Saving Lives, Losing Millions at Pr. George's Hospital
With Few Paying Patients, Center Is Caught in Its Own Death Spiral
By Brigid Schulte
Washington Post Staff Writer
Monday, December 22, 2003; Page A01
At 11:40 on a Friday night, a bleeding man on a stretcher, steered by a pair of grim-faced paramedics, careens into a dying institution.
Gunshot to the right biceps, the right hip and femur, they call out. Large caliber bullet, probably a .44 magnum. At close range.
The man, the fifth trauma of the day, is known at this point only as Evan Doe, E being the fifth letter of the alphabet. Trauma patients, like hurricanes, are named in alphabetical order.
"Looks like he got beat up, too," says Willie Blair, one of the few trauma surgeons still willing to take emergency patients at any hour at Prince George's Hospital Center, the hospital on the hill in Cheverly that has been close to bankruptcy off and on for decades.
"What's your name?" a physician's assistant asks, as nurses in blue scrubs busily hook him up to IVs and monitors.
A moan.
"Have you ever had surgery? Are you allergic to anything?"
"Hey man, you in there?" Blair asks calmly, as he unwraps the makeshift bandage on the delirious patient's bicep. Blood spurts like water from a drinking fountain.
"He's got a hole this big!" an emergency technician calls out. "You can look all the way through it!"
The machines start to beep, waves start to form and numbers appear on a screen: Blood pressure. Heart rate. Numbers that signify life and the 27-year-old Doe's chances of hanging onto it.
With every $11.66 bag of IV fluid, every $9.60 oxygen sensor, from the snap of the first 6-cent pair of latex gloves, a different gauge of vital signs starts to run. Tiny drops of cost after cost that explain why the 59-year-old hospital itself is hemorrhaging.
Evan Doe has no health insurance. Latest occupation, a staff member writes on the paperwork: unemployed. He has no way to pay for what it will cost to save his life.
And one out of nearly every two people who come here is in similar straits. They have either no insurance or low-paying Medicare or Medicaid to cover their bills. At no other hospital in the state is the proportion of charity and Medicaid patients so high.
"I think he's losing blood," a nurse says, panicked.
Fourteen different lab tests to determine his blood type: $197.63.
Ten packs of red blood cells: $914.
Four pints of fresh blood, at $47.98 a pint: $191.92.
"Okay, take some pretty pictures, baby," Blair calls out.
X-rays of his chest, cervical spine and pelvis: $126.75.
A trip to the operating room will add $3,000 to the cost. In the next few days, Evan Doe will consume $1,068 worth of drugs, require $2,311 worth of lab work and use $7,049 in medical supplies. By the time he's discharged to his weeping mother, 11 days later, he will have run up a $46,328.28 tab that the hospital will never recover.
And that doesn't include doctors' fees.
Willie Blair, a burly, 57-year-old surgeon who has worked at the hospital since Evan Doe was 5, will get nothing from him and a stipend from Prince George's so small that he calls it insulting.
Rick Smith, an orthopedic physician's assistant, studies Evan Doe's X-rays on the old-fashioned light board. What had been Doe's hip is now a pulverized, powdery mass. The thighbone is shattered. He will need at least three surgeries if he's ever to walk again. The nerves in his right arm are probably severed, meaning he may lose all feeling in his hand and fingers.
"What are we going to do?" a technician asks.
Smith shakes his head. "Run and hide."
Location Cuts Both Ways
Prince George's Hospital Center is caught in a death spiral, as are virtually all other nonprofit community or public hospitals in America where the poor and uninsured -- 43.6 million by the latest count -- go to be healed.
Across the country, 293 public hospitals converted to private, for-profit ventures from 1985 to 1995. An additional 185 closed.
In this area, D.C. General Hospital was shut down by the city two years ago. Greater Southeast Community Hospital, now in its second bankruptcy, lost its accreditation for four months and the city nearly yanked its license for providing poor care. And public hospitals are not the only ones in trouble. Nationally, one-third aren't breaking even.
The economics of places like Prince George's are simple. The higher the number of indigent or low-paying patients, the more money the hospital loses. With money running low, the hospital can't buy the latest equipment to keep up with the competition.
With outdated technology and patients who can't pay, it can't attract new doctors or hold on to old ones, much less replace the decaying tile.
So, year after year, the hospital operates in the red. It lost $43 million from 1999 to 2001. This fall, officials threatened to close the facility within weeks without the immediate infusion of millions.
For Prince George's, location is everything.
Sitting just two miles from the District line and some rough border neighborhoods, it attracts a clientele that can't pay. Or pay much.
With better regarded medical facilities such as Georgetown University Hospital within 45 minutes by car, those with means in Prince George's County choose to go elsewhere. Howard University Hospital attracts many from the black community. Nearly two-thirds leave the county for health care.
Yet, paradoxically, the fact that it lies just inside the Maryland state line is the only the reason it is still alive.
For 30 years, a state commission has collected what amounts to a tax from profitable hospitals to help support facilities, such as Prince George's Hospital Center, that have large numbers of patients who can't pay. The state can do that because, alone among the states, Maryland has a waiver from the strict reimbursement guidelines of the federal Medicare program.
The waiver started as an experiment to answer what has become a pressing national issue: There are millions of people without insurance or money. They get sick. Somebody has to treat them. And somebody has to pay. It failed in four other states.
"We have always said we're two miles from going out of business," said Noel Cervino, the chief financial officer of Dimensions Healthcare System, referring to the hospital's proximity to the District. Dimensions, a private, nonprofit corporation, runs Prince George's, along with Laurel Regional Hospital and Bowie Health Center.
The waiver system allows Prince George's to survive, yes. Thrive, no. The hospital gets a chunk of money from the state's uncompensated care pool -- about $19 million last year. The state allows the hospital to cover the rest of its costs by charging higher fees to patients and insurance companies for every procedure.
But all that has done is drive paying patients and their insurers elsewhere for better deals.
Plus, the state system doesn't factor in doctors' costs.
With so many indigent or government-insured patients -- along with their own rising malpractice insurance premiums -- physicians such as Willie Blair say they simply can't make a go of it at Prince George's. Uninsured patients may pay them nothing. And Medicaid and Medicare don't come close to covering their costs.
Even if Evan Doe applies for Medicaid and qualifies, Blair, who charges $400 for a trauma evaluation, will see no more than $32.
To keep doctors at the hospital, Prince George's has to pay them. It has hired 80 of its own, including anesthesiologists, obstetricians and the doctors who run the intensive care unit. The hospital also subsidizes private physicians, such as Blair, to keep them in "the pit," the high-intensity trauma room and emergency department.
Other institutions have their own doctors on staff and subsidize their trauma teams, too. But, unlike Prince George's, they make up any losses with a greater volume of paying patients.
Blair and trauma surgeons like him, who together see 2,500 patients a year, will spend 24 hours on call at Prince George's every eight days, treating the region's poorest patients. For their trouble, they get the top rate of $52 an hour.
The son of Mississippi sharecroppers, Blair knows what it's like to be poor. He took turns going to school with his brother so they could care for their 10 other brothers and sisters. He didn't learn how to drive until he was 30. He lived in an apartment until he was 35, concentrating, not on the good life, but on paying his school loans, the mortgage on his mother's house, his brothers' keep.
True, he now drives a shiny black Mercedes-Benz. He sends his daughter to Tufts and his son to a $13,000-a-year private school. He has his own paying patients at Prince George's, Suburban and other hospitals to help him do that. He knows no one is going to cry a river for what doctors make. But the poor of Prince George's are becoming a drain.
"I went to medical school, not business school. I see people who need to be taken care of -- not dollar signs," Blair said. "But when my secretary says the paycheck bounced, I've got to worry."
The salaries and subsidies Prince George's lays out add up to about $9 million a year. The hospital bills the patients. But many accounts receivable simply end up in wastebaskets. The hospital collects only $2 million. That leaves a $7 million deficit every year.
County Executive Jack B. Johnson (D) has promised $30 million over five years to bail the hospital out of the current crisis. But without some fundamental change -- more paying patients, a regular infusion of public funds, or a sale -- the hospital will continue to linger with a weak and thready pulse, or, eventually, close.
Moody's Investor Services has rated about $80 million worth of the hospital's bonds as junk, making it virtually impossible to borrow money and increasing the likelihood of bankruptcy.
"If I were a betting man," said Bruce Gordon, a hospital industry analyst at Moody's, "I would have bet that they'd have gone under long before now."
An Aura of Distress
Five minutes after arriving at the hospital, Evan Doe vomits. It may be the sign of a head injury.
His condition is serious enough that the trauma team considers shipping him to Maryland Shock Trauma Center in Baltimore.
Willie Blair says that conversation is taking place more frequently, as fewer doctors at Prince George's are willing to take on complicated cases for the meager financial return they provide. Still, Blair and those who remain are regarded as among the best. The trauma room has a 97 percent "save rate," according to hospital records.
Time is becoming a factor for Doe, who agreed to give The Washington Post his medical bills on condition that his name not be used.
He is in his "golden hour," the period immediately after a massive injury when a patient's chances of survival are highest. A trip to Baltimore would cost 45 precious minutes.
Instead, the doctors page Sagar Nootheti, one of only three orthopedic surgeons who still takes calls at Prince George's. There used to be nine. Nootheti will be paid $20.83 an hour for what will be a three-hour surgery, one of the most complicated he will have ever performed.
Technicians wheel Blair's gunshot victim down the hall for a CT scan. One of them mashes the automatic door opener. Nothing. He mashes it again. Curses. He steadies the stretcher with one hand, and reaches with the other to open it manually.
That is what it's like in a hospital on the financial edge. There are no unattended patients bleeding in the hallway. Paychecks come on time. Unlike at D.C. General, where staff ran out of suture, supplies here are plentiful.
But there is an aura of distress. Emergency doors stick. The carpet is worn and stained. The phone rings and rings. And on the second-floor maternity wing, so many people have stood in the same spot waiting for the elevator that the tile has worn away all the way down to the cement.
As the gunshot patient lays sedated and bleeding in the hospital's only CT scanner, the six-year-old machine keeps mysteriously resetting, forcing the technician to start over again and again.
On the lighted sign above the front entrance, the "P" in Prince George's Hospital Center is out.
But it's what can't be seen that is critical.
Prince George's is the only trauma center for Southern Maryland, the go-to facility for catastrophic injuries in a four-county, 1,500-square-mile area with 1.1 million people. That doesn't include increasing numbers of emergency cases from far Northeast and Southeast Washington, whose nearest hospitals in the District closed or cut back services.
For years, hospital officials say, they have been unable to afford more than one trauma surgeon. When that surgeon follows a patient to the operating room, the center shuts down, forcing helicopters and ambulances to race somewhere else. Until recently, Prince George's went dark more often and for longer periods than any other trauma facility in the state. In 2002, it was closed the equivalent of 60 days.
The equipment, though serviceable, is old. Computers don't talk to each other, and certain systems are available only at strange hours of the night. Most record-keeping is still done laboriously by hand; more expensive computerized systems having been vetoed.
When the hospital does try to upgrade, it often falls short. In the 1990s, hoping to attract more non-emergency surgical patients who could pay, it opened The Pavilion, with a splashing fountain out front, wood paneling and terrazzo floors. Build it, and they will come, the chief executive at the time announced. They haven't.
Vince Sayan, who helped save 13-year-old sniper victim Iran Brown at the Bowie center, no longer uses Prince George's Hospital Center. His paying patients scheduled for surgery kept getting bumped from operating rooms by the constant in rush of nonpaying traumas. He found it difficult to communicate with the increasing number of foreign nurses. And taking emergency calls, with the complicated cases and little or no pay, nearly put him out of practice.
"It's overwhelming," he said.
The differences are palpable when you see the competition.
Across the Montgomery County line at Suburban Hospital in Bethesda, the trauma center has state-of-the art high-beam operating lights, a portable sonogram to make quicker, more accurate diagnoses and a digital X-ray machine that enables doctors to call up a patient's records online. The hospital's old X-ray light board is used as an extra bulletin board.
Its CT scanner can do in minutes what it is taking Prince George's older, clunkier model up to an hour to do on Evan Doe. Prince George's recently unveiled a new machine. But even that one doesn't match Suburban's GE Lightspeed.
At Holy Cross Hospital in Silver Spring, where a number of patients from Prince George's County prefer to deliver babies, the newly renovated maternity rooms, which will all be private, look like cozy hotel suites. They have wood floors, brass lamps and cushy pullout couches where fathers are welcome to stay the night.
At Prince George's, the decor matches the pathology. Maternity rooms are unimaginative, with views of a heating duct and a gravel rooftop. Most are shared. And on the walls are posters warning of fetal alcohol syndrome and the burden of child support payments.
Ricardo Scartascini, an obstetrician listed as one of the best in several local consumer guides, delivers babies at both hospitals. For 30 years, he has preferred to take his difficult cases to Prince George's, where his own children were born. But his insured patients don't always want to go. "The main reason," he said, "is the way the unit looks."
'Take Me to Prince George's'
Those who have worked at the hospital for years call it simply "the Prince." And they say with the zeal of missionaries that they are there to care for those no one else wants to care for.
Carol Bragg, a cardiac nurse, has been there 28 years. She drives past five hospitals on her way to work. "It's just home," she says.
The Prince wasn't always seen as the hospital of last resort. When it opened in 1944, the county was rural, mostly filled with working-class folks and tobacco farmers. Operated by the county, the hospital was where everybody went when they were sick or about to deliver.
Over the years, the county changed. More and more middle-class families settled there, yet the hospital's mission -- and fortunes -- increasingly became tied not to that growth in prosperity but to the problems of drugs, violence and family disintegration in communities near or across the county's borders with the District.
In the 1980s, faced with mounting losses, county leaders decided to get out of the hospital business. A disastrous transfer to one private, nonprofit organization was followed by the Dimensions takeover.
Through the years, the county, which continues to own the facility, made regular payments to help keep the hospital afloat. County leaders paid political debts by making appointments to a board that became increasingly insulated.
But in 1997, the bottom fell out. Changes in federal and state law squeezed payments to hospitals at the same time that a nursing shortage occurred. The hospital began paying millions extra to private agencies and looked overseas for nurses just to provide care.
Talk to officials in the county or state and they'll say Maryland's unique rate-setting system should work as long as the hospital is run efficiently. Since Prince George's is in trouble, the reasoning goes, it must be management's fault. It's top-heavy, state officials and outside consultants have said over the years. It pays its doctors too much. It doesn't go after patients aggressively to get them to pay.
A look at hospital tax filings shows that executive and doctor pay is largely in line with other area institutions of similar size. And the layers of management have shrunk in the last five years, from their fancy corporate office to cramped rooms on the hospital's third floor. Dimensions officials dispute the charges but acknowledge they've made mistakes.
"We're not arrogant. We don't think our way is the only way," said Cervino, the chief financial officer. "We just haven't found the silver bullet."
The years of turmoil have tarnished the Prince's reputation in the medical community and the public at large. In a recent survey of area doctors, only 13 percent thought their peers at Prince George's could competently perform complex adult surgery, one of the lowest scores in the region. The years of downbeat headlines have left their mark, while other area medical institutions have made their mark in what are seen to be more heroic ways.
George Washington University Hospital saved President Ronald Reagan's life. Johns Hopkins separates Siamese twins. Children's Hospital heals the tiniest souls.
But Prince George's is where 5-year-old Kimberly Brice was pronounced dead after her 4-year old brother shot her. Where a nurse was strangled at her station in the mid-1990s. Where the faceless victims of violent crime continue to wash up and are saved or die. It is, unfairly in some respects, seen as the poor black hospital that anyone with means will avoid. That includes much of Prince George's affluent African American population. When it comes to health care, class trumps race. And reputation trumps everything.
What is not so well known about the hospital is revealing. Surprising, even. If you're in a crash on the Baltimore-Washington Parkway, this is the place you want to come. The tiniest preemie babies, those born at 24 weeks on the quivering edge of viability, have a higher survival rate at Prince George's than the national average.
A few hours before Blair's patient is shot, Audrey Scott, Gov. Robert L. Ehrlich Jr.'s secretary of planning, stops in for a quick bite at the Hilltop Cafe, a clean, well-lit nod to the power of paying patients, with glass-enclosed cabinets displaying $1.50 scones and a counter for ordering Starbucks lattes.
Thirty-five years ago, Scott came here to have her first child. Today Scott's 98-year-old mother is having another bout of heart trouble and has just been admitted to the intensive care unit. A few years ago, her mother went to one of the fancier hospitals. She hated it and asked to come back to the Prince.
"The nurses call me every morning and evening and let me know how she's doing," Scott said. "If an ambulance started going someplace else, I would jump up and say, 'Take me to Prince George's.' "
'If I Go, Who Will Stay?'
It's 3 a.m. Blair's gunshot case is in surgery, and the CT scanner is broken. The technician thinks the ball bearings in the old machine are bad again.
In the hallway, a woman cranked on a PCP dipper screams, "Satan Be Gone! Satan Be Gone! Satan Be Gone!" as she has every 45 minutes when her sedative wears off. Two drunks sleep off their binges, hooked up to "banana bag" IVs of vitamins.
The radio crackles to life. A hand trauma. A hospital in Southern Maryland won't take him. The helicopter will be landing in minutes. A nurse and technician take the elevator to the helipad on the roof. They shiver in the cold. "We used to have nice, big red coats with 'PG Hospital' on the back," one says.
Downstairs, the trauma team phones the hand surgeon on call and gets his answering machine. "In case of an emergency, call Prince George's Hospital Center."
At 4:25 a.m., two ambulances are on their way in with two men who've been in a serious car accident. Without a working CT scanner, the hospital can't responsibly take them. Henrietta Hale, the nurse manager, has just minutes to decide what to do.
"Is it up?" she calls down the hall.
The engineer, Val Vaysberg, a former Soviet naval officer, has been roused from his Owings Mills home, 45 minutes away, and has been tinkering with it for two hours. The first test works. Hale tells the ambulances to keep coming.
It turns out Blair's patient was bleeding so profusely during his CT scan that he shorted out the machine. Vaysberg shrugs. "It has its ups and downs."
Blair emerges from his "lair," an old patient room where he catches a few z's, watches TV, or reads books on black history.
His 24 hours on duty are about up, and the stint at the Prince has cost him. Nine patients. One with insurance. The rest uninsured.
Why does he stick with it?
Blair has just turned 57. Nootheti, the orthopedic surgeon, is 59. The average age of doctors at the Prince is over 50. There is no replacement team in the wings.
"If I go," he says, "who will stay?"
A few weeks later, Blair's patient is in a wheelchair, happy to be out of the hospital and away from its limited cable TV offerings. "No wrestling on Thursdays, man," he says. He has returned for more X-rays and physical therapy, running up more charges he can't pay.
Outside, the sun begins to set. The lights in the sign over the main entrance flicker and buzz to life.
The "P" in "Prince George's Hospital Center" is back on. Only now, two other letters, "er," are dark.
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