Urgent care

In the late 1980s, eight hospitals operated in downtown Milwaukee. Today there is only one, Aurora Sinai Medical Center.
Aurora Heath Care officials insist the city’s only remaining downtown hospital will remain in operation for the long-term future. However, Sinai, which serves many inner city residents, lost about $24 million last year, and Aurora officials have eliminated some services at the hospital in an attempt to improve efficiency and reduce costs.
The decline of hospitals in downtown Milwaukee and Sinai’s struggles demonstrate an emerging health care crisis in Milwaukee’s inner city.
"It is an absolute crisis," said Dr. Thomas Reminga, an emergency room physician at Columbia Hospital and a past president of the Milwaukee County Medical Society. "That’s not overstating it at all. It’s a huge issue. It is a crisis in the inner city."
"I think the whole health care system is headed for a meltdown," said Dr. George Schneider, volunteer medical doctor for the Greater Milwaukee Free Clinic in West Allis.
An array of socioeconomic factors are converging to create the health care crisis in the inner city. First and foremost, a growing number of lower-income city residents do not have health insurance. According to a 2002 survey by the state Department of Health and Family Services, 57,000 Milwaukee residents, or about 10 percent of the city’s population, do not have health insurance.
About 336,000 Wisconsin residents, or about 6 percent of the state’s population, were without health insurance, according to the survey. Nationally, the U.S. Census Bureau estimated that about 44 million Americans were without health insurance at that time.
Health care providers who provide care for uninsured patients lose money on those patients, largely because government reimbursements such as Medicaid do not cover the cost of the care. With that losing monetary proposition, the numbers of doctors and primary care clinics has dwindled in Milwaukee’s inner city.
The losses absorbed by health care providers to care for uninsured residents is passed on to full-paying patients in the form of higher fees. That contributes to higher health care costs in the Milwaukee area. Ultimately those costs are paid by businesses and their employees in the Milwaukee area who are saddled with some of the highest health care costs of any metropolitan area in the nation.
"Emergency rooms in general are being over-utilized and pressured to provide services, really because there is not enough primary care in the community, especially in the inner city," Reminga said. "When people don’t have access to regular medical care, they use emergency rooms. When they have a problem and when a doctor is not immediately available, then they come to the emergency room. This is a huge problem for the inner cities. They have minimal, if any, access to urgent care. For people who are in the inner city and not insured, the clinics are open 9 to 5 and not on weekends, and it may take months to get an appointment with a doctor. What are people to do if their child is vomiting or is having severe headaches?"
In 1998, Dr. Kevin Izard joined a medical practice in the inner city with two other doctors, Dr. Wayman Parker and Dr. Karen Watson. A Milwaukee native and an African-American, Izard said he wanted to practice medicine for people less fortunate in the inner city. Izard said he found out the hard way how difficult that task can be.
About one year ago, Izard, Parker and Watson broke up their practice because they were losing too much money. The government funds they received for treating uninsured patients was not adequate to keep their practice in business.
"The reimbursement is just too low," Izard said. "We were getting about 60 percent of commercial rates. There were some months after paying all the bills there was nothing left for me to take home. We all had to split up because we were losing too much money."
A handful of clinics serving uninsured patients, such as the Greater Milwaukee Free Clinic in West Allis, stay afloat with the help of private donations. The clinic is open two nights a week. The treatments are free, and care is provided by volunteers. The number of patients served at the clinic increased by 30 percent to 1,600 in 2003 and is up 15 to 20 percent so far this year, said Dr. George Schneider, volunteer medical director for the clinic.
The Sixteenth Street Community Health Center saw its patient load increase by 11 percent last year to 18,000 patients.
Izard now splits his time between teaching at the Medical College of Wisconsin and practicing medicine at the Family House Medical Clinic at 11th Street and Concordia Avenue. Like many clinics in Milwaukee, the Family House Medical Clinic has a long waiting list to see a doctor.
"My next open spot is in the last week of August," Izard said.
Wisconsin Hospital Association vice president Bill Bazan said some overcrowded central city clinics have two- to four-month waits for patients to see primary care physicians.
Uninsured residents who want to see a doctor right away often must go to hospital emergency rooms instead. Hospitals are trying to discourage that practice because it costs much more to treat patients in an emergency room, but without more physicians in the central city, lower-income residents have nowhere else to turn.
"People that don’t have insurance, and don’t know the system and don’t know where to go, when it gets so bad they come to the hospital ER. ERs are the safety net providers for the economic poor and uninsured in Milwaukee County," Bazan said.
The five major hospital systems in the Milwaukee area and the four federally funded qualified health centers in the city are working together in an attempt to increase primary care services in underserved areas of the city. They have made an appeal to U.S. Health and Humans Services Secretary Tommy Thompson for $8.85 million in federal funding to boost primary care in Milwaukee’s central city by expanding clinics and adding more clinics and doctors.
"There is a solution, and unfortunately it’s government funding for the uninsured," Reminga said.
Bazan said more funding is needed from the federal, state and local governments, as well as the private sector to increase the number of primary care physicians in the central city.
Aurora has provided funds to help Milwaukee Health Services, Inc. add more hours at its Martin Luther King Drive clinic to increase access to primary care for low-income city residents and relieve Sinai of some of those patients. Covenant Healthcare System is participating in several programs to encourage residents to receive preventative care from primary care physicians. Columbia St. Mary’s sponsors several clinics for low-income residents.
The entire community has a stake in increasing access to primary care for low-income residents because all businesses and their employees in the region must pay higher health care costs when low-income residents make inappropriate visits to the emergency room, Bazan said.
"There’s cost-shifting that goes on," Bazan said. "That’s why employers health insurance premiums are going up."
All Milwaukee-area hospital absorb some losses to care for uninsured residents. Last year, hospitals in Milwaukee County provided $83 million of free care, which was not reimbursed by anybody, Bazan said.
Most hospitals are able to offset the losses they incur from treating uninsured patients with revenues from full-paying patients. However, at Aurora Sinai, the city’s only downtown hospital, uninsured patients far outnumber full-paying patients.
"Eighty percent of our patients at Sinai are government pay or no-pay," said Paul Nannis, vice president of government and community relations for Aurora Health Care. As a result, the hospital lost $24 million last year. As a whole, the Aurora system’s revenues exceeded its costs by $22 million last year, despite the losses at Sinai.
"We lost more at Sinai last year than we made as an entire system combined," Nannis said. "We can’t continue to do that."
In recent months, Aurora officials made some changes at Sinai to improve the hospital’s bottom line, but those changes are further limiting the options for inner city residents in Milwaukee.
The emergency room at Sinai no longer fully treats non-emergency patients.
"Everybody who comes to the ER receives a medical evaluation right away," said Len Wilk, administrator of Aurora Sinai Medical Center. "If it is a true emergency, they are seen as quickly as possible. If it would be more appropriate for a primary care visit, they are referred to other clinics."
Aurora also closed its pediatric clinic at Sinai, because Children’s Hospital still has a clinic in space it leases at Sinai, Wilk said.
Aurora also closed its psychiatric unit at Sinai and St. Luke’s Medical Center, consolidating those services with psychiatric units at Aurora Psychiatric Hospital in Wauwatosa and St. Luke’s South Shore in Cudahy.
"All of our (psychiatric) units were below capacity," Wilk said. "With the (government) reimbursement we have, every hospital can’t have every service."
In another element of the inner city’s health care crisis, overcrowding at the Milwaukee County Mental Health Complex has resulted in delays for transferring psychiatric patients from hospital emergency rooms to receive treatment at the county facility.
"There is a crisis in psychiatric care in the inner city," Reminga said. "The inner city has a huge reservoir of people with psychiatric issues. That’s at the core of why they are where they are. They’re mentally ill and don’t have jobs or insurance, and they have nowhere to go. Psychiatric care is under-funded and under-covered by the health insurance industry."
Covenant Healthcare’s St. Michael Hospital in Milwaukee also made a change to its psychiatric unit. The hospital has stopped accepting highly volatile, involuntary patients, but is still taking care of the same number of patients, said Covenant spokeswoman Anne Ballentine. The change was made to ensure the safety of the hospital’s other patients, she said.
Like Aurora Sinai, St. Michael lost money last year because of the large number of uninsured residents the hospital serves. The hospital lost $10 million in 2002 and $16 million in 2003. Earlier this year, the obstetrics unit at St. Michael was shut down and transferred to St. Joseph Regional Medical Center, also a Covenant hospital.
The number of patients treated at Covenant hospitals for uncompensated care has increased by 55 percent over the last three years, Ballentine said. That includes charity care, which is care for low-income patients. It does not include losses caused by shortfalls of government funding such as Medicaid and Medicare.
"We lose money on almost all Medicaid and Medicare patients," Ballentine said. "Seventeen percent of every dollar we charge (full-paying patients) goes to covering the losses we experience in treating Medicare and Medicaid patients."
Medicaid, a combination of federal and state funds for health care of lower-income patients, only pays 58 cents for every $1 of cost, Bazan said.
Last year, Froedtert Memorial Lutheran Hospital lost $33 million as a result of government reimbursement shortfalls for treating uninsured patients. That does not include charity care and bad debt losses. The hospital lost $26 million for charity care and bad debt in 2002.
Milwaukee-area hospitals say they will continue to provide care for uninsured patients, and will use revenues from full-paying customers to cover those costs.
"We wouldn’t and can’t turn anyone away from the emergency department," said Eileen Jaskolski, vice president of mission services for Columbia St. Mary’s Hospital in Milwaukee.
"We take our mission and our moral obligation to provide care to those who need it very seriously," said Carolyn Bellin, spokeswoman for Froedtert.
"We are sponsored by a Catholic order of sisters. We have an iron-clad policy that says we will not turn away any people because of inability to pay," said Robert Speer, director of community partnerships for Covenant.
The rest of the patients and their employers will continue paying for that care.
The inner city health care crisis:
What to do about it
Dr. Thomas Reminga, an emergency room physician at Columbia Hospital in Milwaukee, has some ideas from the front lines about how to reform the American health care system.
Reminga says 30 percent of the American people do not have health care insurance, and too many employers do not offer health insurance to their employees.
The companies that provide health insurance for their employees and the workers who are fortunate to have health insurance are paying higher premiums to cover the costs of tending to those who do not, Reminga says.
Reminga, the past president of the Milwaukee County Medical Society, is president of Infinity HealthCare, a Milwaukee-based company that provides physicians and radiologists to emergency rooms in hospitals throughout Wisconsin and northern Illinois.
He also is the associate chairman of the Department of Emergency Medicine at Columbia Hospital, the director of Emergency Health Services in Milwaukee County, a member of the board of directors of the Wisconsin State Medical Society and chairman of the Medical Advisory Committee of the Milwaukee County Emergency Medical Services Council.
Reminga says several changes are needed to reform the nation’s health care system:
* Create more jobs for inner city residents.
* Increase government funding for the uninsured to provide incentives for health care providers to open primary and urgent care clinics in the inner cities.
* Require employers to provide at least catastrophic insurance coverage to employees.
* Require more insurance coverage and societal awareness for psychiatric care.
* Make the costs of medical procedures known to consumers, and make the consumers more affected by the cost differences between the providers.
"Today, nobody knows what a blood test costs. The patient doesn’t know what a blood test costs. The doctor doesn’t even know what a blood test costs," Reminga said. "If patients had an interest in what things cost, they would have a conversation with their physician and the hospital. I think, really, that’s the only real solution to bringing health care costs to any kind of semblance of competition. When nobody know or cares what it costs, then you get what we’ve got now."
Other people in the community are also calling for reforms to a system that is not working.
* "I think some kind of a national health care system has to be implemented where everyone is covered."
– Dr. George Schneider, volunteer medical doctor for the Greater Milwaukee Free Clinic in West Allis.
* "We know the greatest determining factor to getting care is insurance. It’s time people were insured."
– Paul Nannis, vice president of government and community relations for Aurora Health Care.
* "We have to do a better job of recruiting and retaining primary care physicians in Wisconsin, particularly in the inner cities. There has to be an emphasis on incentivizing practitioners to stay in this community. We have to figure out a better way to get consumers educated about how to access care, how to be compliant with therapies and how to look at prevention as a solution, and only look at emergency care when it’s absolutely necessary."
– Bevan Baker, City of Milwaukee health commissioner.
* "I think there is a moral obligation to serve lower income people. If you’ve got a health care organization that wants to serve southeast Wisconsin, but doesn’t want to serve the central city, I’m wondering what’s wrong here. We need to have Sinai (Aurora Sinai Medical Center) stay open. If there are problems with reimbursement, I’d be happy to work with them."
– Milwaukee Mayor Tom Barrett.
* "We have to create capacity for primary care before we can assist people in changing their behavior patterns. We don’t have capacity now."
– Wisconsin Hospital Association vice president Bill Bazan.
August 6, 2004, Small Business Times, Milwaukee, WI