By Peter White
NASHVILLE, TN — The life of Nashville General Hospital is hanging by a thread just like one of its patients not too long ago.
Van Douglas, 62, has too much income to qualify for TennCare but too little to buy insurance. So when a brown recluse spider bit him on his forehead, Douglas went to General Hospital’s emergency room. A month later a knot appeared under his arm. A cat scan revealed a large mass between his lungs unrelated to the spider bite.
During the next four months Douglass had five biopsies. A staff oncologist at General identified the growth as a B-cell lymphoma and immediately ordered chemotherapy for Douglas.
“If it weren’t for the chemo and the doctors, I wouldn’t be here today,” Douglas said.
His cancer is in remission. One of the doctors who treated Douglas is leaving Nashville General this month to take a job in a Cookeville hospital.
Mayor Barry proposed to end in-patient care at General last November without consulting the Hospital Authority or General’s CEO, Dr. Joseph Webb. Dr. Mike Schatzlein, a Hospital Board member, resigned a week later.
Barry’s abrupt announcement on November 9, 2017 came with a promise to keep the hospital operating until June 2018. According to Bruce Naremore, General’s Chief Financial Officer (CFO), other hospitals immediately started sending recruitment letters to General’s nursing staff. He said the poaching is causing an exodus from the hospital because medical workers are afraid it will close.
In her letter to the Hospital Authority Barry wrote, “I believe we all can agree that the current operating model for Nashville General Hospital has not been working and is not sustainable without significant changes.”
Reverend Judy Cummings said General Hospital began to have financial troubles after it moved to Meharry in 1994. “Before that the hospital was always funded and always had everything that it needed,” she said.
“You have to have the money. When you ask for $50 million and you’re only given $35 million you are set up to fail and that is what has happened,” she said.
“The subsidy is $44 million. The hospital provided $70 million of indigent care. That seems like a pretty good investment to me,” said Pastor Jay Voorhees.
“We can do a transit system, we can build a soccer stadium , we can build a convention center We seem to always have the money available to do those things. And we can have the money available to have the leading safety net hospital in the nation if we decide that’s what we want to do,” he said.
Last Thursday, Webb met with Vice-Mayor David Briley, Meharry officials, and members of the city council in the mayor’s office.
At a meeting of pastors, staff, and political leaders at the hospital Saturday, Briley said the city has “reset” the discussion about General’s future. “We need to set a date where we decide exactly what we are going to do, “ he said.
Briley’s remarks were well received but controversy remains about what kind of care indigent patients will get at General and how to pay for it.
“I believe a transition to an ambulatory outpatient facility model is the best approach. Funding a hospital at a required in-patient staffing level that far exceeds the number of occupied beds is not the responsible thing to do,” wrote Barry in her November letter to hospital authorities.
While the number of occupied beds has dropped from 63 in 2010 to 34 in 2017, that doesn’t mean the hospital is wasting money. According to CEO Webb, what Barry wants to do will gut the hospital’s ability to keep people out of hospital beds by keeping them healthier.
“We are doing what we need to do. It is evidence-based, it is proven, it shows outcomes, it is not wasteful. It is an international model we are using that is being used across the world all the way from Australia to Switzerland. It is that model we started using three years ago and that is why we’re seeing the outcome we are seeing, “said Webb.
General now provides tertiary care. That means an emergency room with specialists on staff and a lot of medical technology to deal with acutely ill patients. If the hospital were limited to outpatient services it would no longer be a hospital but just a big clinic.
“From the emergency room you have to have a place where you can stabilize them and then we transition them into a care model to manage their chronic illnesses,” Webb said.
Webb noted that Nashville has a major disease burden and it’s at epidemic levels. In layman’s terms, there are a lot of really sick people in Nashville.
“If you put them in a model where they can learn to take care of their chronic illnesses then you see these outcomes that were mentioned earlier,“ he said.
The Mayor’s idea to cut staff and operations got some traction last month when the Crosslin CPA firm released an audit of General’s finances for the fiscal year that ended last June. It noted “material misstatements” in ten hospital accounts.
“I didn’t fall off a turnip truck here,“ said General’s CFO Naremore. He is a CPA and a former auditor. He has been a CFO at for-profit and community hospitals. He’s been through 30 audits and never got a qualified opinion like the one in General’s latest audit.
“In the 2016 audit we had about 30 findings. This year we had about 20 but that’s not the story they want to tell. It’s overblown,” he said.
Although Naremore thinks Crosslin is a good audit firm he noted that they had zero hospital audit experience before doing the General audit. “The most valuable and challenging part of a hospital audit is valuing what the patient receivables are worth that were on your books,” he said.
He said hospital bills can take 120 days or longer to settle.
“Their net change on our receivables was $200 thousand on $44 million of receivables. That’s less than one half of one percent. If they consider that material weakness, they’re freaking crazy,” he said.