How the debate over CPMC's controversial multi-hospital project revived the idea of healthcare planning in San Francisco
A complex and controversial project that would involve five San Francisco hospitals — including building a huge showcase facility for the wealthy atop Cathedral Hill — has prompted a debate about what average city residents need from the health care system.
California Pacific Medical Center, an affiliate of Sutter Health, proposes to downsize St. Luke's Hospital, which primarily serves a low-income population in the Mission District, as part of a $2.5 billion proposal to renovate and retrofit three existing medical campuses, close another one, and build housing and a megahospital on Cathedral Hill that would draw patients from around the country.
CPMC's grandiose plan was being considered strictly as a land use decision, despite its far-reaching impact on the city's health care system. So Sup. David Campos created legislation calling for the city to create a citywide health services master plan and to use that as another tool for gauging future medical projects.
Debate over that legislation left some activists on both sides unhappy, with progressives disappointed that it won't be able to stop a CPMC project they see as neglectful of the poor, and moderates wary of creating a new way to challenge development projects in the face of widespread unemployment in the construction industry.
But it struck a fine enough balance to win 8-3 approval by the board Nov. 16, enough to override a threatened mayoral veto. "I'm really happy and excited about the passage of this legislation," Campos told the Guardian after the vote.
The legislation has a two-part mandate, with the first part kicking in as soon as it has final approval. It requires the Planning Department, with input from the Department of Public Health, to prepare a health care services master plan to identify current and projected needs for health care services and where they should be provided.
The second part, which begins in 2013, requires Planning to determine whether medical projects are consistent with the findings of this plan. That delay is credited to a last-minute amendment Campos granted during a Nov. 15 committee hearing after the hospital industry complained that the process could jeopardize its ability to meet state-mandated seismic retrofitting deadlines for projects already in the planning pipeline.
The passage of Campos' legislation comes eight months after President Barack Obama signed the Patient Protection and Affordable Care Act. Hailed by its supporters as the most significant change to the U.S. health care delivery systems in 40 years, the reform package has also been greeted with criticism on both ends of the political spectrum. Progressives complain that it relies too heavily on private insurance companies and medical providers, while Tea Party supporters says that it's government run amok and they have vowed to "kill the bill." Senate Minority Leader Mitch McConnell (R-Ky) recently compared so-called Obamacare to "tyranny" in a speech to conservative legal scholars.
But here in San Francisco, the debate over Campos' legislation — as heated and divisive as it was at times — yielded a surprising amount of consensus around the long-neglected idea that government should play a role in health care planning.
The passage of Campos' legislation marks the first time in 30 years that a government entity has mandated health care services planning in California. That approach West Bay Health Systems Agency, whose creation he opposed as governor of California.
Lucy Johns, a San Francisco-based health care planning consultant who wrote the only health care services master plan California has ever had, recalls what happened in the mid-1970s after President Gerald Ford signed legislation that established health system agencies nationwide.
"California established 14 health systems agencies, including the West Bay Health System Agency, which governed the nine Bay Area counties," Johns told the Guardian. "The legislation mandated that they be established by every state, with the federal government providing the funding. So every state had to decide how many, how big, and how structured the health system agencies would be."
Johns notes that state legislators were constrained when it came to the decisions these health service agencies made. "The governing bodies of the health systems agencies had to have a membership that was 51 percent consumer and 49 percent healthcare provider, which included doctors, nurses, and hospital administrators," she said.
That history served as a backdrop for discussion of the Campos legislation, with the Planning Department staff report noting, "With the elimination of the West Bay Health Systems Agency in 1981, there is no longer a routine or comprehensive analysis of health service resources, needs, trends, and local impacts conducted for changes to or within medical uses."
"It's truly a historic moment for San Francisco," Campos said after his legislation passed its Nov. 16 first reading (the second and final reading is set for Nov. 23, after Guardian press time). "We are the first city in the country to make sure land use decisions are aligned to our health care needs. That's an unprecedented step that will shape the future of healthcare planning for years to come."
Campos acknowledged that the passage of Obama's heath reform package — which includes a mandate to purchase private health insurance beginning in 2014 — was also a catalyst for his legislation, along with the CPMC project.
"But it had more to do with seeing that the city didn't have the tools it needed to evaluate projects in terms of whether they met the city's healthcare needs and how they might impact people's access to healthcare," Campos said. "The main catalyst came from the community, which felt it was being asked to make decisions that will have long-lasting health care implications, but didn't have any way to understand those needs. Those concerns were compounded by changes at the national level — and the recognition that these changes offer us an opportunity to engage in planning."
Campos' legislative victory came two months after members of the Cathedral Hill Neighbors Association joined nurses, medical workers, patients, and community groups in voicing concerns at a Sept. 23 public hearing about the draft environmental impact report for CPMC's Cathedral Hill hospital and the other facilities that are part of its proposal.
These groups collectively expressed fear that downsizing St. Luke's, closing the CPMC California campus, and transforming CPMC Pacific campus to an outpatient-only hospital will force low-income people to travel farther to access health care services while offering better service to the wealthy at Cathedral Hill. And neighbors worried that the proposed complex would increase traffic and require the demolition of rent-controlled apartments.
Formed in 1991 through the merger of Pacific-Presbyterian Medical Center and Children's Hospital of San Francisco, CPMC has been affiliated with Sutter Health since 1996 and currently has four medical campuses in San Francisco: Pacific in Pacific Heights, California in Presidio Heights, Davies in the Duboce Triangle, and St. Luke's in the Mission.
But CPMC's longtime goal was to build a facility intended to be like the Mayo Clinic of the West Coast, a 15-story, 555-bed full-service hospital and specialty care facility at the corner of Van Ness Avenue and Geary Boulevard. Company officials have made approval for that project conditional on keeping St. Luke's open in the face of the state's deadline on seismic safety standards that the hospital doesn't now meet.
"St. Luke's Hospital was the big issue that got our attention," Le Tim Ly, lead organizer for the Chinese Progressive Association, told the Guardian. His group has worked with residents in the city's southeast sector around environmental justice, air quality, and pollution issues when they became aware of the threat to St. Luke's. "All this, coupled with efforts to downsize Luke's, left us alarmed by the disproportionate impact on an already impacted area."
But alarm over CPMC's plans has now revived the idea of healthcare planning.
As recently as the beginning of November, representatives for the Hospital Council of Northern and Central California — whose members include CPMC, Chinese Hospital, Jewish Home, Kaiser Permanente, Laguna Honda, St Luke's, St. Mary's, San Francisco General Hospital, and Veterans Affairs Medical Center — seemed opposed to any change in the way healthcare planning is done in San Francisco.
At a Nov. 1 hearing on the Campos legislation at the board's Land Use and Economic Development Committee, Ron Smith, the Hospital Council's senior vice president for advocacy, said his organization favored maintaining the city's current procedures. "We would like to propose that the Health Commission does the planning, the Planning Commission does the land use, and that there is a required determination process which is in the current legislation," Smith said. "We're proposing that that continue."
But two weeks later, after Campos amended his legislation so projects now in the planning pipeline are exempt from having to comply with the city's health care services master plan, some members of the Hospital Council seemed to have a change of heart.
CPMC's Chief Executive Officer Warren Browner surprised just about everybody when he publicly stated in mid-November that CPMC supports health care planning. "We strongly support the efforts of the city — we are in favor of health planning," Browner said at a Nov. 15 hearing on the legislation.
"That statement was extraordinary," said Lucy Johns, recalling CPMC's history of resisting government control. "The conversation about this legislation has already changed the discourse, at least in public."
Linda Schumacher, chief executive officer of Chinese Hospital, a community-owned, not-for-profit facility, explained at the same hearing that her organization had been concerned that Campos' legislation would affect her hospital's ability to move ahead with a $150 million project that has been in the pipeline since 2003.
"We thank you for that amendment that allows the effective date to be changed," she said.
"It shows how much progress had been made, even before this legislation goes into effect," Campos said of the hospital industry's apparent shift in attitude. "It's a monumental step, something that was not expected as recently as a few months ago."
But Ly of the Chinese Progressive Association said he believes the Hospital Council still doesn't want to see the city getting involved. "As recently as a month ago, their folks were speaking out against any kind of legislation. But I think they started seeing the writing on the wall."
Ly fretted about the potential negative impact of Campos' last-minute amendments. "Sup. Campos' plan represents a victory. But we could use that information as soon as possible. The 2013 deadline means the city will be handicapped: it will have information it can't use yet."
Ly ventures that the hospital industry's approach will be to try to lessen the impact of the legislation. "As written, it still provides the Planning Commission and the board with the discretion to approve projects," Ly said. "Ultimately, the struggle is about values. Just because there are plans and guidance doesn't mean the healthcare needs of the community will become a top priority — it just provides us with tools to make an assessment."
Campos counters that his bill will allow the city to create incentives for, and apply pressure on, the hospital industry. "If they truly want their projects to be expedited and approved before state-mandated seismic retrofitting deadlines kick in, they'll propose plans that work for the community," Campos explained.
But even as it publicly vows to be supportive, the Hospital Council continues to express concerns about the Campos legislation. "It's the council's job is to be supportive now that the board has approved Campos' plan," Smith said. "And Sup. Campos was very generous. He started talking to us in June. But we really didn't get a handle on his proposal until much later. We think the idea of healthcare planning is very good. We still have concerns about the process, but now the board has voted on the legislation, our goal is to do our best to work with the law."
Concerns that the legislation would be used to mire projects in repeated appeals and give too much weight to critics' concerns was raised at the Nov. 16 hearing by Sup. Sean Elsbernd.
"Right now, if anyone has concerns, there's a conditional use process and a CEQA [California Environmental Quality Act] process," Elsbernd told the Guardian. "But this turns up a brand new appeal. It means the appeals are heard at the same time, but you've now created a third route."
Campos responded to these concerns by amending the legislation to clarify that the board must act on consistency determination appeals at the same time it acts on other related appeals, so projects won't be delayed.
Evidently this wasn't enough to appease the San Francisco Chamber of Commerce. "We cannot be supportive of that piece of legislation," Rob Black, the Chamber's vice president of public policy, told the Guardian after the legislation was approved. "We believe appeals should be done at the Department of Public Health in conjunction with service providers, since San Francisco provides 20 percent of service, and private organizations provide the remaining 80 percent."
Black says the Chamber was pleased Campos amended his legislation so as not to slow down projects that are currently in the planning pipeline. But he claimed Campos' legislation could actually limit access to healthcare services. "The Chamber is concerned that Campos' legislation will make it harder for doctors to pool together in pods, and if we don't do that, it won't make healthcare more available because services will be more expensive," Black said. "But we absolutely think" the city should analyze gaps in providing health care to San Franciscans.
Campos' aide Hillary Ronen confirmed that Black is correct in saying that anyone can appeal a hospital project's consistency determination. "But the final analysis will revolve around asking if the proposed project meets the health care needs of San Francisco," she said. "If it doesn't, and the board doesn't believe there's a compelling public policy reason to approve the project, [the board] can override the approval."
Mary Michelucci, a registered nurse for 40 years and a member of the California Nurses Association, is hopeful that Campos' legislation will rein in the hospital industry.
"I hope that any plan that would favor patient care over profit would be the way to go," Michelucci said. "Running a hospital is expensive. But with the profits that Sutter and CPMC are making, they can afford this."
Michelucci says the dispute over St. Luke's came to a head three years ago, when nurses began to suspect that CPMC was planning to let the facility fail, suspicions that intensified when CPMC closed St. Luke's neonatal intensive care unit 18 months ago.
"Now the babies who need neonatal special care are transported to CPMC's California campus, which is in the Richmond," Michelucci said. "But the moms may be discharged and most of them live in the Mission or Bayview-Hunters Point."
Michelucchi still fears that CPMC will wage "a horrific campaign" against the California's Nurses Association as it continues to push the plan for its megahospital. "CPMC wants to be in complete control of the registered nurses," she said. "We, unfortunately, are their conscience, while they are a business model in the business of healthcare. The decisions they make about healthcare are not in the interests of patients or nurses, and we are the thorn in their side."
All this is happening against the backdrop of the worst economic recession since the Great Depression, and for construction workers facing high unemployment rates in San Francisco, CPMC's megaproject clearly represents light at the end of a very dark tunnel.
"CPMC is my future," William Hestor, a 28-year-old father of two and member of SEIU-United Healthcare Workers, said at the Nov. 15 hearing. "We worked hard on a contract and we just want to make sure our hospital is built on time."
CPMC media spokesperson Kevin McCormack told the Guardian that the real issue between CPMC and the CNA is union membership at CPMC's Cathedral Hill facility. "CPMC is reducing beds at St. Luke's because the beds aren't in use, but the facility will be able to take care of 90 percent of patients' needs and if you need specialist care, a shuttle will take you to Cathedral Hill," McCormack said. "This centralized arrangement is the best way to attract the best staff and equipment."
McCormack noted that there are union members and 1,200 nonunion nurses working at CPMC facilities in San Francisco. "We are bringing together nonunion and union nurses together at this facility, and we don't feel we have the right to force our nonunion nurses to join," he said, adding that since the Teamsters, the Carpenters, and SEIU-United Healthcare Workers (UHW) are already unionized at the Pacific and California campuses, they'll be allowed to unionize at Cathedral Hill.
CNA member Eileen Prendiville, who has worked in San Francisco as a registered nurse for decades, recalls the negative changes she has already seen at CPMC's facilities, including eliminating registered nurses and specialty services.
"If you pull services, as they have, of course you'll have fewer patients. And the physicians start leaving, so it's a vicious cycle," she said. "St. Luke's was a small community hospital but now it's all about corporate medicine."
Sup. Eric Mar sided with those seeking to exempt current projects from the city's health care services master plan. But Sup. Sophie Maxwell noted that the Planning Commission will take a facility's historical role into account in determining whether projects are consistent with the city's health care services plan.
"We believe that addressed community concerns," Maxwell said. "St. Luke's would never have been targeted for closure had this legislation been on the books in the past."
Campos insists his legislation is not simply about CPMC. "Ultimately this legislation stems from a number of pleas we have heard in the last couple of years from people throughout the city," he said. "It takes the institutional master planning process to the next level. We have tried to consolidate the appeal process under existing law. Important as the legislation is, it's key to make sure we have the right master plan because that's where the heavy lifting will take place."
Meanwhile, the final EIR is being completed for the CPMC project, which should go before the Board of Supervisors for approval early next year.