St. Louis’ Busiest Safety Net Hospital Braces For Health Law Challenges

North St. Louis County, Mo. – On a recent weekday afternoon, Christian Hospital ambulances raced to a car fire on Interstate 270, a patient’s cardiac arrest and a man with a knife wound.

Other private ambulances, as well as those operated by the cities of Hazelwood and Florissant, also delivered dozens of patients to the north St. Louis County hospital that day.

“I’ve looked out and seen 10 ambulances at one time, lined up to get in,” said Chris Cebollero, chief of Christian’s emergency medical services.

Rarely in the public eye, Christian Hospital operates the busiest emergency department in the St. Louis area, with more than 110,000 annual visits — more than 300 a day on average — at the hospital’s main campus and its affiliate, Northwest HealthCare. The Christian emergency department serves more Medicaid and uninsured patients than any other area hospital’s ER, according to the St. Louis Regional Health Commission.

“Christian Hospital is the major safety net provider of care for a vast majority of our region right now,” said Robert Fruend Jr., the commission’s executive director. “They have an incredibly large service area, from Illinois to North County. There aren’t many community health centers or hospitals around Christian right now, and the number of families in poverty in that area has skyrocketed.”

Christian’s ongoing struggle to serve the disadvantaged is not likely to get any easier under the Affordable Care Act. Federal and state reimbursements and “disproportionate share” payments to hospitals that treat a greater percentage of the poor are being reduced. And with Missouri’s reluctance to expand its Medicaid program, federal dollars are expected to get even more scarce.

But the success or failure of health reform will hinge in large part on efforts by overburdened hospitals such as Christian to find the most cost-efficient ways to serve the poor.

Christian’s emergency room is often jammed with dozens of adults and children. Many patients are walk-ins, and hospital officials estimate that as many as 40 percent of patients are using the ER for primary care and urgent care, rather than true emergencies.

“Some people believe our unemployment in North County is double the state rate, and those people come into the ER when they need to be treated,” said Ron McMullen, president of Christian Hospital, which has more than 400 physicians and about 2,100 employees.

He said there are times when the community hospital is overwhelmed by its high volume of patients, but adds, “We try to get people in and out very quickly, and we usually do it pretty well.”

Similar to any other ER, patients are triaged: a patient who suffers a heart attack gets seen quickly; someone with a twisted ankle must wait.

To reduce demand on ER services, Christian has succeeded in hiring a few additional primary care physicians. “If we hadn’t done that, we would have been flooded,” McMullen said.

Christian, one of 13 hospitals in the BJC HealthCare system, logged 112,117 emergency department visits last year — almost 14,000 more emergency visits and trauma cases as Barnes-Jewish Hospital. That figure includes Christian’s 28-acre campus on Dunn Road (near the intersection of Interstate 270 and Highway 367) and its 24-hour emergency care facilities at Northwest HealthCare in Florissant.

Christian’s main campus offers a fairly comprehensive range of services, from cancer, stroke and heart care to 14 surgery suites, psychiatry and orthopedics. But, except in emergencies, it no longer delivers babies. DePaul Health Center provides obstetric services in North County.

In addition to its emergency room, Northwest HealthCare has imaging and laboratory services, physical and occupational therapy, and centers for breathing and sleep disorders.

Changing Economy

For more than a century, Christian has served North County’s diverse population of working-class families and the poor. But many of the steady factory jobs that fueled the area’s economy have disappeared since the 1980s, and the recent recession compounded the pain, leaving the hospital in a precarious financial position.

“We’ve seen the financial viability of the hospital diminish,” McMullen said. “What’s put Christian in trouble in recent years is the migration of (paying) patients away from North County, leaving more people with little or no health insurance. … In effect, BJC subsidizes the care at Christian from some of its other hospitals.”

In the past two decades, residents with blue-collar jobs and health insurance coverage moved away from North County, many relocating to St. Charles County. At the same time, residents of the city of St. Louis, many poorer and without health insurance, moved in.

According to a 2011 study sponsored by the St. Louis County Health Department, 26 percent of males in North County have no usual source of medical care — a high percentage compared to other study regions.

That demographic shift also left North County’s population hollowed out, with fewer middle-aged wage earners and more senior citizens and children. And with the financial downturn, many area residents lost their jobs and health insurance.

“It is hard to get a physician to take a low-income, uninsured person, period,” Fruend said. “Our community health center networks haven’t yet expanded fully north to meet the changing needs of our population.”

Christian officials said that 50 percent of their patients are on Medicare; 16 percent are on Medicaid; 23 percent are privately insured; and 11 percent are “self-pay” or uninsured. In addition, a substantial portion of patients’ accounts are classified as “bad debt” because they do not pay their bills. In the emergency department, more than half the patients are uninsured or on Medicaid — the highest proportion in the St. Louis area except for its two leading children’s hospitals.

The sum of these circumstances has left Christian, which has an average census of about 255 patients, performing the functions of a tax-supported public hospital. Unlike most metropolitan areas, St. Louis no longer has any public hospitals. In 1979, city officials closed Homer G. Phillips Hospital; St. Louis City Hospital closed in 1985, and St. Louis County Hospital closed a year later.

Since 2000, three free-standing hospitals in the greater St. Louis area that served large populations of uninsured patients have closed: Forest Park Hospital, Normandy Community Hospital, and Kenneth Hall Regional Hospital in East St. Louis.

Revenue from the other 12 hospitals in the BJC HealthCare system, including Barnes-Jewish Hospital, subsidize a substantial portion of Christian’s operations, according to Steven Lipstein, president and chief executive of BJC.

“BJC provides the funding to support (Christian’s) operating loss plus any additional cash requirements that the hospital has,” Lipstein said. “Without BJC-like organizations that can pool together revenue and expenses, it would be difficult to sustain important community assets such as Christian Hospital as stand-alone hospitals.”

Last year, Christian had revenue of $275 million and an operating loss of $17 million, according to hospital officials. In the first six months of this year, Christian had revenue of $125 million and an operating loss of $14.6 million. Those figures exclude any investment income or loss.

“Christian Hospital is a very well-run hospital, and it’s been well-capitalized over the years,” Lipstein said. “But over the last decade, the hospital’s unreimbursed care and free care (its charity care and bad debt together) has grown from $15 million in 2002 to about $32 million in 2012.”

It’s a Catch-22. Any failure by health providers to serve the poor, including preventive care and professional attention to ongoing illness, results in a sicker population with more chronic conditions and higher treatment needs — and ultimately, greater health care costs for institutions and taxpayers to absorb.

In the last decade, BJC HealthCare has poured $173 million of investments into Christian. Since 2002, those funds have gone toward such projects as rebuilding the hospital’s kitchen, renovating patient floors, buying new medical equipment, and building Northwest Healthcare on the site of the former Christian Hospital Northwest. About 30 percent of Northwest Healthcare’s emergency patients are children.

“BJC’s game plan is to continue to use all available sources of revenue to help us sustain our mission at Christian Hospital,” Lipstein said, “and to continue to advocate that everyone who lives in America should have health insurance.”

Quality Of Care

Christian Hospital is a spacious, well-appointed hospital with a large intensive care unit, a diabetes center, a psychiatric ward, a surgery center that performs about 6,000 surgeries a year and a cancer resource center geared toward patients recently diagnosed with the disease — and their families.

It draws favorable reviews from its patients, 62 percent of whom told independent surveyors they would “definitely recommend the hospital,” according to the Hospital Compare website sponsored by the federal Centers for Medicare & Medicaid Services.

Christian’s readmissions and death rates for heart attack, heart failure and pneumonia as well as serious complications are within the national average, the website says, and its rate of central line-associated bloodstream infections is “better than the U.S. national benchmark.” Christian’s deaths among patients with serious treatable complications after surgery and also its rate of serious bedsores per patient are worse than the U.S. average.

“Christian is one of the most efficient operations in all of BJC Healthcare,” BJC’s Lipstein said. “When it comes to clinical staffing, Christian meets all the community standards for outstanding medical care.”

But like other hospitals in the St. Louis area, many patients at Christian Hospital’s emergency room wait for long periods of time.

According to Hospital Compare, Christian’s patients spend 6 hours, 6 minutes on average in the emergency room before being admitted as an inpatient; 2 hours, 9 minutes on average after a doctor decides to admit them as an inpatient; 42 minutes on average before being seen by a doctor or nurse; and 1 hour, 6 minutes on average to receive pain medication after arriving in the ER with broken bones. These times exceed the Missouri average and the national average.

McMullen said that Christian’s quality of care is in the top 25 percent of hospitals nationally among community hospitals. He said that Christian’s main campus is well within the national average of those patients who leave the ER before being seen by a health care professional, and within the top 10 percent nationally at Northwest Healthcare.

But to ease congestion, Christian is undergoing a $17.3 million expansion of its main emergency department.

Christian’s charges are higher than its nearby competitors, to compensate for its high cost of charity care and bad debt. For example, Christian’s average charges for cardiovascular surgery are $94,202, compared to $78,100 at St. Mary’s Health Center in Richmond Heights, according to the American Hospital Directory.

“We want to do what’s necessary to keep the northeast campus of Christian Hospital physically viable until about 2040,” McMullen said. “At some point, the public sector is going to have to step up to the plate to make sure the financial viability and physical viability of the hospital is there. … We’re going to need to have a public or political discussion about the future of and availability of hospital care in North County.”

Ideally, McMullen said, patients would rely more on primary care physicians, and public health care dollars would follow an uninsured person to any hospital the patient visits.