Hospitals nationwide appear to be seesawing over the fate of hundreds of inpatient beds and, with them, the future of thousands of jobs, entire communities and how patients will get care. The add-them, subtract-them decision isn’t so much a show of uneasiness as it is the result of hard realities, often unique to a hospital’s geography, as well as redesign born of healthcare reform.
In California, billions are being spent on retrofitting or new construction to ensure that hospitals meet earthquake standards that take effect in 2030. The deadly 1994 Northridge quake resulted in a legislative mandate that has caused some hospitals to close, downsize or sell to others who envision something other than intensive care beds on hospitals’ pricey, seismically rocky coastal real estate.
Whether the end result will provide sufficient beds to handle California’s growth and aging Baby Boomers depends on where in the state you live. In a 2015 report, the California Health Care Foundation said the San Joaquin Valley and the Inland Empire may be hard pressed to meet demand by 2040.
Different factors play out in rural areas, especially in southern states. Changing reimbursements have inhibited the ability of smaller hospitals to weather financial challenges, to satisfy requirements for installing electronic records and to lure and retain physicians, especially specialists. Some may call them “mom and pop” hospitals, but many smaller hospitals are critical “way stations” for healthcare emergencies, tending to patients until they’re transported to higher-acuity locales.
With fewer than 100 beds – many of them unoccupied – these hospitals are closing or becoming freestanding emergency departments where state laws permit.
Sometimes a single decision can push a once-successful small hospital to the edge. That’s occurring in Coalinga, Calif., where the district hospital took a huge fiscal hit when California shifted care of nearby state inmates to distant, newly created prison hospitals.
In New York City, the problem has been a chronic oversupply of beds coupled with costly, politically charged labor agreements. Sometimes that has meant paying sizable staff and operational costs when there were few or no patients to oversee.
Nearly 20 city hospitals have closed since 2000, and Mount Sinai Beth Israel has been facing a fiscal crisis threatening its existence. It’s opted to try something radically different. Over the next four years, it will replace its existing 856-bed hospital with a 70-bed hospital with an ED as part of a massive expansion of outpatient care services.
The scale of transformation at Mount Sinai is astounding. Some of the 4,000 unionized workers will need to be retrained or laid off. Perhaps $700 million in hospital real estate will be sold. The institution’s goal is focused on outreach and public education, to avoid or remediate medical issues before they necessitate costly inpatient care.
The seesaw effect of the Affordable Care Act of 2010 is nowhere close to flattening. The U.S. Centers for Disease Control said the nation’s uninsured rate in 2015 fell to 9.1%, the lowest on record. It was 16% when the law was signed, 14.4% in 2013 before its major provisions kicked in, and 11.5% in 2014.
The newly insured continue to seek treatment for ailments they habitually ignored, some of which have become chronic and irreversible. Many will need highly specialized care, complex surgeries and other sustained interventions and costly hospitalizations. Hospitals in regions of historically high unemployment and shortages of medical access can expect high rates of inpatient utilization to endure for years.
The reward for doing what matters – cradle-to-grave education and prevention, and doing it very well – will be empty hospital beds. That still sounds like a “pay me later” experiment, where later means future generations while today we’re addicted to “Hot ‘n Now” results. Ultimately, for hospitals, it forms the only solid ground when choosing to add or subtract inpatient beds, or just flat out go out of business.
(Also published as an op-ed in the July 30, 2016 edition of The Fresno Bee)