As a physician I spend a great deal of time pondering my peculiar industry - medicine, specifically in my home of Cleveland Ohio. I am employed by MetroHealth, a county hospital dwarfed by both the Cleveland Clinic and University Hospitals. One wonders how these entities will weather the upcoming changes. My opinions have no connection to MetroHealth in any way and do not represent the hospital in any way, shape or form. Lets ponder...
First of all I do not forsee such a glut of new patients as many predict. When people need care they will seek out an ER, even if uninsured. With greater access to care there may be more visits, but I would challenge the notion that our nation's uninsured sit at home and die for lack of care. This is a hard area to predict at this time.
I do forsee the American medical system moving toward a European system (e.g., Germany) wherein 80% are on a public plan and 20% on a private plan. According to wikipedia (sure, attack me, but google 1st to see sources there = solid)16.7% of the American public were uninsured in 2009; 14.3% in Ohio. In 2008 17.55% uninsured in Cuyahoga County per OH governmental records. The proportion of medicaid recipients (i.e., expanded medicaid product) will increase as the uninsured rolls greatly diminish.
A shift which many have not fully understood is expected to come as well: many of the currently fully insured will be dropped from their company plans - the company will pay a penalty for such actions, but in the end this will be cheaper that insuring the employee. An example that was verbalized to me was AT&T: 6 billion $ in health care costs, but if they dropped all from health care coverage they would pay 1.5 billion $ in yearly penalties. For publicly traded companies that must perform for their investors such a change appears logical - I will not discuss the moral issues involved, but the P&L sheets will look better if such shifts occur. Watch for a slow domino effect of large companies to enact such changes, then an avalanche as they all do to remain viable. Oh and the employee who has lost coverage will then be permitted to buy coverage - the expanded medicaid product that is being rolled out to the uninsured as well. The 80% figure become more manifest.
Will some retain private insurance? Oh yes, it will remain but becomes a bargaining chip for contracts between employers and employees. It will be a luxury for an employee. It could also be paid for by a wealthy individual at their own discretion.
The Health care reform rules were written by business for business - it did not matter who won the election in 2012, the march to the status above would grind on regardless. Since Obama won though, that debate is moot so we can move on.
How will the individual hospital systems in Cuyahoga County be affected by these changes?
I am not sure what the "other" category means in the charts above. I would lump it in with commercial insurance for lack of a better explanation.
MetroHealth: small footprint compared to the other 2, receives money for disproportionate share of charity care in the area (i.e., safety net hospital) - money slated to evaporate as the uninsured transition to being insured (expanded medicaid). 19% commercial will drop to some degree but the 19% engaging with Metro do so for the quality, not the frills, so the drop may not be drastic. Also, 12.8% self-pay converts to expanded medicaid. MetroHealth is used to running with no frills (no pergo floor, marble, or art walks with a docent) so may be able to continue on relatively uninterrupted by the changes to come.
Cleveland Clinic: has the lion's share of commercial patients, which will drop appreciably. A relatively small self-pay portion so converting them to medicaid patients helps minimally. Their ability to shift operations to a leaner budget will ultimately determine their survival. Gone will be the days of fancy decor and voluminous ads. Watch for further hospital changes as CCF needs to "trim the fat" to remain viable; this could mean more closures or simply CCF drops less profitable hospital(s) from their system allowing it to sink or swim on its own. Watch for active campaigns to court the 20% of private insured patients - a distinct 2 tier system will be apparent. "Call today for an appt today" will become 'call today for an appt 1) today if privately insured, 2) get in line if on public plan.'
University Hospitals: a relatively small commercial base (compared to CCF) may drop somewhat but unlikely to shift hugely - quality will maintain their base. An amazingly small self-pay portion (2% - how do they get away with that and remain not-for-profit status one wonders) will shift to expanded medicaid but helps minimally as only 2%. UH gets by on CMS payments it appears, so their margin will determine their success. UH is "less frilly" than CCF, so trimmed down already. The CWRU affiliation is likely to protect them in some degree as well. UH will weather the storm reasonably well I would suspect.
Conclusion
In the end I suspect that CCF is in for the biggest changes as the health care models begin to shift. They have very wise business people now (part of their frills), so will move as needed but eventually this means letting themselves go so CCF will be left somewhat rudderless as further shifts occur. CCF has tried to tighten their belt, but I suspect they are somewhat blind to the fat they possess. CCF will not be able to remain everything to everybody (jack of all trades and master of all), but will need to redefine its niche. My opinion would be it return to being a specialty referral center as it had originated. Time will tell.
