You may have also received an invitation to participate in tomorrow's
"Future of the Hospital" forecasting game. (An open invitation is
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
- 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
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.