One Physician's View Of The Lakewood Hospital Debate

We are facing the most important health care decision in the history of the City of Lakewood. The proposal to close or keep Lakewood Hospital and surrender its assets to the Cleveland Clinic (CCF) will profoundly affect all current and future residents of our city. Lakewood’s dilemma, as an inner ring suburb, is ground zero for the national debate regarding our government’s responsibility to provide health care to its most vulnerable citizens. Lakewood Hospital is the main focus of our health care assets and is the ultimate health safety net for our community. If the hospital is removed, how do we guarantee the care of our citizens in an increasingly monetized health care delivery system? Currently, the disparity in life expectancy between the populations living on our eastern border is 10 years shorter than the life expectancy in the suburbs to our west. The most common cause of personal bankruptcy is an individual’s own cost of health care. An increasingly aged population will reach their senior years with an increasing burden of chronic disease and declining financial reserves. 

What is the responsibility of our local government officials and citizens towards our poor, aged and sick neighbors? Our elected officials have an obligation to monitor the health of our community, delineate our health care needs, organize appropriate responses and provide necessary health care assets. For the last 100 years, Lakewood Hospital has accomplished all of these obligations. If this institution disappears, how will this be accomplished? I contend that a private Cleveland Clinic Foundation (CCF) office building will not adequately meet our community’s health care needs.

 The CCF was formed by four surgeons who left Lakeside Hospital during the 1920’s to gain control of their own medical practices. They extrapolated the lessons they learned from World War I battlefield triage to provide health care on an assembly line model. They had no inherent fiduciary responsibility to ensure the needs of anyone and were accountable only to themselves. Unlike Lakewood, Metro, Parma and Southwest Hospitals, the CCF was not created to accomplish a governmental obligation to citizens, nor does it have a religious sense of stewardship such as St. John’s, St. Vincent Charity, Mt. Sinai, and Deaconess Hospitals. Therefore, the Clinic operates in a predictable way. First, CCF views all relationships through the lens of its own agenda and strategic plan (i.e. “What’s good for the Clinic is good for the world”). Second, CCF defines quality primarily through a large advertising budget rather than any external accountability (“there is the right way, the wrong way and the Clinic way”). Third, the CCF will always compete primarily on economics since this is the incentive utilized by the private and public health care system (“It is only business”). Fourth, the CCF will attempt to use its size to dominate any discussion (examples from the proposed Letter of Intent -- “The Clinic will be the principal healthcare system affiliate of the New Non-profit Tax-exempt Entity” and “the Clinic…shall have the option to substitute itself or its appointees for any or all members of the LHA Board of Trustees except at least one member to represent the City”). I submit that the real purpose of the hospital closure is to extend CCF’s control over the Lakewood market and remove a competitor. This accomplishes the long term strategic plan of the Clinic for its own benefit and not ours.

What is the current health situation in the City of Lakewood? We have significant ongoing health care needs and, under CCF direction, declining health care assets. Health care decisions need to be based on objective data specific to our population. Subsidium, a consultant from Atlanta, Georgia, was hired to evaluate our community needs and Lakewood Hospital. This consultant reports generically that there are 3000 unnecessary beds in northern Ohio. This figure would constitute virtually all the currently open and staffed beds in all the community hospitals in Cuyahoga County. Actually, it represents the “bed licenses” that exist only on paper but not operational beds. Subsidium suggested that a community needs 2.6 hospital beds per 1000 population. Therefore, we will need approximately 130 real acute care beds in our area to service Lakewood residents. The consultant looked at our total service area and calculated that we need 400 total beds to cover this part of Cuyahoga County. They opined that with the 150 current beds at Lakewood Hospital and the 325 beds at Fairview Hospital that we were over bedded by 75 beds (i.e. 150+325=475). This assumes that Fairview Hospital can devote all their beds to our needs and ignore beds needed to cover Fairview, North Olmstead and Cleveland to the south, west and east. In fact, if you remove the 150 beds held by Lakewood Hospital, the area will be more than 75 beds short.

The 2013 Community Needs Assessment reports that limitations to mental health care, ready availability to physicians, access to affordable health care and available healthcare transportation are significant needs in our community. How will the elimination of this hospital which includes a geriatric psychiatry unit, a skilled nursing unit, an acute rehabilitation unit and de facto open access to all resolve these problems?

The actual extent of disease in our community (i.e. numbers of heart attacks, strokes, surgeries etc. experienced by our population) was not well delineated in the report by Subsidium. The consultant reports without explanation that the hospital is experiencing a decline in admission and procedures and therefore that the hospital is not viable. Yet, the story behind this decline was a “death of a thousand cuts” orchestrated by the Cleveland Clinic. Their data really documents that, under CCF management, many specialty specific services (i.e. Oncology, psychiatry, cardiac surgery, electrophysiology, trauma and pediatrics) have been transferred to other CCF hospitals. The core independent primary care base has declined without the recruitment of replacements except those employed by the Clinic. In addition, many of the CCF physicians who maintain privileges at Lakewood Hospital only do so to transfer patients to other CCF hospitals (i.e. thoracic surgery, vascular surgery and neurosurgery). The Clinic reports that they have transferred cases in orthopedics and general surgery to our hospital but these CCF physicians maintain their practices in Lorain, Ohio while the CCF local surgeons are operating at Fairview and Lutheran hospitals. This guarantees that the patients will not establish a relationship with Lakewood Hospital and will have difficulty with post-operative outpatient care.

We are told that successful preventive and wellness management in the future will eliminate the need for inpatient admissions (i.e. “as we grow older we will never be sick”). This flies in the face of the nature of disease. The primary determinants of disease are genetics, aging and bad luck. Disease is not randomly distributed in the population. Physicians believe that our DNA “loads the gun” and our risk factors “pull the trigger”. This means that although we can delay the onset and progression of disease, we still cannot entirely eliminate the disease process. Furthermore, many preventive measures have not been proven to be cost effective in populations that do not carry specific genetic risk. The preventive approach to medicine is important and may be helpful for many people, but these are really educational issues that do not require medical personnel.

The aging process is particularly an issue for our community. After a certain age, all of us convert from disease avoidance to chronic disease endurance and management. Medical success has delayed the onset of chronic disease from our fifth and sixth decades of life to our seventh and eighth decades. This leads to increasing pressures on government managed insurance as we convert from the private insurance we carry in our youth to the government insurance we require later in life. As we live longer, increasing numbers of the elderly are living beyond their retirement plans and are exhausting their Medicare health benefits ending up on Medicaid. With the increasing employment mobility of our children, many of the elderly are living alone with no nearby children to support them. The elderly consume more health care and have less support than the remainder of the population and therefore, need the safety net function of a nearby hospital to survive. We also have a large nursing home and assisted living population adjacent to Lakewood Hospital that require frequent hospitalizations. This group of elderly has significant problems with mobility and transportation. More than 13% of our population is older than 65 and Subsidium reports that this group will be increasing by more than 10% in the next few years. The 2013 Community Need Assessment lists access to care as one of our most important needs. In Lakewood 8.4% are unemployed, 16% are uninsured and 22% receive Medicaid. This population has not been accepted by the CCF in significant numbers and these people have relied on the hospital as their only safety net. What will become of them? 

What is the current state of Lakewood Hospital? Unfortunately, under current management the hospital is in trouble. It is not just Lakewood Hospital that is having a problem; most community hospitals operated by the CCF network (referred by the Clinic’s administration as “the Enterprise”) are experiencing declining revenues. Crain’s Cleveland Business reported that in 2013 Main Campus had an increase in net revenue of 7.3%, while four of the five community hospitals reported had a decline in revenue from 1.1% to 5.5%. The physical plant has been partially renovated and partially neglected. The hospital completely refurbished the Acute Rehabilitation and Orthopedic wards at its own expense and then turned them over to the Clinic. We spent several million dollars of the hospital’s money on refurbishing the CCU which was then closed within a few months when services were shifted to Fairview. The Emergency Room was completely redone. Unfortunately, the primary medical-surgical beds used by the majority of patients received minimal rehabilitation. If we close the hospital, the costly upgrades of the emergency room, CCU and acute rehabilitation, representing millions of dollars of assets, will have been squandered. The deficits of the physical plant in the short run are not grievous or fatal but will need to be addressed in the near future.

The most serious problem is the decline of the medical staff. Twenty years ago when the CCF assumed management of Lakewood Hospital, the medical staff consisted of between 40-50 active physicians representing a broad spectrum of primary care, specialty care and surgical specialties. These physicians were embedded in and loyal to both the city and hospital. Most had practiced primarily at Lakewood Hospital over long periods of time frequently more than 20 years. With the assistance of the hospital they were able to recruit a few new physicians per year to replace themselves as they left practice. Unfortunately, over the last 15 years, the independent physicians are no longer receiving assistance in recruiting and are gradually leaving practice without replacement. While CCF declined to assist the independent physicians in recruiting new physicians, they also did not embed new Clinic physicians as replacements. Most of the Clinic’s primary care physicians in Lakewood were in practice here before they joined the CCF. The CCF did heavily advertise in the Lakewood community using the hospitals resources to the detriment of independent physicians. This resulted in many of the newer, younger physicians developing practices outside of the Lakewood area. A few other physicians joined CCF, Metro or University and became less involved in the hospital and community. Overall, with the aging of the remaining physicians there will be a progressive and serious deficit in primary care, specialty and surgical members of the staff. 

Where will we be taking healthcare into the future? With the adoption of the plan envisioned by the Letter of Intent, there will be profound changes in what we will need to do as a community to protect our neighbors. Overall, we will need to develop a new type of safety net once the hospital is taken from our community. The earliest issues will develop around the rapidity of access to acute care hospital services through an emergency room. A number of medical issues revolve around what are called “time is tissue” issues. With these problems, the patients need acute hospital interventions in which any delay leads to increased death and debility. These diagnoses include stroke, heart attack, sepsis, low blood pressure, perforated bowel and cardiopulmonary arrest. Any delay is harmful. As currently envisioned, necessary treatments, such as surgical interventions, specialty support or invasive radiologic procedures will not be available at the free standing emergency room and a stop there will only delay definitive treatment. EMS will need to leave the city to get to the nearest appropriate facility, most likely Fairview or Metro Hospitals. Besides the delay in treatment, this will decrease EMS unit availability because of the prolonged turnaround time estimated to be 23 minutes extra going to Fairview Hospital and even longer to Metro or Main Campus CCF. The loss of 150 hospital beds due to Lakewood Hospital’s closing will also have a profound effect on our neighboring hospitals. Diversions of EMS units to more remote hospitals due to lack of hospital beds is likely to be an issue. Diversion is already a significant west side problem. Fairview Hospital had 48 days last year during which they had some type of diversion according to the County EMS data base. St. John’s Hospital, Southwest and Metro all had more than 30 days in 2014 in which they had some limitation on access due to lack of beds. With the loss of Lakewood Hospital this will get worse unless we can induce Fairview Hospital to increase its capacity.

Accessibility of care will be an issue. With a virtual monopoly by the CCF in Lakewood, what will happen to those without insurance, low reimbursement policies with high deductible payments or simply plans not accepted by the CCF? The Clinic has started to accept some Medicaid plans this year but admit that they can only “afford” to take a limited number of these patients before the economic consequences would be prohibitive. With the increased number of elderly who have exhausted Medicare, this will be an increasing problem as they are forced to switch to Medicaid. With the loss of the current independent community specialists, no local surgery center and no contractual obligation to maintain specialists by the CCF beyond the Clinics assessment of what the community needs, there is also a significant risk that our citizens will have significant transportation issues going to Fairview, Avon or Main Campus CCF. We will need transportation resources that leave the borders of Lakewood that are timely and affordable.

We will no longer have the Hospital to act as a bell weather for the health problems in our community. There will be a significant risk that problems will not be easily identifiable and the disadvantaged will become invisible. We will need to develop our own internal data sources and data base that will allow us to monitor incidence and prevalence of disease in our community, locations of service that our citizens utilize, types and adequacy of insurance and socio economic factors. We need to be able to rely on our own independent information to guide policy development and not those supplied by CCF.

We will need to work on increased economic development of the city in a general sense to compensate for the loss of health care personnel, physicians and physician offices. The current medical office building at 14601 Detroit Ave. will largely be empty. Currently, it is about 1/3 empty, 1/3 CCF and hospital administrative offices and 1/3 independent physician offices (several of which are already in the process of moving). The city will be losing an estimated $500,000 in income tax revenue and $1 million in direct payments. If we are not able to compensate for this we may become trapped in a cycle of decreasing services and increasing taxes which could significantly damage the city.

We need to decide what to do with the residual assets of the Lakewood Hospital Association and Foundation. First, since a formal assessment has yet to be done, we need to get a reliable valuation of tangible property. This includes determining the true value of 850 Columbia Road, the land along Detroit Ave. that the Clinic will be acquiring and the hard and soft equipment assets contained in the hospital which are being transferred to the CCF. Next, the structure of the eventual “New Not for Profit Entity” contemplated in the Letter of Intent needs to be designed to protect the investment and distribution of these residual assets. It will need to be structured so that its governance and actions are transparent, accountable, diverse and representative. Its first purpose should and must be the protection of our citizens and not furthering the strategic plan of the CCF or any other health care entity. Community control has to be maintained in a board that is truly responsible to our citizens. Its flexibility cannot be constrained by any entity beyond our citizens. Currently, the Letter of Intent aims to place significant controls on the residual assets by the New Nonprofit Entity. It states, “The Clinic will have right of first refusal for any health and wellness program, product or service…in excess of $500,000 per year in estimated annual revenue or grant. The Clinic will have the right to two voting members on the…governing board”. The CCF also seeks to control the land it does not want once it is returned to the City of Lakewood (“…no health care system provider would be permitted to operate or manage a facility, and no signage identifying such provider would be permitted, on the land currently leased by the City to LHA…”). Essentially, despite the management failure of the hospital and the resultant closure of the hospital we entrusted to the CCF, they want to restrain the City from taking other measures to meet the community’s needs and obligations. This cannot be permitted. The Clinic wishes to maximize their profit from this transaction. We will be selling land on Detroit Ave, equipment from the hospital, and an entire building at 850 Columbia Rd. when no independent formal assessment of the value has been undertaken. 

We are indeed at a crossroad. The citizens of Lakewood need to rise to this occasion and reassert control and responsibility for our own health. Our forebears at the turn of the twentieth century established Lakewood Hospital to meet the social needs of a new city. Our city leadership recognized the importance of this institution 75 years ago when they acquired it from the private sector as our community’s asset and safety net. Multiple generations of neighbors and health care personnel have invested in the development of this community asset. We owe it to all of them to salvage what we can from this experience with the Cleveland Clinic. Will we now cede this community based resource to a private semi profit “Enterprise”?

Terence Kilroy, MD

15431 Edgewater Dr.

Lakewood, Ohio 44107