Rebuilding Place in the Urban Space

"A community’s physical form, rather than its land uses, is its most intrinsic and enduring characteristic." [Katz, EPA] This blog focuses on place and placemaking and all that makes it work--historic preservation, urban design, transportation, asset-based community development, arts & cultural development, commercial district revitalization, tourism & destination development, and quality of life advocacy--along with doses of civic engagement and good governance watchdogging.

Friday, May 31, 2019

Another example of a failure to do public capital planning in DC: Council votes to stop funding United Medical Center

Yes, cities and counties often have financial problems because of hospitals and providing care to the impoverished.

That's why DC closed DC General Hospital and why Prince George's County has finally successfully off-loaded the Dimensions Health Care system to the University of Maryland Medical System.
Sky View 2
The new UMMS Capital Region Medical Center under construction as of January 2019..

But sometimes, parts of your community can be under-served by other health care actors as a result, and the fact that needs remain means that cities and counties can't be cavalier about closing hospitals when alternative care options aren't present.

-- "A glaring illustration of the need for comprehensive health and wellness planning in DC: Providence Hospital," 2018
-- "Prince George's County's problems as but one more example of the impact of outmigration," 2005
-- "More shenanigans in DC health planning," 2006
-- "Muddled thinking by Steven Pearlstein (Post business columnist," 2006
-- "An indication that there is little respect for planning: Maryland healthcare edition," 2011
-- "When the problem is defects in the structure of "the market", financial incentives won't do much good: Maryland's health enterprise zones," 2013

That's especially true of the part of DC "east of the Anacostia river," where health disparities, because of race and income, are pronounced ("The District's racial and income divide is cutting short the lives of black residents," Washington Post).  From the article:
The District’s latest “health equity” maps shows a city divided by race and income. How well you live, or sometimes whether you live at all, can depend on what side of the line you are on.

On one of the maps, we see that Woodley Park in Northwest Washington is the neighborhood where residents have the longest life expectancy, 89.4 years on average. Residents in the St. Elizabeths neighborhood, in Southeast, have the shortest, 68.2 years.

Woodley Park is wealthy and predominantly white. St Elizabeths is poor and predominantly black. The difference that makes: 21 years of life. “Your zip-code may be more important than your genetic code for health,” says the report that accompanies the maps, which can be found on the D.C. Department of Health website.

The disparities are stark, the consequences appalling. And the cause is no mystery. As the report notes, they are the result of “historical forces that have left a legacy of racism and segregation, as well as structural and institutional factors that perpetuate persistent inequities.”
-- The Social & Structural Determinants of Health, Office of Health Equity, District of Columbia, Department of Health

So I disagree with the Washington Post editorial, "United Medical Center: When will D.C. realize it doesn't belong in the hospital business," in favor of the City Council's original decision to close United Medical Center, which operates "East of the River" in Ward 7 ("United Medical Center will close by 2023," Post).

Note that this decision, was reversed, in later votes, but the appropriation was half of what was requested. This funding gap will accelerate the hospital's decline ("DC Council moves to reduce cuts in funding for struggling hospital," WTOP-radio; "'Spinning its wheels': Lots of money, few bold initiatives in 2020 DC budget," Post).

UMC is the only hospital operating "East of the River."

Note that UMC isn't the only hospital that's had issues.  The university medical school affiliated hospitals (Georgetown, Howard, and GWU) have taken on private partners.  One independent, Sibley, merged into the Johns Hopkins Health System.  Excepting Howard, these hospitals serve high income patients, which is why it was easier for them to land partners.

Providence, is downsizing out of the hospital business, which has impacted Washington Hospital Center, the anchor of the Medlantic system.  Howard University Hospital has had many management and financial issues, but has finally turned the corner in association with a for profit health care management firm ("Howard University Hospital turnaround experts Paladin Healthcare say hospital may make money next year," Washington Business Journal).

In Montgomery County, Holy Cross and Washington Adventist continue to expand and/or relocate to have access to more of MoCo's high income population, although the hospitals fought over WAH's move to a more accessible location deeper into the county, with better proximity to patients from Prince George's and Howard Counties too.

And as mentioned, in Prince George's County, UMMS has taken over Dimensions, and is building a new hospital in Largo, mostly with state support.

Washington Business Journal photo.

UMC provides care in an under-served area of the city.  There have been various initiatives to build a new hospital over the past couple administrations.

But I've argued that the non-public process disserves the city and the needs of the population that the hospital serves.  

And that there is an incredible opportunity to do visionary planning for a new hospital East of the River, complemented by a parallel economic development initiative focused on graduate health education and medical and biotechnological research.

-- "Update on DC's plans to build a new United Medical Center"
-- "Ordinary versus Extraordinary Planning around the rebuilding of the United Medical Center in Southeast Washington DC | Part One: Rearticulating the system of health and wellness care East of the River"
-- "Ordinary versus Extraordinary Planning around the rebuilding of the United Medical Center in Southeast Washington DC | Part Two: Creating a graduate health education and biotechnology research initiative on the St. Elizabeths campus"
-- "Ordinary versus Extraordinary Planning around the rebuilding of the United Medical Center in Southeast Washington DC | Part three: the potential for donations around an expanded program"

Proving my point that lack of public processes creates problems, the proposed fix of building a new hospital affiliated with GWU in return for special privileges for the main GWU hospital in Foggy Bottom, ran into opposition.

And in response, rather than create a new public process and come up with a good solution, or better yet, an innovative-transformational solution, the City Council voted to stop funding the hospital over a four year period and the executive branch issued an RFP with almost zero input from citizens and stakeholders.  

And the likelihood that the city will not get it together enough to plan, fund, and build a hospital in four years means that area will become even more under-served than it is currently.

This points to failures in two areas of planning: both capital planning as I just wrote about but also comprehensive health and wellness planning, an example being that the city lacks a health and wellness master plan.

Community health needs assessments required as part of the ACA.  Plus, I learned when reading about the potential closure of the only hospital in Berkeley, California, that hospitals are supposed to produce "community health needs assessments" as part of the Affordable Care Act ("Questions loom over Sutter Health's community benefit spending," Modern Healthcare). From the web:
The Patient Protection and Affordable Care Act (ACA) added section 501(r) to the Internal Revenue Code which imposes new requirements on 501(c)(3) organizations that operate one or more hospital facilities. Under section 501(r), each hospital facility operated by a 501(c)(3) organization must meet the following four general requirements on a facility-by-facility basis in order for the organization to maintain its 501(c)(3) tax-exempt status:1

- Establish written financial assistance and emergency medical care policies
- Limit amounts charged for emergency or other medically necessary care to individuals eligible for assistance under the hospital's financial assistance policy
- Make reasonable efforts to determine whether an individual is eligible for financial assistance before engaging in extraordinary collection actions
- Conduct a Community Health Needs Assessment and adopt an implementation strategy at least once every three years
(Although I will say the requirements aren't too specific, and the plans I've read are so general as to be practically useless.)

Separately, the City of Berkeley commissioned a study of the impact of the proposed closure of its only hospital:

-- Health Impact Assessment of the Proposed Closure of Alta Bates Medical Center, City of Berkeley
-- "Report: Alta Bates closure would critically impact poor, people of color," East Bay Times
-- "Editorial: Closing hospital may save Sutter money, but cost East Bay dearly," San Francisco Chronicle

According to the study:
The recent Rapid Health Impact Assessment, published by UC Berkeley's Institute of Urban and Regional Development, found that consequences of the hospital closure include:
  • Longer wait times at nearby emergency rooms 
  • Reduced access by the elderly, poor and uninsured  
  • Delays in ambulance transports and potentially increased deaths
Additionally, the study found that closing the community hospital would result in longer wait times at remaining regional emergency rooms, ambulance travel times would be delayed, and emergency responders response time longer.

The study also says among its findings, the "impact on the poor, the uninsured, and people of color who are much more likely to not have a primary care doctor and not seek alternative care" if the hospital closes.
No such assessment likely conducted concerning Providence Hospital.  A comparable assessment should have been produced wrt Providence and the likely impact on Washington Hospital Center.

Washington Business Journal photo.

It's not that Providence shouldn't have been allowed to close, because DC is probably "over-hospitaled".

But Providence's location is less than two miles from Washington Hospital Center, and the part of the city "west of the river" still remains served by five other primary care facilities within the city, plus three facilities in Montgomery County reasonably close to the DC-Maryland line. 

But even so there would be impacts. And these impacts should have been mitigated proactively rather than reactively ("Providence cuts causing ‘dramatic increase’ in MedStar Washington Hospital Center volume," Washington Business Journal).

No such assessment likely conducted concerning United Medical Center. By contrast, east of the river, with the closure of UMC, Howard will be the closest hospital, while others may go to the new hospital in Largo.  And an assessment comparable to that done concerning Alta Bates Medical Center, the only hospital located in Berkeley, California, should have been conducted before the DC City Council decided to stop funding UMC.

What a difference between the editorial page of the Washington Post vs. the San Francisco Chronicle.  The Post focuses on the city's budget and yes, the long term financial negatives of owning a hospital.  The Chronicle focuses on how a large city in its metropolitan area will lose its only hospital and the negative impacts this will have.

What a difference between the City of Berkeley Government and the DC Government.  Berkeley commissioned an impact study of the closure of its only hospital, while without such a study, DC City Council commanded the closure of the city's only hospital east of the river.

Where's the Coalition for Smarter Growth? CSG was very active pushing a Metrorail-centric location for a new hospital in Prince George's County ("Hospital design case studies showcase benefits of urban design and community connections for new Prince George’s Regional Medical Center"). It has been quiescent concerning UMC.

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At 5:51 PM, Anonymous Richard Layman said...

a semi-similar case (at least in terms of negotiating community benefits) in Pittsburgh:


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