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Papers collaborate to explore effects of hospitals fleeing inner cities Date: 07/28/14

Lillian Thomas

By Joe Rojas-Burke

Hospitals in the U.S. have been abandoning inner cities for years. By 2010, the number of urban hospitals still operating in 52 big cities had fallen to 426, down from 781 in 1970. Meanwhile, hundreds of medical centers built with cathedral-like grandeur have opened for business in affluent suburbs. A hard-hitting series produced by the Pittsburgh Post-Gazette and the Milwaukee Journal Sentinel laid bare the consequences of this trend for people in neighborhoods where hospitals closed.

Lillian Thomas, an assistant managing editor at the Pittsburgh Post-Gazette, talks about how they did it:

Q: What prompted you, in the very beginning, to start pulling on this string?

A: University of Pittsburgh Medical Center, the dominant health care provider in the Pittsburgh region, closed a hospital in the economically depressed town of Braddock four years ago and opened a new hospital in the more affluent suburb of Monroeville not long afterward. The Post-Gazette covered both, and many people protesting the Braddock closure asked why a health care giant that could afford to build a brand-new facility insisted it couldn't afford to keep an existing hospital going. I knew that this had happened elsewhere, but didn't know whether it was common or whether other large systems used resources from profitable hospitals to subsidize struggling hospitals.

Q: Can you say a bit about the fellowship and the resources it provided to make this project possible?

A: The O'Brien Fellowship was started two years ago at Marquette University, funded by a donation from Peter and Patricia Frechette. It pays a salary and provides moving, living and equipment expenses. The idea was to give journalists who might not be able to dive deep into a project the chance to do so. It's very much a working fellowship – my fellow fellows and I had the luxury of focusing on one major project, but we were working with students, guest lecturing in Marquette classes, and working to make use of the time to produce stories that we hoped would have impact.

Q: How did you form the collaboration between the Post-Gazette and the Journal Sentinel?

Lori Bergen, dean of Marquette’s Diederich College of Communication, worked with Milwaukee Journal Sentinel editors, particularly managing editor George Stanley, to create a fellowship that would result in in-depth, public service journalism. They wanted to involve Marquette students and to make collaboration with Journal Sentinel journalists possible.

I worked with undergraduate students, three each semester, on my project. They helped with research and one designed an interactive timeline. I also helped coordinate a related project that was done by the Milwaukee Neighborhood News Service, an online publication that has offices at Marquette. Marquette students designed the landing page and graphics for that project on diabetes in low-income neighborhoods.

My proposed project on barriers to health care in low-income neighborhoods was of interest to the Journal Sentinel, and we decided in the early fall of my fellowship year that the JS would publish most of the stories in my project. I began to work with data reporter Kevin Crowe on the project of tracking down information for interactive metro maps, and his persistence in bugging CMS and the long, hard work of figuring out and mapping hospital closures were huge contributions to the project. Allan Vestal took all that and made maps that allowed users to find income, disability, federally designated shortage areas and hospital closures in the top metro areas. Photographer Gary Porter worked with me on the Milwaukee stories. Projects editor Greg Borowski asked good questions, made good suggestions and was a calm force in the complicated process of putting together a multi-part project.

Photo: 90.5 WESA via Flickr
UPMC East opened in the summer of 2012.

Mounting the series on both publications' websites and preparing slightly different versions of every piece for each paper to publish was a challenge. We had several phone meetings with those involved from both papers, but mostly Greg made sure the JS people involved had regular contact with their PG counterparts in photo, data, graphics etc.

Q: What were your goals as you set out on this project?

A: I spent a lot of time thinking about the large-scale economic forces involved in health care as I reported during my fellowship year at Marquette University.

I wanted to show the power of the system as it exists to push medical care away from the poor, and how it constrains health care providers. I also wanted to make clear that those economic realities are not the result of immutable forces — they are the result of decisions made over many years.

To document the fact that providers have retreated from the urban poor, I worked with my colleagues at the Milwaukee Journal Sentinel to gather data on income, hospital closures and federally designated physician shortage areas. Kevin Crowe and Allan Vestal of the Journal Sentinel created interactive maps of the top U.S. metropolitan areas that showed that health care resources are scarce in poor neighborhoods, where health care needs are high, and often abundant in affluent communities, where health is better and people are more able to reach health care resources.

Some of those decisions were made with one purpose but had unintended consequences, such as the decision by many companies during World War II to offer health insurance to attract workers and the subsequent decision by the federal government to give employers tax breaks for providing such insurance. The consequence of a decision to try to help the wartime economy was a large private insurance market that meant that price was no longer a factor for most patients in most circumstances. If insurance is footing the bill, you don’t care whether your surgery costs $35,000 or $50,000.

The consequences of other decisions were clear. When government officials lowered reimbursement levels for Medicaid, they knew that it would make privately insured patients more profitable than Medicaid patients.

To try to get a handle on how those decisions play out, I asked the doctors, administrators and academics I interviewed to talk about the way the health care market is skewed. Eventually I wrote a long, dense, reader-unfriendly piece, mainly to make sure I could explain the issues to myself. Then with the help of Greg Borowski (my awesome loaned editor from the Journal Sentinel during my fellowship), I boiled it down to a pretty tight package.

To get at how the system plays out for patients and doctors, I used the story of John Patton Jr., a man I followed over many months as he bounced around the health care system in Milwaukee. Though his overall health care was episodic, disconnected and incomplete, Patton got good and compassionate care nearly everywhere he went. The people in the system were often excellent, but the system kept them from giving him comprehensive care.

Finally, I wanted to show that though such constraints can make it difficult, they don’t make it impossible to give good health care to the poor. It’s possible to change the system, and many providers are doing it. I did a lot of reporting (much of it still to be published in future installments of the occasional Poor Health series) on health care systems that have chosen to focus on the poor. Instead of looking at the bottom line and saying “low-income patients are money losers, let’s keep away from them,” they’ve said, “how can we change the way we deliver care to make the poor less expensive to treat?”

Q: Last thing: Did you have a hard time finding John Patton Jr. and convincing him to tell his story and be photographed? What tips might you have for reporters seeking real people to animate their reporting?

I knew from the start that it would be tough to find a person who would show the challenges I was writing. And I knew that going top-down wasn't going to happen because of HIPAA and health systems' reluctance to open their doors to reporters. Staffers at free clinics tended to be much more open, though, and I spent a lot of time hanging around clinics in church basements and former health care facilities. It's obvious, I guess, but the way to find people for your stories is to spend a lot of time in places where those people are likely to be. Diane De La Santos, who heads a nonprofit in a former hospital, let me spend time at the free clinic there. You couldn't miss the tall man who talks a blue mile, and once I introduced myself to John Patton Jr., I was pretty sure I had my guy. He is a wonderfully engaging, funny and kind man. Also one who's made plenty of bad choices in his life. He had no qualms about talking to me, letting me accompany him to appointments, and being photographed. In fact, he was so open that I knew he could inadvertently open himself to reaction that could hurt him, but I think his candor let me tell a balanced story about him. I was fortunate to find him.

Lillian Thomas is an assistant managing editor at the Pittsburgh Post-Gazette. She spent the 2013-14 academic year as an O'Brien Fellow in Public Service Journalism at Marquette University's Diederich College of Communication, where she collaborated with Marquette students and journalists from the Milwaukee Journal Sentinel.