University of Chicago Medical Center Redefines Role, Reduces Emergency Care Access: Critics Blast Urban Health Initiative as Payer “Cherry Picking”

Urban Health Initiative 

To address these needs, and reduce the number of patients with nonemergency conditions visiting the UCMC, the hospital launched the Urban Health Initiative in 2005. Among the key officials who launched the program was the hospital's Vice President for Community and External Affairs, Michelle Obama. Since becoming First Lady, Michelle Obama has resigned from the $317,000-a-year post, which was nixed shortly after her departure. However, during her time at the hospital she nurtured the health initiative and helped bring a public relations firm, ASK Public Strategies, co-owned by Barack Obama's chief campaign strategist, David Axelrod, to help sell the program to the public.

Those efforts proved somewhat successful, as the public generally accepted the Urban Health Initiative, and the hospital earned editorial plaudits from publications such as the Chicago Sun Times. But not all coverage was positive, and some critics decried the $8 million plan as an effort to curb access to the UCMC ED.

Troubling Incident 

In August, 3 months before the presidential election, Sen. John McCain criticized his opponent for campaigning to expand health care for Americans while Axelrod ran a campaign to “cut coverage for the poor.”

And in a Washington Post story that ran at the time,1 Jeffrey Schaider, MD, chairman of emergency medicine at the public institution John H. Stroger Jr. Hospital of Cook County, also expressed skepticism about the UCMC's motives. Dr. Schaider said his ED sought as part of its mission to treat all patients, whether their ailments proved urgent or not. It's simply not practical for low income workers to always visit clinics that may have limited hours, he said.

“Often, the patients think it's something serious when it's happening to them,” Dr. Schaider told the Post. “And a lot of the time, the patients are right.”

It was to Dr. Schaider's hospital that the mother of 12-year-old Dontae Adams, Angela, turned after she said UCMC officials began pressing her about insurance coverage last August, a story made public 6 months later.

“I asked them why that should matter. My child's lip was literally gone,” Adams, a medical assistant whose only insurance is her son's Medicaid coverage, told the Chicago Tribune.2

Despite her demands and pleas, the UCMC medical staff refused to admit Adams' son, and after giving him a tetanus shot, prescriptions for antibiotics and Tylenol No. 3, told her to follow up with the Cook County public hospital system in 1 week.

The Tribune exposed this troubling incident (hospital officials maintain the boy's care met medical, legal and ethical standards) just days after the UCMC announced plans to trim its workforce and escalate plans to ensure that only patients truly requiring emergency care presented at its ED. Citing significant financial concerns, the hospital said it was laying off 450 workers, or 5% of its staff, and cutting $100 million from its annual budget. Unannounced, but also planned, was a reduction of hospital beds devoted to the ED, from 31 to 21.

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Nicholas Jouriles, MD

These changes prompted Terry Vanden Hoek, MD, Interim Chief of Emergency Medicine, and Joe Garcia, MD, Chairman of Medicine, to resign their administrative posts out of concern that the changes would only increase wait times at the hospital for the poorest patients. It also sparked the response from ACEP and stirred discontent among emergency medicine academics who were following the initiative's progress. The pair of resignations led to a Wall Street Journal story written with a skeptical tone about the hospital's efforts, and an emphasis on increased waiting rooms times since the health initiative's creation.

Later, in March, more than 190 physicians at the medical center signed a letter sent to the hospital in protest of the proposed cuts, saying they posed a threat to patient safety.

“Emergency department overcrowding is not new, of course,” said William Barsan, MD, professor and chair of the Department of Emergency Medicine at the University of Michigan. “The key difference is that most places are trying very hard to still provide care to everyone who comes in the door. The concern at the University of Chicago is that they're saying, ‘Most of you people don't need to be here, so we're going to do whatever we can to discourage you from coming in.'”

Hospital officials deny such accusations.

Patients are seen and treated first, before meeting with specialists who seek to find them a medical home, said David Howes, MD, Professor of Medicine and Pediatrics at the University of Chicago's Pritzker School of Medicine, as well as Interim Chief of the school's Section of Emergency Medicine, and the Emergency Medicine Residency Program Director.

“I don't really understand why others would be critical of what we're doing, because we're doing our very best to provide very detailed follow-up with our patients. And to give them a medical home with a care provider that they will be able to see going forward, instead of just sending a person out of an ER with a paper that says, “Call your doctor,” when they don't have doctors, which is not helpful.

“The idea of linking patients who are seen, completely evaluated and treated, and then approached to provide them with a medical home that meets their needs, in consultation not only with a patient but other family members if available … is the wave of the future. It may cost a little more, but it is very appropriate. We think the Urban Health Initiative is a potential model for the future of not just emergency services, but our health care system. We need to get people to the right medical home. That's our mantra, and it doesn't exclude emergency care–far from it.”

Dr. Howes said physicians are pleased with the UCMC administration for its commitment to emergency care after they dropped their proposed reduction in the number of ED beds. In consultation with the emergency medicine faculty, he said the UCMC is considering options that will allow more rapid treatment of patients with minor illness who will then be referred to others for follow-up care. Most important, he said, is that the UCMC will continue to meet its commitment to providing care to acutely ill ED patients based on the severity of their problem without regard to ability to pay.

“The administration now understands, perfectly, the right way to do this is to continue to have a full emergency department capability,” he said.

Dr. Howes and other UCMC officials said there are encouraging signs that the program, by providing a more holistic approach to medical care, is working.

Positive Effects Versus Waiting Room Reality 

A spokesman for the hospital, John Easton, said the institution will soon launch a study to assess the effects of the Urban Health Initiative on the community. The initial results from the hospital's perspective have been positive, he said, with fewer nonurgent cases presenting to the ED; non-emergency patients dropped from 40% to 4% during the last year. Of referrals to clinics and other care centers collaborating with the Urban Health Initiative, Easton said 8% had been seen 2 or more times by a primary care provider, 67% had had a general physical exam, 79% of patients with hypertension were taking regular medication to treat their condition, 4% identified as smokers had enrolled in smoking-cessation programs, 52% had their cholesterol checked, and the left without been seen rate was 13%.

But some emergency physicians, including Drs. Barsan and Donald Yealy, MD, vice-chair of the University of Pittsburgh Department of Emergency Medicine, say those numbers may belie the reality of the situation inside the waiting room of the UCMC ED.

Drs. Barsan and Yealy said they have heard the UCMC's “left without being seen” rates have been as high as 15 to 20% since the inception of the Urban Health Initiative. Easton said the hospital's left without being seen rate for 2008 was 13%. That figure is far above the norm for EDs.

“These are people the system has failed completely,” Dr. Yealy said.

No one disputes that the economic crisis gripping the United States, and the world at large, began applying near mortal pressure to the finances of some hospitals. Even prior to the present crisis in many EDs there is little or no capacity as visits nearly doubled to 119 million between 1996 and 2006. Now, as people lose their jobs and no longer can see their primary physicians, the burden on EDs should only increase. That burden will especially affect finances if, as expected, a greater proportion of patients who present no longer carry medical insurance.

A recent perspective in the New England Journal of Medicine suggests that the financial problems now being encountered by EDs might get far worse.3 Ralph Catalano, PhD, a professor of public health and director of the Robert Wood Johnson Health and Society Program, University of California, Berkeley, wrote:

“Medical care providers will first see a small decrease in demand as copayments become more onerous, more patients lose their insurance, and some people take fewer risks and perhaps become healthier. People who seek care will be more likely to have insurance and may feel that their employment status and social standing are threatened by society's lower tolerance for their physical or behavioral deviance. As time passes, however, I would expect to see increased demand for services from people who ‘deferred maintenance' because of costs and therefore become ill.”

For EDs that may mean, at some point during the next year, a “shock” is coming, Catalano said, when asked specifically about emergency medicine.

“The persistent and perhaps worsening nature of the current downturn, which began over a year ago, raises the possibility of response ‘spikes',” he said.

From this perspective, there's nothing evil about what the UCMC is doing to try and cope with its financial pressures, Dr. Yealy said.

“I don't blame the University of Chicago for being in a situation where, if they continued to do things as they did previously, it's much more likely to threaten their solvency,” he said. “They felt like they had to make a decision, and they've made one of the more draconian choices. It's very clear this is a decision where the business concerns may have outweighed some of the medical or moral decisions. I suspect they would say, ‘No money, no mission.'

“But if they keep this up they're going to look a lot like a specialty hospital in a few years.”