15 Key Factors Affecting Hospitals' Longer-Term Outlook

1. Promise fades for more paying patients. The health reform bill was going to vastly expand the number of paying patients, but hospitals still would have had to wait three or four years to see a big spurt in paying patients, says Allan Baumgarten, a Minneapolis-based research consultant whose work focuses on healthcare policy, finance and local market strategies. Now hospitals will need to use that time to plan for a future with a weak trickle of paying patients, he says.

2. Reimbursements lag further behind inflation. Long-term federal and state budget deficits will keep reimbursements behind inflation, says Dick Clarke, president of the Healthcare Financial Management Association in Westchester, Ill. That, coupled with the failure to expand the pool of paying patients through reform, will mean hospitals will really have to work on expense reductions. In the first year of the recession, Mr. Clark says, "hospitals already picked the low-hanging fruit, reducing per-unit supply costs and the cost of personnel," so it will be more difficult this time around.

3. Number of paying patients in long-term decline. Higher unemployment results in fewer covered patients, which means more bad debt and charity care, Mr. Baumgarten says. It's worse than you might think, he adds, because for every one person who loses a job, you can figure two will lose coverage, accounting for the worker's family. "This is a long-term problem because it won't be easy for the economy to regain lost jobs," he says. "The risks for hospitals are significant."

4. Overcapacity of beds in some areas. Mr. Baumgarten says many hospitals have been extending their geographic reach, especially into affluent suburbs, to increase their pool of paying patients. But when everyone is doing this, it can lead to overbuilding and overcapacity. For example, he says three new hospitals recently went up in Williamson County, Texas, north of Austin, which already had three small hospitals. He wonders whether the area can sustain so much new construction.

5. Negotiating strength moves to insurers. Hospitals used to have the advantage over insurers in price negotiations because beds were scarce and insurers needed to have them, Mr. Baumgarten says. Hospital systems with highly regarded brand names and robust geographic presence have enjoyed strong leverage. But as utilization declines and hospitals create overcapacity, he thinks insurers might be able to skip over a stubborn hospital that demands a large pay increase.

6. Insurers may not need to be tough negotiators. Health plans are passing on much of their insurance risks to employers, patients and providers, Mr. Baumgarten observes. Large employers are increasingly self-funded, an arrangement where the insurer simply manages the account and is not on the hook if costs rise. And in high-deductible plans, the plans pass on part of the risk to patients and providers. Patients have to pay large amounts before they meet their deductible and hospitals and doctors have to collect it.

7. Patients continue shifting to high-deductible plans. Dodging rising premiums in traditional plans, many people have been switching to high-deductible health plans with comparatively low premiums. Mr. Baumgarten says high-deductibles lower the demand for services. "When you have to pay everything out-of-pocket until the deductible is met, you're less likely to seek care," he says. He believes it's unlikely people will switch back from high deductibles even if healthcare inflation subsides.

8. Hospitals forced to become more efficient. Hospitals have long complained about insufficient Medicare payment levels, but as rate hikes cool off, Mr. Baumgarten thinks hospitals may decide Medicare rates aren't so bad after all and that these rates could be enough if hospitals learned to be more efficient. One way this can be done, he says, is to collaborate very closely with physicians and other providers to reduce the total cost of a particular episode of care both inside and outside of the hospital.

9. Payors move to bundled reimbursements. Mr. Clarke says CMS has launched several pilot projects that explore paying providers for the whole episode of care, such as the Acute Care Episode (ACE) demonstration. Instead of reimbursing for volume, he predicts payors will move toward reimbursements for outcomes, or "payment for value." Expect more pilots, soon followed by some permanent changes in reimbursements from both public and private payors, he says.

10. Providers coalesce into integrated systems. Facing declining income and changing payment methodologies, hospitals will need to fundamentally restructure the way they deliver care, Mr. Clarke says. "Organizations will need to pull together in a different way," he says. "The old incentive to admit more patients will be replaced by the new incentive to improve outcomes." He thinks hospitals will have to approach healthcare from a new perspective: keeping patients out of the hospital.

11. Physicians fall in with hospitals.
Despite bad experiences with acquiring physician practices in the 1990s, hospitals are back at it, Mr. Baumgarten says. He sees this as a win-win situation in many cases. Hospitals need physicians to increase admissions and to coordinate care, and group practices need hospitals to access capital for projects like EMR. Some analysts believe a group practice of less than 350 doctors cannot amass the necessary capital and cannot be sustained.

12. Small hospitals seek shelter with larger ones.
"The number of small, freestanding hospitals will decline fairly significantly in the next five years," Mr. Clarke says. "In many cases smaller institutions will not be large enough to address upcoming challenges, such as taking a bundled payment." He thinks they will join larger institutions that have the means to organize hospitals and doctors into integrated systems.

13. Capital needed for IT introductions.
Mr. Clarke says hospitals will need to buy more equipment and redesign facilities to change patient flow, but the biggest investment will be in healthcare IT, a very expensive proposition.

14. Non-profits' debts stay comparatively small.
While many nonprofit hospitals face debts, they tend to have much lower debt loads than those of privately held organizations, Mr. Clarke says. Because nonprofit hospitals can't go into private equity markets, their ability to develop capital is more constrained and they can't amass huge debts, he says.

15. Discounts for construction become available. With overall demand for construction in the basement, Mr. Baumgarten sees outstanding discounts for hospitals that want to build and have the money to does so. The cost of materials is down and contractors will negotiate price just to get the business. However, hospitals face the risk of overbuilding caused by the downward trend in patient volume. Already some new projects are being scaled back, with unfinished space set aside for future expansion.

Contact Leigh Page at leigh@beckersasc.com.


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