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Rising from a Hospital's Ruins

When a county or city shuts down its public hospital, it isn't off the hook. There's still political pressure to provide health care for the needy.

It was the "hospital of last resort." For 135 years, poor people in Milwaukee knew what to do when they got sick: make a beeline for County General--later known as Doyne Hospital. Located as it was eight miles into the suburbs, it wasn't so convenient for those from the inner city, but the county hospital was as solid in its commitment to providing care as its massive brick-and-stone architecture.

By the 1980s, however, that commitment was getting expensive. Hospital managers had to make regular visits to the county board of supervisors to report yet another budget shortfall. The county would bail the hospital out, but supervisors were growing increasingly tired of the ritual--to say nothing of the drain on resources and the threat to the county's bond rating.

By 1995 the supervisors had had enough. They closed Doyne down, an act that cut a psychological hole in the fabric of the community. There was concern, especially in less-affluent neighborhoods where generations of families had been born or treated at Doyne, that the poor would have nowhere to go when they got sick or just needed to get a prescription filled.

The same fears have been running through neighborhoods in Austin, Boston, Detroit, Tampa and dozens of other places where public hospitals have closed recently or been turned over to private management. With the rapid upheaval and rising costs in the health care industry, more and more local governments are getting out of the hospital business. In 1980, some 1,800 hospitals were considered "public." Today, after a wave of closures, consolidations and privatizations, fewer than 1,200 remain.

For local officials, closing a public hospital is politically risky. The hospital is often a symbol of the community itself--its history, troubles and hopes for healing. Just ask Anthony Williams, the mayor of Washington, D.C. Facing budget woes, Williams sought earlier this year to close D.C. General, the city's lone public hospital for nearly 200 years. Many African-American residents relied on the hospital for care, and they were proud of the generations of black physicians who had been trained there. Williams eventually won the battle and the hospital closed in June, but the backlash is likely to be a factor in the next election.

Milwaukee's experience suggests that there is life after closure, that a community can learn to live without a public hospital and still provide a safety net of care. But it also suggests that the long-term commitment is not as solid as a standing and functioning hospital.

In terms of immediate results, Milwaukee is looking pretty good. Five years after the hospital closed, the county's medically indigent have, by most accounts, roughly the same access to medical care that they did before. For some people, particularly in the inner city, access has actually improved. What's more, the nature of that care is changing for the better: Fewer people use emergency rooms and more people visit clinics where doctors try to prevent health emergencies from happening. And all of this is being accomplished for less money and with a more stable budgeting process. "We can provide for indigent care without running a county hospital," says County Executive Tom Ament. "We can provide it in a better way. And we can provide it in a more cost-effective way."

Milwaukee's been fortunate in that the county was able to convince the area's private hospitals and clinics that all health providers, not just the county, were responsible for the safety net. All 10 of the area's private hospitals and 15 neighborhood clinics have signed contracts with the county to treat the medically indigent. The burden doesn't come cheap. The hospitals especially have had to suck up big financial losses to make it work. "When Doyne was there, it was easy for other hospitals to say that the uninsured and underinsured were Doyne's problem," says county Health Director Paula Lucey, who also worked as a nurse at Doyne for 20 years. "Now, taking care of the poor is everybody's problem."

It's also still Milwaukee County's responsibility, with this difference: Instead of acting as a provider of health care through Doyne, it is now a purchaser of health care through the private and non-profit hospitals and clinics. The county took the $37 million a year in local, state and federal money that it had used to pay for indigent care at Doyne and put it into a program called GAMP, which is short for General Assistance Medical Program. GAMP covers many of the people who used to go to Doyne--people who are actively seeking care. Under GAMP, however, Milwaukee residents who might otherwise have gone to Doyne can now go to dozens of hospitals and clinics. Like Medicaid, GAMP pays those hospitals and clinics a fee for seeing patients.

So far, GAMP has been successful because the many providers who participate have been willing to cooperate with one another and the program. But even as the first few years of the new approach go smoothly, gaps and glitches are surfacing.

Some are transitional issues. GAMP patients have to unlearn 135 years of going to Doyne's emergency room whenever a health problem surfaces. Not surprisingly, many have trouble navigating the complex network of clinics, physicians and hospitals. To be sure, many patients have figured it out and are medically much better off with the new system of clinics. A good number are still confused, however, and that can become dangerous if people put off getting treatment because they don't know how to enter the system. "A lot of people just don't know where to start," says Sharon Wright, who heads three clinics in a neighborhood north of downtown. Since Doyne closed, Wright says, more people are coming to her clinics in advanced stages of cancer and AIDS. "They're waiting longer to go, where they wouldn't have before."

In addition, the uninsured remain a huge problem: GAMP covers only 20,000 of Milwaukee's 120,000 uninsured, and for many people--mostly the working poor--access to health care is a case-by-case struggle.

There are also serious gaps in care, particularly a lack of dental care, of urgent care and of specialists willing to see GAMP patients. The biggest concern, however, is the county's commitment to indigent care over the long haul. Many of the current players in Milwaukee are the same people who guided Doyne's closure and carefully monitored the transition. They won't be around forever. "This system relies on a lot of people doing the right thing," says Len Wilk, administrator of Sinai Samaritan Medical Center. "A change in those people could make a big change in that commitment."

Sinai Samaritan is the closest hospital to downtown Milwaukee. It sits where a new convention center and the classical county courthouse give way to a down-at-the-heels neighborhood--a community where Pabst Beer workers lived before the nearby brewery closed. Today, streetlights within the neighborhood are adorned with colorful banners that say, "The Right Care, Right in the Community." They are advertisements for the hospital, but the message mirrors Milwaukee County's GAMP philosophy. No longer do the poor and uninsured have to drag themselves out to the county hospital in the suburbs. Now, they can get health care right in their own neighborhood at a local clinic or hospital.

In the communities surrounding Sinai Samaritan, the locals are taking those banners at their word. Since Doyne Hospital closed, many of them have turned to Sinai. Some have GAMP; many do not. Either way, this new caseload represents a significant drain on the hospital's bottom line. The year before Doyne closed, Sinai Samaritan wrote off $7.8 million in "uncompensated care" in the form of charity care and bills that patients were unable to pay. By 1999 that figure jumped to $19.3 million. Sinai Samaritan was hit hard because of its central location, but other Milwaukee hospitals are also eating bigger losses on uncompensated care.

Why would private hospitals agree to take on this burden? One answer is that all of them are nonprofits and think of themselves as civic- minded. But it's also a matter of self-interest. Without a public hospital, poor people will show up sick on the private hospitals' doorsteps no matter what. If GAMP didn't exist, many of those people would only show up sicker and with no coverage at all to pay for care. GAMP payments are modest and don't cover all costs, but at least they're something. "Hospitals are losing money on GAMP, but not as much as they'd lose without it," says Bill Bazan, the Milwaukee-area vice president of the Wisconsin Health and Hospital Association.

Of course, in a system that emphasizes primary care, it is the neighborhood clinics, not the hospitals, that are really on the front lines. GAMP's funding philosophy is to take care of the clinics first, figuring that hospitals have the resources to take care of themselves. The 15 GAMP clinics come in all shapes and sizes. A few are large federally funded operations that see thousands of GAMP patients. Others are small outfits tucked away in homeless shelters; one is located in a grocery store. Some clinics have multi-lingual staff to serve Milwaukee's growing number of Latino, Hmong and Russian immigrants. Milwaukee also has a handful of free clinics outside the GAMP system that heed Doyne's mission of taking all comers, regardless of their ability to pay.

Since Doyne closed, nearly all of the clinics have seen their caseloads increase. That's a good thing. It means that some people whose main contact with doctors was previously at Doyne's emergency room are now getting day-to-day care in a more appropriate and inexpensive setting--and one that's more convenient to them. Just getting a prescription filled used to mean a long bus ride to Doyne. Now, neighborhood pharmacies such as Wallgreens do the job. "We have maintained access while maintaining the quality," says Paula Lucey. "Patients now have many more choices in terms of how to access care."

The Madison Street Clinic on Milwaukee's south side demonstrates one channel into the system. Madison Street is a free clinic housed in an old library. It is not a GAMP clinic, but homeless people and undocumented immigrants are drawn to Madison Street by a food bank run out of the clinic's basement. During meal hours, doctors wear stethoscopes around their necks as an advertisement for the free health services upstairs. As new patients come in, their financial situations are assessed. About half are found to be eligible for GAMP, Medicaid or some other program. Those patients are then handed off to GAMP clinics that can handle their long-term health needs. "Access has improved a lot," says Steve Ohly, clinic director at Madison Street. "What I love about GAMP is that it helps us to find people a health care home."

From the county's perspective, GAMP isn't cheap, but it's a bargain compared with the constant drain of running a hospital. Doyne's budget rose steadily in its final years, and that doesn't include annual bailouts that ran as high as $15 million a year. Moreover, Doyne's physical plant, parts of which had not been updated since the 1920s, was due for $50 million worth of maintenance.

GAMP, on the other hand, has been funded steadily at the same level for all five years since Doyne closed. The county even managed to slightly reduce its share of that expense by squeezing a little more out of the feds. "The county's support of the hospital was about the same as it is for GAMP," Lucey says. "But the kicker was those deficits. We were always in surprise mode. GAMP has created tremendous stability for the county."

Doyne's closing left pieces of health care infrastructure missing, some of which GAMP is helping to put in place, but others that it can't.

Dental care is one of those gaps. Doyne had several dental chairs for indigent dental care, although as a practical matter, people usually only went there to have teeth pulled. In a similar vein, GAMP will pay for extractions, but no other dental care.

That doesn't help GAMP patients with day-to-day needs for dental care. One effort to bring service to the poor is the Madre Angela dental clinic. It's a free clinic that sits in a storefront on 16th Street, the main drag through a largely Mexican neighborhood on the south side of Milwaukee. In the basement, children play on the drab brown carpet while their parents lie in a row of six dental chairs. The open mouths are as visible to passersby as they are to the dental hygiene students doing cleanings. One patient has only half his teeth left.

The basement dental clinic opened in February 2000 with financial support from four area hospitals, churches and foundation grants. It handles some dental emergencies, but half of the 1,600 patients it saw in the first year came in for cleanings and fillings--the type of care that is meant to save teeth and prevent emergencies. The clinic relies heavily on the services of volunteer dentists, residents and students. It opened with hand-me-down equipment.

Madre Angela is free to all, and while it sees people on GAMP, it operates outside of the county's system. That was a deliberate choice by its founders, not because they don't like GAMP but because they'd rather fix teeth than worry about how to bill for it. Recognizing the critical need for dental services, however, the county found a way to support the clinic's mission in an alternative way. It funneled $50,000 worth of a federal grant to the clinic to buy new chairs and carts, a sterilizer, a compressor and x-ray developer. "It was a godsend that we were able to purchase this equipment," says clinic coordinator Isaam Lutfiyya.

Dental care isn't the only missing piece in post-Doyne Milwaukee. There is a severe lack of urgent care facilities. For a patient with a sinus infection, for example, there aren't many suitable places to go. It's not an emergency worthy of a hospital's care. Yet such an infection can cause enough pain that a person shouldn't have to wait a week for an appointment at a clinic to get care. Moreover, many clinics keep irregular hours, making 24-hour emergency rooms a more convenient, if more expensive, place to receive care.

Gaps are also forming in the networks of specialists available to GAMP patients. To be part of GAMP, clinics were asked to form links with specialists who would agree to take GAMP patients on referral. But many specialists have grown frustrated with the paperwork involved and simply dropped out of the program. The family care clinic at St. Michael Hospital, for example, sees only 50 GAMP patients, but about half require specialist care. "We always tried to use St. Michael's physicians because we were confident they would provide good care," says clinic director Sandy Olsen. "But there really isn't anyone here, especially orthopedic surgeons and allergists, who are willing to take GAMP."

Ultimately, the greatest indigent care challenge in Milwaukee, as it is everywhere, is coming up with the money to fund it. By doing away with the hospital itself, the county also did away with many of the interest groups that support care for the poor. In the old days, Doyne's majestic building embodied the safety net itself, along with the ethic of 2,000 doctors, nurses and staff who worked there. All that is now replaced by the mere will of a slew of private and public players, each with its own agenda, finances and politics. "It's a delicate balance," says Bill Petasnick, president and CEO of Froedtert Memorial Lutheran Hospital, Doyne's neighbor and the hospital that was enlisted to act as the public hospital for two years after Doyne closed down. "It only works if everyone cooperates. If any one player pulls out and assumes that the others will keep it going, this thing comes unglued."

A continuing debate surrounds the constant tug and pull over scarce resources. Should coverage be expanded to more people? After all, GAMP can only afford to cover one-sixth of the county's uninsured population; those who earn a few pennies over minimum wage are on their own. Should clinics and hospitals be paid more for doing their part? Nearly every player connected with GAMP wishes there were more money to go around. What they all fear is that they'll get stuck with less.

Meanwhile, with the economy slowing down, financial storm clouds are forming for GAMP. Milwaukee County faces a $50 million budget deficit next year as tax revenues fall. Politicians looking for budget cuts may put indigent care on the chopping block--which is itself a change from the days of Doyne. In the past, squeezing money out of indigent care meant cuts at the hospital and a likely battle with 2,000 unionized employees. Now that the county buys indigent care like a commodity, however, health care represents little more than a line item in the budget. The task of cutting back may now be simpler. "I'm nervous about next year," says Karen Ordinans, the county board chairman and a GAMP supporter. "There are supervisors who would cut funds out of GAMP tomorrow and spend it on roads, parks and the sheriff instead."

That outcome would only confirm all the worst fears about closing Doyne in the first place. It would also undermine the lesson Milwaukee's example has to offer--that the responsibility for indigent health care doesn't go away when the public hospital does. Doctors, politicians and bureaucrats can indeed come together to hold the safety net in place. But no one of those players can bail out on the others. The real problem with closing a public hospital is that memory tends to fade. Recollections of extinct public hospitals such as Doyne are already growing fuzzy. The question is whether localities will continue the mission that guided those hospitals for so many years and find new ways to carry on that tradition.

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