What’s going to replace hospitals that downsize?

I recently rounded on patients at Providence Hospital as the attending physician on the family medicine residency program’s inpatient service. Providence recently closed its maternity ward as the first step in a planned redevelopment of the hospital grounds into a “health village.” In the short term, the hospital’s decision to stop delivering babies may worsen maternal health disparities, as the entire eastern side of Washington, DC is now a “maternity care desert” with no labor and delivery services. In Providence’s defense, it lost $23 million in fiscal year 2016, and its long-term plan to replace hospital beds with ambulatory services and spaces that support community health and wellness is part of a broader national trend. As Dr. Neel Shah wrote recently in Politico’s “The Case Against Hospital Beds”:

Some corners of the health care world are already starting to embrace new, less bed-focused models of care. … [At a] venture-capital based birthing center franchise, birthing families are often admitted and discharged on the same day, and beds are in the corner of the room (for resting and breastfeeding after the baby is born), rather than in the center; the idea is to encourage the mom to use movement as much as possible to support her labor by literally sidelining the bed. Health systems are increasingly investing in other types of spaces where bedrest is not the default, including skilled nursing and rehabilitation facilities, as well as home visiting nurses and health coaches to help high-need patients with acute and chronic conditions stay out of the hospital.

Before the hospital building boom that began after World War II, most acutely ill persons were cared for at home by family members with the help of visiting physicians. Emerging technology may enable this historical arrangement to become the future of health care. A recent JAMA Viewpoint argued that the expansion of telehealth and virtual care capabilities means that it’s time to start training and credentialing a new physician specialty called the “medical virtualist,” who would possess specific expertise in providing remote care the way a hospitalist possesses expertise in hospital care. (I’m not sold on this idea, as studies continue to show that primary care physicians who care for their own patients in the hospital have as good or better outcomes than do hospitalists.) In “A Hospital Without Patients,” Arthur Allen described the Mercy Virtual Care Center, where teams of doctors and nurses use wireless devices to remotely monitor homebound patients around the clock and act as consultants in intensive care units in faraway hospitals:

For now, the future looks like this: Hospitals will keep doing things like deliveries, appendectomies, and sewing up the victims of shootings and car wrecks. They’ll also have to care for people with diseases like diabetes, heart failure, and cancer when they take bad turns. But in the future, the mission of the hospital will be to keep patients from coming through their doors in the first place.

For a family physician with a natural orientation toward prevention and public health, this is certainly an appealing vision. As the years have passed, I find myself enjoying my time at the hospital less and less, mostly because most of the patients on my service wouldn’t need to be there if outpatient health and social services simply worked better. So many admissions could have been avoided if primary care clinicians were able to easily check on patients in their homes and intervene early on in flares of chronic obstructive pulmonary disease or congestive heart failure. If my homeless patient didn’t have to wait months for housing; if my uninsured patient with diabetes didn’t have to choose between buying insulin and glucose monitoring supplies; if my debilitated patient with Medicare could be transferred directly to a rehabilitation center rather than needing a hospital stay first.

There should be plenty of dollars available to redirect into prevention as hospitals downsize. Since 2014, Maryland has piloted a successful statewide experiment in giving hospitals financial incentives to keep patients well (and beds empty), overriding the traditional goal of keeping beds full to maximize revenue. The ever-present danger is that savings from hospital downsizing will go to pad executive salaries rather than flowing back into the community, as seems to be occurring at the fabulously wealthy “nonprofit” Mayo Clinic system.

Perhaps the future will see Providence Hospital’s shuttered maternity ward replaced by a modern birthing center and comprehensive prenatal and postpartum care enhanced by telehealth services. Or today’s maternity care desert could remain just that: a desert, where minority mothers continue to suffer pregnancy complications and deaths at appalling rates. In my view, the role of policymakers should be to encourage a health care environment that makes it easy for hospitals and health systems to do the right thing.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor

Image credit: Shutterstock.com

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