Tuesday, December 29, 2009

Tragic Choices at Grady Hospital

On October 3, Grady Hospital in Atlanta closed its dialysis clinic. Grady committed itself to cover the cost of dialysis for three months for any of the 96 patients under its care who did not have an alternative source of dialysis. The three month extension is up on January 3. An undetermined number of patients - possibly as many as 50 - do not yet have a settled plan for continued treatment.

Grady has been serving the poor in Atlanta since 1892. A quarter of Georgia’s physicians have had at least part of their training at Grady. The hospital has 953 beds. The Grady Health System, which includes nine neighborhood health centers, does 921,000 outpatient visits per year, but has been in dire financial straits for many years.

In 2007, in the context of massive financial losses, the board voted to turn Grady over to an independent 501(c)(3) corporation, hoping that a more business-like board could bring managerial discipline to the hospital and make tough decisions the more political board was not willing to make.

This past summer the board showed it could make tough decisions when it voted to close the dialysis clinic, which was losing $2.5 million each year.

The dialysis clinic is a prototypic safety net program. 35% of the patients are undocumented and uninsured. Another 30% are documented but uninsured. 8% are prisoners. The facility itself is old, with outmoded equipment.

In a September ruling as to whether Grady should be allowed to close the clinic, Judge Ural Glanville of the Fulton County Superior Court recognized the severity of the trade off between Grady's stability and the importance of the clinic to the patients it served:
"Indeed, no value can be placed on human life. Nevertheless, when contemplating the use of injunctive authority, the court is required to balance relative equities, even in cases involving issues of life and death. If the court were to require [Grady] to maintain...the services forming the basis of the complaint, it would likely result in an adverse effect on the services offered to other individuals and the public at-large."
A group of plaintiff's brought a class action suit to block the January 3 funding cutoff, but on December 15 the suit was dismissed.

Predictably, Grady is being vilified as an uncaring killer. When confronted by a City Council member the chair of the Grady board responded by accusing the Council of grandstanding - demanding that the clinic be continued without providing funds to do it. I think this was a useful confrontation.

Uninsured patients, most notably immigrants, and especially undocumented immigrants, are caught in the middle of a life-and-death form of the game of "hot potato." Grady Hospital, as a safety net provider, inevitably loses, since its mission is to care for those who have nowhere else to go. When the public, through its government, stints on funding, safety net programs like Grady are left holding human lives in their care. What is a safety net provider to do if the funds allocated to it by the public don't allow it to meet the needs of its patients?

Clearly, a safety net provider is accountable for using the funds it receives in the most efficient manner possible. But we the public can't be allowed to turf our moral accountability to the Gradys of the world. We the public created safety net providers to care for the underserved, not to take on the burden of our sins in the manner of Jesus. I believe Grady is right to provoke a crisis over dialysis services. If some of its patients are still in limbo on January 3, Grady can't simply set them loose. It will have to continue to provide for them. But it should keep pointing the finger at its funding sources, with the message that Winston Churchill gave in World War II - "Give us the tools, and we will [do] the job," along with this corollary message - "If you choose not to give us the tools, acknowledge that you are the killers, and take responsibility for your decisions!"

(For a previous post on Grady Hospital, see here.)


Anonymous said...

Dr. Sabin,

While I agree with everything you say in this blog entry, I think one of the major problems with Grady deciding to close it's dialysis clinic was the decision-making process.
The decision was made behind closed doors (an executive session of the board meeting) without public involvement. It lacked transparency, justification, inclusiveness and revisability.

While I don't see any particular problems with choosing to close one service over another, I think the process used must be "fair and reasonable." And when the board decides it is going to close one service over another it appears that community involvement, outside of the business community, is essential to fairness.

Jim Sabin said...

Dear Anonymous -

Thank you for your thoughtful comment. I didn't know anything about the initial decision-making process, but I couldn't agree more with your emphasis on a transparent process that provides clear justification. The core argument Norman Daniels and I make in Setting Limits Fairly is about the need for fair process.

I did find on the web a November 2 presentation made to the board about the status of the patients who had been receiving dialysis. That kind of posting contributes to the openness you call for.

The dialysis clinic decision is about as difficult as could be imagined for Grady to handle, since the danger of direct and relatively immediate loss of life is involved. Years ago, when I was working at a neighborhood health center in a poor area of Boston, I saw how each year the center moved to the brink of firing its invaluable public health nurses as part of its annual budget battle. That was bad, but putting patients as vulnerable as those the dialysis clinic into the middle is vastly worse. The underlying message is "We'll be happy to continue caring for the patients, but we can only do it if you [the public, through its agencies] provide the funding" may be 100% true. but it's hard for the public to hear the message when what the Brits call "shroud waving" is going on.

In addition to its public statements, I hope Grady is telling the patients - "Grady Hospital can't continue paying for your dialysis forever, but we won't leave you in the lurch..."