How Safety-Net Hospital Closings Affect PCPs

Closing a safety net hospital kicks up a significant ripple effect for primary care physicians and underscores the need to involve those providers in the planning and aftermath of such a disruptive process, a study has found.

The study -- Effect of Closure of a Local Safety-Net Hospital on Primary Care Physicians' Perceptions of Their Role in Patient Care– appears in Annals of Family Medicine. It examines the August 2007 closure of the 450-bed Martin Luther King Hospital in South Los Angeles, and interviews 42 primary care physicians who were affected.

"The primary care doctors were trying to figure out what they were going to do," study lead author Kara Odom Walker, MD, told HealthLeaders Media. "They were really frazzled by the whole upheaval and trying to deal with it the best way they could. There was a lot of rich conversation that did not make it into the study."

The study found that many of the primary care physicians complained of profound professional and personal upheaval owing to the disruption of the care network. "A lot of medicine is informal networks of care where you call your friend, your local gastroenterologist who has been there forever to see your patient in who needs to be seen sooner than later," Odom Walker says.

The disruptions included reduced access to specialty care, overcrowding at nearby hospitals and emergency departments, delayed and poorer quality of care for patients, reduced communication and disrupted patient connections, and a loss of colleagues and opportunities to teach residents and medical students, the study reported.

"The usual way of doing business was completely disrupted and patients were confused," Odom Walker says. "It wasn't that their doctors' doors were closed, but patients felt like 'Oh my goodness what should I do next?' They were showing up with more acute issues at their physicians' offices or running out of medicines because a lot of these patients go to the emergency room and use it to refill prescriptions."

The study calls for greater input and participation from primary care physicians when a major disruption such as hospital closures loom in a healthcare delivery system.

"When a hospital closes or downsizes they really do need to think more about what happens to the primary care doctors because oftentimes they are not at the table," Odom Walker says. "Primary care doctors really know what is happening at the ground level but they are too busy seeing patients and keeping the doors open on their hamster wheel. They do experience the impact and they need to know what alternative strategies are available to get patients into care."

Odom Walker says she was not surprised to hear about the disruption within the MLK service area. However, she was surprised to learn that physicians from outside of the service area also were impacted by the hospital's closure.

"This was a safety-net hospital where mostly uninsured patients went. So you wouldn't expect private-pay patients and physicians who are mostly serving insured populations to be affected, but there is a ripple effect," she says.

"Even within the nearby Kaiser system, because those patients didn't have anywhere else to go, they just showed up in the ED and they couldn't be turned away. Then there were referrals through the ED with specialty care. You saw those delays building up."

The study did not specifically examine the emigration of physicians from the area after MLK closed, but Odom Walker says there is anecdotal evidence to support their departure.

"People did talk about how their colleagues were leaving and not going down the street—they were going to different parts of the state or out of state," she says. "It was not so much in primary care, but many of the specialists who were committed to serving an underserved population said, 'If I can't practice here anymore I will go somewhere else.'"

Odom Walker says she's not sure what could have been done differently when MLK closed.

The hospital lost its accreditation and shuttered with little warning. "But if more primary care physicians were at the table they would have thought about how to get the word out a little better so patients wouldn't have experienced so many delays in care, or put off getting medications refilled, that there were doctors still in the area to take care of them, and an action plan to get them to the care that is needed," she says.

With Medicare and Medicaid facing possible budget cuts, Odom Walker says it's time to develop some uniformed procedures for hospital closings so that other communities aren't thrown into disarray if their safety-net hospital shutters.

"That would be an important next step—thinking through who, what, when, where, and how to do this in a way that doesn't affect people's lives," she says. "Right now there is no true oversight of a hospital closing. It is a contract with the community and no one is there to oversee that bond."