December 2018
Final Report
RAPID HEALTH IMPACT ASSESSMENT
Proposed Closure of Alta Bates Campus Berkeley, CA
EMERGENC Y
AL TA BAT ES HOSPIT AL
EMERGENC Y
AL TA BAT ES HOSPIT AL
2 5 EXECUTIVE SUMMARY
8 INTRODUCTION
8 P roposed Closing of Sutter Alta Bates Campus, Berkeley, CA 9 Overview Of Potential Health Issues from an Urban Hospital Closing 11 What is He alth Impact Assessment (HIA)?
12 Scope of this Rapid HIA (RHIA)
12 K ey RHIA Focal Areas
13 Hypothesized Impact P athways
17 R apid HIA Methodology
18 O VERVIEW OF ALTA BATES HOSPITAL
19 Alta Bates C ampus Patient Utilization
20 Emer gency Department
20 Hospital Service Area
26 SUMMIT CAMPUS IMPACTS
26 C ampus Utilization & Capacity to Absorb Alta Bates Campus Patients 28 Sut ter Health Plans for Summit Campus expansion
30 IMP ACT ON VULNERABLE POPULATIONS
31 P regnant Women & Newborn Babies
32 P eople of Color
34 P eople with Disabilities
34 Uninsur ed & Publicly Insured Patients
35 T he Aging and Elderly
36 Mental He alth & Suicide Prevention
36 Homeles s People
37 Adverse Impacts on Vulnerable Communities in the Alta Bates Hospital Service Area 42 IMP ACTS ON UC BERKELEY STUDENT HEALTH CARE
46 IMP ACT ON EMERGENCY SERVICES
47 Alta Bates Emer gency Department (ED) Utilization
47 Analyses of Travel Times to Alta Bates vs Summit Campus Emergency Departments 50 Impacts on Ambulance Travel Times
53 Ambulance Diversion
53 R egional Emergency Department impacts
56 DISAS TER EVENT IMPACTS
58 Potential Impact from Chevron Refinery Fire
60 EC ONOMIC IMPACTS
61 Alta Bates C ampus as an Economic Base Multiplier
63 APPENDIX
66 REFERENCES
Table of Contents
Authors:
Jason Corburn, PhD
Amanda Fukutome
Marisa Ruiz Asari
Jennifer Jarin
Vaughn Villaverde
Research Assistants:
Laura Atukunda
Riya Desai
Cindy Ochieng
Report design:
Marisa Ruiz Asari
Institute of Urban and
Regional Development
University of California Berkeley
2018
RAPID HEALTH IMPACT
ASSESSMENT
Proposed Closure of Alta Bates
Campus, Berkeley, CA
Page
3 Figures
5 F igure 1. HIA Key Findings Overview
7 F igure 2: Likely Health Impacts from the Closing of Alta Bates Medical Center, Berkeley, CA 10 F igure 3. Alta Bates Closure key milestones time line 11 F igure 4. Health Impact Assessment process
12 F igure 5. Rapid Health Impact Assessment guiding research questions 14 F igure 6. Hypothesized Impacts from Alta Bates Campus birthing center closing 14 F igure 7. Hypothesized Impacts from Alta Bates Campus Emergency Department (ED) closing 15 F igure 8. Hypothesized Impacts of Alta Bates Campus ED closing on Emergency Medical Services 15 F igure 9. Hypothesized Impacts of a Regional Disaster on ED access without Alta Bates Campus 16 F igure 10. Hypothesized Impacts from Alta Bates Closing on Local & Regional Economy 17 F igure 11. Examples of inputs to Rapid HIA
19 F igure 12. Alta Bates Campus ED patient discharges (2016) from cities impacted by the DMC hospital closure 19 F igure 11. Alta Bates Campus utilization overview 2016 22 F igure 13. Increased Alta Bates Campus discharges from Contra Costa County & regional zip-codes 22 Figure 14. Alta Bates Campus Hospital Service Ar eas: RHIA & CHNA defined 24 Figure 15. ED Visits by Cause: Comparing the RHIA Defined Alta Bates Campus HSA to State and County Rates 31 F igure 16. Outcomes for largest birthing centers in Alameda & Contra Costa Counties, 2016 32 F igure 17. Number of live births across regional birthing centers 2016 33 F igure 18. Percent race/ethnicity in the HSA compared to county and state rates 34 F igure 19. Alta Bates Campus expected payer source 2016 37 F igure 20. Total Homeless patients at select East Bay hospitals 2016 - 2017 6 38 F igure 21. Alta Bates Summit Medical Center CHNA Communities of Concern 40 Figure 22. High Health Care Need Communities in the RHIA defined HSA 41 Figure 23. Heart Disease ED visits per 10,000 residents for all ZIP Codes in the RHIA defined Alta Bates Campus HSA 41 F igure 24. Select ZIP Codes - Asthma and Diabetes ED visits per 10,000 residents 43 F igure 25. Student vs Alta Bates Campus mental health care utilization 48 F igure 26. Travel times to Alta Bates & Summit Campuses from ZIP Codes in the HSA 52 F igure 27. Emergency response time line
54 F igure 28. Additional ED visits/year hospitals can absorb before exceeding (ACEP) standard 55 F igure 29. Alta Bates & Summit ED utilization & American College of Emergency Physicians’ recommended capacity 59 Figure 30. Emergency Department patient surge volume after Chevron refinery fire, Richmond, CA, 2012 62 F igure 31. How hospitals contribute to regional economies Page
4 9 Map 1. Alta Bates Campus & Regional Hospital Network 18 Map 2. Alta Bates Campus and affected buildings
21 Map 3. Rapid Health Impact As sessment defined Hospital Service Ar ea (HSA) 23 Map 4. Large volume increases in Alta Bates Campus ED discharges from West Contra Costa County 2013 - 2016 25 Map 5. Comparing RHIA & CHNA defined Hospital Service Ar eas 27 Map 6. Summit Campus and affected buildings
38 Map 7: 2016 CHNA defined service area CHVI scores 39 Map 8: Percent Uninsured across Census T racts in the RHIA defined Service Ar ea 39 Map 9: Percent of Families (with Children) in Poverty across Census T racts in the RHIA defined Service Ar ea 44 Map 10. Population density in ZIP Codes surrounding UC Berkeley, Alta Bates Campus, and Summit Campus 49 Map 11. Projected Heart Disease ED Visits & Travel Times to Summit Campus for ZIP Codes North of Alta Bates Campus 50 Map 12. Travel times to Alta Bates vs. Summit Campus at 5:30pm from select ZIP Codes in the Alta Bates HSA 57 Map 13. Surge event: Earthquake along the Hayward Fault
EMERGENC Y
AL TA BAT ES HOSPIT AL
Maps
Page
5 EXECUTIVE SUMMARY
Sutter Health has proposed to close Alta
Bates Campus in Berkeley, California, by 2030.
Alta Bates Hospital serves the City of Berkeley
and the entire East Bay with 347 beds, 22
Emergency Department treatment stations,
about 50,000 Emergency Department (ED)
patients, and over 5,000 births in 2017. In 2016,
the hospital billed almost $2 Billion in patient
revenue.
2-4 Sutter Health has determined that
state-mandated earthquake safety upgrades
would be too costly to keep the major functions
of the hospital open. Sutter Health stated in 2016
that they plan to relocate most inpatient care and
emergency services from the Alta Bates Campus
site in Berkeley to an expanded Summit Medical
Campus in Oakland approximately three miles
from the Berkeley campus.
Proposed closure of Alta Bates Summit Medical Center - Alta Bates Campus Vulnerable
populations
HIA FOCUS AREA
Emergency
Department
access
Regional
economy
Figure 1. HIA Key Findings Overview
• Likely decreased access to urgent and chronic care for vulnerable populations.
• Likely increase in Bay Area elderly population will increase hospital care needs.
• Uncertainty regarding replication of high-performing
birthing center and related maternal & newborn care
currently at Alta Bates.
• Increase in homeless patients at East Bay hospitals & this population will likely delay or avoid care.
• Increase in private vehicle travel times to hospital
emergency department for West Contra Costa County
patients.
• Likely increased burden on regional emergency medical services, including emergency department over-crowding
& an increase in ambulance diversions.
• Lack of a coordinated disaster preparedness plan for
Bay Area regional health care providers that includes UC Berkeley.
• Likely loss of living-wage jobs for entry-level hospital workers & some skilled positions, such as nurses.
• Limited information on proposed Sutter relocation &
construction plans made some projections difficult.
People with disabilities
Uninsured
People of color
Elderly
Pregnant Women
Homeless
Wait times & capacity
Travel times
On call times for EMS
Capacity for surge event
Wages
Employment
Municipal costs
Select Key Findings
6 This Rapid Health Impact Assessment (RHIA)
was commissioned by the City of Berkeley’s, Alta
Bates Regional Task Force and highlights some
of the likely health impacts from the closure of
Alta Bates hospital. More specifically, the Rapid
HIA focuses on the health impacts to: (1) already
vulnerable populations, such as the elderly, the
uninsured, and people of color; (2) University
of California, Berkeley, students; (3) emergency
medical services, including travel times to the
emergency room and regional emergency room
capacity in the case of a disaster, and; (4) the local
economy.
Alta Bates Campus has served as a regional
community health asset since its founding in 1905
by nurse Alta Alice Miner Bates. Alta Bates has
the greatest number of hospital-births out of all
hospitals in the East Bay. Further, Sutter Health’s
own 2016 Community Health Needs Assessment
(CHNA) report noted that the Alta Bates Summit
Medical Center Service Area currently serves
a large percentage of the region’s vulnerable
communities with high chronic health care needs.
Alta Bates Campus also has one of the highest
volume emergency departments (ED) in the East
Bay. The ED has experienced a sharp increase
in patients from West Contra Costa County,
many of whom were likely served by Doctors
Medical Center (DMC) in San Pablo, which closed
in 2015. In 2017 the Alta Bates Campus ED
was operating at about 6,000 visits above the
capacity recommended by the American College
of Emergency Physicians.
4 Research from across California and the United
States has found that hospital closures in urban
areas can displace patients, particularly those
already vulnerable, from familiar and usual
sources of care, and overburden the hospitals
that remain open. More specifically, Emergency
Department (ED) closures can adversely impact
regional morbidity and mortality.
Overall, we found that the closing of Alta Bates
Campus will have potentially significant adverse
health impacts related to: birthing/obstetrics;
ED care for the elderly, uninsured, homeless and
people of color; private vehicle travel times for
certain areas of the East Bay, particularly Western
Contra Costa County; disaster response capacity,
and; some UC Berkeley student health care
needs. We also found that the closing of the Alta
Bates campus will adversely impact employment
for low-wage workers, reduce spending in the
local economy and potentially reduce community-
based health promotion investments.
A summary of the likely impacts appears in
Figure 2. We describe the key impact, the likely
magnitude of impact on a scale of 1-3 stars, with 3
being the greatest impact, and offer examples of
key data for each impact.
This RHIA utilized a detailed review of the
scientific literature, existing provider data, and
interviews with select professionals to estimate
likely impacts. However, the projected impact
analyses and some conclusions were limited
due to the fact that Sutter Health did not provide
detailed relocation and re-construction plans for
either the Summit or Alta Bates campuses. The
findings here are based on available hospital
and public health data. Despite these limits, we
find that the closing of the Alta Bates hospital
campus in Berkeley, CA, will likely have significant
adverse public health impacts on populations
along the corridor from Berkeley to San Pablo
unless specific actions are taken to increase ER
and inpatient care access for already vulnerable
populations, increase existing hospital emergency
department capacities and increase 24-hour
urgent care facilities, especially those serving
West Contra Costa County.
7 Figure 2: Likely Health Impacts from the Closing of Alta Bates Medical Center, Berkeley, CA (Magnitude: 1 = less likely to 3 = highly likely)
Key Issue Likely Health Impact Magnitude
of impact Examples of Supportive Data
Birthing/
obstetrics
Reduced access to high quality
prenatal, birthing & neonatal care *** Over 5,000 births per year at Alta Bates - highest in the region Current birthing center has excellent maternal & infant outcomes Elderly care
Delayed care, increased severity
of disease & likely avoidable
hospitalizations
*
Already high % Medicare serving facility; senior population increasing Hospital closures have resulted in delayed care & increased mortality for elderly
Uninsured &
homeless
Delayed care, increased unnecessary
hospitalizations, increased care costs
& potential spread of infections
**
About 41% of patients in 2016 were Medi-Cal or uninsured 600% increase in homeless patients at Alta Bates between 2016 - 2017
People of
color
Delayed care, increased unnecessary
hospitalizations, increased care costs
& some increase in unnecessary
deaths
***
Over 63% of patients at Alta Bates were people of color (PoC) in 2016 West Contra Costa County has high % PoC utilizing Alta Bates & will experience greatest increased travel times to reach Summit campus People with
Disabilities
Accessibility barriers due to
increased distance and unfamiliarity
with relocated services
**
12% of the population in the HSA are living with a disability, of which at least 61% are racial/ethnic minorities
UC Berkeley
Students
Loss of familiar ED & in-patient care;
loss of some emergency mental
health & suicide prevention
**
Estimated 4,000 UCB student visits to Alta Bates ED per year About 2 ambulance transfer per day from Tang Health Ctr. to Alta Bates Loss of familiarity & proximity of care may adversely impact students Emergency
Department
Increased crowding at EDs across
the region, increasing wait times;
Increase travel times to ED for some;
Increased ‘time-on-task’ for many
regional EMS providers.
***
Loss of 22 ED treatment stations at Alta Bates
Increase private vehicle travel times to Summit hospital during PM peak rush hour, with some areas needing over 50 minutes to reach ED.
Summit will need to double current ED capacity to accommodate all Alta Bates patients
Berkeley EMS reports 10-12 min. increase in transport times to Summit compared to Alta Bates, which would add on average 2 extra hours of EMS ‘time-on-task’ per day if Alta Bates closes Disaster
preparedness
Loss of ED capacity to treat
earthquake & fire victims, potential
increase in avoidable deaths &
hospitalizations; likely increased
cost of long-term care.
***
Est. 900 people needing ED care in first days of HayWired scenario earthquake & 1,000-1,200 from a major fire at Chevron in Richmond w/out Alta Bates.
Regional ED capacity in an emergency/disaster will be significantly compromised without Alta Bates
Concentrating ED capacity in fewer locations may limit access during a disaster if roadway network to those facilities is compromised.
Economics
Local government EMS spending
increase; low wage workers
disproportionately lose jobs; Nurses
may also be adversely impacted;
local service economy suffers
*
Potential increased cost to local governments to provide additional EMS services due to longer time on task
Potential loss of nurses out of region, increasing shortage of skilled practitioners
Estimated loss of $20M to local economy from annual hospital contracting & services
8 Sutter Health announced in 2016 that it will
close its Alta Bates Campus in Berkeley and
consolidate its current inpatient and emergency
services approximately three miles away at its
Summit Campus in Oakland, CA. Sutter Health
has stated that the closure of the Berkeley
hospital campus is expected to occur gradually,
with full closure occurring by 2030 (Sutter
Health, 2018). Some services have already been
relocated from Alta Bates Campus to Summit
Campus, such as the cardiac catheterization lab,
which began to close as early as 2010.
Alta Bates Campus was established in 1905 by
a nurse named Alta Alice Miner Bates. In 1906
the facility became the emergency hospital for
many in the East Bay, especially as hundreds
of San Franciscans fled to Berkeley after the
Earthquake and Fire of 1906. Between 1910 and
1912, the hospital built two wings and had about
40 beds. In 1928 a new hospital was opened on
the same site with 112 beds. In 1985, the 1928
building was replaced with a 300 bed, three story
structure, that exists today (Sutter Health, 2018).
Alta Bates Campus currently serves the City
of Berkeley and the entire East Bay with 347
beds and 22 Emergency Department stations,
generating approximately $1.89 billion in total
patient revenue in 2016.
1,4 Alta Bates Campus
is one of the only hospitals serving the East Bay
corridor from approximately San Pablo in Contra
Costa County to Berkeley in Alameda County (see
regional hospital network Map 1). Without access
to Alta Bates Campus, West Contra Costa County
residents will likely rely on Kaiser-Richmond,
which has limited capacity, and hospitals located
18-25 miles east, such as Contra Costa Regional
Medical Center and John Muir Hospital (Alta
Bates averages 9 miles from most West Contra
Costa County origins).
In response to the announcement of the
proposed closure of the Alta Bates Campus, the
Mayor’s Office of the City of Berkeley convened
the Alta Bates Regional Task Force to explore
ways to prevent this closure and keep Berkeley’s
only acute and emergency care hospital open.
The Berkeley City Council voted in 2016 to work
to keep the hospital open, and the Task Force
is one venue where information and policy
alternatives are being explored. The Task Force
is comprised of officials from Alameda and
Contra Costa Counties, and the cities of Alameda,
Albany, Berkeley, El Cerrito, Emeryville, Oakland,
San Pablo, and Richmond, California. The task
force also includes stakeholders from labor
unions, non-profit organizations, the University of
California Berkeley, and members of the public.
The Task Force commissioned this Rapid Health
Impact Assessment (RHIA) in the Spring of 2018,
to better understand the potential impacts of the
hospital closure on health care utilization and
access to emergency medical services (EMS).
Research on hospital closures suggests that the
events can displace patients from usual sources
of care and force them to access facilities that
may lack their prior medical records. Emergency
Department (ED) closures can adversely impact
morbidity and mortality in a region. The closure
of an ED can have a significant impact on a
region as patients may have to travel farther
to obtain care and the remaining EDs have to
Proposed Closing of Sutter Alta Bates Campus, Berkeley, CA
INTRODUCTION
9 bear the extra patient volume, especially for
patients experiencing time-sensitive illnesses
requiring prompt intervention. EDs provide care
not only for the critically ill, but also for those
unable to access care by other means, and are
seeing a rising trend in patient volume in both
the US and California. Significant increases in ED
volume create a strain on existing emergency
care capacity and emergency medical service
providers, and can adversely impact patient
health outcomes.
Overview of Potential Health Issues from an
Urban Hospital Closing
Research in the public health, medical and health
care services literatures suggests that urban
hospital closures can have adverse impacts on
population health, access to care and patient
outcomes. However, research also suggests that
whether or not a hospital closure will adversely
impact access and/or patient outcomes can
Map 1. Alta Bates
Campus & Regional
Hospital Network
10 depend on a host of factors, such as if there
are other high-performing institutions in close
proximity, if these institutions are accessible to
the poor, and if these same institutions can serve
additional patients, particularly in the ED (Hsia
& Shen 2011; Joynt et al., 2015; Liu et al., 2014).
Urban hospital closures have seen an increase
in both California and the US. Most recently and
related to this trend, Doctors Medical Center
(DMC) in San Pablo, California, closed in April
2015. Since that time, as we will highlight in
more detail below, residents living in Northwest
Alameda County and West Contra Costa County
have become increasingly reliant on the Alta
Bates campus for emergency and inpatient care.
Hospital closures can have a significant impact
on emergency department (ED) access. A
2015 national survey by the American College
of Emergency Physicians titled “Review of
the Evidence on the Use of the Emergency
Department by Medicaid Patients and the
Evolving Role of Emergency Medicine Physicians,”
revealed that patients in crowded EDs have a
greater likelihood of experiencing long wait
times, leaving without being seen by a physician,
feeling unsatisfied with their care, and having
worse medical outcomes including delays in
diagnosing myocardial infarction and increased
mortality rates. Horwitz, et al., (2010) reported
that only 67% of acutely ill ED patients were seen
within the recommended times in the US. In
2009, Pines, et al., reported on the complication
rate of patients with acute coronary syndrome
(ACS) as a function of crowded versus non-
crowded EDs, and found a significant increase in
serious complications (approximately 6% vs. 3%
incidence of death, cardiac arrest, heart failure,
late myocardial infarction, arrhythmias, stroke, or
hypotension) in those patients presenting during
overcrowded EDs.
ED overcrowding may also reduce the quality
of care and increases medical errors, as the
emergency staff may have to continually focus
on new patients. ED closure can also eliminate
hospital capacity for accommodating critical
incidents such as infectious disease epidemics
and disasters, another issue we explore in more
detail below.
The locations of urban hospital closures do not
seem to be randomly patterned, as Sager (2013)
and Ko et al. (2014) found that racially segregated
communities and especially predominantly
African-American neighborhoods are more
likely to experience a hospital closing than
predominantly white, Latino or Asian-American
majority neighborhoods. Nationally, one in three
urban African-Americans receive their primary
and other care at a hospital while for whites this in
about one in six.
A 2014 investigation by the Pittsburgh Post-
Gazette/Milwaukee Journal Sentinel revealed
that people in poor, urban neighborhoods are
Hospital
Seismic Safety
Law Updated
Sutter Health
Announces
Closure
Systematic
Transfer of
Service Lines
Alta Bates
Campus
Proposed
Closure
1994 2016 2016-’30 203020152008
Extensions
granted
Doctor’s Medical
Center Closes
Figure 3. Alta Bates Closure key milestones time line
11 less healthy than their more affluent neighbors,
but more likely to live in areas with physician
shortages and closed hospitals (Thomas, 2014).
A more detailed review of the medical literature is
included in each section below, and suggests that
urban hospital closings can have adverse impacts
that disproportionately impact already vulnerable
populations - such as the elderly, people of
color, and the homeless - emergency department
access, regional emergency management
systems, and the local economy.
What is Health Impact Assessment (HIA)?
Health Impact Assessment (HIA) uses a
combination of procedures, methods and tools to
analyze the potential, and sometimes unintended,
effects of a policy, plan, program or project on
the health of a population and the distribution of
those effects across population groups. HIA is a
process that aims to create healthier communities
by providing decision-makers with an
understanding of the potential health impacts of
a proposed project, and makes recommendations
that could reduce adverse impacts. Importantly,
HIA does not endorse or oppose a project or
policy; rather, the purpose of conducting an HIA
is to inform stakeholders and decision-makers
about the population health implications of
proposed actions, to identify and examine trade-
offs, and to encourage the exploration of health
promoting alternatives.
A Rapid or sometimes called a “desktop HIA” ,
does not include the extensive community and
stakeholder input of a typical HIA or original
data collection, such as surveys. Instead, the
Rapid HIA (RHIA) utilizes existing data and
limited stakeholder engagement to generate
analyses that can inform ongoing policy debates
and identify areas for additional study. The
key stages of the HIA process are highlighted
in Figure 4, and this RHIA includes the first
three major steps of screening, scoping and
assessment. While there is no single best
approach to HIA, each HIA
process should reflect the
needs of its particular context.
This Rapid HIA aims to extend
the knowledge and awareness
for communities and decision-
makers about select health
equity issues raised by the
proposed closing of Alta Bates
hospital in Berkeley, California.
Health
Impact
Assessment
Screening
Scoping
Assessment
Recommendations
Reporting
Sharing results and
recommendations with
decision makers
Measuring and
evaluating progress on
HIA recommendations
Determining if and why
the HIA is necessary
Identifying the health
impacts and scope of
the HIA
Evaluating the health
effects and impacts
Identifying actions and
risk mitigation strategies
to improve health
Monitoring
& Evaluation
Figure 4. Health Impact
Assessment process
*Figure adapted from Mecklenburg County
12 Figure 5. Rapid Health Impact Assessment guiding research questions Vulnerable
populations
Emergency
Department
Access
Regional
economy
How might the proposed closure impact already vulnerable populations such as those who are low-income, people of color, the elderly, the uninsured, UC Berkeley students, and expecting mothers? How might the proposed closure influence access to emergency department care for Bay Area residents, particularly travel times & in the event of a major disaster, such as an earthquake or fire? How might the proposed closure impact local jobs and the regional economy, such as from reduced hospital spending?
Rapid HIA research questions:
Scope of this Rapid HIA
On July 27, 2017, the City of Berkeley, California’s
Community Health Commission voted to
authorize a scope of work for a Health Impact
Assessment analyzing select impacts from the
proposed closing of Alta Bates Campus. After
reviewing this preliminary scope, a revised scope
of work was developed by Professor Jason
Corburn and University of California, Berkeley
(UCB) researchers at the Institute of Urban and
Regional Development (IURD), in consultation
with the Health Commission and other City of
Berkeley stakeholders. A Rapid HIA screening
and scoping document was produced by
UCB in December 2017. City of Berkeley staff
commented on and suggested revisions to the
initial draft scope of work (SOW). A final SOW
was developed by Professor Corburn based on
feedback and a preliminary review of availability
data.
Since a detailed closing plan, including specific
time frames and services, was not provided by
Sutter Health, this RHIA was not able to offer
detailed analyses of potential impacts from the
removal and/or relocation of inpatient services.
The RHIA analyses are based on the best and
most up-to-date information we were able to
obtain from Sutter Health on the closing and
relocation of services from Sutter’s website
and the Sutter Vision for 2030: https://rebuild.
altabatessummit.org.
Key RHIA Focal Areas
Based on consultation with the Alta Bates
Regional Task Force and key stakeholders, we
refined this RHIA to focus on the following areas:
1. Impacts on vulnerable populations, including
but not limited to low-income, under and
uninsured populations, people of color,
elderly, pregnant women, and those with
13 limited transportation options;
2. Impacts on health care and emergency
department services for University of
California, Berkeley students;
3. Impacts on Emergency Department access
and regional ED capacity;
4. Impacts on Emergency Medical Services
(EMS), specifically to paramedic ‘time-on-task;’
5. Impacts on regional hospitals’ disaster
response ED capacity, particularly in the case
of an earthquake and fire, and;
6. Impacts on local employment and the regional
economy.
Hypothesized Impact Pathways
Based on the six agreed upon focal areas
described above and the three key RHIA
research questions (Figure 5), the research team
performed a preliminary review of the scientific
literature on hospital closures, ED closures in
urban areas and previous studies of the impacts
of hospital closures, specifically the report on
the closure of Doctors Medical Center. The
authors of this RHIA hypothesize at least five
potential pathways between the closure of Alta
Bates Campus and population health outcomes,
informed by a preliminary research review.
These hypothetical scenarios are highlighted in
the Figures 6-10 and described below. In each
pathway diagram, a up arrow indicates a likely
increase while a down arrow indicates a likely
decrease. The hypothetical scenarios helped to
further refine our review of the literature and data
analysis. The hypothesized pathways of potential
impacts from the closing of Alta Bates hospital
included:
Scenario A: Birthing center closes (Figure 6)
In this scenario, we hypothesized that the Alta
Bates Campus birthing center & related prenatal
and postpartum care, including the NICU, close
and there is some replication of these exact
services in any one location in the region.
Scenario B: Emergency Department closes
(Figure 7)
In this scenario, the Alta Bates Campus ED closes
and some additional capacity is provided for at
Summit in Oakland.
Scenario C: ED closes & regional ED patients
increase (Figure 8)
In this scenario, we hypothesized the Alta
Bates Campus ED closes & the remaining open
hospitals in the region experience increased ED
patients.
Scenario D: Disaster & ED access (Figure 9)
In this scenario, we hypothesized potential
impacts to ED access during a disaster in the
absence of Alta Bates Campus.
Scenario E: Economic Impacts (Figure 10)
In this scenario, we hypothesized potential
economic impacts to jobs and the local economy
from the closure of Alta Bates Campus.
14 Birthing
Center
Closure
Scenario A:
Multi-service
labor & deliver
unit closes
(approx. 6,000
births/yr.)
Prenatal care and access
within hospital for low
income women of color
NICU capacity and
services (55 beds and approx.
1,000 patients/yr.)
Multi cultural & multi-
lingual labor & delivery care
Crowding at regional
birth centers
High risk C-sections &
episiotomy procedures
High-level expert
birthing care Maternal health
Low birth weight &
preterm babies
VBAC and exclusive
breast feeding before
discharge
Maternal morbidity,
especially for women of
color
Emergency
newborn care
Knowledge
about birth plan &
postpartum options
Access to options
for midwifery & doula
services
Emergency
Department
Closure
Scenario B:
+
Alta Bates ED closes
(Loss of 22 ED
treatment stations
& redistribute
approx. 50,000
patients /yr.
Urgent and non-urgent
care access for people of
color
Urgent and non-urgent
care for uninsured,
elderly, homeless & other
frequent users of ED
Emergency room
screening for mental health &
suicide prevention services
Urgent and non-urgent
care access for UCB students Avoidable
hospitalizations
Delayed treatment
for some infectious &
chronic diseases
Immune function &
other stress-related physical/
mental health outcomes
Severity of illness
due to delayed or lack of
treatment
Infectious disease
contagion
Mental illness &
suicides
Cost of future disease
management & mental
health services
Familiarity with new
urgent care locations
Stress about where
to go & decreased
quality of urgent care
Referrals for mental
health care, esp. for
homeless & students
Figure 6. Hypothesized Impacts from Alta Bates Campus birthing center closing Figure 7. Hypothesized Impacts from Alta Bates Campus Emergency Department (ED) closing 15 Alta Bates
Emergency
Department
closes
Access to urgent &
chronic care for vulnerable
populations across region
Ambulance travel
times
Travel times by private
vehicle & transit to
regional EDs, especially for
Contra Costa County residents
Patient volume at other
EDs
Severity of illness
Ambulance diversions
Cost to local
government to
provide more EMS services
Stress for already
vulnerable
populations regarding
where to get care
Immune function &
other stress-related health
outcomes
Delayed care
Morbidity
Avoidable
hospitalizations
Crowding at all
regional EDs
Wait times for
urgent & non-urgent
care within ED
Need for costly air
ambulance services
EMS time-on-task
Earthquake along
Hayward Fault (i.e.,
HayWired scenario)
Fire at Chevron
Richmond Refinery
Est. 14,000 people
require out-of-home
medical care in
Alameda & Contra
Costa Counties
Estimated 1,460
patients to ED @Kaiser
Richmond from West
Contra Costa County
Est. 3,800 patients to
ED within the first 3
days
Est. 700
patients
would have
used Alta
Bates ED in
first day
Delayed care
Severity of
unattended injuries
Mortality
Avoidable
hospitalizations
Costs of treatment
from delayed care
Est. 1,400
patients
would have
used Alta
Bates ED
Figure 8. Hypothesized Impacts of Alta Bates Campus ED closing on Emergency Medical Services Figure 9. Hypothesized Impacts of a Regional Disaster on ED access without Alta Bates Campus ED Closure:
Regional
Impacts
Scenario C:
+
Disaster
Events
Scenario D:
Overcrowding
& long wait
times at
remaining
regional EDs
Access to EMS
& chronic care
physicians
16 Figure 10. Hypothesized Impacts from Alta Bates Closing on Local & Regional Economy Alta Bates
Campus
closes
Clinical staff
Some Drs. and nurses go
to other hospitals in region
Some Drs. and nurses
leave the region
Layoffs - nurses and low
wage workers
$ to local economy
Spending on food,
flowers, transit, lodging, etc.
Nurses
Low wage service
workers
Local purchases &
spending
Hospital visitors to
local area
Poverty
Economic inequality
Nursing shortage
Low-wage worker
displacement due to
unemployment & reduced
incomes
Physicians
Local tax base
Regional economy
ED Closure:
Regional
Impacts
Scenario E:
$
Local business closures
17 Rapid HIA Methodology
A mixed set of methods were used to complete
this RHIA. As mentioned above, a detailed
review of the scientific literature related to
hospital closing was conduced to develop the
hypothesized pathway diagrams and support data
collection. We analyzed hospital and patient data
using the California Office of Statewide Health
Planning and Development (OSHPD). The RHIA
also includes detailed reviews of reports by local
hospital systems, emergency medical providers,
and county health departments, which helped
us obtain existing utilization information. Key
findings from existing reports and analyses were
summarized and incorporated into our analyses.
Data for multiple years and for multiple hospitals
in the region, including Alta Bates Campus,
were obtained from OSHPD. OSHPD conducts
an annual, standardized survey required of all
hospitals and health services in the state. Each
facility is required to report data on patient
capacity, inpatient utilization, ED utilization, and
expenditures. We generated summary statistics
on hospital and patient utilization for Alta Bates
and Summit Campuses, as well as select hospitals
in the East Bay region. Where possible, we
utilized data from 2017, and otherwise reference
complete OSHPD datasets from 2016. Five year
estimates from the 2016 US Census, American
Community Survey data were gathered to define
ZIP Code populations and other community-scale
demographics in the region.
Previously published health outcome data from
the Alameda and Contra Costa County Health
Departments were summarized by ZIP Code.
In addition, ZIP Code level hospitalization data
(2011) was accessed through the Sutter Health
“Health Needs Maps” website (http://www.
healthneedsmap.com). All these data are publicly
available and as such this assessment was exempt
from review by the human subjects’ protection
office of the University of California, Berkeley.
Meetings with Sutter Health, City of Berkeley and
UC Berkeley’s Tang Health Care providers also
informed the analyses and provided qualitative
data. A list of interviewees & reviewers of a first
draft of this report appears in the appendix.
A summary of the inputs used appear in Figure
11. A full list of references appears at the end of
this document.
Scientific Literature Reports Existing data
• CA Health Inter-
view Survey (CHIS)
• OSHPD
• City of Berkeley &
County EMS
• US Census
• Alta Bates CHNA
• Haywired
• Doctors Medical
Center Closure
• County Health De-
partment Surveil-
lance Reports
Interviews
• Regional stake-
holders
• UC Tang center
providers
• Sutter Health
• UCB students
• PubMed & Google
Scholar
• Ovid, Proquest &
Ebscohost
• Web of Science &
Science Direct
Figure 11. Examples of inputs to Rapid HIA
18 *map is not drawn to scale
OVERVIEW OF ALTA BATES
Map 2. Alta Bates
campus and affected
buildings
Alta Bates Campus is one of the most utilized hospitals and birthing centers in Alameda and Contra Costa Counties, with a total of 66,268 patients in 2016. The hospital service area, in which 75% of patients reside, encompasses 9 cities across the East Bay. The hospital has recently seen a large increase in patients from West Contra Costa County after the closure of Doctor’s Medical Center in 2015.
The Alta Bates campus of Alta Bates Summit
Medical Center is a 347-bed acute care hospital,
located in the city of Berkeley, in North Alameda
County, California. Alta Bates was purchased by
Sutter Health Corporation and integrated with
Summit Medical Center in Oakland and Herrick
Hospital in Berkeley to form Alta Bates Medical
Center in the year 2000. Aside from providing
emergency, acute and specialty care services, Alta
Bates campus is also a major regional birthing
center.
The Alta Bates Campus currently has 5 buildings
that are out of compliance with the Hospital
Seismic Safety Law, and must be retrofitted
by 2030 or stop providing all inpatient and
emergency services.
10 These buildings, depicted
in Map 2 below, include parts of the general
hospital and all of the emergency department.
EMERGENC Y
AL TA BAT ES HOSPIT AL
Source: OSHPD, 2018
19 We detail Sutter’s response to the seismic
upgrade on page 28 below.
Alta Bates Patient Utilization
Alta Bates Campus is one of the most utilized
hospitals in Alameda County, and is the 3rd
largest general acute facility in the region. Of its
347 beds, the facility currently has 146 general
acute beds, 16 in intensive care, 116 perinatal,
55 in intensive newborn nursery, and 14
coronary care beds.
4 In 2016, Alta Bates Campus discharged 66,268
patients, more than any other non-Kaiser
hospital in Alameda County except Highland
Hospital at 81,500. Of the 66,268 patients that
were seen at Alta Bates Berkeley, 19,887 were
hospitalized, including 5,930 patients admitted
from the emergency department. Of the 19,887
hospitalized patients, 30% were admitted for a
birth-related diagnosis and 33% were admitted
with a pregnancy-related diagnosis, for a total
of 63% of all hospitalized patients. In 2016, Alta
Bates Berkeley delivered 5,863 babies, more than
any hospital in Contra Costa County or Alameda
County, making it the region’s largest birthing
center. After birthing and pregnancy patients,
the third highest patient diagnosis was infection-
related, which made up only 6% of hospital
admissions.
8 Alta Bates also operates an ambulatory surgery
center, which conducted 6,975 surgeries and
medical procedures in 2016. The most common
principal diagnoses from the ambulatory surgery
center were: eye disorders (22%), other reasons
347 beds
3rd largest
general acute
care facility in
the region
66,268 patient
discharges, 2nd highest
of non-Kaiser hospitals
in Alameda County
2016
45,900
ER visits
in 2016 - 7%
increase since
2013
61% of ER visits
were Medi-Cal
and Medicare in
2016
7% of ER visits
were uninsured
patients in 2016
5,863 live
births in 2016
- highest in the
region
16,494
discharges from
Contra Costa
County in 2016
- 31% increase
since 2013
EMERGENC Y
AL TA BAT ES HOSPIT AL
Figure 11. AB utilization
overview 2016
Figure 12. Alta Bates Campus ED patient discharges (2016) from cities impacted by the DMC hospital closure
0 3000
6000
9000
12000
15000
Berkeley Albany El Cerrito Richmond San Pablo
City
Patient discharges
Source: OSHPD, 2016
20 (15%), digestive system (14%), cancer (12%),
and genitourinary system (11%). Of the 6,699
surgeries that were performed at the ambulatory
surgery center in 2016, 60% were related to
either eye and ocular surgeries (25%) or digestive
surgeries (35%).
8 Emergency Department
The Alta Bates Campus has one of the largest
emergency department (ED) patient volumes
in the region, operating over capacity by
approximately 6,000 visits per year in 2017. That
year the ED had 22 emergency treatment stations,
down 3 stations from 2016.
3,4
In 2017 Alta Bates Campus documented 50,414
emergency department visits, an additional
4,524 visits than 2016, despite having three
less treatment stations. 63% of emergency
department visits not resulting in admission
were classified as severe, with 27% being life-
threateningly severe and 36% being non-life-
threateningly severe. Of the remaining visits,
27% classified as moderate, 9% were classified as
low/moderate, and 1% were classified as minor.
4 Based on our review of the literature it is unlikely
that the ‘severe’ visits – comprising over 60% of
total visits – could be treated in an urgent care
facility or primary care setting.
Given the high volume of ED patient traffic, Alta
Bates Campus reported 57 hours of ambulance
diversion in 2016, and 13 in 2017.
3,4 During these
hours the hospital closed its ED to incoming
ambulances, resulting in those ambulances being
diverted to other hospitals. High ambulance
diversion rates can be an indicator of ED
overcrowding, and is associated with poorer
health outcomes for patients as well as lost
revenue for hospitals. A more detailed discussion
on ED access and impact of an Alta Bates Campus
closure on the regional emergency medical
services network can be found in the section
below on EMS.
Hospital Service Area
For this RHIA, we calculated the Alta Bates
Campus hospital service area (HSA) using the
latest available OSHPD (2016) patient origin data.
This HSA best reflects the geographic area from
which patients are coming from to receive care
at Alta Bates Campus. As we describe below,
the RHIA defined HSA is slightly larger than the
area Sutter Health defines as the HSA for Alta
Bates Summit Medical Center (which includes
Alta Bates, Summit, and Herrick campuses) in
their 2016 Community Health Needs Assessment
(CHNA) report, since we aimed to capture the
recent increase in patients coming from West
Contra Costa County.
Using all 2016 inpatient and ED origin data,
this RHIA defines the Alta Bates campus HSA to
include the 32 ZIP Codes in the region where
approximately 75% of patients lived. The HSA
spans across 9 cities in Alameda and Contra
Costa Counties: Oakland, Alameda, Emeryville,
Berkeley, Albany, El Cerrito, Richmond, San
Pablo, and El Sobrante (Map 3). While 75% of
patients in 2016 came from these 32 ZIP Codes,
66% of all patients that year came from Alameda
County, and 25% from Contra Costa County, for a
total of 91% of all patients.
6 According to the US Census, the RHIA HSA
includes 839,299 residents, 44% of which are
people of color and 18% of which lived below the
poverty line in 2016 (ACS 2012-2016). Roughly
18% of the population in the service area are
African American and 25% are Hispanic/Latinx.
In the HSA 25% of the population receives
Medicaid coverage and 11% are uninsured.
Since people with Medicaid and the uninsured
may utilize a hospital for primary care more than
those with other health insurance, there are
approximately 301,146 people in the HSA that
21 Source: OSHPD POMS, 2016
ZIP Code Community
94806 San Pablo
94803 El Sobrante
Richmond
94805 East Richmond
94804 South Richmond
94801 Richmond - North, Iron
Triangle, Point Richmond
94530 El Cerrito
94706 Albany
Berkeley
94720 UC Berkeley Campus
94710 West Berkeley / Marina
94709 Northside Berkeley
94708 Tilden/Berkeley Hills
94707 North Berkeley / Kensington
94705 Claremont / Elmwood
94704 Berkeley Downtown / South
of Campus
94703 Northwest Berkeley
94702 Northwest Berkeley
94608 Emeryville
Oakland
94621 East Oakland / Coliseum
94619 Oakland Hills / Laurel
94618 Rockridge
94613 Mills Campus
94612 Downtown Oakland
94611 Piedmont / Oakland Montclair
94610 Oakland Grand Lake /
Lakeshore
94609 Oakland MLK
94607 West Oakland / Jack London
94606 Oakand / Cleveland Heights
94605 Oakand Hills / Eastmont
94603
East Oakland / Brookefield
94602 Oakland / Glenview
94601 East Oakland / Fruitvale
94501 Alameda
Map 3. Rapid Health Impact Assessment
defined Hospital Service Area (HSA)
32 ZIP Codes from which 75% of all Alta
Bates Campus patients came from in 2016
0 1.5 3mi
N
22 may seek non-urgent care at Alta Bates Campus.
Health outcome data also suggests that residents
in the Alta Bates Campus HSA experience health
inequities and disproportionate rates of illness
and injury including asthma, diabetes, assault,
unintentional injury, and substance abuse
compared to the State of California and both
Alameda and Contra Costa Counties (Figure 15)
(Sutter Health, 2013).
According to Sutter Health’s 2016 Community
Health Needs Assessment (CHNA) report, the
HSA defined for all three campuses (Alta Bates,
Herrick, and Summit) included 24 ZIP codes in
Oakland, Berkeley, and Emeryville, what they
call their “core market.” Approximately 20% of
this population lives below the poverty line and
about 59% are People of Color. We highlight the
differences in the Sutter CHNA defined service
area and the RHIA defined service area in Figure
14 and Map 5. Rather than include patients from
all three campuses in the Alta Bates Summit
Medical Center, the RHIA defines the HSA solely
for the Alta Bates Campus, in order to identify
specific needs of the Alta Bates Campus patient
population and evaluate impacts of the proposed
campus closure.
0 10000
20000
Contra Costa County 94530, 94801, 94803,
94804, 94805 and 94806
2016
2013
Figure 13. Increased Alta Bates discharges from
Contra Costa County & regional zip-codes
RHIA defined
service area
CHNA defined
service area
Population 839,299 557,296
Number of Cities 9 3
Number of Zip
Codes 32 24
Figure 14. Alta Bates Hospital Service Areas:
RHIA & CHNA defined
Source: ACS 2012-2016 estimates
32 ZIP codes
RHIA defined
Alta Bates
Campus
hospital
service area
839,299
residents
36% of population
below 200% of the
federal poverty level
18% of population below
100% of the federal poverty level
44% People of Color
Area
Patient discharges
Source: OSHPD, 2013 & 2016
23 Map 4. Large volume
increases in Alta Bates
ED discharges from West
Contra Costa County 2013
- 2016
Alta Bates campus
H
We determined that the larger number of
residents from West Contra Costa County
utilizing Alta Bates Campus in recent years
demanded that we expand the HSA to include
these communities in our analyses (Figure 13).
The increase in patients from West Contra Costa
County can be partly attributed to the closure
of Doctor’s Medical Center (DMC) in the city
of San Pablo, California in 2015. Of the 66,268
patients that visited Alta Bates Campus in 2016,
approximately 18% were from 6 zip codes in
Richmond, San Pablo, El Cerrito, and El Sobrante
(94530, 94801, 94803, 94804, 94805 and 94806)
located in West Contra Costa County (Map
4). From 2013 through 2016, there was a 24%
increase in patients visiting Alta Bates Campus
from Contra Costa County and a 39% increase in
patients visiting Alta Bates Campus from the six
zip codes above.
5,6
Since these communities are in close proximity
to Kaiser Richmond (which has limited ED
capacity and primarily serves Kaiser members)
the closure of Alta Bates Campus is likely to
West Contra Costa
County in the RHIA
defined service area
Additional Cities in
the HSA
Source: OSHPD, 2013 & 2016
24 have a significant adverse impact on access
to ED and hospital care for residents of West
Contra Costa County. These same communities
are also some of the most vulnerable in terms of
having the largest African-American populations,
having preexisting health conditions and being
uninsured.
For example, according to Contra Costa Health
Services 2010 Community Health Indicators
Report:
• African Americans in Contra Costa had a
shorter life expectancy (73 years) than any
other racial/ethnic group in the county.
• African Americans also experienced higher
rates of new cases of colorectal, lung and
prostate cancer, new cases of HIV and AIDS,
hospitalization for non-fatal assault and self-
inflicted injuries, low birth weight infants and
teen births, and a higher percent overweight
and obese fifth-graders.
• The communities of Richmond and San Pablo
had the highest health risks and death rates
(particularly for African American men) from
heart disease, all cancers, diabetes, stroke and
homicides.
• African Americans in Richmond had 254
asthma hospitalizations and ED visits per
10,000 people, compared to 105 for all racial/
ethnic groups.
• The rates of sexually transmitted infections
and people living with HIV/AIDS are
significantly higher in Richmond than in
Contra Costa County.
• A larger percentage of Hispanic students
in Richmond high schools reported
contemplating suicide than other students,
according to the 2011 California Healthy Kids
Survey, Grades 9-11.
The RHIA addresses potential impacts of the
proposed hospital closure on vulnerable
populations served by Alta Bates on page 30 of
this report.
Figure 15. ED Visits by Cause: Comparing the RHIA defined Alta Bates Campus HSA to State and County Rates Asthma Type II Diabetes Assault Unintentional
Injury
Substance
Abuse
0 200
400
600
800
1000
HSA 75%
State of CA
Alameda County
Contra Costa County
Cause for visit
ED visits per 10,000 residents
Source: Sutter Health Needs Maps, 2013
25 Map 5. Comparing RHIA & CHNA defined
Hospital Service Areas
Alta Bates
Campus
2016 CHNA defined Alta
Bates Summit Medical
Center HSA
RHIA defined Alta Bates
Campus HSA
H
Source: OSHPD POMS, 2016 & Alta Bates Summit
Medical Center CHNA, 2016
26 Campus Utilization & Capacity to Absorb Alta Bates Patients The Summit Campus hospital on Hawthorne
Avenue in Oakland includes an emergency
department (ED) and a new patient pavilion
that was renovated in 2014. Despite the recent
renovation and a current emergency department
expansion underway, 9 buildings at the Summit
Campus do not currently meet seismic standards,
and must be retrofitted or stop all inpatient and
ED services by 2030 (Map 6).
10 In 2017, Summit Campus saw a total of 60,038
patients, both hospitalized and from the ED.
47,117 patients were seen in the ED, of which
25% were admitted to the same hospital. In 2017,
Summit had 25 ED treatment stations, down from
32 stations the year prior.
4 Of the approximate 47,000 ED patients in 2017
(including those later admitted to the hospital),
35% were classified as severe and life threatening,
33% were classified as severe but not life
threatening, 25% were moderate, 6% were low/
moderate, and 1% was minor.
4 Since the closure of the Alta Bates Campus
catheterization lab, the Summit campus has
become the central heart attack and ST-
Elevation Myocardial Infarction (STEMI) patient
receiving location. The hospital performed 345
cardiovascular surgery operations in 2016, and
saw 2,531 cardiac catheterization patients (1,106
diagnostic 1,425 therapeutic), which resulted in
3,426 catheterization procedures in total.
8 The Summit Campus includes an emergency room and hospital with 403 licensed beds in 2017. Sutter has indicated that all inpatient and emergency care capacity at Alta Bates Campus will be relocated to the Summit Campus by 2030. However key details about the expansion as well as the capacity for the Summit Campus to absorb an additional 40,000 ED patients remains in question.
SUMMIT CAMPUS IMPACTS
27 *map is not drawn to scale
Total Emergency
Department Patients
47,117 403 147,095 60,038 29 025
Licensed
Beds
Licensed Bed Days
per year
Total patients Diversion
Hours
Summit Campus at a glance in 2017
Total
Live
Births
EMS Treatment
Stations
Map 6. Summit Campus
and affected buildings
Source: OSHPD, 2018
The Summit Campus does not currently have the
capacity to serve the volume of patients seen at
the Alta Bates Campus, particularly for birthing
and emergency care.
Summit currently does not operate a birthing
center, and relocating services to Summit would
require that a new birthing facility be built at the
Oakland campus, with the capacity to deliver
nearly 6,000 babies per year.
To replace Alta Bates Campus emergency
department, Summit
Campus would need
to expand its capacity
by an additional
50,000 emergency
department visits per
year (the number of
ED patients seen at
Alta Bates campus
in 2017), for an
approximate total
of 100,000 visits
annually.
In the case of a relocation of all ED services from
Alta Bates Campus to Summit, the total patient
volume at Summit Campus would exceed any
Emergency Department in the East Bay or San
Francisco, including SF General, the highest traffic
ED in the broader region which had 72,716 ED
encounters in 2016.
8 28
Sutter Health Plans for Summit Campus Expansion
Sutter Health is proposing to relocate all East
Bay inpatient and emergency services to its
Summit Campus in Oakland. The Sutter website
dedicated to the proposed closure of Alta
Bates Campus (https://rebuild.altabatessummit.
org), indicates that Sutter plans to build a new
acute care medical center and ED at the Summit
location by the year 2030.
The following section outlines select Frequently
Asked Questions (FAQs) and responses from
Sutter regarding the hospital closure, along with
the RHIA’s relevant key findings.
What services will Sutter Health continue to
provide in Berkeley?
Sutter response:
We are committed to making future investments
in Berkeley and see it as a primary location to
provide outpatient care. Our Herrick Campus on
Dwight Way has been identified by the city as a
prime location to deliver medical services. We
plan to expand Herrick’s services, which include
our Comprehensive Cancer Center and Behavioral
Health program. In addition, we currently have
three large care centers, including our newest one
near the Herrick Campus on Milvia Street, where
people can also visit our urgent care center.
RHIA analysis:
Since we did not have details from Sutter on what
services will remain at Alta Bates Campus, we
focused on impacts to the birthing center and ED.
Will the new facility in Oakland be able to
provide enough emergency care?
Sutter response:
We plan to enlarge, upgrade and strengthen the
current Summit Emergency Room so that we have
the capacity to handle more than 90,000 ER visits
a year. By the year 2030, we plan to completely
rebuild our ER within a second critical care tower
to be constructed at the Summit Campus.
RHIA analysis:
We detail the ED impacts throughout this report.
A key finding is that the new Summit Campus ED
will need a capacity of approximately 100,000
visits per year, but plans to serve 90,000.
4 This
exceeds the number of visits seen by any ED in
the East Bay or San Francisco.
Oakland is farther away than Berkeley from
where I live. What if I’m having a heart attack or a
stroke and need to call 9-1-1?
Sutter response:
Any non-Kaiser patient in the Alta Bates Summit
service area calling 9-1-1 today for a heart attack
or stroke is already transported to our Oakland
campus, where we have one of the most advanced
heart centers in California. Additionally, the
Summit Campus ER is located next to two major
freeways (I-580 and I-980) in Oakland. It’s actually
faster for most patients in the East Bay – including
those from West Contra Costa County – to get
to our Oakland campus than it is for them to get
to our Berkeley campus, especially during an
emergency.
29 RHIA analysis:
We offer a detailed travel time analyses in the
Emergency Services section, on page 43. We
found that private vehicle and transit travel times
will increase for some communities. Where travel
time increases exceed 30 minutes, the literature
suggest patients will experience adverse health
outcomes.
What will happen to the Summit Campus?
Sutter response:
In August 2014, the new 238-bed patient care
tower opened at the Summit Campus in Oakland.
This new tower meets the state’s 2030 seismic
regulations and is equipped with the latest
technology, ensuring the highest level of medical
care and patient safety. We plan to create a
modern footprint at this campus that will allow us
to build another building – a second pavilion – that
will include new operating rooms, intensive care
units, a modern, expanded Emergency Room and
space for our Women and Infants Birthing Center
and Newborn Intensive Care Unit. It is our plan
to relocate inpatient and emergency hospital
services, including all staff and doctors, from
Berkeley to Oakland by 2030.
RHIA analysis:
As noted above, needs at an expanded Summit
Campus would include a comprehensive birthing
center and significantly increased capacity in
the ED. The Summit Campus is located less than
3 blocks away from the Kaiser Oakland ED.
Although Kaiser Oakland is not accessible to all
patients, its ED has the capacity to see 96,000
visits per year, and was operating 32,313 visits
below capacity in 2017.
Summit currently has the
capacity to see 50,000 ED visits per year, but was
operating under capacity by 2,883 visits in 2017.4
This suggests that while patients currently have
the option to utilize Summit Campus or other EDs
with more capacity, many are choosing to utilize
the Alta Bates Campus ED which was operating
above capacity by over 6,000 visits in 2017.
What happens next?
Sutter response:
Planning a project of this scale takes years and
must be thoroughly vetted and collaboratively
developed. We will keep our community
informed with accurate and timely information.
This transition must be planned far in advance to
ensure the community’s ongoing health needs are
met without interruption. Please visit this site for
updates or use the information on the Contact Us
page to reach out to us.
RHIA analysis:
Our review of the literature suggests that the
timing of events is crucial to prevent adverse
impacts to those seeking both chronic and urgent
care. A more detailed plan would be necessary,
including public awareness and engagement,
to ensure treatment options are clearly
communicated to current Alta Bates patients and
those seeking urgent care in the region.
*All Sutter Health website text referenced reflects updates as of June 7th 2018
EMERGENC Y
AL TA BAT ES HOSPIT AL
30 IMPACT ON VULNERABLE
POPULATIONS
Vulnerable populations are more likely to be impacted by the proposed closure of Alta Bates Campus, this includes low-income and people of color, Medi-Cal and Medicare patients, pregnant women, and the homeless.
The Alta Bates Campus and ED provide key
medical services to a high volume of patients from
vulnerable populations in the Bay Area region which
include but are not limited to: pregnant women,
People of Color, low-income, uninsured and Medi-
Cal patients, the elderly, and people living with
disabilities. While people of color make up 44% of
the Alta Bates campus Hospital Service Area (HSA),
they represented 63% of hospitalized patients and
56% of ED patients in 2016. An additional 41% of
patients in 2016 were Medi-Cal recipients or self
pay/uninsured, and 23% of hospitalized patients
were over 60.
8 A wealth of evidence suggests that vulnerable
populations may be more severely impacted
by hospital closures, and should be taken into
special consideration in the context of Alta
Bates and the capacity of the East Bay regional
healthcare network. Chen et al (2015) found
that vulnerable populations, particularly African
American and Medicaid patients, have higher
measures of non-urgent ED scores, and are more
Excess burden on already vulnerable people
Increased health inequities
Increased morbidity
Increased mortality
Vulnerable
populations
Uninsured
People of color
Elderly
Pregnant women
Homeless
Delayed critical care
56% of ED patients and 63% of
hospitalized patients were people of color
ALTA BATES PATIENT
DEMOGRAPHICS 2016
41% of patients are uninsured/self
pay or are Medi-Cal recipients
68% of inpatient discharges were
women
23% of hospitalized patients are elderly
31 frequent users of the ED for both non-urgent
and urgent reasons. A 2011 study looking at
major medical services such as outpatient care,
specialty care, marker conditions, births, and
mental health and substance abuse services
found that urban hospital closures led to
disproportionate disruptions in accessing care,
especially for uninsured African-Americans and
Latinx populations, and all women on Medicaid
hospitalized for births (Hsia & Shen, 2011).
The ED visit rate to Alta Bates Campus for
patients living in low-income ZIP Codes (i.e.,
the lowest quartile), increased 23% from 2006
to 2014. There was no change in ED visits for
patients living in higher-median-income ZIP
Codes over this same period. This is not a surprise
finding, but it does suggest that the Alta Bates
Campus ED currently serves an increasingly
number of low-income residents in the Bay Area.
Pregnant Women & Newborn Babies
As noted above, Alta Bates Campus is one of the
region’s premier birthing centers. The age and
gender distribution of hospitalized Alta Bates
Campus patients reflects the high utilization of
its birthing and pregnancy-related services: in
2016, 68% (13,564) of inpatient discharges were
female, and 32% (6,322) of inpatient discharges
were male. 30% (6,018) of inpatient discharges
were for patients under 1 year old, reflecting high
utilization of birthing and the NICU.
8 In 2016, Alta
Bates Campus had 2,145 more births than Kaiser
San Leandro, the second largest birthing center in
the region that year (Figure 17).
3 While being one of the most highly utilized
birthing centers in the region, Alta Bates Campus
has some of the best health outcomes for birthing
services when compared to other regional
birthing centers and CA state averages (Cal
Hospital Compare, 2018). As depicted in Figure
% C-Section in Low-risk
pregnancies % Episiotomy Exclusive breastfeeding
before discharge %
% Vaginal birth after
C-Section (VBAC)
Alta Bates Campus 19.4 2.8 86.5 33.2
John Muir - Walnut
Creek 23 7.2 73.7 20.8
Kaiser - San
Leandro 20.2 6.9 80.7 21.8
State of CA Average 25 9.1 68.5 12.3
Figure 16. Outcomes for Largest birthing centers in Alameda & Contra Costa Counties, 2016 *numbers are reported as percentages (Adapted from CA Health Care Foundation & CHART 2014) Lower is better Higher is better
32 16, Alta Bates Campus reports the
lowest regional rates for C-Section
in low-risk pregnancies and
episiotomy procedures, which
can put mothers at risk for post
surgical complications. Alta Bates
Campus also has the highest rates
for exclusive breastfeeding before
discharge and vaginal birth after
C-section (VBAC) which are both
positive birth indicators for mothers
and newborns.
Alta Bates Campus also has an
active 55-bed, level III newborn
intensive care unit, operated by a
200-person healthcare team (Sutter
Health, 2018). Compared to other
birthing centers in the region, the
Alta Bates Campus NICU has experienced a
consistently high occupancy rate and discharged
a high volume of newborns. In 2016, the NICU
was at nearly 60% occupancy and discharged 964
patients, 350 more than John Muir Walnut Creek,
which had the second highest number of live
births for a non-Kaiser hospital. That year, John
Muir Walnut Creek had a NICU occupancy rate of
27% with 614 patient discharges.
3 Lorch et al (2013) found that when hospital
obstetric units in Philadelphia closed, neonatal
and fetal mortality increased almost 50% in the
first three years after the closure compare to
surrounding counties where hospitals did not
close. This study also found that low income
women tended to receive their prenatal care at
the hospital, not a doctor’s office, and this may
have also had an impact on birth outcomes.
Given the comprehensive prenatal, labor and
delivery, postpartum and specialty newborn care
provided at the Alta Bates Campus as well as
the high volume of births, we determined that
the hospital closure will likely have an adverse
impact on maternal and newborn health in the
region, particularly in the short term. While Sutter
plans to open a new regional birthing center at
the Summit campus in Oakland, the timing and
specific services that will be offered have not been
disclosed.
People of Color
Alta Bates Campus serves diverse communities in
terms of race, ethnicity, and socioeconomic status,
and hospital and emergency department patients
have consistently included a high proportion of
low-income and people of color.
In 2016, 63% of inpatient discharges and 56%
of emergency department discharges were for
people of color (African American, Hispanic/
Latino, Asian/Pacific Islander or Native American).
Of the 63% of inpatient discharges for people
of color, 22% were African American, 25%
were Hispanic/Latino, 16% were Asian/Pacific
Islander. White patients made up 32% of all 2016
discharges. For the ED, 56% of discharges were
people of color, including 38% African American,
14% Hispanic/Latino, and 10% Asian/Pacific
Islander. White patients made up 38% of 2016 ED
Figure 17. Number of live births across regional birthing centers 2016 0 1000
2000
3000
4000
5000
6000
Alta Bates
Berkeley
Kaiser San
Leandro
(not open in
2013)
Kaiser
Walnut Creek
Kaiser
Oakland
John Muir
Walnut
Creek
Contra Costa
Regional
Medical Center
Hospital/Birthing Center
Live Births
Source: OSHPD, 2016
33 discharges.8 African American people in particular
were overrepresented in both inpatient and ED
discharges from Alta Bates in 2016, making up
only 18% of the population in the RHIA defined
Alta Bates Hospital Service Area (HSA).
Within the Alta Bates HSA, an estimated 20% of
the population has limited English proficiency;
this figure is higher than both Alameda (18%) and
Contra Costa Counties (14%) (ACS 2012-2016).
Limited English proficiency can create language
barriers between patients and providers, but
can also contribute to decreased healthcare
utilization particularly when a patient must access
a relocated or unfamiliar facility.
Fishman et al (2018) studied ED and clinic usage
in Chicago and found that patients living in
medically under-served areas (MUAs) and areas
with lower spatial access to primary care clinics
had higher odds of preventable ED use. Analyzing
data from the National Hospital Ambulatory
Care Survey, Johnson et al. (2012) observed
higher preventable ED use among those who
were female, non-Hispanic black or Hispanic,
older, or publicly insured, and that areas with
large concentrations of ethnic and racial minority
populations have been shown to have high rates
of preventable use of EDs. While a significant
portion of preventable ED use can be addressed
by improved access to primary care, EDs still serve
as an essential care provider for those unable to
access care by other means. Chen et al. (2015)
found that lower-income vulnerable populations,
particularly African Americans and Medicaid
patients, more frequently utilized the ED for both
non-urgent and urgent reasons, and these same
populations tended to utilize the hospital ED for
medical conditions that could be addressed in a
primary care setting.
With high rates of ED and hospital service
utilization, and representing large percentage
of the population in the HSA, people of color
will be disproportionately burdened by the
closure of Alta Bates Campus. We are especially
concerned with access for both urgent and non-
urgent conditions, and the continuity of care
for people of color that are already relying on
Alta Bates’ ED for regular care. Related to the
closure of Alta Bates Campus, we would expect
short term (first 1-3 years) delays in seeking
treatment, increased severity of some diseases,
increased hospitalizations due to delays in
seeking care, increased costs of treatment (i.e.,
medications, doctor visits, etc.) and potentially
increased morbidity and mortality (especially from
conditions already disproportionately burdening
Figure 18. Percent race/
ethnicity in the HSA
compared to county and
state rates
0 10
20 30
40 50
60 HSA 75%
Alameda County
Contra Costa County
African American Hispanic/Latinx Asian White
Race/Ethnicity
Percent
Source: ACS 2012-2016
34 people of color such as diabetes, heart disease
and asthma) for people of color in the region.
The high utilization of the ED for both urgent
and non-urgent conditions raises an opportunity
in the Bay Area for increased coordination and
communication between primary, urgent, and
emergency care providers. While the region
has a network of urgent care facilities that may
be able to absorb some of the preventable ED
patient traffic, urgent care hours of operation and
insurance plans accepted may still pose barriers
to low-income and people of color.
People with Disabilities
According to the US Census, 95,840 people or
11% of the population in the HSA are living with
a disability, of which at least 61% are racial/
ethnic minorities. White people represent 44%
of the population in the HSA, however they make
up only 9% of people living with disabilities.
Conversely, the Native American and Pacific
Islander populations, which combined constitute
less than 2% of the total HSA population,
represent 31% of people living with disabilities in
the area.
While this RHIA does not frame disability as a
medical condition, we recognize that people
living with disabilities may be adversely impacted
by the closure of Alta Bates Campus due to
transportation barriers and increased distance,
unfamiliarity with relocated services, and other
accessibility challenges.
Uninsured & Publicly Insured Patients
As discussed above, Alta Bates Campus serves
a large number of low-income patients. In the
HSA, over 18% of the population lives below the
federal poverty level, and 36% of the population
live below 200% of the federal poverty level. This
has a large impact on children and young people,
as 61% of public school students are eligible for
free/reduced price lunch, compared to 44% in
Alameda County and 40% in Contra Costa County.
This is consistent with the high rate of Medi-Cal
covered patients (25%) and uninsured patients
(11%) in the hospital service area (ACS 2012-
2016).
Alta Bates Campus’ 2016 expected payer sources
(Figure 19) for emergency department patients
highlights that a large percentage of Alta Bates
patients are from vulnerable populations, as
68% of Alta Bates ED patients were expected to
pay via either Medicare, Medi-Cal or were self-
pay/uninsured.
8 Medicare serves populations
over 65 and also serves people with disabilities.
People utilizing Medicare represent vulnerable
populations, such as the aging/elderly,
socioeconomically vulnerable and people with
disabilities. Medi-Cal serves socioeconomically
vulnerable populations, by qualifying people/
families that are at 138% of the federal poverty
level or below (i.e. $28,677 annually for a family
of 3), which is very low-income for California and
especially the Bay Area (DHCS, 2018).
Uninsured patients are also extremely vulnerable,
as uninsured patients can include patients that
are low-income, homeless and/or undocumented
immigrants. Hsia et al (2013), found that between
2005-2010 in California, ED visits by Medicaid
beneficiaries increased by 14%, significantly
higher than privately insured patients. According
to the 2006 California Health Care Foundation
34% 26%
7%2%
31%
Medicare
Medi-cal
Private insurance
Self-pay/uninsured
Unknown
Figure 19. Alta Bates
Campus expected payer
source 2016
Source: OSHPD, 2016
35 report, Overuse of
Emergency Departments
Among Insured
Californians, even insured
patients can be more
frequent ED users than
uninsured patients,
particularly those with
Medicaid coverage,
which still leaves them
with difficulties in
accessing primary care.
The Aging & Elderly
Aging people and the elderly (60+ years old)
account for a disproportionately high percentage
of inpatient discharges and emergency
department visits at both Alta Bates and Summit
Campuses. Despite representing only 18% of
the population in the RHIA defined HSA In 2016,
the 60+ year old population accounted for
approximately 23% of inpatient discharges and
over 30% of emergency department visits at the
Alta Bates Campus. That same year, the 60+ year
old population accounted for approximately
65% of inpatient visits and 39% of emergency
department visits at the Summit Campus.
8 The aging and elderly population is expected to
increase in the coming decades. According to
the Public Policy Institute of California, the 65+
year old population is expected to grow 87%
from 2012 to 2030, and the California Health
Care Foundation has similar findings, noting that
California’s 65+ year old population is projected
to more than double from 2000 to 2030, growing
to 8.8 million.
In 2012, the RHIA defined HSA had a 65+ year
old population of 93,537, and with an 87%
growth projection, will reach 174,914 in 2030
(ACS 2008 - 2012). This growing population is
critical to consider because this age group is
among the highest users of both emergency
and inpatient care. The California Health Care
Foundation noted that due to seniors’ high rate
of hospitalizations, acute care hospital days are
projected to increase by 76% from 2000-2030,
and by 2030, the 65+ group is projected to use
over half of the state’s acute care days, despite
representing only 18% of the population.
The CA Health Care Foundation suggests that
by 2030 there will be an insufficient number of
acute care beds in the SF Bay Area due to the
increasing numbers of hospitalized elderly. And,
considering the high utilization of the emergency
department by the 60+ year old population and
the quick growth rate of that demographic, it is
unlikely that a new emergency facility designed
to meet current capacity would be able to
accommodate the combined growth of the elderly
and regional population, which could impact
timely care for all patients needing to access
emergency treatment.
A study that included focus groups with seniors
two years after the closing of a Pittsburgh hospital
(Countouris et al 2014) found that seniors’ health
was adversely impacted from a combination of
feelings of sadness and loss, fear of finding a new,
unfamiliar facility, and powerlessness. Elderly in
this study also expressed concerns about having
to navigate a new facility/location, uncertainty
about transportation that resulted in canceled
doctor’s appointments, and higher parking
costs at the new facility. Bindman et al (1990)
found that hospital closures resulted in delayed
treatment for the uninsured and elderly because
“I know seniors that don’t drive and used to regularly use DMC (Doctor’s Medical Center, San Pablo) for speciality and emergency situations. Now that DMC is closed, some have to travel 2 hours by public transportation to see speciality doctors.
That has a huge impact on whether or not they receive care.”
- Local government official, Bay Area
36 of inconveniences and difficulties in finding new
providers.
Buchmueller et al (2006) revealed that hospital
closures in the Los Angeles area increased travel
distances to ED and ancillary care and contributed
to an increase in heart attack deaths, most notably
for the region’s elderly population.
This RHIA suggests that the elderly and uninsured
will be adversely impacted from the closure of
Alta Bates Campus, both due to ED and chronic
care needs. The elderly living in the HSA may be
most adversely impacted if an adequate number
of beds are not provided (such as at the Summit
campus), due to their increasing numbers and
inpatient needs. The uninsured and publicly
insured will be adversely impacted from the lack
of access to a familiar ED for both chronic and
urgent medical needs. We expect, especially
in the short term, interruptions and delays in
seeking care, increased severity of disease,
potential greater spread of infections, increased
need for costly future care and potentially
increased hospitalizations. We are less confident
in the possibility of increased mortality, but this is
a possibility especially for the elderly.
Mental health & Suicide Prevention
While the Sutter Herrick Campus in Berkeley
is a designated site for mental health care, the
Alta Bates Campus ED plays a significant role in
treating and identifying mental health patients
that may first be seen through emergency care. In
2018, the Lancet Public Health journal published,
“Suicide in the USA: A Public Health Emergency”
noting that the rate of mental health/ substance
abuse-related ED visits increased 44% from 2006
to 2014, with suicidal ideation growing 415% over
this period.
The Alta Bates Campus ED acts as a first-
responder to screen for, intervene and refer for
mental health care and suicide prevention. In
2016, almost 4% of ED patients were transferred
to psychiatric care.
8 Since the hospital ED is often
associated with traumatic events, it is the ideal
environment to perform suicide risk assessments.
Individuals in a suicidal crisis often seek help at
a hospital ED. EDs also frequently provide care
for people with other risk factors for suicide,
such as serious mental illness, substance use
disorders and chronic pain. The ED visit is an
important window of opportunity, however brief,
to intervene and save lives (Ahmedani et al 2014).
EDs can reduce suicide attempts among high-
risk patients by delivering a combination of
interventions that includes suicide risk screening,
discharge resources, and other interventions (Betz
et al 2016; Larkin & Beautrais, 2010). A multi-site
study found that when compared to treatment as
usual, a combined set of interventions starting in
the ED resulted in a 5% decrease in the proportion
of patients who attempted suicide in the 52 weeks
after their initial ED visit and an overall 30% drop
in the total suicide attempts (Miller et al 2017).
The presence of the Herrick Campus, with its
comprehensive mental health services, may be
able to accommodate any potential delays in care
for those currently utilizing Alta Bates Campus.
Significant impacts on mental health for the
population in the HSA from the closing of Alta
Bates Campus may be difficult to quantify.
Homeless People
Homeless people and families, some with mental
health care needs, tend to rely on the ED for
care (Karaca et al 2013). Nearly three out of four
inpatient stays by homeless individuals began
in the ED, compared with half of stays for non-
homeless patients. Due to multiple barriers in
accessing care, including lack of insurance and
transportation as well as poor continuity of care,
homeless people frequently use EDs as their
primary or only source of health care.
37 A 2002 study by Kushel et al. examined the
factors associated with emergency room visits
among 2,578 homeless and marginally housed
persons. They found that 40.4% of the 2,578
visited an emergency room one time or more
during the previous year, and that less-stable
housing, chronic illness and victimization were
associated with emergency department use
among homeless and marginally housed persons.
The study also suggests that emergency care is
a primary option for homeless and marginally
housed persons due to convenience and 24-hour
operation, and because they face challenges
in addressing medical needs outside of an
emergency setting.
In 2017, many Bay Area hospitals reported
increases in homeless patients from the prior year.
Figure 20 shows the total number of homeless
patients that visited the Alta Bates Campus and
5 other major East Bay regional hospitals in
2017, and the volume increase in patients
from 2016. Kaiser Richmond and Kaiser
Oakland combine hospital data, and are
represented as one site in the analysis.
The figure highlights that all six hospitals
saw a significant increase in the number
of patients from 2016 to 2017, with
the Alta Bates Campus seeing nearly
a 600% increase in homeless patients,
rising from 60 to 409. Highland Hospital
had the smallest percentage increase
in homeless patients but served 1,118
homeless patients in 2017. Importantly,
aside from Highland and the Herrick
Campus, at least 89% of homeless
patients seen were either emergency
department patients or inpatient from the
emergency department, underscoring
how essential emergency room care is for
the homeless and marginally housed.
6 While the cause behind the increases
in annual reported homeless patients
across Bay Area hospitals is unclear, a
recent quicknotes memo published by OSHPD
suggests that the number of homeless patients
has been historically underreported (OSHPD,
2018).
We find that the loss of Alta Bates Campus and
its critical emergency and mental health care
services may have an impact on the surrounding
area’s homeless population, particularly if the
increasing trends in homeless patients seeking
emergency care continue.
Adverse Impacts on Vulnerable Communities in
the Alta Bates Hospital Service Area
Alta Bates Campus currently serves some of the
most vulnerable communities in the Bay Area,
such as those mentioned above in West Contra
Costa County as well as many communities in
Alta Bates
Campus
Kaiser
Oakland/
Richmond
Herrick
Campus
Summit
Campus
HighlandContra Costa
Regional
Medical Center
Figure 20. Total Homeless patients at select East Bay hospitals 2016 - 20176
38 Oakland and other parts of Alameda County.
Community vulnerability includes not just current-
day utilization of hospital care, but the likelihood
of future needs based on health-influencing
risks, such as poverty, low education, housing
displacement, exposure to pollution and violence.
These same communities are also vulnerable
since a large percentage of the populations living
there have preexisting health conditions that
require chronic care.
The 2016 Alta Bates Summit Medical Center
Community Health Needs Assessment (CHNA)
recognized these vulnerable communities as
the medical center’s “communities of concern.”
The 2016 CHNA identified 13 ‘vulnerable
community’ ZIP Codes that represented 65% of
the population served by all three campuses in
the Alta Bates Summit Medical Center.
Figure 21. Alta Bates Summit Medical Center CHNA
Communities of Concern
Source: Alta Bates Summit Medical Center CHNA, 2016
ZIP Code Community
94601 East Oakland/Fruitvale
94602 Oakland/Glenview
94603 East Oakland/Brookefield
94605 East Hills/Oakland Zoo
94606 Oakland/Cleveland Heights
94607 West Oakland/Jack London
94608 Emeryville
94609 Oakland/MLK
94612 Downtown Oakland
94621 East Oakland
94702 Northwest Berkeley
94703 Northwest Berkeley
94710 West Berkeley/Marina
To identify communities of concern in the 2016
CHNA defined hospital service area, the CHNA
authors identified significant health needs and
developed what the report calls the ‘Community
Health Vulnerability Index’ (CHVI), which
combines the following indicators of community
vulnerability into one CHVI index value (Map 7):
• Percent Minority
• Population 5 Years or Older Who Speak
Limited English
• Percent 25 or Older Without a High School
Diploma
• Percent Unemployed
• Percent Families with Children in Poverty
• Percent Households 65 years or Older in
Poverty
• Percent Single Female-Headed Households in
Poverty
• Percent Renter-Occupied Households
• Percent Uninsured
For this report we were not able to calculate CHVI
scores for the additional ZIP Codes included in
the RHIA defined HSA using the 2016 CHNA
Map 7: 2016 CHNA defined service area CHVI scores
Oakland
Berkeley
Emeryville
Source: Alta Bates Summit Medical
Center CHNA, 2016
39 Map 9: Percent of Families (with Children) in Poverty across Census Tracts in the RHIA defined Service Area
Source: Community Commons, 2018
Map 8: Percent Uninsured across Census Tracts in the RHIA defined Service Area
Source: Community Commons, 2018
methodology. However, we reviewed each of
the CHVI indicators to assess the vulnerability of
the additional ZIP Codes (primarily communities
in West Contra Costa County) using ACS 2012-
2016 estimates. This review indicated that many
communities in West Contra County likely meet
the same standard of vulnerability as the 13
communities of concern in the 2016 CHNA, which
did not include any ZIP Codes outside of Alameda
County. The vulnerable communities from West
Contra Costa County include ZIP Codes within
Richmond, San Pablo, El Cerrito, and El Sobrante;
cities for which Alta Bates Campus saw a 39%
increase in discharges between 2014-2016.
Maps 8 & 9 highlight select CHVI indicators for
communities in the RHIA defined HSA. As both
maps indicate, communities in West Contra Costa
show high levels of vulnerability at comparable
rates to those in Oakland, Emeryville, and parts
of Berkeley, in Alameda County. In addition to
the review of CHVI indicators, we reviewed data
compiled by Sutter Health on their interactive
Health Needs Maps website. The website
provides 2011 data on hospitalization and ED visit
rates by condition, reported per 10,000 residents
and aggregated by ZIP Code. We compared
the following 11 available reported causes
(conditions) for ED visits and hospitalizations
across all ZIP Codes in the RHIA defined hospital
service area (HSA):
1. Asthma
2. COPD
3. Diabetes
4. Heart disease
5. Hypertension
6. Mental health
0 1.5mi 0 1.5mi
40 7. Assault
8. Self-inflicted injury
9. Unintentional injury
10. Stroke
11. Substance abuse
From this data, we identified high need ZIP Codes
that fell within the top quartile relative to all zip
codes in the HSA for each condition. We then
ranked the top10 ZIP Codes in order of highest
need (those that fell within the top quartile most
often for the 11 conditions).
Figure 22. High Health Care Need Communities in the RHIA defined HSA
ZIP Code Community
94801 Richmond/Iron Triangle
94804 South Richmond
94806 San Pablo
94621 East Oakland
94612 Downtown Oakland
94609 Oakland/MLK
94608 Emeryville
94607 West Oakland/Jack London
94605 East Hills/Oakland Zoo
94603 East Oakland/Brookefield
Figure 22 lists the top 10 high health care need
ZIP Codes in the RHIA defined HSA from highest
to lowest need. ZIP Codes that overlap with the
2016 CHNA communities of concern (listed in
Figure 20) are highlighted in yellow.
Consistent with our review of CHVI indicators
in the RHIA defined HSA, we found that West
Contra Costa County ZIP Codes are particularly
vulnerable. Zip Code 94801 in Richmond,
which includes unincorporated North Richmond,
the Iron Triangle neighborhood, and relatively
wealthy Point Richmond, ranks first out of all zip
codes in the HSA for ED visits for all 11 conditions,
and is 1st for stroke, 2nd for diabetes and heart
disease, 3rd for asthma and 4th for injury-assault.
The 94804 South Richmond ZIP Code ranked
1st in heart disease-related ED visits, and the
94806 San Pablo and 94804 Richmond Iron
Triangle ZIP Codes were ranked 3rd and 4th for
highest incidence of diabetes-related inpatient
hospitalization. As highlighted in Figures 23 and
24, many of the high health care need ZIP Codes
experienced ED visit rates greatly exceeding
those of both Alameda and Contra Costa
Counties as well as the state of California in 2011.
While there are many vulnerable communities in
the RHIA defined HSA that fall outside of West
Contra Costa County (primarily in Oakland and
Emeryville), these communities are currently
served by existing services at the Summit
Campus, as well as Highland Hospital and Kaiser
Oakland, and are likely to be less adversely
impacted by a closure of Alta Bates Campus.
As noted above, we predict a disproportionate
adverse impact on access to chronic and urgent
care for the communities of West Contra Costa
County, particularly Central and North Richmond,
from a closure of Alta Bates Campus. Access
to care in these communities has already been
adversely impacted by the closure of Doctors
Medical Center and the limited capacity of Kaiser
Richmond.
41 Figure 24. Select ZIP Codes - Asthma and Diabetes ED visits per 10,000 residents Asthma Diabetes
Richmond & Iron Triangle
Emeryville
San Pablo
Alameda County
Contra Costa County
0 100
200
300
400
500
600
Visits per 10,000 residents
Source: Sutter Health, Health Needs Maps, 2011
Tilden/Berkeley Hills - 94708
Northside Berkeley - 94709
Berkeley Hills / Kensington - 94707
Berkeley Claremont / Elmwood - 94705
Albany - 94706
Oakland Rockridge - 94618
El Cerrito - 94530
Piedmont / Oakland Montclair - 94611
Berkeley Downtown / South of Campus - 94704
Oakland Grand Lake / Lakeshore - 94610
Alameda - 94501
Central Oakland - 94606
Oakland Dimond - 94602
El Sobrante - 94803
Oakland Hills / Laurel - 94619
Berkeley Sacramento Cooridor - 94703
West Berkeley - 94710
Berkeley San Pablo Cooridor - 94702
East Richmond - 94805
Oakland Fruitvale - 94601
Oakland Temesal / Bushrod / Pill Hill - 94609
West Oakland - 94607
Oakland Uptown - 94612
East Oakland / Coliseum - 94621
Oakand Hills / Eastmont - 94605
San Pablo - 94806
Emeryville - 94608
East Oakland / Elmhurst - 94603
North Richmond, Iron Triangle, Point Richmond - 94801
South Richmond - 94804
0 50 100 150 200 250 300
California
Alameda County
Contra Costa County
Figure 23. Heart Disease ED visits per 10,000 residents for all ZIP Codes in the RHIA defined Alta Bates HSA Visits per 10,000 residents
42 In the 2017-18 academic year, the University of
California Berkeley had 30,574 undergraduate
students, 11,336 graduate students, and
approximately 12,000 staff (UC Berkeley Office
of the Vice Chancellor of Finance, 2017). Since
we did not have complete information on
staff health insurance, this RHIA focuses on
the potential impacts of the closing of Alta
Bates Campus on student health care access.
Roughly half of UCB students are enrolled in
the Student Health Insurance Plan (SHIP), with
the remainder enrolled either in alternative
private insurance plans or through Medi-Cal.
SHIP covers medical, counseling, prescription,
vision and dental services. In interviews with
Tang Center staff including Executive Director
of University Health Services, Claudia Covello,
and Medical Director Dr. Anna Harte, we learned
that a larger proportion of graduate students
are likely enrolled in SHIP . This is due in part to
undergraduates being able to remain on their
parents’ insurance plans until
age 26. Regardless of insurance
enrollment, all students have
access to the on-campus Tang
Health Care Center.
The University Health Service
Tang Center is a fully-accredited
outpatient center designed
to address most medical, mental health and
health education issues. The Tang Center
employs about 300 physicians, registered
nurses, nurse practitioners, medical assistants,
physical therapists, pharmacists, nutritionists, lab/
radiology/pharmacy technicians, social workers,
licensed psychologists and psychiatrists, and
health educators. An urgent care facility is open
seven days a week but limited to working hours,
with reduced hours on weekends.
While the Tang Center is a student health asset,
it is not a licensed hospital and therefore relies
heavily on Alta Bates Campus for timely referrals
of acutely ill patients for conditions including
appendicitis, ectopic pregnancies, blood clots,
and head injuries requiring scans. According
to the Tang Center, they refer approximately
2,500-3,000 students per year to the ED, 21% for
surgery and 41% for emergency care alone (not
all, but most, go to ABMC). Approximately 1-2
students per day require ambulance transport to
the hospital. An additional 2 students per week
may require hospitalization for psychiatric care
from Tang.
There can be daily communication between
Tang practitioners and Alta Bates and this close
relationship enables students to receive referrals
for potentially serious illnesses. In addition
IMPACTS ON UC BERKELEY
STUDENT HEALTH CARE
Cal
The UC Berkeley student population may be adversely impacted by increased travel times to the Summit campus. The campus can generate about 4,000 student ED visits per academic year, and the UC Tang Center alone estimates about 1,500 student ED referrals per year. While the Tang Center can meet the majority of urgent care student needs, it is not open 24 hours and does not perform imaging, surgery, and some emergency services make the UC Berkeley student population particularly reliant on Alta Bates Campus. 43 to urgent care referrals, the Tang Center also
refers students to Alta Bates Campus for some
outpatient diagnostic procedures, maternity care,
and specialty care.
We reviewed SHIP billing data to estimate the
student utilization of Alta Bates Campus and
Sutter health care facilities more generally. As
noted, this is not the universe of all student health
care issues and students on other insurance
or without insurance are likely also accessing
the hospital. In addition, our review of studies
from the Journal of American College Health
suggested that across US universities, there were
approximately 100 ED visits per 1,000 enrolled
students (McKillip et al, 1990).
With approximately 40,000 students in 2017,
we estimated that UC Berkeley generates as
many as 4,000 student ED visits to Alta Bates
Campus per academic year. (We note here, but
did not analyze, that the East Bay has a number
of students at other institutions that will likely be
similarly impacted by the closure of Alta Bates
Campus. For example, there are an estimated
7,000 students at Berkeley City College, and
7,900 at Contra Costa College, but many of these
are commuter students and we were unable to
obtain data on these students’ health insurance
status or residence).
Student mental health is a critical issue on the
UC Berkeley campus. Severe episodes of stress,
depression, thoughts of suicide and other mental
health issues are prevalent in both undergraduate
and graduate settings. Receiving timely treatment
for these mental health issues is critical to the
health of students and the general UC Berkeley
population.
Our analyses of SHIP claimant data by diagnosis
code from August 2016 through May 2017
revealed that of the 8,111 SHIP diagnoses, 15%
were for some type of mental health-related
diagnosis, including, but not limited to: suicide
attempts, thoughts of suicide, psychosis, bipolar
disorder, depression, schizophrenia, eating
disorders and substance abuse. While a majority
of these were likely treated at the Tang Center,
we do note that 7% of the Alta Bates Campus ED
diagnoses in 2016 were for mental disorders/
episodes. Figure 25 compares SHIP utilization for
mental health related issues and those presenting
at the Alta Bates Campus ED.
While we cannot determine the exact number of
students visiting Alta Bates Campus for mental
health care, our conversations with Tang and Alta
Bates staff suggest that a high percentage of the
mental health and suicide/self-harm visits to Alta
Bates Campus are from UC Berkeley students.
Similarly, a significant proportion of UC Berkeley
Figure 25. Student vs Alta Bates mental
health care utilization
Suicide/self harm Mental disorders/episodes
Alta Bates ED
SHIP utilization
0 20
40 60
80 100
120
0 500
1000
1500
2000
2500
3000
3500
Number of Diagnoses
Source: SHIP , 2017 & OSHPD, 2016
44 students that utilize mental health services seem
to have received a referral after being seen at Alta
Bates Campus, sometimes through the ED for
issues such as anxiety and depression. The fact
that Sutter’s Herrick campus will not be affected
by a potential closure is significant and will likely
off-set any potential care that is now provided at
Alta Bates.
However, since Herrick does not have an ED,
a limited number of students that require
emergency psychiatric services will be impacted
by the closure. Runyan et al (2017) noted that
when young people are unfamiliar with where
to access care and support, this can adversely
impact suicide-related episodes. In addition, the
ED can provide important discharge counseling
protocols for patients with potential suicide risks
(Runyan, et al. 2017).
For accessing emergency care, travel by
ambulance or private vehicle from the Tang
Center to Summit or another ED besides Alta
Bates will likely increase time to receive care.
In addition, a number of students with chronic
disease rely on Alta Bates Campus for routine
specialty care for diagnosis and follow up. In the
event of a closure, these students may have to
travel farther, requiring more time to access care
and money to get there, and potentially resulting
in delays. The perception of this distance by
students could also change the way they access
care.
These impacts will be further compounded
by students’ time constraints, inexperience in
navigating the healthcare system, and financial
limitations. We predict that adding these barriers
will further complicate health care access for
students and may delay student utilization of care.
As depicted in Map 10, the 94704 (southside) and
Map 10. Population
density in ZIP Codes
surrounding UC Berkeley,
Alta Bates Campus, and
Summit Campus
25-30k
20-24.9k
15-19.9k
10-14.9k
5-9.9k
< 5k
People per square mile
(thousands)
UC Berkeley
Alta Bates Campus
Summit Campus
UC
AB
S
0 1.5mi
N
45 94709 (northside) ZIP Codes surrounding the
UC Berkeley campus and Alta Bates Campus
are the most densely populated in the RHIA
defined Hospital Service Area (HSA), with
25,297 and 20,165 persons per square mile
respectively. This greatly exceeds the density
of most other ZIP Codes in the HSA, with the
next highest being 17,766 persons per square
mile in Downtown Oakland (94612) and an
overall average of 5,989 persons per square
mile in the HSA (ACS 2012-2016).
Thus the student population may be most
adversely impacted during a campus or
regional emergency, in which a large volume
of students and residents in areas surrounding
the UC Berkeley campus require access to
timely care. We discuss the impacts of a
disaster scenario on emergency services in
more detail on page 56.
We interviewed students and met with
student organizations already concerned with
the potential impacts of the closure of Alta
Bates Campus. We heard from students that
had direct experience at Alta Bates Campus
and received treatment for appendicitis,
hand lacerations, allergic reactions and
other injuries. A common theme among the
students was that Alta Bates Campus and its
ED was close-by, familiar and served them
when the Tang Center was closed.
In general, students we heard from were not
familiar with other hospitals in the region
and would need more information on what
alternatives were available if Alta Bates
Campus were to close. We also heard from
both UCB health professionals and students
that they viewed Alta Bates as an ‘extension’ of
the UC Berkeley health care network. The likely
short-term impacts to student health on Alta
Bates closing are difficult to estimate, but may
include a disruption of familiar care options
and longer travel times to a 24hr ED.
Student 1:
“It was around 9pm so we could
not go to Tang first. I knew a
friend of mine had gone to Alta
Bates previously for a night time
emergency, since it was the closest
emergency care available, so that is
why we chose it.”
Student 2:
“I don’t know of another urgent care
facility nearby that I trust, and had
the situation been worse, it may have
been too far to go.”
Student 3:
“[Alta Bates closing] would be
extremely detrimental as students
would no longer have a location
that was close for emergencies.
Particularly for more emergent
situations, [when] there is a need to
go see a doctor immediately. If not
then it could cause more harm than
good to go somewhere farther away.
UC BERKELEY
STUDENT VIEWS
ON ALTA BATES
CLOSING
46 Whenever an urban hospital closes there are
concerns over travel times for ambulances to
reach the next closest ED and potential adverse
health outcomes from delayed access to care.
Liu et al. (2014) reviewed California emergency
department closures between 1999 and 2010
and found that patients who lived near a closed
emergency department and were later admitted
had a 5% higher chance of dying in the hospital
than those who did not live near a closure. They
concluded that ED closures do have significant
effects on patient outcomes.
Crandall et al. (2016) studied outcomes in EDs
for serious trauma after the closing of a large
medical center in Los Angeles. They did not
find any significant impact on trauma-related
health outcomes, but did find that one hospital
ED surrounding the closure had a tripling of
uninsured patients visiting their ED in a ten year
period. Lee et al. (2015), found that in NY State,
urban hospital ED use increased in areas where
hospitals have closed and that ED visits have risen
by 23% in the United States over the last decade.
Shen and Hsia (2016) studied changes in acute
myocardial infarction (AMI) among Medicare
patients whose communities experienced
increased driving time to an ED due to the
closing of an ED in their community. They found
that patients whose driving time related to
local ED closure increased by ≥ 30 minutes
had a statistically significant increase in 90-day
mortality by 6.58 percentage points (CI 2.49,
10.68) and 1-year mortality by 6.52 percentage
points. Patients whose driving time increased
by 10 – <30 minutes also had a significant
but less pronounced increase in 90-day and
1-year mortality, by 1.60 percentage points
(CI 0.53, 2.67) and 2.05 percentage points (CI
0.96, 3.14), respectively. Patients whose driving
time increased by less than 10 minutes did not
experience worse mortality rates after an ED
closed in their community.
IMPACT ON EMERGENCY
SERVICES
Longer wait times
Longer travel times
Longer on call times for EMS
Decreased capacity for surge
event
Emergency
Department
access
Excess burden on already vulnerable people
Increased health inequities
Increased morbidity
Increased mortality
Delayed critical care
In 2017, the Alta Bates Campus ED received 6,424 visits over the recommended number by the American College of Emergency Physicians (ACEP). Modeled travel times to Summit hospital surpass 40 minutes for the evening rush hour period for 10 ZIP Codes north of Alta Bates. For the Summit Campus, the average City of Berkeley EMS time on task is about 10-12 minutes longer than for transports to Alta Bates Campus. The additional travel time to Summit can result in about 2 hours of time an ambulance is away from service compared to ED transports to Alta Bates. 47 Hsia et al. (2012) used California data from 1999-
2009, and found that patients with an increase
in distance to the nearest ED (0.8 miles average
distance increase) did not have significantly
higher mortality in general or for specific
conditions, including those with acute myocardial
infarction, stroke, asthma or chronic obstructive
pulmonary disease, and sepsis. However, Nichol
et al. (2007) found that increased journey distance
to the hospital appeared to be associated
with an increased risk of mortality. Berlin et
al. (2016) studied acute myocardial infarction
(AMI) mortality in Switzerland and found a 19%
increase and a 10 % increase for men and women
respectively, all over 65 years, for those with
the longest driving time to a university hospital
compared to the same population group with the
shortest driving times to the same hospital.
Alta Bates ED Utilization
Alta Bates Campus had a total of 50,414 ED visits
in 2017, a 21% increase since 2010. The campus
treated an average of 126 patients per day in
2016 and 138 patients per day in 2017. Alta Bates
Campus currently has 22 emergency treatment
stations in their ED.
4 The American College of
Emergency Physicians (ACEP) recommends a
standard of 2,000 visits annually per emergency
treatment station. In 2016, Alta Bates Campus
had approximately 1,836 visits per emergency
treatment station, but this rate increased to 2,292
visits per emergency treatment station in 2017.
3 This increase resulted in 6,414 ED visits over the
ACEP standard in 2017.
Our analyses of OSHPD data and review of the
literature suggests that ED visits are increasing
nationwide and in the Bay Area. Further, there
may already be an inadequate supply of ED
treatment stations to keep up with this increasing
demand. The closing of Alta Bates Campus will
remove at least 22 ED treatment stations and, as
noted above, require a doubling of ED capacity
at Summit to accommodate the patients from the
Berkeley facility.
Analyses of Travel Times to Alta Bates vs Summit
Campus Emergency Departments
Sutter has indicated that it plans to relocate all
in-patient and emergency department services to
the Summit campus in Oakland by 2030, though
little details have been provided to date about the
extent and time line of the proposed expansion.
A concern is whether the move to Summit will
increase the travel time to the ED for some
people in the region.
Using Google Maps GPS navigation software,
the RHIA modeled travel times via private vehicle
to Alta Bates and Summit campuses during
the morning and evening peak traffic periods
(8:30am and 5:30pm). We compared these
periods to travel time at 12am as the non-traffic
period. We estimated travel times for all ZIP
Codes in the RHIA defined Alta Bates Hospital
Service Area. The analysis routed travel to Summit
and Alta Bates campuses from the center point
of each ZIP Code in the HSA, and recorded an
estimated range in minutes to each destination.
Figure 22 provides detailed findings of travel
times from all of the ZIP Codes north of Alta Bates
Campus, using the high end of each travel time
range. Findings revealed that travel times to both
Alta Bates and Summit Campuses from ZIP Codes
in north Alameda County and West Contra Costa
County are longest at the 5:30pm peak traffic
time. For the PM rush hour, all ZIP Codes in West
Contra Costa County (in Richmond, San Pablo, El
Sobrante, and El Cerrito) as well as Albany and
Berkeley, have increased travel times to Summit
Campus when compared to Alta Bates Campus.
These findings also overlap with ZIP Codes
identified in the vulnerable communities section,
indicating that there is a potential negative impact
of increased travel times on already vulnerable
populations that are served by Alta Bates.
48 Overall travel times at 5:30pm are longest from
ZIP Codes in West Contra Costa County, four of
which have a total travel time between 50-60
minutes to the Summit Campus. An additional
six ZIP Codes near the West Contra Costa and
Alameda County border fall within a 40 – 50
minute range of travel time to the Summit campus.
Timely transport to care is critical for a range of
health emergencies, but can mean the difference
between life and death for ST-segment elevation
myocardial infarction (STEMI) patients (i.e., a heart
attack in which an artery is blocked). Mathews
et al. found that up to 40% of STEMI patients
use private vehicle or non-EMS transportation to
reach the hospital. While ambulance transport
time is also critical, ambulances have life-saving
equipment to treat a time-critical patient.
Map 11 depicts travel times via private vehicle
to the Summit Campus during peak evening
traffic within 10 minute increments, and projected
annual emergency department visits related
to heart disease. We calculated the number of
estimated heart disease patients for each ZIP
code by multiplying the population by the actual
percent of ED visits for heart disease (from 2011).
Richmond, San Pablo and El Sobrante have both
the longest travel times to Summit and the largest
estimated heart disease related ED visits. 13 ZIP
Codes have estimated travel times greater than 30
minutes to Summit Campus, which is currently the
closest STEMI receiving center in the region.
No Traffic (12am) Traffic (8:30am) Traffic (5:30pm) Estimated annual Heart Disease related ED visits
City
ZIP Code Time
to AB
Time
to S
Diff
(S - AB)
Time
to AB
Time
to S
Diff
(S - AB)
Time
to AB
Time
to S
*
Diff
(S - AB)
Population x % heart disease ED
visit per ZIP Code (2011)
Berkeley
94702 10 12 2 18 22 4 20 40 20 321
94703 5 10 5 10 16 6 12 22 10 177
94704 6 12 6 9 22 13 12 26 14 645
94705 6 14 8 8 20 12 9 24 15 248
94706 16 10 -6 35 26 -9 28 45 17 367
94707 16 16 0 30 35 5 30 50 20 215
94708 20 22 2 22 28 6 22 35 13 280
94709 12 16 4 18 30 12 18 35 17 195
94710 10 8 -2 20 16 -4 24 40 16 86
94720 9 20 11
10 26 16 12 30 18 32
El Cerrito 94530 20 14 -6 45 35 -10 40 45 5 185
Richmond
94801 26 22 -4 55 45 -10 45 50 5 165
94804 18 12 -6 45 35 -10 35 45 10 1,023
94805 18 12 -6 50 40 -10 35 45 10 249
El Sobrante 94803 26 22 -4 40 40 0 35 55 20 459
San Pablo 94806 26 22 -4 60 50 -10 45 50 5 1,275
Figure 26. Travel times to Alta Bates & Summit Campuses from ZIP Codes in the HSA 49 Map 12 depicts travel times to Summit Campus
and Alta Bates Campus via private vehicle at
5:30pm for three ZIP Codes in the RHIA defined
HSA. Each of these ZIP Codes experience shorter
travel times to Alta Bates Campus than Summit
Campus during peak evening traffic time, and one
relies on heavily congested freeways including
580 and 80.
Given that 15% of households in the HSA report
having no vehicle (ACS 2012-2016), the analysis
also tested travels times via public transportation
(bus and BART). We did not find significant
differences in travel time to Alta Bates Campus
vs. Summit Campus for ZIP Codes north of Alta
Bates in the HSA for public transit. Travel times via
public transit averaged approximately 1 hour from
West Contra Costa County to both Alta Bates and
Summit campuses.
Projected annual Heart Disease related ED visits Alta Bates Campus Summit CampusSAB 20 - 29 minutes
30 - 39 minutes
40 - 49 minutes
50 - 59 minutes
#
Map 11. Estimated Number of Heart Disease ED visits & Private Vehicle Travel Time for Peak Period to Summit Campus for select ZIP Codes
Travel Time to Summit Campus
during Peak PM Period
0 1.5mi
N
50 Impacts on Ambulance Travel Time
Though this RHIA does not include an analysis
of projected ambulance travel times, we assume
that emergency vehicles are likely to travel faster
than private vehicles in both traffic and non-traffic
conditions.
When an ED closes it can cause ambulances
to travel to further, and may also result in ED
crowding. Overcrowding can cause increased
ambulance time on task – the total EMS time
from receiving a 9-1-1 call to arriving on scene,
then arriving at the hospital, and returning to
service. That window represents time that the
ambulance and associated staff cannot respond
to new incoming calls, and cannot be at the Fire
Department garage maintaining the vehicles or
completing trainings and other tasks.
The Alameda County Emergency Medical
Service (EMS) system responds to about 160,000
20 - 29 minutes
9 - 19 minutes
30 - 39 minutes
40 - 49 minutes
50 - 59 minutes
Alta Bates Campus Hospital Service Area (HSA) Alta Bates Campus Summit CampusSAB Map 12. Travel times to Alta Bates vs. Summit Campus at PM Peak Period from select ZIP Codes in the Alta Bates HSA 0 1.5mi
N
51 emergency calls annually. Under normal protocol
a fire department unit and Paramedics Plus
ambulance respond to emergency medical
calls, however the Berkeley Fire Department
EMS division owns and operates four of its own
ambulances and therefore generally provides the
emergency transport services in the Berkeley area.
In 2014, the Berkeley Fire Department transported
5,049 patients to Alta Bates Campus, while
Paramedics Plus transported less than 500 from
the Berkeley area to the same campus.
Given this large volume of Berkeley EMS
transports to Alta Bates Campus and findings
from the general travel time analysis (Figures 22
& 23) which indicate that 5 ZIP Codes in Berkeley
have increased travel times by vehicle to Summit
Campus compared to Alta Bates Campus during
no traffic hours, we focus the ambulance travel
time analysis on the experiences of the Berkeley
Fire Department, referencing data and insight
provided by the Fire Captain for the City of
Berkeley.
The Berkeley Fire Department transports about
7,000 patients annually to local hospitals, of which
there are 14 receiving facilities throughout the
county. Receiving centers are determined by
matching the closest hospital with the equipment
that the patient needs. For instance, if someone
standing on the corner of Telegraph and Ashby
has a major heart attack and is being transported
by ambulance, they may be transported to Summit
rather than Alta Bates Campus, since Summit is
the closest ST- elevation myocardial infarction
(STEMI) receiving center and can adequately
address the needs of a major heart attack patient.
The vast majority of all-cause City of Berkeley
EMS transports are taken to Alta Bates Campus,
followed by Kaiser Permanente in Richmond, and
the Summit Campus in Oakland (4,576, 1,093, and
578 transports in 2016, respectively).
We assume that most of these transports were not
for major heart attacks, since Alta Bates Campus
is not a STEMI receiving center. Despite this,
closing the Alta Bates Campus ED may result in
extra time spent transporting patients to care and
decreased regional EMS capacity for ambulance
transports, which is particularly concerning
for patients with conditions for which quicker
transport time is related to measurable differences
in health outcomes.
If Alta Bates Campus closes, the Berkeley Fire
Department expects that most of the emergency
transports would instead be taken to the Summit
Campus in Oakland. For the Summit Campus,
the average City of Berkeley EMS time on task
averages about 10-12 minutes longer than
transports to Alta Bates Campus. According to the
data from Berkeley EMS, there are an average of
12.5 emergency trips made to Alta Bates Campus
daily. If Alta Bates Campus were to close, the extra
time needed to transport these patients to the
Summit campus instead would add up to about
two hours extra of time on task in total per day.
Without additional resources, response times to
incoming emergency calls for all causes would
likely increase due to the additional time on task
required to transport patients to Summit and
to get back to Berkeley, where they can receive
another call. Assuming there are no additional
ambulances in rotation to offset additional time
on task for transport to Summit, patients with
intermediary or high risk of mortality, including
those requiring time-sensitive interventions – such
as coronary revascularization in acute myocardial
infarction, fibrinolytic therapy for acute ischemic
stroke, early goal directed therapy in sepsis, and
trauma center care for injuries may not receive
the timely response associated with a survival
benefit, and subsequently mortality rates for life
threatening conditions may increase. While Alta
Bates is not a critical stroke or STEMI receiving
center, stroke and major heart attack patients in
Berkeley will still be disproportionately impacted
by the proposed closure due to the added time
on task and decreased capacity of Berkeley EMS
52 to respond to all 9-1-1 calls. This impact may
be worsened by an increase in diversion hours
at Summit Campus after the proposed closure
of Alta Bates Campus, which we discuss in the
following section.
We find similar impacts on ambulance transports
in West Contra Costa County, where the closest
ED is at Kaiser-Richmond hospital, with the next
closest being Alta Bates Campus, followed by
Summit Campus. According to Patricia Frost,
Director of Emergency Medical Services for
Contra Costa County, prior to the DMC closure
the Kaiser Richmond ED received about 31% of
all ambulance transports, but after the closing
this increased to 52%. From January 1 to March
31, 2016, 11% of the 4,692 EMS ambulance
destinations in West Contra Costa County, 516
in total, went to Alta Bates Campus. From 2014
to 2016, the Alta Bates Campus experienced a
123% increase in transports from Contra Costa
County EMS, going from 2.5 trips to Alta Bates
per day to nearly 5.7 trips to Alta Bates per day.
If Alta Bates Campus closes, we would expect
these patients to go to Alta Bates Summit in
Oakland, which is further away from West Contra
Costa County than the Alta Bates Campus.
The additional distance is likely to increase
emergency service travel times and time-on-task,
which would keep ambulances out of rotation
longer and increase emergency response wait
times for others in Contra Costa County. In
addition to increased distance to Alta Bates
Summit, there could be time on task added if Alta
Bates Summit is on diversion status or is not on
diversion status, but is overwhelmed with a high
volume of patients. Closing Alta Bates Campus
will likely increase time on task for Contra Costa
EMS, forcing the county to either contract out
for additional ambulances or try to absorb the
additional time on task, which could put lives at
risk.
The 2014 Contra County Health Services report
analyzing the potential impacts from the closing
of the ED at Doctors Medical Center in San Pablo,
noted the following impacts which are worth
repeating here as they likely apply to the closing
of Alta Bates’ ED:
1. American Medical Response ambulance crews
will experience longer time-on-task for all
911 phone call
Event identification
EMS system response time
Ambulance “time on task”
Dispatch “Chute” Travel Treatment
Transport
Call transferred to medical call taker
Call location pre-alerted to dispatcher
First responders & ambulance crew notified
Ambulance en route
Ambulance arrives on scene
Crew departs scene
Crew arrives at medical facility
Crew is
available
for call
Figure 27. Emergency response time line
Source: National As sociation of State EMS Officials, 2011 53 transports going to more distant hospitals as a
result of the DMC closure.
2. In addition to possible delays in fire and
ambulance response resulting from increased
time on task, the West County community has
raised a concern that there may be an increase
in the number emergency calls. Increased 9-1-1
usage may result when patients choose to access
9-1-1 rather than private transport due to the
longer driving distance and lack of familiarity with
routes to other facilities.
3. 9-1-1 ambulance traffic from the region would
overwhelm Kaiser-Richmond’s ED or require
transporting patients to other EDs that would be
further away, impacting ambulance availability
within the county.
4. Kaiser-Richmond will experience 80 – 100 new ED
patients per day on top of the 78 it already sees
daily. That is an increase of at least 102 percent.
While there are 12 other EDs in the region,
Kaiser-Richmond will be disproportionately
impacted. The reason for this is that patients
typically choose the next closest ED for their
ED needs, barring significant new healthcare
resources in the community or an extensive
public education campaign.
Ambulance Diversion
Crowded EDs can also result in ambulance
diversion, which is when ambulances are
redirected to bring patients to a different ED than
they would under normal conditions for timely
treatment. Beyond indicating overcrowding,
diversion is harmful in itself, as it increases time to definitive care and can be associated with poor
outcomes for patients with certain conditions,
particularly stroke and acute myocardial infarction.
According to OSHPD, Alta Bates Campus had
182 hours of ambulance diversion in 2014 but
only 57 hours of ambulance diversion in 2016.
Sun et al. (2006) assessed the effects of nearby
hospital closures on ED ambulance diversion
in Los Angeles County from 1998 to 2004. They
documented ambulance diversion hours due to
ED saturation and found that hospital closures
increased ambulance monthly diversion hours by
an average of 56 hours for the first 4 months at the
nearest EDs.
In 2016, both Alta Bates and Summit campuses
practiced ambulance diversion for about 60
hours during the year.
3 However in 2017, Alta
Bates’ diversion hours decreased to 13, and
Summit decreased to 29. Comparatively, Highland
Hospital in Oakland had 161 hours of ambulance
diversion in 2017.
4 Since Summit is already
practicing diversion, there is a high likelihood that
additional diversion hours would be added to the
Summit ED after a closure of Alta Bates Campus.
Regional Emergency Department impacts
The San Francisco Bay Area is home to more than
80 acute care hospitals, serving a region of more
than 7 million people, situated within 9 counties
and 110 cities (ACS 2012-2016).
11 In Alameda and
Contra Costa Counties, there is a large hospital
network in place to serve the counties’ more than
2.7 million residents. However, the hospitals within
this network are not evenly distributed throughout
the region, and this may impact where patients go
for care if Alta Bates Campus is to close.
As we discuss throughout the report, the regional
hospital network was recently impacted by the
closure of Doctor’s Medical Center (DMC) in 2015.
The closure of DMC resulted in a regional gap
in ED care, making Kaiser Richmond (which has
limited capacity for non-Kaiser patients) the only
ED besides Alta Bates Campus along the corridor
from San Pablo to Berkeley. This RHIA has found
that Kaiser-Richmond experienced an increase
in ED utilization since DMC closed, going from
40,065 ED visits in 2013 to 64,680 in 2017.
4,7
According the 2016 Contra Costa EMS System
Performance Report there was an approximate
54 12% increase in EMS responses from 2014-2016 in
the county, with an average of 271 EMS responses
per day (in 2016). Since 2014, there has not only
been a large increase in total ambulance usage,
but, as a result of the DMC closure and distance
to the next closest hospitals, there has also been
a large increase in ambulances originating from
Richmond, San Pablo and nearby areas that
travel high traffic roads and freeways to Kaiser-
Richmond, Alta Bates Campus, Contra Costa
Regional Medical Center in Martinez and John
Muir Medical Center in Walnut Creek.
Within Alameda and Contra Costa County,
only 6 hospital other than Alta Bates Campus
(Summit Campus, Kaiser Richmond, Kaiser
Oakland, Highland Hospital, Alameda Hospital
and Children’s Hospital Oakland) receive a
significant (25% or more) number of patients
from the RHIA defined Alta Bates Hospital Service
Area (HSA), and in 2016 Alta Bates Campus was
overwhelmingly the most utilized non-Kaiser
hospital by residents of Berkeley, Albany, El
Cerrito, Richmond and San Pablo.
Given the increasing reliance on Alta Bates
Campus ED by patients from West Contra Costa
County and the high utilization by Berkeley
residents, it is unclear where people in the HSA
will seek emergency care, both independently
and by ambulance transport.
To assess the capacity of regional hospitals to
absorb additional ED patients, we used the
American College of Emergency Physicians
(ACEP) standard of 2,000 ED visits annually per ED
treatment station. Figure 24 shows the additional
number of ED visits (using 2017 data) that could
be absorbed by regional hospitals per year should
Alta Bates Campus ED close, before exceeding
the ACEP standard. If Alta Bates Campus were to
close and all of the 50,414 ED patients in 2017
utilized the remaining open EDs, particularly
Highland Hospital and Kaiser-Oakland, there
would be capacity in the region even without
an expansion of Summit Campus in Oakland. In
2017, Highland could have absorbed 48,003 visits
before exceeding the ACEP standard, and Kaiser-
Oakland could have absorbed 32,313 visits before
exceeding the ACEP standard. However, whether
or not the 50,414 patients that went to the Alta
Bates Campus ED in 2017 will utilize Kaiser and/
or Highland in the event of an Alta Bates Campus
closure is unclear, given the disproportionate
utilization of the campus (in 2017 Alta Bates
Campus ED surpassed the ACEP standard by over
6,000 visits).
Figure 28. Additional ED visits/year
hospitals can absorb before exceeding
American College of Emergency
Physicians (ACEP) standard, 2017.
0 10000
20000
30000
40000
50000
Summit Oakland Kaiser Oakland Highland Hospital Alameda Hospital K Number of visits
55 Highland Hospital receives the majority of its
patients from central and east Oakland, and in
2016 the hospital received 62% of its ED patients
from 10 ZIP Codes. 8 of the 10 ZIP Codes fall
within the Alta Bates Campus HSA, however just
14% of Alta Bates Campus ED patients came from
those same 8 ZIP Codes.
6 Since there is currently
relatively low utilization of Highland by the
population primarily served by Alta Bates Campus,
it is not likely that Highland will become the
primary receiving center for Alta Bates Campus
ED patients. It is more likely that the majority
of Alta Bates Campus’ current patients would
choose to utilize Summit, which is already near
capacity and would need to double its capacity to
accommodate all of the patients that utilize Alta
Bates Campus ED annually.
Figure 25 shows the relationship between the
number of ED stations, total ED visits and the
ACEP standard for the Alta Bates and Summit
campuses. To calculate the emergency
department capacity, based on the ACEP
standard, the number of emergency department
stations is multiplied by 2,000, which is the ACEP
standard for yearly visits per emergency treatment
station. In 2017, Alta Bates Campus had an ACEP
defined capacity of 44,000 (22 ETS*2,000) and
was over capacity by 6,424 visits. Meanwhile, Alta
Bates Summit had an ACEP defined capacity of
50,000 (25 ETS*2,000) and was under capacity
by 2,883 visits. Summit Campus would need
to expand their emergency treatment stations
by at least 24 to accommodate the increase in
patients from Alta Bates Campus. Sutter Health
has stated on their Vision 2030 website that they
would increase the Alta Bates Summit Campus
emergency department capacity to accommodate
90,000 visits per year. However, this would
be insufficient to accommodate all Alta Bates
Campus emergency department patients, should
the campus close.
# ED
Stations
(2017)
ACEP standard
(yearly visits per station)
ACEP Defined
Capacity
2017 Total ED
Visits
Visits that exceed capactiy
(+ exceeds, - under capacity)
Alta Bates campus 22 2000 44000 50414 +6414
Summit campus 25 2000 50000 47117 -2883
Total 47 94000 97531 +3531
Figure 29. Alta Bates & Summit ED utilization & American College of Emergency Physicians’ recommended capacity ACEP standard of
2,000 ED visits
annually per
treatment station
56 In this section, we estimate the potential impact
of the closing of Alta Bates on emergency
department capacity during two disasters, an
earthquake and large fire. We base these analyses
on the HayWired Reports Volume I & II which detail
likely impacts from an earthquake on the Hayward
fault line, and data from the aftermath of a 2012
fire at the Chevron refinery in Richmond, CA.
The entire Alta Bates HSA runs along the Hayward
fault line, and the Working Group on California
Earthquake Probabilities calculates that there is a
33-percent likelihood of a large (6.7 magnitude
or greater) earthquake occurring along this fault
line in the next few decades (USGS, 2018). In
order to fully examine the potential impacts of a
major earthquake along the Hayward fault line,
the USGS, along with a number of stakeholders,
created the HayWired scenario and resulting
reports.
The HayWired scenario is one of many plausible
scenarios for the region’s next major earthquake. It
investigates the likely impacts of a 7.0 magnitude
earthquake along the Hayward fault, with an
epicenter under the city of Oakland. In this
scenario, the 7.0 magnitude earthquake strikes on
April 18, 2018 at 4:18pm, just around the start of
the week-day rush hour (USGS, 2018).
According to FEMA data, there are an estimated
837 people mortally injured, 461 life-threatening
injuries, 3,007 injuries requiring a high degree
of medical care, and 12,263 injuries that require
medical attention and cannot be treated at home
after the initial quake. In total, there are 16,568
casualties from the earthquake, 837 fatalities and
15,731 people that require medical attention. The
HayWired scenario rounds FEMA’s estimates to
800 fatalities and 16,000 injured and needing
medical attention. FEMA estimates that 84% of
displaced households will come from Alameda
County (68%) and Contra Costa County (16%)
(USGS, 2018). Using these same percentages, we
estimate that those injured and needing medical
attention would total to 13,440 in Alameda
County and Contra Costa Counties, with 10,880
needing medical attention in Alameda County
and 2,560 in Contra Costa County.
Access and time to treatment will be critical for
many of the injured, and considering that the
majority of the impact will be felt in Alameda
County and Contra Costa County, there will
be increased pressure on the existing hospital
network and emergency services to respond to
and treat the surge of patients in the ED. If all of
the injuries that occur in Alameda County seek
treatment at hospitals in Alameda County in an
even manner (all hospitals are evenly impacted
by the event), there would be an estimated
837 additional patients seeking treatment at
each emergency department as a result of the
quake. For instance, in the event of the HayWired
Haywired Earthquake Scenario:
84% of households are displaced in
Alameda and Contra Costa Counties
14,000 estimated injuries requiring
medical attention from Alameda and
Contra Costa Counties
$57 billion in total direct economic
loss
DISASTER EVENT IMPACTS
57 Map 13. Earthquake along the Hay-
ward Fault & Hospital Locations
Source: HayWired
Report Volume I
scenario, Kaiser San Leandro, which addresses
the highest # of ED cases/day in Alameda County,
would need to serve an estimated 1,028 patients.
This is a 438% increase from their daily average
number of visits. If Alta Bates Campus were to
close, the number of surge patients requiring ED
treatment in Alameda County would increase by
an additional 64 visits for each hospital in the
county.
In Contra Costa County, we estimate 2,560 injuries
needing medical attention. We estimate that
roughly 280 people from Contra Costa County
would access emergency treatment at Alta Bates
Campus. Since the Kaiser Richmond emergency
department is the primary receiving center for
West Contra Costa County residents, we would
expect at least half of the remaining 2,280 to
go to Kaiser Richmond. The Kaiser Richmond
Emergency Department could be overwhelmed
with an estimated 1,316 people needing
treatment the day of the earthquake. If Alta Bates
were to close, we estimate that Kaiser Richmond
would experience an additional 282 ED patients
immediately following the earthquake.
In the 1994 Northridge earthquake, a magnitude
6.7 earthquake in Los Angeles, there were over
0 1.5 3mi
N
58 9,000 people injured and 57 fatalities. Research
conducted around the Northridge Earthquake
showed that injuries increased significantly with
age. 60-79 year olds were 10.9 times more likely
to be injured, and people 80 and older were
34.6 times more likely than 0-19 year olds to
sustain earthquake related injuries (Peek-Asa,
1998). The Northridge Earthquake highlighted
that those most impacted by injuries are likely
to be the aging/elderly (60+), and aging/elderly
populations already experience issues of mobility,
from issues related to driving restrictions, physical
limitations or other cognitive/familiarity issues that
inhibit their ability to access far away or unfamiliar
hospitals.
Approximately 13% of the population in the Alta
Bates Campus HSA are over the age of 65, with
an additional 12% between 55-64. Compared
to other cities in the HSA, Berkeley has a high
concentration of elderly, as people over 65 make
up between 20-30% of the population in three of
its ZIP Codes (94705, 94707 and 94708). The ZIP
Codes with the highest total number of elderly
(65+) in the HSA are located in Richmond (94806),
Alameda (94501) and Oakland (95611), each with
over 6,500 residents over 65. These six zip codes
would be particularly vulnerable to the impacts of
an earthquake without Alta Bates Campus.
Though our earthquake analysis does not account
for potential post-earthquake barriers to local
hospitals, it is critical to note that the Summit
Campus is bounded by freeways, including 580,
980 and 880. Under the Haywired scenario there
is a high possibility that local freeways will be
compromised and hospitals, including Summit,
may not be accessible by all that need care.
Concentrating ED care in fewer locations in the
East Bay may compromise access to emergency
medical treatment after an earthquake.
Potential Impact from Chevron Refinery Fire
On August 6, 2012, a major fire erupted at the
Chevron Refinery in Richmond, CA. A Level 3
community warning and shelter in place order
were immediately issued. There were no injuries
or fatalities at the scene, but the emergency
departments at Kaiser-Richmond and Doctors
Medical Center began to receive patients that
complained of respiratory problems. Emergency
departments were overwhelmed and placed on
diversion status. American Medical Response
(AMR), a subcontractor for emergency services,
requested mutual aid resources, and an
ambulance staging area with one ambulance
from San Ramon Valley Fire and two Paramedics
Plus Units from Alameda County was established
at San Pablo Town Hall. Tents were set up at both
Kaiser and DMC, establishing separate areas for
patients to be seen. Within the first two hours after
the fire, 200 patients sought emergency treatment
at DMC. On the peak day four days after the fire,
regional EDs (mostly in Contra Costa County), saw
2,876 visits related to the fire, and an approximate
4,500 visited the ED over the next 3 days. In
total, the fire sent over 15,000 patients to the
emergency department for 18 days following the
event (CCHS, 2012).
Figure 26 shows the regional emergency
department surge pattern for ED visits related to
Chevron Fire Example:
Estimated 15,000 related emergency
department visits over 2 ½ weeks
2,876 visits to emergency
departments on peak day (4 days after
fire occurred)
200 ED visits
within the first 2 hours after the fire
59 the Chevron fire in the two
weeks following the incident.
At the time of the fire, both
DMC and Kaiser-Richmond
EDs were in full operation.
Before its closure, DMC had
25 emergency treatment
stations, and Kaiser Richmond
had 15 emergency treatment
stations. Even with two hospitals receiving the
surge of patients, both emergency departments
were quickly overwhelmed and both hospitals did
not return to normal operations until August 23rd
(CCHS, 2012).
As highlighted in the Alta Bates Campus
Utilization and Hospital Service Area sections
above, Alta Bates Campus has seen an increase
in patients from West Contra Costa County since
the closure of DMC in 2015. If this scenario were
to happen without the ED of Alta Bates Campus,
we estimate that between 1000- 1,200 people
would seek treatment at regional EDs in the first
three days of the event. Kaiser Richmond would
be most impacted, but it is unclear where patients
from Contra Costa County and northern Alameda
would seek treatment without Alta Bates Campus.
We estimate that Summit and Highland Hospital,
as well as urgent care facilities in Contra Costa
County would need to absorb the increased ED
patient load.
Without Alta Bates Campus, the emergency
response plan to provide residents from Contra
Costa County with timely care in the case of
a major fire would need to be addressed. As
noted above, a fire or earthquake disaster may
overwhelm ED capacity and services at hospitals
throughout the region, and these impacts may be
critical if the Alta Bates Campus closes.
Figure 30. Emergency Department patient surge volume after Chevron refinery fire, Richmond, CA, 2012 “The magnitude of the earthquake that’s going to happen here is so significant that we really do need to have every critical facility in the best possible earthquake shape possible.” - Nancy Skinner (NY Times Article)
60 Hospitals such as Alta Bates Campus are major
generators of economic activity. As a result,
closure of a hospital can not only impact those
employed there but the local and regional
economy. In 2016, Alta Bates Campus reported
earning almost $1.9 billion in revenue for
providing care to patients, with billing including
Medicare (35% of total revenue), Medi-Cal (26%),
and private insurance providers (38%).
2 Though
Alta Bates Campus earned almost $1.9 billion in
revenue, with spending, adjustments and other
deductions, their net income was approximately
$19 million in 2016.
Much Alta Bates Campus’ revenue is subsequently
spent on hospital clinical and nonclinical
operations. In 2016, Alta Bates Campus reported
spending a total of $604 million on operations. Of
this, $284 million was spent on direct expenses,
which includes purchases of supplies and
equipment, leases and rents, and purchased
services such as parking and security.
2 Of the $604 million spent on operations, the
other $320 million was spent on employee
compensation. Aside from high-skilled and high-
paying staff such as physicians, surgeons, and
nurses, Alta Bates Campus is also a major source
of low-skilled jobs. According to SEIU-UHW, the
hospital directly employed 280 people in low-
skilled, lower-paid jobs in 2015 (Rauber, 2014).
These positions include clerks, patient aides, food
service and custodial staff, nursing assistants,
and technical support staff. With average hourly
wages between $20 and $24 per hour, these
lower paid positions nonetheless offer generally
higher wages when compared with similar jobs in
different settings.
In line with their announced plan to systematically
shut down service lines and transfer them to
Summit campus, Alta Bates Campus has already
reported significant decreases in spending for
certain service lines. Cardiac Services saw a 68%
reduction, with spending going from almost $4.4
million in 2012 to less than $1.4 million in 2016.
Radiology Services - for both diagnostic and
therapeutic purposes - had a decrease of 57% or
over $19 million over the same time period.
Adolescents service lines showed no spending by
2016.
1,2
ECONOMIC IMPACTS
Alta Bates generated over $1.9 billion in patient revenue and spent $604 million on operations and employee compensation in 2016. Accor ding to their filing with the State of CA, Alta Bates has reduced their overall spending by over $81 million since 2012. The closing of Alta Bates will adversely impact the local economy but the extent of the impact will depend on the nature of replacement services, hiring and contracting at the Summit campus.
Excess burden on already vulnerable people
Increased economic inequality
Increased costs for local governments
Decreased regional spending
Lost wages
Lost jobs
Lost contracting
Regional
economy
61 According to their financial disclosures, Alta Bates has even started to reduce spending in their
birthing center. Between 2012 to 2016, Labor
and Delivery Services saw an almost 23%, or $7
million reduction in spending, while spending on
Neonatal Intensive Care fell almost 35% over this
same time period.
1 Impact Magnitude
Low wage
workers
165 workers already laid off since 2012
Community
benefits
Potential reduction of $91 million in charity
care
Local
economic
activity
Potential loss of $1.5B annually in local
economic activity
Alta Bates as an Economic Base Multiplier
Alta Bates Campus, like all hospitals, has a large
impact on the regional economy. Hospitals draw
in billions of dollars in revenue from medical
reimbursements. These reimbursements come
overwhelmingly from outside the region:
Medicare brings in federal dollars; Medi-Cal
brings in a combinations of federal and state
dollars; and private insurance brings in money
from corporations based across the country.
With this continuous source of revenue,
hospitals like Alta Bates Campus typically spend
overwhelmingly within the metropolitan area
or its surrounding region. In fact, economists
estimate that an average urban hospital spends
at least 80% of its patient revenue within the
metropolitan area (Erickson et at., 1986).
The nature of hospital operations necessitates
that Alta Bates Campus contracts with local
companies for everything from medical supplies
and equipment to food for its patients, staff,
and visitors. They must also contract with
local companies for purchased services such
as laundry, parking, and security. Alta Bates
Campus also contributes to the regional economy
by employing hundreds of staff. If not through
direct employment, Alta Bates supports dozens of
jobs through its purchasing of services.
As a nonprofit hospital, Alta Bates Campus
is required by law to reinvest any surplus
revenue back into the community in the form
of community benefit programs. According
to its Community Benefit Plan, Alta Bates
spent over $97 million in 2016 for community
benefit programs, activities, and initiatives.
The vast majority of this community benefit--
over $91 million--comes in the form of charity
care, providing free medical services for those
without coverage and unable to afford the cost
of their care (Sutter Health, 2016). The rest is
spent funding various public health programs
such as asthma and diabetes resource centers,
neighborhood revitalization programs, and youth
outreach and career development services.
As a result, Alta Bates Campus acts as what
economists call an economic base multiplier.
That is, the hospital generates significantly higher
$1.9 billion in patient revenue
generated in 2016
23% reduction in spending on Labor &
Delivery Services from 2012-16
35% reduction in spending on Neonatal
Intensive Care from 2012-16
165 lower wage workers
already laid off by Alta Bates since 2012
62 downstream economic output in proportion to
its revenue. A number of studies highlighted
this economic base multiplier effect on urban
hospitals in Pittsburgh, PA, Syracuse, NY, and
Minneapolis, MN. These studies found that the
multiplier ranged from 2.63 to 2.69, meaning
that every dollar that a hospital earns in patient
revenue generates between $2.63 and $2.69
in economic activity for the surrounding region
(Moore, 1974 & Doeksen et al., 1997).
We used the economic-multiplier idea and
conservative assumptions to estimate the
hospital’s likely contributions to the local
economy. Given that in 2016 Alta Bates Campus
spent $604 million, we estimate that the hospital
is likely responsible for generating approximately
$1.5 billion in economic activity for the Bay Area.
The economic impacts from the closing of Alta
Bates Campus will likely also include loss of low
wage jobs. These workers may lose income and
experience other hardships. Skilled workers, such
as physicians and nurses will either be relocated
to Summit, find work elsewhere, loose their
jobs, or leave the region to find work elsewhere.
If skilled nurses leave, the region’s health care
facilities may experience an increase in the
nursing shortage.
There is little doubt that Alta Bates Campus
provides economic benefits to the local and
regional economy. The exact adverse impacts
from the closing are difficult to estimate, but our
review of OSHPD data suggests that close to $1.5
billion in local economic activity could be lost.
Majority of hospital patient revenue sources are from outside of the region (i.e. Medicare, Medi-Cal, and Private Insurance)
Total Patient
Revenue 2015:
$1.89 billion
Direct Spending on
Supplies and Operations
Regional spending on:
purchased services, supplies,
direct costs
(e.g. utilities, rent)
Employees spend money
locally for living expenses &
recreation
By law, nonprofit hospitals
must spend surplus on local
community benefit
Employee
Compensation
Surplus Revenues
(“Profits”)
Figure 31. How hospitals contribute to regional Economies 63 APPENDICES
A. Acknowledgments, Reviewers &
Interviewees
Alta Bates Regional Task Force, Members
Andy Katz, Alta Bates Regional Task Force
Member
Anna Harte MD, Medical Director, UC Berkeley
University Health Services
Mary Kay Lacey, Bateman Neighborhood
Association
Bahar Navab, Associate Director, University
Health Services
Carolyn Bowden, Community Organizer,
California Nurses Association
Claudia Covello, Assistant Vice Chancellor,
University of California, Berkeley Student
Affairs & Executive Director, University Health
Services
Community Health Commission, City of
Berkeley
Cynthia Frankel, EMS Coordinator, Alameda
County Emergency Medical Services
Daniel Caraco, Alta Bates Regional Task Force
David McPartland, EMS Captain, Berkeley Fire
Department
Declan Walsh, Research Analyst, SEIU-UHW
West
Dominic Chan, California Nurses Association
Gabriel Quinto, Mayor, City of El Cerrito
Jacquelyn McCormick, Senior Advisor to the
Mayor, City of Berkeley
Jesse Arreguin, Mayor, City of Berkeley
Patrick Richards, Associate Director, Business
and Finance at University of California,
Berkeley
Rochelle Pardue-Okimoto, Mayor Pro Tem, El
Cerrito
Scott Donahue, Council member, City of
Emeryville
Calculation
Description
Calculation Notes
AB HSA AB CHNA zip codes +
non-CHNA zip codes
sending highest
numbers of patients
to AB = approximately
75% of AB patients
See Table 1
below for more
information
Surge Event
Injuries Alameda
County Estimate
(16,000 Haywired
estimated
injured)*(estimate
of 68% of displaced
households coming
from Alameda
County)= 10,880
estimated injuries in
Alameda County
Assumes that
the percentage
of displaced
households is
equivalent to the
percentage of
injuries occurring
in Alameda County
Economic Loss
Estimate
$2.5 (economic base
multiplier)*($1.9
billion in patient
revenue in 2016)=
$4,750,000,000
Economic base
multiplier = $2.5
per every dollar in
patient revenue
B. HSA Calculation & Discharges by ZIP Code
64 Zip Code 2016 # Patient Discharges
from Alta Bates Campus
94613 10
94720 276
94612 866
94619 875
94618 972
94610 992
94602 1,106
94709 1,130
94708 1,186
94603 1,194
94606 1,215
94707 1,230
94710 1,295
94607 1,297
94621 1,579
94611 1,629
94605 1,751
94609 1,855
94705 1,992
94601 2,241
94704 2,394
94608 2,754
94702 2,922
94703 3,035
Total CHNA patient discharges 35796
94805 822
94803 1,145
94501 1,431
94801 1,557
94706 1,737
94530 2,156
94804 2,764
94806 3,134
Total non-CHNA zip code patient
discharges (approximately 75% of
all ABC patient discharges)
14746
65 Hospital County 2016 ED Visits/Beds (AMA benchmark
is 2000 visits/Emergency Treatment
Station (ETS)
2017 ED Visits/Beds (AMA benchmark is
2000 visits/Emergency Treatment Station
(ETS)
Alta Bates Berkeley Alameda County 1836 visits/ETS (25 ETS) 2292 visits/ETS (22 ETS) Alta Bates Summit Alameda County 1481 visits/ETS (32 ETS) 1885 visits/ETS (25 ETS) Highland Hospital Alameda County 1211 visits/ETS (57 ETS) 1158 visits/ETS (57ETS) Kaiser Oakland Alameda County 1289 visits/ETS (48 ETS) 1327 visits/ETS (48 ETS) Kaiser Fremont Alameda County 2347 visits/ETS (16 ETS) 2452 visits/ETS (16 ETS) Kaiser San Leandro Alameda County 1645 visits/ETS (40 ETS) 1739 visits/ETS (40 ETS) Alameda Hospital Alameda County 1404 visits/ETS (12 ETS) 1369 visits/ETS (12 ETS) St. Rose Hospital Alameda County 2037 visits/ETS (17 ETS) 2134 visits/ETS (17 ETS) CHORI Alameda County 1289 visits/ETS (37 ETS) 1261 visits/ETS (37 ETS) San Leandro Hospital Alameda County 2739 visits/ETS (12 ETS) 2,851 visits/ETS (12 ETS) Washington Hospital
Fremont
Alameda County 2236 visits/ETS (23 ETS) 2168 visits/ETS (23 ETS) Eden Medical Center Alameda County 2097 visits/ETS (22 ETS) 1943 visits/ETS (22 ETS) Stanford ValleyCare Alameda County 1768 visits/ETS (18 ETS) 1886 visits/ETS (18 ETS) Contra Costa Regional
Medical Center (CCRMC)
Contra Costa County 2122 visits/ETS (20 ETS) 1499 visits/ETS (26 ETS) Kaiser Richmond Contra Costa County 2256 visits/ETS (28 ETS) 2310 visits/ETS (28 ETS) Kaiser Antioch Contra Costa County 1588 visits/ETS (36 ETS) 1699 visits/ETS (36 ETS) Kaiser Walnut Creek Contra Costa County 1183 visits/ETS (52 ETS) 1224 visits/ETS (52 ETS) John Muir Concord Contra Costa County 1876 visits/ETS (32 ETS) 1858 visits/ETS (32 ETS) John Muir Walnut Creek Contra Costa County 1206 visits/ETS (44 ETS) 1262 visits/ETS (44 ETS) Sutter Delta Antioch Contra Costa County 1906 visits/ETS (32 ETS) 1835 visits/ETS (32 ETS) San Ramon Regional
Medical Center
Contra Costa County 1526 visits/ETS (12 ETS) 1578 visits/ETS (12 ETS) C. Acute Care Hospitals in Alameda County and Contra Costa County with Basic or Comprehensive EDs 66 RHIA
Reference #
Report or Data
Set Source
Data Set Description URL Data Used in HIA Data Location 1 Annual Financial
Disclosures
Report 2012
Hospitals and long-term care (LTC)
facilities report detailed annual
facility-level data on services capacity,
inpatient/outpatient utilization,
patients, revenues and expenses by
type and payer, balance sheet and
income statement.
https://siera.
oshpd.ca.gov/
FinancialDisclosure.
aspx
Total Patient Revenue Page 12
Clinical Operations Page 17
Nonclinical Operations Page 18
2 Annual Financial
Disclosures
Report 2016
See above https://siera.
oshpd.ca.gov/
FinancialDisclosure.
aspx
Total Patient Revenue Page 12
Clinical Operations Page 17
Nonclinical Operations Page 18
3 Hospital Annual
Utilization Data
2016 (including
ALIRTS)
Contains basic licensing information
including bed classifications; patient
demographics including occupancy
rates, the number of discharges and
patient days by bed classification, and
the number of live births; as well as
information on the type of services
provided.
https://www.
oshpd.ca.gov/HID/
Hospital-Utilization.
html#Pivot
Overview of capacity
and services offered
Pivot Table
4 Hospital Annual
Utilization Data
2017 (including
ALIRTS)
See above https://www. oshpd.ca.gov/HID/
Hospital-Utilization.
html#Pivot
Overview of capacity
and services offered
Pivot Table
5 Patient Origin
and Market
Share Reports
2012-2013
ZIP Code of residence for all ED visits
and hospitalizations
https://www.oshpd.
ca.gov/HID/POMS-
Report.html#Pivot
Pivot Table
REFERENCES
OSHPD Data Sets
67 6 Patient Origin
and Market
Share Reports
2016 - 2017
See above https://www.oshpd.
ca.gov/HID/POMS-
Report.html#Pivot
Pivot Table
7 Facility Summary
Reports 2013
Patient level data are reported
through the Medical Information
Reporting for California (MIRCal)
system. These reports display a
numerical and percentage breakdown
of patient level data. These Summary
Reports combine report periods into
an annual view of a facility's Hospital
Inpatient (IP), Emergency Department
(ED), or Ambulatory Surgery (AS)
patient level data.
https://www.oshpd.
ca.gov/HID/Facility-
Summary-Reports.
html
Patient Payer Mix
Emergency Department
Ambulatory Services
Inpatient services
Downloadable
Report
8 Facility Summary
Reports 2016
See above https://www.oshpd.
ca.gov/HID/Facility-
Summary-Reports.
html
Patient Payer Mix
Emergency Department
Ambulatory Services
Inpatient services
Downloadable
Report
9 Seismic
Compliance
Unit: Seismic
Performance
Ratings
Description of the seismic
performance (SPC) rating criteria
https://www.
oshpd.ca.gov/
FDD/seismic_
compliance/
SB1953/
SeisPerfRatings.
html
Definitions of SPC +
MPC ratings
Web page
10 California
Hospital and
Skilled Nursing
Facility Data
2018
This page presents information
for California hospitals and skilled
nursing facilities such as site plans
(also called "keyplans"), building
numbers, SPC/NPC ratings and
various links associated with the
facility. Links to the OSHPD Report
Center for open, closed, and old
projects are included.
https://www.oshpd.
ca.gov/FDD/Forms/
Keyplans/index.
html
Building Site Plans
+ SPC Ratings of
Buildings
Open Projects
Web page
11 General Facility
Listing 2017
All California hospital facilities in
2017
https://www.oshpd.
ca.gov/HID/Facility-
Listing.html
Acute care hospitals in
region
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acgov.org/Public- Safety/Paramedic-Plus-
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November 2017.
Associates in Process Improvement. Alameda
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acphd.org/media/476290/2016%20alameda%20
county%20ems%20system%20quality%20
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RAPID HEALTH IMPACT
ASSESSMENT