The Death of MLK: Demise of LA Hospital Sends Shockwaves Through Ailing State Emergency Care System
Article Outline
- Scrambling in the Aftermath
- The Beginning of the End
- The Horror Stories
- Politics and Race
- Bandaid on a Hemorrhage
- Impact Without Measure
- A Darwinian Contention
- The Ripple Effect
- The White Hats
Nearly 4 years of mounting problems ended quickly in mid-summer at Los Angeles’ Martin Luther King Jr.-Harbor Hospital. Federal inspectors forced the final closing of the beleaguered county medical center, once the pride of impoverished South Central Los Angeles.
The shutdown added to what many are calling a growing crisis in emergency medical services for Southern California. The loss of King-Harbor’s 29 emergency treatment beds worsens an already over-stressed system, emergency physicians said.
“We’re the epitome of a dysfunctional system, day in and day out,” said Dr. William K. Mallon, president-elect of the California chapter of the American College of Emergency Physicians.
“The system is near collapse, but the process is a slow one. I don’t know when it will catch the attention of the general public out there,” Mallon said. “It really should be alarming to them, but, because it is happening slowly, they don’t see it.”
Mallon and others said 70 emergency departments (EDs) have been shuttered in the last 2 decades in the state. In Los Angeles County alone over the past 4 years, 11 have closed (one was later revived).
The County Board of Supervisors, which oversees emergency medical services, offers up statistics indicating that any countywide crunch has been eased over the last few years, noting a recent decline in diversion hours. However, those overall figures hardly silence the concerns.
Jim Lott, executive vice-president for the Hospital Association of Southern California, said the current trends are causes for alarm.
“Literally, over the last 2 1/2 years, they’ve taken out the capacity for a 100,000 emergency room visits a year,” Lott said. “….You take all of those combined, and there is a synergistic mal-effect on that area.”
Asked about potential solutions, Lott said without a hint of humor: “Pray. Every night, every morning, every chance you get. Pray.”
Scrambling in the Aftermath
Divine intervention aside, there are several actions and proposals being pushed in that region and across the state. Among them:
1) County Supervisors implemented an interim plan to shift the 47,000 annual emergency patients of King-Harbor to 9 surrounding private hospitals, with county compensation to those medical facilities.
County officials said the rerouting of cases is generally working out, although new service trends have yet to be firmly established. Some of their official assurances, though, clash with reports of ED waits of up to 18 hours at some impacted hospitals. The Los Angeles Times reported that the King Harbor closure, along with other escalating problems, leaves more than 20 area hospitals in danger of closing or declaring bankruptcy.
2) County Supervisors are also pressing forward with Requests For Solutions (as opposed to “Proposals”) from other medical institutions possibly interested in contracting to reopen King-Harbor. Even if an operator can be found, it would be at least a year before the hospital would be back in service.
3) Legislators acted to keep more than $100 million in public health care funds—money that had been destined for King-Harbor until it closed—within the Los Angeles area. Otherwise, that money would have been dispensed to hospitals on a statewide, rather than regional, basis.
Emergency physician Michael Salomon, president of California ACEP, described a bleak scenario at the state level. Emergency physicians are facing continual attacks from administration-entrenched HMO interests to drive down medical costs, while calling for further reductions in programs to compensate doctors for care, he said.
“We are sick and tired of funding the system because the government won’t do it,” Salomon said. “What’s happening in Los Angeles is the start of the collapse of the system. The only silver lining in that cloud is it may prevent the collapse from spreading further.”
How the county handled that responsibility with King-Harbor still sparks controversy. County Supervisors tried to avoid discussion of blame as it became obvious that the hospital headed toward inevitable collapse.
It had opened in 1972 as a shining example of health care reform in the aftermath of the Watts Riots of 7 years earlier. Then-Governor Pat Brown commissioned a panel to examine causes of the civil unrest in the Watts area. Plans for a new hospital emerged from one reason cited for the riots: a lack of adequate access to medical facilities in that section of South Central Los Angeles.
Martin Luther King Jr. Hospital became King-Drew soon after opening, to reflect its revised status as the teaching hospital of nearby Charles R. Drew Postgraduate Medical School. It would evolve into a central part of the Drew/UCLA Undergraduate Medical Education program. The 537-bed hospital employed nearly 2,400 workers, treating 167,000 outpatients and 11,000 inpatients annually on a budget of about $400 million.
The Beginning of the End
Chronic issues began to escalate about a decade ago. Medical agencies started withdrawing accreditation or support for the hospital, for failure to find and correct problems, some of them involving blatant patient neglect.
The American College of Surgeons lifted its approval of King-Drew as a trauma center after inspections in 1999 and 2002. Later, state inspectors had the county remove the hospital’s designation as a pediatric trauma center. The Joint Commission also criticized the performance of the trauma center.
The deaths of 3 patients in the cardiac monitoring section led the County Department of Health Services to shut down that unit in late 2003. Five other questionable deaths and more lapses in patient care brought increased scrutiny from the US Centers for Medicare and Medicaid Services (CMS) in 2004. Twice, it found that hospital police were relying too heavily on using conducted electrical weapons to control unruly mental patients.
The hospital would show improvement, only to lapse again and again into sanctions by the state or federal agencies. Problems seemed to span the range of services there, from the pharmacy to the ED.
Reviews by CMS showed that some nurses did not know how to mix or prepare medications; others had either removed patient monitors or silenced them, resulting in some deaths. Basic equipment was not properly sterilized. Substandard training and poor supervision were regularly cited as problems.
All this earned the hospital the informal name of “Killer King.”
In late 2004, the Board of Supervisors brought in Navigant Consulting Inc. on a $13.2 million contract to run the hospital, with little effect on the quality of care.
Within months and after 8 more questionable deaths, County Supervisors angrily demanded that their then-director of the Department of Health Services relocate his office to the hospital.
“Take your schedule, tear it up and spend every moment that you’re working for us on solving the crisis,” then-board chairman Gloria Molina told the director. Supervisor Yvonne Burke vowed, “That hospital will be closed over my dead body.”
Two years later, CMS reported that King-Drew had failed a pivotal inspection that would strip it of $200 million annually in federal funding. In an agreement with CMS to extend funding, County Supervisors reduced the hospital bed count to 42, a decrease of more than 75%. Supervisors also turned management over to Harbor-UCLA Medical Center, making it the King-Harbor Hospital.
The Horror Stories
Despite the focus on the hospital, horrific episodes continued. A middle-aged woman was escorted in by her companion last May. She complained of severe abdominal pain and was soon vomiting blood and thrashing on the floor. During the next 45 minutes, 911 operators received calls from her boyfriend and another person, pleading for them to send an ambulance—they were rebuked. Security cameras showed a hospital maintenance worker calmly sweeping up beside her body, shortly before she died.
During a final federal inspection 2 months later, CMS personnel themselves witnessed a mental patient cutting her arms with a scalpel she had taken from the ED.
The CMS letter arrived at the hospital on August 10: “We regret to inform you that the most recent survey of (King-Harbor) has revealed that the hospital is not in compliance with a number of Medicare Conditions of Participation.” The agency was terminating the Medicare provider agreement. King-Harbor remained substandard in 15 of 23 categories evaluated earlier, CMS reported.
Days before federal funding ended, staff shortages brought on by no-shows and earlier departures caused the county to issue a declaration of an “internal disaster,” closing the ED.
Some health care professionals find it hard to believe that county officials could not have rescued the ailing hospital after almost four years of warnings.
The Board of Supervisors was adamant that the failure was not due to a commitment for funding. “It cost a lot more to run, but the quality of medical care actually delivered there was seriously substandard,” said Joel Bellman, a spokesman for County Board of Supervisors’ Chairman Zev Yaroslavsky.
“In fact, over the last 4 years, the board was engaged in an almost entirely unanimous and very costly multi-pronged effort to invest in a number of different strategies…to turn that place around,” Bellman said.
County Supervisors had the Drew University relationship revised. They completely overhauled the management, brought in the consulting firm, reconfigured services, installed a “strike force” of health department supervisors, conducted staff reviews and retraining efforts, recruited an administrator from the outside “and basically gave her carte blanche,” and repeatedly gained CMS extensions, Bellman said.
“Finally, we ran out of time; we ran out of extensions. We spent millions of dollars, but it wasn’t enough.” Bellman conceded that King-Harbor “wasted a huge amount of money -- just squandered. Some of it was corruption; some of it was just incompetence.”
Lott, of the hospital association, also cited the soaring budgets for the hospital, especially given the basic problems. A typical hospital “with a similar mix of patients” averages about 4 employees for every bed—King-Harbor had 11.5 workers per bed, he said.
“The cost for running King was way out of line for comparable hospitals of its size, type and population it serves,” Lott said.
Politics and Race
Bellman said other chronic problems crippled efforts at reform. An entrenched bureaucracy, political strife and obstacles with union worker protection contributed to the resistance to meaningful change, he said. Bellman also mentioned what the Los Angeles Times had also concluded in a series of articles on King-Harbor’s woes: racial tensions. The newspaper articles in 2004 described a scenario in which county officials were hesitant to act due to concerns that it would appear they were discriminating against the minority community and the predominantly black hospital leadership.
“There were longstanding problems there,” Bellman said.
Mallon and Lott said there were other factors—primarily mismanagement at the hospital itself—but that political interference played a role.
“I think government is certainly an issue,” Lott said. “King-Harbor Hospital has had 40 years of defective management. In the private sector, I doubt you could allow 40 years of that defective culture, defective business, to go on.”
With the prospects of closing King-Harbor looming for so long, county officials still appeared to scramble to prepare an interim emergency services plan. Those plans were still being adjusted more than a month after the closing.
“This isn’t easy work, and we can’t foresee every impact at this stage,” County Health Services Director Bruce Chernof told supervisors in the first session after the closing in August. “A major emergency room has been shut; a major delivery artery has been rerouted…”
A consulting firm was enlisted to begin drawing up Requests For Solutions for a new managing institution. They hope to identify a finalist by the end of the year.
Congresswoman Maxine Waters of Los Angeles wanted—and got—the board’s commitment to reviving the hospital: “…that this is not a permanent shutdown, closure, boarding up of Martin Luther King, never to be seen or heard from again. This will be reopened.” Her comments drew applause at an August board meeting.
At a later meeting, Director Chernof told the supervisors that county payments to the hospitals most impacted by the closing “helps cover the patients they see, but it doesn’t deal with the fundamental issue of how crowded emergency rooms are in general….The way we help these private hospitals in the long run is to reopen an emergency room [at the King-Harbor site].”
For the most immediate issues, the county began trying to work out agreements and compensation plans with 9 surrounding hospitals to handle ambulance traffic previously destined for King-Harbor. Those other hospitals, which have a combined 273 ED beds, were also guaranteed priority for transfers of the King-Harbor patients into other county facilities.
County officials estimated a budget of about $13 million annually to the contracted hospitals, and $3 million to the physicians themselves. Payment was proposed at $2,000 for each inpatient, with about $350 for an emergency case.
They kept an ambulance stationed at King-Harbor to deliver arriving emergency patients to one of the other hospitals.
Outpatient clinics remain opened at King-Harbor. The county added a 16-hour daily urgent care clinic at the site. Officials credited a public information campaign in the area for the steady increase in traffic to the urgent care facility.
In the 7 days ending September 15, it attracted 433 patients, up 26% from the prior week. The county initially projected an annual patient count of up to 30,000 for the urgent care clinic. However, the county also consolidated clinic operations—a separate pediatric one had reported less than 10 patients daily, so that was folded into the clinic for adults.
An average of about 40 of those clinic patients were transferred weekly to hospitals.
County health officials commended the upswing in urgent care clinic usage, although ED physician representatives questioned the ultimate effectiveness of those clinics as a viable option.
Bandaid on a Hemorrhage
Mallon said that such urgent care clinics may offer some help in easing crowding. Too often, he said, those clinics superficially treat a patient in pain. They may give them a painkiller and a few lab tests, for example—then advise them that they better go to an ED if they want their problem promptly diagnosed and resolved, he said.
Another problem for county and contracting hospitals was the issue of compensation for non-ambulance emergency patients who would have otherwise gone to King-Harbor. Ambulance transports could be easily tracked, but an overwhelming majority of ED patients were walk-ins at King-Harbor. Chernof admitted they were still trying to refine a method to determine which ones would be compensated.
Chairman Yaroslavsky seemed to challenge the notion that the county should compensate private hospitals for the rerouted patients, because no private hospitals had compensated the county for their patient loads when the private EDs closed in the past.
County supervisors were reminded of the added pressures for hospitals by Rob Fuller, chief operating officer for Downey Regional Medical Center. That hospital was only 7 miles away from King-Harbor, and was expecting to be impacted significantly by the closing. It would have to hire more emergency physicians or have others expand their practices, he said.
Even with the county compensation to offset costs, he told County Supervisors that Downey Regional anticipated losing between $6 million and $8 million on the added services for the former King-Harbor patients.
The county board requested weekly updates on the emergency patient counts at the surrounding hospitals. As expected, the most impacted were Downey Regional Medical Center (with 22 emergency beds), St. Francis Medical Center (39 beds) and Centinela Freeman Regional Medical Center (38 beds).
Impact Without Measure
Oddly, for all of the statistics produced by the county’s Department of Health Services, officials there reported that one key figure was still missing—average emergency patient volumes at the area hospitals prior to the King-Harbor closing. By the end of September, it was still searching for a baseline figure, to get an accurate indication of the increases in emergency patient loads.
The first 4 weekly board updates generally carried a theme that the evolving county plan was going better than anticipated; patient volume was up, but manageable at the surrounding EDs, staff assured the County supervisors.
That did not always square with outside reports. The Los Angeles Times on September 23 published an article that said St. Francis had an average wait of 11.5 hours for ED patients to be moved to a room in August. The situation had eased somewhat in September. County supervisors also asked the staff to check on another report that a hospital had up to 18-hour ED wait times at one point.
The Board Chair challenged some of the hospitals’ motives and figures about an overburdened system, as if they were exploiting the situation. Yaroslavsky indicated he believed one disputed emergency volume estimate by a doctor as “political rhetoric to try to raise the temperature level and leverage the county to put up more money… “
“It’s not going to fly with me,” he said. “I think we ought to do what we -- you know, bear our share of the burden, but not help put the artwork up on the CEO’s office anywhere…”
A Darwinian Contention
Conservative county officials explained the medical care situation in near Darwinian terms; that this is just another industry shake-out in the ever-evolving field.
Yaroslavsky spokesman Bellman said California hospitals have faced squeezes ever since Prop 13 ushered in an era of government tax and budget cuts 3 decades ago. So “this is not an alarming new development to be panicked about,” he said.
“These hospitals are not all going to close,” Bellman said. “There are always going to be hospitals in financial trouble that are going to be on the verge of closing. But it would be way too easy and, frankly, not really honest, for readers…. to universalize too much. We all know that in any industry there are going to be weaker members and stronger members.”
“Just because there is an economic controversy, and the more vulnerable, precarious members get squeezed out, it does not necessarily mean there is a universal crisis. Some facilities are going to be better funded and better managed than others,” Bellman said.
Unsustainable hospitals may get “washed away, just the way weaker and more vulnerable members of a population are the first to go if there is a disease epidemic or a drought, or die in a heat wave. The elderly, the young, the vulnerable people with respiratory illness, unfortunately, they are the first victims…. But that does not mean there’s a universal problem where everyone is equally in jeopardy,” he said.
The arguments about free enterprise and survival of the fittest, however, did not touch on the point that the government requires emergency care, even for those who cannot pay for the services.
The Ripple Effect
Mallon said the often-understated importance of the King-Harbor closing is that “its closure has more financial repercussions than a hospital that serves, for example, a better payer mix.
“When hospitals close, the patients don’t go away,” Mallon said. “They redistribute. In fact, some of the patients who had minor problems don’t get care until they actually become sick; not only do they redistribute, some of them become quite a bit sicker and need to be admitted to hospitals.”
King-Harbor’s position as a primary county hospital for indigents further aggravates the ripple effect, Mallon said. “Many of these hospitals surrounding Martin Luther King are already not in the best of payer mixes, so their financial health is tenuous.”
Mallon doesn’t accept the argument from county officials that the impact of the closing was minimized because of King-Harbor’s reduced size, and the fact that some of the other hospitals only have increases of a few emergency patients daily.
When it comes to seriously ill patients, “the influx doesn’t have to be huge. For a community hospital, we’re talking admissions of 5 or 10 patients a week of that nature—that would really hurt the financial viability of that community hospital,” Mallon said. “So the surrounding hospitals are taking it on the chin.”
The closing of the King-Harbor trauma center was offset somewhat by the opening of the California Medical Center trauma center. Mallon said USC’s hospital enlarged its catchment area, “but Los Angeles already didn’t have enough trauma centers.”
County-USC regularly goes on “code overload” for ambulance diversions. That is an “everyday event” for several hospitals in the system, Mallon said. At one point in September, the 90-bed ED there was holding 68 patients that had been admitted into a hospital that had no available bed space for them, Mallon said.
The squeeze at the public county hospital means that community and private hospitals can no longer count on offloading indigent patients. “The county hospitals can’t suck it up any more, so the community hospitals are beginning to pay a higher price,” Mallon said. He remembered the situation about 10 years ago, when he had graduated from residency. “County-USC was pretty much an open door for patients that didn’t have insurance; they were just accepted,” Mallon said. “But now our code-overload has gotten so bad that we can’t take those patients, further stretching the resources and financial tightrope the community hospitals are walking.”
As for the feared “domino” effect, “I always hesitate to say that. It takes a lot to have a hospital actually close up its doors,” Mallon said. “What I can say is that they are all crying uncle. And it is a serious cry.”
He also worries that county officials may not be hearing that plea. “While the Board of Supervisors woefully cried over the closing of Martin Luther King, at some level I think there was some relief in it from their viewpoint.” Mallon said he gets the impression that the county sees it as a “black hole” and political liability. “They want to be out of the business of health care.”
The White Hats
Emergency physicians are aware of this sort of peri-apocalyptic vision of what is happening to the specialty. “I don’t think most of the community really knows, because most of them are healthy,” Mallon said. He explained that most people lose sight of the fundamental aspect of insurance and even public health care—that the costs of treatment have to be paid for by the majority, who are not in need of the services.
“There is another sort of tangent to this I think people out in taxpayer land, the lay public, don’t get. As a specialty, emergency physicians really do wear the white hat. We’re open 24/7. We take our EMTALA mandate seriously, which is to treat people regardless of their ability to pay. That safety net role is being jeopardized by poor management of the whole health care system.”
PII: S0196-0644(07)01661-7
doi:10.1016/j.annemergmed.2007.10.006
