Meeting with Health Commissioner underscores need for physician leadership
Physicians Organizing Committee’s (POC) membership of doctors and other healthcare workers are continuing to advocate for a new St. Luke’s Hospital in San Francisco that will include a full complement of high quality, accessible services for the 370,000 people who live in the predominantly lower-income, culturally diverse working class neighborhoods south of Market Street.
Founding organizer Geoffrey wilson reviews POC’s next steps in the fight to maintain St.Luke Hospital with POC Organizing Committee Member Micheal Treece, M.D., a pediatrician who has been serving the St. Luke’s community for 15 years. [/caption]“We have a document detailing exactly what services this hospital provided in the year 2000 based on over 130 years of service to the community,” said St. Luke’s pediatrician Michael Treece, M.D., who has done public speaking, circulated petitions, held individual and group meetings and testified at public hearings to save St. Luke’s from closure by Sutter Health’s San Francisco subsidiary, California Pacific Medical Center (CPMC). “The current plans to replace this hospital with one that’s a third of its current size do not reflect community need.”
Treece and a dozen other POC members have pursued the San Francisco Health Commission, the SF Planning Commission and the SF Board of Supervisors to advocate for the health needs of the community served by St. Luke’s. They have yet to find a responsible governing body with the willingness or ability to respond to those needs.
According to POC member George Wu, M.D. “In the case of St. Luke’s, an entire hospital was on the chopping block until an organized community, doctors included, instilled the political will in our public officials to challenge CPMC’s plans to shut St. Luke’s down and replace it with an outpatient clinic. Meanwhile they’re projecting to build a 555-bed hospital on Cathedral Hill north of Market Street, where the majority of the City’s hospitals already exist. They begrudgingly agreed to replace our 229 bed, 12 story hospital with an 80 bed, 6 story hospital, claiming that was all that was needed. This was after gutting the hospital of psychiatry, pediatrics, neonatal care, occupational medicine and other key services and diverting many of the privately insured patients to their other four hospitals such that 90% of our patients are either on Medi-Cal or Medicare.”
Critics of CPMC’s Institutional Master Plan, which involves replacing two of their current hospitals with new ones, and making significant service changes at their other two hospitals in San Francisco, say the plans bear little relationship to patient demographics or community need. Bob Prentice, former director of the public health division of the San Francisco Department of Public Health (SFDPH) said CPMC was only keeping St. Luke’s alive to placate opponents of its citywide development plans.
Master plan, major problems
“Anybody who believes that they’re seriously investing in this hospital for any purpose other than to gain the political support that they need to get Cathedral Hill Hospital is delusional,” said Mr. Prentice, the director of the Bay Area Regional Health Inequities Initiative (BARHII), a collaboration of public health directors, health officers, and staff from ten northern California counties and the City of Berkeley. BARHII wants CPMC to invest equitably in Cathedral Hill and St. Luke’s.
Throughout the City’s hearings evaluating CPMC’s Institutional Master Plan, several POC speakers and allies in the community criticized the absence of an overall city health needs assessment to use as criteria for what is required and how this left the City reacting to CPMC’s plans to increase their market share instead of being able to enforce the health needs of the local population.
The poverty of legislative solutions
District 9 Supervisor David Campos, whose district includes St. Luke’s Hospital, took the lead in November of 2010 in championing legislation to create a citywide health services master plan for the first time in 30 years, but he capitulated at the last minute and exempted Sutter’s extensive $2.3 billion Institutional Master Plan from having to comply with the City’s needs assessment. “In effect, this means there will be no change in the status quo,” said POC Operations Manager Brian Tseng. “Sutter’s plans to drastically change the healthcare landscape in San Francisco trump the overall needs of the patients they serve. Sutter has been authorized to ignore the needs assessment and proceed with their Plan.”
According to POC Membership Coordinator Shane Kangas, several of POC’s members look forward to providing their input in an effort to make the City’s healthcare master plan the best model possible which will mandate an equitable distribution of services to meet the needs of all the residents of the city. “But at the same time they’ve seen Prop Q ignored, the Bielensen Act hearings eviscerated and the refusal of the State Attorney General’s office to enforce their own orders to keep the 32-Bed Inpatient Psychiatric Unit open at St. Luke’s. They understand that legislation is no substitute for organizing,” said Kangas.
San Francisco’s Proposition Q, passed in 1988 with a promise to mitigate the closure of vital services in the private sector, has been criticized by healthcare advocates for lacking any enforceability, as has the Bielensen Act, a state law mandating counties provide similar notice as to the consequences of their own projected elimination of public health services. (See sidebars on Proposition Q and the Bielensen Act)
“Perhaps this will be a tool going forward,” noted POC member John Rouse, M.D. an attending psychiatrist at SF General Hospital’s Psychiatric Emergency Services (PES) unit. “But not without first organizing a medical consensus in conjunction with nurses and others for what patient care services are needed both in the hospitals and the community-based outpatient clinics. We also need an organized grouping that is willing to advocate — especially for patients without the money or political clout to get their needs considered.”
Persistent advocacy pays off
Treece and other POC members who had testified in front of multiple venues about St. Luke’s got their first indication that their persistent testimony was starting to sink in when, at the conclusion of their June 2009 hearing on CPMC’s Institutional Master Plan, SF Health Commissioners Ed Chow, M.D. and James M. Illig called for “enforceable commitments” to be imposed upon Sutter’s request to build a new 555-bed hospital on Cathedral Hill at Van Ness Avenue and Geary Street while drastically downsizing St. Luke’s.
Illig, as President of the Commission, stated that he wanted the Health Commission’s findings to act as a “Medical Environmental Impact Report” and echoed the concerns George Wu, M.D. Rishi Kapila, M.D. and other POC members had raised at several hearings, including, “the lack of psychiatric beds, skilled nursing beds, and CPMC’s overall failure to meet their charity care commitments.”
At the same meeting Commissioner Chow, as Vice President, called for a resolution or “white paper” to be forwarded to the City’s Planning Commission, calling on them to evaluate several key points before granting building permits, including CPMC’s inadequate charity care contribution to San Francisco and the impact of their projections to further reduce inpatient psychiatric services.
How to enforce “enforceable” demands
On July 30, to follow up on those commitments and to see how far the Health Commission was willing to go to set “enforceable demands,” Dr. Rouse, Dr. Treece, Tseng and POC founding organizer Geoffrey Wilson met for an hour with Dr. Chow, the Commission’s only serving physician. At the top of their agenda they stressed the medical consequences of the continued dismantling of St. Luke’s and called upon Chow to do everything within his power to get the Health Commission to use the list of services from the year 2000 as a measure of what St. Luke’s should be offering vs. CPMC’s projection that an 80-bed facility will provide adequate service.
“Given the absence of centralized planning and history of private corporations being allowed to close vital services regardless of the health needs of the city,” Tseng said he wanted to, “get Dr. Chow’s assessment of the progress the Health Commission had made to get CPMC to accede to the health needs of the community in their Institutional Master Plan.”
Health Commission forwards eight points of compliance to Planning Commission
In the meeting Chow summarized the Health Commission’s 8-point “Resolution 02-10” issued on March 16, 2010 that lists quantifiable benefits CPMC must provide in order to gain approval of their Master Plan. (See Sidebar: Health Commission Resolution).
Chow noted that the resolution was forwarded to the Planning Commission, who said they would hold Sutter to the agreements before approving any building permits. At several check points along the way there would be pubic hearings and a review of mandatory reports from CPMC before they would be granted permits to proceed with the construction and modification of existing health resources in their Master Plan.
Still no psych
Dr. Rouse pointed out the glaring lack of action on the part of the Health Commission or other City authorities to stem the wanton elimination of much needed services such as inpatient psychiatric beds throughout San Francisco, which have been reduced from 223 in 2000 down to 81 in 2010.
Rouse noted that the eight points included nothing about psychiatry and questioned why the City and County of San Francisco continue to grant over $7 million a year in property tax breaks to CPMC, which turns away indigent patients with mental disorders who either end up at San Francisco General Hospital’s Psychiatric Emergency Services for acute inpatient psych care or in the SF Jail. He noted that the SF Department of Public Health (SFDPH) continually cites a “lack of funds” as justification for closing its own psych units, further reducing services.
Said Dr. Rouse, “The patients are ending up on the streets in increasing numbers, abandoned, abused, incarcerated and even dead prematurely. Psychiatric Emergency Services is regularly at overflow capacity and it’s dangerous for everyone involved. If the City does its job by making sure that CPMC does its own share, it will take some pressure off of SFDPH and there can be more services for everyone.”
Tseng added, “Alternately, with non-profit services 79% below what other hospitals in the city provide, the City and County of SF can revoke CPMC’s non-profit welfare exemption and make them pay their county property taxes so San Francisco can use that money to fund the care CPMC isn’t — but should be — providing.”
Blue Ribbon blues
Wilson noted that, “CPMC claims they are using the findings of the ‘Blue Ribbon Panel’ of ‘healthcare experts’ that they formed in 2008 to justify what they will do with St. Luke’s, but the Blue Ribbon Panel completely sidelined the need for psychiatric care. There was a widespread call for psychiatric care from patients and neighbors in the first community meeting the panel held to get community input in early 2008. At the second community meeting, Eugene Lee, M.D., the last psychiatrist at St. Luke’s 32-bed Inpatient Psych Unit before CPMC closed it, made an impassioned appeal to restore the mental health services. Several people spoke in support of his position, but none of this appeared in the notes of the meeting.”
Rouse affirmed, “It’s a question of ethics. If we don’t look at the health needs of the community, Sutter can focus on sports medicine and barometric surgeries — the big money makers.”
Another process to flout?
When Tseng asked how the Planning Commission would enforce the eight points, Dr. Chow said they would be reviewing CPMC’s progress at quarterly public hearings on the Master Plan and could withhold permits if the terms were not met.
Treece noted, “They could have done that all along but haven’t and now we’re facing two-thirds of the hospital’s capacity being eliminated, including all inpatient pediatrics.”
In response, Chow maintained, “It’s not the size of the hospital, but how it’s used and what the needs are. It doesn’t seem to be that big a problem, given that some of the St. Luke’s medical staff were on the Blue Ribbon Panel who agreed with the conclusions regarding what the hospital should offer.”
Denying Chow’s assertion, Dr. Treece explained, “You can’t assume abstention or silence means agreement. Many of the medical staff have been susceptible to intimidation from their employer, and there are many who are not satisfied with the current plans. CPMC has said to the staff, ‘accept the hospital or get nothing, take it or leave it.’”
Who’s looking out for the patients’ interests?
Dr. Chow explained that while the role of the Health Commission is to preserve care, the Commission’s power to make recommendations is limited. Although healthcare entities are required to present any plans to reduce services before the Health Commission, the commission has no power and no authority to prevent the closure of services. When pressed by Tseng as to who does have that authority, Dr. Chow conceded that the Health Commission only has advisory capacity, and that the SF Planning Department, which approves or denies permission to build, modify or demolish buildings, is not mandated to prioritize healthcare needs in its decisions.
Commission’s power limited, Chow encourages POC’s continued advocacy
Treece noted that, “CPMC has violated Prop Q numerous times, including when they reduced women’s care and skilled nursing facility beds without hearings. I can’t imagine they won’t do the same thing with these eight points. If there is no government entity that protects the health needs of the community, then we have to build that from the community.”
Chow acknowledged that’s precisely why it is so important for POC’s members to attend hearings and put forward the medical needs of the community as medical professionals. He said that as a Health Commissioner, he is not there to voice his own opinions; his job is to make recommendations based on the facts and the input from the community. He acknowledged how difficult it is for doctors to take time off from seeing patients to testify, but said he very much appreciates POC’s efforts and needs to hear from the medical community. He encouraged POC to bring physician concerns to the public hearings.
Towards the end of the meeting Tseng gave Chow a copy of the extensive list of services St. Luke’s used to provide in the year 2000, before CPMC took over, and recommended the Health Commission use that as a starting point to measure Sutter’s performance. Tseng also gave the Commissioner an article about Provena Hospital in Urbana, IL having it’s non-profit status revoked for only providing a “pretense of charity care”; the transcript of a presentation by Steven T. Miller of the IRS speaking about the problem of non-profit hospitals not providing sufficient community benefit to merit their status; a Federal Trade Commission retrospective report entitled “Price Effects of Hospital Mergers (Summit and Alta-Bates)” from November 2008 classifying Sutter’s merger of Alta-Bates and Summit as a classic case of an anti-trust violation and a July 30, 2010 New York Times article describing how St. Luke’s was being used as a “bargaining chip” by Sutter.
Dr. Chow said, “There is no question that St. Luke’s is a bargaining chip. The hospital is something the community wants and CPMC is going to have to comply with those wishes to get what they want. The question is, ‘Are they establishing a hospital that is viable and meets community needs?’ We are asking at least 20 years assurance from CPMC. They haven’t agreed yet, but we put it at 20 years because with the changing of medicine and the future of acute care we thought it was a good start.”
A history of bad faith
Wilson reminded Chow of the history of bad faith negotiations that Chow himself had seen, including when CPMC attempted to make a case in front of the Health Commission claiming they were closing the 32-bed Inpatient Psychiatric Unit at St. Luke’s because “it wasn’t needed.” This was after laying off all the psychiatrists except for one part-time position so they couldn’t legally admit more than a few patients at a time.
Wilson explained that in San Leandro, Sutter had reneged on their 20-year commitment to San Leandro Hospital with a ballot measure, claiming the hospital was a money loser and they couldn’t keep it open. (See San Leandro article on page 4)
At the conclusion of the meeting Rouse asked Chow, as the only doctor on the Commission, if he had ever been to Psychiatric Emergency Services to see the conditions that have resulted from the massive closure of acute inpatient psych beds in the City. Chow admitted he hadn’t, to which Rouse extended an invitation to visit PES that day. Dr. Chow did visit the unit and spoke briefly with POC members there about the chronic over-crowding, lack of staffing and high patient acuity on the unit.
“It’s important that responsible officials have first hand knowledge of what they are deciding on,” said Rouse. “We clearly have to keep organizing and taking our case to all those responsible for these decisions as well as to all those affected by them.” Rouse, along with Treece, pledged to continue to do public speaking, meetings, letter writing, phone calls and other organizing needed to build a consensus for what services St. Luke’s should provide. All those interested in participating in the campaign should contact David at (415) 434-9335.