For a glimpse of what life without D.C. General Hospital may be like, walk with Rosetta Keeton down the deserted corridors of the former St. Louis Regional Medical Center. A once-bustling hospital renowned for its black physicians and trauma care, the 350-bed building is a shell of its former self. Several of the nine floors are boarded up; a lone nurse minds the empty 23-bed inpatient wing.
The inner-city public medical center shut down most of its operations in 1997 in a move prompted by many of the same problems that plagued D.C. General -- chronic money woes and abysmal health among the largely minority populations it served. In its place is ConnectCare, a private, nonprofit network of primary and specialty clinics akin to the system that will take over in the District.
For the first year after Regional's closing, the health of the city's African Americans got worse, not better. But if the numbers looked bad, the anecdotes were even more alarming. A gunshot victim bled to death in what remained of the ER. Desperate teenage girls called asking where to go to deliver their babies. And the very clinics intended to serve the poor sparred over paying customers and shunned the neediest.
"It was hell, sheer hell," said Keeton, who worked in the old hospital and initially opposed its closure but now serves as ConnectCare's ombudsman. "People were panicking; people were angry. The patients were angry they didn't know where to go; staff at other hospitals were very angry at the fact they had to take care of poor folk they hadn't bargained for."
Four years later, Keeton still feels the sting, but she and many officials are guardedly optimistic about ConnectCare's prognosis. They don't know yet whether residents' health is improving, but they are convinced that in the long run, the new approach of shifting from hospital-based urgent care to community-based preventive care will improve health in the most economical way. Clearly, observers say, the lesson of St. Louis is that the path of change is long and treacherous, fraught with possible racial strife, money woes and missed medical opportunities.
"Every time you tear the system down, you lose some people and some people get hurt," Keeton said.
No two cities are exactly alike, but the parallels between St. Louis and the District offer some insights. As of Monday, both will be without a public hospital, both trying to serve about 65,000 uninsured or underinsured predominantly black residents.
The two communities are hardly alone. Across America, cities are getting out of the hospital business. From 1980 to 1999, the number of public hospitals declined from 1,778 to 1,197.
Some cities, such as Tampa, have relied on a direct tax to pay for a new, private health network. By steering low-income residents to outpatient clinics, officials say, they have drastically reduced costly emergency room visits in the last 10 years. In smaller communities such as Asheville, N.C., a volunteer collection of doctors, hospitals and pharmacies provides a cost-effective safety net for the poor.
But the obstacles for the District -- like those in St. Louis -- are far more complex. Racial divisions, turf battles, transportation difficulties and the sheer size of those urban centers make Tampa and Asheville seem quaint.
"Indigent care gets pitted against a lot of other urban priorities," said James Kimmey, ConnectCare chairman. "There is no evidence in our case that privatization provided better services, and it allows the public sector a lot of opportunities to back out."
In the early going, patients in St. Louis struggled with the notion that instead of one-stop care at the familiar hospital, they would be forced to navigate a maze known as ConnectCare.
One of the five ConnectCare clinics is housed in the old hospital, a red-brick building on a dilapidated stretch north of downtown. Others are scattered across the city, in bare-bones spaces, often with linoleum floors, overstressed air conditioners and no cafeteria.
Clinic physicians average 30 patients a day, allowing them about 16 minutes per person. That's similar to the 15-minute slots given at private doctors' offices. But with a clientele that is often less educated and in poorer health, that is rarely enough time, said Barbara Bailey, administrator for two of the clinics.
Despite a new computer system and an aggressive outreach program, Bailey said the most difficult aspect of her job is keeping track of such a transient population. "Every single time they step into my clinic, we require them to sign a piece of paper saying, 'My information has not changed,' " she said.
Another problem is that the clinics are open only on weekdays. So when Rogers Beamon had an allergic reaction to a new medication one recent Saturday, he boarded a bus for St. Louis University Hospital. With his Medicare card in hand, the former radiology technician said, he was treated well.
"They took my vitals, gave me an IV for fluids; everyone was very pleasant," he recalled. But Beamon didn't have the $170 Walgreens wanted for his new prescription. "I had to wait until Monday, get my primary-care doctor to write me a prescription so I was able to get it for $7.50" with ConnectCare's discount. He wonders what will happen if he has to wait for a lifesaving drug.
In addition, ConnectCare requires referrals for specialty services, much the way private insurers manage their systems. Hospitals receive a voucher from ConnectCare for treating the poor.
"The health care community is treating the indigent as footballs," said Democrat William L. Clay Jr., the local congressman. "Nobody really wants to take responsibility."
Many in the African American community resent the fact that while the city's black areas are now without a single hospital, the white sections have several.
"First they closed Homer G. Phillips, then City [Hospital] and now Regional," said Yvonne Haynes, who works at the Stella Maris Child Care Center, across the street from Regional. "Those were the hospitals we were using."
Haynes has insurance but knows that many in her community relied on Regional's emergency room, especially for treating injuries such as gunshot wounds. "Now they have to go all the way to" Barnes-Jewish Hospital, several miles away, she lamented. "It's just unfair to us. We need every health facility we can get."
The cases at Regional didn't fit neatly on a standard medical form, said Keeton, and the patients don't always fit comfortably in their new surroundings. "We had patients who think nothing of wheeling their IV out into the parking lot so they can have a smoke," she said. "Or there's the patient who just needs routine care but isn't the ideal patient -- maybe he stinks or he's drunk."
Many ConnectCare patients say they feel unwelcome at private hospitals. Pam Willingham, 48, used to visit the public hospital for annual checkups and shots; in 1996, she had a gallbladder operation there. She didn't like the long lines at the Max C. Starkloff clinic near her home in south St. Louis, and when she was referred to Barnes-Jewish Hospital, employees there lost her paperwork three times. "I felt like, 'I guess they really don't want to help me,' " she said.
James Buford, president of the Urban League, said the city has "a bastardized system dependent on the goodwill of all people involved. . . . White folk don't want to be around black folk in the hospital. Then the word spreads and people refuse to go to any hospital. People are falling through the cracks."
After the first year though, Willingham said, the system has run much more smoothly. ConnectCare vans shuttle patients to appointments, a new $3 million computer system has sped up service at clinic pharmacies, and Willingham is impressed that doctors have taken the time to recommend physical therapy for her bursitis.
But for the former patients and employees of Regional, it is difficult to separate cold facts from raw emotion -- even four years after the closing.
Kimmey, ConnectCare's chairman and a professor of public health at St. Louis University, labels ConnectCare "a medical success and a financial failure." Last year, ConnectCare pleaded for a $10 million bailout to meet its $42 million in expenses. Each year, the network cobbles together payments from the city, St. Louis County, the federal government and charities to cover costs, although the city has yet to deliver on its promised $5 million payment for this year. It is a pittance compared with the $33 million the city funneled to Regional.
And ConnectCare must compete for paying customers with four clinics that qualify for higher federal reimbursement rates. Those clinics are quietly opposing efforts by ConnectCare to receive similar rates, a potential boost of several million dollars.
In some respects, the situation in Washington may be more hospitable to privatizing indigent care than the one in the St. Louis area was, said experts in both cities.
As part of the District's privatization plan, all city-funded clinics will become part of the network, which means that rather than compete for the higher reimbursement rates, they will share that lucrative status.
Most significant, "the District is much more involved in paying for health care than St. Louis has been," said Larry Lewin, a private consultant who studied both systems. Although the systems see comparable numbers of patients, the District has budgeted $90 million for the first year, compared with $42 million for ConnectCare last year.
"On paper, the response looks better," said Boston University public health professor Alan Sager, who opposed the closing of D.C. General. "In reality, hospitals are not interchangeable parts in some health care machine. They have a more ecological role."
Even if closing D.C. General does achieve Mayor Anthony A. Williams's financial and medical goals, no one predicts the effort will be trouble-free.
"It makes sense to close down the hospital and use the money to give people access to health care elsewhere," said Gregg Bloche, a professor of law and health care at Georgetown and Johns Hopkins universities. "But the community-corroding impacts of shutting down are powerfully countervailing factors."
Keeton predicted that Washington has at least two difficult years of transition ahead. "It's not a pretty thing in the beginning."