The heated arguments associated with the future of DC General frequently devolve to whether the current building and its employees and management should be "revitalized" to meet current needs--primarily for the city's poorest and mostly medically uninsured--or whether the institution should be scrapped and a new one generated in its place. To his credit, the mayor had his eye on a broader issue: how to provide proper medical care to all the city's needy. He opted to privatize the hospital as he had Greater Southeast Community Hospital in late 1999. (see previous article), and bids were requested in 2000. Only two proposals were received: one to salvage DC General; the other to create a citywide cooperative system to provide health care to the needy.

The unassuming front entrance of the modern part of DC General belies the extraordinary range of traumas and illnesses treated here for DC's neediest, and mostly uninsured residents.

Well before the public debate heated up and became a racially-tainted diatribe against Mayor Williams, many reasonable people had concluded that not only was the now- oversized facility no longer economical to operate (nor is it the best use of the large tract of land on which it sits), but that many of the personnel were probably beyond practical revitalization as well.

Perhaps the most telling informal expose' of conditions within the medical staff at the hospital was written by Stephanie Mencimer, staff writer for DC's City Paper in August, 2000. In an article entitled "First, Do No Harm", the teaser reads "When some DC General Hospital doctors talk about putting patients first, they're not being Hippocratic. They're being hypocritical." The long and sometimes rambling article documents such things as: surgical mistakes and a strong reluctance to investigate them; staff refusal to accept demands for performance accountability; management attempts to overturn disciplinary actions against poorly performing physicians; complaints about the quality of the nursing staff from doctors who have refused to update their own skills, fought financial reforms, and hounded out reform-minded administrators; civil-service protections (albeit salary caps as well) which make the medical staff impervious to dismissal; an accreditation system that evaluates hospital procedures, but not physician competency; doctors with poor records both at DC General and in prior employment; doctors on full salary that are perpetually late as well as some who only see only eight patients a month; others that have retired and returned immediately under substantially higher salaries; surgeons without certification and unsupervised residents acting as "ghost doctors"; overtime billing on the "honor system"; missing records; no productivity standards; "erroneous billing" without subsesquent investigation; and skimming off those few patients with insurance and Medicaid. And perhaps most telling of all: DC's Department of Health estimates that 90% of Medicaid patients, 97% of Medicare patients, and 67% of DC's 80,000 uninsured residents go, by choice, to other hospitals!

That article did not get into the failures of the Public Benefits Corporation, the separate agency established to run DC's public hospitals and clinics outside the Department of Health. It's performance has also been embarrassingly incompetent, including what appears to be a massive misuse of funds which eventually led to the firing of its boss. That individual is still suing the DC Government for $1 million in severance pay--which was to be paid regardless of malfeasance! Privatization of the city's public hospitals would certainly justify developing an alternate solution, particularly since the current head of the PBC submitted the only other--and losing--bid (to revitalize DC General).

Interestingly enough, those campaigning to keep DC General open seldom refute any of the claims made above, but rather focus on the uncertainties of changing to a relatively unknown quantity (Doctors Community Healthcare Corporation (DCHC)--the contractor that recently took over the struggling Greater Southeast Community Hospital (GSCH))--with a very limited track record, albeit a gutsy willingness to take on hospitals chronically losing money. These opponents of the Mayor's plan to close DC General focus on different issues: the need to keep a hospital in the depressed Eastern part of the city; the realistic concern that the remaining hospitals may become overwhelmed by the influx of additional emergency cases; doubts that DCHC can step up to the magnitude of DC General's caseload in a short period of time; assertions of DCHC's 'financial instability'; unfair financial groundrules between the two bidders; and claims that DC could well afford to pay more to keep DC General going. Behind these stated concerns the basic worry seems to be that those many impoverished souls already at greatest risk are being placed at even greater risk by a heartless, bean-counting, racially-insensitive, city government. The issue has fueled racial tensions to a worrisome level. The Mayor, on the other hand--and to his credit-- insists that he is not being paid--nor was not he elected--to simply "rearrange the curtains". He intends to do what he considers best for the long-range future of the District. He seems to be willing to take the greater risk to achieve the greater improvement in public health care in the nation's capital. NARPAC supports his judgment--and courage--and doubts that his political future will be jeopardized by so doing. His explanation is provided below:

The Mayor's Plan for A Healthier City
Washington Post, March 25, 2001

In late March, 2001, Mayor Williams wrote a letter to the Washington Post explaining his rationale for accepting the new plan: (italics added by NARPAC)

The nation's capital should be the healthiest city in America. Instead, the life expectancy of its African American men is 10 years lower than the rest of America's, and the city has the country's highest rates of infant mortality, diabetes and HIV infection. Obviously, the District's health care system is failing and needs reform.

Of the 140,000 annual visits to D.C. General Hospital, only about 10,000 are inpatient admissions. About 4,000 of the patients admitted are uninsured, and local taxpayer dollars must pay for their care.

D.C. General will not be closing. Its emergency room will maintain 24-hour full-service capability for most of the more than 50,000 annual visits, which include more than 12,000 ambulance runs. Two advanced cardiac-life-support ambulances will support this emergency center.

But the large number of people who visit D.C. General but do not require hospitalization shows that many of the hospital's patients are using the emergency room as their primary care provider, which is both an expensive and ineffective way to provide health care. Emergency rooms don't provide the care people need to live healthier lives.

Therefore, the centerpiece of our health services reform plan is to change that practice by providing a network of more than 100 primary care locations. These locations will provide 30 percent more primary care, specialty and inpatient services than the current system. For the first time, thousands of uninsured residents will have ready access to regular health care. Meanwhile, inpatient and trauma care for the most seriously injured will be maintained at D.C. General until Greater Southeast Community Hospital is capable of delivering these services.

D.C. General staff, including trauma staff, will be offered hiring preference by Greater Southeast. And let me be clear -- Greater Southeast will be held to its commitment to provide the same level of trauma services now offered at D.C. General within three months. Only then will trauma services move from D.C. General to Greater Southeast.

The media have reported that D.C. General's CEO backed a plan to build a new hospital on the D.C. General site that would require no capital investment by the city. But no such plan was submitted for evaluation by the city.

The plan that was submitted by the Public Benefits Corp., which has been operating D.C. General, was fully reviewed by evaluators appointed by the D.C. Council, my office and the financial control board. The unanimous decision of these evaluators was to select the Greater Southeast proposal, which included the commitment to build the network of neighborhood-based primary care providers. The Greater Southeast proposal received more than twice the points of the Public Benefits Corp. plan, which would have continued inpatient operations at D.C. General.

Some believe that closing D.C. General is part of the National Capital Planning Commission's 1997 redevelopment plan, but the land on which the hospital sits is federally owned and designated for the provision of health care and human services. Further, I am committed to maintaining the site as a health care campus.

Finally, our health initiative places the responsibility for the reform plan with the District's department of health, not with any for-profit company. The health department has proven expertise in the management and oversight of large health services contracts.

The management of Greater Southeast has been in place for more than a year and has turned a failed institution into a safe and effective facility. However, the District will have specific contractual power to conduct reviews of this contractor's ability to deliver upon its commitments in order to protect the interests of patients and taxpayers.

I am confident that our community will come together to ensure that this reform leads to a substantially improved health care system for the District's neediest citizens.

-- Anthony A. Williams

This view of DC General shows the building with most of the still-active 450 beds. The over-utilized trauma unit is to the left rear.

NARPAC Commentary

The Activists

The pitched battle over the future of DC General--and far more basically, the proper health care for the city's disproportionately large number of poor--has degenerated into an embarrassing street fight in which many of the most vehement antagonists have far less than humanitarian interests at heart. There is not a single latent demagogue left sitting on the sidelines:

o union members and civil servants using racist charges--and tactics--to protect their jobs, not their patients, even though it is highly questionable whether the professional and administrative staffs of hospitals should be licensed to put their own welfare and job security ahead of that of their patients;

o duly elected officials on the DC Council and the ANC commissions who would rather further their own political agendas than help the sick and needy, even though most of them have already demonstrated their inability to face tough decisons themselves;

o the management and professionals of DC's several profit-making private hospitals who fear the inconvenience and unbillable costs of treating the traumas and sicknesses of the ghettos, even though some of those cases present the greatest medical challenges;

o black 'religious' leaders who see a rare opportunity to fan the flames of racism by making their Devil the white man and government rather than poverty and despair, even though their own contributions to the health and welfare of their flock are difficult to find;

o white liberal activists who see a perfect opportunity to rail against the incompetence of elected authority and the abuses of democracy as they visualize it, even though they lack constructive alternatives (beyond the status quo) and never run for elected office themselves;

o preservationists who have never seen an outdated building or an under-utilized piece of prime real estate that should be allowed to fall into more productive use, even though the obvious solution to the inevitable and growing costs of caring for the poor involves increasing city revenues;

o statehood and inner city isolationists who refuse to look towards the more prosperous suburbs to share the special burdens of caring for the poor, even though some form of 'poverty-sharing' is clearly key to creating a level playing field across the metro area;

o emotionalists who deify the poor and underprivileged as some sort of sacred trust to be defended as they are rather than as a major national socioeconomic challenge requiring major changes, even though a 'war to defeat poverty' would almost certainly be more meaningful than a 'war to defend poverty';

o a general reluctance to support analysis and fact-finding into the sometimes primitive and desperate acts of the poor which obfuscate the underlying problems requiring solutions;

Underlying Problems

NARPAC believes that there has been far too little open analysis and discussion of some of the underlying issues which could seriously effect the solutions sought . Although we have no secret sources of indisputable data, the following assertions appear supportable:

o An abnormal number of people in Washington appear to secure their livelihood by administering to--or claiming to represent--the poor, but the fraction of the city's population in that category continues to grow;

o An abnormal number of DC's poor are uninsured, and must find means to use public services for their very survival: resolving this issue should be the major focus of the DC Council, but so far, has not been;

o A very large number of the indigent are in need of health care as a result of a lack of knowledge of, and application of, preventative medicine;

o Faith-based organizations appear to have done little to improve the life-styles of the poor (unwed teen mothers, crack babies, etc.);

o For many poor, "going to the doctor" means going to a hospital emergency room because treatment is free. Actual counts of emergency room visits bear little relation to the real care required, most of which could be provided by clinics (as the mayor notes in his letter);

o For many poor, "getting to the doctor" means calling an emergency vehicle which (NARPAC believes) can only deliver the patient to a hospital, not a clinic;

o Aside from care for the mentally ill and bussing special education students, there is no public service provided by DC that is less efficient than DC's EMS system, and its peculiarly costly requirement that a fire truck answer every call for an ambulance;

o But those who truly do need emergency care are suffering from problems seldom confronting the private hospitals in the self-sufficient parts of town. NARPAC would wager that DC General gets most of the cases involving shootings, knifings, major child and spousal abuse, crack mothers and babies, the homeless in extremis, and so on. Not only are these the embarrassing conditions of the poor, they are harder to treat, and require extreme tolerance from the care givers at all levels. To assume that these cases can be treated equally well at any hospital by any staff is probably simply untrue;

o Another major uncounted cost of inadequate health care and guidance for the poor is the tendancy to perpetuate and propagate the need for public care either by transmitted disease, or by producing offspring that may become lifetime-dependent on public care;

o There appears to have been no attempt to merge the operations of DC General with some other organization(s) with a better track record. At the very least, one could envision some sort of non-profit adjunct corporation to a successful private hospital (of which DC has several)--or to a consortium of those hospitals--as a replacement for the near-worthless Public Benefits Corporation. There was disappointment when Howard University Hospital declined to submit a bid;

o There appears to be no effort whatsoever to make treatment of the area's poor a regional, rather than an inner city, problem. There is apparently no cooperative medical arm to the Metro Washington Council of Governments, though the surrounding jurisdictions provide excellent health care. At the very least, it should be possible to develop programs for sharing administrative expertise, scarce medical skills and medical equipment, and the procurement of costly medical supplies:

o The location and design of DC General Hospital was based on its intent to become-- and remain--a major health-provider for all Washingtonians, certainly not just the poor, or just those in need of real emergency treatment. It is surely DC's least productive hospital per square foot of building space, per employee, or per acre of prime land;

o The location of the hospital is certainly not optimal from a logistics standpoint. Although it is remarkably close to the centroid of DC's poorer residents who genuinely need emergency care, and have no other hospital, half of that area is on the far side of the Anacostia River and can only be reached by crowded (ambulance and fire truck- unfriendly) bridges. A far better solution would be to have one trauma center on each side of the River: one centrally located in Ward 7 (say at Ft. Chaplin Park), and the other more centrally located in Ward 6 (near Lincoln Park).

o From an emergency access standpoint, Greater Southeast is even worse. It is located near the southern extreme of the District, up against the Maryland border, with relatively poor access roads. This also speaks for adding trauma centers more centrally located for the needy residential population.

o Most of DC's Northeast and all the Southeast borders are shared with Prince George's County--the destination of choice for many of DC's emigrant black young people. There are one or two hospitals within a relatively short distance (well within the Beltway) that could cooperate with DC (PG Hospital in Cheverly). However, the density of hospitals in Southern Prince George's is quite low--and one wonders if some who have moved to PG County are still using DC hospitals.

o DC General sits on some 60 acres of potentially prime real estate, originally held by the federal government, but turned over ( in what form, NARPAC is not sure) to DC for the development of a hospital. It is bordered on the East by the Anacostia River (with open parkland on the other bank), the South by the DC Jail (another anachronism), and on the North by the DC Armory (yet another outdated facility) and RFK stadium--no longer the home of the Washington Redskins. Presumably, all of the facilities are also on once- or still-federal land.

The full sprawl of the DC General Hospital is best photographed from the adjacent RFK Stadium parking lot. The Anacostia River is a short distance behind the photographer.

The Physical Site

In the grand Third 100-Year Plan for the Federal City by the NCPC, all of this area becomes part of a grand eastern extension of the National Mall along East Capitol Street to the Anacostia River:

"While the existing Capital Hill neighborhood of quiet streets and historic row houses will remain undisturbed, the Anacostia waterfront will be transformed into a new ecological precinct, with the river and parks as centerpieces and environmental stewardship the theme. The area will celebrate parks, islands and wetlands; an aquarium is proposed for Kingman Island (in the Anacostia). The RFK stadium site, now mostly parking lots, will contain a major memorial, surrounded by new housing and commercial development. This proposal for the Anacostia waterfront would not only increase total park acreage in the District, but also make it more accessible to more people for more activities."

The DC General property actually interrupts the Eastern extension of Massachusetts Avenue, which by the time it reaches the hospital has petered down to a narrow residential street, and resumes as a relatively undeveloped street on the far side of the river, forming the Southern boundary of the huge, undeveloped Ft. DuPont Park. Though not foreseen by the NCPC plan, reconnecting Massachusetts Avenue with a new bridge would help open up "East of the Anacostia".

As is demonstrated in NARPAC's section of Economic Challenges, DC property, even with its constraining building height limits, can generate up to $2 million dollars per acre in high density residential or commercial revenues. The DC General operating deficits have never exceeded $40M per year--a sum that could be generated by the 'best use' development of one-third of its unused acreage--much in the manner that the Maritime Plaza, Navy Yard, and Southeast Federal Center are now being developed further down the Anacostia. NARPAC does not share the mayor's stated position that the current DC General site should be maintained as a health care campus, but can understand his desire not to cross this bridge at this time.

The question of what happens if the DCHC goes 'belly up' is a valid one. It already applies since DCHC is now operating the Greater Southeast Hospital. There does not appear to be any judgment as yet as to how well they are doing there. In fact, an audit is apparently underway at this writing to determine the adequacy of their overall financial structure. Why DCHC's situation should be much different than when it was allowed to buy out GSCH, NARPAC does not know.

Nevertheless, the total loss of public health care is simply not an option for DC, and there is little question but that the city should hedge its bets., and the contract with DCHC should include some items regarding the consequences of bankruptcy. In addition, the city should probably maintain some fall-back position, including: maintaining the DC General facility in stand-by status for some length of time; developing a plan to mobilize resources to take over from a defunct DCHC; and perhaps seeking at least temporary solutions involving regional or federal assets. In NARPAC's view, however, retaining the status quo rather than risk developing a far better system, is not a sensible option.

The massive Archbold Hall building (left) is typical of the now-surplus facilities at the DC General Hospital site--reminders of earlier hopes and expectations.

Excerpts from DCHC Proposal

Just after the above section was written for the April web site update, the DCHC proposal became available on the DCWatch web site. The excerpts provide below give the flavor of that proposal, and indicate that in many areas, DCHC proposes to follow the broader path towards a system approach to solving the health care problems of DC's neediest. Note that there is no connection between DCWatch (above) and the name of DCHC's program for "Washington Alliance for Community Healthcare (DC-WACH):

Greater Southeast Community Hospital Corporation I (GSCH) is pleased to present its response to the DCFRA RFP # 00-R-039. Through a newly created subsidiary corporation to be known as the Community Healthcare Improvement Corporation (CHIC), GSCH as the responsible prime contractor will develop, implement and manage the Washington Alliance for Community Healthcare (DC-WACH Program). The DC-WACH Program is designed exclusively to provide and coordinate healthcare for the uninsured and indigent population of the Distinct of Columbia. GSCH will be responsible for the oversight and implementation of the daily operations of this plan.

DC-WACH is a unique public / private program designed to coalesce the healthcare resources of the community in an effort to enhance the quality, efficiency and accessibility of healthcare for the uninsured and underserved population of Washington; DC. DC-WACH proposes to bring together some of the most successful and well-known healthcare providers and insurers within Washington, DC to participate in this program. Providers and health maintenance organizations (HMOs) such as Greater Southeast Community Hospital, Hadley Memorial Hospital, Children's National Medical Center, Washington Hospital Center, Providence Hospital, George Washington University Medical Center, Chartered Health Plan, Capital Community Health Plan, Unity Medical Group and the consortium of non-profit healthcare providers have been contacted and have indicated some level of interest in participating......

DC-WACH's goal will be to integrate an array of such providers and one of more HMO insurers into this program under the coordination of DC-WACH. Under the proposal, DC-WACH will provide the following services:

* Ambulatory, primary and specialty physician care at more than 150 sites
* Hospital inpatient and outpatient care
* Emergency and Urgent Care
* Dental Care
* School Health Services
* HIV / AIDS Services
* WIC and Maternal and Child Health Services....

The primary goal of the DC-WACH program is to significantly increase the quality and efficiency of delivery and accessibility of medical services for the underserved and uninsured population of Washington, DC.....

GSCH is uniquely qualified to meet the requirements of the RFP and to provide and coordinate primary healthcare, specialty healthcare, in-patient services, emergency / urgent care and public school care. Greater Southeast Community Hospital, a 450-bed, full service hospital, has a long tradition of providing comprehensive, integrated and coordinated healthcare to the residents of Wards 6, 7 and 8 including the indigent and needy. The mission of Greater Southeast Community Hospital is to improve access to quality healthcare services by working closely with the community to identify areas of need and to develop or extend prevention programs....

Currently, GSCH and HMH along with other DCHC facilities continually emphasize the enrollment of patients into Medicaid and other available insurance programs. In the case of Medicaid, GSCH has dedicated positions to track and process patients through the complicated process of eligibility and verification. Since the GSCH change of ownership in 1999, this program has increased the conversion or enrollment of patients into the DC Medicaid program by as much as 30 percent. It is these types of successful operations that will allow GSCH to improve the conversion of patients from the ranks of the uninsured to the insured....

GSCH believes that currently a significant number of providers provide important services for the residents of Washington, DC. In developing this proposal, GSCH believes that the more of these providers that participate in the DC-WACH program, the more effective it will be. In preparing this proposal, GSCH entered into discussions with the numerous HMO insurers and healthcare providers. However, since DC-WACH is designed to be a public / private partnership, final selection and subcontracting arrangements were not entered into with any of these parties because GSCH believes that participation by the city in this selection process is very important.....

DC-WACH proposes to create an advisory board that will act as a "think tank," which will continually review the performance of DC-WACH with regard to the requirements described and agreed to within the RFP. This group of individuals will be expected to provide direction and recommend solutions. Potential advisory board members could include individuals from selected key subcontractors; community members, members of the DC City Council and members of the senior staff of the District's Department of Health. The advisory board will also have the benefit of GSCH's parent organization, Doctors Community Healthcare Corporation, and its team of healthcare management specialists to this project. Specialists in the field of quality assurance, medical management, customer service, accounting, finance, healthcare operations and contract operations will be accessible by the local management team. It is envisioned that DC-WACH will also have an executive director position in which the daily operations of this coalition will be overseen....

DC-WACH also proposes to establish a Physician Advisory Committee (PAC). The chair of this committee will also hold a position on the executive advisory board and the management team. The physician advisory committee will consist of the medical directors of each selected subcontractor (i.e. CCHP, Chartered, Unity, Children's), a representative physician from the District's DOH, the Quality Assurance and ethics director and one or two project medical directors....

DC-WACH also proposes to provide an easily accessible van transportation network that will provide transportation for patients with no transportation resources. This program will be developed in concert with the District's plan to provide additional EMS / Ambulance resources. Van transportation will be provided from the neighborhood clinics to and from the DC General ambulatory care site and GSCH...

. DC-WACH will work with the District in order to develop a comprehensive pharmacy program for the eligible target population. Currently this is not addressed in the RFP. However, DC-WACH is eager to develop a plan that can better the healthcare for this population. DC-WACH believes that its all encompassing provider network and pharmacy providers could indeed offer the District a valuable and high quality service.....

Each uninsured patient who presents him or herself to any access site of DC-WACH will be subject to eligibility criteria that is developed and agreed to by the District of Columbia. Current eligibility criteria submitted with the RFP requires each potential enrollee to be a "bona fide" District resident. DC-WACH proposes that it will make every attempt to verify resident status using standard techniques....

DC-WACH proposes that it will analyze and review the need for a new acute care facility to be constructed upon the DC General campus. During the implementation and execution of this contract, DC-WACH will propose to review utilization and cost data that will give significant insight into the feasibility of financing the construction and operation of a community oriented acute care hospital upon the current DC General site within the next three to five years. DC-WACH will provide a report of these findings no less than 24 months after the execution of this contract....

DC-WACH proposes that CNMC will provide for the administration of the current School Health Program. The program will be administered under similar terms as outlined in the Memorandum of Understanding between the PBC and DOH. However, DC-WACH would like to reserve the right to review this document and renegotiate terms directly with DOH....

DC-WACH will assist in the coordination, referral and planning of services utilized by the department of corrections and its designated contractor. DC-WACH would also very much like to meet with the District and the Department of Corrections in order to offer access to specific components of the DC-WACH system. Specifically, GSCH and HMH would be interested in discussions that would enable these facilities to provide inpatient and outpatient care to this population....

(Regarding employment opportunities at each of the several organizations (ORG) proposed, identical wording is used:) The employees of this ORG will be selected and employed by ORG...... All employees that are current PBC employees will be encouraged to apply. Preference will be given to those qualified PBC employees who apply based solely on the fact that they are current PBC employees. Each employee will be a newly hired employee and will become eligible, according to current GSCH policies, to all GSCH employee benefits as currently structured for similar GSCH employees.....

Further NARPAC Commentary

Many of NARPAC's earlier stated concerns are covered in this proposal. In fact there are only two exceptions worth noting:

o The DCHC proposal does not include cooperation in the metro area beyond DC's boundaries;

o The intent to consider a new facilitiy on the grounds of the current DC General Hospital seems needlessly constraining--why not look to other sites as well?

This is not yet the final chapter in the saga of providing appropriate health care to DC's neediest, but NARPAC hopes that highly partisan and very local politics will not distract the City from doing what is needed for the long run for the most people.