It sounded like a rather simple idea to solve a longstanding problem. Cooper Green Mercy Hospital was a drain on Jefferson County’s coffers for years, especially after the county filed the biggest bankruptcy in U.S. history. Why should the county stay in the hospital business when the area is blessed with many quality hospitals and healthcare facilities that could better care for the poor?
This has been the public rationale of the three Republican Jefferson County Commissioners, who voted in August 2012 to close the 40-year hospital for the indigent within 30 days. Instead of a hospital, Cooper Green Mercy would transition into a super-clinic, the central hub in a spoke of specialty clinics that could deliver more efficient, cost-effective healthcare to the population it served.
But simple ideas and plans are rarely simple, especially in the costly and complicated world of the healthcare business. The commissioners, already sensing the depth of the problem, twice moved the transition deadline, finally settling on December 31 to pull the trigger by giving up its hospital beds, closing its emergency room and re-opening on January 1 as an outpatient clinic.
Vocal community critics say county officials jumped the gun with inadequate planning and a clear understanding of the consequences their decisions would unleash. And now they say officials have shot themselves in the foot – and the community in the heart.
At least 210 Cooper Green Mercy Hospital employees, including CEO Dr. Sandra Hullett, got lumps of coal for Christmas when Jefferson County Manager Tony Petelos placed them on administrative leave without pay on December 20.
Instead of a smooth transition, more than 40,000 of Cooper Green’s uninsured and under-insured patients have stumbled into the New Year with no clear direction as to how the county healthcare safety net will catch them if they fall ill.
The December 11 letter they received about the transition caused more confusion about where they could go for emergency room services or what hospital would accept their “blue cards.” They wouldn’t have known anyway, since Petelos announced on December 18, a week later, that the county would enter into memorandums of understanding with the health systems of the University of Alabama at Birmingham, St. Vincent’s and Brookwood. But MOUs are not contracts, and those hospitals aren’t obliged to take Cooper Green patients — yet.
Even with the agreements, the county safety net is frayed because the indigent care system itself is crippled, according to the county’s top healthcare official.
“Everyone is focused on the closing of inpatient services at Cooper Green on December 31. But no one is focused on how to handle outpatient care after December 31,” said Dr. Mark Wilson, head of the state-run Jefferson County Department of Health. “The system is broken.”
Wilson said the instability at Cooper Green caused more than half its doctors to flee the hospital; most have already found jobs elsewhere.
Patients were thrown into further anxiety when Jefferson Clinic, P.C., the medical group that provides doctors to Cooper Green, sent them a December 27 letter saying that the group still doesn’t have a county contract to continue services past January 31. Without a contract, the group will cease providing services on that date.
“After January 31, 2013, you will need to secure another healthcare provider to attend to your medical needs,” the letter from Chief of Staff Dr. Rowell Ashford II stated. “If you are confronted with a medical emergency, you are advised to go to an emergency room.” The letter added that the patients would be responsible for having their medical records transferred to their new healthcare providers.
County Manager Petelos said that he is taking a proposed contract with the doctor’s group to the commission meeting next week. “It’s unfortunate that they sent that letter, because we’ve been negotiating with them for months. But that was their decision,” he said.
Petelos also said he finalized plans to turn the hospital MOUs into contracts for commission approval, also by next week. Details about how much money they’ll get from the indigent care fund will come then, he said. In any case, “we are going to take care of our patients,” he said. “We will get other doctors and nurses they need.”
Critics say dismantling Cooper Green’s indigent care system without a clearly better replacement plan has been a constant community-wide criticism since the commission voted to “get out of the hospital business.”
“Right now, it’s chaos. Maybe it will get straightened out in time, but it’s chaos,” said Commissioner George Bowman, who oversees the county’s health and human services committee. He has sat helpless and out-voted as the commission majority decided Cooper Green’s fate over his objections.
“I don’t know that anything can be done to alleviate the anxiety that many patients have, because they don’t know exactly where their healthcare is going to come from, how they’re going to see their doctors and where they’re going to go. Right now, they don’t know. They just don’t know.”
But Petelos said the current facility is seeing more than 200 patients a day, and the numbers continue to climb as more come to receive services both at the urgent care facility (their new name for the emergency room) and at clinics. “I don’t see that as chaos,” he said.
Hezekiah Jackson IV, president of the Metro Birmingham NAACP, has been working with Cooper Green’s St. George’s Clinic. He said its exasperated doctors decided to close operations and find other places for its displaced HIV/AIDS patients. But it’s been tough placing patients who have no insurance. “People with money have other choices” in Birmingham’s healthcare community, Jackson said, “but the ones left at Cooper Green, if they cannot get their medications, they cannot live.”
Jackson also recounted recent story of a Cooper Green patient who suffered a seizure and died last week because she didn’t know where to go to get her medications after the December 31 deadline. “This happened because there was no clear direction as to what the continuum of care would be,” he said.
Petelos had not heard about the patient’s demise and will look into the situation. But he said that the county pharmacy is still open and operating as it was before December 31. He also said he was working to dispel incorrect notions that patients have about continuing care at Cooper Green.
“We have bought newspaper ads and sent letters to all the patients explaining the process. Any time an organization makes major changes, there is always going to be confusion,” he said. “But we’re trying to be proactive and trying to get the word out as best we can.”
Nonetheless, Cooper Green’s Advisory Board and Commissioner Bowman believed a healthcare authority steered by local medical professionals could have better managed both the county’s indigent care fund and a smaller hospital than the new hub-and-spoke clinic system.
An August 2012 report issued by Cooper Green’s former leaders showed that losing inpatient and ER services meant losing an array of cost-saving measures and revenue-generating services that allowed the facility to deliver comprehensive quality care at lower costs than private hospitals.
By ending in-patient services, the report said, Cooper Green’s pharmacy could lose a federal drug program that allowed patients to get a 75-percent discount on their medications; pharmacy costs would shoot up by $5.7 million. Cooper Green would also lose $7.3 million in extra Medicaid revenues that indigent hospitals receive for in-patient services.
Other revenues it would lose included patient collections totaling nearly $7.8 million. With the surrender of Cooper Green’s hospital beds on December 31, Cooper Green is temporarily unable to collect patient co-payments as of January 2, according to an internal letter dated January 1.
Cooper Green supporters said the commissioners’ rationale for closing the hospital was flawed, that it was not a drain on the county’s general fund. The indigent care fund – combined with revenues from services and federal payments — kept the hospital in the black, but for what some contend are millions of dollars in unnecessary administrative service charges from the county itself. They also point to court records in the 2009 civil lawsuit on behalf of the hospital’s patients by Cooper Green’s Advisory Board chairwoman Maralyn Mosley, which say at least $71 million from the indigent care fund was commingled in the County’s general fund and not appropriately allocated to the hospital.
But Petelos called those and other figures “misleading and incorrect. We have audits and other court orders that show the indigent fund has been spent appropriately.”
Some indigent patients are feeling the limitations of a replacement system they say currently isn’t working.
Community activist Sheila Tyson said last month that a Cooper Green patient had racked up a $7,500 bill at St. Vincent’s Hospital. The fast-food worker couldn’t see a doctor because she didn’t have the required $25 co-pay. Even going to the emergency room saddled her with a $400 fee, none of which she would have had to pay had she gone to Cooper Green. Tyson says she has dozens of similar stories. “And it’s sad. We don’t know what we can do, except cry with them.”
Anna Brown, a Cooper Green patient and advocate, said she wouldn’t have been so upset about transitioning the hospital into a new healthcare model if the county’s plan readily offered the people something better.
“But that was not done. What they’re doing to us as patients is wrong. What they’re doing to the employees is wrong. You do not treat people this way,” she said. “Taking away our hospital and not giving us anything in return…I just hope it doesn’t take a lot of people paying for this with their lives before they [the commissioners] realize they’ve made a grave mistake.”