Cutbacks at Jackson Health System will affect everyone's healthcare in Miami-Dade

Mar 14, 2010 — The Miami Herald

John Dorschner

Mar. 14, 2010 (McClatchy-Tribune Regional News delivered by Newstex) -- With Jackson's governing body scheduled to meet Monday to decide how to cut up to $229 million out of the struggling public-health system, the situation is personal for Gaston Procopio, whose 51-year-old mother is getting radiation treatment at Jackson Memorial.

"She depends on that treatment for her life," Procopio said. The radiation oncology program is one of those that Jackson Chief Executive Eneida Roldan has proposed to shut down in a recovery plan that includes laying off 4,500 workers and closing two suburban hospitals.

"We're worried. We don't know what's happening," said Procopio, whose mother also goes to Jackson's Jefferson Reaves clinic in Overtown, another possible cut. "We may have to go to Europe, where they have socialized medicine."

The Procopios' family problem is one example of the reverberations that a smaller Jackson Health System will have throughout Miami-Dade. Mayor Carlos Alvarez wants the Public Health Trust to finish its agonizing decisions on Monday so the County Commission can consider them on Tuesday.

Regardless of the exact form the cuts take, experts say everyone in the county is likely to feel the impact:

The poor and uninsured will struggle to find care. Some will go to emergency rooms, the one place in America where the law requires everyone to be treated. Others will stay at home, getting sicker and sicker.

Those who have health insurance will have the immediate problem of longer waits in ERs, where delays can already be mind-numbing and painful. The longer-term problem: higher insurance premiums to cover the cost of private hospitals dealing with more uninsured.

Taxpayers face a different danger. They already put $350 million a year into Jackson -- through a half-penny sales tax and property tax. If the Jackson cuts are too small, then the county will have to finance Jackson's payroll -- $80 million a month. In that case, the mayor has said he'll have to cut basic services such as police.

PROPOSED CLOSINGS

"This is de facto rationing, no question about it," said Michael Kosnitzky, a former chairman of the Public Health Trust, which oversees the Jackson Health System. "Poor people often need public transportation. The farther away help is, the less likely they are to get it."

That was one reason the system purchased Jackson North and South -- to facilitate easier access to care. If facilities are closed down, Kosnitzky said, patients are "going to sit home, get sicker. Morbidity and mortality rates are going to go up."

"The repercussions to the health of the community are going to go on and on," said Robert Schwartz, who oversees family medicine at the University of Miami. "This is going to create long-term problems for Miami-Dade."

Roldan is getting major opposition about the proposed hospital closings from the County Commission and members of the Public Health Trust, but regardless of the specifics, it's clear that fewer people are going be treated.

For example, one alternative to closing the Jackson North and Jackson South hospitals is to close Jackson's inner-city primary-care clinics. One of those, Jefferson Reaves Sr. Health Center in Overtown, gets 30,000 patient visits a year from the inner-city poor -- and serves as the training center for the University of Miami's family medicine program.

Half of the clinic's patients have chronic diseases -- high blood pressure, diabetes and others -- and if their conditions are kept under control in primary care, they stay out of hospitals, says Schwartz.

"If that clinic closed, there would be more strokes, more heart attacks," said Schwartz. "The ripple effects would just be enormous."

Among them: closing down training for primary care would mean fewer family-practice physicians, many of whom tend to end up in clinics treating the poor.

One clear issue for a smaller Jackson -- and a central theme of the need for healthcare reform nationwide -- is that, by law, the one place where people in America must be treated is an emergency room. "Everyone is entitled to be stabilized," said Daniella Levine, president of the Human Services Coalition.

"The problem is post-emergency care. Where do you go?" asked Levine. A person with breathing problems who doesn't get clinic help, for example, is likely to soon be rushed by ambulance back to the ER.

And they're likely to have longer waits in the ER -- if they can get in. Consider Jackson Memorial's emergency room, ground zero for the county's poor and uninsured. It gets more than 140,000 visits a year. One of the proposed cutbacks is to remove 45 beds from that ER -- almost half of its 96 adult beds -- meaning it is more likely to fill up. A full ER is put on "diversion," forcing ambulances to take patients elsewhere.

That will likely mean more ambulances going to the University of Miami Hospital, across the street from Jackson Memorial. "We're bound to see an effect," said William Donelan of the University of Miami medical school. So, too, he added, will the ERs at Mercy Hospital in Coconut Grove and Mount Sinai Medical Center in Miami Beach.

If Jackson North and South closed, it could send patients to a broad range of alternatives, from Homestead in the South to the Memorial facilities in South Broward.

"There's a real human cost," said Merrett Stierheim, a Miami-Dade leader for decades as top administrator at the county (twice), the city of Miami and the Miami-Dade School Board.

Stierheim points out that about 400,000 men, women and children in the county live below the poverty line. "And if you accept that about 100,000 or 150,000 more are undocumented" -- persons who generally can't get treatment except in emergency rooms -- "then you have more than 500,000 who are in need of a healthcare safety net. That's huge."

Stierheim has become a volunteer advisor to Jackson. On Thursday, he hosted a meeting of about 25 civic and business leaders at the United Way office to discuss the dire financial situation.

"Our feeling is that community leaders need to be aware of this problem and how big the risks are," said Stierheim. He and a smaller group of business leaders will "meet with Dr. Roldan and drill down into the plan and then report back to the group."

One of those at the meeting, Levine of the Human Services Coalition, said: "Ideally, all the different players in the healthcare system will recognize the interdependence and they will step up in an collaborative way."

REACHING OUT

Linda Quick, president of the South Florida Hospital and Healthcare Association, has organized a group of hospitals to pay for the treatment of about 100 dialysis out-patients who are already getting their funding cut by Jackson.

But Quick said some hospitals have hesitated to join that project because "they were worried that it was the camel's nose under the tent" -- the first of many money-losing programs that Jackson will try to offload to other hospitals. The area's hospitals say they can't afford that.

Kosnitzky, former head of the Trust, said it would be best if South Florida's healthcare providers would come together "to support Jackson in a more systematic way," offering primary-care treatments so that expensive emergency-room visits can be avoided.

He urged Baptist Health South Florida, the prosperous nonprofit, to get involved with Jackson's recovery.

"They don't want to write a check to Jackson, but certainly it's going to come out of their coffers," particularly if Jackson South, near two Baptist facilities, is shut down.

Baptist responded that it already pays community clinics $1.5 million to provide primary care for 83,000 patient visits. Going forward, Chief Executive Brian Keeley doesn't want to predict what the effects of a shrunken Jackson will mean to his system. "I really don't know until they announce a final plan."

All participants acknowledge that a thoughtful, coordinated recovery plan, improving inefficiencies in Jackson's operation, would be the best way to go.

But that takes time -- far more time than appears to be available. Because Jackson is projected to run out of cash in May, the Public Health Trust wanted 10 business days to decide on a proposed plan that would slash a third of the workforce.

The Trust scheduled a vote on March 22. The mayor said that was too slow -- he wants a plan ready for the commission meeting next Tuesday.

"We can come up with potential solutions," said Stierheim, "but the Trust doesn't have a printing press for money, and the county doesn't have a press."

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