A quick post on something we do not think about often.
We look at the world through our own professional lens. If you toil at a big urban hospital, your sphere of interest encompasses GME, training, research, and safety net care. Conversely, if you work at a small, rural hospital, you concentrate on ER and ward coverage, adequacy of services, and connectivity to neighboring facilities and unavailable technology.
I often find discussing inpatient needs and policy with others from varying regions eye-opening. Having practiced urban or suburban medicine my entire career, small 50-100 bed hospitals seem distant. Simply, I don’t have a clue what grinding alone, at 3AM, confronting a case on which I am green feels like. To function without intensivists and with a threadbare staff requires a skill set I do not have (but I could acquire of course…of course).
In thinking about the institutional diversity of our country, the word immense comes to mind. Truly. Like different tribes, many of your professional concerns do not resemble mine, despite our common degree. I deliberated on this brick and mortar heterogeneity—size, ownership, profit status, and payer mix—when I read a recent study published in JAMA scrutinizing a large swath of US facilities. I had not looked at basic hospital facts in some time.
Below I present some essentials (data from HCUP).
Hospital Quantity: You will notice America’s large number of hospitals (5700). But also place our diversity in context. Hundreds of wards have closed over the last few decades, aligning with national trends to scuttle unneeded beds in large cities and rural communities.
Non-profits dominate nationwide, with for-profits trailing behind. The latter comprise one in seven facilities, predominantly in the south (TX). On rural vs. urban, CMS defines rural as all counties outside metropolitan statistical areas with <50,000 people. Rural hospitals constitute 40% of the total, and the 60% remaining situate in urban settings.
Bed Size: Many of you at urban or academic facilities may be surprised to learn half of US hospitals size less than 100 beds. Your QI efforts; your fixed costs; your dependency on limited numbers of payers; your attempts at complying with regulatory burdens must be viewed in perspective. Our needs all differ, and of note, rural and critical access hospitals face unique challenges.
By Payer: Finally, hospitals rely on three flows of revenue: Medicaid, private or commercial sources, and the big gorilla–Medicare. Why big gorilla? Hundreds of commercial plans exist—mostly regional, and Medicaid varies from state to state. Medicare, however, has pseudo monopsony power. They pay identically in all 50 states and oversee a unified delivery system. CMS moves the market and as Medicare goes, so do our hospitals. Think penalties (a 1% Medicare hit equals ~0.4% revenue decline), as well alterations in CMS payment methods. Its one thing if a local carrier requires bundled payments, but it’s another when Medicare asks demands the same. Similarly, notice the decade’s long decline in commercial contribution to income. The weight of public reimbursement continues to grow, and with this enlargement comes an “attentiveness” a hospital might lack when faced with multiple, weaker payers.
To wit, you know the saying, “When Americans sneeze, Canada catches a cold”? Well guess who gets the flu when the HHS secretary skips her flu shot? Its not Canada. 🙂
**UPDATE**: CMS released a proposed rule to clarify the definition of an inpatient versus observation stay. The rule however, does not address the 72-hour bar to qualify for skilled nursing care:
The proposal says hospital stays spanning more than two midnights would qualify a patient for coverage under the Part A benefit for hospital services.
A stay of fewer than two midnights would be covered by the physician benefit, Part B. The policy presumption of patient status still could be overridden by the admitting physician and through that doctor’s documentation, CMS said.
(Of note, proposed rules generate comments from the public, and after a preset period–usually 2-3 months, the administrative agency in question–CMS here–proceeds based on the feedback they receive.)
UPDATE#2: WSJ article today (gated) on doctor-owned hospitals. A small sliver of the pie, they number few and have an uncertain future due to the ACA.
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.
Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.
Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.
He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.