‘A huge shift’ in care for Eastern Iowa hospitals

CEDAR RAPIDS - Mercy Medical Center broke ground on two major projects this summer - a 60,000-square-foot, three-story outpatient medical building in Hiawatha and a clinic near Kirkwood Community College - that will have urgent care and primary care services in addition to imaging and lab services.

The construction illustrates a major shift in health care - hospitals pushing to care for patients outside traditional hospital walls through more preventive care, outpatient procedures and follow up services.

'We're certainly seeing a huge shift - some of that is driven by technology,” said Dr. Mark Valliere, chief medical officer at Mercy, explaining that surgical procedures are better than they were even five years ago. 'It's also what patients are seeking. They're pushed to high-deductible health plans and are looking for cost effective services.”

Common surgeries such as hysterectomies, appendectomies and gallbladder removals are all now outpatient procedures while more orthopedic surgeries - those involving the musculoskeletal system - are heading in that direction, too, with the length of stay in the hospital getting shorter.

Mercy has used its main campus for outpatient procedures for quite some time, Valliere said, but patients are looking for a different, more convenient experience.

The Hiawatha Medical Park, which will feature an ambulatory surgery center, urgent care, lab and radiology services, will open in spring 2016.

Volume to value

Xi Zhu, an assistant professor of health management policy at the University of Iowa, said a number of factors are driving these changes, but they all revolve around the idea of moving from volume to value. Payers such as Medicare and Medicaid are now more interested in the type of care being given rather than the number of patients seen.

'There are external factors and pressures from payers to have more value - care with good patient satisfaction and isn't breaking the bank,” Zhu said.

Decreasing readmission rates, creating Accountable Care Organizations and transitioning to a pay-for-performance payment model are all ways to control costs, he said.

'It's all about providing the appropriate care at the appropriate place with the appropriate cost,” he said.

Outpatient procedures at Mercy now greatly outpace the number of inpatient procedures, Valliere said - with 10,000 to 11,000 inpatient procedures performed last year compared with almost 600,000 outpatient procedures, which also includes lab work and other services.

'But the revenue is an awful lot closer” between inpatient and outpatient procedures, he added. 'There is a huge imbalance between the number of people touched and dollars.”

Ted Townsend, president and CEO of UnityPoint Health-St. Luke's Hospital, said this move to outpatient services has been taking place over the last 30 years, however, the edges keep moving.

'There's new technology, a new approach comes along,” he said. 'We keep moving the dial.”

The Surgery Center of Cedar Rapids, which is jointly owned by St. Luke's and community physicians, added 7,000 square feet to the building in 2014, which included two operating rooms and 12 additional patient care rooms. Surgery Center Cedar Rapids performs about 7,400 procedures each year, and officials said at the time of the expansion that the new space will allow an additional 500 procedures annually.

'The surgery center is less intimidating,” Townsend said. 'It's also a lower cost alternative.”

Despite the shift, occupancy rates at Mercy have held steady, Valliere said, explaining that occupancy rates for the past five years have stayed within plus or minus 5 percent of one another, and 2015 even had the highest rates in that time frame.

'It could be flu related,” he added. 'We had a busy flu year. Some things are not predictable.”

Townsend said St. Luke's has seen a steady step down in admissions, dropping from about 19,700 in 2008 to 17,700 in 2014. There was a bit of a bounce back in 2015 as well, he said.

Being proactive

Providing proper follow-up care to reduce readmission rates and ensuring patients are receiving preventive care services are two other pieces of the cost puzzle, experts said.

Mercy and St. Luke's clinics are working to get patients up to date on things such as annual mammograms, colonoscopies and immunizations. Initiatives such as medical homes - a comprehensive, team-based approach to primary care medicine - and care coordinators - who work to find possible gaps in patients' files, such as a missed Pap smear - are ways hospitals are working toward keeping patients out of the emergency room.

The addition os social workers and case managers at clinics help primary care physicians better track and manage patients, Townsend said.

'We're trying to refocus to a more appropriate utilization of health care services,” he added.

'But it's difficult to tell in a five-year period and reflect on the impact on admissions,” Valliere said. 'We need a few more years before we can say there's a downturn in diabetes complications, for instance. But we think it will.”

In addition, payers now can penalize hospitals if patients are readmitted, which is pushing health care organizations to improve follow up practices and avoid unnecessary care, Zhu said.

Mercy has worked to decrease heart-failure readmissions by opening a clinic that works with that populations and implement a telemonitoring program that looks at patients weight, blood pressure and other parameters to make sure patients are healthy.

'We can watch patients remotely and be more proactive,” Valliere said.

St. Luke's has introduced care coordinators to work with patients following a discharge from the hospital. The coordinators answer questions regarding medications and go over discharge instructions. Townsend said this focus has helped bring readmission rates down from 18 to 20 percent in 2009 to 11 to 12 percent in 2014.

'It's hard work, there are a lot of moving parts,” he said.