A year ago, my mother had to go to Grady Hospital. We waited 24 hours in Grady’s dystopian, crazy-filled emergency room triage pen. I blogged through the last 16 hours of it.
Well, I’m doing it again. Journalism as performance art.
Right now, I’m sitting in Grady Hospital’s emergency triage ward. For 24 hours straight, I’m going to walk the halls of Grady, documenting everything I see as a live blog on Peach Pundit.
Grady is facing a $100 million budget cut of county, state and federal funds. If they lose that money, Grady is going to cut its mental health services and it’s going to be like killing the power on the containment field at Ghostbusters Headquarters.
I am aware of HIPAA and I’m not going to break the law. But unless people really understand what Grady has to do to get through a day, those cuts aren’t going to be viewed as insane as they should be.
Let’s see what a day here is like.
The hardest thing today, for me, has been confronting the merciless reality of how many Vivians inundate Grady. Vivian is at once a human being, flesh and blood, wit buried beneath a layer of destitution and at the same time representative of an unending maw of need. Vivian is fragile. Vivian needs help. Vivian will simply, anonymously and quickly die without help.
I say this not to be maudlin. And I’m not saying it because I want to make some emotional appeal. It’s exactly the opposite.
Grady seems so wrapped in visible chaos that people’s natural reaction is to run screaming in the opposite direction. Emotional distance seems sensible, but that distance somehow metastasizes into indifference. Reasonable cost-benefit calculations weighing the marginal value of a dollar spent on care here become lost because few enough care to take a close look around.
Good public policy can be cold and ruthless in the face of limited resources. Everyone cannot be saved. Some probably shouldn’t be.
But some can.
Vivian has some new clothes. A new pair of shoes. Someone in social services is going to track down her sister.
Robert Johnson, come to the front desk. You have been reaped, and will begin your training immediately.
“I don’t want to wait any more. I’ve been through it,” Cliff said. He’s got chest and hip pain. A bad heart, too, he says. “When they first told me fifteen hours. Now it’s eighteen. Still sitting and waiting to see the doctor. That’s entirely too long to wait. My time is just as important as the next person’s time. Your time isn’t important when you come to Grady Hospital. When you’re sick, you want to be seen. Hopefully it’s going to improve and make things better.”
And then … a demurral. “Grady is a good hospital. Don’t get me wrong about that. There are a lot of people here who probably shouldn’t be here. Homeless people. If you don’t have transportation when you leave, they’ll take you home. Grady takes on a lot. It’s just … people want to come here.”
When I sat down again in the ER waiting room half an hour ago, the wait time was 15 hours. A moment ago, a doctor and a nurse came out to say that it had lengthened to 18 hours.
Right now, there are 200 people in the ER and 120 people waiting to be seen. I’m not sure what happened, but if someone gets in a terrible accident or has a heart attack or gets shot, they’re jumping the queue.
It looks like a lot of people just jumped the queue.
Closing in on a day here. I’ve been sitting with a hospital administrator for a little while, talking about Grady’s culture and how it’s marketed.
Grady spends a bit less than two million a year on marketing. It’s chicken-feed compared to Northside or Emory Healthcare. While the spending Grady does is smart, there are natural limitations to how much the hospital can change perceptions based solely on paid outreach. The hospital relies on word of mouth from its patients. And when seventy-five percent of the patient load comes through the ER, that’s a double-edged sword.
Hence, the remodel of the ER.
The working culture here appears to have changed dramatically under the hospital’s new leadership. The hospital’s employees have withdrawn from a state of open revolt. Esprit de Corps. Which, given the war they face, seems appropriate.
As we sat and talked, I watched as a member of guest services wheeled Vivian back into the hospital. She pointed at me and smiled. I almost feel like I accomplished something. I know better, though.
I’m slowing down a hair. I have to really wonder how medical interns pull twenty-four hour shifts. It’s remarkable how much mental acuity goes away after even a few extra hours of active wakefulness.
I’ve been chewing on the numbers in Grady’s most recent annual report, and I still don’t quite understand where an increase of 22 percent in revenue comes from. The city’s population didn’t increase by a fifth overnight. I don’t think the hospital magically added an extra wing. There’s nothing in the annual report that explains the growth. Because indigent care kept pace with the growth, it appear organic.
How did they grow that? Understanding where growth comes from helps explain whether or not it’s sustainable — whether or not a seventy-four million dollar ER expansion is justified.
I’m going to start knocking on a few doors now.
A man is having a seizure in the chair next to me.
One moment ago, he seemed to be dead asleep. The next, he begins to shake. His arms thrust into the air as he starts to slide down in his seat. He’s grunting. His breathing is hoarse.
An orderly comes, and holds his head as it shakes back and forth. I hear a thump; his head hits the back of the chair, and the wall. I can’t tell if the orderly’s hand caught the brunt of the blow.
“Will you get me some gloves,” the orderly asks a guard. “We need a stretcher.”
A moment later, a physician’s assistant and a nurse arrive with one. They deliberately let him slide a bit farther to the floor. It makes it easier to get him into the stretcher. He falls face first onto the mattress. They wheel him off, through the double-doors to the ER proper. And life goes on.
I’m back in the hospital after a quick call to a friendly voice in the administration.
The morning rush is on. There’s a shift change afoot. The quiet and disquiet of the night is breaking, right along with the dawn.
Vivian says she can’t walk. I can’t tell if it’s true, of course. Her entire line might be her shining me on, but her physical appearance disturbs my untrained and inexperienced eyes.
The trouble with Vivian starts with her surroundings. She’s surrounded by madness in the literal sense. Through the night, a half-dozen people of questionable mental health have been variously shouting or panhandling or otherwise annoying people nearby, and it takes an unusual reserve of compassion or duty to see past that. Vivian is unapproachable because, in context, she’s easily dismissed as potentially disturbed.
As though any of us have some superior claim on sanity these days.
To that, add the bystander effect. She’s at a hospital. If no one is helping her here, it must be because no one really needs to. Nevermind the rain, and the cold.
I’ve had short conversations with both an Atlanta Police officer and a Grady security guard about Vivian, and more broadly about the state of human disorder surrounding the hospital at night. “People want to talk about top-down solutions, but if it doesn’t come from the bottom up, individuals helping individuals, it’s not going to happen,” the police officer said. “And on some level, people need to help themselves.”
The Grady security guard — in between performing spoken word poetry and referencing Ayn Rand — said as much as well. The Navy veteran has been watching the parade of mental illness accumulate around the hospital for eight years, And he says there’s no overcoming it. It’s a self-sustaining culture.
“Do you think people are going to want to pay to go through this,” he said. “If you have a burn, or get shot, or get in a car wreck, there is no better place than Grady. But if you have a cold? Regular people aren’t coming here.”
I left Vivian for a moment to write. I’m being panhandled for the third time tonight. “I need a quarter to get a cup of coffee,” he says. I reach into my pocket, and he immediately asks for fifty cents, then a dollar, then fifty cents again.
I have a quarter.
Vivian is still out here.
It’s forty-five degrees. The wind has picked up, and the light rain doesn’t feel all that light any more. It’s cold, man.
Her red and white striped umbrella is folded at her feet. I assume it’s because she’s afraid it’s going to blow away. She’s hunched over again. There’s a rivulet of mucus on her left pant leg, but you can’t really see it unless you’re sitting next to her.
A guard shooshed me away from the benches outside of Grady’s ER two hours ago, while I was sitting next to her the last time. He examined her Grady bracelet, noted that she had been discharged three days ago, and asked her to move, too. She asked for a wheelchair. He told her that he would bring a wheelchair for her. Two hours ago. I left. I’m back. And she’s still there, hunched over like she’s tying her shoes.
She’s not asleep.
I grabbed a third-year Morehouse medical student as he was walking into the ER. I told him that she’d been out there for hours, and that I was worried about her level of responsiveness. I have no idea what’s too little responsiveness, in any medical sense of the word, of course. He said he would ask someone to help. But I must look like one more homeless person trying to button-hole a doctor with too little time to spare right now.
Grady’s long-term plan involves broadening its client base beyond the urban underclass of Atlanta, with more insurance-covered patients. I’m wondering how tough a sell that might be tonight.
I find myself reaching for signs of normality around me. The fellow playing a furious full-volume game of Candy Crush Saga at the table behind me (Divine! Sweet! Delicious! Tasty!) implies ownership of an Android device of reasonably recent vintage.
“Come outside, you punk bitch!” A man wearing a medical mask shouted at one of the McDonald’s cashiers, pointing. He was addressing a woman.
Jack and I are silent. So are most of the patrons here after that.
If the shouting doesn’t do it, the smell of ass wafting through the air is probably a barrier to entry for folks living in Decatur and Virginia Highlands.
I’ve been sitting in the completely health-inappropriate McDonald’s with Jack for the last hour, people-watching next to Grady and talking about the merits of rebranding the hospital under Morehouse’s university moniker.
I’m not out of the game tonight. Far from it. Getting spooned out of the pudding is probably closer to an authentic Grady experience than I might have otherwise expected.
I still find it highly peculiar that Grady treats an urban population with a diabetes rate around fourteen percent has one late-night meal option close to the hospital: McDonald’s. Yes: there are healthy options at McDonald’s. Yes: people should take responsibility for what they eat. Yes: there is nothing inherently evil about McDonald’s.
Except their french fries.
The cops came in to McDonald’s a few minutes ago, to roust people who had overstayed their welcome. Apparently, nursing a McCafe coffee at a table doesn’t cut it.
I’ve been spooned out of the ER. I suspected this would happen, despite getting the high sign from a Grady spokeswoman earlier this evening.
The security guards have decided that I shouldn’t be in the ER. My contact at the hospital hasn’t sent me an email that I could show the folks at the desk. I am unofficial. So I’m outside. I’ll wait here, or in other places around Grady, until the cavalry shows up later this morning.
I’m sitting with Vivian. And I’m being spooned out of here as well by another officer. She’s being run off as well.
The people who are most tired are also the people least likely to be asleep.
Folks who have been waiting for half a day are close enough to being called to want to remain awake, just in case their name is called unexpectedly.
A clinic assistant with three security guards have begun roaming the waiting area, double checking wristbands of the people in the waiting area. Three seats down from me, they shake a man awake. “Where’s your wrist band?” the assistant asks. He doesn’t answer. “Time to go.”
Wordlessly, he rises and ambles slowly to the door, looking around for some source of potential respite, or perhaps a way back into the room without being seen.
It’s forty-nine degrees outside, with a light rain.
“Please listen for your name!” she shouts after making a pass through the room. “Let me know if you’re here so that I don’t take you out of the system.”
A woman is taking a bath in the bathroom.
Which, when you think about it, makes a perverse kind of etymological sense.
“When I went to the bathroom, there was one man waiting in line, and then me,” my seatmate said, setting the scene. “We were waiting for something like fifteen minutes. We talked, trying to figure out if anyone is in there.”
It seemed inappropriate for them to knock. Given the circumstances, there’s something disturbing about trying to rush a sick person out of the bathroom. “But, you know, something could be wrong with her. Soon, there were three more people standing in line. We were waiting for a nurse to come and check at this point. I said, ‘Look, I don’t know if someone is in there sick, dead or what.”
A nurse arrives to restore order. ”Ma’am, you’ve got to come out there.”
A frail voice replies. “I’m taking a bath!”
She opens the door. The bathroom is rank with urine. The woman’s clothes are a spill all over the floor, with more piled up on a walker. She emerges, clothed.
I downloaded Second Life. Someone shoot me.
Still here. I’ve been talking with Jack McClure, a hospital IT guru and an avid observer of the health care financial madness afflicting Georgia. Jack came down at midnight to chill with me in the waiting room … because apparently my blogging induces insomnia.
As we’ve been standing here, watching people fall asleep, he posed an interesting question. Suppose Deal did take the Medicaid money, or found some other way to cover the uninsured public caught between affordability and the Medicaid income cut-off? Would what we’re seeing here change?
Would Grady’s ER not be filled with the city’s poor?
I think it’s possible that a whole lot of people would find primary care physicians, or perhaps urgent care facilities, if they had insurance. Plenty of people here are poor. But plenty others are simply uninsured, and know better than to come to Grady when they suspect they’ll be facing a fourteen-hour triage.
“I wonder why there aren’t a bunch of physician’s assistants camped outside of the ER, offering to take care of problems for forty bucks a pop instead of taking the wait.” Jack said.
Now, I would trade forty bucks for ten hours of my life back. But I’ve actually got forty bucks.
It’s started to get really quiet.
I’m sitting next to Gary, a fellow who says he is waiting for treatment for a pulmonary embolism. “They told me not to shave, because they don’t want me to bleed to death. They tell you when you have shortness of breath, you come to the ER. And then they make you wait all day. The wait time itself is scary.
Gary, 56, is homeless. He’s also a college graduate and a former marketing guy for AT&T. He holds a political science degree from Howard, and would head to Capitol Hill during school to watch legislators work. He both looks and sounds a bit like Avery Brooks. He came here in 2009 with a good job and a home.
A layoff took his job, and then his home. The health problems made the trifecta for impoverishment.
“I feel like a bum,” he said. “I look like a bum. But I’m not a bum. Before this happened to me — not just the medical issues, but the financial stuff — I would have never known it was like this here.”
Budget cuts for no reason.
When a hospital goes “on diversion,” that means that it’s full. It’s a warning to ambulance services that no new patients can be admitted.
The nurses came through a moment ago to give people a status update. There are about one-hundred and one people waiting for care in the ER waiting room. About one-hundred and eighty are in the ER itself. “We thank you for your patience. As you can see, this is difficult for us, and for other hospitals as well. There’s crowding everywhere.”
Take a look at the diversion notices for Atlanta.
This table isn’t comprehensive; some hospitals don’t bother to report here … they just go on diversion. Basically, every hospital in metro Atlanta with an emergency room is on diversion right now. Technically, Grady is on diversion. Only, not really. Grady is never on diversion. They’ll take patients, regardless.
The scandal is that hospital administrators are quite aware that people coming through their emergency rooms are statistically much more likely to lack insurance and result in indigent care than their standard patient load. The financial incentive to divert to Grady isn’t counter-balanced by any meaningful requirement for hospitals to maintain emergency services in any proportion to their total revenue or relative to the size of the population they’re supposed to be serving as stated in their certificate of need.
This is why Grady is going broke.
My seatmate just exchanged words with a woman who had appealed to the crowd for a seat. Her leg hurts; she’s got a rod holding her right leg together, and it hurts to stand.
The fellow next to me has been waiting to be seen for the last 13 hours or so. He came in complaining of numbness along one side of his body, and had no interest in giving up his seat. The two started tossing snide comments at one another, comparing scars like it’s St. Crispin’s Day.
A moment ago, he got up. Seat space looks like it’s going to be a point of contention.
She’s now showing the people around her pictures of the bread she bakes at home. She wants to start a cooking blog. “I only eat whole grains. I don’t eat white bread.”
I can feel the eyes around me rolling.
“Environmental Services, to the waiting room, Environmental Services to the waiting room.”
A woman is gingerly spreading a blue absorbent cloth on the floor in the waiting room, while the smell of urine drifts through the room. Downwind, another woman rushes quickly to a tan garbage bag, steps on the foot pedal to open it, and vomits inside.
“Environmental Services to 305, 306 and 308. Environmental Services to 305, 306 and 308.”
“Whoever has the pencils, would you please bring them back,” a nurse shouts to an indifferent crowd. “We only have three of them, and there’s nothing for patients to use to write! Whoever has the pencils, would you please bring them back?”
We’re starting to enter the rough period. Last year, this is right about the moment when the amount of distress around me rose to the level where I needed to start writing about it.
I don’t hold it against Grady, of course. It’s the nature of the world.
“David (not his real name) Owens! David Owens!” The front desk has been calling for him for the last ten minutes.
A fellow has dragged a small plastic chair over to one of the regular seats, ostensibly to rest his feet. He’s immediately admonished by the staff. We’re now out of places to sit.
“David Owens!” Someone? Any one? I’m waiting for people to start standing up Sparticus-style. “I am David Owens!” “No, I am David Owens!”
David Owens! Present yourself, or you will be killed and eaten for dinner, sir.
The guy sitting across from me has taken note of my laptop. We started talking a bit about Facebook. I rather assumed that he wants to sign into Facebook to check in with friends and family while waiting in Purgatory. Not so much.
“Ever play Second Life?” he asks.
Second Life? Really? Am I going to have to dredge up my old Friendster account while I’m at it? But he’s serious.
“You can make real money there,” he notes.
The lady with the purple nightcap on has finally managed to start getting on some people’s nerves.
A taciturn fellow sitting next to me, out of nowhere, turned to me a moment ago to tell me just how much he wished she would stop complaining about not being seen. He’s been here since nine this morning, while she’s been here all of five hours, he notes.
“It’s like going to jail. It’s like getting locked up and thrown in jail.”
Donte is waiting for the transportation van outside. He’s wearing a hat that looks an awful lot like the one Jayne wears in the Firefly TV series, a crazy red-and-green jacket and red pants that are unintentionally Christmas-like. He sounds just exactly like Chris Tucker. And he’s just been discharged from Grady’s psych ward.
I don’t know what to believe, but I shut up and listen.
“All the doors are locked. There ain’t no bars. You know those plastic couches? That’s your bed. A little couch with the square pieces that go to it?” He’s referring to a footrest. “That’s your bed. They got another room in the back for people who have good Medicare,” he says.
So. How do they handle people who are dangerous there? I ask.
“They just give you a shot and take you in the back and strap you down,” he says. Thorazine. “People are trying to shoot me with the needle, and I ain’t need no needle. So I try to resist the needle, and he hit me, bang, my arm with the baton. I’m telling the doctors trying to stick the needle in my arm and I don’t need that! I don’t want that! I ain’t cutting up. So he has the baton in one hand and banged my hand for no reason.”
Donte is excited.
“So I just took the needle and squirted it in the air. Shh shh shh shh shh.” Donte’s arm waves like he’s Tony Montana with an Uzi and a point to make. “Everybody is going to get some. And then he came over and stuck the needle in my leg and strapped me down. It’s like going to jail. I ain’t never coming here again.”
“Environmental services, to room 308, environmental services, to room 308.”
We are watching the stop-motion film “Santa Claus is Comin’ To Town” on ABC.
There’s something weirdly menacing and surreal about the juxtaposition of that film on the relatively small TV wired to the ceiling and the really terrible smell of someone having crapped their pants wafting from the front row.
People nearby are holding their hands over their faces, breathing through their jacket sleeves, but there’s no really strong, visceral reaction from anyone nearby. It would seem … rude … to acknowledge the indignity of the moment.
I’m seeing some of the fatigue setting in in the room. The animated conversations filling the air at two in the afternoon have started to give way to people trying to figure out how to take a real nap while they wait for their name … without missing their name, of course.
A nurse comes through in various states of exasperation, shouting names every 15 minutes or so. It’s impossible to tell what ails most people here.
The ethnic mix has changed a little bit. A few white faces dot the crowd. Again, I only mention this because in Atlanta, any place that’s uniformly black or uniformly white is such a social aberration that it probably merits a word.
The last time I was here, the power outlets always seemed to be a source of tension. Grady’s waiting room feels like it’s about a hundred years old. While there are 80 people waiting for someone to heal them, there are exactly six wall outlets. People found themselves in heated negotiations for a couple of minutes of juice for their phones. Given the fact that there’s a fifteen-hour wait to be seen and there isn’t much to do except wait and play Candy Crush Saga or Tiny Death Star, the ER quickly turns into a room full of people out of power.
I brought a power strip. I am very popular.
I stepped outside for a moment. It’s grown dark, but it’s not too cold yet, or raining hard. Curled metal benches line the walkway next to the emergency room. One is occupied.
You can’t see a face under the big red-and-white umbrella. You can’t see much of anything, hunched so far over that the lonesome figure in the brown leather coat hidden under an upturned hood could be tying shoes. No one could sleep in that position, with an umbrella covering up like a blanket. An anonymous figure, alone and quiet, laid low, ignored by the handful of people walking by.
I sat down.
“They just walked on by. They don’t give a crap about nobody out here. They don’t care.”
Her name is Vivian. She’s 67, she just found out. Slight, missing teeth, a couple of rubber bangles on her wrist below the white plastic Grady admission bracelet on her left arm, a couple of dollar bills carefully hidden, cupped in her left hand. It’s an indignity to note it, but she needs a bath. I’m the first person who spoke to her since she Grady’s people walked her out of the hospital hours ago.
“They put me out in the middle of the night,” she said. “They used to have a lot of bums in there. I understand. I’m not a bum. But I can’t stay out here, in the street. I can’t do it. I’ve worked, I have income, I get Social Security. I’ll go into a senior citizens’ home if I have to.”
I offered her an orange, and asked her if she had anyone she could turn to. She said she’s been homeless for a couple of weeks. She gave me a phone number for her brother in Decatur. I called it, expecting it to be disconnected. But her brother answered. I told him where I was and where she was.
“I’ve let her stay with me four times,” he says, clearly distraught. The timber of his voice changed. He grew quiet. “I don’t know what to do. My wife said she would leave me if she comes and stays again. I’ve placed her in homes before.”
“Give me half an hour, forty-five minutes, and I’ll come get her,” he said, using the kind of tone reserved for getting creditors off the phone. “I’ll talk to my wife, and I’ll come and get her. Give me an hour.”
The wait time is now up to fifteen hours between arrival and treatment.
It’s going to be one of those days here. It’s Monday, which is always slammed. It’s raining, which increases the likelihood of car accidents. And it’s cold, which means more people coming to the ER just to get out of the cold.
Not long ago, the friendly woman sitting next to me shouted at a passing nurse, to say that her chest hurts and she has trouble breathing.
The nurse didn’t exactly brush her off, but this looks like a dance the two of them have done before. As the nurse turned away, my new seating companion looked around at the crowd, as if to ask if anyone saw that. “I just said that I have trouble breathing,” she repeated.
Breathing problems are one of the indicators of additional trouble that bump people higher in triage priority … and up the queue. It’s what gets people out of the crowded ER waiting room and into the crowded halls of the ER itself, where people are often stacked up on beds in the hallway because there’s no space in an actual room
Most of the time, when a hospital decides it’s going to expand services, it starts a slap fight with other hospitals fearing the added competition. Building a new hospital, or adding to an existing one, requires a certificate of need in Georgia. The hospital has to demonstrate that there’s enough demand for the services to justify adding capacity in the market.
It’s anticompetitive, of course. But that’s kind of the point. If the market becomes oversaturated, doctors might just start sending more people to hospitals unnecessarily or changing their diagnoses to drag more cash out of the diluted patient pool.
So there’s almost always an expensive challenge made when a hospital decides to file for an expansion.
Well, Grady filed for a certificate of need in September to do a seventy-four million dollar expansion and renovation of its emergency department. Given the twenty-two percent increase in the amount of services it provided last year, that expansion seems merited. The changes will boost its ER capacity by about 20 percent and will, hopefully, reduce wait times.
You know who filed a challenge? No-damn-one.
Grady’s leaders hope this will start drawing more insurance-carrying patients into its ER. Nine out of ten don’t have coverage, according to this piece from the Atlanta Business Chronicle. If Grady can change its patient mix and bring more insurance money into the hospital, it might solve its long-term financial issues.
The decision deadline on Grady’s certificate of need is January 16th, about a week before Fulton County decides if it’s going to cut the hospital’s legs out from under it.
I’m trying to squeeze in as many interviews with policy making-types as I can before five p.m., since most of them will be heading home soon.
I spoke a moment ago with Brian Robinson, Governor Nathan Deal’s deputy chief of staff for communications, about how the governor views the effect of refusing the Medicaid expansion on hospitals like Grady, and on rural hospitals that have also been closing or threatening to close as a result.
The short take, on his position: It’s not Deal’s fault. Blame Obama.
The ACA cut payments to hospitals taking lots of indigent patients with the expectation that Medicaid expansion would make up the difference. If the federal government wants to solve this problem, it can by reinstating those payments or finding another way to cover those costs, he said. But the U.S. Supreme Court ruling that affirmed the right of states to refuse to take federal Medicaid money changed the game.
“They’re imposing a huge mandate on the state,” Robinson said. “The administration has not conformed to the new reality. … There’s a gun at half of the state’s head over this issue. We’re not the outlier. We’re one of half of states.”
Robinson’s argument is that taking the federal money also incurs a financial obligation, one that hasn’t been fully disclosed. He disputes the presumption that the state would only have to pick up ten percent of the costs associated with expanded Medicaid in coming years. “We can’t afford the ‘real’ portion,” he said. “There’s no way the state is going to keep funding at ninety percent. That’s malarkey.”
Instead, Georgia policy makers are considering other models. Arkansas, for example, has been moving people onto private insurance instead of Medicaid. It’s certainly something that the state is going to look at and take seriously. We’re constantly crunching the numbers. But I don’t think there is a ready answer on the horizon.”
I don’t think his argument about the costs of expanded Medicaid holds water. If the federal government is picking up anything like 90 percent of the costs of expanded Medicaid — eighty percent, or seventy, or even sixty percent — the value to the state in increased productivity and labor competitiveness far outweighs the costs. If the value of the expansion is only a one-hundred percent return on investment instead of a nine-hundred percent return … it still beats the hell out of most ways to spend money, public or private.
And calling for the federal government to simply reinstate DSH payments gives short shrift to the degree of gridlock in Congress to make such a move, and the practical limitations of the president to simply change the rules through regulatory order.
Howard Mosby just cruised through the ER waiting room. Random. He didn’t see me until I shouted at him as he was walking back into the hospital.
Mosby is a state representative covering part of Decatur. He’s chairman of the DeKalb legislative delegation. And, as I often forget, he’s also Grady’s Vice President of Medical Affairs and the hospital’s former auditor.
He told me he sat in on a meeting this morning between the Fulton County legislative delegation and the Fulton County board of commissioners. The board, it seems, is trying to argue that they’re not really cutting twenty-five million from Grady’s budget because they’ll be contributing sixteen million or so to cover the new bond obligations Grady incurred after its 2008 financial restructuring.
Mosby isn’t buying it. The Fulton legislators aren’t buying it. The health care advocacy community isn’t buying it. “It’s not operations,” he said.
But that’s the spin.
Meanwhile, the smell of urine is wafting through the air in the emergency room waiting area. Things appear to be getting back to normal.
A Grady EMS paramedic just walked an older African-American woman gingerly through the room to seat her in an open chair. She’s wearing hospital scrubs and a purple nightcap. I thought at first that it was a hospital-issue cap, but she apparently brought it with her.
She appears completely comfortable in the waiting area. She greeted the crowd like old friends. “How’s everybody doing?” she said to everyone, and a low chorus of “how are you, mother?” echoed back.
“Been blessed, been blessed,” she replied.
She asked me how long the wait would be and I told her about 12 hours. She yelped. “I wouldn’t have come here, telling them that I’ve got chest pain and what, if I thought it was like that today!”
The paramedic handed her an electronic notepad to sign off. ”You’ve been through this once or twice,” he said, smiling. “You know the deal.”
She’s missing half her right foot, and it hurts, she said. “My feet hurt. I need a wheelchair, but no one will bring me a wheelchair. I’m having chest pains and I can’t even pee-pee.” Her daughter called an ambulance about two hours ago after the chest pains started and her blood sugar started falling. She lives in midtown.
I asked her how often she’s had to come to Grady. “I’ve been coming here since 2009 … but I can’t count it. I’m kind of not all together right now. My sugar dropped down so low.”
I told her I would be here until noon tomorrow, and she looked at me like I’d just dismounted a unicorn. ”You’re going to leave the same time as me!” she hollered.
The formal responses to my Grady adventure are starting to emerge — a member of the hospital staff came down a moment ago to make sure I’m playing nice.
And I am, in relative terms.
Grady Hospital itself isn’t the problem, of course. I think they’re doing an admirable job given the conditions.
The spokeswoman for the Fulton County Sheriff’s office tells me that they don’t really have a financial dog in the fight — that they’ve got a self-contained medical facility.
I expect a call from John Eaves at the county commission sooner or later.
“Everybody knows its the thirteenth floor. Even people who don’t work here knows it’s the 13th floor.”
I’m sitting next to a nineteen-year-old woman with a nine-month old baby on her knee. Their wait will be short, a mercy in a sense. Her cousin was driving a MARTA bus on the highway near Candler Road earlier this morning when it began hydroplaning. She cracked up, causing a four-car pile up. She’s injured, but not critically. But the driver was pregnant. She’s in the trauma ward now.
She works here.
“I sit with patients who can’t walk, or are having seizures or stuff,” she said. Most of the time she works in other parts of Grady, but she has had service in Grady’s mental health ward, on its thirteenth floor.
“It’s not like people think. People think it’s really scary, but patients are really calm,” She said. Then … she demurred a bit. “Well, people get really rowdy when the sun go down. But everything is organized.”
Orderlies and aides have to take a week-long self-defense class to work the thirteenth floor, she said. “They teach you how to calm a patient down, so they won’t bite you, stab you or spit on you. They teach you how to but the mittens on. And the vest, like a straight-jacket, but just a vest. You tie it under the bed. It takes two to put one on. They’ll resist a lot.”
She hasn’t yet had to restrain anyone. She hasn’t been stabbed, or bitten. She’s been spit at, but they missed, she said. “I have had a patient throw pee on me,” she said. But that wasn’t on the thirteenth floor. Mental patients aren’t always on the 13th floor. And you don’t have to be a mental patient to decide it’s a great day to fling poo, it seems.
She earns nine dollars an hour. Ten with a shift differential.
A nurse came out a moment ago and stood in the middle of the waiting room.
“I want to thank you for coming to Grady, and I want you to know that we care about you!” she shouted. “We have one-hundred and sixty five in the emergency room, and eighty-one that are waiting to be seen.”
She told people that if they had been given tests, those tests are being evaluated. “If you feel like your condition has changed, or your pain has changed, please see one of the nurses in the back. Thank you.” As she turned to leave, a handful of people approached her with questions. Some beckoned her to them.
This whole interaction with the people in this room is new.
Last year, waiting with my mother, it was hard not to notice the studious indifference of staff to the length of time people were expected to wait for service on a busy day. Apparently, someone comes out every four hours to make this kind of solidarity announcement now.
So, Grady stands to lose forty-five million from Deal’s decision to reject Medicaid expansion. The hospital faces an additional twenty-four million loss from Medicaid budget cuts.
And, on top of all of that, add the frankly inexplicable intent of the Fulton County Board of Commissioners to cut their contribution to Grady Memorial in half.
As Michelle Wirth reported for WABE, the county’s 2014 budget calls for a twenty-five million cut in payments to Grady.
A few years ago, Grady’s financial condition had deteriorated to a point where it was quite likely to have had to eliminate its level one trauma services.
Grady is the only level one trauma center in Atlanta. (Whoops — Atlanta Medical Center received level one designation in 2011, it seems.) Without a level one center, NASCAR won’t race near Atlanta, insurance premiums start spiking for Atlantans and many, many more people die. So the financial patrons of the area banded together, installed new management and started righting the ship.
For the most part, Grady had regained solvency. In 2012, Grady booked revenue of about eight hundred and eighty million, an increase of about twenty one percent and one of the largest periods of service growth in its recent history. However, about two hundred and sixty one million of that revenue was considered uncollectable.
Between 2011 and 2012, Grady’s provision of free care grew by about seven percent. Last year, uncollectable accounts grew by twenty-two percent, in tandem with its overall service growth.
Grady appears to be pretty efficient. While its service provision grew about twenty-two percent, its cost for offering those services only grew by about ten percent. Put it this way: every additional dollar spent on salaries last year resulted in twice as much health care getting to patients.
But Grady still operates at a deficit without help from the county and the state. Last year, without DeKalb and Fulton County kicking in, Grady would have lost about thirty-six million.
Take out the federal cuts and Fulton County’s contribution, and Grady is bleeding money again. The only way to manage that is to find things that lose money at the hospital and cut them.
What would Grady cut? Well, it will stop providing care for county prisoners. Half the people I’m starting at in this emergency room would find themselves in the ill-equipped clinics of Fulton and DeKalb County … which is probably going to turn some of their frankly non-emergency health problems into emergencies.
And Grady’s outpatient mental health services would be redirected to county clinics, too. We’ll talk about what that looks like in a moment.
Apparently, numbers aren’t coming through on posts. I’m working to fix that.
The one thing I know has changed is the level of financial threat Grady faces today.
The problem starts, believe it or not, with the Affordable Care Act. Grady is considered a “Disproportionate Share Hospital,” one that takes an out-sized portion of indigent patients. Until the ACA passed, the federal government sent money directly to these hospitals to offset some of their costs for treating poor, uninsured people.
But as the Washington Post noted in a story earlier this year, “Disproportionate Share Hospital payments — DSH for short — were supposed to be gradually reduced by an estimated seventeen-point-one billion between 2014 and 2020. Public hospitals have long relied on federal DSH funds to offset the costs of treating a large number of uninsured patients. Requiring states to expand their Medicaid programs would have brought in new money that more than offset the DSH cuts.
But things turned in June 2012 after the Supreme Court left it up to states to determine whether they wanted to expand Medicaid. Some conservative state leaders, including Georgia Gov. Nathan Deal, quickly and staunchly rejected what they viewed as another growing entitlement program.”
Deal is turning down about thirty-three billion dollars from the federal government over the next decade more than 90 percent of which comes at no added cost to Georgia. Georgia would pay nothing during the first three years, and 10 percent of the cost after that.
Grady’s share of that is about forty-five million.
Late last year, my mother had been complaining constantly about a pain in her lower abdominal area and weakness in her legs. She hadn’t seen a doctor in about 10 years. A few months earlier, she lost her job as an electronics inspector, and with it her meagre insurance coverage.
When I saw her frantically looking for a health policy over the weekend that December, it became clear that she needed medical attention.
We called first. My mother and I were on hold for about 45 minutes waiting for a nurse to walk her through the basics before directing her to see a doctor within 24 hours. When Mom said she was uninsured, the nurse directed her to the walk-in clinic on Jesse Hill, right next to Grady.
The only alternative would have been to wait for a charity clinic’s hours. The charity clinic on North Decatur is open Wednesday and Thursday from 6 p.m. to 8 p.m., by prior appointment only.
So off we trundled, right around 10:30 on the morning of December 10, 2012, to Grady’s clinic. Five hours later, we were told that she would need real testing, and that she needed to go through the ER.
They had a 17-hour triage wait at that point.
I’ve deliberately chosen the second Monday of December to replicate that experience. I want to see whether anything has changed.
Out of respect for the medical privacy of folks I may write about today, I’ll either be posting people’s comments without their full names or posting their comments without getting into the reasons they might be here.
That said, I find myself sitting next to Sherri, who works in Kroger’s meat department in Sandy Springs, lives in Clayton County, and couldn’t care less if I use her full name or not. “That’s the problem. People don’t want God in their Kool-Aid,” she said. She has been meticulously sharing the Gospel and her personal testimony with whoever happens to be within arm’s length. “You’re dealing with me and Jesus, and not the hospital.”
She’s waiting here because her 27-year-old son is bleeding in uncomfortable places. She’s insured. He’s insured. They’ve had a bad experience or two with hospitals in Clayton County, which leaves Grady as the next option.
“Grady is a good hospital. It has the top-notch doctors. They’ll take good care of you,” she said. “If you go to a good private hospital, you have to have good insurance to get seen.”