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Narrative Matters

Making A Public Hospital Work

I can now look back and see all the strikes that Philadelphia General had against it: It was run by multiple schools with no one really "owning" it; it lacked access to the social support systems that are essential to prevent a critical care hospital from becoming a long-term care facility for poor populations; and neither the schools of medicine nor the city appeared to have considered who would care for its patients when it closed, which it did in 1977.

Better Models

 
In contrast, my time s pent at Harbor General Hospital in Torrance, California, in the early 1970s as a resident in medicine provided a more positive public hospital example. Although it had Quonset barracks for tuberculosis patients, it did not "house" forgotten patients. Like all public hospitals, it did serve those who had lost critical connections. Late one night I admitted a frightened young woman who was pregnant with her second child and ultimately ultimately diagnosed with pseudomonas endocarditis, a serious—in her case, fatal—infection of the heart valves. Over the ensuing days she expressed concern about the fate of her three-year-old daughter. With difficulty, I reached her sister and parents, who were sailing on their yacht, to tell them of her grave condition and to make arrangements for the child. What I got were cold responses; the woman was truly on her own. A ward nurse offered to adopt the girl, an idea that, unfortunately, was squelched by Social Services.

For more than three decades I have worked as a medical student, house officer, faculty member, medical director, and CEO in public hospitals. These experiences have convinced me of the enormously important role that well-run public hospitals play in serving parts of the population that often are not well cared for by the private sector. These safety-net institutions also play a role that benefits society at large by providing special services such as trauma care to all. Eighty percent of urban public hospitals are Level I trauma centers, compared with 38 percent of not-for-profit and private hospitals. Moreover, the severity and diversity of disease at public hospitals provide a training ground for America’s future doctors. These hospitals are unique, important settings in which to teach medical students about broad societal and public health aspects of medicine in ways that other institutions cannot.

Despite the importance of public hospitals to America, the Philadelphia story continues to be played out in new versions in Detroit and St. Louis, and now perhaps in Washington, D.C. But the good news, which I gleaned from training at Harbor General and San Francisco General, is that steps can be taken to prevent public hospitals from deteriorating to the point that closing them remains the only option. Ingredients exist for good governance. Sometimes the experience is not one of a downhill spiral to closure, but vitalization and stability. This has been the story in Denver.

Quite simply, the Denver Health formula has been based on four strategic principles: attracting and keeping strong physician staff with full academic appointments at the medical school affiliate but employed by the hospital; building an integrated service system that links the hospital to an entire continuum of care; establishing financial health by integrating the diverse array of county, state, and federal funds; and maintaining operational flexibility.

Staff Matters

Top Better Models Staff Matters A Continuum Of Care Public Health Care Financing... Autonomy From City Government

 
The relationship between a public hospital and a medical school should be a modern marriage in which both partners have goals and separate lives but are mutually supportive. Denver Health, known as Denver General when I arrived in 1973 as chief of the renal division, has a high-quality, committed physician staff with full faculty appointments at the University of Colorado School of Medicine. Not all public hospital physicians enjoy this privilege. Moreover, in many other safety-net institutions, physicians are supplied by an affiliated medical school but spend much of their time on that school’s campus rather than at the public hospital.

Professional staff at public hospitals often work for lower wages and under more difficult working conditions than elsewhere. The physical plant may not be as up-to-date as that of a private hospital, and the intensity and demands of the patients, both medically and socioeconomically, are greater than those in other hospitals. Public hospital workforces are more ethnically diverse than those at private hospitals, reflecting the communities they serve and perhaps explaining the extraordinary commitment often seen in public hospital staffs. I’ve observed a chief of the pulmonary division making house calls for terminally ill cancer patients; an attending physician going out at 2 A.M. to pick up an elderly woman to be at her dying husband’s bedside; and an internist going to a crack house to find a patient who went AWOL. This kind of commitment runs deep in public hospital systems, including among nurses, clerks, ER and ambulance staff, and even electricians.

In the 1980s a cardiologist I was recruiting needed a $50,000 piece of equipment. The department of medicine at the University of Colorado School of Medicine was willing to contribute to it, and I had some unspent hospital funds. But joint purchasing was impossible, and purchases greater than $1,500 required city council approval, which wasn’t forthcoming in those days of deficits. The choice seemed simple: Let go of the cardiologist or get around the system. So I ordered the equipment in $1,495 increments. This seemed incredibly clever, but when a single piece of equipment arrived at the loading dock with more than thirty requisitions attached, the jig was up. The medical director called, and his voice told me I might be job hunting: "We will put a city tag on every $1,495 piece so that the machine will never work." He didn’t carry through on the threat; my strategy worked, and I got my cardiologist.

A Continuum Of Care

Top Better Models Staff Matters A Continuum Of Care Public Health Care Financing... Autonomy From City Government

 
Truly integrating the care at Denver General Hospital with that in its eleven community health centers was key but required breaking down a wall between the hospital and neighborhood clinic physicians. The solution seemed logical—place house staff in the neighborhoods for continuity-of-care clinics, and have the clinics’ staff physicians serve as attending physicians on the inpatient service. A little drama played out. The inpatient service was foreign territory to the clinic physicians, and having them serve as attendings upset everyone—the clinic doctors; the residents, who complained about the quality of the clinic doctors who at that time were not prepared for the intensity of the inpatient service; and the inpatient physicians, who aligned with the residents. Despite tensions, the result was that we were able to recruit some of our best house staff to the clinics. And when they became the attending physicians, everyone was happy.

We also succeeded in offering true integration across the whole continuum of care. The components of Denver Health—the 911 system, an acute care hospital, community health centers, school-based clinics, the public health department, a nonmedical detoxification center, an HMO, and a regional poison center and nurse advice line—provide nearly seamless care. They also facilitate access to diverse revenue streams.

Public Health Care Financing 101

Top Better Models Staff Matters A Continuum Of Care Public Health Care Financing... Autonomy From City Government

 
Consistent, first-person lobbying for all available funds is de rigueur for a public hospital CEO. When I became medical director at Denver Health twelve years ago, and soon after that, CEO, my transition from bedside to boardroom was complete. It was quite an eye-opener.

In 1991 Denver Health was in sore need of money. Most politicians don’t want to fund institutions that are in the red, any more than investors want to invest in losing companies. I remember telling the city council, "The airport would be in the red too if half the people who flew didn’t pay." That argument didn’t go anywhere. The answer ended up coming in the form of disproportionate-share hospital (DSH) funding (a federal program that offers dedicated funding to hospitals that provide a disproportionate share of their care to Medicaid and uninsured patients). Colorado was getting a fraction of potential funds, but the state was reluctant to have the local safety net become dependent on federal dollars that might disappear. "DSH is the cocaine of public hospitals," stated one skeptical state legislator. We saw it more like penicillin. How do you transform cocaine into penicillin? And why shouldn’t the federal government support safety-net hospitals like ours, when these institutions provide our national health insurance by default? We needed to convince one of the smartest and most powerful legislators who opposed DSH to support accessing these dollars.

In the summer of 1997, after the legislative session, Denver Health’s chief financial officer and I drove 180 miles to a small rural town in southeastern Colorado to lunch with the legislator. "What brings you all the way down here?" he asked, as we sat down at the restaurant table. "To have lunch with you and talk about DSH." He responded, "I hate DSH." With a lump in my throat I said, "By the time lunch is over you will love DSH as much as we do." This meeting turned the tide in our favor.

Autonomy From City Government

Top Better Models Staff Matters A Continuum Of Care Public Health Care Financing... Autonomy From City Government

 
Along with DSH came financial stability, but this was not sufficient. It was critical to separate Denver Health from the city’s operational control. After four years of soliciting community input, developing a new purchasing system, building a new peronnel system separate from the city’s civil service system, and creating legal structures for a new entity and a meaningful long-term contract with the city, we became independent.

We did it by building support for the shift among the political leadership and the community. "Not every decision is made from data," Mayor Wellington Webb once said to me, when I was presenting statistics about the necessity of the governance change. He and I then set out on a campaign to convince any group that would listen about Denver Health and the needed governance change. One fact that surprised listeners was the degree to which centers of excellence such as emergency and trauma care link the entire population, not just the poor, to our system. This brings prominent citizens to us, such as the wife of a chairman of a major bank, whose tribute to Denver Health we quoted in our newly developed capital campaign brochure: "When we had the [auto] accident, we were surprised that the paramedics were taking us to DH...We can’t give enough praise to the doctors and nurses."

Every audience we spoke to during our campaign had the same response: "We never knew everything that DH did for the community." The benefits that public hospitals bring to whole communities are often a well-kept secret that should be broadcast far and wide.

Equally important as getting community groups to buy change were city leaders’ attitudes. Mayor Webb and the city council did not see the hospital’s new autonomy as a way to remove Denver’s financial obligation to the disenfranchised, but rather as a means of improving health care delivery. This is not a divorce, said the mayor, publicly. We are just going to live in separate houses.

The city’s contribution of about 10 percent of Denver Health’s operating budget has been maintained every year since the 1997 separation. The governance change permitted us to develop a competitive, market-based salary structure for physicians and other professionals, to enjoy operational flexibility, and to successfully issue revenue bonds. Over the past decade we’ve delivered more than a billion dollars of unsponsored care, supported $130 million of capital improvements from operations, and been in the black every year.

Stable leadership at both the hospital and the city has been crucial to Denver Health’s turnaround. Prior to my (nine-year) tenure, six people had served as CEO during the previous twelve years. Factors contributing to my staying power have been stability in Denver’s political leadership and my now direct reporting to the Denver Health Board. A constantly changing leadership is a serious issue for safety-net institutions. Some of the most successful hospitals, like Parkland in Dallas and Cook County Hospital in Chicago, have benefited from stable leadership. The recent losses of talented leadership from institutions such as Tampa General and Los Angeles County Hospital are deeply troubling. Given the critical community role of the safety net, we need to ask how stable, high-quality leadership can be maintained in locally controlled institutions.

If our nation is going to care for the forty-four million uninsured people and thousands of others who rely on public hospital systems, we need to adapt approaches like the ones that have worked in Denver to other communities, rather than letting these systems spiral downward and then abandoning them and the communities they serve. The dying of America’s public hospitals affects us all.

Editor's Notes

 
Patricia Gabow is CEO and medical director of Denver Health and professor of medicine at the University of Colorado School of Medicine.

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