First, We Blow Up All the Hospitals

A few recent stories are, I believe, reaffirming one of the big problems about healthcare: hospitals are 19th century institutions operating under 20th century business models in the 21st century.  It's time to rethink what we want a "hospital" to be. 

Atrium of Lucile Packard Children's Stanford  Credit: Steve Babuljak, Architect Magazine

The Boston Globe reported on Stanford's new Lucile Packard Children's Hospital, which cost a cool $1.3 billion and is touted as, of course, the "hospital of the future."  As they describe it, it doesn't look like a hospital at all, but rather: "It is some hybrid of hotel, museum, and high-tech laboratory."

The Globe notes a similarly ambitious, $1.2 billion renovation at Boston Children's, along with big hospital projects in numerous other cities.  "These hospitals are kind of high-tech hotels,” Mark Wietecha, president of the national Children’s Hospital Association told the Globe. “Everybody’s competing by building cooler hotels. They can do more, save more lives, all good stuff — but not cheap."

Then there was the NBC News story on the debacle with the new VA hospital in Denver.  Again, it's big and beautiful, another "cool hotel."  However, it took 14 years to plan and build -- 5 years late -- and its costs ballooned from $328 million to, umm, $1.73 billion (and counting...), despite somehow neglecting to include a place to treat PTSD, which will require further investments.  

Inside the Ricky Mountain Regional VA Medical Center Credit: Dan Elliott/AP

Meanwhile, the VA continues to struggle with how to improve access to services for veterans generally.   

The problem is that hospitals are big and getting bigger, going from building to buildings to campuses.  They are expensive and getting more expensive.  At some point, we have to ask: is this really how we want to spend our healthcare dollar?

Some hospitals are figuring other ways to spend their -- I mean, "our" -- money on our health.  Take Nationwide Children's Hospital.  Located in a somewhat blighted neighborhood of Columbus (OH), its Healthy Neighborhoods Healthy Families (HNHF) program "treats the neighborhood as the patient," as their summary in Pediatrics put it.   

Source: Nationwide Children's

The hospital is leading a partnership that has built 58 affordable housing units, renovated 71 homes, given out 158 home improvement projects, and helped spur a 58 unit housing/office development.  They've also hired 800 local residents and instituted a jobs training program. 

They're already seeing lower murder rates, higher high school graduation rates, and are studying impacts on emergency room visits, inpatient days, and rates of specific conditions such as asthma. 

The lead author, Kelly Kelleher, MD, told Fast Company:

 It’s essential if we want to change things.  Every city has certain pockets of disadvantage. Those particular pockets account for a disproportionate share of all the challenges children face. . . if you’re a pediatrician and you look at the numbers, you have to do something to participate in the solution around eliminating poverty in these neighborhoods. Medical care’s never going to change some of these outcomes.

"This is a national trend," Jason Corburn, professor of city and regional planning at the University of California, Berkeley, told NPR. "It's happening in cities across the country," citing similar efforts in Atlanta, Boston, New York, and Seattle.  

Or take a program, led by researchers at the University of Pennsylvania, that focused on cleaning up vacant lots in Philadelphia.  It sounds simple, but resulted in significant improvements in residents' mental health.  The authors concluded: "Making structural changes to the lowest-resource neighborhoods can make them healthier and may be an important mechanism to address persistent and entrenched socioeconomic health disparities."   

As Eugenie South, one of the co-authors, told The Washington Post:  

...there’s something that’s actually important about the green space...It’s a relatively low-cost intervention … and it’s a pretty simple intervention.  It’s very simple to replicate. It’s not complicated and could be easy for a city that hasn’t done this. 

Or a hospital. 

It is true that hospitals (excuse me, "health systems") are diversifying -- building/buying satellite locations, free-standing emergency rooms, urgent care centers, and physician practices -- but those big buildings remain the locus, and their sunk costs weigh on hospitals' finances. 

There's a great quote from Philip Betbeze of HealthLeaders: "the future of the hospital is not a hospital."  The future requires, as Richard Darch, CEO of Archus, more recently wrote, "radically and fundamentally rethinking the hospital, and even discarding the term ‘hospital’ to the history books."  Mr. Darch sees hospitals as "anchor institutions" of their communities, with a greater focus on wellness and structured more as a campus than a single place. 

I'd go further: not a building, not even a campus, but as a dispersed array of services - some medical, many not -- that are delivered as close to our homes as possible (and, preferably, in our homes). 

Do an image search for "hospital of the future" and you'll get pictures of futuristic buildings with some cool-looking technologies thrown in.  What I want to see are images of services being delivered where I am, focused around me, aimed at my convenience -- not at the convenience of the people delivering my care. 

"Mission Control" at Medically Home.  Source: BizJournals

As I previously wrote about, organizations like Medically Home or Hospital at Home believe that future is now.

Some will argue, well, we're not going to do surgery at home.  We're not going to have NICUs at home.  We're not going to put doctors and nurses in every sick person's home.

Perhaps, but there are a lot of things we're now doing in hospitals that don't need to be.  There are a lot of expensive devices that are now centralized in hospitals that could be decentralized or even made mobile.  There are a lot of interventions that aren't medical at all. 

It requires us blowing up our concept of a "hospital."

Don't donate money for hospital expansion/renovation plans.  Don't buy bonds for them either.  Don't sit passively on hospital boards that push for them or expensive new equipment. 

Instead, we should be questioning: how can a "hospital" most impact our communities' health?  What kinds of investments in our communities' health can they be making?  How we do push healthcare and health down as close to where and how people live as possible?

The argument will always be, well, payors won't pay for those kinds of things.  The business models don't support them.  To that I say: it's time not just for new kinds of "hospitals," but also new kinds of business models. 

Let's get to it.