71 million
and have threatened to bolt. 

Grady officials estimate it would take $366 million to meet long-ignored
capital needs, like replacing quarter-century-old beds, antiquated
computers, and the trauma ward X-ray
<http://health.nytimes.com/health/guides/test/x-ray-skeleton/overview.html?i
nline=nyt-classifier>  machine, which conked out two years ago. Department
chiefs predict a growing difficulty in recruiting physicians and residents.

And despite the efforts of the hospital’s passionately committed staff,
patient care is clearly suffering. There are interminable waits for
appointments, some services have been discontinued and the hospital ranks
below average on safety measures like preventing bed sores, infections, and
even death in low-risk procedures. One study, for example, ranks Grady
nearly dead last in the nation in following standards for treating pneumonia
<http://health.nytimes.com/health/guides/disease/pneumonia/overview.html?inl
ine=nyt-classifier> .

The hospital, sandwiched between downtown and the neighborhood where Martin
Luther King Jr.
<http://topics.nytimes.com/top/reference/timestopics/people/k/martin_luther_
jr_king/index.html?inline=nyt-per>  was born, was the place where victims of
the 1996 Olympics bombings and countless other disasters have been treated.
It is so intrinsic to the city’s identity that Maynard H. Jackson Jr., the
first black mayor, liked to say that Grady babies should be allowed to vote
twice. 

But Grady’s value is more than sentimental — it is essential to the region’s
health. With 675 beds and 16 operating rooms, the hospital handles more than
850,000 outpatient visits a year and admits more than 30,000 inpatients. It
is home to the only Level 1 trauma center in north Georgia and the city’s
only emergency ambulance fleet. It has one of the country’s largest AIDS
<http://health.nytimes.com/health/guides/disease/aids/overview.html?inline=n
yt-classifier>  clinics, a dialysis
<http://health.nytimes.com/health/guides/test/dialysis/overview.html?inline=
nyt-classifier>  unit and a 24-hour emergency center for sickle
<http://health.nytimes.com/health/guides/disease/sickle-cell-anemia/overview
.html?inline=nyt-classifier>  cell anemia. 

All are now at risk.

The prospects that Grady could close, and that Atlanta’s health
infrastructure could crumble, have forced a civic re-examination of the
region’s commitment to its least fortunate, a reckoning that has revived old
antagonisms over race, power and class.

Virtually every aspect of Grady’s operations has come under scrutiny: its
nine neighborhood clinics, its subsidized pharmacy, its care for Atlanta’s
growing population of illegal immigrants, even its 60-year-old governance
structure. Some have suggested that Grady must compete for paying customers
in Atlanta’s fierce medical marketplace, while others say that taxpayers
should contribute more to continue its mission. Will Grady outsource, or
simply downsize? And if it must downsize, which patients should be turned
away?

“Grady is that last resort,” said Sandra Crayton, managing director of
Alvarez & Marsal Health Care Industry Group, one in a long line of
consulting firms hired to help the hospital bail itself out. “The board has
a very difficult, and in some cases nearly impossible, balancing act. It’s
sort of like Solomon and the baby. What are you going to do?”

A Patchwork of Care

The patient in Trauma 3 was a Grady baby, though no one could have guessed
it when the ambulance pulled in at 1 a.m. that Saturday.

He beat considerable odds by being white, and from suburban Cobb County,
where most folks give Grady little thought until they need a surgeon in the
middle of the night. 

The bearded, middle-aged man was bleeding
<http://health.nytimes.com/health/guides/injury/bleeding/overview.html?inlin
e=nyt-classifier>  from a self-inflicted gunshot wound to the left side of
his chest. “Don’t let me go out in pain,” he moaned in a drawl to the
doctors and nurses treating his injury. “I was born at this hospital.”

Grady’s chief of emergency medicine, Dr. Leon L. Haley Jr., smiled slightly:
“Well, tonight, he’s not going to die at this hospital.” And so the creaky
but miraculously effective patchwork of an emergency room jolted into
action. 

The ER did not have a working X-ray machine that night, so doctors had to
roll in a portable one to locate the bullet. The X-rays were produced on
film rather than digitally, causing a 10-minute delay in diagnosis. There
were gurneys without wheels, and a computer system so outdated that doctors
had to call up four separate programs to compile records on a single
patient. 

But six days later, the patient was discharged in good condition.

“We’ve gotten really good at MacGyvering,” said Dr. Philip H. Shayne, an
emergency room physician. “We use paper clips for a lot of stuff.” 

That may no longer be good enough. On any given day, a patient taken to
Grady’s storied emergency room, or to any other unit in the hospital, may
still receive care as good as any in the city. But the signs of stress
<http://health.nytimes.com/health/guides/symptoms/stress-and-anxiety/overvie
w.html?inline=nyt-classifier>  are everywhere, in overworked staff, in
broken equipment, in outmoded systems.

Last month, the Joint Commission, the country’s leading health care
accrediting agency, raised serious concerns about Grady’s status after
observing numerous significant shortcomings during a five-day inspection.
Although the commission has not yet released a public report, hospital
officials, speaking anonymously, said the commission’s concerns included
broken equipment, sanitation and the adequacy of staff supervision. 

Those foreboding findings came only two years after the federal government
threatened to deny Grady Medicaid payments because the hospital sometimes
waited nearly two years to conduct reviews of patient deaths. That problem
has been resolved, hospital officials say.

But an analysis of hospital standards by Ashish Jha, a professor at the
Harvard School of Public Health, ranked Grady in the lowest fifth of all
hospitals in the treatment of heart attacks in 2006, the lowest tenth for
heart failure
<http://health.nytimes.com/health/guides/disease/heart-failure/overview.html
?inline=nyt-classifier>  and in the lowest 1 percent for pneumonia. The
hospital also lagged when compared with its inner-city peers.

Other quality indexes, including one compiled by the Georgia Hospital
Association, rank Grady well below the state averages for all hospitals and
for those of similar size.

The hospital’s burden is most visible in the emergency room, where the
hallways that recent night, as most nights, were chockablock with stretchers
— one man, shackled to his gurney, writhing through an acid trip; a woman
fighting seizures
<http://health.nytimes.com/health/guides/symptoms/seizures/overview.html?inl
ine=nyt-classifier> ; asthma
<http://health.nytimes.com/health/guides/disease/asthma/overview.html?inline
=nyt-classifier>  patients sucking down oxygen. Their comings and goings —
more than 300 a day — are tracked in doctors’ script on a greaseboard, a
relic rarely seen in an age of big electronic screens. Because of crowding,
it can take 24 hours to move a patient to intensive care, Dr. Haley said. 

Elsewhere in the hospital, there are long waits in the pharmacy. The
equipment for cardiac
<http://health.nytimes.com/health/guides/test/cardiac-catheterization/overvi
ew.html?inline=nyt-classifier>  catheterization and magnetic resonance
<http://health.nytimes.com/health/guides/test/mri/overview.html?inline=nyt-c
lassifier>  imaging breaks with regularity. Because Grady often cannot pay
suppliers on time, there have been temporary shortages of essentials like
neck braces, electrodes and even saline.

A third of the ambulances need to be put out of their misery, said Astria L.
Benton, a paramedic supervisor. Every week or so, a vehicle simply gives out
while in transit, and Ms. Benton prays that the patient will not die before
she can orchestrate a rescue.

“No one wants to talk about it,” she said, “but it could happen.” 

The orthopedic department has a waiting list for elective procedures that
one doctor quantified as “infinity.” Its doctors intermittently instruct
other departments to not send them patients. That has been a particular
problem for certain AIDS patients, who find themselves in wheelchairs
because they cannot get needed hip replacements. 

Ophthalmology was among the hardest hit departments in a recent employee
buyout, losing 60 percent of its staff, including several experienced
nurses, said Dr. Geoffrey Broocker, the department chief.

Dr. Curtis Lewis, the hospital’s chief medical officer, said in an interview
that the quality of care at Grady has “not declined to the point of danger.”
But, Dr. Lewis added: “It would be naïve to believe that hospitals that have
more resources can’t do more than those that don’t.”

Dr. Lewis and the hospital’s general counsel, Timothy Jefferson, said the
hospital had not been sued for malpractice in a case that related directly
to inadequate resources. But a review of recent filings found several cases
in which staffing appears to have been an issue.

A lawsuit filed by the family of a 23-year-old man who died after suffering
a brain injury
<http://health.nytimes.com/health/guides/injury/head-injury/overview.html?in
line=nyt-classifier>  in a 2004 skateboarding accident claims that for more
than 12 hours he was seen only by medical residents — doctors being trained
in a specialty — even as his condition worsened. The hospital is close to
settling the case. 

In 2006, a 27-year-old teacher who survived a fiery car crash nearly died in
intensive care after nurses failed to detect and clear a blockage in his
breathing tube, another lawsuit alleges. In a deposition provided by the
patient’s lawyer, a nurse testified that the intensive care unit for burn
victims was short-staffed that day, and that the patient’s nurse, who did
not normally work in the unit, was caring for three patients instead of the
customary two. 

Finding Someone to Pay

Michael B. Russell is a Grady baby — of sorts.

The son and successor of Herman J. Russell, the city’s most prominent black
general contractor, he was born in 1965 at the Hughes Spalding Pavilion,
which Grady opened across the street in 1952 to serve a growing black
middle-class too affluent to qualify for charity care. When integration
eroded the demand for such a place, Hughes Spalding evolved, becoming a
children’s hospital. 

In April, Mr. Russell was called upon to aid his birthplace. He and A. D.
Correll, the chairman emeritus of Georgia-Pacific and an éminence grise of
the Atlanta business world, were drafted to lead a task force on Grady
formed by the Metro Atlanta Chamber of Commerce at the hospital authority’s
request. 

That one co-chairman was white and one black was a not-so-subtle attempt to
bridge the racial divide that has undermined Grady for decades. Grady’s
specialties, especially trauma care, are vital to the entire region and draw
patients of all races from around the area. But it has long been viewed as a
hospital that primarily serves blacks, who comprise 48 percent of the
population of Fulton and DeKalb counties. 

Only those two central Atlanta counties — and none of their suburban
neighbors — make annual appropriations to the hospital’s budget for the care
of indigent residents, even though two in 10 Grady inpatients and one in 10
outpatients arrive from other counties, often by ambulance.

Contributions from the two counties, themselves politically and racially
divided, have stayed essentially flat for a decade, even as the population
and its percentage of uninsured grew. The county commissions in Fulton and
DeKalb have been reluctant to increase their contributions when the state
has refused to do so, and when suburban counties will not contribute at all.

Only the state can force other counties to pony up money for Grady. And the
state legislature and the governor’s office are controlled by white
Republicans, whose core constituents have historically not viewed themselves
has having a direct stake in the hospital’s future. 

In the coming session, however, the legislature, which has long viewed Grady
as someone else’s problem, seems moved by the magnitude of the current
crisis to consider providing aid, perhaps by financing a statewide trauma
network. Grady lost $42 million on charity care for trauma patients alone in
2005, according to the Georgia Hospital Association.

Grady’s ability to plead for public resources has been compromised over the
years by its own actions. 

There have been charges of corruption and cronyism, most notably in 2005,
when a powerful state senator was convicted of using his influence to secure
overpriced Grady contracts for his temporary services business.

Handicapped by staff shortages and anachronistic technology, the hospital’s
administrative inefficiency is legendary. Over the last three years, one of
every five Medicaid reimbursement billings has been kicked back by the state
because of filing mistakes, according to the Georgia Department of Human
Resources. 

When the outpatient oncology clinic studied its 2006 billings, it discovered
that the paperwork on one in four patients had vanished before Grady could
even file for reimbursement, said Dr. Otis W. Brawley, who left as chief of
oncology last summer. Grady’s system for tracking aging equipment is so
outdated it is difficult to anticipate needed replacements.

The hospital board has long been reluctant to make money-saving changes that
might reduce its traditional mission. Late last year, it rejected the advice
of financial consultants and its newly hired chief executive to close an
expensive outpatient dialysis clinic for the poor, fearing that many of the
clinic’s uninsured patients, including many illegal immigrants, would have
nowhere else to go.

But the board has also been politically clumsy, and prone to
micromanagement. In May the board’s own consultants concluded that “Grady
does not currently have the depth of leadership” necessary to transform the
hospital. 

The Chamber’s task force trod more gingerly. “Grady’s problems are nobody’s
fault,” said its report, released in June. Yet, it insisted, the board must
create a new nonprofit corporation to run the hospital, instead of the
public authority that has run it up to now. The change would allow Grady to
attract philanthropic dollars, expand into money-making services and remove
politics from its day-to-day operations, the task force predicted. Mr.
Correll promised at least $200 million in private donations if the nonprofit
was formed.

The task force’s involvement was in keeping with “the Atlanta way,” the
long-standing tradition of bringing together black political power and white
business power to address civic problems like segregation and sewer
construction. But there was no way to muffle accusations that white business
leaders, who see the hospital as vital to the region’s growth, were trying
to take over one of the city’s most prominent black-run institutions. 

Even after the reorganization was endorsed by Shirley Franklin, Atlanta’s
influential black Democratic mayor, black board members who supported it
were accused by Grady patients and other local black politicians of being
“sell-out Uncle Toms” and worse. They asserted that the move amounted to
privatization and would jeopardize Grady’s mission. 

When the board hesitated to turn over control to the nonprofit corporation
without guarantees of increased financing, Republican state lawmakers
threatened to change the hospital’s governance by legislative fiat. 

The task force stuck to its guns, insisting the issue was not race but
economics. “We stirred the pot, no question about it,” Mr. Russell said. “I
hope the old Atlanta way will lead to some degree of progress and we can get
Grady on the right footing.” 

Finally, in November, the Grady board essentially voted itself out of
business, hoping the new nonprofit corporation will begin to overcome the
hospital’s political troubles. It agreed to do so, however, only with
strings attached, demanding that the state and counties pledge hundreds of
millions of dollars to Grady. The conditions surprised and angered many of
those who had been most supportive of the deal. Dozens of details have yet
to be settled, and it is not yet clear how things will be resolved.

The financial pressure is not likely to subside soon. Grady’s share of
federal assistance to charity hospitals has shrunk sharply as the state,
which distributes the money, has extended it to more hospitals that serve
far fewer indigent patients. At the same time, the Bush administration has
enacted a new rule that, unless stopped by Congress, will reduce payments to
public hospitals by billions of dollars. 

“While so many people are helping,” said Otis L. Story, who was hired in
April to be the hospital’s fourth chief executive officer in seven years,
“there appear to be opposite pressures pulling us into further financial
distress.” 

The Last Open Door

Hillary Estrella Reyes is one of the newest Grady babies.

Just three days after she was born in late October, she slept in the lee of
her mother’s hospital bed. Tucked into a bassinet with a knit cap and
blanket, she was an oblivious example of the explosion in Hispanic growth in
Georgia and at Grady. A third of the hospital’s newborns are now children of
Hispanic parents. 

Grady’s crisis has not touched Hillary’s parents, Patricia and Daniel Reyes,
who seemed calm as the nurses wheeled the baby away for a checkup. They paid
for prenatal care in $100 installments, and Medicaid will cover the cost of
the delivery, because the baby is a citizen.

But her parents are in the country illegally. Without Grady, families like
theirs would face an uncertain future in their new city. Where would they go
in case of a serious ailment? And what of Hillary, who was born with an
unusually rapid heartbeat? If Grady were to close, her options for care
might be severely limited.

Grady’s disappearance is a prospect Mr. Reyes, a janitor, and his wife —
like many of the hundreds of thousands Grady serves — are unable to
visualize. Asked about it, Mr. Reyes could do nothing but shrug. 

“I haven’t got sick yet,” he said. “Thank God.”