Michael Dowling: Are hospitals obsolete? No, they are evolving

While there's no doubt that hospitals have been changing dramatically over the past two decades, news stories and op-eds suggesting that they are becoming obsolete represent naïve points of view from armchair intellectuals who clearly haven't spent much time recently in a hospital.

Certainly, the industry's ever-shifting landscape is riddled with shuttered hospitals across the country, especially in rural areas. The number of hospital beds continues to decline, while consolidation among health systems continues to increase.

But those of us on the front lines of healthcare delivery know all too well that the importance of hospitals will only grow more pronounced, as the population ages and baby boomers move into their golden years. The downside of increased longevity is that our hospitals are often filled with mostly elderly individuals with multiple, chronic illnesses who can’t be treated appropriately at home or anywhere else, despite our best efforts to do so.

While facts about the changing nature of our industry are often portrayed as breaking news, many of us have spent the past 10-15 years adapting our models of care, moving more and more services to outpatient settings where patients can be treated more conveniently and less expensively. To get a true sense of how healthcare delivery has changed over the years, just take a look at the finances. A decade ago, 85 percent of Northwell Health's revenue came from its hospitals. Today, that number has dropped to 54 percent and it will continue to drop in the coming years.

Hospitals will evolve to reflect ongoing changes in the way healthcare is delivered and paid for.  That's why, with the exception of maternity and pediatric services, hospitals are becoming more like intensive care units, treating trauma and emergency patients, and those requiring major surgery and other highly skilled, advanced care. Unfortunately, it's common for those nearing the end of life to spend their final days or weeks in a hospital. While hospice and home care is certainly preferred, it's often not an option for those without an adequate support system in place.

Most healthcare leaders understand the care continuum is constantly shifting, and like many health systems, Northwell has spent years investing in different parts of a delivery system that is far less fragmented and siloed than years ago, with primary care, ambulatory care, hospital care, home care, rehabilitation and long-term care all playing integral parts in meeting the needs of patients of all ages.

Interestingly, the movement of clinical services out of the hospital and investments in ambulatory expansion into communities where health systems previously did not have a presence can actually lead to increases in hospital admissions. As health systems enlarge their outpatient footprint, they come into contact with an entirely new patient base, some of whom will require integrated care that can only be provided in a hospital setting.

As all healthcare administrators know, much of the patient movement out of the hospital has been driven by CMS, which has also raised the stakes on penalties for hospital readmissions. These statistics can sometimes be a helpful indicator of care quality, but using readmission rates as a primary metric to gauge the caliber of a hospital is dangerously simplistic. While policymakers seem to think patients can be treated with assembly-line efficiency, restoring people back to good health is far more complicated than building a car.

No two patients are alike, and while most of us have standardized care as much as possible to treat a range of illnesses and diseases, the unique nature of each individual means some people may have to be readmitted after they leave the hospital. This is not necessarily a reflection of poor care, only that a patient requires additional time with their care team.

Looking forward, we should also recognize that the same evolution that has led to significant outpatient expansion does not ensure the long-term success of ambulatory services. Advances in telemedicine and other medical technologies such as wearables and self-monitoring devices has empowered patients to take care into their own hands. As this technology continues to develop, patients will become more adept at monitoring their own health and turning to Dr. Google to determine their own course of treatment. Eventually, this shift will lead to the decline of some primary care practices, but rest assured that the highly skilled care offered by hospitals will remain a constant.

Urgent care centers and mini-clinics will continue to proliferate in strip malls and retail locations, but those services are often scarce in low-income communities, which makes it increasingly important to preserve safety-net hospitals. In spite of the financial losses sustained by hospitals in most underserved areas, they tend to be the economic anchor of their communities, employing hundreds of people and supporting local businesses. Allowing them to fail would create even greater health disparities within local neighborhoods where chronic illness is already prevalent.

All of us recognize that evolution is a natural part of the healthcare industry. Over time, some hospitals will be downsized, while others will be converted to ambulatory facilities or specialty care centers. Certainly, there will be some underutilized facilities that will be forced to close. But as our history has shown, most will adjust to the changing needs of their communities and continue to fulfill our shared mission.

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