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Denver Health ant! Hospitals Experience I. L. K~rowski The city and county of Denver, with a resident population of 500,000 (the exact count is in dispute and will be settled in court), represents the core of the Denver metropolitan area, which has a total population of 1.6 million. The daytime population soars to about 800,000. Like most core cities, Denver is facing a multitude of problems, though these may not be of the magnitude of those facing the eastern cities. Denver's geopolitical bound- aries have been frozen by actions of the state. It appears the state action was a reaction to the federal initiatives, particularly in school desegregation. Thus, a federal action intended to bring people together had the unintended consequence of separating them in new ways. Thus, with limited growth and a limited tax base, the city and county finds itself increasingly at the mercy of the federal and state policies. Nowhere is this more true than in the area of health services delivery. In the 1970s, federal policy shifted incrementally from a focus on increasing access, improving quality, and removing financial barriers tO a focus on restraining the increases in cost of service. In 1981, it appears the direction of federal policy is reversing with the impending implementation of a procompetition, deregulatory ap- proach. The effect will be to shift the focus of financial responsibility from the federal government to the state and local government, the employer, the insurer, the providers, the family, and the individual. The impact of this health policy change on Denver General Hospital is best viewed in the context of Denver's Health and Hospitals system. The mission of the Department of Health and Hospitals is three-fold: (1) to provide health services to the medically indigent; (2) to provide 230

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Denver Health and Hospitals Experience 231 emergency health care to anyone in the city and county of Denver, re- gardless of residence; and (3) to provide general public health services for the protection of the public, including disease control, regulation of insti- tutions, vital statistics, etc. The Denver system has been evaluated by na- tional experts and has been repeatedly honored for its innovative design. The system is unique; it combines a public general hospital, emergency medical services (including ambulance and paramedic services), a decen- tralized community health center program, a component of the community mental health center program, and a home care system under dual public/ private governance. In addition, the Denver system includes the public health protective services of disease control, coroner's office, and environ- mental health. This complex system has evolved in response to community needs and to gaps in the community health services. The policy directions of the federal and state governments, through program initiatives, have been followed by the city and by the agency. An extensive development of ambulatory ser- vices has enabled Denver lo substantially reduce the infant mortality rate, in addition to reducing total costs by minimizing our patients' hospital utilization. Thus, the overall goal is to help people to live increasingly independent lives and to safeguard the public's health through the provision of effective and efficient health services. The system functions both as an agency of Denver city and county gov- ernment in concert with other local government services and as a provider of health services in concert with other local health services providers. A classic example of coordination of essential governmental services is the city and county's Emergency Response System through the 911 line. In order to be effective, this service has been established as a closely integrated system between the Department of Public Safety, i.e., fire and police, and the emergency medical services of health and hospitals. Thus, local gov- ernment can maximize its citizen protection by having health services re- sponse for the victims of crimes, accidents, and fires. As a provider of health serivces, the Denver health and hospitals system complements the work of the voluntary nonprofit, the university, and the private hospitals by serving primarily the medically indigent, and those who are a danger to the public health by virtue of a medical problem such as tuberculosis. As a result of Denver health and hospitals attending to these community needs, the community is better protected and the community's health professionals and hospitals are able to serve the majority on the broader community's health care needs. This relieves those institutions of significant costs that, in the absence of the Denver health and hospital system, would be passed on to them, to their patients, and to the health insurance system. In addition, there are fewer people on the streets of the

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232 PART II: PRACTICAL APPLICATIONS Denver metropolitan area who suffer from far advanced disease conditions than is evident in most cities. The system has been responsive and effective. This is not to say that Denver health and hospitals cannot be improved, and we are constantly searching for ways to increase both effectiveness and efficiency. The health and hospitals system has developed under the lead- ership of Mayor McNichols, the Board of Health and Hospitals, and many leaders in the community and in the health and hospitals agency. In the course of this development, many services have been initiated under the direction of and funding by federal and state government. However, there has been a significant change in the source of funds. In demonstrating the local government commitment, I will review the revenue source data for fiscal years 1976 and 1980. There is a consistent trend occurring over these years, shifting the financial burden from the federal and state governments to the city and and county. The expenditure of these resources demonstrates the mayor's recognition of the importance of health service a component of effective local government. Most notable over the 4 years is the increase in the city's contribution from $7.4 million to $22.1 million, an increase of 198.6 percent. This combined with the fact that the Denver charter wisely prohibits deficit spending forced the mayor and the city tO give attention to the growing problem of mandated services, costs and revenues, and medical priorities for services. Through a study designed to look into these matters, a $10 million reduction from the projected 1982 budget of S92 million was found to be unavoidable, and the areas for service reduction were established. Ambulatory care services felt the brunt of the impact of the reductions. This occurred because these services are less well reimbursed and because the services are of a less immediately life-threatening nature. It may be argued that some specialized outreach services should have been maintained. However, because spe- cialized outreach services were not mandated and are less well reimbursed than the treatment services, reducing treatment services would have only led to greater revenue loss and therefore forced reductions in even more service. In addition, outreach services most often increase utilization of treatment services, which would have been reduced further and could not have withstood additional demand and maintain quality of service. There is another dimension of the problem that must be considered, i.e., the standards for the quality of care. If services become compromised tO the extent that there are reasonable questions of the system's capacity tO provide quality services, services must be eliminated rather than continued at a substandard level, for, if we provide care below community standards, the risks and costs of professional liability for the city and county would be considerable. The city and county of Denver and the Department of Health and Hos-

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Denver Health and Hospitals Experience 233 pitals are caught in a dilemma between the mandate for community oriented service and the mandate for fiscal responsibility. The city and county gov- ernments do not have the tax base to maintain the level of health care services originally planned. It should be clear that the decisions being made are, in fact, rationing health services, and the pattern of financing these services will have significant influence on public protection, public health, and personal health and in general the degree to which Denver can provide . . . commumty orlentec primary care.