Searching for Middle Ground
By MELANIE KILGORE-HILL
Changes at Nashville General, Meharry Impact Future of Indigent Care
Editor's Note: Decisions regarding Nashville General continue to evolve as stakeholders work their way through a number of issues from providing needed care to adopting a cost efficient, sustainable delivery model to launching a training program for medical students to adequately train the next generation of physicians. As the debate continues, Mayor Megan Barry hit a 'reset' button on the discussion regarding inpatient care at Nashville General on Jan. 11 with the decision postponed until the end of 2018. Mayor Barry's Jan. 11 letter to Metro Council is available here.
In the meantime, Nashville General has extended CEO Joseph Webb's contract through June of 2018 (before Mayor Barry announced pausing decision until end of 2018) with an option to renew for another year. Meharry has held private meetings regarding recommendations about the future of Nashville General, which have drawn criticism for not being open and transparent to all stakeholders. However, Meharry officials have pointed out the medical college is a private entity ... not a government agency ... and is therefore not required to hold meetings in a public forum.
While a lot has happened in the few weeks since Nashville Medical News went to press, the article that appears in the January issue contains important insights and observations from key leaders at the center of the debate.
The recent announcement of a potential end to inpatient services at Nashville General Hospital at Meharry has prompted a flurry of questions regarding the future of medical care for the city's most at-risk population.
In her surprise November announcement, Nashville Mayor Megan Barry cited increased operating costs and decreased inpatient volume as catalysts behind a shift toward outpatient services at the city's safety net hospital. It was a move few saw coming.
Shortly before the Mayor's announcement, Meharry Medical College made headlines with news of a partnership with HCA Healthcare under which Meharry third- and fourth-year students will train at TriStar Southern Hills Medical Center. Although Nashville General has served as the school's training hospital for many years, Meharry President James Hildreth, PhD, MD, said partnership with a new organization has been a long time coming.
"Patient volume is a big factor in the ability to train students to become physicians, and we began working on identifying a new partner a year ago when it became clear that the patient volume at Nashville General wasn't going to turn around quickly," Hildreth said.
The situation at Nashville General has led Meharry officials to develop relationships with affiliate hospitals outside of Tennessee to train students. Hildreth said the college now sends as many as 80 percent of the program's 105 third- and fourth-year students out of Nashville - a trend he hopes to reverse through the new arrangement with HCA.
James Hildreth, PhD, MD
"HCA is one of the most efficient, best run healthcare organizations in the country and, in some ways, is leading many of the changes that will be happening in medicine," Hildreth said. "There's also a long and deep connection between the two organizations." Many Meharry-trained physicians work at HCA hospitals nationwide, and a Meharry alum will oversee the HCA-Meharry training program.
While patient volume was a primary factor in his decision, Hildreth cited additional advantages to a Meharry-HCA partnership. "Having students train in that environment is exciting because students will be exposed to a whole range of clinical specialties under one roof instead of having to hopscotch around the country," Hildreth said. "It will enrich their experience and give them a more realistic idea about which specialties they want to pursue."
Mayor Barry said the partnership would benefit the community, as well. "The great new partnership between Meharry Medical College and HCA TriStar Southern Hills Medical Center has provided the community with an opportunity to rethink how we can best provide healthcare for our most vulnerable populations," she said.
Hildreth knew the decision to partner with HCA would come as a surprise to many, given the sometimes overlooked fact that Meharry actually owns the building where Nashville General Hospital is located. "The reason why so many hospitals are closing their doors is that it's too challenging for a small, free-standing hospital to be successful today," he said. "In a larger context, we own the building but don't have any say over how it's run."
Under the current arrangement, Meharry owns the building and provides physicians, while Nashville General operates under control of hospital administrators and the Hospital Authority of Metropolitan Nashville and Davidson County.
"We really are two separate, autonomous organizations, but one of the things we've tried to do is work with (hospital CEO) Dr. Webb on an integrative delivery model to create seamless care delivery for patients," explained Hildreth.
The care model adopted by Nashville General under Webb's three-year leadership emphasizes preventative services and disease management through a medical home model. After Mayor Barry announced inpatient services at Nashville General would end, Hildreth proposed the idea of Meharry leading the efforts in defining a new model. "This building is ours, and we have a vested interest in caring for the indigent," Hildreth said. "We're taking the lead in deciding a new model for indigent care. We want to emphasize that we're not going anywhere. As long as there's clinical activity in that building, we'll be a part of it."
Hildreth has high hopes for the outpatient model, as 90 percent of patient encounters at Nashville General are currently ambulatory. His goal is to sustain and improve outpatient services for the indigent to reduce the number of emergency room visits among a population that often utilizes the ED for complications from chronic diseases like diabetes and hypertension. As planning continues, Hildreth said it might be possible to offer limited, specialized inpatient services like behavioral health. "There might be some way to leverage the facility to satisfy the most needs," he said. "Those are the kinds of conversations that still need to take place."
Hildreth is now leading a work team of all stakeholders in the situation to make recommendations to the mayor and Metro Council about the best model for indigent care in Nashville moving forward. He also is attentive and sympathetic to the outpouring of emotion from Nashville General supporters. "I don't fault them for being upset because Nashville General has been an icon in this city for a long time," he said. "We intend to fully maintain that spirit and mission."
Nashville General Hospital first opened as City Hospital on April 23, 1890 with one physician, seven nurses and 60 beds. From day one, the hospital's mission was to provide healthcare services to the desperately ill or those persons unable to care for themselves. In 1998, Metropolitan Nashville General Hospital moved from its original site on Hermitage Avenue to the Meharry Medical College campus, blending the two historic medical institutions that shared a single goal.
Mayor Megan Barry
That commitment, Barry said, isn't going away. "Metro looks forward to supporting a model for integrated care that is focused on the needs of patients, addressing current gaps in service and ultimately using our resources in a way that will improve patient outcomes," the mayor said. "I'm grateful to Dr. Hildreth and Meharry Medical College for helping to lead the process of bringing community stakeholders to the table to develop that model."
Still, the patient volume argument used to justify the overhaul concerns Nashville General Chief Executive Officer Joseph Webb, DSc, MSHA, FACHE. "The notion that we have all these empty beds is a misconception," said Webb, noting that the hospital is licensed for 150 beds by the state through a Certificate of Need. Of that total, 114 have been listed as operational.
Joseph Webb, DSc, MSHA, FACHE
"When we look at those 114 beds, we would have to utilize semi-private occupancy - which would increase infection control risks," he said. When you reduce that number to private occupancy and remove bassinets, Nashville General has 86 single occupancy rooms. Webb said the hospital's occupancy rate for 2017 was 58 percent, just a fraction below the national average of 61 percent.
Apparently, those numbers don't add up for city officials. "Over the years, the number of Nashvillians being served through the inpatient hospital at Nashville General has declined by half, with less than 30 patients a day in October of this year, while the hospital has required more and more dollars every year from taxpayers," Barry said.
In the absence of inpatient services, Webb's primary concern is the long-term care of those who do require inpatient care. "There are a number of hospitals across the city, so once inpatient services are no longer offered how do you maintain quality healthcare?" questioned Webb, noting Nashville General's 32,000 emergency department visits annually.
Webb said the chronic disease care model implemented under his watch has led to statistically significant improvements in patients with diabetes and hypertension. "Rather than dismantling that, you should be duplicating it," said Webb, stressing the difficulty of continuing the current model in an outpatient only setting.
"You start to create fragmentation in care delivery when you disrupt the transition of care," he said. "It's similar to an ecosystem because you have an emergency department for difficult-to-manage patients in crisis or those without a primary care provider. The most expensive level of care is crisis, but once you stabilize patients and put them in inpatient care, your patient isn't going somewhere else. The outpatient function doesn't work as well because you no longer have that resource to stabilize the patient, and he's no longer embedded in your integrative delivery system. Once you disrupt that in this difficult-to-manage population, you lose a coordinated method of care."
Webb said metrics being used to measure outcomes for this population have shown statistical improvement since interventions went into place. "If you're in healthcare and have researched any of these areas, you can appreciate a model that will deliver outcomes in the midst of an environment where you have the worst possible health outcomes in the nation," he said.
"We're showing that through proper modeling, you can improve outcomes with statistical significance, which indicates that it is not by chance," he continued. "You don't change a model generating those kinds of outcomes, although a funding model might need to change."
Funding a safety net hospital is no easy task, and Webb said it's unrealistic to expect an indigent care hospital to maintain a 75-day supply of cash. He believes that misperception is being used to fuel the removal of inpatient services for the poor in a city recognized as the apex of healthcare in the United States. "Nashville has an $84 billion healthcare industry, and we're ready to disrupt the one system that seems to be working for indigent care in search of a better one," Webb said. "Right now there seems to be a lot of question marks."
Just where will Nashville's indigent receive inpatient care? That question represents the biggest question mark yet, with no firm answers.
"If we can refocus the work at Nashville General toward meeting the demand for its ambulatory clinic care services, while also creating an indigent healthcare fund to ensure the handful of new patients needing inpatient care can get it at other hospitals, then we'll allocate our limited resources more effectively toward the best healthcare outcomes," Barry said.
According to the mayor, 90 percent of indigent healthcare in Nashville is provided at other hospitals. However, Webb said patients routinely get transferred to Nashville General from hospitals whose missions don't include indigent care.
"If you do get those hospitals to switch missions, their margins will be impacted, and a private system isn't likely to change their mission just to care for an indigent population," Webb said. "I'm curious to see if those individuals are going to receive free care or if some funding will be provided to care for them. And if they get funded ... how will you fund them in multiple hospitals, and why would you when you could fund them in one place and get the outcomes you're getting now? Economically and from a pure health outcomes standpoint, we need to look at this for what it is and ask what's the most economically feasible and patient-centered way of addressing healthcare in Nashville."
Those questions and many more are sure to be on the table in the coming months as stakeholders look at the best way forward for patients, providers and the community.