At Swedish Medical Center’s Cherry Hill hospital, the “EMERGENCY” sign glows bright in the dusk above the emergency-room entrance. Some 18,000 people sought help here last year.
Right next to the sign, there’s another one on the building: “After-Hours Clinic.” Operated by Country Doctor Community Health Centers, this clinic — like Swedish’s ER — is open evenings and weekends.
This isn’t competition, but a partnership few would have predicted before the Affordable Care Act, also known as Obamacare. Swedish, a huge, specialty-oriented medical center, has plunked down startup money and a cheap lease to help tiny Country Doctor, whose two clinics were started by idealistic community activists in the late 1960s and early ’70s.
So what has brought these two very different organizations together? In a nutshell: the Affordable Care Act (ACA), with the rumbling disruptions in business-as-usual it has energized. It has changed incentives, brought insurance to people who never had it, and focused attention on unnecessary costs — for example, emergency-room visits for sore throats and ankle sprains.
Both sides see themselves benefiting from this partnership in ways that are part financial, part philosophical. Swedish gains a nonemergency after-hours alternative for patients; County Doctor creates another avenue for those who have had trouble accessing daytime care.
The ACA, by bringing insurance to more, makes the deal affordable for Country Doctor. And by signaling that doctors’ and hospitals’ future livelihood will be linked to value, not volume, the ACA has led Swedish to seek such a partner.
“Before the ACA, hospitals were kind of silos and the alternative providers were silos,” says Howard Springer, Swedish’s administrative director for accountable-care services. Now, for the first time, he says, the two have mutual incentives to cooperate.
The average person may not have read the ACA’s fine print or interpreted the writing on the wall as employers and governments increasingly refuse to play by the old fee-for-each-service rules. But many hospital and clinic leaders understand their world is heading in a new direction.
To make it financially, they’ll have to come together, one way or another, to provide a sort of health-care soup-to-nuts menu, each organization serving not just individual patients but the health of larger communities. This, both of these partners say, is new ground.
“We are not all things to all people,” Swedish’s Springer says. “We are illness-care providers, with a heavy emphasis on specialty care and inpatient care.”
Country Doctors’ clinics, by contrast, focus on primary care and low-income patients, says Dr. Rich Kovar, medical director for County Doctors’ clinics.
It just makes sense for Country Doctor and Swedish to each focus on what it does best, Kovar says. “This is not the solution to all our problems, but it’s the right direction.”
Care for communities
On one recent evening, Brian Stevens, a former sheet-metal fabricator, waits to be seen in the Country Doctor After-Hours Clinic, a bag of clothing and personal effects at his side.
Now homeless, Stevens, 44, does odd jobs for people, such as cleaning gutters and wrestling with climbing rosebushes. A few weeks before, he fell from a scaffold. At a hospital emergency room, he got an X-ray and was told he had no broken bones, and should see his primary-care doctor for follow-up care.
Even though he is newly insured by Medicaid, he couldn’t get in to see a doctor for the next two weeks, and he was hurting.
Another problem: He left his medications on the bus earlier that day.
Patients like Stevens are what Country Doctor does, says Dr. Rich Kovar, medical director for Country Doctor’s clinics.
These days, the clinics pay staff members and use electronic records. But their mission, Kovar says, hasn’t changed from their counterculture origins. Country Doctor began in an abandoned fire station with an all-volunteer staff, and what became Carolyn Downs Family Medical Center grew out of a community effort by the Seattle Black Panthers.
“Our specialty is people without insurance and on Medicaid. That’s what we do,” Kovar says.
Swedish, on the other hand, has been on a different track, building up its specialty centers and services, transforming its southern campus at Cherry Hill into a center for neurosurgery and cardiac care, beefing up its transplant program and building a showcase Orthopedic Institute at its First Hill campus.
Federal regulations have long required hospital emergency rooms to treat all, regardless of ability to pay. Many patients, unable to access care elsewhere because they lacked insurance or were at work during doctors’ hours, sought care in ERs for conditions such as coughs and bladder infections that could have been treated in a doctor’s office.
But as report after report has noted, the ER, with its high costs and lack of continuity for patients, is the wrong place for patients like Stevens, who may need social-services help as much as medical care.
The ACA, by fostering the notion that clinics, hospitals and doctors must think in terms of caring for communities, fueled concerns already afoot. Employers, looking for value, were complaining that uncompensated costs of inappropriate ER visits ballooned their insurance premiums, and the state’s Medicaid program was threatening to restrict payments if hospitals didn’t find ways to better connect patients with primary-care doctors and other services.
At Swedish’s Cherry Hill emergency room, nearly 19 percent of patients seen last year — more than 3,000 — were treated for nonemergency conditions.
“Vulnerable, homeless people — those patients are a huge expense to Swedish,” Kovar notes.
Country Doctor’s clinics, unlike hospital ERs, don’t have high overhead. Half of their patients have had no insurance — above even the 35 percent statewide average for community clinics.
Linda McVeigh, executive director of Country Doctor Community Health Centers, said her organization has long wanted to open such a night-and-weekend-hours clinic.
At about 62,000 patient visits last year, Country Doctor’s daytime clinics were nearing full capacity, and clinic providers often scrambled to find after-hours care for patients.
But after-hours care for people without insurance, cash or credit cards, McVeigh noted, has been virtually nonexistent. “Our poor triage nurses were hugely frustrated that they had nowhere to send people,” she said.
But before the ACA expanded Medicaid eligibility this year, she said, an after-hours clinic was not financially possible. The clinics, as Federally Qualified Health Centers, are focused on underserved patients and bound to take all, regardless of ability to pay. “My concern was that we would get all uninsured patients,” McVeigh said.
The Medicaid expansion makes that less likely. Unlike large medical centers, which often say they lose money on Medicaid reimbursements, Country Doctor’s leaders say they can operate very well on that amount.
Now, McVeigh is eager to bring more patients to the clinic, which opened quietly in December.
Because of federal regulations, Swedish ER staff members can’t simply say to patients with nonemergency conditions: “Hey, why don’t you go next door to Country Doctor?”
But Springer notes there is a “teachable moment” after a visit, when ER staff can explain to a patient that the next time they need a prescription refilled or their rash checked, they might go next door. And, he says, Swedish plans to promote the clinic in the neighborhood.
“My concern at this point is keeping us afloat for the next few months until we can get to a break-even point.” McVeigh says.
Kovar is enthusiastic about the partnership, but even so, he adds: “It’s a gamble. We’re betting the bank.”
“Every reason for us to be partners”
Up to now, major medical centers and community clinics haven’t formed partnerships in this town — or much of anywhere, actually, with very few exceptions.
“Before the Affordable Care Act, hospitals didn’t really partner or even know who the alternative-delivery providers were in their communities,” Springer said.
He recalls a question he put to chief financial officers of regional hospitals at a meeting in 2011: How many knew the name of the heads of their local community-clinic organizations? Not a single hand went up.
Since then, the ACA has changed the willingness and ability of both partners to form such a strange-bedfellows partnership, he said.
Both organizations are contributing. Country Doctor is providing staff, and Swedish, through its foundation, has given $200,000 to sustain the clinic through the startup, leased the building for $1 a year, and pledged to help advertise the clinic.
Kovar and Springer credit Dr. Ralph Pascualy, who heads the Swedish Medical Group representing Swedish medical providers, for seeing early on that Swedish was going to have to make a change.
“The business model had been working pretty well on fee-for-service,” Springer said. “That is not the model that is going to survive in the future.”
Pascualy and others realized that ACA aims to change incentives in health care, moving away from making money by simply doing more and more services — the fee-for-service model that Springer and others call a “volume-based” approach.
The new model, Springer said, will be more focused on value and accountability — meaning offering to provide efficient, cost-effective care to a whole group of people for a price that works for those who pay health-care bills, such as insurers or employers.
But to do that, Swedish calculated that it would have to “embrace and partner with other providers in the community,” Springer says, even though relationships may have been nonexistent or strained in the past.
“We’re trying to change it with this — this was intentional,” says Springer, who sees the model potentially rolling out more broadly.
“This is a kind of trust walk,” Springer says. “There is no reason for us to be competitors. There is every reason for us to be partners.”