Lowcountry hospitals are normally locked into a fierce battle for patients.
But starting Tuesday, three hospital systems are teaming up on a new project to keep patients out — specifically out of their emergency rooms.
The Medical University Hospital, Roper St. Francis Healthcare and East Cooper Medical Center want to make sure that uninsured ER “frequent fliers” are connected to one of several community clinics for free or discounted primary care.
But these hospitals aren't collaborating for the sake of collaboration. There are millions of dollars at stake.
The money is tied to the state government's broad alternative plan to expanding Medicaid under the federal Affordable Care Act. Conservative leaders say they want to help make residents healthier, but don't want to grow South Carolina's Medicaid roll to accomplish that.
“Our system is broken. My Medicaid system is broken. Their hospital system is broken,” said S.C. Medicaid Director Tony Keck. “This program is designed truly in the spirit of system improvement and process improvement, recognizing that good people, many times, work in bad systems, so you have to change the system.”
The Legislature passed a proviso this spring to incentivize hospitals in South Carolina to improve health outcomes.
To that end, the Medicaid agency decided every hospital in the state needed to submit a formal “Healthy Outcomes Plan” in order to receive 100 percent of their annual Disproportionate Share Hospital payments. The agency distributes more than $450 million each year in DSH payments to compensate hospitals for the care they administer to the uninsured.
“What we're saying is we want you to engage with these uninsured patients differently than you have in the past. We think they could be much better managed,” Keck said. “You don't have to participate in it if you don't want to, but if you don't, you don't get your full allocation of DSH money.”
Every hospital in the state submitted a plan and many, like the three systems in Charleston, chose to partner with each other. Trident Health submitted a plan separate from the other Charleston hospitals.
Starting Tuesday, Medical University Hospital, Roper St. Francis Healthcare and East Cooper Medical Center will target 1,243 uninsured ER “super-users” in the Lowcountry, many suffering chronic conditions like diabetes, hypertension and cardiac disease. The goal is to ensure that these patients aren't using the emergency room for primary care simply because they don't know where else to go.
Within the Roper St. Francis system alone, data shows that more than 100 patients visited an emergency room at least 15 times last year. One patient went 77 times.
“It's impossible for one hospital alone to solve this complex problem,” said Dr. Mark Lyles, the Medical University Hospital's chief strategy officer and the project's clinical leader.
The collaboration is actually a renewed effort by these three systems to leverage an existing program called AccessHealth Tri-county Network, which helps connect low-income, uninsured patients with health care resources in the community.
These clinics include the Franklin C. Fetter Family Health Center in Charleston, the St. James Santee Family Health Center in McClellanville, the Barrier Island Free Medical Clinic on Johns Island, the Dream Center Clinic in North Charleston, the Charleston Mental Health Clinic, the Dorchester Mental Health Clinic in Summerville and the statewide Welvista Medication Assistance Program.
The legislative proviso allocated millions of dollars to help bolster some of these free clinics and federally qualified health centers.
By collaborating with these clinics and the other hospitals, “We're really protecting the dollars that we get,” said Anne Sass, grants director for the Roper St. Francis Foundation. “If we did not submit the application, we would only get 90 percent of our Disproportionate Share funding.”
For Roper St. Francis Healthcare, 10 percent of their projected DSH funding is $2.2 million next year. For the Medical University Hospital, which treats the most uninsured patients in Charleston, 10 percent of their annual DSH payment equals $3.75 million, and for East Cooper Medical Center, that's $250,000.
But participating in the Healthy Outcomes project this year doesn't mean that the hospitals have to produce any real results to get their money.
“We didn't feel the need to immediately put very defined outcome goals on the project,” Keck said. “One, because we don't know how fast we can move and improve. And two, the first phase of this is to learn what works and what doesn't work.”
The hospitals must submit emergency room admissions data to the Medicaid agency, but will not be judged by those numbers this coming year.
“It will probably be this time next year before we see any of that preliminary data,” said Melanie Matney, executive director of Access Health SC, who helped the Charleston hospitals submit their plan. “It takes a while to make a change.”
Reach Lauren Sausser at 937-5598.