Up­side found af­ter hos­pi­tals close

Modern Healthcare - - NEWS - By Me­lanie Evans

Af­ter the abrupt clo­sure of 160-yearold St. Vin­cent’s Hos­pi­tal in New York City in 2010, dis­lo­cated pa­tients flooded nearby hos­pi­tals. The dis­rup­tion made the com­mu­nity an ap­peal­ing case study for re­searchers at the UPMC Cen­ter for Health Se­cu­rity in Bal­ti­more, who ex­am­ined the Man­hat­tan hos­pi­tal’s clo­sure for clues into how a sus­tained swell in de­mand might af­fect other hos­pi­tals.

Hos­pi­tals near St. Vin­cent’s—a Level 1 trauma cen­ter and safety net hos­pi­tal—scram­bled to find space and staff. Hos­pi­tals added work­ers in psy­chi­a­try, speeded up physi­cian cre­den­tial­ing, added triage and pa­tient­care units, and placed pa­tients in beds in the hall­ways.

Hos­pi­tal clo­sures typ­i­cally cause up­heaval among the pa­tients, com­mu­ni­ties and other providers in the mar­ket. It is less clear, how­ever, whether the clo­sures re­sult in worse health out­comes for the com­mu­nity.

Now, an am­bi­tious new study in Health Af­fairs by other re­searchers sug­gests that based on broad mea­sures of qual­ity and ac­cess, pa­tients col­lec­tively may be no worse off—and some types of pa­tients may fare bet­ter with dif­fer­ent providers.

The Health Af­fairs re­searchers, who ex­am­ined 195 hos­pi­tal clo­sures be­tween 2003 and 2011, found the death rate for Medi­care ben­e­fi­cia­ries in af­fected com­mu­ni­ties was no dif­fer­ent fol­low­ing the clo­sures, even among peo­ple who were re­cently dis­charged from a hos­pi­tal. The cost of care and the length of hos­pi­tal stay also were no dif­fer­ent. That was largely true even when the re­searchers looked at pa­tients who needed im­me­di­ate med­i­cal at­ten­tion, such as pa­tients with trauma, stroke or heart attack.

Re­mark­ably, fewer pa­tients in com­mu­ni­ties with closed hos­pi­tals died from heart at­tacks. Be­yond that, fewer Medi­care pa­tients re­turned to the hos­pi­tal within 30 days of leav­ing. And when the only hos­pi­tal to serve a com­mu­nity closed, death within 30 days of hos­pi­tal­iza­tion in that com­mu­nity de­clined.

Th­ese find­ings sug­gest that pa­tients found bet­ter care than what was of­fered in the hos­pi­tal that failed. “We sus­pect that to some de­gree the mar­ket is do­ing a de­cent job” de­ter­min­ing which hos­pi­tals re­main open, said study co-au­thor Dr. Karen Joynt, an as­sis­tant pro­fes­sor at Har­vard Uni­ver­sity and se­nior ad­viser in HHS’ Of­fice of the As­sis­tant Sec­re­tary for Plan­ning and Eval­u­a­tion.

Other stud­ies, how­ever, have shown that clo­sures are par­tic­u­larly hard on the most vul­ner­a­ble and acutely ill pa­tients. Joynt cau­tioned that her study looked at the av­er­age re­sults across mul­ti­ple years and nearly 200 hos­pi­tal clo­sures. The re­search also looked only at re­sults for pa­tients cov­ered by Medi­care. That ex­cluded the unin­sured. This is a crit­i­cal point be­cause hos­pi­tals that pro­vided more care to poor pa­tients were more likely to close. “I don’t want it to be in­ter­preted as it’s to­tally fine if a hos­pi­tal closes,” she said.

The closed hos­pi­tals stud­ied by the re­searchers were more likely to be safety net providers in ur­ban ar­eas owned by for-profit com­pa­nies. They also tended to be small, with 64 beds on av­er­age, com­pared with an av­er­age of 94 beds among hos­pi­tals that re­mained open. They also were in ter­ri­ble fi­nan­cial shape, run­ning an av­er­age op­er­at­ing loss of 20%.

For pa­tients served by St. Vin­cent’s in New York, the void in care was ad­dressed by nearby hos­pi­tals’ stepped-up ca­pac­ity, an ex­pan­sion of ex­ist­ing safety net ca­pac­ity and an in­flux of com­pet­ing com­mer­cial providers.

But a year af­ter St. Vin­cent’s closed, for­mer pa­tients with the great­est med­i­cal needs re­ported anx­i­ety, longer wait times and greater dis­tances to ac­cess care, re­searchers from the City Uni­ver­sity of New York re­ported. “They didn’t know where their doc­tors were,” said Diana Romero, a CUNY as­so­ciate pro­fes­sor in com­mu­nity health, one of the study’s au­thors.

Safety net clin­ics re­ceived state fund­ing to in­crease ca­pac­ity, which the Callen-Lorde Com­mu­nity Health Cen­ter used to ex­pand its hours and hire more clin­i­cians, said Wendy Stark, ex­ec­u­tive direc­tor of Callen-Lorde, a com­mu­nity health cen­ter that spe­cial­izes in care for les­bian, gay and trans­gen­der pa­tients. Mean­while, the city’s ma­jor health sys­tems opened new clin­ics and spe­cialty ser­vices.

On the other hand, St. Vin­cent’s psy­chi­atric ser­vices have never been re­placed, Stark said. In ad­di­tion, new com­pe­ti­tion for in­sured pa­tients and prof­itable ser­vices has widened the gap be­tween pri­vate providers and safety net providers fol­low­ing the hos­pi­tal’s clo­sure, she added.

Joynt said the re­search might be use­ful as hos­pi­tal op­er­a­tors and com­mu­ni­ties con­sider which in­pa­tient fa­cil­i­ties are nec­es­sary, given that hos­pi­tal con­sol­i­da­tion is con­tin­u­ing in the face of rate squeezes, flat or de­clin­ing ad­mis­sions and a gen­eral shift to­ward out­pa­tient care.

Source: Health Af­fairs

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