The head of Cleveland Clinic Indian River Hospital, undaunted by nearly $200 million in operating losses since Cleveland took over the facility in 2019, said he expects the Vero Beach hospital to break even financially by the end of 2025.
“We have a tremendous plan on the operations side that looks at how we create a sustainable delivery system for the future, said Cleveland Clinic Indian River Hospital Vice President and Chief Medical Officer Dr. Richard Rothman.
“We don’t have the final numbers (for 2024) yet. But year-over-year (losses in 2023) have been cut in half. And we’re expecting by the end of 2025 to be month-over-month back to break even.”
Rothman knows that’s an ambitious claim for a facility that posted a $60-plus million operating loss for 2023. Maybe his passion for the hospital and its extraordinary potential has equipped him with a pair of rose-colored glasses.
Maybe, after heading up Cleveland Clinic’s COVID Operations and Recover Task Force and emerging from the darkest days of the pandemic with his optimism intact, Rothman sees any complex problem as surmountable – if you work hard enough.
One project Rothman is particularly exuberant about is the new three-phase Emergency Department expansion and renovation, which quietly got underway in December. The $20 million endeavor is fully funded, thanks to generous 32963 residents and other local donors to the Cleveland Clinic Foundation, with John’s Island residents Chase and Wendy Carey leading the pack of island benefactors.
When completed in Summer 2026, it will add 8,750 square feet in the Emergency Department, transforming the Patient Pavilion into space to treat 38 more emergency room patients.
Currently about 55,000 patients per year – an average of 150 per day – come through the Indian River Emergency Department, 30 percent of whom are admitted to the hospital.
Rothman gave Vero Beach 32963 unprecedented access to hospital facilities, including the Emergency Department, earlier this month, and agreed to a series of lengthy interviews.
After a barrage of bad press in this newspaper surrounding Leapfrog safety grades and the Indian River County Hospital District’s mishandling of a $13.6 million funding request to offset Cleveland Clinic’s losses on “uncompensated care,” Rothman realized the best way to shore up the community’s confidence that Cleveland Clinic is as committed as ever to Vero was to address the tough questions.
The tour of the beleaguered Emergency Department was a start. It’s definitely not an area of the hospital anyone would voluntarily show off to a visitor in terms of looks, but Rothman said it’s “among the most sought-after emergency departments in the Cleveland Clinic network.”
The original “round” of 30 patient rooms, which longtime Vero residents might remember from decades past, seemed quite organized, but that’s just the beginning. The only patients who experience that area are the ones brought in by ambulance.
By early afternoon the Emergency Department was nearly filled to its 67-patient capacity, with two ambulances in the bay. The specially designed, secure behavioral health beds were also full, one with a young boy. Rothman said a growing number of pediatric mental health patients have been showing up in the emergency department.
Temperatures were headed swiftly downward, so along with people suffering from garden-variety maladies and respiratory bugs, there were a couple of homeless people, possibly hoping to get a hot meal and a warm bed for the night.
“In a couple of hours, the ambulances will be stacked out there,” Rothman said stoically. Just another Thursday.
The walking wounded who arrive in the waiting room of the CCIRH Emergency Department are escorted back to one of a maze of cubicles where their vitals are taken and nurses triage their condition to see how urgently they need to be seen by a doctor.
There are two sets of these cubicles marked with station numbers printed on brightly colored paper. One set of stations is made up of white walls that appear semi-permanent. But another set of cubicles consists of portable office partitions arranged to offer some semblance of privacy, but not much. It’s better than pulling a curtain or being out in the open, but less than ideal.
“That’s just temporary,” Rothman said.
He sees this setup every day so apparently he’s grown accustomed to it. It’s just another reality of modern hospital medicine. He’s seen the artist renderings of the sleek, post-renovation Emergency Department. He knows change is afoot, so he focuses on progress.
“How temporary?” we asked. “How long have these been here?”
Thinking back, Rothman replied that the office-cubicle partitions were set up when the COVID-19 triage tents in the parking lot came down. So years. It’s been that way for years.
“But all the patients are being monitored,” Rothman said, again, focusing on the care.
No one was sitting or lying in any of the hallways unattended at any time we were in the emergency department. Rothman pointed out that every staff member was fully engaged with patients, not hanging out at the nurses’ station.
Having winnowed most of the pricey traveling nurses from the ranks and replaced them with permanent local nurses, the hospital’s all-important patient-to-Registered Nurse ratio in the Emergency Department is now 3 to 1, Rothman said, which is the national industry standard. For trauma patients or more serious cases, the ratio would typically be 1 to 1 during critical stages.
And the waiting room was empty. In high-season January, that’s progress.
Wait times – meaning the time from walking in the door to being seen in a cubicle – are way down to a few minutes. In busy season, it’s 9 to 13 minutes, with off-season wait times down to 5 to 7 minutes. The longest a “lower acuity” patient who ends up being discharged from the emergency department typically waits is 27 minutes.
Evaluating patients swiftly saves lives, he said. Rothman demonstrated how quickly the Emergency Department staff can get a stroke patient from the ED to the stroke treatment lab where a neurosurgeon can remove a clot, or coil off an aneurysm to stop a brain bleed – less than a minute’s walk.
Last week, the hospital’s fifth CT Scanner came online and Rothman proudly shared a picture of the new machine.
He celebrates the fact that on independently conducted direct-mail patient surveys, of which nearly 10 percent are completed and returned, overall patient satisfaction with the Emergency Department is way up.
Where only 50 percent or 60 percent of patients rated their emergency care experience as positive in January 2024, nearly 80 percent of patients responding to the survey gave Cleveland Clinic’s ER good marks this past November. More than 80 percent of patients who responded rated the emergency department doctors high for courtesy – a factor Rothman said correlates closely with overall patient satisfaction.
A systemic problem of “boarding” patients waiting on admission in the Emergency Department due to a lack of available staffed beds in the hospital has been solved over the past year or so, Rothman said.
“Thanks to Hospital at Home, we no longer board patients in the Emergency Department,” he said. “We have not had a challenge with staffed beds in the hospital since my tenure (as VP and CMO) has started.”
Before being promoted to interim VP and CMO after Dr. David Peter’s departure in December 2023, Rothman, 42, established and ran Cleveland Clinic Florida’s Hospital at Home, whereby patients can be treated or recover at home with active medical monitoring from the Hospital at Home Vero Beach headquarters.
Those are the successes that fuel Rothman to tackle the financial woes that have dogged Cleveland Clinic’s Vero operation, though Cleveland Clinic as a whole was in the black for the fourth quarter of 2024.
The taxpaying public still wants to see the hospital’s detailed turnaround plan, how Rothman will stop the bleeding of $60-plus million in cash annually. But on a more basic level, the source or sources of the bleeding must be located.
How much of the money Cleveland Clinic Indian River Hospital has been losing is related to the Emergency Department? The answer, it turns out, is $11 million per year, which makes up roughly half of all the uncompensated care at the hospital. But that number requires some unpacking.
The way Cleveland Clinic tracks losses is by patient, not by department, so the only way to quantify losses associated with the Emergency Department is to track the care provided to all patients who arrive through the Emergency Department – wherever they end up – for the duration of their stay in the hospital. That could mean surgery or even cancer treatment.
Of the 3,553 “charity care” patients seen in the Emergency Department last year, 800 were admitted to the hospital, and 400 were admitted to the behavioral health facility. Of the 800 medical patients, 185 required acute surgeries such as open-heart surgery, brain surgery, procedures for broken bones, and surgery for acute abdominal conditions.
“So many of these patients who are coming into the Emergency Department have not seen a physician. So let’s kind of give you a scenario. A 50-year-old patient hasn’t seen a physician, comes into the Emergency Department with chest pain. All of a sudden their blood glucose is 300 or 400. Their markers of heart injury are elevated,” Rothman said.
“They’re having a heart attack, but their blood pressure is now well above normal. So now we’re not just treating a heart attack, we’re treating hypertension, diabetes. When it’s this advanced and we do a cardiac catheterization, they’re not amenable to a stent. So now we have to call our heart surgeons in to do a heart surgery,” Rothman said.
“Preventative medicine is so important as we think about holistically treating everyone in the community. It’s not to say that the Emergency Department won’t still play a significant role, but we can prevent these heart attacks,” he said.
That is a much bigger, long-term community-wide problem that Rothman, whose specialty is internal medicine, wants to solve, while also fixing the hospital’s finances.
Will the $20 million in physical and technological improvements to the Emergency Department improve the bottom line? Rothman believes so, as providing care will be more efficient.
The Vero hospital’s patient mix is a tricky one, as 70 percent of patients are covered by Medicare or Medicaid, with a negligible number of those being on Medicaid.
Rothman said Medicare patients enjoy the greatest access to all kinds of care – meaning whatever they need is very likely “covered,” so that’s good for seniors on Medicare.
So at least the hospital knows it will receive something for treating Medicare-covered patients.
The amount Medicare pays for so-called “covered” expenses, however, is what adds to the losses.
Medicare reimbursements to the hospital and to doctors cover only a fraction of the true cost of care. Even with copays, deductibles and Medicare supplement insurance, every patient age 65-plus who arrives in the Emergency Department is an automatic financial loss to the hospital.
So in Vero Beach as is the case everywhere else in the U.S., 70 percent of the hospital’s customers get their care at a deep discount, and there are not enough younger, working people with excellent private insurance provided by corporate employers to make up the difference.
On top of that, there is true “charity care” provided to about 13,000 patients annually with no ability to pay, and the bad debt arising from people who don’t pay what their private insurance won’t cover. This is exacerbated by seemingly wholesale claim denials.
Rothman said the hospital employs more than 100 people whose sole job is to fight with insurance providers to get treatments and procedures pre-approved on the front end, and to get denials reversed on the back end. The people who perform this thankless job, he said, are true miracle workers.
But because the vast majority of the hospital’s reimbursements come from Medicare, and those reimbursement rates are well-known, the amount Medicare reimburses needs to be the goal in terms of efficiency.
The closer the hospital can get to providing care at a cost that matches the Medicare reimbursement rate, the closer it can get to ending 2025 in the black.
