Fourth in a series. Today's focus: Consolidating care in the community

Grady Hospital's commitment to providing the poor and uninsured in Fulton and DeKalb counties the health care they need extends well beyond its acute care wards and surgical suites in downtown Atlanta. The hospital operates nine neighborhood health clinics providing primary care services; last year, they handled more than 200,000 patient visits.

But running those clinics comes at considerable cost. This year, they are expected to lose as much as $4 million. At a public hospital that is hemorrhaging money, figuring out how to cut services without sacrificing care for needy patients has to be the first order of business. The clinics offer such an opportunity.

To start, Grady and the county health departments of Fulton and DeKalb counties must do a better job of coordinating the services each already provides to needy patients. On top of the $42 million Fulton County spends on direct public health services every year, it gives Grady $84 million. DeKalb County spends a similar amount on its public health services, in addition to providing Grady a $20 million annual subsidy.

The Fulton County Department of Health and Wellness staffs a dozen community health centers around the county. Its DeKalb counterpart runs five. In addition, there are nine other independently operated community health centers subsidized by the federal government in Fulton and DeKalb counties providing essentially the same services. That means basic medical care for poor and uninsured patients is widely duplicated at publicly-owned clinics.

The 26 clinics compete with Grady in trying to attract Medicare, Medicaid and privately-insured patients in primary care settings. Not all of them offer direct physician care as Grady does, but they all have the same goal —- providing basic care so patients don't wind up in hospital emergency rooms or needing more expensive care.

Only one of Grady's nine clinics operates in the black. All the rest lose money nearly every year. Two clinics on the northside of the counties illustrate some of the problems:

Grady's North DeKalb clinic is projected to lose $1.6 million this year. The busiest of all the Grady clinics, the Chamblee facility also attracts the fewest insured patients. It serves a large population of immigrants, including refugees and others in the country legally but with no insurance.

The DeKalb County Board of Health runs a clinic at the same location. It leases space to Grady to provide the more costly primary care services offered to adult patients, but the county does not directly subsidize Grady's services there. DeKalb should consolidate services with Grady or start paying the hospital a direct subsidy; that would probably be around $1 million to $1.5 million annually. If it doesn't, Grady should consider closing that clinic.

The Grady clinic on the northside of Fulton County has a different set of issues. Unlike its counterpart in DeKalb, it gets a small subsidy from Fulton County. But roughly half of Grady's North Fulton Neighborhood Health Center patients are also uninsured, contributing to its projected $570,000 loss for this year.

On top of that, the facility needs an estimated $2 million to refurbish and purchase new equipment. That's impossible unless Fulton County helps pay for it. If the county doesn't agree, that clinic should close. Indigent patients could go instead to the county health department clinic a few miles north in Alpharetta.

On the southside, Grady has other options. Several of the Grady clinics there might qualify for federal funding because they are in underserved areas. One or two may be easily merged with federally-funded clinics that are already operating nearby.

In addition, the Morehouse School of Medicine, which trains doctors at the hospital, has expressed an interest in owning and operating several of the Grady clinics where its physicians work. These include the Center Hill, East Point and South DeKalb clinics. But the Fulton-DeKalb Hospital Authority, which governs Grady and all its clinics, would have to agree —- a change the authority has been reluctant to embrace.

At a minimum, local officials must do a better job of streamlining primary care services, something they've talked about for years but clearly failed to accomplish. Not only will that help Grady survive, but it might also save taxpayers in Fulton and DeKalb millions of dollars.

—- Mike King, for the editorial board (mking@ajc.com)

WHERE WE STAND

If Grady Memorial Hospital is to survive to fulfill its unique mission in metro Atlanta, its governing board, the Fulton-DeKalb Hospital Authority, must make fundamental changes in governance. Hospital management should be shifted to a nonprofit board better equipped to run the facility in a competitive medical marketplace. Elected officials in both counties must also decide the proper level of local funding for the hospital. Because Grady Hospital is also the sole provider of care for patients around North Georgia needing special services they can't get elsewhere, the state of Georgia should directly subsidize some Grady operations with tax dollars.

Previous editorials in this series have examined trauma funding (July 1), the decisions Fulton and DeKalb leaders must face (July 18), and state support for specialty care (Juy 29).

 DALE E. DODSON / Staff 
GRADY'S STRUGGLING NEIGHBORHOOD HEALTH CLINICS
Like the hospital, the nine Grady clinics take in a lot of uninsured patients. But many of these patients could also get care at one of 17 health centers operated by the Fulton and DeKalb county health departments or at nine other privately run clinics subsidized with federal funds. To stay solvent, Grady must consider selling or consolidating some of its clinics. 

.......................................Percent......Net
.......................................insured ....profit
Clinic............Visits ....Revenue ..patients..../loss
1. Asa Yancey ....22,460 ..$1,497,000....68%......-$37,000
2. East Point ....16,856 ....$739,000....57% ....-$115,000
3. North Fulton ..14,026 ....$764,000....49% ....-$570,000
4. DeKalb ........26,186 ..$1,486,000....59% ....+$264,000
5. Otis W. Smith..13,011 ....$699,000....60% ....-$110,000
6. South DeKalb....8,380 ....$436,000....56% ....-$424,000
7. North DeKalb ..24,541 ..$1,197,000....35% ..-$1,660,000
8. Lindbergh......20,199 ..$1,488,000....53% ....-$593,000
9. Center Hill ....1,773 ....$133,000....68% ....-$115,000

Map of metro Atlanta locates Grady Memorial Hospital and the nine clinics. 
Source: Strategic Operating Plan, Alvarez & Marsal report to Grady trustees, projections for 2007