The Plight of America's Urban Hospitals

The troubles plaguing King-Drew Hospital in Los Angeles are extensive but not unique. Ed Gordon discusses the problems faced by urban medical centers across the country — especially those in communities of color — with Dr. Ivan Walks, former health chief in Washington, D.C., and Alan Sager, director of the Health Reform Program at the Boston University School of Public Health.

ED GORDON, host:

From NPR News, this is NEWS & NOTES. I'm Ed Gordon.

It may be a familiar scene in your city: an urban public hospital forced to reduce its services or even close its doors because of dwindling funds, limited resources, financial mismanagement or mounting cases of malpractice. In Los Angeles, for example, the King-Drew Medical Center, which serves many poor African-Americans and Latinos, closed its trauma unit nearly two months ago after ongoing reports of medical mishaps, some involving deaths. And in the nation's capital, DC General Hospital, the District's only public medical facility, shut down a few years ago due to insurmountable financial and fiscal problems.

Can urban hospitals faced with limited resources and other pressures continue to operate? We'll talk about that with Dr. Ivan Walks. He was health director in Washington with DC General when it closed back in 2001. He joins us via phone from South Carolina. Also on the line, Alan Sager, director of the Health Reform Program at Boston University's School of Public Health. He has studied the trend of urban hospital closings around the country, and he joins us from Boston.

I thank you both very much. Mr. Sager, let me start with you. You, perhaps, are the most knowledgeable person in the United States when it comes to public hospital closings. You've been following this trend for some time. When we talk about public hospitals in America, are we talking about a crisis?

Mr. ALAN SAGER (Director, Health Reform Program, Boston University's School of Public Health): Yes, we are. It's a long-standing chronic crisis.

GORDON: And in what ways have we found ourself in this quandary?

Mr. SAGER: We've seen closings of public hospitals in large cities throughout the country--Philadelphia, St. Louis and Washington, DC--threats of closings in New York and other cities, Detroit. And there's a stark problem of more and more vulnerable patients facing the risk of denial of needed health care.

GORDON: Dr. Walks, you lived this. You had to face that when you were with DC General. What was the biggest problem and concern you had to face?

Dr. IVAN WALKS (Former Health Director, DC General Hospital): The biggest concern that we had to face in Washington, DC, was really the question of culture. The folks who really believed that this public hospital was important for the community, and who really viewed it as more than a hospital, but as a symbol of something that the community had gotten when the community so often feels that it doesn't get very much from the government, that whole political and cultural issue was really a much larger issue than the health-care issue.

GORDON: Dr. Walks, isn't that part of the problem, the idea that the lobbying behind these kinds of hospitals, because they substantially service the poor, and those that are not placed in a strong position, as far as Washington is concerned, just have no clout in trying to keep these hospitals open?

Dr. WALKS: There are really many problem but let me just hit one of them that isn't, I think, often mentioned. We always talk about these hospitals as not having enough money. And then someone else comes up and says, `Well, no, money isn't the problem.' For example, King-Drew, they say, gets more money per patient than the other hospitals. The challenge is the money is often lumped together; money used to pay malpractice cases, money used for things other than patient care, supplies and resources are lumped together. So what you have is a hospital that gets a bunch of money but doesn't get money to buy new equipment, pay for training, those kinds of things. And so I think clarifying the argument and making sure that when you're talking about dollars for a hospital, you're talking about real dollars for patient care and resources, is the issue, and you're comparing apples to apples. So there are many political conversations that go on and what gets lost in the argument is: Are the sick people really getting care? Are we actually getting better health outcome? That's where I think we should focus these concerns and these questions.

GORDON: Alan Sager, would you agree with that? And I guess I would echo what Dr. Walks said, and add to that: Are poor people getting not only care but adequate care?

Mr. SAGER: No, they're not. One of the problems that Dr. Walks is minimizing is that hospitals matter, for their emergency rooms, for their outpatient departments and for their inpatient care, and for their potential to organize care for large neighborhoods. As a result of the closing of DC General, there's now only one hospital left in the whole eastern part of the District, and that hospital is in the far corner, and it's been in bankruptcy twice, and it provides dangerous care to many patients. It has that legacy. We hope it's getting better. The--on the other hand, there are many hospitals in the wealthier western part of the district. In northern St. Louis, there are no hospitals left. So we have huge expanses that have become health-care wastelands, to a great degree.

Hospitals matter. We know that in--over the seven decades I've been looking at 1,200 hospitals in 52 cities, we see that race of the people who live around the hospital is one of the two biggest predictors of which hospitals close, and efficiency never predicts survival. In other words, the more efficient hospitals are actually a little more likely to close.

GORDON: If in fact they are housed in minority neighborhoods.

Mr. SAGER: Whether or not.

GORDON: Dr. Walks, let me ask you to respond to that, please.

Dr. WALKS: I'd be happy to. I don't remember minimizing the issue of hospitals, but let me clarify the issue of hospitals. I am focused on health care, and I think we need to be focused on `Is a community healthier?,' `Is a community doing better?,' and if you look at organizations that are extremely reputable, like, for example, The Kellogg Foundation, others, that have looked in Washington, DC, at the health-care status and the availability of health care pre-and-post-to-the-DC General transition, you will not find any reports of people are getting worse care, people can't get the care they need because DC General is closed. Those stories just don't exist, those assessments just don't exist. What you find, instead, is doctors and others and people who are doing reports, and patients, actually, saying, `You know, I can get better care.'

And it's not because the hospital is gone. Let me not fight with Alan Sager about this. It's not because the hospital's gone. It's because there's a comprehensive system of care put into place called the DC HealthCare Alliance. And so when we talk about hospital closings, I don't agree with the fact that a hospital is critical to organizing care in a community. What I think is this: Someone has to organize the care in a community. What you really have to do is look at the fact that hospitals across the board have changed so much in the last 20 years. You no longer have this issue of the rich hospitals are being paid a lot of money by the insurance companies and the poor hospitals are not getting paid very much. The reimbursement rates have come down from the insurance companies, and they're now not so different from what you get from Medicare in other places to account for all these changes.

The hospital that was mentioned, Greater Southeast in Washington, DC, the first time it went into bankruptcy actually had over 90 percent of the patients coming in had some kind of coverage--insurance, Medicaid, something like that, but management was a huge issue. So what I would recommend we do--when we talk about closing hospitals, which I'm not in favor of, I would want us to talk about `How can we put a system of care in place that focuses on efficient spending of the dollars available, but second that to a focus on preventive health care, keeping a population healthy, and stop reimbursing for procedures every time someone is sick, exclusively, and start reimbursing for preventive care and keeping neighborhoods health?' That's how you organize care in a community, not by saying, `We're gonna maintain what's already been there,' when we know those same communities continue to have poor health status, continue to have ...(unintelligible) health care...

GORDON: Yeah, Dr. Walks, let me stop you there, and ask you this. I have heard many, many stories--the Los Angeles Times did an extensive series on King-Drew Medical Center, and I've heard many, many stories--horror stories, quite frankly--about public hospitals in many cities, just giving inadequate care, where police have demanded not to be taken to emergency rooms and the like at these hospitals. Are these anomalies, in your mind?

Dr. WALKS: No, they are not anomalies, but they are sensationalized. I think that you--that we can--if you look at the front page of one of the leading newspapers today you'll find an article on medical errors. This is not unique to urban hospitals. There are a lot of hospitals that are making these kinds of errors. And I think the stories are just gut-wrenching, especially when you look at some of the King-Drew stories. It's horrible some of the things that have happened. You don't fix that by saying, `Leave the hospital alone.' And you don't fix it by saying, `Shut the hospital down.' You fix it by looking at what are the challenges facing the hospital and the community and let's think comprehensively about how we can better provide comprehensive care. It's about having the answers, you know?

GORDON: Alan Sager, what about fixes? What about fixes?

Mr. SAGER: Yeah. Right. It's good to recognize that many of our public hospitals such as Jackson in Miami or Cook County in Chicago or Parkland in Dallas or some of the New York hospitals provide superb emergency care. They're specialized in trauma and so on. There are several problems that need to be addressed at the same time. The first is to follow the old medical motto of `first do no harm.' Recognize there's no free market that's going around closing hospitals, but hospitals in lower-income and minority areas are being closed disproportionately, cumulatively, decade after decade, until there are none left in huge areas of cities. And patients are forced to rely on the world's most expensive teaching hospitals in many cities, and they're often maldistributed. So that, in Washington, for example, the four Level 1 trauma centers are all on one side of town, partly owing to the closing of DC General. So the fix needs to make sure that we identify first which are the needed hospitals and emergency rooms, and make sure that the hospitals and emergency rooms required to protect the health of the public are paid adequately. Second...

GORDON: All right.

Mr. SAGER: ...managing a public hospital is the hardest management job in health care. We need to recruit the most skilled and experienced hospital administrators into those jobs, which means paying the dollar we need to to get the best people. Third...

GORDON: All right. Quickly for me.

Mr. SAGER: ...we have to look at quality up and down the board, and look at the public hospitals that have succeeded in providing superb quality care and make sure that all public hospitals, and, for that matter, all non-profit and for-profit hospitals, imitate the examples of the best public hospital.

GORDON: All right, Dr. Ivan Walks is former chief health officer...

Dr. WALKS: Can I just make one quick comment?

GORDON: ...for--Doctor, I wish I could let you but...

Dr. WALKS: This is critical.

GORDON: I'm up against the clock, Doctor.

Dr. WALKS: ...(Unintelligible) You are? Oh, well.

GORDON: I'm so sorry. Dr. Ivan Walks and Alan Sager, thank you very much for joining us. Greatly appreciate it. Hate to cut you off there, Doctor, but I've got to hit a break here.

Dr. WALKS: All right. Thank you.

Mr. SAGER: Thank you.

GORDON: Coming up on our Roundtable, the new Cuban crisis and a new mayor for Los Angeles.

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