Medical Emergency: The University of Chicago Hospitals face a crisis of conscience

As the issue of national health care becomes the focus of an increasingly heated debate in the national political arena, the issue is equally Important here on the South Side, with the University of Chicago’s Medical Center Generating a lot of talk in recent weeks. First, the UCMC announced its plans to lay off 450 employees and to cut up to an additional 500 jobs through attrition. Then criticisms began to surface regarding its treatment of Medicaid, Medicare, and uninsured patients. While restructuring plans within the emergency room are in the works, in-patient capacity is being reduced through the elimination of more than thirty beds.

All of this is related to the UCMC’s transition to become Chicago BioMedicine. The transition will bring organizational change, but, most importantly, Chicago BioMedicine represents a total reconfiguration of priorities, with a growing emphasis placed on lucrative, high-tech specialty medicine and less attention on primary care service and general medicine. The University’s stance is that the restructuring will allow the hospitals to focus their energies on the areas of “specialized care,” in which they excel, allowing others to focus on the less glamorous side of medicine.

Then, of course, there is the Urban Health Initiative, or UHI, which has garnered a lot of criticism recently, such as accusations that it comes “dangerously close” to the illegal practice of “patient dumping.” Additionally, the emergency room structure that it will leave in its wake will likely result in a decline in the quality of care provided to Medicaid, Medicare, and uninsured patients. But what exactly is the Urban Health Initiative, and why is it so controversial?

In 1986, the U.S. Congress enacted the Emergency Medical Treatment and Active Labor Act (EMTALA) to remedy the practice of “patient dumping,” the act of turning away Medicare, Medicaid, and uninsured patients from emergency rooms in order to save hospitals money. EMTALA requires that any hospital receiving government assistance provide treatment for all individuals seeking care for emergency medical conditions, regardless of their insurance status or ability to pay. Virtually all hospitals in the United States receive some form of government assistance and are thus subject to EMTALA, and the UCMC is no exception.

With the UCMC estimating that approximately forty percent of cases treated in its emergency room would be better treated by primary care physicians and that twenty-five percent of patients arriving at its ER do not have a regular primary care physician, receiving patients without primary care doctors is a serious problem. This is where the Urban Health Initiative comes into the picture: the initiative is supposed to provide patients with the opportunity to find permanent and appropriate “medical homes” by transferring patients who arrive at the ER with non-urgent cases to community clinics and nearby hospitals. This is where some of the controversy arises: according to the American College of Emergency Physicians, the country’s largest group of emergency doctors, these transfer practices come “dangerously close” to breaking the federal guidelines outlined in EMTALA.

The UHI is essentially a two-step process whereby patients classified as non-urgent and low-complexity are removed from the ER and then directed to the “medical homes” they deserve. While the UCMC has been very successful in accomplishing the first part, its execution of the second step leaves much to be desired. The truth is, there aren’t many available statistics about the success of the UHI at helping these patients find “medical homes.” Even the statistics published by the University are unimpressive—only thirty-eight percent of patients referred to clinics by the UHI had seen a primary physician more than once. While the UCMC boasts of its commitment to supporting health care alternatives within the South Side community, its actual contributions to improving this infrastructure are mediocre at best. The University claims it has invested $8 million towards these programs since the UHI’s inception four years ago. Where has this $8 million gone? Aside from the $650,000 it says it has given to assist renovations and support medical programs at community clinics and a $40,000 financial aid program to encourage UCMC graduates to practice on the South Side, your guess is as good as mine. And considering that the UCMC paid over $6 million to its five top-salaried employees in 2006 alone and that it will spend $700 million on its new pavilion, this figure seems suddenly much less impressive.

Even doctors and medical students within the University have expressed concern over the new direction of the UCMC and UHI, although fear of reprisals has kept many from making public statements. One University of Chicago medical student who chose to remain anonymous described several policies currently being debated among the hospital leadership that could lead to a “segregated, two-tiered hospital in which patients with private insurance receive distinct treatment from those on Medicaid, Medicare, or without insurance.” Two prominent doctors at the UCMC recently resigned their leadership posts as a result of disagreements over these proposals. The medical student also criticized UCMC CEO James Madara’s reasoning that the UCMC must decide between “health care at the cutting edge or treating the poor,” holding the conviction that “a medical facility located in an urban center must do both.” The student also worried that “the values that attracted people to the UCMC—patient care, education, and dedication to the community—were being lost.”

While the University might like us to think that the recent plans to restructure the UCMC have arisen out of necessity in light of the recent financial crisis, the decision to place priority on high-tech specialty care at the cost of primary care and general medicine has been a long time coming. In 2005, Madara published an article in the Journal of the American Medical Association outlining a vision for the future of academic medical centers such as the UCMC. In the article, Madara observes that many academic hospitals are located in “economically marginalized” communities and argues that expecting such a medical center to be the primary health care provider for the community is “overly simplistic.” Madara suggests that academic medical centers redefine the term “community” to reflect the population that such a high-caliber institute could best serve—patients requiring “highly specialized and complex care”—instead of the geographically adjacent population. Madara is careful to add that this new understanding of “community” would not be defined by a patient’s insurance status or income level. He does not address, however, the fact that the application of such a redefinition would effectively result in a priority shift toward privately insured and non-local patients, intentionality aside.

Additionally, Madara argues that the presence of a large, academic hospital could drive community clinics out of business due to competition. Questions have been raised, however, over whether community clinics on the South Side of Chicago even have the capacity to adequately meet the increased demand that will come as the UCMC begins to send non-urgent cases elsewhere. In a plan released on February 9 of this year, the UCMC announced the closure of a University of Chicago-supported community health center. The clinic will now be housed in the UCMC Duchossois Center for Advanced Medicine, which is home to most of the UCMC’s adult primary care services. The catch? According to a story published by the Huffington Post, the Duchossois Center is not currently accepting new patients. It appears that even as the UCMC places limits on who can access care at its ER, it is also cutting back on alternate health services in the community.

Under Madara’s leadership, Chicago BioMedicine will completely redefine the role of the UofC hospitals within the South Side community. As the UCMC becomes increasingly closed to the local community, it is time to reevaluate the moral obligations of the University of Chicago. As an institution with its fair share of baggage when it comes to community relations, it finds itself at a critical crossroads: what kind of neighbor will the University of Chicago choose to be?