Do We Even Need Hospitals Anymore?

You may have also received an invitation to participate in tomorrow's "Future of the Hospital" forecasting game.  (An open invitation is found here:   http://www.iftf.org/future-now/article-detail/future-of-the-hospital-infographic/  for those among you who have yet to register.) Sponsored by the California Health Care Foundation and others, this twenty four hour competition looks like an attempt to crowdsource the question: "Do we even need hospitals any more?" 

This is a very good question.

Intrigued, I have explored the forecasting game's website, twitter feed, "challenge" posts and decided to register.  Why this one? I receive invitations to a number of such "let's re-invent health care before  we become obsolete" type events. I occasionally participate by helping formulate questions. 

But this is the first time I would like to help brainstorm answers in this format. The difference is the series of smart questions posted under the first challenge: "Construct a 21st century safety-net system that is fair, economically sustainable and delivers high-quality emergency care services to all in need." This challenge includes these sub-topics:

• Should hospital relocations and closures be stopped through the legal or political systems?  What if minority communities could sue to prevent a hospital closure?
• What if the drop in operating EDs across the country is a positive sign of market forces at work, creating a more efficient healthcare system?
• Could EMTALA (the act that requires hospitals to provide care to anyone needing emergency health treatment regardless of citizenship, legal status or ability to pay) be strengthened to restrict closures in medically underserved areas?

This is great stuff, much of it resonant of the 2006 Institute of Medicine's study on challenges facing 21st century hospitals.

Hospital closures -- whether full closures or partial closures such as  stand alone Emergency Department closures -- are complex and, often, emotionally fraught.  Whoever said every divorce, from the perspective of family life, is the death of a civilization might have known a thing or two about community hospital closures. In a secular society, schools and hospitals often substitute as the institutions where all of our paths eventually cross at transcendent moments of our lives -- birth, death, life-threatening illness. Hospitals, while primarily health care institutions, are also civic institutions.

As a result, in the throes of a pending closure, it can be a challenge to address the larger questions about efficiency, the changing nature of hospital delivered care, and equity. I look forward to the forecasting game's insights. As a warm up,  I offer here a few thoughts on the topic of permission to close a hospital.

Permissive hospital closings are the inverse of the long-debated hospital building certificate of need ("CON") process.  In some states -- but no longer on the federal level -- a hospital's advance permitting to build requires a determination of need. A CON is not required in California, for example, but is required in New York.  There is considerable diversity of approach in between the hands-off wild wild west approach and the fairly searching scrutiny required in some states. Just as you might imagine, this means hospitals are often built on spec as it were in some states, in anticipation of demographic trends, and then have to be re-purposed as other kinds of facilities.  There are risks.  In other places, it can be arduous to open a hospital, essentially protecting market share for long-established institutions.  There are risks to harm to competition in these places.

In these different contexts, you can see that requiring permission for full or partial hospital closure might seem more or less consistent with that jurisdiction's thinking about hospitals as public goods. All of this is further complicated by the fact that, though the majority of hospitals in the United States are not for profit, states like California have substantial for profit hospital chain presence.

Add to this mix the reality that some parts of the country are over-supplied with acute care hospital beds (and their attendant hospital-based medical specialty providers) and some are under-supplied and realize that tomorrow's forecasting game ought to be lively.

Reinvent community hospitals for the 21st century? I'm game.