by Tyler Kindred

There is a growing trend in health care. The traditional, inpatient, overnight stay hospital has been gradually replaced by the ambulatory care facility. Perhaps in part due to the increased efficiency of our modern health care system, and in part to growing health care cost. 

Last summer, MemorialCare announced its proposal to transition the hospital in San Clemente into a 103,000 sq.ft. advanced outpatient care facility, potentially leaving San Clemente without emergency services.  Many people in the city have fought against the proposal; starting petitions, rallies and even forming the non-profit foundation Save San Clemente Hospital.

The proposed change is not a purely financial decision, as stated by Tony Struthers, Administrator at Saddleback Memorial Medical Center San Clemente: “This is not a reflection of the financial difficulties that the hospital has experienced, but a change in the way care is being delivered. Fewer patients are being seen in the hospital and more and more patients are seeking care in outpatient settings. This is a trend that is sweeping the nation and is not just isolated to our community.” 

And even with the onset of a new, larger housing development in Rancho Mission Viejo on the near horizon, the growing San Clemente population isn’t anticipated to increase the need for the current hospital. 

“We do not anticipate growth in Rancho Mission Viejo to dramatically affect our volumes in San Clemente. MemorialCare Health System is planning on putting an outpatient center in the community of Rancho Mission Viejo in the very near future,” said Struthers.

In September, it was proposed to remove inpatient beds from the campus, and replace the existing emergency room with an advanced urgent care center. If the current ban against freestanding emergency rooms in California is lifted, as it has been in some cases, emergency services will be able to be kept on campus. This lift on the ban against freestanding emergency rooms may be a midpoint between two polarized opinions.  

Chuck Hahn, an advisor to Save San Clemente Hospital, told us: “The legislation establishing a stand-alone ER is one possible solution. We have provided several win-win solutions to MemorialCare and the City that would maintain the emergency room and a smaller boutique hospital at a cost similar to what MemorialCare wants to build. We hope they will sit down with the community and build the hospital we need and one they promised when they purchased it.”  

Save San Clemente Hospital, a non-profit whose mission is “… to stop the closure of San Clemente Hospital, ensuring that every resident has access to quality healthcare”, was formed after Saddleback Memorial Care announced its intention to close the hospital.  Community members have gathered in opposition, and in one case, wearing red and forming a large ‘S.O.S.’ on the sands of a beach.  

The national move toward outpatient facilities has been encouraged by more advanced technology. Patients, increasingly concerned with saving hospital expenses, become more likely to check in to outpatient services. 

Tony Struthers explained, “This is part of a national trend because of the need to reduce the costs of care. Technology has also played a huge role in moving care from the inpatient setting to the outpatient setting. For example, most surgeries are now being performed in outpatient surgery centers and not in hospitals. Therefore, we believe that we will actually be able to serve more people in our community and not fewer.”

And the trend toward outpatient services certainly is national.  Inpatient admissions fell 7.8% per Medicare beneficiary from 2004-2011, while outpatient rose 33.6% in the same period, according to a report done by the Medicare Payment Advisory Committee in 2013.(1)

One recent study, published by The Journal of Urology, was designed to test the cost differences between outpatient and ambulatory care facilities. By investigating Medicare claims from 1998 - 2006, the research identified elderly patients who underwent common outpatient urological procedures. Each procedure measured price-standardized payments, and compared them to hospitals, ambulatory surgery centers as well as physician offices.  The results of the study showed that for nearly all procedure groups, ambulatory surgery centers and physician offices had lower overall episode payments than hospitals. Urodynamic procedures, for instance, were less than a third of the cost at ambulatory surgery centers than at hospitals.

As stated by the lead researcher of the study, John M. Hollingsworth, M.D., an assistant professor of Urology at the University of Michigan Health System: “For comparable procedures, hospitals were associated with significantly higher 30-day payments than ASCs (Ambulatory Surgery Centers) and the physician office… In fact, offloading 50% of the procedures examined from hospitals to ASCs would save the Medicare program nearly $66 million annually…Outpatient facility payments were noted to be the biggest driver of the payment differences across ambulatory care settings.”(2)  

But amongst the larger concerns of the Save San Clemente Hospital organization, is not just for those who can, if barely, afford the care, but also for those who cannot.  

“Even MemorialCare (the hospital owner) has said in their own public benefit statement they serve 30% underserved and poor area residents and a growing population of seniors.” Chuck Hahn continued, “As a not-for-profit hospital that is their public benefit - that is why they receive certain tax benefits. If they close and open an advanced urgent care then these vulnerable populations will be subject to: a) less access to care b) increased mortality rates, and c) those uninsured will have to pay for services.”

An equal concern is the commuting times required in emergencies, since the travel to nearby emergency centers could have a detrimental effect in severe scenarios. This is where the new legislation could play a vital role. “…This is a possibility with the introduction of AB911 by Assemblyman Brough and SB787 by Senator Bates which would allow us to maintain emergency services on our campus without the presence of an acute care hospital. As of mid-April it is beginning its journey through the legislative process,” said Struthers.