From Roger McCullough’s early days working at the University of Alabama at Birmingham (UAB) Medical Center, he knew of the important work being done at nearby Cooper Green Mercy Hospital. In the 1970s, Roger McCullough audited a cancer information specialist, a position that provides resources to families and individuals to help them take care of cancer patients. 

As he shadowed one of the specialists, McCullough met a 21-year-old man diagnosed with cancer. With no job, no insurance, and a home address outside Jefferson County, the man had nowhere to go for healthcare.

“That was the first time it hit me that we live in a country where if you can’t afford to live you die,” says McCullough, now director at Cooper Green. In the 40 years since, Cooper Green Mercy Health Services remains the primary place where Jefferson County poor can receive care. “If you are outside Jefferson County, that same young man today likely would face the same barriers to healthcare,” McCullough says.

A Vital Piece

Cooper Green opened in 1972 as an in-patient care hospital with 319 beds. The hospital was partially a response to the demand for equal rights by Jefferson County’s black population. The county was the epicenter of the civil rights movement during the 1960s. Birmingham was considered the most segregated city in America and became the site of Martin Luther King Jr.’s campaign of nonviolent direct action in 1963. 

As the city struggled with inequality on its streets, the same scene played out in Birmingham’s hospitals. While white patients had access to UAB Hospital’s modern facilities, African-Americans received care in a separated and segregated basement facility. The disparity gave rise to the need for a healthcare facility that would adequately treat residents of the County regardless of race, income or social status.

Cooper Green was born out of that social upheaval. The hospital was established about a block away from the UAB medical complex. UAB continued to serve as the safety net healthcare organization for the state of Alabama while Cooper Green served the same role for Jefferson County citizens. 

The number of in-patients declined in the ensuing years as race became less of an issue in healthcare. UAB Hospital also offered a 1,000-bed facility adjacent to Cooper Green’s campus. “The need for the in-patient beds gradually declined to the point that it was no longer financially sustainable,” McCullough says. Meanwhile, Jefferson County struggled financially and sought ways to trim expenses. Cooper Green ended its in-patient service in December 2012 and began transitioning to a multispecialty ambulatory clinic model providing comprehensive healthcare and primary care.

The transition did not go as smoothly as many had hoped. The hospital’s significance to the civil rights movement made the change a major story in the media and the attention drew protests from people in the community. “At the end of the day, Cooper Green is a symbol for a long and hard-fought battle for healthcare equality in Jefferson County,” McCullough says. 

The decision to end in-patient services was also made quickly by the county board without fully working through critical details, like how the city’s other hospitals would handle the influx of emergency room patients that previously went to Cooper Green. “It proved to be far more complicated to close the in-patient facility,” McCullough says.

Complicating matters, Jefferson County filed for a $4 billion dollar bankruptcy in 2011 – at the time the largest-ever municipal bankruptcy in the United States until Detroit surpassed it in 2013. McCullough says the county’s financial struggles created distractions as officials tried to develop a new healthcare model for Cooper Green. Primary care providers lost faith in the clinic’s future and began leaving, creating waits as long as 17 weeks to schedule a primary care doctor’s appointment. 

To clean up the confusion left in the transition’s wake, a court-appointed receiver appointed McCullough as interim director of the clinic in May 2014. McCullough spent 30 years with UAB before retiring and going into management consulting. As the new head of the clinic, one of McCullough’s first tasks was to fix the long wait times to see a doctor. “You can’t tell a homeless person to go back under a viaduct for 17 weeks before they can get treatment,” McCullough says. 

The clinic hired nurse practitioners to diagnose and treat conditions, improving patient capacity and cutting down waits. That resulted in more positive media coverage and renewed interest from primary care physicians, who started coming back to the clinic. “The whole image of the organization began to change, the community perspective began to change,” McCullough says.

With more doctors and nurse practitioners, the clinic started a behavioral health clinic and women’s health clinic. “We were slowly able to add services back as our capacity for patients increased,” McCullough explains. “We are fully capable at this point of providing comprehensive care for patients well within our budget.”

Reaching Patients

Cooper Green today has 14 primary care providers and some 30 specialists. The outpatient clinic has an onsite pharmacy, radiology, lab, urgent care and other specialty services. Although it has stabilized its staffing numbers and services, the clinic is still working to reach more patients.

Sixty-three percent of the clinic’s 11,500 patients are indigent, defined as uninsured people whose incomes are 200 percent of the federal poverty level or less. The Affordable Care Act was designed to help all Americans get insurance coverage, but McCullough says the premiums and deductibles in even the cheapest plans are still out of reach for many of Jefferson County’s poor. Further, the state of Alabama has not expanded Medicaid, resulting in only 10 percent of Cooper Green patients with Medicaid coverage and about 23 percent with Medicare. 

Providing comprehensive healthcare to those individuals who could not otherwise afford it is Cooper Green’s mission. The clinic is accomplishing that goal through a partnership with the UAB Health System. As a leading academic medical center, UAB has resources and equipment that Cooper Green lacks. Many of the clinic’s specialists are UAB faculty members who practice at Cooper Green a few days a week. 

When a Cooper Green visitor needs more advanced care than the clinic can provide, it refers the patient to UAB, which then takes over the care and bills Cooper Green for the services. “The indigent poor in the county come here for their care,” McCullough says. “When we can’t provide care onsite, we’re the pathway for them to get advanced specialty care and to get hospitalized, specialty care.”

Cooper Green is working to become even closer to UAB by developing a new electronic medical records system that will allow doctors at either location to view a patient’s full medical history. “We have been able to show in the last two years that it’s a financially viable model,” McCullough says of the partnership between a comprehensive clinic such as Cooper Green and an academic medical center like UAB.

Economic hardship also increases the likelihood of psychological and social barriers to seeking out healthcare. “It’s a real challenge for us to engage this population in healthcare, keep them involved in primary care and encourage them to take responsibility for their own healthcare,” McCullough says. Cooper Green strives to make that access easier by cultivating a non-judgmental atmosphere where patients can be comfortable regardless of their background. 

Even for those who are willing, transportation to health services is another major hurdle for the poor. The clinic is also enlisting primary care physicians in outlying areas to provide services to the local indigent. Those providers then bill Cooper Green based on Medicaid rates.

Primary care visits are up more than 40 percent from May 2014, but Cooper Green has not seen a corresponding increase in specialty clinic visits. McCullough says that is an indicator that Cooper Green is doing a good job of managing its patient’s primary care, reducing the need for specialty services.

Cooper Green’s image today is that of a hospital that effectively treats society’s most vulnerable patients. “We’ve gone from almost closing our door during that transition to becoming a successful and financially viable, sustainable model for healthcare delivery to the indigent poor in the county,” McCullough adds. 

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