Brackenridge Choice Still Pending

Brackenridge Hospital Oversight Council member DeAnn Friedholm (Photo By John Anderson)

Despite the welcome brevity of the Brackenridge Hospital Oversight Council's Monday meeting, debate persists over how Austin's public hospital will continue to provide tubal ligations and other reproductive services to indigent patients. After five months of meeting with city staff and women's health groups, BHOC members (health care professionals and citizens) took just 30 minutes to vote on recommendations to city staff's "hospital within a hospital" proposal, which calls for the city to withdraw Brack's fifth floor from its 30-year lease agreement with Catholic health-care provider and Brackenridge manager Seton Healthcare Network and to create a separate hospital facility. At its meeting today (Oct. 25), the City Council will consider the BHOC's recommendations, take public testimony, and decide on a lease amendment that would enable city staff to continue developing its plan.

In June, the U.S. Conference of Catholic Bishops altered its Ethical and Religious Directives to prohibit Catholic health-care providers like Seton from managing facilities that permit tubals and other services that the church finds objectionable. By federal law, though, public hospitals must provide legal reproductive health services; hence the city's current plan. Wary of future changes to the directives, BHOC members DeAnn Friedholm, Donna Ammons, Dan Barry, and Chair Dr. Jim Brand (Margaret Uriegas was absent) unanimously recommended that the city should itself take back all maternity services at Brack. But city staff believes that route is impossible.

"There are some limitations to practicality," said Trish Young, CEO of the City of Austin/Travis Co. Community Health Centers. "Seton needs to preserve its financial viability, and we need to continue these [reproductive] services." According to city information provided at the BHOC's Oct. 9 meeting, if the city took over all maternity services, Seton would lose 34% of all Brack admissions and incur unknown operating losses, possibly provoking them to withdraw from Brack. No one's beating down the city's door to take their place.

Acknowledging the city's preference to stick with Seton, BHOC members approved a separate set of recommendations addressing the hospital-within-a-hospital. "We don't want to stick our heads in the sand," explained Brand. At a projected construction cost of $6-$7 million, the city would convert Brack's fifth floor into a separate, fully licensed facility with a lab, pharmacy, nursery, and operating units accessible via a separate entrance. The city projects that approximately 1,000 women would deliver babies annually at the facility, which would also perform tubals. Seton would continue to provide maternity services on Brack's second floor.

Among the BHOC's stipulations: The quality of care on both floors must remain equal, with an independent group or city staff nurses conducting customer satisfaction surveys and reporting directly to the BHOC and the city. The city should amend its lease with Seton and pass a city ordinance to provide a single BHOC that will monitor care at both facilities, members concluded.

Birth control counseling and family planning services, the BHOC continued, must remain accessible on Brack's second-floor maternity units. Less certain is how emergency contraception would be distributed. The BHOC recommended that women in need of emergency contraception must be sent immediately to the city-operated fifth floor. In some instances, the Catholic Directives allow contraception to be administered, but not if a woman is already pregnant -- including instances of rape. "Seton has not given us clear direction yet on how they will handle emergency contraception," Young said, explaining that Seton still is reviewing those protocols.

BHOC members repeatedly praised Seton's indigent care, but they agreed that Seton -- not taxpayers -- should bear the entire cost of the new facility. (Under the current staff proposal, Seton would front the money for construction, to be reimbursed by the city over time.) Members also recommended that if future changes in church directives restrict medical services, "the city must seek without restriction other possible arrangements with other potential contractors before or during the discussions with Seton about resolving the problems." Friedholm said, "Any further changes may be the straw that breaks the camel's back." The Brack lease already permits the city to seek other contractors, but strongly advises entering into discussion with Seton beforehand.

"We know this is not an ideal situation," Young said, "and we're trying to come up with a reasoned solution to make sure we continue to provide all the services our patients require."

Among council members, Danny Thomas and Beverly Griffith have questioned the deal most vociferously. Last week Thomas produced a list of 23 questions on matters ranging from construction costs to continuity of family planning education. Although city staff was able to answer most of the questions, the total cost of the build-out remains indefinite, they said, because plans are not complete. Thus far, the city has relied upon cost estimates provided by a hired consultant -- more precise numbers will supposedly be provided after council approves the lease amendment.

Griffith has insisted that the city consider several alternatives to the hospital-within-a-hospital -- including the city taking over Brack's second floor, a functional, operating maternity unit. City staff has explored that option, but not as thoroughly as its own proposal. While describing Seton's indigent care as "devoted and skillful," Griffith last week asked the city auditor's office for a financial profit-loss statement and a list of prices for services at Brack. "It's real important to sit down with Seton -- as partners -- with the operating statements and see what the facts are," she said. "That will dispel any misunderstanding about how the cash flows, and doesn't, and from where."

But Seton executives told the auditors that Seton doesn't itemize services. Young explains that hospital financial accounting presents unique complexities that make achieving precision difficult. "It's not a simple task to say, 'this is how much it costs to do a single service,' because services aren't delivered that way," she said. "If a mom delivered a baby, she may start out in labor, then go to surgery for a C-section while the baby goes to the NICU [Neonatal Intensive Care Unit]. It's hard to say what it costs to provide all of those services."

According to city data, two-thirds of patients who deliver babies at Brack pass through the clinic system, and 75% of the 3,600 annual deliveries are paid for by Medicaid. "We're dealing with low-income women who have very few choices," said Brand, the BHOC chair. "I hope our patients will continue to have choices."