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National Capital Medical Center

THE EVOLUTION OF THE NATIONAL CAPITAL MEDICAL CENTER (NCMC)
A triumph of politics over rationality?

summary

The NCMC bandwagon is powered by political steam, based on an urge to pander to constituent wishful thinking. The parameters for this unnecessary new hospital were established from thin air well before the city's healthcare needs were properly defined. The 'experts' report' is interpreted by NCMC proponents as strongly supporting their ambitious goals. In fact, reading both the fine print and between the lines, the opposite conclusions come into view, and far more comparative, quantitative, data could have been included . The new NCMC does not address the city's real health problems, and is likely to exacerbate them rather than relieve them. Furthermore, the extent to which non-DC residents inflate the need for DC hospital beds is completely ignored, and the possibilities of finding regional solutions to regional healthcare problems are not addressed at all. The city's administrative and legislative leadership needs to get a grip on reality: focus on the basic healthcare issues facing the nation's capital city, and give up dreams of building a world-class medical castle on a bed of "underserved" sand.

This analysis consists of eight major sections:

o background issues in some detail;
o the sense of the community which rejects NCMC as an inappropriate use of major city funds;
o the mistaken emphasis on location, location, location:
o the greatercimportance of DC's most pressing health problems;
o the importance of avoiding negative consequences of surplus beds;
o issues concerning city finances, poor use of Reservation 13, and violating established decision-making process;
o the need for more rigorousanalysis of existing statistics;
o and acknowledging two major risks , including financial overruns, and the possible collapse of other hospitals

o In addition, NARPAC has produced a separate chapter evaluating the new ACEP "national report card on the state of emergency medicine. Though this fledgling effort be the American College of Emergency Physicians (ACEP) has merit, it is of little use in trying to determine DC's need for a extravagant new hospital.

background

NARPAC has been summarizing every article in the Washington Post dealing with matters of city government since 1997, dividing them into seven different topical categories, including "human services". This category includes most matters associated with the health and welfare of DC residents, from foster care to its (slowing) shrinking TANF (Temporary Assistance to Needy Families) caseload. Over these past eight years, hospital problems of one kind or another have created a good fraction of those headlines.

In 1997, in fact, there were no significant mentions of problems with DC hospitals, and one of the few 1998 references (mid-summer) came from the recently-formed Public Benefits Corporation (PBC), asserting that all the hospitals under their purview would be "in the black" soon, including DC General. By fall, 1998, Avram Goldstein of the Post was warning that "Financial Pressures Cripple DC Hospitals", pointing to the over 80,000 uninsured DC residents as well as increasing pressures from the cost-cutting HMO's. In 1999, the big stories were about the decline and fall of the Greater Southeast Community Hospital (GSECH), deep in the poorest sections of DC East of the Anacostia River. Only in the following year, when GSECH was finally bought out, did the attentions turn to DC General, the big white elephant just West of the Anacostia River near the RFK Stadium.

The summer of 2000 brought almost daily reports of various scandals reaching to top management. NARPAC wrote about "The Day of Reckoning for DC General and the PBC " in August of 2000, summarizing a long series of improprieties and other issues long pushed under the bed sheets by both the hospital and the corporation. By then, emergency management was in place and large staff cuts were underway, and the whole question of misguided healthcare came to the fore. By year's end, there was early talk of closing the hospital, once a proud symbol of black pride in DC. Nurses went on strike, PBC and (new) hospital management were fighting each other, and the future of this institution began to collapse.

The Congress was now involved, the DC Council was floundering, 41 Ministers of God trying to lobby the Mayor were constrained by uniformed officers, and DC's Control Board was trying to grab the reins. By the Spring of 2001, the inevitable end was in sight. By the last week of June, the last inpatient was moved out, and all that remained (until the present) was an Emergency Room. But remarkably enough, despite hysterical early claims to the contrary, the overall loss of medical care to those in need could not be quantified. There was grumbling and some awkward situations among the hospitals that absorbed the initial load, but somehow that load itself seemed to decline.

The rest of 2001 was spent wrestling with a new health care plan for the city. Even though none of the dire consequences had materialized, it was becoming increasingly obvious that large numbers of needy DC residents were simply not getting the type of care necessary, and many were continuing to end up in the hospital unnecessarily. Furthermore, the political trauma had not subsided at all. The virtually empty hospital stood as a stark reminder that black interests and needs were simply being ignored by the city government, despite the continued displeasure from the DC Council that a firm step had been taken to shut down a losing proposition.

Meanwhile, the situation was aggravated as it became known that new uses for the large (67-acre) DC General site were being considered. The Mayor and his economic development advisors and local redevelopment enthusiasts (including NARPAC) were pressing to redevelop "Reservation 13", as the still-federally owned property was known. As Spring of 2002 turned to Summer, a private firm had offered to redevelop the site and include on it a new $70 million hospital. In July, NARPAC offered its commentary on Reservation 13.

Far more important, the mayor had been directed by the DC FY02 Appropriations Act to submit a plan for the development of Reservation 13, and he did so on March 31st, 2002. A bill to approve that plan was introduced on May 1st, and an open hearing was held on May 28th. The measure was officially enacted in January 2003. Bill 14-0648 had two major provisions, the first dealing with the inclusion of a new hospital on the site, the second with the use of all revenues generated on Reservation 13 for health purposes:

Section 3 required a Hospital Set Aside: "Approximately 2 acres within the Independence Avenue District of Reservation 13 shall be set aside for the development of a new full-service hospital, including approximately 200 beds, and emergency department with level 1 trauma care, general pediatric care, behavioral health services including substance abuse and mental health, long-term or transitional care capability, outpatient diagnostic and ambulatory care, and specialty clinic services."

Sections 4, 5, and 6 established a "Reservations 13 Benefit Area"; made it a special taxing district; and specified the allocation and administration of the funds raised therefrom. In short:

o "The proceeds from the lease or sale of any real property in Res 13 ....shall be deposited in DC's Tobacco Settlement Trust Fund......to be used solely for the purpose of constructing and maintaining a new full-service public hospital (as specified above);...or

o "If, instead of a public hospital, a private full service hospital is constructed....the proceeds from the lease or sale of any real property in Res 13.....shall be used solely for the purpose of providing health care to the uninsured residents of the District", and that

o ".....such funds" (proceeds) ... (will have no) "fiscal year limitation and shall not revert to the General Fund at the end of any fiscal year, or at any other time."

Section 7 extended this use of proceeds to include any "payments in lieu of taxes" that might be generated by any properties exempt from "normal" taxes.

This overt commitment to a replacement hospital and better health care may have been useful in reversing the political damage wreaked on the DC Council and the Williams Administration by the closing of DC General, but it surely was not based on either the real-world needs for a new hospital, or the funding requirements for suitable public health care. As is subsequently discussed, there was no sound basis for the type or size of hospital "legislated" by the bill. Moreover, while the ear-marking of revenues for a specific purpose may seem attractive, it serves only as a minimum, since compensating reductions in the usual appropriations sources are not prevented.

By January 2003, even the remaining ER at DC General was not doing well, and the Greater Southeast Community Hospital was in serious danger of being closed as well. Later in the year, the recurring financial problems at the nearby Prince George's Public Hospital in Cheverly were also drawing headlines, and the Post's Goldstein was reporting on the views of medical experts claiming that the city could not afford four separate trauma centers. In an early November statement that surprised many, Mayor Williams let it be known that the city would help finance a new hospital for the southeastern sections of the city, and that Howard University (which has its own substantial teaching hospital) would manage it. While Howard U was talking initially about a new 110-bed teaching hospital, by early 2004, their planning was addressing a much larger, 200- 300 bed, facility. Clearly , negotiations had been progressing quietly for some time.

On November 4th, 2003, the Council enacted Bill #15-546, the National Capital Medical Center (NCMC) Negotiation Act of 2003. which became effective 21 days later, authorizing the Mayor to "enter into discussions with Howard University for the purpose of negotiating for a new hospital on the Public Reservation 13 site." By May 15th, 2004, Bill #15-680 approved the resulting NCMC Memorandum of Understanding (MOU) Approval Act of 2004 submitted to them on January 15th, with an effective date of September 8th.

By now, the NCMC was to involve a 99-year lease of a portion of Res 13 not to exceed 9 acres on which Howard University would build, own and operate.....a new, full-service, world-class, Trauma Level 1 Hospital that would contain 200-300 beds. It was further agreed that the University could also "develop: medical offices for community physicians; a new School of Public Health; and a complex designed to carry out research to improve the quality of healthcare in the District for all its residents (with support from one or more federal agencies and in partnership with any appropriate private or public research entity)."

Meanwhile, by Spring of 2004, Prince George's County had bailed out their hospital, GSECH had gotten its lost accreditation back, and planning for the hospital on Res 13 fell below the radar horizon of the press. Through the rest of 2004, there were only sporadic commentaries that the new hospital was getting bigger and bigger, while its justification was getting less and less credible.

By February of 2005, the Post reported that "DC Has a Deal in Principle to Build New Hospital", and that the estimated $400M costs would be split evenly between Howard U and the DC government. By summer, when the Council held hearings on the NCMC proposal, resistance to the plan began to crystalize from a variety of sources. DC's new City Administrator Robert Bobb was personally spearheading the campaign to gather public support for the NCMC, with a series of briefings to local ANCs, endlessly repeating his oversimplified litany that "it's all about location, location, location". His detractors seem to think "it's all about health, health, health".

More important, the city had engaged a reputable consulting firm, Stroudwater Associates to "objectively" appraise the NCMC plan.. By December, 2004, they had produced a detailed review of the Howard University proposal and it was being touted by NCMC proponents as demonstrating the soundness of their plan. In many quarters, it was apparently being accepted without question and apparently without being read! But as 2005 draws to an end, the controversy is growing stronger, not more muted, and NARPAC has tried to separate the wheat from the chaff.

the sense of the community

NARPAC has spent the better part of nine years deriding the tendency of neighborhood organizations to pursue their local interests at the expense of the "larger picture". "NIMBYism" is the lifeblood of local activism, and so is "YOMMism" (You Owe Me More). It came as a considerable surprise, then, when both the local Advisory Neighborhood Commission in which the NCMC would be located (ANC 6B), and the overwhelmingly democratic Ward 6 Democrats, both produced unanimous resolutions rejecting the NCMC plan for only slightly different reasons. In essence, both resolutions:

o oppose the NCMC as currently proposed;

o support the use of Res 13 for the delivery of a more modest set of health care services and the need to improve health care services citywide; and

o strongly oppose circumventing established Certificate of Need decision-making processes which assures the inputs of health care experts.

This opposition is also echoed "officially" by the president of the DC Hospital Association. Six reasons are given for this strong local opposition to the proposed NCMC. These are discussed below, along with the wording of the ANC 6B resolution in italics, with "whereas" replaced with "because":

location, location, location

Because the original justification given for the NCMC is to serve currently medically under- served residents, especially those east of the Anacostia River; and

Because the NCMC would be located west of the Anacostia River on lots Band C of Reservation 13, within the boundaries of ANC 6B;

NARPAC finds it somewhat disconcerting that the strongest proponents for the NCMC stress "location, location, location" at Res 13, while Ward 6 leaders essentially assert that "Ward 7 and 8 need additional health facilities more than Ward 6 does". It is also clear from the argumentation that location is being emphasized primarily to minimize ambulance travel time, rather than just the convenience of being able to receive ambulatory care, or endure hospitalization, closer to home (arguments with which we would perhaps sympathize more). But the issue of ER-accessibility issue is complicated by several considerations:

a) the "centroid" of the under-served population is across the Anacostia River in Wards 7 and 8, but the existing Greater Southeast Community Hospital GSECH, has a rather marginal ER, and ambulance personnel will often prefer a longer run to an alternate location;

b) the primary alternative today is the also-limited ER at DC General, but the three bridges across the Anacostia (South Capitol St's Douglass Bridge, Pennsylvania Ave's Sousa Bridge, and East Capitol's Young Bridge) can all result in major delays, particularly during DC's protracted rush hours;

c) the third and often used (but little acknowledged) alternative is the Prince George's Community Hospital in Cheverly, MD, a quick 1.5 miles outside DC's eastern boundary and accessible from Kennilworth and New York Avenues without bridge delays. The development of efficient regional health care facilities rather than parochial and duplicative jurisdictional assets deserves far more attention in the Washington Metro Area;

d) there is a very substantial difference in operating costs and medical expertise between an "Emergency Room" and a "world-class Level 1 Trauma Center". This distinction has been generally ignored (or taken for granted) throughout the NCMC debate. With limited human and financial resources, it is almost certainly an unaffordable "luxury" to establish another Level 1 Trauma Center within DC. It is common practice nationwide to sort through the myriad of emergencies (and non-emergencies) brought by ambulance to an ER, and send on to the trauma centers only those that require their specialized "high acuity"capabilities;

e) statistically, according to the Journal of the American Medical Association, DC is the only "state" (an obvious misnomer in this instance) that has access to a Level 1 or 2 trauma center within 45 minutes by either ambulance or helicopter. For the entire US, the average is 69.2%, with Maryland (87.5%) and Virginia (71.5%) both above that average. In eighteen states, less than 50% of their population has such access 45 minute access. This is one area where DC does not lag its peers.

f) urban EMS statistics are often skewed in the underserved areas of cities by the use of ambulances instead of (the relatively unavailable) private vehicles and/or taxis, and the use of ERs instead of (the relatively unavailable) neighborhood clinics;

It would appear to NARPAC, and apparently many others as well, that the city's underprivileged would be better served by several more properly dispersed, first-class clinics and perhaps three well-functioning ER's than a single world-class medical Mecca serving primarily paying patients, presumably primarily from outside DC's city limits (see below). It is difficult to dispel the suspicion that the only possible "winner" in the current plan would be Howard University which would get a new hospital building for half-price. Whether they could ever make a success of it is quite another matter.

And, in fact, the Stroudwater Associates' experts are quite clear on this subject:

Whereas hospitals generally serve a regional market, access to primary care services are required close to home, within an urban neighborhood:

o people may require regular care from their primary care provider, especially when managing chronic diseases, but generally require only occasional or periodic access to hospital-based services;

o Primary care shortage areas are concentrated in areas served by the former DC General, which is also where the chronic disease incidence is the highest in DC;

o Improved access to essential healthcare needs within Wards5, 6, 7, and 8,including primary care, urgent care, and chronic disease management, should be an important goal for meeting community needs.
DC's most pressing health problems
Because the serious unmet medical needs of Washington residents are primarily for chronic care for conditions such as asthma, hypertension, heart disease, diabetes, cancer, HIV-AJDS, conditions which are better treated by family doctors and in outpatient specialty clinics and ices than in a hospital, emergency room or trauma center;

Much has been made of the fact that many of the "unmet medical needs" of the poorer DC residents are better treated (earlier) in clinics rather than (later) in hospitals and ERs. Dr. Eric Rosenthal, a DC activist in many areas as well as a respected ER doctor, repeatedly made this point in DC's premier "E-mail discussion group" TheMail at DC Watch during 2005, and his theme was finally published in a Washington Post OpEd on November 9th:

THIS HOSPITAL PLAN NEEDS A CHECKUP
DC Won't Be Any Healthier

The District recently announced that it would delay its final proposal for a National Capital Medical Center on the campus of the former DC General Hospital. A staff member in City Administrator Robert C, Bobb's office said, "We think it's best to take that extra couple of weeks and get things right". I agree. But to get things right, the city needs a new approach.

The city's argument for the new medical complex revolves around proximity, not health. Because many residents in the eastern part of the city live farther from a medical center than do many residents. in the west "the theory is that Washington needs another medical center in the eastern part of the city. While appealing on its surface, this argument is thin justification for another medical center, given that all DC residents already live close to at least one of nine acute care hospitals, all of which include emergency rooms and five of which have top-level trauma centers. That proximity has not improved their health, however. The District still suffers from terrible rates of disease and premature death.

The new medical complex would include a 250-bed hospital, a trauma center and an emergency room. It would be owned and operated by Howard University, but it would cost the District several hundred million dollars in start-up funds and probably require large operating subsidies. The hospital is not intended primarily for poor, uninsured Washingtonians; most of its patients are expected to have health insurance.

The city argues that "fairness demands the medical center be built", but fairness actually demands the opposite. In Washington, life expectancy for black women is five years less than for Americans in general (71.6 years versus 76.7 years), and life expectancy for black men is nearly 20 years less (57.5 years versus 76.7 years). Fairness in life expectancy should trump fairness in proximity.

The city also has not shown that the District needs another medical center. Washington is well above the national average in terms of trauma centers, ER visits and hospital beds per capita. The city's own consultant, Stroudwater Associates, has .found that the center could threaten Howard University Hospital and Greater Southeast Community Hospital and that it might even force them to close.

Chronic diseases such as asthma, high blood pressure, diabetes and obesity cause most serious illness in Washington. These diseases are best treated by family doctor,.. and outpatient specialists, such as cardiologists. Unfortunately, good, accessible outpatient medical care is just what many DC residents lack. As a result, people with chronic diseases often become sick enough to need an emergency room or hospital stay.

Since DC General closed, the city has insured more than 40,000 people through its Healthcare Alliance. As Mayor Anthony A. Williams has said the Alliance has increased outpatient care, decreased emergency room use and lowered the rate of "avoidable hospitalization."

Washingtonians concerned about health should hope that the delay in the National Capital Medical Center proposal represents a decision to begin a planning process that takes a hard look at why DC residents become sick and addresses those causes. Health policy experts who have not embraced the medical center might step forward if the city showed it were serious about becoming a healthier place. We soon will see if it is.

(Eric Rosenthal is a pediatrician who lives and works in the District)
There is no shortage of available data on the causes of death in DC, its surrounding states, or for the US as a whole. The top chart below shows the major causes for DC residents from '95 to '01 in two year increments. Heart disease and cancer are 5x to 6x more lethal than any other listed category. Progress is apparently being made in reducing cancer, strokes, HIV and homicides (!), but heart attacks, asthma ("COPD" on the charts) and diabetes have changed little.

The lower chart compares the major causes of death for the US average, DC, Maryland and Virginia. Again, DC ranks significantly higher than the norm in several areas, and several of those lesser areas are, according to medical experts, better treated early by family doctors and outpatient treatment. It should be noted, however, that the two major "killers", and thus the major source of hospital patients, do not involve those susceptible to ambulatory treatment.


It is also possible to quantify the "avoidable hospitalizations" based on data for both '00 and '03 made available by the DC Primary Care Association. (The DCPCA is a strong advocate for greater emphasis on local clinics and ambulatory care rather than hospitalization). These data are broken out by four age categories (separate bars), and three income categories (layers of each bar). The left hand grouping shows data from 2000 while the right hand side refers to 2003. Note that the bulk of the cases are for people over 40, and that the majority of "low poverty" patients are over 65. Those low poverty cases are apparently choosing, by choice rather than necessity, in- hospital treatment.

To a first approximation then, there were some 16,000 avoidable hospitalizations in DC in '000, and just over 14,000 in '03. If the "voluntary hospitalizations" are removed, however, these numbers drop by several thousand, and NARPAC doubts that more than about half of the true "avoidables" could be realized within the next twenty years! Since there are currently about 80,000 DC resident admissions to DC hospitals per year, this would amount to somewhere between a 6% and 9% reduction at best. Nevertheless, as shown further along, this could result in the saving of several hundred needed beds.

avoidable hospitalizations

It should also be noted that there is a significant shortage of local health care centers, particularly in the areas they are most needed. According to the DC Primary Care Association, strong advocates for better health care centers, the total space of current DC centers is just about 267,000 sqft, of which 69% (186,500 sqft) is well below satisfactory for its intended purpose. The city's full needs for quality space range from 231,000 to 482,000 sqft. At $200 per sqft (not including land acquisition), meeting even the highest demand would cost only about $80M, or one-fifth of the projected building costs of the NCMC. Surely this alternative demands greater attention.

negative consequences of surplus beds

Because construction and operation of the NCMC is likely to result in the closure or dramatic downsizing of the current Howard University hospital and Greater SE Hospital and result in a negative impact on the viability of Prince Georges Community Hospital;

Because the loss of these medical facilities due to the construction the NCMC will decrease the access to health care facilities in the currently underserved areas;

. Because a more appropriate health care facility on Reservation 13 could both strengthen the existing health care facilities and provide a spur to expanded health care in underserved areas;

Because the cost of the NCMC would preclude the expansion of ambulatory care in underserved areas;

The four "becauses" above relate to the most fundamental question that must be addressed. Is it likely that DC actually needs more hospital beds in the foreseeable future? A casual reading of the Stroudwater Associates "experts' report" can be interpreted as "yeah, probably", and this is the verdict promulgated as factual by the NCMC proponents. But a more careful reading of the fine print suggests "well, probably not", and this is the conclusion (and fear) of the opposition, including NARPAC. It is quite possible that a brand new world-class set of hospital beds would draw patients from existing hospitals and cause their financial demise. Note that there are only 2767 active beds in DC, for an average of 307 per hospital.

It is important to understand that the currently surviving nine hospitals in DC have significantly more "licensed beds" (3914) than are currently "operational" and presumably staffed (2767). Hence the existing total capacity exceeds that currently in use by more than 40%. Presumably this results from cutting back of active hospital capacity due to a lack of need. NARPAC has no way of knowing how many of these non-operational, but licensed, beds could be put back into service. Nevertheless, one alternative to building a new hospital with 250 beds must be to re-open some fraction of the 1147-bed latent capacity in existing facilities.

The experts' review addresses this subject directly, but in NARPAC's view, on tippy toes:

Depending on assumptions relating to admission rates and population trends, the range of possible inpatient beds (needed) indicates a surplus of up to 334 beds or a need for 349 additional beds in 2008 (see below). Considering all factors the projected need for 286 additional beds by 2008 is reasonable and well within the range of possible bed demand projections. (But) existing hospital licenses permit 3914 beds, allowing the addition of about 1275 (?) beds to existing hospitals. The question for DC is whether a need for beds will require a direct action or investment by the city. If existing hospitals do not expand (?) or if any hospital closes, then there will likely be a shortage of beds available to DC residents.

Based on NARPAC's experience with management influence over analytical assessments, we would conservatively estimate that this statement went through at least ten separate drafts to change its sense from negative to positive. Clearly, future projections are very sensitive to the underlying assumptions (sound familiar?) and it is dangerous to accept the analysts' words without exploring their calculations and "inputs". Hence we have recreated their (simple) calculation process, and find that the "range of possible needed beds" is much broader than indicated above, and biased more towards the down side. Determining the number of needed beds in DC hospitals is a relatively straightforward arithmetic process. Four representative "cases" are shown on the summary table below. Numbers on white background are "input values" for Stroudwater, tan for NARPAC; calculated results have green backgrounds; results are in orange and yellow; and supporting data are in grey. In essence, NARPAC thinks the Stroudwater "base case" is really at the high end. We also believe that the "possible" need for beds is much lower than the "experts'" opine, even with a substantial increase in resident population (90,000), but no increase in patients from the suburbs, since they are rapidly improving their own hospitals.

summary comparison of needed beds estimates

Step one: start with an estimated DC resident population and an assumed basic annual "admittance rate" (such as 140 patients per 1000 residents per year); include the possibility of an "avoidance rate" (such as -5%), multiply to get total number of DC residents admitted to hospital over the course of a year. It should be noted that DC's current admittance rate of 139.5 is, according to Stroudwater, some 17% higher than the national average of 119.5;

Step two: assume a typical average "stay time" per patient (in days), and multiply by total admittances to get total DC inpatient days. Divide by 365 (days) to determine absolute minimum number of active beds for DC patients. Note that DC's average length of stay (ALOS) of 5.6 days is some 10% higher than the national average of 5.1 (Maryland achieves 4.6);

Step three: Pick a best estimate for the average "bed utilization rate". Divide into minimum number to get a more realistic estimate of needed beds for DC patients. Stroudwater estimates DC's utilization is currently (a very high) 75%;

According to Stroudwater experts:

Assuming no improvement in admissions rates, no change in length of stay, no change in population trends, and continued in-migration of 48%, then there will be a need to add 349 beds in DC by 2008.

What they apparently didn't bother to say is that this same calculation shows that DC was shy of some 363 beds in 2003 even though DC hospitals were cutting back the number of their "operational" beds at that time.

. The experts then show that if recent population trends continue unchanged (i.e., flat) and DC could achieve average national hospital utilization rates (in both admissions rates and length of stay), then there would be a surplus of 334 beds in DC in 2008. On the other hand, they go on to note that if DC hospitals get only modest improvements in utilization rates, and achieve modest growth in population (some 23,500 people) then there will be a need for 104 additional beds.

Step four (a major unexpected influence!): Estimate the number of non-DC residents that also need beds (as a percent of the aggregate total), assuming that the "immigres" require the same stay time. Scale up total needed beds and inpatient days A full 48% of DC's hospital beds are occupied by non-DC residents! It has proven nearly impossible (within NARPAC's limited resources) to find out where these patients come from, which hospitals they are in, or whether they are paying (insured) customers or not. In any event, we have no adequate trend line over time, or any other basis for predicting whether DC will (or should!) continue to be a "health-provider of choice" for much of a metro region which has substantially greater resources than its core city.

A smattering of recent data from the DC Hospital Association indicates that if anything, the trend is in the wrong direction: according to the DCHA patient data base, DC residents accounted for 53.6% of all inpatients in 1998, but only 51.3% five years later in 2003. In 2003, 37.2% of DC hospital patients were from Maryland; 9.3% from Virginia; and 2.2% from everywhere else. Half of these immigres had their bills paid by Medicare, Medicaid, or Medical Charities. The majority of the rest were under managed care or Blue Cross.

Step 5: Compare the new total needed beds to both operational and total (licensed?) beds.

Note that this simple arithmetic approach assumes that "in-migration" needs scale up and down automatically with DC population chosen. This has a substantially magnifying effect on the answers generated. If DC adds residents, do the suburbs match the increase? If DC cuts its patient admission rate due, say, to better clinical care, do the suburbs do the same? This is a significant weakness in the alternatives methodology. Hence NARPAC shows the new in-migration numbers at the bottom, along with the new in-migration rate that would apply, if the baseline in-migration was held constant

The seemingly complicated chart below explores eight separate, but additive, variations in the parameters discussed above, and all compared to Stroudwater's "base case". Each variation is tested for three different population levels all of them higher than the current (base case) level of 567,808 residents. The blue bands indicate the parameter being changed in each variant and indicates the magnitude of the impact:

1. add city population up to 105,000 (with a constant share of in-migration): the needed beds increases by over 600, but stays a little below the currently licensed total;

2. Lower base admittance rate from 140 to 125/1000: needed beds declines by over 600 for the high-population alternative;

3. Add an additional "avoidance rate" of up to 9%: needed beds drop another 300 for the high-population case;

4. Add an additional "avoidance rate" of up to 9%, but keep population low: this shows that 400 beds would be "saved" if the population did not increase as projected in the other alternatives;

Click to enlarge

5. Lower the length of stay toward national norms: get down to 4.7 days, and count 138 too many beds even with increased population;

6. Up the bed utilization rate from 72% to 75%: get rid of another 100+ beds 7. Fix in-migration of out-of-DC patients at current level: lower total bed requirements by another 150 in the "worst case" population rise;

8. Drop in-migration rate below current level as suburban hospitals improve: reduce total bed requirement to minus 542, even with a population of 672,000, which equates to 100,000 more than in the 2000 Census.

This very substantial in-migration of outsiders to DC hospital beds also raises the question of why healthcare is not a regional rather than a jurisdictional responsibility. Just like the current imbalance in regional poverty, where DC essentially operates as the "region's poor house", one wonders, with DC's relatively low income per capita, why it should also become the "region's community hospital".There is no consideration at all given to this dubious eventuality.

city finances

Because the cost of the NCMC will put heavy burdens on the District's ability to borrow funds for other needs, such as school modernization;

Because the proposed agreement between Howard University and the District may put the District at risk for ongoing and continued annual outlays of expenditures for the operation of the NCMC;

NARPAC cannot cite a single example, other than this one, where a local ANC or an entire DC Ward has opposed a major program thrust essentially gratis into one of its neighborhoods because, among other things, it would be financially unsound for the city as a whole. There is, in fact, a current shortage of capital investment funds due to the high debt burden already being carried by the city, and many other capital programs that should be in line before this one. And since the carrying charges for those bond issues are paid from the operations budget, it is equally appropriate that local leaders recognize the dangers of squandering those funds as well. It should be of substantial concern to all DC residents that the Human Services Budget already consumes a full 48% of all DC spending from both local and federal sources (FY04 actuals).

inefficient use of Res 13 and surrounds

Because the proposed location of the NCMC has spread beyond the limits of lots B and C of Reservation 13 to include the use of the RFK parking lots for hospital parking and to include the consolidation of certain city medical facilities currently on Reservation 13 to a site on lot L located along the proposed extension of Massachusetts Avenue;

Because the NCMC proposal is incompatible with the Master Development Plan for Reservation 13 in that it eliminates underground parking and reconfigures roads including those in what were to be residential areas;

NARPAC was impressed in 2004 that the Ward 6 residents adopted such a cooperative approach to developing a productive, moderately high density, mixed commercial/residential, plan for Res 13. They were clearly aware of the need to improve the tax base of the city on an exceptional waterfront property. They appeared to assiduously avoid trying to make Res 13 a protected extension of their own back yards. In fact, this site has already been somewhat tarnished by the arbitrary situation of a rather garrishly designed, private special ed school on the corner of the site abutting the Stadium/Armory Metrorail Station. While no one can possibly complain about the valuable service being performed by the St. Coletta School for the city's most vulnerable kids, it still appears to NARPAC (and many Ward 6 residents) that this under-utilization of prime taxable property was a foolish decision, and even looks like one.

blatant violation of established decision-making process

Because the City Administration has proposed to legislatively circumvent the established Certificate of Need process specifically for this project;

Because legislation proposed by the City Administration concerning the Certificate of Need process does not seek to reform or eliminate the process but solely to exempt the NCMC project.


NARPAC agrees with the residents of Ward 6 that it is totally inappropriate for the leadership in the nation's capital city to circumvent DC's established Certificate of Need process, or any other extant process, particularly if it is solely for this specific proposal. We too believe that health care experts should make health care planning decisions, and not the DC Council. It seems to be a remarkably open admission that this politically-driven plan would not pass muster.

NARPAC Add-on: precious little analysis of existing statistics

As anyone knows who has rummaged thru this web site, we place considerable emphasis on what some experts consider "fact-based planning". As demonstrated above concerning the calculation of future hospital bed requirements, it is not difficult to reproduce the "experts'" calculations, and show the importance of the various assumptions and variables.

We also believe that long-range planning, such as would be required for a brand new "world class" hospital with perhaps a 40 to 50 year life span, should be based on some knowledge of past trends as well as the accomplishments of similar institutions. For instance, there are some 5000 community hospitals across the US today, and surely there must be some common threads to help predict the future.

The 8-graph chart below gives some indication of what kinds of data are readily available from DC's own hospital association. These bars represent each of the last eleven years ('94-'04), a period during which DC's population was relatively unchanged, but the metro area's population was continuing to grow smartly. Reading from upper left to lower right, it is clear that the number of active beds has been declining, and all else being equal, would probably continue to decline. Admissions dipped at the turn of the century, but now seem surprisingly steady. The number of "patient-days" has been declining somewhat. The number of ER visits took a jump in the year DC General was closed, but has not yet settled back to the level of the mid-nineties. Admissions per bed has climbed as both length of stay has declined (very slowly), and bed occupancy rates have returned to the '94 level after a drop in '99 and '00. The ratio of ER visits to hospital admissions has risen and declined again, but remains well above the '94 level. NARPAC cannot pretend to read these tea leaves, but simply point out that they exist for the asking.

11 year activity levels at DC hospitals

Perhaps more interesting, is the following chart dealing only with changes in hospital 'length of stay"(LOS), a primary factor in determining the number of hospital beds needed (as discussed above). Data drawn from the equally available Maryland Hospital Association repeats data collected by the American Hospital Association for all US hospitals (green line) and Maryland's 48-odd nearby hospitals (blue line). Clearly, LOSs have been declining with no apparent end in sight. DC's numbers (only for the last eleven years from above)(red line) do not seem to be on the same track. The Stroudwater :"base case" which shows a need for additional beds, uses an LOS of 5.6, (black line) already outdated for DC, and almost a full day longer than already achieved for Maryland. As a sort of "best case" it suggests that DC might achieve a level of 5.1, already the US norm. But why would anybody suggest building a brand new hospital predicated on a utilization rate that is outmoded before the foundations are laid, and may be off by a factor of two by the time the hospital finally gets up to speed?

Finally, there are broader trend lines buried in the national data which may, in fact, provide useful clues, if not definitive bases for projections. Four representative scatter charts are shown below which analytically-inclined decision-makers might find useful. These data are all drawn easily from the Census Bureau's Statistical Abstract for '04-'05, and the linear "trend lines" are drawn by Lotus 1-2-3. Reading again from upper left to lower right, NARPAC never tires of showing the clear relationship between a person's educational attainment and their per capita income. Wealth and education are as intimately related in 2004 as they were a few years back: an example of good correlation! The upper right chart shows the less impressive correlation between hospital admission rates and the "education score" for each of the 50 states and DC, but correlation, none-the-less. Smarter residents spend less time in hospitals.

The bottom two charts raise the race card, since there are generally recognized to be some diseases which victimize blacks more than whites and others. The lower left chart demonstrates again an old NARPAC contention that being black, per se, has virtually NO influence on mean household income (within the considerable scatter indicated). On the other hand, the lower right chart suggests that there is some correlation between being black and being in the hospital. And the future demand for DC hospital beds may well vary with shifts in demographics. For instance, if the percent of blacks in DC continues to drop at recent rates, then 20 years hence, their share may drop from 60% to 50%, hospital admissions could drop from 140/1000 to 133/1000. Given no other changes, that corresponds to a drop in needed hospital beds of 145. NARPAC suggests that such fact-based planning may further illuminate the need, or lack of need, for a $400M new hospital inside DC.

NARPAC Add-on: a wishful dismissal of the two major risks

The Stroudwater analysts must have worked long and hard to phrase their Key Risk Factors in a fashion that allows them to be ignored by DC leadership. NARPAC quotes below the risk summaries as presented in their report (in bold), but strips the supporting "bullets" of their protective coatings:

RISK 1: (Financial) Losses from NCMC could be higher than those projected by Howard University if the assumptions, which project performance better than other DC hospitals, are not achieved.

o financial profitability will be difficult if not impossible for NCMC as a brand new gilt-edged hospital getting the same reimbursement as other DC hospitals, but with much high levels of debt and depreciation expense;

o given NCMC's location, only about 20% of its hospital patients are likely to undergo surgery, leaving no basis for higher emphasis on surgical cases and higher "acuity", thereby limiting the hospital's reimbursement potential;

o to get higher reimbursements, NCMC would need to attract a base of highly regarded surgeons. A 'world-class Level 1 trauma center' would be an essential drawing card, but it will still take years to earn a reputation for excellence in 'interventional care'. Meanwhile, NCMC will operate in the red.

RISK 2: The success of the NCMC in attracting patients could result in the closing of Greater SE Community Hospital and/or Howard University Hospital, thereby reducing access to services in communities now served by these facilities and further contributing to losses at NCMC.

o if the vulnerable GSECH goes under, an even larger investment will be required at NCMC, and its patient load will include a larger portion of indigent and uninsured patients, further raising its non-reimbursed expenses. And there will be no hospital at all located East of the Anacostia;

o with Howard U faculty physicians helping support NCMC, the patient base at HUH will be eroded, and the facility will become unsustainable as a full-service acute care hospital. If it goes under, it will send more marginal patients to NCMC and leave the city with no additional beds. It currently runs at significant operating losses. Compared to other DC hospitals, it serves a relatively 'low acuity patient base' which could also end up dragging down NCMC's financial and professional aspirations.

summary

The NCMC bandwagon is powered by political steam, based on an urge to pander to constituent wishful thinking. The parameters for this unnecessary new hospital were established from thin air well before the city's healthcare needs were properly defined. The 'experts' report' is interpreted by NCMC proponents as strongly supporting their ambitious goals. In fact, reading both the fine print and between the lines, the opposite conclusions come into view, and far more comparative, quantitative, data could have been included . The new NCMC does not address the city's real health problems, and is likely to exacerbate them rather than relieve them. Furthermore, the extent to which non-DC residents inflate the need for DC hospital beds is completely ignored, and the possibilities of finding regional solutions to regional healthcare problems are not addressed at all. The city's administrative and legislative leadership needs to get a grip on reality: focus on the basic healthcare issues facing the nation's capital city, and give up dreams of building a world-class medical castle on a bed of "underserved" sand..

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This page was updated on Mar 5, 2006



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