Story by Jacob Olson
Country Doctor has provided affordable health care on Capitol Hill for more than 40 years. Now it is finishing 2013 with a new attribute sure to be valued by area residents: convenience. But, in the rapidly changing economic landscape of the Affordable Care Act, the new clinic is about more than making it easier for the community to seek urgent care.
Opened quietly in early December, Country Doctor Community Health Clinic’s new after-hours Clinic — located next door the the Emergency Room at Swedish Medical Center – Cherry Hill Campus at 16th and Cherry and made possible by a partnership between CDCHC and the hospital — is already proving to be a valuable resource as an alternative to visiting the ER for a non-emergency or to waiting days to get in at a regular clinic where they may or may not be an established patient. But if the nonprofit walk-in urgent care clinic wants to keep its doors open over the long run, it will need to see a significant increase in its patient load before a $200,000 Swedish Foundation grant to cover the clinic’s operation costs for the first three months runs out
“This is something that wasn’t going to get much traction [before] because it could potentially have a negative impact on the revenue of the ER docs,” CDCHC executive director Linda McVeigh said. “But you know the world has changed, and reimbursements for visits to the emergency room that aren’t true emergencies are decreasing rapidly, just because of all the Affordable Care Act,” she said.
“You go in the ER with a cold and you’re a Medicaid patient..it’s going to cost the state, what, five-hundred dollars? You come to us, it’s going to cost the state at the most maybe one-hundred dollars, so there’s that excess cost related to ER visits that’s a big incentive to drive down.”
Richard Kovar, CDCHC’s medical director, said that with two nurse practitioners, two medical assistants, and two front desk personnel on hand at any time, the after-hours Clinic is currently staffed to accommodate about 25 to 30 patients on weekdays when it is open from 6pm to 10pm, and even more patients on Saturdays and Sundays when it is open from noon to 10pm. That’s a potential total of about 250 to 300 patients per week. That is also about the number of patients it will take for the clinic to be self-sufficient, McVeigh said.
In keeping with Country Doctor’s mission, the after-hours Clinic will seek to provide “high-quality, caring, culturally appropriate” health care to everybody, regardless of insurance status or ability to pay. However, while Country Doctor currently serves a patient population that is about 53% uninsured at its federally-subsidized primary healthcare clinics—the Country Doctor Community Clinic on Capitol Hill at 19th and Republican, and the Carolyn Downs Family Medical Center in the Central Area, at 21st and Yesler—McVeigh said she hopes that the portion of uninsured patients seen at the unsubsidized after-hours Clinic will be around 35%.
Country Doctor is banking on the prediction that a significantly higher number of patients it sees at the after-hours Clinic will be on Medicaid, especially through Washington State’s Apple Health program, after the national Affordable Care Act takes full effect on January 1st, and that other patients might also be newly enrolled in subsidized insurance exchanges. Indeed, while private, for-profit, medical centers like Swedish generally lose money treating patients on Medicaid and Medicare, Federally Qualified Community Health Centers like Country Doctor generally receive better compensation from Medicaid through extra subsidies, often times making the payouts from the government program preferable to private insurance, who might persistently negotiate down prices or refuse to pay for certain items, for FQCH’s like Country Doctor, Kovar said.
The Affordable Care Act encouraged the opening of the new after-hours clinic not only because Country Doctor stands to possibly see increased revenue through a potentially more well-funded payer mix than before, but also because the bill is making it less lucrative for private hospitals to treat some patients in the ER, McVeigh said.
The prospect of saving money, especially come January, by steering patients away from what Kovar termed “inappropriate use” of the emergency room, and towards the after-hours clinic, as well as the chance to help Country Doctor provide better healthcare to the community, has motivated Swedish to assist the clinic in its new venture. In addition to the $200,000 start-up grant from the Swedish Foundation, the hospital is leasing the space for the after-hours Clinic, used by Swedish as a resident family medicine clinic from 9am to 5pm on weekdays, to CDCHC for just $1 per year. There are even talks of eventually setting up another Country Doctor after-hours Clinic at another Swedish location if the Cherry Hill effort proves a success.
“I think it’s been good we’ve started off slow,” said McVeigh, who described the new after-hours clinic’s December 2 launch as a “soft opening.” “We have an all new staff, in a whole new facility. All of those staff are using a whole new electronic health record, so it’s been good there haven’t been 40 people a night storming the doors,” she said.
“But we need to build up a patient population there, or we’re not going to be able to continue it, because we won’t be able to afford it.”
As for Country Doctor, the organization stands to be able to both provide better care to the community at large, and also to its existing patients at its primary care clinics, through running the after-hours Clinic.
“First of all, it’s our mission to provide access in our community, to care, and this is one way to do it,” McVeigh said. The director said that over the last several years Country Doctor has been realizing it needs to able to provide “episodic care” to people who do not necessarily want to establish ongoing care with a primary physician, and that patients who call in to Country Doctor, especially those who are not established patients, will often be able to be seen much sooner at the after-hours Clinic than they would be if they had to wait for appointment at one of CDCHC’s existing primary care clinics. Even for existing patients, the wait time for a non-emergency appointment can be up to a week, McVeigh said. She hopes the after-hours will free up some of the urgent care needs the primary care clinics currently get swamped down with so that those sites can better focus on providing ongoing care for patients who make the clinics their “medical home.”
Though it is set up to provide one-off care to people with urgent needs, the after-hours Clinic still upholds CDCHC’s mission of providing more comprehensive health care, in part by trying to connect urgent care patients to places where they can establish longer term care.
“Our goal is to hook people,” Kovar said. “We’re referring people who do not have a medical home to medical homes,” he explained. “By nature of them coming to here to be seen, they are now an established patient, a new patient [with CDCHC], and then if they live in other communities, where there are other community clinics, other community health centers, we will recommend them to those health centers,” Kovar said. Connecting urgent care patients with primary care is also one way that the after-hours Clinic can help “break the cycle” of people waiting so long to get care because they believe they cannot afford a doctor that they end up in the emergency room, and possibly the hospital, McVeigh said.
One of the biggest challenges in getting the after-hours Clinic off the ground was finding clinicians to staff it, both McVeigh and Kovar said, due to the nights and weekends schedule the clinic demands, and other challenges. Though Country Doctor was unable to hire any MD’s to staff the clinic, they were able to hire of staff of four nurse practitioners, three of whom are recent graduates of Seattle University’s nursing program, located just a few blocks away from the Cherry Hill location of the clinic.
“We’re pretty excited about the fact that we have ARNPs staffing that clinic,” McVeigh said “I think it’s the wave of the future, because there aren’t enough docs.” McVeigh and Kovar also both said that it is a benefit to have practitioners already familiar with and invested in the local community. Indeed, in addition to the new-hires at the after-hours clinic, most other practitioners for CDCHC live in or close to the communities they work in. “90% of us live in the neighborhood,” Kovar said. “This is our community.”
You can learn more at countrydoctor.org.