Ambulatory care centers are decreasing the volume in rural EDs.
In the past decade, Immanuel-St. Joseph’s-Mayo Health System in Mancato, MN. has weathered many changes. The 272-bed hospital with a primary service area of 70,000 people has adapted easily to shifts in the health care system in a state on the cutting edge of managed care.
So, hospital management definitely knew what was on the horizon when Minneapolis-based NOW Care Centers, Inc. opened an ambulatory clinic in a town that had previously relied solely on their hospital and it’s emergency department.
"It means the income for the physicians in the ED is impacted a little bit. They [the ED group] have fewer people now," says Jerry Crest, Executive Vice President at Immanuel-St. Joseph’s. "They are covering less hours, they have less overlap. So, that means we still have physicians there, but we don’t have quite as many hours of professional coverage a month. It’s still 24 hours a day, of course. But we used to have 32 hours of coverage in 24 hours. We may be down to 30, or something like that."
The hospital can withstand the loss in patient volume, but Crest says he is concerned about the overall effect on the community.
Though increasing the choices available to health care consumers may serve to reduce costs in an urban environment, the same is not true in a rural, or semi-rural setting, he says. "What you are really doing, is adding to the cost, because we still have to be available to handle the emergency cases that come along. So, our costs don’t go down because we drop a few walk-in cases that come in in the evenings."
Following the opening of the NOW Care clinic, the hospital system opened an urgent care clinic of its own to compete. Now, says Crest, there are two more facilities with two more sets of physicians, and two staffs operating in a community that had been served by one.
"The cost to the community in Mancato, Minnesota, has gone up because we have two urgent care centers now, in addition to an emergency department, open on the evening and weekends," he says. "We have to maintain the staffing and everything else in the emergency department and now we’ve added new costs in the form of urgent care."
Though the people who used to come to the ED with an earache are now paying less for their care at an urgent care facility and are being seen faster, the surgical patients and cardiac patients will end up paying more for their care, which ultimately affects the community as a whole, he adds. "The total cost of delivering service has gone up and the total charges ultimately, to the employers or to the people who use those services, is going to go up."
Hospitals are going to have to rethink the way they operate, if they are going to go forward in the changing health care environment, says William Wenmark, the CEO of NOW Care.
"Many of them are too large, too inefficient in the way they do things . . . HMOs are not going to pay for a sore throat to come through the ED. They are not going to pay the facility fee. Why would they have a laceration repaired in the emergency room, when they could have it done in an urgent care at a third of the cost?"
Traditionally, hospitals have used urgent care as a way to finance part of the cost of treating the higher levels of acuity that came to the ED, says Charles Pexa, MD, FACEP, medical director of NOW Care.
But, in some cases, the urgent care inflated the actual volumes of the emergency department, so they were overstaffed for what they were designed to do, he claims.
"When you looked at ERs, they seemed to have a very large number of patients coming through, when in fact a significant percentage of those patients were urgent care," says Pexa. "ERs were saying they were seeing 100,000 patients a year, when maybe 50,000 of them were urgent care."
On the other hand, the additional staffing necessitated by the volume often helped the ED better perform its vital functions, he says. "Nevertheless, these large numbers of patients allowed the ER to maintain the staff that it had. In a sense, it was also good because if you had something really bad come in, you had all these doctors ready to handle it."
But now, in the state of Minnesota, most managed care plans have educated their members well, and they are calling nurse advice lines before going to the ED or doctor’s office, says Pexa. "If it’s something minor, they send them to an urgent care because it costs less."
By the time an urgent care center opens up down the street, acknowledges Crest, it may be too late for EDs to do anything but react to the decrease in volume.
"I think hospitals have probably made a mistake over the years," he muses. "We’ve said, Well, we’ve got to staff that emergency department, we just have to charge those people more.’ Why? Maybe instead if someone walks into our emergency department with an earache and doesn’t need our emergency services, maybe we ought to charge them a lot less than they have been historically. Put the charges where they belong. Treat the others like they were urgent care with the charge structure and maintain one quality viable system in the community."
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