Systems ponder placing federally qualified clinics within EDs of hospitals
Systems ponder placing federally qualified clinics within EDs of hospitals
One way to help offset large amount of uncompensated ED care
Top executives of Detroit's five major hospital systems, in an effort to offset what some see as "inappropriate" ED care, i.e., primary care services for uninsured or underinsured patients, are considering a plan that would put federally qualified health centers (FQHCs) inside their hospitals' EDs. The FQHCs reportedly would be paid a monthly fee for each patient they treat.
"The rationale for considering this plan arose from the growing number of inappropriate uses of emergency services for primary care and chronic disease management," says Chris Allen, executive director and CEO of the Detroit/Wayne County Health Authority, which initiated a study of the situation. "The ED is episodic care at best. We're interested in patient-centered medical 'homes' and primary care access, rather than the emergency room."
Such a plan would benefit the hospital systems and the EDs, because a number of the uncompensated care cases occurring in the ED become bad debt, or are written off as charity cases, Allen says. "While hospitals provide wonderful services in the community, the average ED visit is $500. If it's a primary care case, it would be a $40 fee in the FQHC," he notes.
In Michigan last year, there was about $2 billion worth of charity or uncompensated care provided, and in Wayne County, it was in the neighborhood of $700 million, Allen says. "So, if care is being provided and not reimbursed, is there another way to provide that care in a patient-centered manner for nonemergent cases?" he poses.
Jesse Thomas, CEO of Molina Healthcare of Michigan in Troy, says, "The goal would be to get more revenue to the FQHCs by pushing as much appropriate business in that direction as we can." Thomas chairs the hospital-health center subcommittee of the Uncompensated Care Work Group initiated at the request of the Detroit housing authority.
Thomas notes that in addition to giving these patients a medical home, "EMTALA obliges you to follow the patient to the outcome of the service you rendered, and that's difficult in many EDs." If a satellite FQHC were set up in the ED, he says, primary care could be redirected to "a more appropriate delivery environment." Thomas adds, however, that "the ED has to be in agreement that this is a legitimate way to establish a medical home for basic care."
Obtaining that agreement might be difficult, if Jedd Roe, MD, MBA, FACEP, chair of the Department of Emergency Medicine at William Beaumont Hospital in Royal Oak, MI, is any indication. "Putting a clinic inside an ED seems problematic on many levels," Roe says. The first, he notes, is that the mission and goal of the patient visit is entirely different. EDs are there to diagnose and treat emergencies, determine patient need for the OR or admission, and act as diagnostic centers for health care systems, while the clinic is there to act as the primary care provider for the patient and all that entails.
"The two types of visits are very different operationally and require different resources," he says. "I believe ED efficiency is hard enough to manage with the regulatory environment without putting an FQHC inside the department and making triage more complex and likely compromising ED flow."
Allen says, "You could use a model where triage includes both the ED and the FQHC, so you can adequately respond with the right care for the right reason at the right time. There has to be collaboration."
How likely is it that the plan will be implemented? "There is consensus among all health system CEOs in this area that business as usual is not working and that something else has to be tried," says Allen.
Gregory Henry, MD, FACEP, vice president of risk management at the Emergency Physicians Medical Group, Ann Arbor, MI, is not as critical as Roe, although he's not convinced such a plan would accomplish its goals. "This will not save the hospital money. It will only do so if they will be laying people off," he states. "Part of the cost of the ED is not only helping patients, but being paid to be available."
The FQHC in the ED "just provides another way to send out the bills," he says. "I do not mind that, but you should call it what it is." Henry also questions whether an FQHC would operate 24/7, "but as long as they say we'll get paid for stuff we are not getting paid for, I'm OK with it." Operationally, he says, "it changes almost nothing. They have to register, somebody has to type in the information, somebody has to put them in a room, and somebody has to decide if they are emergent or a 'fast-track' patient."
Still, Henry says, the plan sounds like the establishment of a hospital-supported family practice physically next to the ED. "I don't want to sound overly cynical, but I am," he concludes.
Can FQHCs in EDs really be successful? The plan being considered by executives of Detroit's five major hospital systems to put federally qualified health centers (FQHCs) inside their hospitals' EDs is fraught with problems, asserts Jedd Roe, MD, MBA, FACEP, chair of the Department of Emergency Medicine at William Beaumont Hospital in Royal Oak, MI. "I'm just not convinced that this can be a reasonable business model," Roe says. "It's an EMTALA problem to take someone whose complaint is uncompensated and treat them differently than someone who presents with the same complaint. That's against federal law. In other words, you need to treat all nosebleed patients the same way." There are hospitals that have joint triage areas for an adult walk-in clinic and the ED, he says. In fact, Roe says, such as system was used at a hospital where he worked in Denver. "The way it worked, if the patient was suitable for the adult walk-in clinic, they went to it, but it was not based on the payer's ability," he explains. "You can create that kind of system, but the clinic in that setting was not within the ED." A clinic next door to the ED is one thing, Roe emphasizes, and a clinic within the ED is entirely another. "With ED stress and overcrowding, we are all about efficiency and patient flow," he explains. "While clinics have a certain patient flow, you're talking about a different kind, such as no-shows and patients with appointments; so, you're got competing operational interests and very different kinds of patients." Finally, "I'm not even sure, from a legal or compliance standpoint, that if you had a clinic within the ED, you could bill as a clinic," says Roe, because the patients are coming to the clinic through the ED. The bottom line, he says, is that the model is "unnecessarily complex." |
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