Barry's Nashville General proposal raises questions about where care is given and how it's funded

Mayor Megan Barry's proposal to close the inpatient services at Nashville General Hospital reignited the debate over the future of the city's safety net hospital. 

Barry revealed her plan the same day Meharry Medical College unveiled a landmark agreement with HCA Healthcare to train students at TriStar Southern Hills Medical Center. 

Barry wants to make Nashville General an ambulatory surgery center and outpatient clinic, while creating a fund to pay for indigent care at Nashville's other hospitals for the city's poorest residents. 

The proposal — released with few details a day before the city closed for Veteran's Day — raised concerns and questions from the hospital's board, employees and patients.

It caught community and hospital leaders off guard.

Dr. Jan Brandes, chair of the Hospital Authority, said she got a call from the mayor's office about an hour before the press conference saying Barry would make an announcement.

"We did not have an opportunity to talk to our employees prior to that announcement. We certainly want to be very supportive of the mayor and we feel confident that she will be helpful to the hospital authority in moving forward over this next year of transition and move toward a strategy that in the long term allow us to be good stewards and protect the health of our most vulnerable citizens,” Brandes said.

More:Meharry to train students at HCA hospital under 'historic' agreement

More:Nashville General to end inpatient care, Mayor Megan Barry announces

Battle to change Nashville General is years in the making

The fight to change Nashville General has been going on for years. 

Barry's administration hired restructuring expert Kevin Crumbo to advise the city on risk management and government issues, but he was not tasked with writing a report, said Sean Braisted, a spokesman for the mayor 

Barry wants to find a model that meets the needs of the community but without in-patient care.

It's a trend emerging in health care with the growth of freestanding emergency departments and surgery facilities to a plethora of clinics. It would be a radical change to the services offered on the Meharry campus in North Nashville. 

Rev. Edwin Sanders of the Metropolitan Interdenominational Church said changing demographics in North Nashville brought with it "a waning enthusiasm for the facility."

"We haven't seen the kind of support that the hospital needs through at least the last four administrations," said Sanders. 

Hospitals wonder how the city would disburse funding 

Saint Thomas Health and Vanderbilt University Medical Center would get most of the patients who need hospitalization, industry officials said. 

Barry's proposal to create a fund to help offset the indigent care costs raised questions about how reimbursement would be measured as well as how hospitals would bill the fund. 

When asked whether the fund would use a Medicare or Medicaid base or whether the city would become become a government payor, Braisted said, "Metro will work with key stakeholders over the coming months to look at best practices in other cities and find a model that works for Nashville."

The care required by patients at Nashville General is expensive and nearly half were either indigent or self-pay in 2015. 

Craig Becker, CEO of the Tennessee Hospital Association, said the funding question looms over the other area hospitals that would get those patients.

"Sadly, these are patients health systems often shun,” said Dr. Bruce Siegel, president and CEO of America's Essential Hospitals, of which Nashville General is a member. 

Nashville General faces “a triple threat” of stressors

Nashville General is an urban example of a national trend as hospitals shutter around the state and country because of escalating costs and declining patient admissions.

It's licensed for 150 beds and staffed for about 120. But its average number of in-patients has declined to about 40.

Dr. Mike Schatzlein, the former chief of Saint Thomas Health who was one of five recently appointed to General's board, said declining in-patient activity raises questions about the ability to sustain quality care.

Changing demographics, advancements in expensive technology and large numbers of uninsured people coupled with shifts in where people want to get intricate procedures have left many hospitals with shrinking in-patient volumes.

Siegel said "Tennessee is ground zero for the stressors" that impact safety net hospitals -- not expanding medicaid, a population of very sick, poor people, and prospective cuts to federal payments to hospitals to subsidize uncompensated care. 

"To put it most succinctly, it's a triple threat," said Siegel. "All those things come together at Nashville General."

Brandes said the board and hospital leadership had been discussing different strategies but had not voted on a proposal.  She wants to be true to the mission of the hospital, caring for the health of the city's most vulnerable population. 

Asked if the mayor's proposal is a decree or a guideline, Brandes said she didn't know. 

The hospital authority is entering uncharted territory, and she said her priority is to support the staff caring for patients while finding a blueprint for Nashville General moving forward. 

"We obviously have more information than we had a week ago about plans and now we will be putting forth proposals to really serve our mission,” said Brandes.

Schatzlein said, as a new board member, he wants the authority to focus on care coordination and getting people care close to home. 

"I believe we’re on the right path, but I can see how people could not see the end of the path and be worried. I'd like to reassure them that this will be a good path. I and others will work to make sure that it is,” he said.

Reach Holly Fletcher at hfletcher@tennessean.com or 615-259-8287 and on Twitter @hollyfletcher.