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The Mechanics
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Health Care Tue Jun 18 2013

The Future of Chicago's Safety Net Hospitals

Roseland Community Hospital has been in the news recently because of its financial struggles. According to Crain's, Loretto Hospital in Austin is a possible purchaser of Roseland.

Roseland is a safety net hospital, which means it is what the National Association of Public Hospitals and Health Systems describes as a hospital which provides "a significant level of care to low-income, uninsured, and vulnerable populations." A safety net hospital is not the same thing as a public hospital, which is operated by a government. Public hospitals can be safety net hospitals, but a safety net hospital is not a public hospital.

John H. Stroger Jr. Hospital of Cook County is a public hospital that is also a safety net hospital. Mount Sinai Hospital is a safety net hospital, but it is not a public hospital.

The unfortunate thing about the news regarding Roseland is it might be a sign of what's to come for safety net hospitals. As time progresses, safety net hospitals need to come up with solutions on how to stay afloat as they could lose patients as a result of Medicaid expansion.

The Cook County Health and Hospitals System has created a possible solution for themselves, which is the creation of CountyCare. CountyCare is a Medicaid program which covers services as long as they're provided by the CCHHS and "community providers" selected by the CCHHS. In a way, it's like a normal insurance plan that has in-network and out-of-network providers. The difference is the network is incredibly limited and this is through Medicaid.

The CCHHS might be in a special position because it's part of the Cook County government, it's a system that covers all of Cook County and it has Stroger Hospital. If other safety net hospitals in Chicago attempted to create the same thing it might be even more restrictive because they don't run multiple hospitals and clinics. What will ultimately work in favor of the CCHHS is the fact that they run clinics throughout Cook County, which could result in fewer people coming into the emergency room at Stroger or Provident when they really need to go to a clinic. As a result, less money will be spent on those patients.

CountyCare could prove to be a great thing for the CCHHS, but that only helps a small portion of the safety net care in the city.

Safety net hospitals have been characterized as "last resorts" for a long time, which has created a stigma that won't easily go away. With Medicaid expansion patients will have the comfort of having a form of health insurance and the knowledge they won't be turned away from nicer hospitals. However, people might stay at safety net hospitals if they're in their neighborhood. Safety net hospitals are vital to Chicago because they provide nearby access to health care. If they close, people have to travel farther for health care.

It's also entirely possible safety net hospitals could thrive under the Affordable Care Act because if there are more patients coming in with some form of insurance and fewer hospitals have to provide charity care for it could result in more revenue. It will also be interesting to see if cases of patient dumping start occurring around the country because of an influx of Medicaid patients who go to hospitals that aren't safety net hospitals. Medicaid doesn't reimburse as well as a private insurance and some hospitals might turn away patients who show up at ERs because of what coverage they have.

The next few years will be even more of an uneasy time for safety net hospitals as the options people are aware of for treatment increase. Hospitals that have served the poor and uninsured populations of cities everywhere have to find ways to survive, be it through improving the quality of care offered or other methods such as CountyCare. But even if Roseland manages to survive we have to be prepared for more hospitals in Chicago having financial problems.

 
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shechemist / June 18, 2013 2:59 PM

"It will also be interesting to see if cases of patient dumping start occurring around the country because of an influx of Medicaid patients who go to hospitals that aren't safety net hospitals. Medicaid doesn't reimburse as well as a private insurance and some hospitals might turn away patients who show up at ERs because of what coverage they have."


Hospitals ED's can not turn away patients based on insurance because of the Emergency Medical Treatment and Active Labor Act (EMTALA). If someone wants to drive from Lawndale to Northwestern's ED and they have Medicaid, Northwestern has to evaluated and treat that patient, then eat the most of the cost as Medicaid pays very little. This is what is happening now, which is why many safety net hospitals are in the red and folding.

Monica Reida / June 18, 2013 4:04 PM

Shechemist, you are right about hospital ED's not being able to legally turn away patients based on insurance. However, just because it's illegal doesn't mean it hasn't been done. In fact, the Office of Inspector General for the U.S. Department of Health and Human Services lists multiple instances where University of Chicago Medical Center has committed patient dumping since 2008.

shechemist / June 18, 2013 5:15 PM

From the website: In each CMP case resolved through a settlement agreement, the settling party has contested the OIG's allegations and denied any liability. No CMP judgment or finding of liability has been made against the settling party.

There are two cases listed and one is not a case of 'dumping' as much as a case of a patient not being admitted properly into the ED, after being brought in by EMS, then not triage, who then died in the waiting room.
Clearly a mistake, but dumping?

I've worked in an ED and have never seen people turned away, including people who clearly did not require ED services and had no insurance coverage. I'm not saying that it never happens, but it is a fairly rare event. Even your website sited indicates that it is fairly rare.

Also there is a line between 'dumping' and referring to a specialist for treatment. You can show up to an ED with a broken leg, get a sent home with a stabilizing brace, a 3 day script for pain killers, and a referral to see an ortho doc in 2 days for setting and casting when you have insurance. That isn't 'dumping', that is standard of care.

Monica Reida / June 18, 2013 7:46 PM

I've been in three majors ERs in Chicago and I've gathered that not properly triaging a patient brought in by an ambulance is a pretty egregious error.

I'm not saying that patient dumping is rampant. But it happens even though EMTALA prohibits such an act and I fear it might occur more often in the future. That was the point of the passage you quoted.

I'm also very familiar with being referred to a specialist. Trust me, I didn't accuse Northwestern Memorial Hospital of patient dumping when they evaluated me for a shoulder injury in their ED, prescribed pain killers and told me to follow-up with my internist. I understand that's how health care systems work.

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