Did Managed Care "Burn" Shriners Institute?

With its emphasis on cost-effective, quality care, the increasing emergence of managed care across the United States was expected to be a boon for Shriners Burn Institute of Cincinnati, the 31-year-old, 30-bed, pediatric burn center that provides state-of-the-art burn care and rehabilitation free of charge to all patients.

Part of the national Shriners Hospitals for Children system, the facility is completely funded through an endowment and provides initial care, rehabilitation, and plastic surgery to patients until they reach 21 years of age. In addition, 10% of the hospital’s $22.5 million annual budget is delegated to research.

The institute has met the criteria to be verified as a burn center by both the American College of Surgeons and the American Burn Association. And, notes hospital administrator Ron Hitzler, you can’t be more cost-effective than free.

Yet in January of last year, the hospital, as well as the other Shriners hospitals across the country, began seeing a significant downturn in referrals.

Where once the facility filled an average of 12 or 13 acute care beds a day, they were having trouble filling half that number.

"We just seemed to have been forgotten," says Hitzler.

By gathering information from units across the country where downturns had occurred and tracing information back to referring hospitals, they determined that managed care’s practice of forming preferred provider networks had inadvertently left the charity organization out in the cold, says Greg Hart, principal and director of health care consulting at Larson, Allen, Weishair and Co., the Minneapolis-based firm hired by Shriners Hospitals to recommend a solution to the problem.

Managed care functions by directing and funneling patients into specific paths, Hart says. Because there are relatively few severely burned pediatric patients each year, developing specific protocols to meet their needs is not a high priority for many MCOs.

"It’s a case of a standard process being applied to non-standard patients," says Hart.

Some managed care executives have suggested to Hitzler that hospitals were holding on to pediatric patients longer to fill beds in their ICU units.

"I don’t think that’s the case," Hitzler says. "I don’t think anyone holds on to a patient when they know there is a better level of care available."

The institute also did not see any decrease in referrals from inside the Cincinnati area; it was the out-out-town hospitals that suddenly dropped off, indicating the problem was one of information, Hitzler notes.

James Augustine, MD, FACEP, CEO of Premier Health Services in Dayton, OH, an emergency physician who has referred patients to Shriners in Cincinnati, says there is another possible explanation for the fewer number of patients seen by the facility.

"This is one of the few areas that [emergency medicine has] had success in the area of prevention," says Augustine. "I don’t see anyone not sending a patient because of financial considerations. That’s just not a conversation that takes place."

"I’ve always had a good relationship with Shriners," he adds.

Nevertheless, argues Hitzler, the institute still sees too many children referred from other hospitals who would have had better outcomes if they had been referred sooner.

Since the Cincinnati hospital has begun new efforts to contact EDs and ED physicians across the country, the hospital’s census has gone back up.

Though he declined to name specific hospitals, Hitzler says one hospital administrator told him they simply forgot about Shriners.

"They had been referring to us all this time and suddenly they forgot about us," he says.

This is why it is imperative that the center develop a strategy for operating within a managed care framework, Hitzler says.

"What we are trying to do is figure out how Shriners as a system can fit into the environment as it exists today," he says. "We are out of step with the environment and we need to get in step.

"Somehow developing relationships, whatever they end up being, with managed care organizations is not simple. Having to achieve a presence where we didn’t have to before is part of what the consultants are looking at."

Hart’s recommendations to Shriners include that they "aggressively develop relationships with managed care organizations," courting them in much the way it has physicians and hospitals in the past.

The Cincinnati unit is already negotiating with a large, national organization that should spawn other agreements, says Hitzler. What he would like to see happen is for Shriners to be included on all of the preferred provider panels as a "center of excellence" for severely burned pediatric patients.

"The whole system is really looking at trying to form relationships with MCOs or insurers, not to accept their money, but somehow make ourselves available to their clients or people they insure, if it would ever be necessary."

But the center can’t be content with just being on the list, he says. "It’s how we position ourselves with those with the opportunity to make the referral, so at least they know about us and make the option available to parents."

"The old days, when patients used to come just because they knew about you—it doesn’t seem to work that way anymore."