Cecil Co Health: Harford Hospitals Consolidate, Union Cuts Renowned DE Christiana Hospital Out of Loop
A CECIL TIMES SPECIAL REPORT
New plans for shifting hospital costs and services in Harford, Cecil and Kent counties are generating controversy, some misunderstandings, and some real concerns about forcing area patients to travel long distances to obtain hospital care or being denied transfer to facilities with more advanced services.
Volunteer fire companies that provide most of the ambulance transports to hospitals in the area are concerned that their crews could be tied up for hours by having to transport patients to two facilities or travel greater distances. Western Cecil County residents and officials worry that full emergency and inpatient services—including swift care for stroke patients– now located a short drive over the Hatem Bridge will be lost to a more distant Bel Air facility in Harford County.
And transfers from Union Hospital in Elkton for more advanced services that now are generally provided at the nearby Christiana Care facility in Delaware—which is a nationally-ranked teaching hospital– could be re-directed to the distant Bel Air operation which has fewer specialty services.
Meanwhile, in Kent County, a full-service hospital in Chestertown is proposed for cutback to just a freestanding emergency room, with serious cases requiring travel to Easton—a 90-minute drive from Rock Hall. However, thanks to aggressive lobbying by local officials and the District 36 delegation in Annapolis, Chestertown is expected to receive a reprieve, to allow for more time to study the unique problems of emergency services in such a rural area, under legislation pending in Annapolis. Ironically, the Chestertown saving grace is attached to a broader bill that would expedite the consolidation of hospital services in Harford County.
One constant in the controversy is the role played by the University of Maryland Medical System, which has taken over and merged with three hospitals in the region in the past few years: the former Chester River hospital in Chestertown that is now part of UM’s Shore Health entity; and in Harford County, Harford Memorial Hospital in Havre de Grace and Upper Chesapeake hospital in Bel Air which are now part of UM’s Upper Chesapeake regional entity. UM wants to close the aging Havre de Grace full service hospital and replace it with a new, limited services free-standing emergency room at Bulle Rock, still within the Havre de Grace municipal limits. The Bel Air full service hospital would be expanded and renovated.
Union Hospital in Elkton remains independently-owned as a local non-profit hospital, but signed a co-operation agreement with UM and is working with the Harford County-based operations to shift some inpatient beds and services from Elkton to the other side of the Susquehanna River. But Union also appears to be cutting Christiana—long an important healthcare resource for much of Cecil County– out of the loop, as Union officials say they want to keep care within Maryland.
And another constant is the unique status of Maryland as the only state in the nation with a federally-endorsed program to regulate hospital rates under a Health Services Cost Review Commission, an independent body set up by the state in the 1970s. The commission was created to address spiraling hospital costs, fueled in part by the world-class care provided by the Johns Hopkins Hospital and the University of Maryland with its pioneering Shock-Trauma center.
To some degree, the current consolidation of services comes about as Maryland is a victim of its own success. The Commission cut hospital costs in Maryland from 23 percent above the national average to less than the national average, according to the Maryland Hospital Association. The state’s reward was about $1.5 billion a year in extra Medicare payments from the federal government, the association reports.
(Indeed, during our past life covering Congress for The Baltimore Sun, we heard House and Senate members of health oversight panels sing the praises of the Maryland program and urge other states to do the same. A few states have tried to create similar programs but quickly failed, leaving Maryland the only state with a federal “waiver” from many program rules and given Medicare bonus payments.)
But in recent years some costs, especially for Medicare patients, began to rise above national rates and the federal government re-negotiated the terms of the waiver in 2014 to create a five-year pilot project that pledges to find cost-savings of $300 million. The federal government wants to use the Maryland initiative as a test case for possible broader implementation across the nation.
According to a recent article in the New England Journal of Medicine, the pilot project has already reached a third of its goals, finding cost savings of $116 million in just its first year of operation and before the program is fully implemented in all hospitals in the state.
But apart from the unique Maryland system, also influencing the situation is a nationwide rule adopted in 2008 that penalizes hospitals if Medicare patients released from a hospital after an in-patient stay are re-admitted to the hospital within 30 days. The rule is supposed to pressure hospitals to provide better care in the first place and make sure patients are given proper medication and instructions before release from the hospital.
However, many hospitals figured out a way to legally game the system by classifying patients as “under observation” for two or three days rather than “admitted” as in-patients. In that way, if the patient ended up back at the hospital within a month and needed to be admitted, their first visit wouldn’t be counted so the re-admission penalty would not apply.
A New York Times investigation found many elderly patients ended up with higher out-of-pocket costs because their “observation” stay was treated as an out-patient visit rather than a fully covered inpatient stay. In addition, patients with “observation” status would be denied rehabilitation or brief nursing home care under Medicare because they did not meet the threshold of three days of in-patient hospitalization.
Both of the proposed free-standing emergency facilities proposed in the area—at Chestertown and at Bulle Rock—would have expanded “observation” beds but not in-patient beds.
Dr. Richard Szumel, CEO of Union, and Lyle Sheldon, CEO of the Upper Chesapeake facilities, appeared before a Cecil County Council worksession on Tuesday 3/22/16 to explain their plans and the changing economics of health care in the state. Neither speaker mentioned the Health Services Cost Review Commission initiatives or the “observation” loophole under Medicare.
“In the old days it was all about competition,” Dr. Szumel said, with hospitals competing for patients with duplication of services at a high cost. “Those days are gone,” he said, and the shift is toward regional “collaboration.” Union plans to close its in-patient “behavioral health” (mental illness) beds and transfer those services to Harford County. Union will then convert those beds to general in-patient beds.
In ddition, Union plans to open a “crisis center” in cooperation with the long-established Father Martin’s Ashley addiction treatment program in Harford County. The new center will be in a separate building on Railroad Avenue in Elkton, with 16 beds for short-term detoxification from drug and alcohol addiction.
In Harford County, Sheldon said his operation plans to create a 40-bed, in-patient short-term psychiatric unit with patients staying from four to seven days.
Faced with sweeping changes in the local hospital landscape, Cecil County’s volunteer fire companies have voiced strong concerns, both from leadership and rank and file members posting on social media their accounts of hours spent waiting at Harford Memorial now for a bed to open up so a patient could be admitted. Many ambulance crews worry that they might be left waiting at the new Bulle Rock emergency room only to be told later that they must transport a patient to the full service hospital in distant Bel Air.
Under questioning by Councilor Dan Schneckenburger (R-3), Sheldon said there would be private on-site ambulance services at Bulle Rock to transfer patients to Bel Air if needed. “Well you better tell the fire companies that,” Schneckenburger observed.
Wayne Tome, the Port Deposit mayor and longtime EMS chief for the Water Witch volunteer fire company, told Cecil Times that in his western Cecil town, out of 600 patient transports, 438 went to Harford Memorial. He said he wondered if the proposed private ambulance services at the new Bulle Rock emergency room would be adequate to transport the volume of patients needing transfer to the full-service hospital in Bel Air. Tome is scheduled to meet soon with the Union and Harford hospitals’ leadership.
Councilor Alan McCarthy (R-1) questioned Dr. Szumel about how Union would co-ordinate services with Christiana Care, noting its proximity to much of Cecil County and its advanced surgical and other services that are not available at Union. Currently, many urgent, serious cases are transported to Christiana directly by county EMS staff or transferred from Union to obtain more advanced care.
The Union Hospital official said that “We will utilize Christiana” for “urgent” cases from the easternmost “edge” of the county close to the Delaware line. But, he said, for the most part, “We would like to keep everything in the state of Maryland.”
In an interview with CECIL TIMES, Dr. Szumel said that an urgent need for a cardiac catherization (such as a surgically inserted stent to restore blood flow in a blocked artery) from the eastern area of the county would still go to Christiana. But if the cardiac case was less urgent, the goal would be to transfer the patient to the Bel Air facility, which has its own cardiac catherization program.
“We can get a cheaper cost in Maryland than in Delaware,” he said, explaining that under the new federal “waiver” program, hospitals are reimbursed by the numbers of patients, not the individual services received. (That’s a cheaper cost accounting for Union, not cheaper costs borne by the patient.)
So if a patient came to Union and it was decided he/she needed surgery or services not available at Union, the Elkton hospital would get a better payment deal by directing the patient to Bel Air than if that patient received advanced services at an out-of-state hospital such as Christiana. (The new federal “waiver” program gives hospitals a fixed budget to provide services to an individual patient, rather than counting costs of each individual procedure.)
Szumel said that many of the decisions on where to transport patients are made in the field, by EMS/ambulance crews. So if Cecil County EMS crews decided the patient needed urgent advanced care, they could decide to transport directly to Christiana. But if the patient came to Union first, the hospital’s goal would be to transfer to Harford County for further services as a cost-saving measure for the hospital, not the patient.
Under state law, patients have the right to demand transfer to another hospital of their choice. But most patients facing a medical crisis are unaware of their rights, too sick to exercise them, and too trusting that whatever hospital they end up at is giving the best, most advanced level of care or transferring them to the closest hospital that can provide the most qualified services.
The Harford County hospitals’ situation is more understandable, faced with an aging, inadequate Harford Memorial in Havre de Grace, they are looking for new alternatives and spending millions on new construction.
But Union Hospital—with independent ownership and not formally part of the UM health system—is taking a more puzzling approach.
Union does have a co-operative agreement with Christiana to have pediatric experts from the renowned Nemours children’s hospital, which is part of Christiana’s system, staff Union’s children’s beds in Elkton. But the new, apparent reluctance to refer adult patients to a superior, much closer medical system in Delaware suggests fiscal parochialism at best.
Just ask yourself: if you need advanced medical services where you would rather be treated– Christiana or a local, regional hospital in Bel Air?
CECIL TIMES has submitted detailed questions to officials of Christiana Care for their comments on the Union Hospital/Harford County hospitals plan. We are awaiting an official response and will publish Christiana’s comments upon their response.
[UPDATE: Mike Eppehimer, senior vice president for service line operations at Christiana Care Health System, said in a written statement, “At Christiana Care, our focus is on providing the best, most appropriate level of care and an exceptional experience to all those we serve. We appreciate the opportunity to partner with facilities in Maryland and to serve the people who are our neighbors in Cecil County, helping them achieve optimal health.” ]