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Don't close King-Harbor

Make the best of a bad situation and focus on short-term fixes.

June 15, 2007|Thomas Scully | THOMAS SCULLY is the former administrator of the federal Medicare and Medicaid programs. He is now senior counsel in a Washington law firm.

I LIVE IN WASHINGTON and work in New York City, so I have no personal stake in the raging debate over the fate of Martin Luther King Jr.-Harbor Hospital. But as the federal government's administrator of Medicare and Medicaid from 2001 to 2003, I became very familiar with Los Angeles' public hospitals -- and with King in particular -- as we crafted a $1.8-billion "bailout" of the system.

Apparently, and sadly, not much has changed since then in the incredibly complex mess that is the L.A. County public health system. King was then, and is still, the biggest public health and management problem of all.

But neither pointing fingers nor closing it down will help. The problems at the hospital have festered for years and will require many more years -- and cool heads -- to fix. What's more, these problems are not unique to Los Angeles. Inner-city hospitals serving largely low-income and uninsured patients are a problem everywhere. It is almost impossible to make the economics work in a hospital of, say, 60% uninsured patients and 25% Medi-Cal patients.

It is easy to whine about the problem -- but significantly harder to come up with fixes. It would be nice if there were an easy national solution, but, the fact is, we won't have universal insurance for some time under any party or leadership. As it is, the L.A. system is almost totally funded by the federal government, and, with that support, L.A. has to deal with the hand it has been dealt -- and make the most of it.

There are many different big-city models to look at, but none have worked particularly well. Jackson Memorial in Miami and Grady in Atlanta are huge public hospitals in very poor neighborhoods that do a pretty good job of saving lives, and I would feel confident there as a patient. Philadelphia has no public hospitals yet serves at least as tough a population through private hospitals that get public support and provide great care. Los Angeles can and should learn from these cities, where the hospitals are somewhat more independent of the political structure. But it won't happen overnight, and it needs to keep King-Harbor limping along as it revamps.

In Washington, we closed our horrible public hospital and pushed our lowest-income patients to a private hospital, Greater Southeast, which now provides even worse care. It is certainly worse than King-Harbor and arguably should not be open at all.

Yet I worked hard with former D.C. Mayor Anthony A. Williams on behalf of the hospital -- even lending one of my chief advisors at the Centers for Medicare and Medicaid Services to the hospital for a year to run the ER, just to keep it open. Why? Because that is all they had in that community. Bad as Greater Southeast is, it can be as much as a 30-minute ambulance ride to the closest alternative ER. It just was not an option to shut it down -- and speaking as a former state and federal regulator, that is also the reality for King-Harbor.

So, when the federal government sees a hospital repeatedly fail its surveys, doesn't it have an obligation to pull its federal funding or shut the hospital down? Yes, and the government does, if there is any viable option. But shuttering King-Harbor is really not a smart or realistic long-term move. It may make for good TV, but it won't help the next Edith Isabel Rodriguez, and it won't help the next kid who gets into an ambulance in desperate need of a nearby hospital.

King-Harbor treated nearly 47,000 patients last year, and closing it would just force patients to go farther away to other facilities that could quickly find themselves overwhelmed.

Given the situation, the best the federal government can do is to poke, prod and push the hospital -- and the county -- to improve.

In these situations, the first and most important thing to do is to save the ER, which is the critical lifeline for the community, and focus resources there. Second, downsize the hospital dramatically, keeping only enough inpatient beds to support stabilizing emergency room patients -- and get the rest out of there as fast as possible. Both these steps already are underway at King-Harbor. The hospital has shrunk from 500 staffed inpatient beds years ago to just 40 now -- and the ER is the county's primary focus.

Equally important, don't point fingers. It doesn't help.

I found the L.A. County supervisors to be a smart, tough bunch, who, like most elected officials, have a very hard time making tough political calls to lay off hospital workers and close or downsize facilities. But they are engaged now. The governor is also very engaged, as is the federal government. Looking for blame will only slow things down.

The decline of King-Harbor has been slow and steady, and it will not be quickly reversed. If you were a doctor or nurse, would you want to work there? The state, county and federal government are taking exactly the right short-term steps. Only acknowledgment of the need for major change, and lots of cooperation, will really help the poorest in L.A. County.

Maybe King-Harbor can be rebuilt over time to its original mission -- maybe not. There is plenty of federal money pouring into Los Angeles, and there are many more safe and efficient ways to provide care for those patients.

The best thing for patients is to stop looking for blame, apply the best ER Band-Aid available to King-Harbor and get back to fixing the whole L.A. public hospital system.

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