Patient Flow Enewsletter
Volume 1, Issue 2
Tuesday, January 10, 2004
Grady Memorial Hospital, one of the nation's oldest and best-known public hospitals, announced last month that it would cut about 300 jobs in order to reduce 2004 costs by $11 million. The hospital is part of Grady Health System, serving the 1.3 million residents of Fulton and DeKalb counties, and is a major affiliate of the Emory and Morehouse Schools of Medicine. It is the sole public hospital for the metropolitan Atlanta area and provides indigent and trauma care across the metro region.
Over the last two years, Grady has recorded losses of more than $60 million. Like many safety net hospitals, officials say Grady's finances have been the victim of shrinking federal funds and increased patient demand, many of whom have neither health insurance nor the ability to pay for their care. To compensate, Grady officials recently announced that the hospital would no longer provide free care to uninsured non-trauma and non-emergency patients who live outside of Fulton and DeKalb counties.
As an Urgent Matters grantee, Grady is the focus of a soon-to-be-completed comprehensive site assessment that is looking at the state of Atlanta's safety net. Urgent Matters interviewed former Surgeon General David Satcher, MD, now the director of the National Center for Primary Care at the Morehouse School of Medicine. Dr. Satcher shared his thoughts on how Grady's financial situation affects the local safety net, what needs to be done to ensure greater access to primary care services and how relationships among various community partners can be enhanced.
Interview: David Satcher, MD
Q. What health care challenges face the greater Atlanta area at this time?
A. Atlanta has great resources in terms of doctors, nurses, hospitals and technology, but unfortunately not all of our citizens benefit equally from them. The poor and the uninsured have less access and worse health outcomes, and we have racial and ethnic disparities experienced by our large African-American population and our rapidly growing Hispanic and Asian communities. Our health care system also under-emphasizes primary care and prevention. What we need is a balanced health care system.
Q. What is your assessment of Grady's decision to stop providing free care to uninsured non-trauma and non-emergency patients who live outside of Fulton and DeKalb counties?
A. The Grady Health System has a long tradition of serving our area's neediest patients. But the pool of uninsured people is growing - and health care costs are rising - and financial support for Grady has not kept pace. A growing number of patients are coming from suburban counties that have not built their own health safety net infrastructure to support growing populations. It's a tough position, forcing Grady to make tough decisions. Hopefully these challenges will bring leaders from throughout the metro area, from the county and state levels, together to come up with workable solutions.
Q. What can Grady's new leadership do to still provide a much-needed safety net while ensuring long-term solvency?
A. As I've said, we need a balanced health care system for our community. In other words, we need a strong public health infrastructure, lifestyle changes to achieve health promotion and disease prevention, a cohesive primary care safety net and a seamless continuum of care - including access to mental health services, medical specialty care and the kind of highly specialized tertiary hospital care that Grady is famous for. But if we try to build a system by creating a silo for public health, and a silo for community-based primary care, and a silo for mental health and a silo for hospital-based tertiary care, we will have built an expensive system which still lets too many patients fall through the cracks and which the taxpayers can't afford.
Q. In a city such as Atlanta, where adequate primary care services are available through the safety net, why are so many non-emergent cases still ending up in the emergency department?
A. Availability is only one aspect of access to care, along with factors like location, hours, culture, language and customer service. If your child has an earache and a fever at four o'clock in the afternoon, it may not be a medical emergency, but it's not likely that you'll be able to see a primary care provider that same day, or even the next day - especially if you use a busy safety net practice that cares mostly for uninsured patients. The emergency department is the only health care setting in this country that is legally required to evaluate all patients who present for care, regardless of ability to pay. That's why it's so important to develop effective communications and referral relationships between emergency departments and primary care clinics, and to help each person to find a primary care home that is accessible and culturally appropriate.
Q. You talk about helping people find their 'primary care home' - what do we need to do to better to educate people about what safety net services are already available to them?
A. I think the first step is to involve patients and communities in defining the services needed and managing those services. This is a great strength of the community health center movement, represented here in Atlanta by centers like Southside and West End and Oakhurst and St. Joseph's Mercy Care, because their governing boards are built around consumer-majority control. But we also have to respond to the changing needs of a changing population, so we see more new centers emerging like La Clinica de la Mama. Then we need to make sure that it's easy to find out about services at these centers by having information available throughout the community, at libraries and churches and schools and so on. Finally, we need to make sure that when patients do visit an emergency department, that there is an effective referral relationship in place that ensures a quick follow-up visit with a primary care home in the patient's own neighborhood with a culturally and linguistically appropriate provider.
Q. But in communities like Atlanta, which does not have a strong history of collaboration among safety net providers, how can feelings of mistrust among providers be overcome so that patients have increased access to needed services?
A. We have a good working relationship with all of these providers, and know that each of them shares a deep commitment to serving Atlanta's vulnerable populations. What we do not have yet - and something we are encouraging - is a more systematic and cohesive form of collaboration, or what we've referred to as a seamless continuum of care, starting with simple things like structured referral mechanisms between the Grady emergency department and the neighborhood community health centers, as well as ways for the Community Health Clinics to refer patients back into Grady's sub-specialty clinics without the patient becoming disconnected from their primary care home. These are all very do-able first steps that would improve care and also build trust for higher-level integration of care in the future.
Q. How do you see the role of the Urgent Matters project in helping to shore up Atlanta's health care safety net?
A. The Robert Wood Johnson Foundation is doing a great thing by focusing attention on the emergency department as "the safety net for the safety net" and promoting a cohesive primary care safety net and a seamless continuum of care for all patients, regardless of culture, language or ability to pay. That's really the key to unburdening our overcrowded emergency departments, and making sure that we prevent as many emergencies as we can, treat as many conditions as we can in the primary care home, and then use the emergency department appropriately to do the important work for which it was designed.
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David Satcher, M.D.
Director, National Center for Primary Care
Morehouse School of Medicine
Atlanta, GA
