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.