What happens when the Doctor gets sick?
On a sunny afternoon in her Richmond neighborhood, 17-year-old Brenda Abonze walks slowly down the sidewalk with her sister after a visit with an obstetrician. A warm breeze brushes her dark hair against the sky-blue, spaghetti strap blouse that hangs loosely over her protruding belly.
The checkup had gone well, except for one thing. Abonze, seven months pregnant, had planned to deliver her first child at the nearby Doctors Medical Center. But today her doctor told her that the hospital had closed its obstetrics unit. Abonze, who doesn’t drive, will have to receive her next ultrasound and give birth at Berkeley’s Alta Bates Medical Center—which could be 45 minutes away in traffic.
Now she prays she’ll go into labor at night, after rush hour, and after her husband comes home from his factory job with their car.
“If it comes during the day I don’t know what I’ll do,” Abonze says in Spanish, her hand cupping her abdomen instinctively. “It makes me kind of mad because even if I get someone to drive me all that way, what if I give birth on the freeway?”
Doctors Medical Center in San Pablo, long plagued with financial problems, cut its obstetrics unit in October after declaring bankruptcy—a move that stunned the community that has depended on the hospital for more than half a century. At the peak of the financial crisis, Doctors’ emergency room—one of the largest in the county—diverted ambulances away from its gates to other East Bay hospitals for two months. After an 11th-hour bailout from the county, some 300 layoff notices and the closure of several units, the hospital limps into the new year.
Doctors faces the same thorny question central to the viability of many such inner-city hospitals—scores of which have had to shut their doors—in an era of escalating medical costs and a growing uninsured population: How do you continue to offer health care when many clients are unable to pay for treatment? In the case of Doctors Medical Center, a longtime neighborhood institution relied on by generations of residents mostly living in Richmond and San Pablo, the answer was as plain as it was painful: Slash services that aren’t profitable.
“The issues that Doctors is facing are growing all over the country for hospitals that serve poor populations,” says Thomas Rundall, professor of health policy and management at U.C. Berkeley. “There’s little surplus revenue with which to subsidize the growing number of uninsured patients. So many hospitals are struggling.”
The story of Doctors Medical Center may be that of young women like Brenda Abonze, and of her community’s struggle with poverty. But it’s also the story of how the troubles of one hospital spill beyond city borders. People who are sick or dying or birthing must go somewhere. And they do.
When Doctors stopped accepting ambulances in September, roughly 1,200 patients congested emergency departments at Kaiser Permanente in Richmond, Contra Costa Regional in Martinez and Alta Bates in Berkeley. Meanwhile, physicians feared that if Doctors folded completely, a shortage of hospital beds would clog emergency rooms throughout the East Bay.
To spend time in an urban hospital in financial crisis like Doctors is to feel the pulse of a weakened hero. Medical workers and patients abide in a constant state of limbo, out of step with the sense of dependability the hospital should, by all rights, project.
A white seven-story building, the hospital looms over a strip mall and casino in San Pablo and Abonze’s Richmond neighborhood, which comprises hundreds of one-story, working-class houses on grid streets. Yellow, pink and white rosebushes grow from a circle of grass in the sprawling hospital parking lot. Manicured evergreen shrubs stand as sentries at the emergency room doors.
On a cool evening in October, there are no patients in the emergency room waiting area. Above empty blue vinyl chairs, pale green wallpaper is stained yellow from decades of reclining heads. Two security guards casually watch Game Four of the World Series on an old television perched in a corner of the room.
Dr. Jeffrey Frank has just arrived from his home in Berkeley to work the night shift. He’s 45 years old and has worked at Doctors for 17 years. He became the head hospitalist a year ago, so now labors full-time at the hospital treating patients and directing a team of physicians. He glances around the empty room, the soft light briefly catching his silver earrings. His dark eyes squint behind round glasses, and he shakes his head. “A couple months ago there would’ve been 40 people here,” he says.
He slips a white coat over his collared shirt and khaki cargo pants and strides through the door, the curly brown locks of his ponytail dancing. In the emergency room, fluorescent lights shine on the terrazzo floor. Behind a center console, nurses in blue scrubs murmur softly while clerks eat pizza at a table. It’s unnervingly quiet.
Frank has seen one financial crisis after another at the hospital, but nothing like this. He spends hours each day fielding calls from disgruntled doctors and attending meetings debriefing staff on which services have closed. Over the past few weeks, dozens of doctors and nurses have quit because of the uncertain future of the hospital, so finding enough staff has been difficult.
“It’s been really stressful on doctors and nurses,” he says. “You don’t know what services you’re going to have. You don’t know if you’ll be open next month. I’m way too involved and on call every night, but at least the hospital is still running.”
A nurse beckons from across the room. Frank maneuvers deftly around stretchers to a room slightly bigger than a closet and pulls a blue curtain closed behind him. When he emerges, his cell phone rings and he gives orders quickly.
Tonight he’ll treat just three new patients: one with severe chest pains who is at risk for a heart attack, another who is severely dehydrated from vomiting, and a patient with congestive heart failure who is on death row at San Quentin State Prison. A pair of guards in camouflage uniforms stand outside that patient’s room.
All the patients here tonight are walk-ins; none have been brought by ambulance. There are 42 patients in the building, less than half of last year’s average. At the height of the crisis, the hospital housed just a quarter of its usual number of patients.
Much of Doctors now lies empty, cavernous. Beds made with crisp, white sheets silently wait, for days or perhaps forever: some 22 beds in the seventh-floor burn and wound center, 15 beds in the intensive care unit, 12 beds in the fourth-floor chemical treatment center, half of the 44 beds in the medical care unit and 31 beds on the second-floor obstetrics unit.
Frank steps off the elevator onto the dimly lit seventh floor and pauses. “I haven’t been up here in ages,” he says. He walks down the wide hallway, the squeaking of his tennis shoes echoing off the tile floor and high ceilings. “It’s spooky when you see all the rooms that have been closed down.”
He begins punching numbers into the security system on the door to the old wound center, which closed a year ago, but stops because he can’t remember the passcode. “The beds in the room were always full,” he says, gazing at the door. “There used to be a lot of characters up here.”
Wounds heal slowly so patients would often remain for weeks and the staff would get to know them well. But the hospital lost money on long stays by the many who couldn’t pay. Patients now travel to the county hospital in Martinez for treatment, also 45 minutes away in traffic.
Down the hall, the burn unit—previously one of just 12 in the state—has been empty for almost a year. Burn patients are often the most critically ill of all patients in the hospital. Now they’ll travel to more distant burn centers in San Francisco, San Jose or Chico. Those who can’t make it that far will go to community service centers that don’t offer the same level of care.
The second-floor obstetrics unit, once alive with the sounds of women and newborns, will also remain quiet. Staff costs combined with patients on Medicaid gouged profits. “This is one unit the board didn’t want to let go of because it was such a community thing,” Frank says, furrowing his eyebrows at another glass door to which he has forgotten the passcode. “But it was the biggest money-loser of all the departments we had.”
Doctors Medical Center, formerly known as Brookside Hospital, opened soon after World II brought thousands flocking to the East Bay, many from the deep South, looking for work in the shipyards. Within a few years, the population of Richmond tripled, swelling to 100,000 people, and San Pablo’s population climbed from 2,000 to 25,000. The population boom meant an increased need for services—from housing and roads to health care.
The only other medical facility in the area, Richmond Hospital, was privately owned and mainly served people with financial means. Residents in San Pablo, Richmond, El Cerrito, Pinole and Hercules voted to form a health-care district and to pay a third of the $4 million in taxes—the rest coming from state and federal money—to build a hospital that would serve everyone. Decades later, this worthwhile goal was the cause of much of the hospital’s misfortune.
Because Doctors is just partially supported by tax dollars, it relies largely on paying-patients to sustain its operations. Today the population of the district, roughly 250,000 people, is predominantly poor and working-class. The 2000 Census put the average annual income of a San Pablo resident at $14,000—less than two-thirds of the state average. The average Richmond income is also significantly lower, at less than $20,000.
By federal law, hospitals must treat everyone, whether or not they have insurance.
In poor areas like Richmond and San Pablo, many residents use emergency rooms as primary-care offices so they don’t have to pay. In 2005, Doctors Medical Center received no compensation for a third of the more than 45,000 visitors to its emergency room. Sometimes these patients require expensive surgeries or weeks of hospital care, as in the wound and burn units. That same year, more than 7,500 patients were admitted to Doctors, staying for a total of nearly 37,000 days. Ten percent of those patients paid nothing. Doctors provided charity care worth roughly $24 million in 2005.
In California, managed health care, which controls health services to members who are enrolled in a specific type of health-care plan, is much more common than in other states. Approximately 85 percent of privately insured patients have one of these plans, meaning they go to private hospitals for treatment. About three-quarters of those in Doctors’ district with private insurance go elsewhere, many to Kaiser Permanente in Richmond, Alta Bates in Berkeley and Summit in Oakland. Just one in five patients admitted to Doctors has commercial insurance, with the rest on Medicaid, Medi-Cal, Medicare, county insurance or nothing at all.
Many hospitals in poor communities face similar problems. The federal government once reimbursed a hospital for all costs it incurred to treat Medicare patients, those who are aged 65 and older or disabled. In 1983, the government began paying hospitals a predetermined rate, based on a patient’s diagnosis. This now meets just half of the costs to treat a patient, by some estimates. Business worsened for poor hospitals in 1997, when the Balanced Budget Act cut millions of dollars to Medicare. Moreover, the country’s economic shift—from an industrial to service economy over the past three decades—has left one in six Americans without health insurance. Today, as Baby Boomers age, more people are using hospital services than ever before, and asking for more expensive procedures, but overall funding for hospital care hasn’t kept pace.
A study published in 2005 in the New England Journal of Medicine found that the country lost 16 percent of city-based public hospitals like Doctors between 1996 and 2002. Another study by the Healthcare Financial Management Association, the nation’s largest membership organization for hospital administrators, found that roughly 40 percent of hospitals in the country don’t have the money to maintain aging facilities and that the gulf between the wealthiest and poorest hospitals is widening.
In California the situation is even worse. The set rates that insurance companies pay to hospitals, or “capitation premiums,” are 30 percent lower than all other highly populated states, and California has the lowest Medicaid reimbursement per patient in the nation. One in five patients is uninsured, which is higher than the U.S. average partly because of the state’s larger number of undocumented immigrants. Strict state mandates specifying requirements for meeting seismic safety and nurse-to-patient ratios are also costly. Oakland-based Kaiser Permanente is budgeting a third of the $24 billion it will spend on new hospital construction over the next decade toward complying with California’s seismic mandate. Because the state has a relatively low proportion of health-care workers for patients served, hospitals often must ship nurses in from other states, which is more expensive.
In 2004, the California Healthcare Association reported that California hospitals are losing more than $400 million annually operating trauma centers and emergency departments, and that one-third of California hospitals operate in the red. More than 70 California hospitals closed between 1993 and 2003—a 13 percent drop in hospital capacity. During the same period, the state lost roughly 11,000 staffed hospital beds while the population grew. Not surprisingly, hospitals in poor communities were hardest hit.
Doctors struggled for decades; its financial health became critical in 1997. To prevent bankruptcy, the West Contra Costa Healthcare District reached an agreement with Tenet Healthcare Corporation, the nation’s second-largest private hospital chain. Tenet managed Doctors for seven years, initially investing millions of dollars into new facilities and services in an attempt to attract more paying customers. It didn’t work.
Tenet reported losing $24 million in 2003. After settling the longest nurses strike in California history, it opted out of its 30-year lease 23 years early. The district was once again left with a faltering hospital. Fearful of how the community would cope without Doctors, residents voted overwhelmingly for a $52 annual parcel tax per taxpayer to help keep the hospital open. But the tax was too little to stanch the losses.
Last fall, after the hospital declared bankruptcy, the team of emergency department physicians revealed that they hadn’t been paid by the hospital in six months and said if that didn’t change they would quit in 30 days, a move that would provide the final, lethal blow. CEO Irwin Hansen said the hospital, which costs roughly $144 million a year to run, was between $50 and $100 million in debt and losing a million more per month. He warned that Doctors would close within weeks if it didn’t receive help. “It’s been a race with the Grim Reaper since the day we took over the hospital,” he said after one meeting. “And now he’s got his fangs on my heel.”
Robbie Goodwin, 67, lives alone in Richmond, a half-mile from Doctors. On Oct. 14, she woke at 5 a.m. and couldn’t breathe. She was scared, but it had happened before. Her weak heart sometimes couldn’t pump enough blood to the rest of her body, causing fluid to back up into her lungs—an acute episode of congestive heart failure.
She dialed 911 and the paramedics arrived within 20 minutes. They placed an oxygen mask over her mouth and gave her a diuretic to help clear the fluid. Then they told her Doctors had stopped taking ambulances so they would transport her to the next closest hospital, Kaiser Permanente.
Goodwin had read in the newspaper that Doctors was having financial difficulty but didn’t know it was on diversion. She’d been transported by ambulance to Doctors at least eight times before. The staff knew her there. Last January they had saved her life when a similar episode occurred, she said.
Goodwin, already unable to speak and barely able to breathe, panicked because she knew it would take longer to travel to Kaiser and physicians there wouldn’t have her records. They wouldn’t know that she has had a history of congestive heart failure, diabetes, allergies and a painful stomach condition.
When a stalwart like Doctors stumbles, repercussions ripple through the region. Many physicians worry that the loss of its full emergency services could have fatal consequences. When minutes mean the difference between life and death, a patient doesn’t have time to travel farther to reach a hospital or wait longer for paramedics returning from a facility in the far reaches of the county.
American Medical Response, the county’s ambulance operator, added vehicles and staff to ameliorate the impact of the diversion. Dr. Jeff Smith, the executive director of Hospital and Clinics for Contra Costa County, says no negative consequences to patients’ health were reported because of the diversion, but that many patients were transported outside their communities. This sometimes made it more difficult for physicians to access patients’ health records, for families to visit them and for patients to return home.
Smith also says the diversion would have been difficult to sustain much longer. “Certainly you can’t keep everything on total readiness 100 percent of the time without something breaking,” he says. “It would really only take something like a gasoline tanker crash on Highway 80 during heavy traffic and you could easily be in real disaster mode real fast.”
Meanwhile, patients at Richmond’s Kaiser hospital languished in the much smaller emergency room, many complaining they waited hours to see a nurse and even longer for treatment in medical care rooms. On the same October night that the waiting room at Doctors was empty, 20 people at Kaiser lounged restlessly on padded chairs—a mother held her head in her hands, two children couldn’t sit still, others halfheartedly watched the Tigers-Cardinals game on two 24-inch flat-screen televisions. Kaiser received 24 patients in ambulances that day, well over twice its daily average for 2005.
A 2004 emergency services study predicted that a downsizing or closure of emergency department operations at Doctors would have dire consequences for all area hospitals, especially Kaiser Permanente in Richmond. The study predicted wait times for walk-in patients would likely reach 10 to 12 hours at Kaiser.
Smith said even the five percent increase in patients at Contra Costa Regional strained emergency department services because they were already operating at nearly full capacity. He said it stressed staff, increased waiting times in the emergency room and that operations were nearing a dramatic slowdown because there weren’t enough physicians and nurses to properly treat the swelling number of patients.
Kaiser wouldn’t comment on the impact of the diversion. Smith says the hospital avoided predicted wait times by adding staff and lengthening shifts, but that it was on the verge of being overwhelmed because of limited facilities. They have just eight intensive-care beds while Doctors had 30 before it closed half of them in September.
This occurred with Doctors’ emergency department still receiving walk-in patients, and accepting roughly two intensive-care patients per day from Kaiser; a complete Doctors closure would have magnified the situation immensely. But for many, the biggest worry was another detail in the 2004 report: If Doctors expired, the loss of its 30 intensive-care beds would mean a shortage of intensive-care beds in the East Bay during the coming winter flu season.
Intensive-care unit beds are costly to maintain, so it’s not in a hospital’s financial interest to keep more than it can fill. But during the winter months, the increase in respiratory illnesses sends more patients to the hospital, often leading to an overflow in critical-care units. In times of disaster, the beds are even more crucial. In 1993, for instance, sulfuric acid spewed from a ruptured railroad car in Richmond, sending more than 3,200 people to hospitals with such symptoms as burning eyes and breathing problems. Doctors received 600 of these patients.
When intensive-care beds are filled at a hospital, or in an entire county, as sometimes happens, patients in critical condition must be transported elsewhere. Those in need of critical care must wait until a bed opens up, sometimes 24 hours. This creates a backlog in the system, meaning all emergency room patients must wait longer for treatment.
“If we lost those intensive-care beds it would be a huge disaster,” says Smith. “We would constantly be very short on resources to critically ill individuals, and people would suffer because of that. It would decrease beds available to everyone, rich and poor.”
In early November, nearly two months after the ambulance diversion began, Contra Costa County voted for a joint-powers agreement with the health-care district. The County immediately loaned Doctors Medical Center $10 million (to be paid back over four years) that leveraged a $10 million federal Medicaid grant. Chairman of the Board of Supervisors John Gioia, who represents the district that includes Doctors, was one of the primary architects of the nearly unprecedented deal. “The hospital would’ve closed if it didn’t have an immediate cash infusion,” he says. “We had to do something.”
A week later the hospital begins accepting ambulances back into its emergency department and the periodic squeals of sirens can once again be heard in the parking lot. Days later, the blue vinyl chairs in the waiting area are nearly full and 21 patients fill every room in the emergency department. Patients lie on stretchers, oxygen masks cupping their mouths. Nurses and physicians scurry between rooms, scribbling on clipboards. There are 92 patients in the hospital today, almost twice the number this time last week.
The fifth-floor medical care unit is pandemonium. Just three of the 44 beds are open. Physicians bark orders and loud beeping sounds signal patients calling for nurses. Elevators overflow with families holding flowers. “We’re swamped,” says Martha Iwaihara, the tall, blond, 51-year-old director of nursing. “It’s all we can do to find enough nurses to work.”
Iwaihara, who grew up in San Pablo and has worked at the hospital for 30 years, says the hospital will survive because of the committed staff and community. “We’ve always struggled,” she says. “I heard from the day I walked in the door that this hospital was going to close. But we’ve always bounced back.”
As part of the new agreement with the County, the hospital will be managed by a board that will likely consist of two representatives from Doctors and three from the County. The recent $20 million infusion will last Doctors only about a year, so more has to be done to ensure longterm viability.
To that end, Doctors reached an agreement with the California Department of Corrections to treat at least eight inmates a day from the nearby San Quentin State Prison, which could generate as much as $84 million over the next three years.
Francis Andrews, a woman in her sixties who lives in San Pablo, is among those who are dubious of this arrangement. Andrews has sought care at Doctors for 30 years, but when she took her husband to the hospital recently because he had chest pains, the guards in camouflaged uniforms disturbed her. She says Doctors now feels more like a county hospital, which is heavily funded by taxpayer dollars because it treats so many underinsured patients. Andrews says between the inmates and recent financial problems, she’ll go elsewhere for care.
The loss of certain services will also impact area residents like Brenda Abonze and her older sister, Olga, whose baby is due a month later. Besides wondering how they’ll get to the hospital to give birth, both fear they won’t be able to visit each other when they’re in labor. Erin Yee, director of local Planned Parenthood prenatal programs, says the loss of the obstetrics unit at Doctors will stress the approximately 70 women per month who would’ve given birth there. “It’s another barrier for women with low incomes without many options in the first place,” she says.
CEO Irwin Hansen received criticism for the financial crisis, but said the situation was largely out of his control. “The decisions we’ve made have been very hard for all of us—especially for those we let go and the community that now doesn’t have certain services,” he says. “But I believe it’s going to work financially.”
In a small room in Doctors’ emergency department, a week after the county vote, Robbie Goodwin, the woman who was transported to Kaiser in October, perches on small bed with white sheets, her hands folded in her lap, a blood pressure monitor encircling her left arm. She lived through the congestive heart failure episode but drove to Doctors’ emergency department tonight because of chest pains.
“My life depends on this hospital,” she says, her large eyes unblinking. “And I’m not the only person with a chronic illness that needs to be seen quickly sometimes. I pray they don’t close it.”
Though those like Abonze have new prayers, Goodwin’s entreaties have been momentarily answered. In the coming year East Bay residents will wait anxiously to see whether those who’ve breathed life into Doctors can succeed where so many other communities have failed, and continue to stave off the deathly quiet from its halls.
Jason Witmer has reported for NPR’s All Things Considered and traveled through Asia profiling small-time farmers for The New Farm. He is currently studying journalism at the U.C. Berkeley Graduate School of Journalism.
Patients visiting Doctors Medical Center emergency room in 2005: 45,000
Emergency room patients who did not provide compensation for that care in 2005: 15,000
Patients admitted to Doctors in 2005: 7,500
Number of these patients who did not provide compensation for that care: 750
Number of children born monthly at Doctors before the obstetrics unit closed: 70
Number of uninsured Californians in the state: 1 in 5
Number of uninsured Americans: 1 in 6
Number of California hospitals that closed between 1993 and 2003: 70
Annual budget of Doctors Medical Center: $144 million
Amount of charity care provided by Doctors in 2005: $24 million
County and federal bailout of Doctors Medical Center: $20 million
Estimated amount of time that funding will last: 1 year
Estimated income from a new agreement to treat San Quentin State Prison inmates at Doctors: $84 million over three years
These figures are estimations provided by the following sources: Doctors Medical Center, the California Healthcare Association and United States Census Bureau.