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For years, Meharry Medical College, one of two historically black medical schools in the country, has lived an uneasy existence with Nashville government leaders. In the mid-1980s, the city’s hospital board finally approved a teaching agreement permitting Meharry residency programs to be taught at Metro General, the county’s only publicly owned hospital. That permission arrived only 92 years after the initial request was made.
A decade later, when Meharry’s teaching hospital, Hubbard, ran into financial trouble and had to be shuttered, Metro Council voted to move Metro General to the Meharry campus, in part because the old Metro hospital had aged and in part because Meharry’s accreditation was threatened by the loss of its hospital. Metro government financed the remodeling of Hubbard, a 13-story building sitting in a predominantly black neighborhood across the street from Fisk University, and renamed it Metro General.
Taxpayers subsidized the operation of the building while Meharry doctors took over staffing from Vanderbilt. The merger seems like a no-brainer now, but it was more than 10 years in the making, with much of the opposition on both sides tinged with distrust and racism.
Today, with Metro General in financial peril, battles are still being fought, though thankfully without the racial overtones. To save the hospital in the short-term, three levels of government must cooperate, and two of them are believed to be on rocky terms. Metro General is hoping the Centers for Medicare and Medicaid Services agrees to pay Tennessee an additional $50 million to offset the cost of indigent care in some of the state’s hospitals. Several million of that would be forwarded to Metro General so it can remain open for the last quarter of the fiscal year, from March to June. (The hospital requires at least $8 million to operate for those three months.)
Though a backup plan involving a credit line is being worked out, there are those in state government who say Metro General’s financial crisis would have been averted years ago if Gov. Phil Bredesen and Mayor Bill Purcell had a better working relationship. At least three members of Davidson County’s statehouse delegation—former Metro Council member Gary Odom, freshman legislator Gary Moore and Majority Floor Leader Rob Briley—speculate that if the “Phil and Bill Show” (as one pundit dubbed it) were better orchestrated, General Hospital’s solvency might be more in line with the Regional Medical Center in Memphis (the Med), a public hospital about three times the size of Metro General. “It does appear Nashville is getting a little shortchanged,” says Moore, a Metro firefighter. “I can’t say the reason is a personality conflict between the governor or mayor,” he says, adding that there’s nevertheless something there that prevents Bredesen and Purcell seeing eye to eye. “But there’s a perception that inadequate attention has been paid to Middle Tennessee.”
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Other members of the delegation are either glib about the mayor and governor’s relationship or decline to comment because they have no insight into it. Rep. Edith Taylor Langster, whose father died at Hubbard, whose two sons were born there, and who underwent hernia surgery at the hospital, says it would be too risky for Bredesen and Purcell to upend the hospital’s finances because of personal or professional animosity. “Nobody would want to lose their base of support over something that silly,” she says.
The irony, of course, is that Bredesen was Nashville’s mayor when it was decided to rebuild Metro General on the Meharry campus. He endorsed the merger, risking great political capital at the time. He says the rumors and media references to a feud with Purcell are overblown, sounding aggravated that Briley, Moore and Odom gave it even remote credibility.
“I’m disappointed that somebody would say that,” the governor says. “Bill Purcell has somewhat of a different style than I do. I like him. He’s been a good mayor. We saw each other on Friday and he said some nice things about me. There’s nothing there affecting General Hospital.”
It would be easier to accept Bredesen’s comment if not for two things: many political observers who respect both men say they, in fact, don’t like each other and that their administrations have engaged in low-level sniping—“juvenile shit,” as one observer called it. During a radio interview months ago, Purcell failed to refer to Bredesen by name, repeatedly calling him “my predecessor” throughout the broadcast. For a press conference involving Davidson County, the state economic development department permitted only one person from the Purcell camp to attend, and put the delegate in the back row. There are dozens of similar anecdotes along these lines.
The other contention between the two men’s administrations is David Manning, the mayor’s director of finance who was the architect behind TennCare when he was the state’s financial commissioner during both terms of Gov. Ned McWherter’s administration. More than any other public official, Manning was responsible for transferring the state’s failing Medicaid system into a statewide managed care system like no other in the nation. TennCare was supposed to extend health benefits to even those indigents who failed to qualify for Medicaid. But with escalating health costs and an unstable tax base, cuts in the program over the years have made today’s TennCare look much like the failed Medicaid system it replaced.
Manning stepped down as finance commissioner a year after TennCare was enacted and watched as the program went through six directors in five years. Yet there are those in state government who don’t trust Manning because they think he has manipulated numbers to his advantage, leaving behind an unworkable program that has caused more problems than it’s solved.
TennCare unintentionally crippled General Hospital in two ways: patients enrolled in the health program suddenly had access to all of Davidson County’s hospitals, including Vanderbilt, which has a national reputation for excellence and is two miles from Meharry. And unlike the Med in Memphis, which has only one hospital in its area to compete with, Metro General doesn’t have a trauma, neonatal or burn center.
What’s more, Metro General has had to absorb patients rolled off TennCare but who still need medical attention. The number of patients who had no insurance increased by 27 percent this year, according to figures provided by the hospital, while TennCare patients dropped by 16 percent. Since Metro General treats the poorest of the poor, many of the patients with no insurance receive free medical care. Federal and state authorities typically expect local governments to pay for those patients.
The other factor hindering Metro General is the formula Manning created for distributing public money. Under the formula, the Centers for Medicare and Medicaid Services pays the state based on the number of Medicaid-eligible patients who visit hospitals. TennCare officials, however, redirect a portion of the money to pay for non-hospital visits.
In 2003, for example, Metro General generated $19.3 million in Medicaid-eligible dollars, but the state forwarded only $6.3 million to the hospital. The remaining money, $13 million, bankrolled TennCare doctor visits across the state.
It is this gap in funds that has caused the largest rift between the governor’s and mayor’s administrations. Last Feburary, David Manning was quoted in The Tennessean complaining about the discrepancy between what Metro General is due and what it receives. Manning told the daily the Med receives all the money Medicare and Medicaid Services forwards to the state, but Metro General does not. “We would like to see the state treat Nashville’s indigent-care hospital along the same lines,” Manning said. “Hopefully, the governor will be able to do that.”
To back up his statement, Manning forwarded a spreadsheet to the Scene showing Metro General receives $7 per Davidson County resident in TennCare dollars compared with the Med receiving $21 per Shelby county resident. The numbers average out somewhat if you include TennCare dollars for Vanderbilt, bringing Davidson County’s per capita total closer to $26 per resident.
According to Darin Gordon, TennCare’s chief financial officer, Manning’s statement is misleading, if not completely inaccurate. Manning is blurring the lines between two funds of money, he says, so that only one hospital in the state benefits: Metro General. Under Manning’s “fractured fund theory” (as one administrator dubbed it), the Med would have also taken a huge loss in 2003, receiving $20 million to cover TennCare patients instead of $50 million.
Comments like those Manning made to The Tennessean, and similar comments that Purcell made around the same time to the Scene, are the reason some believe the reputed feud between Bredesen and Purcell is more about Manning than it is about anything else.
“General Hospital is like no other hospital in the state,” says Dave Goetz, the state’s current commissioner of finance and administration. “It was cobbled together through a concept Mr. Manning created when he was in my position at the state.”
Goetz doesn’t point directly to Manning, but it isn’t difficult to imagine whom he is talking about when he says Metro officials are to blame for fomenting discontent among the Davidson County delegation. “That’s where legislators are getting this,” he says. “No one but Metro is complaining. [The formula] is clear to everyone else.”
Bredesen becomes equally animated when the subject of Manning surfaces. “Some of the problems we have with TennCare were created by Mr. Manning more than 10 years ago,” the governor says. “If there’s one thing I’ve tried to do it’s to face problems squarely and head on. I don’t operate through smoke and mirrors. I don’t want to manufacture numbers just to get more money out of the federal government. I’ve invited the [Purcell] administration to talk about solutions in a forward and practical way. I’d love to have some help on this.”
Though the political backdrop to Metro General is significant, understanding it may not help the hospital survive its current fiscal crisis. Dr. Reginald Coopwood, the 46-year-old surgeon who became the hospital’s CEO last spring, has begun to try to change the public’s perception of Metro General as a customer-unfriendly city hospital to one more client-centric and professional. Metro General has begun to do what was unthinkable for a municipal hospital several years ago: run television ads. Coopwood is hoping to entice patients away from Baptist and Vanderbilt so that paying customers will offset those who cannot afford to pay Metro General. He says he often receives feedback from satisfied patients who returned to his hospital after being rolled off TennCare. “We’ve got an organization that has never seen health care as a competitive product,” he says. “We’re talking about the year 2006. We’re 30 years behind in marketing to patients and doctors how and why to come here. That’s what we’re up against.”
Coopwood says there are three scenarios he foresees his hospital undertaking. The first is to continue to rely on government subsidies to the extent Metro General does today, which isn’t a satisfying prospect. “We’ve learned the federal and state governments don’t act as fast as any of us would like,” he says.
Scenario two is to let the hospital close, which complicates Meharry’s ability to teach students who are likely practice in impoverished urban areas once they finish residency. This scenario, obviously, isn’t one Coopwood is willing to consider. He’s hoping for at least three years to change Metro General’s reputation with the public.
Scenario three is to improve the hospital’s finances through marketing and fundraising. Coopwood is hoping simple measures, like giving tours, will offer a different perspective of the hospital. A campaign to collect from patients who can pay a portion of their bill is in effect. And Metro General hopes to expand its fund-raising arm, which has only one employee, Marc Overlock, to write grants and set up a network of financial donors. The Med, by comparison, has five employees working for its foundation.
If saving the hospital becomes impossible, Meharry administrators will need to develop a plan for its students. Public officials are already lobbying for medical centers to consider permitting Meharry residents to learn there. “Other hospitals in the city need to ask of themselves whether they will open their doors to students from one of four African American medical schools in the country,” says Dave Goetz, the finance commissioner, sounding more like the former president of the Tennessee Chamber of Commerce he once was. “There needs to be a more open and cooperative relationship that supports all of this. It would be a terrible loss for Meharry to disappear.”
Unfortunately, because of federal restrictions enacted in 1996, simply moving Meharry students from one hospital to another will be difficult. More than likely, it would require a new round of lobbying from state and local leaders, who would have to leave behind their differences to preserve one of Nashville’s most visible institutions.