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Thursday, January 16, 2014

Out of the Hospital and Off the Books: Should Harborview’s Primary Care Clinics Be Closed?

Posted by on Thu, Jan 16, 2014 at 1:01 PM

  • Erik Stuhaug/Seattle Municipal Archives

This op-ed guest post is by Scott Barnhart, MD, MPH, Professor of Medicine and Global Health at the University of Washington, who has worked continuously at Harborview for 35 years. He was Harborview’s Medical Director from 1999 to 2008.

Harborview Medical Center officials acknowledged last month they were considering moving or closing the hospital’s primary care clinics.

This would be a very bad idea.

Harborview is a critically important medical care resource for many thousands of people in King County, the state of Washington, and even surrounding states. One of the reasons it works so well is that while Harborview has a regional mission, it is grounded in the immediate communities it serves, which include those patients who often have no other options to access health care. These clinics go far beyond the traditional bounds of primary care, providing essential coordinated, complicated, and unduplicated outpatient care to our community’s most vulnerable patients. Labeling these clinics simply as “Primary Care” is incorrect and doesn’t reflect the mix of services required for good outcomes. The likelihood that equivalent robust services can be provided cost-effectively and sustainably is low. Furthermore, these patients will now be geographically and administratively further from the complex array of specialty services at Harborview upon which they greatly depend. Harborview officials have tried to clarify “misunderstandings” about the closure process by saying they are merely entering a planning process and commitments are firm. Planning is a slippery slope, however. While administrators say they are trying to serve patients closer to “where they live,” scattered and isolated clinics cannot serve the function these clinics are required to fill. For patients and staff, the news of closure was devastating. Any consideration of changes should be prefaced with clear commitments to the patients and the community of providing equal or better care backed up with a sustainable financial plan. This has not been done, and to do less opens a door to subtle intentional or unintentional diminishments of care quality and loss of confidence by patients. This will not serve these complex and often very ill patients well and can lead to clinic failures and de facto divestiture of the responsibility for these priority patients.

Harborview is the epitome of a successful partnership between King County and the University of Washington, and with all successful partnerships, there is a need to be very clear on the respective missions and responsibilities of each party. As health systems aggregate, identities and missions can get lost. This risk exists with Harborview’s tight linkage with UW Medicine. Many people may have lost sight of the critical fact of who owns Harborview. It is a public institution, paid for by levies, owned by the people of King County, and is operated under a long term management contract with the UW. The Council appoints a 13-member board who are stewards of the mission and oversee the relationship with the UW. This arrangement has successfully weathered many challenges dating back to the 1960s, when the hospital was at risk for closure had not the partnership been forged.

Harborview’s mission speaks very specifically to providing priority care for patients who are in serious medical trouble or who live at society’s margin—the incarcerated, the mentally ill, substance users, people with sexually transmitted diseases, indigents, non-English speaking poor, victims of violence, and those who have suffered burns or trauma. Speaking frankly, these are patients who other providers have consciously chosen to not serve and thus have no other options. Decisions to close these clinics will have adverse consequences for these patients as they lack alternatives...

...This is why they are included as “priority patients.” Harborview cannot fulfill its mission by closing or moving its primary care clinics to the suburbs. These options have been explored before, and recreating the same or better mix of services has not proved to be fiscally or strategically advisable. This is why many of Harborview’s clinical providers met with the precipitous announcements with surprise. UW Medicine’s mission is similar to Harborview’s with an important distinction—there are no priority populations and clearly no preference to support vulnerable populations. The benefit in the partnership to Harborview is that these priority patients get top-notch care and King County doesn’t provide operating dollars—only construction funds. The benefit to the UW is that Harborview provides a superb site for training, medical research, and clinical service. Less well recognized but of great importance is that Harborview protects the fiscal bottom line of all the other UW and non-UW hospitals by taking in transfer for care a disproportionate share of the un- and under-insured.

In an era of profit-driven health systems, achieving Harborview’s mission is tough. To date, King County, Harborview’s Board, and UW Medicine can be commended for succeeding well in the difficult task of providing equitable services to all. King County tax levies have subsidized building a first-class hospital complex over the years, but the county does not subsidize operating costs. Harborview has survived financially by stitching together a mix of public support from patients on Medicaid and Medicare, while attracting well-insured patients who seek specialty care—this balance between well and less-well insured and a diverse mix of services needs to be preserved. While money is not said to be the issue, Harborview’s fiscal margin is razor thin and on paper in the red. It will be slightly easier to achieve a balance between well-insured and un- and under-insured patients if the primary clinics are closed. UW Medicine, which manages Harborview, is, however, a huge entity (UW Medical Center, Harborview Medical Center, Northwest Hospital, UW Physicians and the UW Clinics) whose total revenues far exceed $2 billion per year. Any short-term savings from closing primary care clinics—perhaps a few million dollars—is miniscule when viewed in context of this enormous revenue stream. For this reason, the differing missions of Harborview and UW Medicine must be critically examined as strategic decisions are implemented.

It’s time for Harborview’s owners, the King County Council, and its appointed board to take stock of what is proposed. This is a strong partnership with neither Harborview nor UW Medicine able to survive without the other. Transparency and open dialogue will strengthen this partnership. King County may want to consider whether the current management contract, conflicting allegiances of staff, all who are employed by UW Medicine, can assure the Council and Board of getting fully independent counsel with respect to the mission and strategic direction of the hospital. Consistent with other government bodies, the Board might also consider opening up board meetings to receive public comment.

Here are some ideas and alternatives to clinic closure. King County should insist on an independent analysis of the finances of UW Medicine’s multiple entities, and the flow of funds between Harborview and UW, including patient fees, state subsidies, and research grant “overhead” dollars. Next, King County should carefully examine alternative organizational models. Is this a time to explore an alliance with Group Health Cooperative—arguably the region’s leader in providing high-quality coordinated managed outpatient care? What about consolidating critical but costly duplicative systems, such as the two electronic medical record systems? Is it time for Harborview to shift fiscal responsibility from Harborview to our neighboring states by ensuring the emergent transfer of uninsured patients from those states to Harborview will include full coverage for medical/surgical costs including costs of long-term care? Each of these suggestions might well save far more than closing some clinics.

Harborview serves as an important teaching hospital for preparing physicians, nurses, and other young professionals who learn to serve vulnerable patients in a high-quality, respectful environment. To move away from this commitment will model to all the staff and trainees that professionalism need not include service to the most vulnerable. Given the increasing recognition of the harm of wealth disparity, this is not a message UW Medicine nor the citizens of King County should want to convey. Harborview has long served as a laboratory for innovation, needed now more than ever. At the dawn of the Affordable Care Act (ACA) this month, there is much uncertainty about how to best organize to serve the thousands of newly insured people in our county. These changes and opportunities will become evident over time, but the rush to make decisions by July 1 is far faster than can be done in a secure fashion for these patients. The ACA may also reverse or greatly mitigate the fiscal loss associated with the care of these patients.

Harborview has earned multiple awards over the years, including the coveted Foster McGraw award in 2007, for its remarkable community service to the very patients whose clinics are now at risk for closure. Whatever motivations or distractions lie behind the recent announcement of plans to divest of on-site primary care, King County Council and Board should look closely at the mission statement. Given the confused mixture of public messages and harm and undermining which comes with uncertain futures, the Council and Board should tangibly re-affirm the mission to care for priority patients. This act would go far to reverse the chilling effect of recent announcements of clinic moves and closure, and will reassure patients, staff, and the community that the overall core values are retained.


Comments (15) RSS

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Gordon Werner 1
I have always found the staff at Harborview to be wonderful, caring, and compassionate.

Posted by Gordon Werner on January 16, 2014 at 1:13 PM · Report this
dnt trust me 2
What's the shorthand for "too long didn't read"


I always appreciate it when people say that to my comments.
Posted by dnt trust me on January 16, 2014 at 1:26 PM · Report this
We need to mount a campaign to save this lifeline!
Posted by Linda J on January 16, 2014 at 1:26 PM · Report this
Sargon Bighorn 4
It took him for ever to get to the point, "In an era of profit-driven health systems, achieving Harborview’s mission is tough."
Posted by Sargon Bighorn on January 16, 2014 at 2:49 PM · Report this
rob! 5
For states like Washington that have agreed to Medicaid expansion under the ACA, hospitals can serve as key points of enrollment. If an uninsured patient is found eligible, hospitals can get paid retroactively for medical treatments going as far back as three months. Has Harborview mounted a comprehensive effort throughout all departments, including clinics, the ER, and specialists, to provide application assistance? If not, why not? If so, I see little reason to disturb the clinics.…
Posted by rob! on January 16, 2014 at 2:50 PM · Report this
This is pretty horrifying. A good friend is alive because of the care he received at Harborview. He wasn't going to a primary clinic, but I agree with the author that they're an important part of Harborview's overall mission.
Posted by LMcGuff on January 16, 2014 at 2:51 PM · Report this
Abe Bergman wrote something in Crosscut, I think, that's a bit shorter.

It's unfortunate that those who usually write academic articles aren't advised to judiciously edit for the general public, which will miss some important stuff because it's tl;dr.
Posted by sarah70 on January 16, 2014 at 3:05 PM · Report this
The writer of this piece is obviously no great literary stylist, but then he's had quite a successful career in a challenging field other than "journalism" (or however the production of content of the Stranger is best described).

So I'll give him a pass on his rather boring, pedestrian, and windy prose.

The content is what matters here, and the writer has the advantage of having a pretty impressive perspective on his topic. He provides some granularity as well as some big picture stuff, not the simplest combination to pull off.

Posted by Functional Atheist on January 16, 2014 at 3:32 PM · Report this
@8, don't get huffy. His perspective, experience, and knowledge are indeed impressive, and (unlike you) I don't think he was being boring, pedestrian, or windy. (Pretty nasty criticism there on your part.) However, he was writing for Slog, which is journalism.
Posted by sarah70 on January 16, 2014 at 5:35 PM · Report this
reverend dr dj riz 12
..thanks dr .Scott Barnhart. i'll pass this around. thanks.
Posted by reverend dr dj riz on January 17, 2014 at 12:36 AM · Report this
Wow slog commenters...all of you are terrible.

Also, apparently little children that can't read. Do us all a favor, don't vote, and move out of the city if you can't handle a short essay on a important topic.
Posted by caltrop_head on January 17, 2014 at 4:31 AM · Report this
Of course, the big give away of Yesler Terrace to land developers and the impact of property values on medical rescue helicopters in their back yard has no impact.

The consideration that with ACA, more of the un-insured will become under-insured and still have some of their care reimbursed is not adequately explained in this well thought and delivered piece.

Closing the "Zoo" seems a non-option to me.
Then again, all other local hospitals lacking a dumping ground might just pry loose some consideration for the greater good of Western Washington Health Care in general.
Posted by Nuclear Marc on January 17, 2014 at 8:55 AM · Report this
Please write to the King County Council and object to this travesty and disaster in the making:;;;;;;;

Posted by Linda J on January 17, 2014 at 5:33 PM · Report this
Seattlebcc 17
Harborview and Medic One pulled me back from death after an anaphylaxis reaction in the middle of downtown and I had insurance. I say keep the clinics open for those without, but that being said, I understand the reality that this isn't just Harborviews issue but a national one brought on by the AMA, Nurses Unions, insurance companies, big pharma and yes, even the patient. The US invests about 1/5 of our overall GDP into healthcare with no pay real sustainable payback. Patients, who for years were under the belief from TV and their own ignorance believe doctors can heal and cure everything, and when they can't, they are sued for big money. Death isn't a reality for most folks, its an option - until the reality sets in. Now enter big pharmaceuticals that for years woo'ed physicians into handing out samples to the patients like candy. Hospitals finally said stop because of the conflict of interest, so what did big pharma do, they went to the TV networks to promote their drugs to the masses who felt that again, your doctor can fix any ailment you have from erectile dysfunction, to insomnia to diabetic nerve pain to depression - but watch out for the little voice of side effects that could kill you. Now enter Government mandated healthcare that isnt any cheaper than regular insurance. This poor and marginalized cant afford it, and medical centers can no longer afford them. Closing clinics tells me something about the industry and the leadership that runs it - the industry has known for decade of spiraling out of control cost and did nothing about it. And now they can no longer afford to run business as usual so guess what, now its time to thin the herd and let the concept of "survival of the fittest" kick in. Don't get me wrong, there are a great many talented, wonderful and caring healthcare professionals across this country who pull a great many hours working in patient care, but they are the front-liners who see these realities everyday and need to speak up en mass against this tragedy of clinic closures But lets face, healthcare today is very much like lawyer and the political theatre. When one is trained for years as a healthcare professional, then one goes back to school for that additional two years of business "theory" to then move on to become a better paid manager than some were ever healthcare providers, one loses their focus on what is important in the philosophy of medicine, to cure and if necessary, care and comfort the sick and dying. Judging by Harborview's consideration, there is a lot of leadership, not only there, but locally and nationally that may believe that is their philosophy, with their professional accolades and kudos to promote this fallacy, but it certainly doesn't show it in reality.
Posted by Seattlebcc on January 21, 2014 at 7:56 AM · Report this
I have been a Harborview nurse for 23 years and worked in one of their clinics for 13, and I couldn't agree more with Dr. Barnhart's analysis. I do think it is important, though, to recognize that part of the problem here is the extraordinarily high overhead involved in operating clinics that are associated with hospitals. Up until recently this has been covered by what are called "facility fees" paid by insurers, including Medicare and Medicaid, but those fees are going away as part of the ACA. And because of this high overhead, Harborview clinics cannot be Federally Qualified Healthcare Centers (FQHC), which means that the higher per-patient reimbursement those centers receive is not available to Harborview clinics.

The real mistake was made years ago, when federal funds were available to move Harborview clinics into neighborhoods and prepare them to become FQHCs. Harborview declined these funds; now they are gone and the medical center is stuck between a rock and and a hard place. There is no money available to replace the facility fees and Harborview Clinics will break the bank without that money to pay for care in hosptial-based clinics.

Nonetheless, we have a mission to fulfill, and we must find the political will to make this possible. Harborview not only saves lives every day, it also saves the community huge amounts of money by making quality primary care available to people who would otherwise defer care until they are very ill and/or seek their care in enormously costly emergency departments. The choice is yours.
Posted by reidob on January 26, 2014 at 2:50 PM · Report this

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