At 5 p.m. on July 26, a shift at High Point Regional Hospital ended, sending healthcare workers into the parking lot in colorful clots. Meanwhile, across the street, a woman wearing gold chains tapped her pink fingernails against a shoulder bag and a volunteer in scrubs crept up to the edge of a gathering crowd. The woman, who I’ll call Susan, declined to give her real name. She was one of more than two dozen people standing outside the Community Clinic of High Point, part of a line that curved around a yard with a single tree, toward the door on Main Street that is neither an entrance nor an exit. At a few minutes past five, a nurse appeared with a clipboard. She ushered the group through a foyer and into the waiting room, which promptly filled with families. Susan sat alone in the back row and patted the chair next to her. “I’ll talk to you sweetie,” she said. Susan called the clinic early on Thursday – as is Community Clinic protocol – because the regular doctor she’d seen earlier that week was worried the numbness in her arms might be a symptom of multiple sclerosis. Diagnosis would mean tests and lab work, things the uninsured Susan would be unable to afford. So the doctor sent her here, to this short building in downtown High Point, so referrals could be made and charity care secured. “I worked in furniture for twenty-seven years,” she said. “I was laid off when it left.” When she was laid off, she lost her health insurance. Since then, she’s been plagued by health problems – gall bladder disease, cancer, thyroid problems and carpal tunnel syndrome – that have made working impossible. Last time she came to the community clinic, which serves adults who are living at or below the federal poverty line, she waited almost three hours to see a doctor. But that doctor saved her life, she said, when he arranged her cancer surgery. “If it wasn’t for them,” she said, “I wouldn’t be talking to you right now.” This time, she’s one of the first patients called. Volunteers stationed at intake windows updated her information, then sent her to a triage station where nurses and medical assistants took her weight and blood pressure. They escorted her into an exam room. Susan wouldn’t be at the free clinic if the company she worked for hadn’t moved manufacturing to China. Before they closed, administrators had asked her to train workers overseas, but Susan had refused. Something about the offer hadn’t sounded right, she said. A notion nagged at the back of her mind. Maybe, she thought, she and her colleagues were no longer going to be part of the business plan. lot of things are changing in the formerly sleepy burg of Kernersville, located three highways up from downtown High Point, right on the border of Guilford and Forsyth counties. Chief among the changes is a sudden influx of medical services. Medical investment in this community reached its apotheosis on Friday, July 27, when state regulators approved the construction of a 50-bed general hospital, a project proposed and undertaken by Novant Health, which owns Forsyth Medical Center. In addition to that project, Moses Cone Health System based in Greensboro will be opening a medical office complex next spring, and High Point Regional recently opened a building that combines doctors’ offices and a fitness facility. Hospital expansion is good, administrators say, because it means services are going where the patients are. “There has been great growth in services that are coming to Kernersville,” said Jo Haubenreiser, the executive director for post acute services at Forsyth Medical Center and a longtime Kernersville resident. “All health systems are appreciating providing services closer to their patients.” Residents of this 20,000-person town have largely applauded the convergence of medical services in their backyard. The Kernersville News trumpeted the news of Novant’s approval with a banner headline in large point font. “This is like V-J Day,” said Jim Roskelly, vice president of corporate planning and development at Moses Cone Health System. He held up a copy of the paper. “Novant must be pretty happy about that.” The comparison to war is an apt one, since Novant battled state regulators for more than a year before they won the right to build their hospital. In May 2006, Novant applied for a certificate of need, which is required by the state of North Carolina before the construction of most new medical facilities. Regulators had determined that Forsyth County needed 90 new hospital beds, and Novant proposed building 39 new ones and relocating 11 old ones in Kernersville. Representatives of High Point Regional Hospital filed a brief opposing the proposed hospital. A hospital in Kernersville was unnecessary, they said, because patients already had ready access to four major hospitals: Forsyth Medical Center and North Carolina Baptist Hospital in Winston-Salem, Moses Cone Memorial Hospital in Greensboro and High Point Regional Hospital. State regulators agreed with High Point Regional, and in October 2006 they denied Novant’s certificate of need application. They questioned Novant’s calculation of demand and the need to move hospital beds, operating rooms and cardiac equipment from downtown Winston-Salem to suburban Kernersville. The decision tabled the $84.9 million project, and Novant Health filed an immediate appeal. Meanwhile, Kernersville residents turned their frustration against High Point Regional Hospital, and some vowed to boycott affiliated providers. “High Point Regional, like all health care systems, worried that relationships with current patients would be damaged if a new hospital moved in,” Haubenreiser said. The state had another concern. Hospitals are required to submit information about how many of their patients are indigent, on Medicaid and Medicare, or are privately insured. More than 12 percent of Forsyth Medical Center’s patients were charity cases, another 16 percent received Medicaid and 30 percent were on Medicare. Blue Cross/Blue Shield of North Carolina and other insurance providers covered the balance of the hospital’s patients. For the Kernersville hospital, Novant Health calculated that only 4 percent of its patients would be charity cases, and less than 5 percent would receive Medicaid. They estimated that more than 45 percent would be on Medicare, the government benefit for retirees that reimburses doctors and hospitals better than Medicaid, its counterpart for the poor. Regulators said the numbers showed that underserved populations would not have adequate access to the new hospital. Hospital administrators deny the allegation that they are chasing better-insured, wealthier patients by building in the suburbs. They simply need to move with the population, and the population is filling in the spaces between the major cities. It just so happens that growth often means wealth and, in Kernersville’s case, that means its residents have above-average family incomes. In downtown High Point, it’s another story.
Jerri White, the executive director of the Community Clinic of High Point, steers the institution from a corner office that, more than a decade ago, probably served a branch bank manager. It’s got brick walls, slit windows and enough room for a desk and love seat. White is instantly companionable, with a voice that betrays a hint of rural North Carolina. “We are a free clinic,” White said. “That is not to be confused with a typical doctor’s office. There’s no crash cart in here. If you’re having chest pains, we’ll send you over to the emergency room.” The clinic sees only indigent patients, those individuals who earn less than $816 a month. White said the clinic opened with the original intention of serving acute cases – patients with strep throat, sinus infections and other treatable conditions that could be addressed outside an emergency room. But since the clinic started seeing patients in 1993, their focus has shifted to managing chronic illnesses like diabetes and high blood pressure that are widespread in High Point and around the state. The clinic is staffed by White, a full-time nurse practitioner, pharmacist, certified medical assistant, nursing assistant, Spanish-language translator and an employee who negotiates pharmaceutical assistance for patients. Retired and practicing physicians volunteer at the clinic several times a week, as do students in nearby nursing and physician assistant programs. The clinic serves an average of 75 to 100 patients by appointment each week. Last year, they provided 6,051 office visits and filled 15,000 prescriptions at the in-house pharmacy. In addition, they obtained $618,422 worth of free medicine for their patients. They did all this with significant financial support from High Point Regional Hospital. The hospital leases the building, which used to house their billing office, to the community clinic for $1 a year. The community clinic exists in the long shadow of the mirrored main hospital. “We are here to help people,” White said. “But we do what we do in collaboration with the medical community.” White said the hospital benefits from the clinic’s intervention. Patients who visit the community clinic often bypass the emergency room, which is the typical medical safety net for the uninsured. The hospital saves hundreds of thousands of dollars in medical bills that would probably go uncollected, White said. “People try to pay their medical bills,” she said, “but not everybody can.” Many of the patients who come to the clinic are laid-off manufacturing workers. They are largely unskilled, and not the kind of people who are going to get hired by Dell, White said. “We do have, I think, a crisis as far as having employment opportunities for the people of High Point,” she said. That crisis has sent more patients her way. And more into local emergency rooms. Recently White raised her voice in opposition to Moses Cone’s plan to build a freestanding emergency department near Highway 68, in an area High Point residents claim as their own. The spat even descended into semantics, with Moses Cone officials referring to the target area as “western Guilford County,” and High Point Regional supporters insisting that it was “north High Point.” “I look across the street, I look next door, I’m surrounded by High Point Regional,” she said. “I know how much support this health system gives to this clinic. What that system can do for us certainly depends on how they are doing financially.” White was one of dozens of High Point residents who opposed what they considered aggressive expansion by Moses Cone. One speaker said that Cone was moving into the High Point area because of the hospital’s inability to snatch more of the Kernersville market from Novant. Unlike Kernersville, the cities of High Point, Greensboro and Winston-Salem suffer from sluggish economic growth, especially compared to the rest of the state. Residents of the Triad’s major cities are more likely to live in poverty than their suburban counterparts, according to data from the US Census. The region’s economic frailty makes it more imperative than ever that hospitals establish viable business plans, which increasingly means specializing and decentralizing services, and attracting those patients who can pay. In the Triad, that also means that hospitals that have traditionally served discrete markets are stepping on each other’s toes in the race to establish themselves in growing markets.
All over the nation, hospital systems are building. They are building orthopedic and cancer hospitals, heart and stroke centers and smaller satellite hospitals in the suburbs. “[Hospitals] are shoring up their periphery,” said Oscar Aylor, a professor in UNC’s School of Public Health. “They are looking at their markets and making expansions at the edges.” Expansion into the suburbs is meant to strengthen the core business – the flagship hospital – by building a stronger referral basis, Aylor said. Because North Carolina tightly regulates the construction of health facilities, the area has not seen the rash of hospital construction that has happened in Indianapolis, Denver, Phoenix and parts of Texas. Hospital construction can be good, Aylor said, as long as it serves formerly neglected communities and doesn’t bring too many beds into a hospital service area. Hospitals proliferated on the East Coast after World War II. Passage of the Hill-Burton Act provided federal funds for a national hospital network. Many of the large industrial cities saw an explosion of post-war hospital construction, Aylor said. The healthcare market has changed considerably since then. Patients, particularly well-heeled ones, have the means to travel to any hospital they choose. No longer are patients confined to the hometown hospital. “Large cities on the East Coast tremendously overbuilt over the years,” Aylor said. “They can’t all survive.” Hospital competition has already intensified near Raleigh and Charlotte, despite the best efforts of state regulators to keep a lid on construction. Population growth is driving a demand for more services. Martha Frisone, the state’s project analyst for the Triad region, said she’s seen a sharp increase in applications for certificate of need in recent years. One the agency did approve was Moses Cone’s application to build a freestanding emergency department – the $20 million project that raised the ire of so many High Point residents. “It’s a way to bring services to the public,” Roskelly said. “Instead of building services and hoping the patients come.” The freestanding emergency department would not have any inpatient beds, and serious emergency cases like strokes or major trauma would be routed to Moses Cone Memorial Hospital. The emergency department is intended mostly to relieve pressure on inner city emergency departments that are already over capacity. “The demand for [emergency department] services is a little hard to figure out,” Roskelly said. “We built an urgent care center a few years ago and we saw a drop in demand for a little while. But then it just went right back up. There is an almost insatiable demand for services.” High Point Regional registered its hostility to the Moses Cone project with the state agency, the same as it did for the Kernersville hospital. Hospital administrators have since withdrawn their opposition to both projects. High Point Regional spokeswoman Diane Reaves issued a statement about the Kernersville project. “We were able to withdraw after working closely with the CON Section and thereby, with Novant, to identify a location that would most effectively serve the residents of Kernersville, ” it read. “As always, our main concern is the well being of the residents of our area.Ê The development of health care services that are both needed and accessible, allows HPRHS and all of our fellow providers to meet the continued health care needs of the patients of this region and to provide high quality health care.” Roskelly of Moses Cone ventured another explanation. “It’s a little hard to oppose bringing services to the citizens of Kernersville when you’re also trying to bring services in,” he said. “That fence is hard to sit on.” Novant has been the most aggressive of the area health care providers in extending its service area, Aylor said. They already operate suburban hospitals in Huntersville and Matthews outside of Charlotte and have invested in a hospital in Brunswick County on the coast. Novant health is also the richest of the three competing hospitals, with $2.2 billion in combined assets compared to Moses Cone’s nearly $1 billion; High Point Regional Hospital took in almost half a billion dollars in gross revenue last year. Healthcare systems need to have deep pockets, because hospitals are among the most expensive structures to build due to rigorous safety standards, sanitation requirements and the high-tech infrastructure. They usually end up costing more than a million dollars per bed. “We don’t just build hospitals willy-nilly,” Haubenreiser said. Hospitals that overbuild end up losing money, Roskelly said. The government doesn’t negotiate its reimbursement rates, he said, and a significant number of patients can’t pay. “There’s almost no way to pass the costs along to the consumer anymore,” he said. Since Hill-Burton and before, hospitals have been assigned the responsibility of caring for the less fortunate. By shifting medical costs to paying customers, they have been able to subsidize care for the needy. “I’d say just about every not-for-profit has to use that approach,” Roskelly said. “Certain payers do not pay adequately.” But what happens to those needy patients if a hospital fails to secure a portion of a booming market? Will Winston-Salem’s indigent win at the expense of High Point’s? “Well, just like any other business, we are looking to grow,” Roskelly said. “And we are expanding where there is growth in terms of the resident population.” In the Triad, it appears the era of monolithic hospitals operating quietly in the center of their own community is over. Or maybe the expansion of the cities’ geographic footprints means the notion of community should be altogether rethought. “I think we’ve already turned that corner,” Roskelly said. “We are in a new era of competition.”
“You never know what you’re going to see,” White said. “Sometimes it looks like the United Nations in here and sometimes it looks like nobody could find a babysitter.” Thursdays are the only evenings the Community Clinic of High Point accepts new patients. People who need appointments must call early that day because the clinic caps admissions at 25. They have to turn away an average of 10 to 25 people every Thursday. As a result, they have a fairly unforgiving no-show policy. Do it twice, and you’re banned for six weeks. Three times, you’re out. The facility itself is humble but functional. There are eight exam rooms, each with a table and an office chair. The clinic paid to have cabinets installed, but the rest of the furniture was donated. There is no music, and just a handful of old magazines and a framed mirror on the back of each door. One of the rooms stores an old podiatry chair, and another contains eye charts and an optometry chair. Clinics like this one rely on the benevolence of hospital systems and doctors. Moses Cone operates two Healthserve Clinics for indigent patients, and Forsyth Medical Center donates a portion of its profits to providing care for the needy. “It’s very difficult to start a hospital like this one without hospital backing,” White says. But as the hospitals increasingly turn their attention to the suburbs, some wonder whether they will continue to invest in the city center. Kathy Norcott, the assistant executive director of Piedmont Health Services and Sickle Cell Agency, works with underserved populations in Greensboro. She and her agency set up free health screenings in public housing developments, inner city neighborhoods and areas with recent HIV or syphilis diagnoses. The agency started as a sickle cell disease screening and support network, but has since expanded its scope to encompass HIV, diabetes, high blood pressure and other conditions that disproportionately affect the African-American community. “We serve a population that doesn’t go to the doctor,” Norcott said. “People who don’t want to go to the hospital.” At a diabetes clinic last week, Norcott encountered an elderly man with dangerously high blood pressure and high cholesterol. He had no regular doctor, so Norcott had to refer him to Healthserve. In High Point when she discovers very ill patients, Norcott usually has to send them to the emergency room because the Community Clinic only takes new patients on Thursday. Transportation is one among many hurdles separating Norcott’s clients from regular healthcare. Public transportation in High Point and Greensboro stops at the county line, and passengers navigating the regional transit system may need up to four transfers to get to their destination. “It can become a burden on a person trying to get to the doctor,” Norcott said. She worries that the construction activity in the western part of the county will have greater long-term impact on the distribution of healthcare. “Doctors follow hospitals,” she said. “So if the new hospital starts taking doctors out that way, it might take doctors out of our community.” When doctors move away, it disrupts the continuity of care, she said. That can be particularly harmful for patients dealing with chronic conditions. Many of her patients cannot afford to move out to Kernersville, which means they might be left behind. As it stands, the main campuses of the hospitals are in no danger of moving. But if they can convince state regulators to allow them to move beds and other facilities, they may be less able to handle patient traffic. When she can, Norcott refers patients to free clinics in High Point and Greensboro. North Carolina now has 67 free clinics, and activists like White are working to bolster the network to 85. “Our real goal is to be out of business because we have a healthcare system that provides care to everyone,” White said. Hospitals are working to be anything but out-of-business. “It’s hard to think about a hospital closing because it leaves a lot of people underserved,” Aylor said. Residents tend to raise a stink when the word gets out that a hospital is closing, he said. That happened in Alexander County, when a hospital announced it would close after years of hemorrhaging money. “There was such a hue and cry from the community that they forced it to stay open,” Aylor said. “But it’s hard to operate a losing service line for very long.”
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