It is no secret that many of New York State’s hospitals are in trouble. Officially, 28 of them are on a “watchlist” created by the New State Department of Health because they are in serious financial distress and have little cash on hand to support operations. What this really means is that they are on the brink of collapse. They would very likely close if they did not receive hundreds of millions of dollars in state subsidies to keep their doors open.
While these facts are alarming, they are hardly new. A decade ago, I served as the Executive Director of the Berger Commission, named for its esteemed Chairman Stephen Berger (but formally called the Commission on Health Care Facilities in the 21st Century). The Commission conducted a comprehensive review of health care capacity and resources in New York State. What we found then is equally true today: we “repeatedly identified communities whose needs could be well served with less than a full service hospital but which require more than an ambulatory care center… Creative and financially viable alternatives, such as free standing emergency rooms or community health centers with urgicare capabilities, could advance the achievement of a rightsized and restructured health care delivery system. The benefits could include enhanced access to services, less duplication, and amelioration of the economic impact of full hospital closures.”
Ten years later, both the need for and interest in these hybrid models of health care is growing. I recently read about the rise of “microhospitals”—“tiny, full-service hospitals with comprehensive emergency services but often fewer than a dozen inpatient beds.” Many are linking patients to primary care and specialty physicians, often in the same building. These microhospitals are popping up in a few places across the country (Colorado, Nevada, Texas, and Arizona), mostly in urban and suburban areas that need additional providers of emergency care but not necessarily large, complex hospital facilities.
While I’ve been preaching about the need for new care models (combined with different reimbursement structures) for a while, its time seems to have come. As inpatient hospital admissions decline and more emphasis is placed on outpatient services that keep patients healthy and out of the hospital, we need to further realign our health care delivery system to meet patients’ needs and allocate resources appropriately.
While we haven’t seen microhospitals, per se, in New York, we are seeing similar approaches with free standing emergency departments, particularly in New York City. The first in the State was opened by Montefiore Medical Center in 2013, taking over the space that was once Westchester Square Hospital in the Bronx. The following year, to fill the gap left after St. Vincent’s Hospital closed, Lenox Health Greenwich Village, part of Northwell Health (then North Shore-LIJ Health System), became Manhattan’s first free standing emergency department. Later in 2014, NYU Langone opened a free standing emergency department in Brooklyn, at the site of the former Long Island College Hospital.
Earlier this spring, Mount Sinai announced that Beth Israel Hospital in Manhattan will close and be replaced by a much smaller facility—perhaps not quite a microhospital, but a drastic reduction from more than 800 inpatient beds to 70. The most complex patients will be referred to other hospitals, but the new hospital will include an emergency department and enhanced access to outpatient services.
Upstate, we’ve seen similar changes. For example, after Lakeside Hospital in Monroe County closed in 2013, nearby Strong Memorial Hospital took over the site and now provides emergency care, primary care, and a range of other services.
In all of these New York examples, existing hospitals had excess, unsustainable inpatient capacity and needed to scale back. But a total closure without replacement services would have created huge gaps in needed care in those communities. Newer, creative models filled the void.
Communities feel strongly about their hospitals. It’s understandable: no one wants the hospital where their children were born to close, no one wants to feel as though emergency care is too far away, and nobody wants to see jobs lost. At the same time, as our health care system increasingly rewards and prioritizes outpatient care and primary and preventive services, the old model of large inpatient hospitals is no longer financially viable in many communities. These hybrid models of care offer a good middle ground that can meet the needs of their patients and residents in a way that’s more prudent and sustainable.
In the prologue to our final Commission report, chairman Steve Berger and I wrote that we were “confident that New York will seize the opportunity to build a health care system that is stronger, better, fairer, more affordable, and that meets the needs of communities.” Ten years later, that work continues. Meaningful change takes time, but communities across New York are beginning to discard old, failing models and experiment with new forms of health care delivery.