Access to health care is the No. 1 community health need, local medical entities say, and access to that care shouldn't be primarily through emergency rooms.
The entities - which include hospitals, the Cole County Health Department and the Community Health Center of Central Missouri - produced a community health needs assessment this year with the goal to identify the core issues to address in the community and to come up with how to provide the right care at the right time, at the right place and at the right cost.
"There's clearly a need in the community to do so," said Brent VanConia, president of St. Mary's Health Center. "Our question is how can we provide access in a different way, a cheaper way, and educate folks on how to access that?"
VanConia, along with other local hospital officials, believes expanding Medicaid in Missouri will help with a portion of the access to care issue, but improved access to care won't solve everything.
"I think one of the things we deal with is that sometimes it's not just that people need care, but that sometimes we give care in the wrong space," said Janet Weckenborg, vice president of operations at Capital Region Medical Center.
She said emergency care continues to be an expensive unit to operate. At any time, emergency departments have to be ready for high-level trauma to walk through the door.
"You have to have all of your resources immediately available," Weckenborg said. "Sometimes, what we find is that communities gravitate to using the emergency room for things that are not that high-class of trauma or an immediate emergent situation."
Dr. Randall Haight, vice president of medical affairs at CRMC, said that when people show up to a hospital's emergency department, doctors treat the immediate illnesses presented, not longer-term health issues, such as high blood pressure, diabetes or other chronic health issues, which would be noticed through regular visits to a physician.
"It (the illness presented) may not be emergent, (it may be) something like a sore throat or tonsillitis," he said. "They get treated and at the same time, they may have high blood pressure or other ongoing illnesses, but because they have no ongoing relationship with a physician, that never gets treated.
"They're getting a piecemeal health care that's truly not in their best interests."
VanConia and Weckenborg said it's important to educate the community on what health resources are available to them before they make the decision to visit the emergency department.
Weckenborg and some of her colleagues have looked into an emergency department model recently implemented by Heartland Health in St. Joseph that has produced results that show fewer patients using the emergency department for less serious issues.
Heartland Health has a goal to decrease the amount of money its population spends on health care.
"So, one way to do that is to teach people when you've got a condition that isn't as serious, we don't want you to use the emergency room," said Janie Schumaker, service leader of emergent and urgent services for Heartland Regional Medical Center. "We want you to go to your medical home or your primary care physician.
"We want to teach people to reserve the emergency room for more serious things."
This prompted Heartland Health to implement a new emergency department model nearly 18 months ago. Their previous model was standard - every patient was seen by a physician and treated no matter the issue.
The new model is based on the severity of patients' issues. As soon as they enter the emergency department, patients are sorted based on the severity of their issue and assigned a number on a scale from 1-5.
One means the condition is serious and if not treated quickly, the patient may lose life or limb.
Fives are assigned to patients with less severe issues, such as a sore throat or an earache.
"Fours and fives are most usually patients who could have been seen in another setting," Schumaker said.
She said fours and fives are bedded immediately, just like others, but they are then seen by a nurse practitioner, physician assistant or physician who completes a medical screening examination.
"That's really key," Schumaker said.
Through the examination, it is determined whether the condition needs treated in the emergency department or not. If not, the patient is navigated to a different venue of care.
How the patient will be paying for his or her health care - whether through private insurance, Medicare, Medicaid or self-pay - determines where he or she will be treated.
Providers within Heartland Health's system, as well as the town's federally qualified health center, hold several appointments every day for patients who come from the emergency department.
If you are a Medicaid patient, you are sent to the federally qualified health center.
The self-pay population is sent to a mobile clinic located outside Heartland Regional Medical Center. The first visit to the mobile clinic is free for those who self-pay.
Privately insured patients are directed to various providers.
While a navigated patient is not charged a facility fee through the emergency department, he or she is charged a small fee for the medical screening examination.
If a patient decides he does not want to be sent away from the emergency department, he must pay a certain amount up front before receiving additional care.
All of the navigation is coordinated by someone hired by the hospital. This person also follows up with the providers to see if patients show up for their appointments.
"The biggest success I can speak to is that when we navigate people, we see a good percentage of patients that keep their follow-up appointments," Schumaker said.
She said the organization hasn't benefited financially from the new model because it actually loses insurance and Medicaid reimbursements to the providers to whom patients are navigated.
"We have also seen a little bit of a decline in lower-acuity (lesssevere-issue) patients coming to the emergency department, though," she said. "Our objective here is behavior change and overall decreasing the health care spend for our population."
Plans in Jefferson City
While CRMC and SMHC have no set plans of implementing this Heartland Health model, hospital officials do see its benefits.
"The advantage there is they (patients) have the option to either pursue the emergency department visit or an alternative method before they've financially committed themselves to do so," said Tom Luebbering, vice president of finance at CRMC. "Whereas if you go ahead and treat them, all of a sudden they've got the burden of paying that bill and they really didn't know what the amount was going to be before that.
"This does give them the opportunity to choose, so to speak, how much they want to pay out of pocket for their health care at that point in time."
VanConia said it really does change patients' behavior.
"If they know they have to pay $50 before they're treated, people know if it's a low-level emergency or if it's a highlevel emergency. And if they're uninsured and they have to pay $50, they're going to go someplace else," he said.
He believes one thing CRMC and SMHC can do is educate people and make them aware of the alternative resources available.
In terms of access to health care, VanConia said, it becomes critical for people to address issues during prevention or in the early stages so it doesn't get to the point that they need to visit the emergency department. Medicaid expansion becomes critical in this, he said, granting greater health care access to 300,000 additional Missourians.
Medicaid expansion and the emergency department
"You do have a few other choices if you at least have Medicaid," VanConia said. "At least you don't have to worry about not having any coverage and being 100 percent responsible for the bill.
"You've got some insurance and coverage, and you can access prevention or it's easier to access the urgent care because there again, it's a cheaper form (of health care) and you've got insurance that can cover it."
In 2010, President Obama signed the Affordable Care Act, a law that includes comprehensive health insurance reforms that will roll out over the next few years. For 2014, the law gives states the option of expanding Medicaid to up to 138 percent of the federal poverty level, with full federal funding for the first three years and at least 90 percent funding the following years.
Missouri's government has not yet decided what the state will do.
Tony Houston, executive vice president and chief operating officer at SMHC, said expanding Medicaid would allow more people to build relationships with physicians and primary caregivers and make them less likely to visit the emergency department for a less severe issue.
"Really, that's where in my opinion the rubber meets the road, relating to the issue around Medicaid expansion," Houston said. "You allow more citizens of Missouri to access health care in a more consistent way, as opposed to here and there as they need it or when it's convenient."
He said he hasn't yet heard this message in terms of expansion.
"It's allowing our neighbors to develop a relationship with caregivers so that they can take care of their total health, not just be there when they have a sore throat," Houston said.
Luebbering said it's a sad reality that the individuals who financially can't afford health care are the ones who access the most expensive form of health care, the emergency department. He said there are some insured payers who access the emergency department inappropriately, as well.
"We're roughly about 5 percent Medicaid and about 5 percent self-paid overall in the hospital. But in our emergency room, Medicaid is about 23 percent of our business and self-pay is about 20 percent of our business," Luebbering said. "It clearly shows that they're not accessing health care in the same way that the insured or Medicare or those with private insurance are accessing our system."
He said there are other resources for people to use, such as primary care physicians or urgent care.
"There are resources in the community that are cheaper than the emergency room that we'd like to move this patient volume into," Luebbering said. "Both facilities (CRMC and SMHC) have urgent care centers which are much cheaper health care for them and the exact same results.
"They're still going to get to see a doctor."