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Is it Still a Hospital if There's No ER?

Analysis  |  By Philip Betbeze  
   July 21, 2016

Closing or keeping open a money-losing hospital can be a career-limiting event. So one smart CEO and his board chose a third option.

Baton Rouge General CEO, Mark Slyter, knew that losing $2 million a month at one of the health system's hospitals was unaffordable and that it was a crisis. But what to do?

Baton Rouge General's Mid City campus had become the city's default safety net organization following the dismantling of Louisiana's unique charity care system over a period of years. The net effect was that huge financial losses were transferred to other hospitals—and Baton Rouge General's Mid City campus was arguably ground zero.

The main problem wasn't necessarily the hospital, but the ED, and specifically, the fact that so many people who didn't need to be seen in that setting were coming.

More importantly, one in three patients had no insurance of any kind: no commercial, no Medicare, and no Medicaid (until July 1, 2016).

And speaking of commercial insurance, only 13% of the patients coming to Mid City's ED had that. Slyter calls the state of affairs in early 2015 "an emergency situation."

But instead of closing the hospital, a decision that would have been draconian and very difficult politically, Slyter and his team found another way—one that allowed the health system to embrace value—by closing Mid City's ED and redeveloping the hospital around gaps in the health system's care continuum.

Data backed up the decision.

"We found that of the people who were visiting the ED there, four of five patients could be treated more effectively elsewhere and were really not emergency patients," Slyter says. "They could be seen in a lower-intensity and lower-cost setting."


Related: 'Microhospitals' Filling Some ER Needs


Thanks to taking time to figure out the patient mix and what those patients really needed, and reorienting the hospital toward that data, the health system could not only limit its immediate cash burn but position it much better for population health principles.

Many citizens protested the decision, but Mid City's ED closed in late April 2015, and the transition began. Is it still a hospital? Merriam-Webster makes no mention of an emergency department in its definition of a hospital, but having one is certainly a requirement in most payer and Medicare definitions of a hospital.

So by those definitions, Mid City is no longer a hospital, but it still hosts inpatients in certain services, and has added more services in the post-acute realm, so it's far from a shell of itself, says Slyter.

"We looked at the ED closure not only as an opportunity to address unsustainable financial needs but to address care more effectively and move us down the path of value, which is where we're convinced we're going as a system," says Slyter.

"Our plan was to reinvent Mid City and make it more focused on community need, but also add to the continuum of care which we have here, at the Bluebonnet campus."

The reinvention largely encompasses ambulatory, not acute care, and focuses on seniors and other patients with chronic health conditions as well as those with behavioral health needs.

Inpatient behavioral health services actually expanded at Mid-City, with 19 beds added to care for patients age 50 and older with depression, bipolar disorder, and dementia, among other diagnoses, and plans include expanding Mid City's Behavioral Wellness Center outpatient services for adults and adolescents.


Related: Mental Health Programs Gaining Momentum


Mid City will also house the Health Innovation Center, a pilot program that will provide comprehensive, team-based care. It will include behavioral health, pharmacy counseling, primary care, nutritional counseling, education and health coaching to patients with complex medical needs such as diabetes or heart disease.

The health system has also expanded primary care clinic access at its Mid City Medical Clinic, including walk-in and weekend appointments. For uninsured patients, the clinic offers a flat nominal fee and reduced lab rates. It also houses a hospice facility, home health, skilled nursing and the system's School of Nursing.

"This was a short-term challenge, but we incorporated it into our long-term planning," Slyter says.

Philip Betbeze is the senior leadership editor at HealthLeaders.


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