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Clinics: An alternative to hospitals?

By ANTHONY MAN

Legislation that would have allowed patients who undergo easy medical procedures to recuperate overnight at nonhospital clinics sparked a brawl this spring among factions within the medical establishment. The hospital industry, which viewed the potentially lucrative clinic idea as a dagger aimed at its financial heart, managed to sidetrack the proposal for the time being.

The idea was advanced by the Illinois State Medical Society, which represents doctors. The bill, sponsored by Rep. Loleta A. Didrickson (R-37, Flossmoor) and Sen. Robert A. Madigan (R-45, Lincoln), would have authorized a pilot program to experiment with a new kind of overnight clinic for people recovering from baby delivery or minor surgery. It would have provided for a maximum of six centers for a three-year trial. An oversight board appointed by the governor would then recommend continuation, expansion or termination to the General Assembly. Without legislative action, the program would automatically sunset.

Backers said the clinics offered nothing but advantages. One key benefit was: The clinics would provide a cheaper alternative for patients who require overnight recuperation but who do not require the services of a full-service, acute care hospital. That would allow outpatient clinics to expand their range of services. Didrickson estimated a clinic might charge $350 a day compared to $800 or $1,000 for a hospital stay. A leading opponent, Senate President Philip J. Rock (D-8, Oak Park) scoffed at such cost comparisons, which he said do not tell the whole story. "It would be cheaper to stay in a Quality 8 motel. So what?"

Most ballyhooed by the medical society were the benefits it said would accrue to the health care system, particularly in rural communities without hospitals. James E. Tierney, a medical society lobbyist, told the Senate Public Health, Welfare and Corrections Committee that the clinics might allow services to continue in places where hospitals have closed. "As we see the medical infrastructure of downstate Illinois disintegrate, we see a vacuum that needs to be filled," he said. The legislation would "provide an opportunity to provide some really innovative health care services."

The Illinois Hospital Association rejected the idea that availability of care would be improved, suggesting instead that the rural health argument was a ruse by the proponents to help sell their bill. The hospital industry said the proposed clinics would do little for the rural areas most in need of more health services because locating clinics in places already too poor to support hospitals and doctors would not make much economic sense. Kenneth C. Robbins, president of the Hospital Association, ridiculed as "laughable" the suggestion that rural areas would be helped.

Jerry A. Hickam, president of Southern Illinois Hospital Services, the parent company of the 151-bed Memorial Hospital of Carbondalc and the 98-bed Herrin Hospital, said many rural areas do not need new facilities. He said their real problem is attracting doctors. In testimony before the Senate committee, Hickam said the legislation "has been cleverly packaged to appeal to the interest of the General Assembly in responding to the enormous health care needs of the inner cities and rural areas of Illinois. Please do not be fooled by the wrapping. The package before you contains a time bomb, ticking away at our community hospitals. If you set it off, this explosive device will shatter our already fragile health care infrastructure."

The hospitals' biggest objection was financial. The association conceded that care might very well be cheaper at the clinics, but the price advantage would be achieved by unfarily undercutting the full-service hospitals. For example, the association said clinics would not have to meet the same building regulations and staffing standards that govern hospitals.

Outpatient surgery is already growing rapidly, and the ability to offer overnight recuperation would allow nonhospital clinics to capture a larger share of the market

Hospitals also feared the potential long-term effects of competition with the clinics. If easy procedures, such as routine hysterectomies, broken legs or noncomplicated deliveries, are handled by the overnight clinics, that business would be lost to hospitals. Yet hospitals would still have the same overhead for services such as emergency rooms and intensive care units, Moreover, if the clinics take the best patients, those who are self-paying or fully insured, the hospitals would be left with everyone else. That "everyone else" category includes money losers: welfare recipients, the uninsured and people with complicated procedures. Even Madigan, the Senate sponsor, used the most common analogy in describing the hospitals fear that "the doctors were going to come in and skim off the cream." Rep. Donne E. Trotter (D-25, Chicago) warned that lower-cost clinics would start "cherry picking those patients away from those hospitals."

The clinics' ability to handle the easiest and most profitable cases is one of the very things that makes the idea so lucrative. Outpatient surgery is already growing rapidly, and the ability to offer overnight recuperation would presumably allows nonhospital clinics to capture a larger share of the market. The effect of an expansion

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Legislative Action Special Section

into overnight care was criticized as completely unfair to hospitals by some hospital representatives. Bill Palmer, administrator of the UMW of A Union Hospital in West Frankfort, said, "We get the roughs [cases] and all the [long] hours and they get the smooths and none of the hours. They don't even have to open till 10 o'clock if they don' t want to." Not requiring clinics to adhere to higher, hospital-level standards would be especially wrong, he said. "It's like having a 35 mile an hour speed limit but saying it doesn't apply to half the people."

Tierney, the medical society lobbyist, said the other side had it all wrong. "These facilities are not designed, nor are they intended, to compete with existing health care facilities."

Whether or not they were designed to compete or would wind up competing with hospitals, the total number of patient beds would almost certainly increase. The hospital association said the clinics would simply add more patient beds to a health care system that already has far too many beds. The medical society said a potential clinic operator would have to go through certificate of need proceedings before the Health Facilities Planning Board, but the hospital association said that might not mean much, since the bill's language was vague enough that the two kinds of beds might be placed in different categories. If that happened, a surplus of hospital beds in a given area might not prevent a clinic from opening with even more beds.

The Illinois Public Health Association, which includes many government public-health professionals and advocates policies it believes will serve the greatest number of people over the long-term, was initially neutral on the bill but eventually opposed it. Jeffrey W. Todd, executive director, said he liked the idea of alternatives in places with inadequate care, but he said there was little reason to believe that those areas would benefit much from the clinic system as outlined in the legislation. He said there might be some hope for improvement in the areas of the state with the greatest need, but that would only come far in the future. That might happen if the clinics opened and were successful in prosperous areas and people learn that quality is not a problem. The experience could then be used to get government funding for overnight clinics in places like Cairo, which has had no overnight care since Southern Medical Center closed in 1986, or Tuscola, where Douglas Jarman Memorial Hospital closed in June.

The business community generally supports ideas that might lower health care costs, and some insurance interests endorsed the clinic proposal. But the prospect that the clinics might save on some charges while ultimately driving up costs in the entire health care system helped earn the opposition of the Illinois State Chamber of Commerce. Although the Chamber of Commerce took a position, the legislation never got much attention outside the medical establishment. Among the health interests, lobbying was furious. The concept of the clinics is a natural one for doctors, who could have the upper hand at the new facilities, especially since they would be logical candidates for ownership interest. For the hospitals, however, the clinics are viewed as potential competitors that could financially cripple hospital operations. The hospital association made defeat a top priority, and hospital trustees, employees and volunteers were urged to call their legislators, some of whom happen to be on hospital boards of trustees.

The competing interests put conflicting pressures on legislators, who have been searching for ways to aid the health care system that do not cost government anything. The public health association's Todd said lawmakers have been facing "a tremendous pressure down here to do something and to try some alternatives." Another conflicting addition to the mix: The hospital forces had a doctor testify on their behalf during Senate committee proceedings, and the doctors had a hospital that wanted to get into the clinic business. The conflicting forces pulled legislators so strongly in different directions that the usual partisan and geopolitical alignments were not in effect on this proposal. It was not strictly Chicago Democrats versus suburban county Republicans. Didrickson, the chief House sponsor, is a Republican from the Chicago suburbs. One of her strongest supporters is a Democrat from deep southern Illinois: Rep. Larry D. Woolard (D-117, Carterville). Another indicator of a different alignment was the relatively large number of representatives voting "present'' when the bill passed the House: 66 "yes," 30 "no" and 16 "present." "Both sides make some very interesting and cogent points, which makes it very difficult to decide how to vote," said one of those voting present, Rep. Louis I. Lang (D-1, Skokie).

'The package before you contains a time bomb ticking away at our community hospitals. If you set it off, this explosive device will shatter our already fragile health care infrastructure'

The difficulty in winning House passage later became a reason why there were no serious attempts at compromise. Rep. John Cullerton (D-7, Chicago) attempted to attach what proponents viewed as a killer amendment. He would have cut the number of clinics in the pilot program, restricted them to health manpower shortage areas where beds are needed, and reduced the usual length of overnight stay to one day. Cullerton's attempt failed, and the proposal emerged from the House intact.

In the Senate, the hospital association had some important allies, including Senate President Rock. He was slow to let the bill out of the Rules Committee, which must authorize consideration of bills by other committees during even-numbered years. The bill was one of the Republican leadership's requests, and it was approved in the last, pre-deadline Rules Committee meeting, with Rock observing later that he has only one vote on the panel. It was approved by the Public Health Committee, but some of those who voted for passage said they would oppose the bill on the floor unless it was modified.

At that point, opponents planned amendments that Madigan, the Senate sponsor, said would have gutted the legislation. Even agreed amendments would have forced the bill back to the House, where passage was difficult and followed a lengthy debate, so the medical society and Madigan pulled the plug on the legislation in mid-June. The doctors used notably strong language in a Medical Society publication, Illinois Medicine, to describe the situation and criticize the forces responsible for their defeat. Society president Dr. James H. Anderson hailed the

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proposal as "a positive, creative approach to providing access to care in rural, suburban and urban settings" that failed only because "a meaningful discussion cannot occur in a climate where facts have been irresponsibly distorted.'' Adrienne Levatino-Donoghue, a vice president of the hospital association, was more restrained in her analysis of the victory and said she did not want to respond to the doctors' tone. "We thought it represented really bad health care policy," she said.

The clinics would provide a cheaper alternative for patients who requrie recuperation but who do not require the services of a full-service, acute care hospital

Madigan said the idea would resurface, and an agreement eventually be reached. He said he would not want a clinic to open in an area where it would damage the existing community hospital, such as Abraham Lincoln Memorial Hospital in Madigan's hometown, which feared the clinic idea and opposed the legislation. Madigan said the concept could be modified so that such a hospital would not be hurt, perhaps by tightening standards to make it tougher for a proposed clinic to get approval from the Health Facilities Planning Board.

"I still think it's a good solution." Madigan said. Sen. James F. "Jim" Rea (D-59, Christopher) a founder of the Rea Clinic in Southern Illinois, voted to let the bill out of committee but wanted to amend it on the floor. He said some areas without hospitals might benefit from overnight clinics, but he too was concerned about the effects of what he saw as possibly unfair competition. "If it's done right, it wouldn't be in competition," Rea said. "There are a lot of things that have to be worked out."

Anthony Man is the Statehouse bureau chief for the four Lee Enterprises newspapers in Illinois, A previous article on the health care system, exploring the problems and promise of rural health, appeared in the May 1989 Illinois issues.

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