As the only full-service safety-net hospital in the area, Nashville (Tenn.) General Hospital attracted patients seeking care from providers they trusted and lower treatment costs than those at other area facilities. However, an initial proposal by Nashville Mayor Megan Barry last November took residents and hospital officials by surprise and nearly shattered Nashville General's relationship with its patients.
The decision to end inpatient services
Last November, Mayor Barry announced the unexpected decision to end inpatient care at the hospital and transition the facility into an ambulatory surgical center providing only outpatient services. While Ms. Barry has since issued an apology to hospital officials regarding her initial statement and introduced a proposal in January to delay any change in services until the end of 2018, Nashville General Hospital CEO Joseph Webb, D.Sc., told Becker's Hospital Review in an interview Mayor Barry's initial statement came as quite a shock to hospital administration and staff.
"It was a big surprise to hear [the announcement] from that setting. My opinion has always been the hospital, as a safety-net hospital, should function in a comprehensive manner, and not as an outpatient center, to service the area's medically complex patient population," Dr. Webb said.
The bigger issue with such a change, however, is the decline in care patients would receive if the hospital transitioned into an ASC, according to Dr. Webb. Under the Emergency Medical Treatment and Labor Act, hospitals are required by federal law to treat and stabilize patients who come into a facility's emergency room department regardless of their insurance status or ability to pay. The issue, Dr. Webb claims, is hospitals are only required to stabilize the patient, not treat them for the full extent of their conditions.
"A hospital isn't obligated to care for [patients] more than just stabilization, which leads to higher readmission rates because hospitals divest those patients without providing adequate care," Dr. Webb said.
"At that point, it becomes an economic issue," he said, adding that if Nashville General transitions into an ASC, patients will have to seek out multiple providers at various facilities for care, creating a "fragmented system [where patient] outcomes are going to become worse."
Community reaction to the change in services
Roughly two weeks after Mayor Barry's initial announcement in November, Nashville-based Meharry Medical College, which maintains a medical residency arrangement with Nashville General, created an 11-member stakeholder team comprising healthcare experts, hospital employees and board members, and elected officials, among other representatives. The goal of the panel is to issue a final recommendation on the hospital's future, according to a letter from Nashville-based Meharry Medical College President James Hildreth, MD, PhD to staff, obtained by the Tennessean.
"The stakeholder work team … [is] examining the city's entire healthcare ecosystem and exploring ideas for improving the health of the indigent from multiple angles, including prevention, ambulatory services, behavioral healthcare, community clinics, and access to nutrition and fitness programs," Dr. Hildredth wrote.
While the exact time table for the panel's recommendations has not been revealed, it has held several listening sessions to obtain feedback from the Nashville community.
"There's been a strong representation from grassroots stating the hospital should remain intact as a full-service hospital," Dr. Webb said. "We see roughly 32,000 [patients] annually in our emergency department. Overall, 40 percent of patients can't pay [for their care]. …Nashville General provides the most reasonable costs in our county — 45 percent less in ER costs than at area hospitals and 15 to 50 percent less on inpatient bed costs."
Hospital's fiscal stability
While Mayor Barry's initial announcement came as a shock to hospital officials and many community members, the proposed solution represented an attempt to aid the financially troubled hospital, which has received various cash-infusions and subsidies to stay afloat during the last few years.
Auditors from Nashville-based accounting and consulting firm Crosslin reviewed the hospital's finances for the fiscal year ended June 30, 2017, and determined hospital management did not maintain proper oversight of transactions or hospital account activity, which resulted in "material misstatements" in the hospital's financial numbers. The auditors' findings were similar to those uncovered in an audit released last January, which found Nashville General did not accurately monitor finances during fiscal year 2016.
However, Bruce Naremore, CFO of Nashville General, told The Tennessee Tribune while he respects Crosslin, the audit firm did not have any hospital audit experience prior to conducting Nashville General's audit.
"The most valuable and challenging part of a hospital audit is valuing what the patient receivables are worth that were on your books," Mr. Naremore told the Tribune.
In 2017, Nashville General presented a budget subsidy request of $55.7M for fiscal year 2018. Metro officials approved $35M with the understanding Nashville General would require additional dollars in fiscal year 2018 to bridge the $20M gap in funding. Earlier this month, Metro Council voted to provide the hospital with the additional subsidy needed for this fiscal year in the amount of $17.1M.
While the $17.1 million figure was less than the hospital's proposed $19.7 million, Dr. Webb said the amount represented a show of support from city officials.
"I felt a sense of relief [when we learned of the $17.1 million subsidy], as did the hospital staff and community. The entire Nashville community has shown tremendous support for NGH," Dr. Webb told Becker's.
"NGH will continue to focus on its mission of improving the health of Nashville by providing equitable access to coordinated patient-centered care to the Nashville population. We are optimistic that the Nashville community and its leadership will continue to support NGH as its essential hospital so that access to healthcare will be available to all individuals without regard to their socioeconomic status or ability to pay," he added.