“My name is Jean Arnold, and I lost my mother at Marin General Hospital,” a tall woman with short gray hair told the crowd that packed the meeting room. “My mother was given her roommate’s medication by mistake.” Fighting back tears, she described what she believed was the hospital error that caused her mother’s death. She blamed Sutter Health for poor management and hoped to see operations returned to local control.
The crowd was gathered at a church in Terra Linda on a Saturday last month to hear a report about the future of the hospital. Arnold was one of two dozen in the audience who rose and voiced their concerns. The meeting drew nearly 200 people, including some Kaiser members. As one 85-year old woman put it, “If I’m away from home and suddenly have a heart attack or a stroke, I’m not going to go to Kaiser, where I have a doctor and where I have advance directives. I’m going to be taken to Marin General. And I want to know that hospital is really qualified to take care of me.”
Although it was a special event, the scene that played out looked much like any other meeting of the Marin Healthcare District board, which owns the hospital and leases its operations to Sutter Health, the giant Sacramento-based corporation. Tempers flare, shouting matches break out, tears flow. While some give ardent testimony in support of Sutter, it’s mostly the critics who hold the floor. The five-member board itself is divided between pro- and anti-Sutter camps, with the anti- camp in the majority for the last nine years.
Now the board is faced with the choice: Commit the hospital to Sutter control—or break free, returning accountability to the locally elected officials. The very existence of the hospital is at stake. The pro-Sutter side is convinced that the hospital can’t survive on its own. The pro-local side believes that severing ties with the corporation will save the hospital and restore topnotch patient care—but if voters don’t pass a funding measure, that could also doom the hospital. The district hopes to announce a decision at its August 9 meeting.
After two decades of battles, the issue has been forced by looming state deadlines to make all hospitals earthquake-proof. Any new construction must be completed by 2013. Sutter’s 30-year lease on Marin General expires in 2015. Sutter officials would like to use the construction deadline to cement the corporation’s hold on Marin General. So they’ve offered to foot the bill—with two daunting conditions: Sutter would own the new part of the hospital and would have an unending lease on the grounds. To sweeten the deal, Sutter would pay the district an initial $10 million, plus $1 million a year that could be used for some sort of community health program. If the district were to agree to this, a new lease would have to be negotiated and approved by the voters.
It doesn’t look as if the district will go for it. The swing vote on the board is John Severinghaus, a retired physician who has always had deep reservations about Sutter’s management. Lately, as the board has been testing the waters of public and expert opinion, Severinghaus has been leaning further and further away from Sutter’s offer. He’d rather see the district financing the seismic construction and hiring new management. Recent polls show that a solid majority of voters would prefer that, too. Voters are not, however, inclined to pay for it—at least, not enough of them. A bond measure would take a two-thirds majority to pass.
Severinghaus is worried. “We have the option of trying to wing it on our own, tell [Sutter] to go away, buy them out or something—and that’s very scary if we can’t get a bond issue,” he says. “Because if we get rid of them and can’t build a hospital, it’ll end up being closed.”
Public dissatisfaction with Sutter has been growing as the hospital has flunked one inspection after another for the last year and a half. Each time, administrators have managed to clear up the cited violation only to be found deficient in some other area. And each time, hospital spokeswoman Kathryn Graham has issued assurances that such problems are to be found in any hospital.
Marin General’s violations were severe enough to put its Medicare reimbursements in jeopardy twice in the last nine months. Out of the 592 hospitals in the four-state Western region of the Centers for Medicare and Medicaid Services, only 35 hospitals, on average—6 percent—are threatened with cutoffs by the feds each year.
A RECENT STUDY by the Lewin Group, commissioned by the district to analyze its options, reported a “widespread perception—among consumers and providers—of quality of care problems” at Marin General. Some of Lewin’s findings were unveiled in a slide presentation at last month’s Terra Linda meeting. Consultant Lucy Johns showed a diagram of the overall structure of Marin General Hospital, with Sutter Health at the top and all lines of authority emanating from it, except for a few coming from the medical staff. A red box marked “MHCD Board of Directors” [Marin Healthcare District] stood apart, with no lines of authority. “That,” said Johns, pointing to the box with her laser, “is the problem. You can see from the overall structure that the MHCD board has no legal authority over quality of care.”
Johns enumerated some of the hospital’s “deficiencies” cited by the Department of Health Services in a 10-month period ending in January 2005: one patient death due to faulty cardiac monitoring, another patient death due to an unassessed risk for falls, two employee deaths due to deficiencies in the pharmacy system, a physician performing surgery without privileges and a nurse practicing outside the scope of practice for nursing in a post-surgical cardiac care unit.
Even pro-Sutter board member Suzanna Coxhead would like to see more local oversight of quality of care. “If there’s a new lease with the hospital [management], I would include quality measurements that the district would expect to have reports on, say twice a year, so you could see trends,” says Coxhead. “And the district should be able to take action if the quality is not satisfactory.”
Would Sutter agree to such terms? Hospital spokeswoman Kathryn Graham won’t say. She responded to the Sun’s question in an e-mail: “…any terms of an agreement would be the subject of discussions between MGH and the District. Discussions re specific terms would not occur until 1.) the District has made its preferred [seismic] option known and 2.) we see if there is mutual agreement on an overall option.”
Coxhead has hung tough on the board for enough terms to see it go from a pro-Sutter majority to her being the sole corporation defender. Now, since the last election in November, she has an ally in Sharon Jackson, a healthcare consultant and executive director of Napa Emergency Women’s Services. Although the new director is viewed by most observers as pro-Sutter, she describes herself as unbiased. She has, however, developed an antipathy toward the “Sutter critics.” She’s seen the same faces showing up at every meeting, and she’s learned to turn a deaf ear to their complaints. “When all you do is attack, after a while people just tune you out,” says Jackson. “It doesn’t mean they’re not right. But it’s really hard for me to hear truth when it comes irrationally.”
Linda Remy, one of the most visible of the Sutter watchdogs, admits that she and many other critics can sabotage their message with an overly emotional style. “We get pissed off, which is detrimental,” she says. “That’s why I was a bad director.” Remy served on the district board for one term, stepping down in 2000 when the fight became too bruising.
Tall, with a wild mane of curly red hair and a broad smile, Remy was swept into office along with another community activist in 1996. Patient safety had already become a focus of local activists the year before, when one-third of the registered nurses were laid off. When someone approached the board with a complaint about the care her mother had received, Remy looked into it.
A health outcomes analyst at UCSF, Remy knew how to research Marin General’s record on patient safety. She obtained a copy of a Department of Health Services [DHS] report from the Automated Certification and Licensing Administration Information and Management System [ACLAIMS], which recorded complaints, investigations and hospital “deficiencies” discovered by the state. The problem reported by the woman at the meeting had been recorded as a deficiency—but Remy saw that Marin General’s previous record was clean. “So I thought it was an isolated incident,” she says. “But I started getting the ACLAIMS profile every month, just as my duty as a publicly elected official. And I kept seeing deficiencies. It wasn’t an isolated incident, it was the first of an unending stream.”
REMY BEGAN MAKING regular reports to the district board—as a member until 2000, and as a concerned citizen ever since. Recently, she compiled a report comparing Marin General’s safety record against the records of other California hospitals. She looked at violations of state regulations between 1986 and 2003, using data from DHS and the Office of Statewide Health Planning and Development. “I found that Marin General is really an outlier,” she says. “It’s one of the 15 worst high-volume hospitals in the state.” It used to be one of the best.
Before 1995, Marin General had no violations. Sutter took over management of the hospital in 1996, after absorbing the corporation that previously had the lease. Since then, says Remy, the hospital has been cited for 425 violations.
Jackson doesn’t buy it. “I’ve reached a point where I don’t believe any so-called data that’s presented in that forum [at district meetings] because I have to assume that it’s all being spun and rationalized with the same bias,” she says. She points to another of Remy’s statements, that Sutter will only fulfill its promise to reimburse the district for the Lewin report if the findings are favorable to Sutter. Remy believes that Sutter intends to trick the district into crippling itself financially so that it can’t fund the hospital on its own. Jackson says that, so far, the district has already been reimbursed for $166,274.75 of $168,975.75 in expenses, including the Lewin report.
There may be a certain degree of spin on both sides of the debate. Certainly in the past, for example, hospital administrators have fostered a siege mentality among the medical staff. After one Pacific Sun article exposed chronic understaffing that left nurses stressed and overworked, former CEO Margaret Sabin distributed a memo to staff decrying what she characterized as attacks on them.
While quality of care problems at the hospital are undeniable, many Sutter defenders blame the messenger: The problems, they say, are a result of the hostile work environment created by the hospital critics and by the press, which reports on patient complaints, hospital errors, understaffing and the acrimony between the district board and hospital administration. “You look at the problems they’re having at Marin General and you look at Novato Community Hospital, with no problems. The reason for the difference is the employees and the medical staff at Marin General have been bombarded with criticism,” says retired physician Marjorie Belknap. Another difference, not noted by Belknap, is that Sutter owns the Novato hospital.
Belknap is a member of the Emergency Medical Care Committee and the county Commission on Aging, but is expressing only her personal opinion as a Marin resident since 1955. She remembers the days before the hospital was leased, when a compliant district board never questioned the administration and there was no hint of strife. Those were also the days before rising medical costs, lowered insurance reimbursements and managed care. And it was a time when the district board used to collect property taxes.
During the ’70s, the district forfeited its tax receipts for a number of years running. The bonds that had financed construction of the East wing had been paid off, the hospital was turning a handy profit and no additional revenue was needed. Then the passage of Prop 13 cut each service district’s property taxes by 54 percent of whatever was collected on average from 1975-78. Since the Marin hospital district had collected nothing, its allowable future collections became stuck at zero. “So we don’t have any tax money coming in to Marin General to help support it,” says Belknap. “That’s what a district hospital needs if they’re going to go it alone.”
The principal argument against splitting from Sutter is financial. Sutter supporters say the district needs the affiliation with a large, multi-hospital system, not only to pay for the new construction but also for its clout in negotiating the highest reimbursement rates with insurers, for its economy of scale in purchases, for its high credit rating in the bond market, and for its ability to make major investments in state-of-the-art equipment. Even if the district were successful in passing a bond measure to finance construction, without a property tax base to support operations, it would have to rely on patient revenues and donors.
The pro-local folks believe that may be all that’s needed; and, if not, that the community would rally around a locally run hospital and come up with any necessary additional funding. Coxhead isn’t so sure. “We need to do more than just break even so we can buy new equipment and set aside reserves for future expenses,” she says. “Marin County residents can go to any hospital in the world for care. And right across the bridge there are hospitals that offer wonderful programs. So we have a lot of competition and you have to provide the best.”
Coxhead and Jackson are optimistic that Sutter has already begun to rectify patient care problems. Two new positions have been created to oversee quality of care: A registered nurse has filled one of them; an M.D. has yet to be hired for the other. There’s also a new Chief Nursing Officer and a new CEO, David Bradley.
“Those two people have given me a lot of hope that things will turn around,” says Vicki Lamborn, an R.N. who also remembers what the hospital was like before it was leased. A labor and delivery nurse, she’s been working at Marin General, off and on, since 1976 and steadily since ‘88. “We’ve been chronically short-staffed and now we’ve hired a nurse recruiter. We hadn’t had one for a long time. They’ve posted a lot of R.N. positions, so I think they’re trying to hire more people. With the last management we had, I felt like they really didn’t care about the nursing staff at all and I think David Bradley does.”
ON THE OTHER hand, Bradley has yet to show his face at any of the district board meetings. If he hopes to convince directors—and the public—that he’s willing to work with them, showing up seems like a good first step. So far, Sutter has given no indication that it would agree to being accountable to the district on any management decisions. Dan Beittel, a now-retired psychiatrist who was on staff at Marin General for 36 years, finds Sutter’s arrogance off-putting. “This has been Sutter’s ongoing rebuttal: ‘It’s none of your business, this is a private corporation and we do not do things in public,’ ” he says.
Another objection Beittel has to Sutter management is their “regional perspective.” They look at the fiscal efficiency of their 27-hospital system as a whole, providing specialized services only at certain locations. To get those services, local patients are sent to another Sutter hospital outside the county. “Sutter has mentioned shifting operations to the hospital that has the volume that can support them, such as vascular surgery,” says Beittel. “Of course, the vascular surgeons at Marin General do not want that to happen. But Sutter doesn’t want to support operations at the hospital that aren’t profitable.”
Still, Beittel thinks the district needs Sutter. Like Belknap, he worries about operating costs. Even if a bond measure for seismic construction passes, he says, “There would have to be an additional bond of a different sort if the district were to operate the hospital directly, or if they leased it to somebody else.”
That would be a tall order. Getting approval for a construction bond alone is iffy enough. The district is still trying to come up with the best formula—the size of the project and the cost to taxpayers. John Severinghaus is in talks with UCSF about a possible affiliation with Marin General, which he hopes would increase the district’s chances at the polls. He also thinks that voters would be swayed if “something quite dramatic happens. And the dramatic thing that may happen is that Sutter may walk away.” Sutter has said that if the district does not agree to its terms, it will build a competing hospital elsewhere in Marin. That might be an idle threat. Even if a suitable site were found—no small task in Marin—Sutter would have to get permits from the county. It’s unlikely that the Board of Supervisors, who support the idea of a locally run hospital, would grant them.
Still, Severinghaus doesn’t expect that Sutter will go down easily. The corporation lawyers could sue the county, if it came to that. They’ve already filed a suit against the district recently, disputing Sutter’s obligation under the lease to finance a seismic retrofit. Severinghaus fears that the corporation will play hardball when the district goes to the voters with a tax measure. There’s no question that, if it chooses, the corporation could overwhelmingly outspend the district in an election campaign.
In 92 pages of data and analysis, the Lewin report ultimately dodged the question of who should run the hospital. The options were winnowed down to two: In one option, Sutter finances and builds a new hospital wing, accepting district oversight for a few years; if it passes probation, the corporation wins a long-term lease, and if it fails, the district could either buy back or lease whatever Sutter has built. In the other option, the district builds the new wing with GO (General Obligation) bonds and decides some time in the next 10 years whether to renew the lease with Sutter or find new management.
Severinghaus likes the second option. “If Sutter agreed to continue to run the hospital for 10 years, making lots of money, then I think they would not spend a lot of money fighting us getting a GO bond,” he says. The Marin General operation earned the corporation $18.8 million over expenditures in 2003, according to its most recent tax filing. “I think that would be a win-win.”
We’ll see whether or not Severinghaus can persuade his colleagues on the board to agree. The Sutter critics for years have suspected the corporation of using profits from Marin General to subsidize some of its other hospitals. From their vantage point, it would be dangerous to give Sutter another 10 years to raid the coffers.
Lately, Severinghaus has been looking like a man carrying the weight of the world. He may be right that the fate of the hospital rests with him, as the swing voter. But the responsibility and the pressure have been taking a toll on all the board members. Even longtime allies have begun sniping at each other. These are five people who care deeply about preserving Marin General Hospital for future generations. None of them will be sleeping well between now and August 9.
