Washington Business Journal
July 7, 2023
Other health systems have been filling the void left by Providence’s exit in D.C.’s underserved east side.
By Sara Gilgore
Community activity buzzes outside the sprawling campus at 12th and Varnum streets in Northeast D.C. A young man walks his dog past the duplexes and bus shelters lining the sidewalks. Chirping birds harmonize with the construction cacophony below, while adults read on benches and kids play in the park across the street.
Walk onto the campus, however, and it gets significantly more quiet — and vacant. More than a dozen parked cars sit in the lot, but no one can be immediately seen in the vicinity for hours on a warm, sunny June afternoon. In this pocket of the District, subtle reminders remain of Providence Health System’s now-defunct hospital, from the mostly empty facility to the statue of St. Vincent de Paul prominently displayed above an updated blue sign. For now.
That lack of activity — and the millions of dollars it’s costing — are why its owner, St. Louis-based Ascension, said it wants to shut down those final few vestiges of its campus and hand the 21-acre property over to developers.
It’s the latest plot twist in a narrative that dates back to 2017, when the Catholic nonprofit shuttered its obstetrics and behavioral health units and, two years later, closed its hospital doors altogether. It aimed instead to create an outpatient health “village” that, for years, was short on details and, for many reasons, never quite came together.
In short, “we were faced with a stark reality that these were not sustainable ventures for us,” Beau Higginbotham, interim CEO for D.C.’s Providence, explained at a June 8 informational gathering held by D.C.’s State Health Planning and Development Agency (SHPDA).
Left in its wake are some frustrated health leaders and many unanswered questions. To be sure, Covid-19 takes much of the blame for health care’s difficult undercurrents, but it’s not what caused Providence to shutter the prior year. Now experts and providers say its final departure leaves a few gaps in the District’s landscape, particularly in maternal, mental and pediatric health, especially for a lower-income population that had composed Ascension’s patient pool for years.
“They are colossal failures when systems like that close down,” said Dr. Tollie Elliott, CEO of Mary’s Center and an OB-GYN who spent nearly 14 years at Providence. “There’s going to be some sort of impact to the residents and the entire city.”
Providence declined to comment for this story, instead directing us to its comments at SHPDA’s hearing. Former and current executives did not return direct requests for comment or declined to speak for this story.
Other health systems have been filling the void Providence’s exit from D.C.’s underserved east side has left. Leaders say they’re striking partnerships, scoping out real estate and shifting services into its communities, beyond full-service hospitals, to help measure up to the need, prevent unnecessary ER surges and connect patients with more preventive care. Some, they say, is easier said than done.
“There are people falling through the cracks,” said Dr. Jessica Henderson Boyd, CEO of Unity Health Care. “I think that demand is still there. It’s just: Are we getting it to patients in the best way that makes sense for them?”
Mallory Mpare is director of Maternal and Infant Health Initiatives at the March of Dimes. ABDULLAH KONTE / WBJ
Mission: Maternal and infant health
When Providence shuttered obstetrics in 2017, D.C.’s other providers felt the effects right away — and, in some ways, still do.
The move reflected a national trend of maternity wards closing, especially by nonprofits like Providence and Southeast D.C.’s United Medical Center that serve predominantly Medicaid patients without enough private coverage or other high-cost services to offset those losses, said Mallory Mpare, director of D.C.-area maternal and infant health initiatives for Arlington’s March of Dimes. “Then they are forced to make a business decision.”
These business decisions have social implications. The maternal mortality rate in 2019 for Black women in D.C. was 71 deaths per 100,000 live births, compared with 63.8 deaths nationally, according to United Health Foundation data. Those outcomes “are less to do with the availability of services, although that is a huge driver, and more to do with the demographic differences across the city,” Mpare said.
The city’s other hospitals have since absorbed the demand that resulted from Providence’s OB service cuts, by hiring up, expanding capacity and securing financing to make it all sustainable. But, they said, the work brought downstream effects, including overcrowded emergency departments, overloaded inpatient units, weekslong waits for appointments and insufficient staffing.
“We’re always full and remain full,” Dr. Gregory Argyros, president of nearby MedStar Washington Hospital Center, said of its maternal-fetal medicine program.
It also further fragmented care between prenatal, labor and delivery, and postpartum — all vital to reducing disparities in maternal mortality. Nearly 20% of women in D.C. don’t see a doctor until at least the fifth month of pregnancy, Mpare said.
Efforts are underway to reverse that. Community of Hope is expanding services for women, infants and children, amid “a pretty significant increase” in births, which nearly doubled year over year in the first quarter of 2023, said CEO Kelly Sweeney McShane. That was driven by the March 2022 relocation of COH’s Northeast family health and birth center, the start of postpartum visits in people’s homes and the addition of midwives and doulas to its team, she said.
On the insurance side, Mary’s Center is looking at how managed care organizations — MCOs, or private payors offering Medicaid — reimburse telemedicine for pregnant women, said Elliott, who was still working at Providence during the OB service cuts. The D.C. Department of Health Care Finance is likewise taking steps to broaden coverage by expanding Medicaid to include doulas and adding maternal health metrics to measure health plan performance ahead of the District’s next wave of MCO contracts, according to Director Wayne Turnage, also the deputy mayor for health and human services.
These efforts matter, Mpare said, because preterm birth, a consequence of not improving this care and access, “has a number of costs to society.”
“Of course, there is the cost of the clinical care, but there is also a cost of caring for children who may be born with defects, and as a society, we take on that burden,” she said. “It’s really in everyone’s best interest to ensure that we’re having the healthiest outcomes that we can.”
Mission: Behavioral health
When Providence collapsed its inpatient behavioral health unit, also in 2017, the story wasn’t much different.
Providence had been one of four D.C. hospitals that provided mental health and addiction services to the most seriously ill patients. Then that load was redistributed to the other three: MedStar Washington Hospital Center, the Psychiatric Institute of Washington and the District-owned United Medical Center.
MWHC, which today has 46 behavioral health beds, took over four of Providence’s 12 beds for patients involuntarily committed back then. It’s now working with the city to ensure Cedar Hill Regional Medical Center — a hospital under construction on the St. Elizabeths East campus to replace UMC in early 2025, slated to have 16 inpatient behavioral health beds — will be able to absorb at least some of UMC’s capacity for involuntary patients, Argyros said.
It’s also adjusting its hiring of behavioral health nurses and technicians weekly, “based on what the needs are,” he said. Meanwhile, Community of Hope recently increased its base pay to ramp up recruitment and patient volumes, as well as revenue, since Covid-era federal funding has run out.
Treating patients beyond a hospital’s walls is key, local leaders agree. MedStar has been working closely with the Department of Health Care Finance and D.C.’s Medicaid office to connect discharged patients with home health care, Argyros said, noting the need to provide care in crises, but also “prevent those crises from occurring that necessitate an inpatient admission.”
Doing so “could pay out dividends from a health outcomes perspective,” Boyd said. “That’s the key — thinking, ‘What are the pieces of the puzzle to invest in that could have as much impact as a hospital bedroom?’”
The work also requires decreasing the stigma around mental health, producing more psychiatrists, psychologists, social workers and counselors, and developing programs for patients to get the care they need. None is an overnight solution.
“We went after the pandemic with hands, feet and everything else we had. We have to go after [behavioral health] in exactly the same way,” said Dr. Hugh Mighty, Howard University’s senior vice president for health affairs and an OB-GYN. “We have to raise it to that level of awareness, we have to bring the resources to bear and we have to be willing to pay to help get those resources in play.”
Several steps to ‘retool’
When Providence started sunsetting its hospital, a 150-year-old cornerstone for acute care, and recommended a $30 million outpatient campus in its stead, it entered a contentious battle — complete with D.C. Council interrogations, opposition from every angle and the city’s unsuccessful lawsuit against Ascension. All of that was before Covid ravaged the health scene, blurring and worsening the effects of Providence’s closures.
Northwest’s MWHC and Howard University Hospital, both within four miles of Providence, experienced “an immediate impact, an acute hiccup, and then as we were able to absorb that, things died down,” Mighty said. Both went after new funding sources, beefed up staffing and expanded services. But “it doesn’t at all relieve the fact that there is a need for health care, especially for those who can’t readily access it,” Mighty said.
Providence had reported declining patient volumes and insufficient revenue intake, citing an overall surplus of beds as justification that the city no longer needed its full-service hospital. With steady turnover at the top, the health system’s leadership had been reliably vague and practically silent for years about its plans for the resulting health village.
It opened that planned campus’s first piece, an urgent care center, in the former hospital’s ER space a few months after the latter’s closure. Two years later, Providence unveiled a new diagnostic imaging center that, its leaders said at the time, came in direct response to community need. But the system didn’t disclose much more than that, other than to confirm in 2020 that the former inpatient towers would lie dormant as its attention turned to its Covid response, working with D.C.’s health department to help expand vaccine access to residents.
At the same time, local health systems embarked on expansion plans to sate increased needs. Nearly all of the region’s providers have since delivered or kicked off new builds, renovations or openings of both inpatient and ambulatory facilities.
Howard, which is laying groundwork to replace its existing hospital, is strengthening its partnerships with FQHCs to provide community-based specialty care that complements its primary care networks. It also plans to bring another clinic to the former Walter Reed Army Medical Center to address prevalent conditions among its patients, such as breast and colon cancers. An urgent care center there is also on the table, Mighty said. “I think you’re seeing the hospital systems retool a bit to meet the need.”
Cedar Hill Regional Medical Center will be a fundamental part of the solution. The planned Ward 8 hospital, to be operated by George Washington University Hospital owner Universal Health Services Inc., won’t directly fill the hole Providence left; its Anacostia site sits 10 miles south. But it will serve some of the same populations and chip away at gaps left by the struggling, nearly 60-year-old UMC, which saw fewer than 3,500 admissions in 2022, per D.C. Hospital Association data.
That matters for the city’s other hospitals, including MWHC, which saw higher ER volumes and inpatient visits the year of Providence’s closure. Cedar Hill, Argyros said, “will be able to provide capacity that we are not currently seeing being utilized at United Medical Center.”
A health care ‘redesign’
When Providence made clear in May that it would not deliver its long-on-the-books health-focused village, it gave perhaps the most clarity yet around the property’s fate.
It creates “this opportunity to redesign what health care looks like as part of this development,” said Emily Singer Lucio, ANC commissioner for 5A03, the area that comprises Providence’s campus.
A development team, led by EYA Inc. and Menkiti Group, has laid out plans to bring housing, education and elderly health and wellness services, among other uses, as it continues to seek community feedback and earn necessary approvals for the revamp. Those plans could include an urgent care center, subject to partnering with a provider, the developers said at a May 10 town hall. The development team did not return requests for comment.
Under its proposal, Providence would sell the land to the development team for a buck. The existing Carroll Manor nursing home, police and fire clinic, and two medical office buildings, which house outpatient behavioral health, internal medicine and additional clinical services from other tenants, would continue to operate.
Ascension said it separately intends to contribute $400,000 to a to-be-determined organization supporting access to maternal and prenatal health care in the District.
There’s “definitely a need for more medical options,” including for Ward 5’s growing elderly and family populations, Singer Lucio said. In particular, she calls for pediatric urgent care, as many of her neighbors currently travel to Maryland.
“It does seem like [pediatric] urgent care is something that people want, so we will be taking a look to see if we can provide that in parts of the city where there’s not that kind of access for children,” said Dr. Kurt Newman, former president and CEO of Children’s National Hospital, calling Providence’s evolution in D.C. “a serious illustration of, in a sense, lack of investment.”
“If we’re not investing as a society, then we are really going to be in trouble,” he said, “and we’re starting to see that.”
The Providence campus is located at 1150 Varnum St. NE. ABDULLAH KONTE / WBJ
Closure time
Providence has said publicly it hasn’t seen sufficient demand for its urgent care services, totaling 14 patients daily and another dozen at its imaging center. By early 2022, it also became clear that the payor mix had shifted to more uninsured patients and fewer commercial and MCO-covered patients than expected, Higginbotham told SHPDA at its June hearing, held to evaluate Providence’s plans to close its urgent care and imaging centers.
The health system reported that its urgent care center alone lost more than $2.6 million since its 2019 launch, a number that shot up to $6.5 million when including the costs to run it, from professional liability insurance to housekeeping. The campus as a whole has lost more than $106 million since the hospital closed in 2019, even with its “always-on approach” to marketing, Sean Fitzpatrick, associate vice president of marketing communications for Ascension, said at the hearing.
“Despite their best efforts to manage and promote these services on the Providence campus, it is not possible to continue operations without sustaining significant long-term financial losses,” Amandeep Sidhu, an attorney with law firm Winston & Strawn LLP, representing Providence, said at the SHPDA hearing.
That’s not surprising for such centers, especially stand-alone clinics not affiliated with a larger health system.
“I don’t think you get into urgent care to make money. Urgent care is there as an access point, usually as a component of a larger system of care,” said Kimberly Russo, CEO of GWU Hospital and group vice president of the D.C. region for UHS. “I think it might be challenging to just have a single free-standing urgent care that’s not integrated into a system.”
SHPDA, tasked with ensuring “orderly” closures of health facilities, could issue its decision on Providence’s plans as early as the third week of July, though it also doesn’t have the authority to compel Providence to continue operating the centers. A shutdown would affect about 25 full-time employees and five providers on site, according to Providence. Plans call for the hospital building to be torn down — though, some nearby residents say losing Providence’s current outpatient services won’t sting too badly, and providers say they can step up.
“With an urgent care that doesn’t see very many patients, and still an unclear plan for their physician office buildings there and what’s going to happen, we’ll be ready to take care of any patient that needs our services,” Argyros said.
Another entity, Denver’s DispatchHealth, filed an application June 30 with SHPDA for a certificate of need to provide in-home urgent care services in D.C. — stressing its commitment “to a targeted outreach directed at the communities adjacent to the Providence urgent care center to assist in filling the void left by its closure,” it said in its application, submitted by Winston & Strawn’s Sidhu and provided by SHPDA to the Washington Business Journal. Though, SHPDA had not yet determined as of press time if the application was complete, Director Terri Thompson told us.
Many say urgent care services help minimize a flight to ERs for every bump or bruise, which crowd those spaces. Exhibit A: Cedar Hill Urgent Care in Ward 8, which opened in October.
“We’ve seen a pretty steady increase in volumes as word has gotten out that we’re open and willing to see patients” — now to more than 1,000 patients a month, the majority of whom live in Southeast and about 20% of whom are kids, said Dr. Randall Lee, co-medical director of Cedar Hill Urgent Care and an emergency medicine physician at GWU Hospital.
The hope: that this center and another planned for Ward 7 will eventually help ease the burden on hospital ERs.
More broadly, however, industry leaders also posit it may be less a question of demand, and more Providence’s own withdrawal from acute care that’s most responsible for its lack of success with urgent care.
“The noise around that closure will always be much, much louder than the noise created by a reopening of a [smaller urgent care service],” Turnage said. “People, out of necessity, scrambled to find replacement providers when Providence closed that hospital” and “did not necessarily come back when Providence restarted some services — and now it’s going to take a little bit more than what they’ve been able to do to draw some demand back.”
