After a short break, Mirabile asked his colleagues a highly pertinent question: What kind of rap-port could be reached between independent providers and community hospitals to ensure that the burdens of charity care are being met in an equitable fashion.
“There’s an element of doing charity care the right way,” said Hennessy. He thought it essential that the financial disclosures are done properly and that patients treated are genuinely eligible. “There’s a portion of the population we’re all aware of that think healthcare is a right,” said Hennessy. “It’s real hard to provide charity care when someone’s walking down to the casinos every other weekend and blowing the money that’s the co-payment or their deductible.”
Participants at the forum were all sensitive to the charge that the in-dependent providers were drawing away the private pay patients and leaving the community hospitals with a higher portion of uninsured and underinsured. “The community needs to start looking at global amounts here,” said Allen. “How much is each hospital doing? Do we need to share that somehow?
As Allen explained, specialists move into their own, physician-run surgery centers not so much because of any gripe with the hospital but because they feel they have more control over the schedule, the timing, and the flow-through of the patients. Mirabile agreed that for a surgeon turn-around time is critical, and that entrepreneurial facilities have an intrinsic advantage.
Whitaker agreed that the move to ASCs was all about efficiencies and incentives. Regardless of the setting, however, “The number one concern of doctors still is the patients.”
“I am concerned about indigent care in these hospital settings,” Whitaker added. “I don’t have a solution for that. I wish I did, but I don’t.”
“If there were a way for these more indigent patients to have access to these better facilities, you’re talking about, we wouldn’t turn them away,” said Kunz. “They just don’t come knocking on your door. There needs to be some way to access it too.”
Kunz observed that his radiology practice entered into a cooperative agreement with Saint Luke’s more than 10 years ago. He believes that his institution’s entrepreneurial spirit made it better able to manage Saint Luke’s outpatient center. As part of the arrangement too, his partners did agree with the hospital to take care of a certain segment of the indigent patients. “It has worked out well for everybody, I think,” said Kunz.
Given that many indigent patients use the emergency room for primary care, noted Jill Watson, “The same doctors are seeing them.” Allen added that other indigent patients receive care through the teaching clinic at Saint Luke’s from residents, doctors in training and fellows. “Then the procedures that are required,” he said, “we do them, typically, in the hospitals.”
The question was raised as to whether a higher level of cooperation was possible between community hospitals and ASCs.
Jeff Colyer, MD, explained the nature of the problem from his perspective. As he saw it, one hospital after another was losing its access to physicians, plastic surgeons like himself, ophthalmologists, psychiatrists and other specialists. Although the problem has been more acute on the Missouri side, Kansas is not immune to the challenges raised by low reimbursement rates and a greater threat of lawsuits from emergency patients than from elective ones. Said Colyer, “Reward has gone down, and risk has gone up. So that’s why a lot of people are moving out of [emergency care.]”
“One thing we’re seeing,” said Allen, “is some collaborative arrangements, joint venturing in hospitals with physicians.” According to Allen, hospitals have come to see the logic in letting physicians manage these centers. “I think, bottom line,” added Allen, “We’re going to have to collaborate. It’s the right thing, long term. We need to be working together, not competing against each other.”
“I think too we’re going to have an overabundance now of ASCs,” said Mirabile. “They’re popping up on every campus.”
“In a free market, [the less competitive ASCs] will close,” Allen responded. “That’s what they should do. If they can’t make it, nobody should subsidize them.”
Still, as Kunz observed, these issues will not be easy to settle. The question as to who runs a hospital, the physicians or the administration, likely dates back to the opening of the first hospital. “We think we do the care,” said Kunz of his fellow physicians. “The hospitals think they do. This battle over control is intense.”
“We are prohibited by law from really cooperating and communicating on some of the issues,” lamented Colyer. The way healthcare is structured in Kansas and in Missouri, explained Colyer, all but breeds conflict. There might be eight or 10 competitive hospitals in a community and 50 different OB-GYN groups in that same community. “They look at the world completely differently, and their power in the market is very different,” said Colyer. “That’s a real challenge for everybody.”
John Hennessy believes that community hospitals are already in the process of reinventing themselves to stay competitive. California, he explained, has had ASCs and imaging centers for a good 30 years. Hennessy elaborated, “The hospitals just boot-strapped themselves and said, ‘We’re going to have to get competitive and talk to the patients about what they want and meet the patient’s needs.’”
“Hospitals that do that will be successful,” said Hennessy. He argued that in the future all hospitals will have to pay more attention to patient needs and concerns. One way to accomplish that will be through more “transparency” both in service and in price. “I’m sure Jim [Denning] loved it when LASIK was twice what it is now,” said Kunz, “but transparency has brought the price down but has also increased the access to care.”
In the cosmetic half of his plastic surgery business, Colyer observed, all transactions are transparent. “Patients call my office and ask, ‘How much is this procedure or that procedure?’ They also find out what
I’m about. They perceive a value to their price,” said Colyer, adding, “We’re actually in the high end of the market. But, we do fine.” The reconstructive side of his practice, however, offers no such clarity. The varying deductibles make it difficult to explain pricing in advance.
Durrie related what happened when his practice switched to 100 percent direct, private pay: His overhead went down and he was able to charge a lot less for office visits.