Cook County Hospital plan: One step toward better health care?
Late last year, Cook County Board President George Dunne moved to do something about Cook County Hospital. The county health care system for the indigent, like the county jail, has been a political football for years. The numbers of medically uninsured in the city have increased, hospitals have ceased taking charity cases, and waiting times in Cook County Hospital's emergency room have come to last eight hours or more. Meanwhile, politicians and blue ribbon committees kicked around ideas for more than five years with no action.
Mandated by state statute to provide health care to Chicago's poor and faced with an aging hospital complex, the Cook County Board until late last year was fixated on the decision of whether to build or not to build. Lay and professional health care reformers, Dunne's political adversaries, the state of Illinois and the local press were opposed to a new building. In late November, Dunne secretly began negotiating a plan proposed by health policy groups two years ago: leasing the University of Illinois hospital, which is one block from the existing hospital, and acquiring bankrupt Provident Hospital on the city's south side.
Health care for the indigent which includes the uninsured who soon grow indigent if they need hospitalization in Illinois' largest city has fallen primarily to the Cook County taxpayers, due to a 19th century public health statute that has remained on the books impervious to changing needs and new public health concepts around the country. Administration of those funds is in the hands of the county's elected Board of Commissioners, itself controlled by one man, George Dunne.
Cook County Hospital is the county's largest single expenditure. Its facilities, including three beaux arts-style buildings, were constructed between 1915 and 1930, served 645,000 patients last year. In 1986, Cook County Hospital spent more than $700 per bed per day and $1,500 per intensive care bed per day.
Recently the University of Illinois' Health and Medicine Policy Research Group has studied the public health systems in such cities as Boston, New York and Milwaukee, and it reports that Chicago's system does not even bear comparison to the behemoth New York system nor to a smaller one like Milwaukee's. "In Milwaukee, it almost made us weep to see how far ahead they are," said Dr. Quentin D. Young, director of the research group and a former director of Cook County Hospital.
The pending merger between the UI and Cook County hospitals and the Provident Hospital takeover plan are sound steps in the right direction, according to reformers, but that solves the facilities problem while ignoring systemic issues. The public health care system is moving into the 21st century with almost
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no integration of county, city and state efforts, and little focus on the communities it is supposed to serve.
The face of human suffering is easily obscured behind the smoke and mirrors of negotiations, political stonewalling and status wars within the medical profession. At bottom, the wrangling is over who will take care of Chicago's and Cook County's medically uninsured estimated in 1987 to number 700,000.
For once, local officials and reformers are in accord on the hospital plan. It makes fiscal sense for all concerned. The county would pay $1 a year to lease the 500-bed UI hospital. The county would buy Dunne hopes for only $1 the 300-bed Provident from the federal government's Housing and Urban Development Department. "It's a win-win-win situation," said Dr. Young, one of a number of reformers who have backed a merger idea for years.
The UI lease deal is fairly assured although by the end of February, the county board had not yet seen a proposal on which to cast a vote, and the UI board of trustees had only approved the merger "in principle." As long as Dunne and representatives of Gov. James R. Thompson's office stay in agreement, it is likely the merger will be rubber stamped by the county and UI boards with the details approved by the state legislature.
The deal is a good one for the university because its hospital has been losing money and faculty, but some fear an administrative nightmare and loss of jobs. Some UI physicians have been treating indigent patients at Cook County Hospital since 1987 when the university, in rewriting its mission statement, diminished its committment to the indigent. But doctors and staff at both hospitals are troubled at the speed with which officials
About 9,000 jobs are involved at both hospitals 6,500 of them at Cook County. Hospital Director Hansen and Board President Dunne have issued assurances that employment will not be affected, but no one doubts that jobs will be erased somewhere along the line. Hansen said at a recent meeting with employees of both hospitals that by 1990 he wants an "employment force" of 8,000, which Hansen said he wants to reach by attrition not "pink slips." If the county doesn't get Provident, Hansen conceded that "all bets are off" on firings.
Provident's fate is now in the hands of a federal judge, who has set no timetable on ruling. Provident is the city's first black-owned and operated hospital. It went bankrupt due to unpaid Medicaid bills and soaring overhead costs, combined with underuse (100 of 300 beds were occupied). It now owes $40 million all but $6 million to the federal government.
Complicating matters is the addition of a fourth hospital into the equation. The UI plans to affiliate its hospital with the for-profit, south side-based Michael Reese Hospital, which is breaking off its 20-year-old affiliation with the University of Chicago medical school. The new UI/Reese affiliation, to be completed by 1990, allows the UI medical school to keep its teaching purposes alive.
One of the primary concerns of UI doctors and staff is that indigent patients will no longer be treated under its affiliation with Reese. In an acrimonious, late January public forum UI medical school dean, Dr. Philip M. Forman, and Michael Reese Hospital president, Dr. Henry Nadler, were pressed to respond to this concern. A questioner suggested that Reese might turn away indigent patients and patients with AIDS, and Nadler responded that patients from UI Hospital with "unusual problems" would be most likely to be admitted to Reese, and he expressed hope that a newly opened Provident Hospital would take some indigent patients on the south side.
Health care for the indigent has a price tag. Medicaid is the federal-state program that has been established to help pay for the health care for the needy, aged, blind and diasabled and for low-income families with children. Each state determines eligibility and which health services are covered and reimburses hospitals, among others, for health services provided to eligible patients. The federal government reimburses a percentage of the state's expenditures. Illinois takes it a step further with hospitals, negotiating ahead of time for the number of patient days alloted each year.
Last year, according to the Illinois Department of Public Aid, Cook County Hospital received $50.5 million in Medicaid, UI Hospital received $23.8 million and Reese received $21.6 million. Hansen said that if the merger with UI is completed, he will renegotiate the county's Medicaid contract to receive more money. Nadler added that Reese does not plan to negotiate for more Medicaid from the state.
But more Medicaid to the county won't solve everything. Fewer and fewer charitable medical institutions exist in Chicago. Ironically, Reese, which is now derided as a profit-making monster by advocates for indigent patients, began as a charitable institution. But hospital charity is going the way of hospitals in general out of business. In the 18 months leading to March 1988, 10 community and rural hospitals closed in the state of Illinois. Ten years ago, there was still a system of charitable hospitals within the city of Chicago. Those hospitals, while they have not closed, simply stopped taking new poor patients. Thus, the burden has fallen ever more heavily on the county.
Dr. Young laments the loss of charitable health care and is a chief critic of what he calls the "marketplace solution" to
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health care. "The marketplace has destroyed the charitable impulse which was the heartsblood of medicine 100 years ago," Young said. "Half of the ambulatory care was delivered by charitably motivated organizations in Chicago as recently as a decade ago. We are training in the medical schools today that it is okay to do a wallet biopsy before deciding further care. Years ago, you only talked like that in a medical school if you wanted to get censured or kicked out."
George Dunne seems to long for a "kinder, gentler" health care system that would take the growing financial burden off the County Board and the county's taxpayers. "Well, we may very well be moving into some kind of universal health care," Dunne said. But such proposals as the national health tax recently recommended by a federal commission to President Bush, will no doubt take years of debate.
Meawhile, the modernization of the public health care system in Chicago and Cook County will require concerted action by the city, county and state. There is now almost a complete lack of coordination by those governments on public health care. "The state of Illinois has enormous unmet responsibility" in the governance of Chicago's public health care system, said the UI's Young. "We are cursed with these Chinese walls between the state, the county and the city. Each fiefdom holds things tight to itself with no communication. We need an integrated system. Something needs to be brought together because there is a huge amount of money involved."
Cook County Hospital has undergone several different methods of governance. Prior to 1969, the County Board was responsible for its administration, and under the able and lengthy tenure of Dr. Karl A. Meyer between 1914 and 1967 there was general stability. In 1969, the Health and Hospitals Governing
Reformers have suggested that the hospital would be better administered by a board of health experts instead of politicians, in the style of the Regional Transportation Authority. They cite the examples of other cities, such as New York, which has 11 public hospitals to Chicago's one, and Milwaukee, where, said one amazed policy researcher, the board president overseeing the hospital could actually speak with competence to public health experts about public health issues, an ability he says is lacking in Cook County Hospital's political overseers. Such a health authority would coordinate health care to the indigent provided via the county, the city and the state governments.
Besides pushing for a new hospital governing authority, many health policy groups have argued for years that the county's health care system is incorrectly focused. They want the county to build a system of community-based, walk-in, outpatient clinics, and focus on "ambulatory" health care. Spending huge sums of public money on centralized, in-patient care is not rational, they say, because many costly, chronic health problems that result in hospitalization might be prevented by an early visit to a community clinic. Groups that have recommended a network of clinics include the now-defunct Cook County Health and Hospitals Governing Commission, Hyatt Medical Services Inc., the Metropolitan Planning Council, a governor's task force and the Health and Medicine Policy Research Group at the University of Illinois.
Last year, Cook County Commissioner Charles Bernardini submitted a resolution to the county board proposing a feasibility study of a county-run network of medical clinics. The resolution was sent to the state's attorney's office for a ruling on its legal ramifications, and after eight months was returned without a ruling. Dunne has not called the proposal for a vote. Critics see political stonewalling in the delay.
The city's health department no model itself of urban progress operates six health clinics, which in 1986 handled 678,000 "major" visits at an average cost of $52 each. The county's three clinics handled visits at a cost below $50 each. (Another dozen non-profit clinics are in operation in the city.)
The major obstacles to any kind of clinic "system" are the Chinese walls again: There is no communication or coordination between clinics, nor between the clinics and the county hospital. Reformers point to the inefficiency of such a system, and they argue that a coordinated clinic system would cost about $100 million far less than Dunne was willing to pay for a new county hospital.
Hopes for an integrated clinic system operated by the county are pie in the sky at the moment. Not only do county officials want no part of it ("The question is what should the mayor's office be doing about it," said County Hospital Director Hansen), the county might not be able to coordinate a clinic system if it had one. Cook County Hospital is notorious in its inability to collect for its services. State officials have said in the past that it neglected to submit medical records with its bills 40 percent of the time, thus making it impossible to get Medicaid reimbursement. A 1986 audit of the hospital found that it was collecting only 70 cents for every $1 it billed.
Dunne and County Hospital Director Hansen pass the responsibility for such clinics to the city. "Neighborhood clinics would require legislation as far as the county is concerned," Dunne said. "Are we supposed to say, 'Okay we will pick up everything.'? Well, that's not my cup of tea. We will pick up what is required of us by law." The feudal system continues.□
Nina Burleigh is a freelance writer living in Chicago.
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