In 2008, the payroll at Toyota in Georgetown was $537 million.
At Lexington's three big hospitals — UK HealthCare, Central Baptist and St. Joseph — the combined payroll for a year is more than $1 billion. That's without benefits.
A major engine of Central Kentucky's economy — health care is poised for even more explosive growth over the next decade. As each hospital builds new, more sophisticated facilities, the rivalry among them will intensify for patients, for awards, and for the best doctors as health care reform ups the ante on how the market is divided.
UK, building a $762 million, 12-floor hospital tower that it expects will serve Lexington for the next 100 years, is the big dog as the state's flagship educational medical complex.
Saint Joseph has made a name for itself as the place to go with heart problems, but it will expand its obstetrics business as it opens a $60 million, 60,000-square-foot women's hospital off Richmond Road this spring.
Central Baptist, long thought of as a baby-deliverer, also touts its cardiac services. In June, it broke ground on a two-story, 20,000-square-foot building in Richmond and is expected to announce plans in 2010 for more construction — possibly in Hamburg.
The three men leading the hospitals — Dr. Michael Karpf at UK, William Sisson at Central Baptist and Eugene Woods at St. Joseph — don't like to talk about the competitive nature of their business. But they do, in fact, vie for attention, donations and the power to call their hospitals the best in their areas.
Karpf, for example, points out that while UK competes with local hospitals in some areas, it also has a unique mission and specialties: "If you need a liver transplant, it's either us ... or Louisville," says Karpf, "Or you're going out of state."
"Our competition is Vanderbilt," Karpf says. "Our competition is Washington University. It's Cleveland Clinic."
Susan Zepeda, executive director of the Foundation for a Healthy Kentucky, a non-profit educational group, says she hears about the need for access, and the expansions seem to address that.
"We do think it's exciting that the hospitals are finding their way into rural communities and stores, where people are," Zepeda said.
Flagship finds its focus
Karpf, UK's executive vice president for health affairs, divides his time among building that $762 million hospital, recruiting star medical personnel and faculty, and travelling to build UK's relationships with rural hospitals and physicians in the state.
He is by no one's definition a shy man. And having come to UK in 2003 from the University of California-Los Angeles — consistently ranked the best hospital in the West — he is used to success.
"I personally went out and talked with the people and asked, 'What do you want?' " Karpf said of his travels. " ... I personally get involved with all the relationships myself."
Karpf said he was looking for niches — services UK could provide that would keep patients from leaving the state to seek care.
UK has a mission to improve the availability and quality of health care throughout the state, Karpf says. Hence, he says, it has to dominate certain areas, such as transplants and trauma care and advanced neurology, and set the pace in others, such as cancer research and treatment.
Such services have to be so sophisticated that Kentuckians would have to leave the state to get better care and, in some cases, so advanced that patients from Ohio, Tennessee and West Virginia would consider coming to UK for their care.
"We are now positioned to compete to become a top 20 academic medical center," Karpf says. "... There are two things that are important — the growth that we have seen (and) the relationships we have built with community providers."
He says UK's range, in geography and specialized treatment, is what sets it apart from the other health chains: "Only 30 percent of our patients come from Fayette County."
About 50 percent come from more than 30 miles away, outside the immediate Bluegrass area.
Karpf and his lieutenants compare UK's new health care approach to Toyota's "lean technology" for its car manufacturing: "We think we make a better product cheaper."
Hospitals around the nation have turned to Toyota for inspiration on rethinking everything from emergency care to nursing routines and infection control.
A healthier Kentucky?
Saint Joseph is the largest provider of cardiovascular care in Kentucky, through its hospitals and management of programs such as the heart-care center at the Appalachian Regional Hospital in Hazard.
Over the next decade, the challenge for Saint Joseph will be to have a "statewide coordinated presence, combined with a more integrated partnership with our physicians," said Woods, CEO of Saint Joseph Health System.
That will put the hospital in "a unique position to significantly reduce the incidence of major diseases like heart disease and cancer throughout the state in the next decade — which in the end is our overriding goal," he said.
In the spring, St. Joseph will open its women's hospital off Richmond Road. The hospital dropped out of Lexington's baby-delivery market in 1978 and returned in 1998, when it acquired Jewish Hospital, formerly known as Humana Hospital-Lexington.
The new $60 million Saint Joseph Women's Hospital, which will be connected to the existing hospital by an enclosed walkway, is in some ways more like a boutique hotel than a hospital: upscale "green" decor, huge windows, a plethora of Kentucky art. There's even a room for community meetings.
Indeed, that's one of the themes of the new wave of competition for Kentucky medical dollars: Going to the doctor, be it an emergency room visit or for surgery, is no longer meant to be a big, scary experience.
Saint Joseph's Jessamine County emergency room, Central Baptist's preventive care emporium, even the new UK hospital, are all meant to be inviting and comforting to patients and their families, with welcoming decor, regional art and even promises of reducing the dreaded emergency room wait.
Saint Joseph-Jessamine RJ Corman Ambulatory Care Center in Nicholasville, which sits on a 55-acre site and cost $11 million, boasts that the average wait time is less than 30 minutes "from door to doctor."
Saint Joseph figures that the 22,000 visits logged there so far come from southern Fayette County, Jessamine County, Garrard County and even Boyle County.
"The need clearly was here," says Woods, "because in Lexington we've not seen a decline in our emergency visits."
One in every three patients who walks through the door in Jessamine County, says Chris Bowe, Saint Joseph's Jessamine administrator, is either self-pay or no-pay.
Even so, says Woods, "We're doing well financially here."
Mini-clinics and spinning
In June, Central Baptist broke ground on a two-story, 20,000-square-foot building in Richmond that will offer primary care physicians, outpatient diagnostic services and clinic space for specialties. That's on top of adding Baptist Urgent Care to its offerings at Nicholasville's Brannon Crossing — which will open Monday.
And Central Baptist is putting the finishing touches on the new HealthworRx wellness center at Lexington Green, in the former CompUSA location. The building is being touted as a preventive-medicine showcase, featuring counseling and exercise.
"We need to be setting the example," says Sisson, Central Baptist's longtime chief executive, striding between the room where the Pilates reformer will live and the one where spinning classes will be held. "We need to be leading."
Central Baptist in November opened a mini-clinic at Lexington's Hamburg Wal-Mart — in a row of businesses that include a bank, eye center, beauty shop, nail salon and Subway sandwich shop. The hospital's parent company will open a similar clinic at the Bashford Manor Wal-Mart in Louisville this month.
Central Baptist already runs a separate diagnostic center at Hamburg.
The hospital says it's going where the patients are, with the services they want.
In 2006, Central Baptist announced plans, still not finalized, to close its Nicholasville Road location and build on 129 acres near Hamburg as "one-stop shopping" for health care, including heart, cancer, women's and children's care, neurosciences and surgery.
The change would ease Central Baptist's access to Interstates 64 and 75 and give it some geographic breathing space from the vast new UK health complex going up a stone's throw away.
The hospital later said it would keep the Nicholasville Road location open and build at Hamburg.
In August, Hamburg developer Patrick Madden said the Central Baptist property, when finally developed, will be "a gem."
But it's unclear when — or if — that will happen.
Sisson says only that the Hamburg property "has been a great purchase," and that an announcement will be made in spring or summer 2010 about Central Baptist's expansion.
Where the patients are
Both Saint Joseph and Central Baptist say they're making it easier to get ear infections checked and flu diagnosed at smaller clinics outside their main hospitals.
Sisson, the only CEO of the three who doesn't have a big new hospital currently in the works, deflects the idea that that might put Central Baptist at a disadvantage. "A building is not a hospital," he says. "I don't worry about that."
One reason Sisson doesn't seem worried might be that Central Baptist is doing well in the obstetrics market and is increasing its appeal to patients driven by convenience — those who might think it's too much trouble to go to a doctor's office but will figure it's OK to get that nagging cough checked out if they're in Wal-Mart anyway.
But, whether patients wind up at a hospital, an emergency room or a clinic, the competition is likely to get tougher for all three hospitals because patients are also getting smarter — as St Joseph's Woods points out.
"Now more than ever, patients are rightfully evaluating which hospitals to go to in the same manner that they evaluate other major decisions or purchases in their lives," Woods said, "including researching quality and the overall patient experience."