Medical Infrastructure - Hospital Closures And Access To Health Care
Top 5 States Ranked by Hospital Beds per 1,000 Population and Total Population
| Beds per 1,000 | Population rank | Beds per 1,000 | Population rank | ||
| District of Columbia | 6.6 | 50 | California | 2.1 | 1 |
| North Dakota | 6.4 | 47 | Texas | 2.7 | 2 |
| South Dakota | 6.2 | 46 | New York | 3.6 | 3 |
| Mississippi, Montana, Nebraska (tied) | 4.9 | 31, 44, 38 | Florida | 3.4 | 4 |
| West Virginia | 4.5 | 37 | Illinois | 3.0 | 5 |
Why do some of the least populated states contain the most hospital beds per 1,000? Do these states have higher hospital admissions rates? Not in every case. The next table shows the top 5 states in terms of hospital admissions per 1,000 per year. Only the District of Columbia had the same ranking in both hospital beds and in admissions.9 West Virginia and Mississippi were in the top 5 in both of these categories.
Top 5 States Ranked by Hospital Admissions per 1,000 Population and Beds per 1,000 Ranking, 2000
| Admissions per 1,000 | Beds per 1,000 ranking | |
| District of Columbia | 255 | 1 |
| West Virginia | 162 | 5 |
| Louisiana | 155 | 8 |
| Alabama, Mississippi (tied) | 153 | 14, 4 |
| Pennsylvania | 150 | 18 |
Twenty-six states had higher rankings for admissions per 1,000 than beds per 1,000, possibly suggesting that there was a shortage of beds in these states. From 1990 to 2000, approximately 500 hospitals closed nationally. In a study of hospitals in 52 mid-sized and large cities by the Robert Wood Johnson Foundation, nearly 28% of the hospital beds were eliminated from 1980 to 1997.
Massachusetts ranked 27th in hospital admissions and 32nd in beds in 2000. More than 30 hospitals closed from 1980 to 2002, and more were warning of closures in 2002. Hospital beds were reduced by 30%: from 23,000 to 16,000 (or 2.5 beds per 1,000 population). In March 2002, Holy Family Hospital in Methune, Massachusetts canceled elective surgeries for a week in order to keep beds open for a backlog of emergency room patients. The same month, the Massachusetts House adopted a resolution urging Governor Jane Swift to declare a public health emergency due to another major hospital closing: Deaconess-Waltham Hospital, a 115-year old community hospital.10 Deaconess-Waltham expects an $8 million loss in 2002. And, it is not alone. Two thirds of the hospitals in Massachusetts are losing money (LeBlanc).
From 1980 to 2000, 45 hospitals closed in Ohio. But, in Ohio there has been debate about how much these closings truly affected quality and access to health care. "Community groups say low-income people are losing services as more urban or inner-city hospitals close. Yet health care analysts say Ohio still has more hospital capacity than people need, even after this year's closings" (Bonfield).11 They may both be right. Avondale residents have seen two large hospitals in mostly African American communities close since 1997. One, Bethesda Oak, "was a favorite for seniors because the hospital was on a convenient bus route. Other hospitals…may be close to Bethesda Oak, but getting to the appointments has become more complicated," according to Tom Jones, chairman of the neighborhood public safety task force. But, Bethesda Oak's average bed occupancy was down to 42 patients a day when it closed. Hardly enough to sustain a 450-bed hospital.
Interestingly, the predictors of hospital closures changed from the 1980s to the 1990s. To some extent, however, the predictors are the same. Low occupancy rates, low Medicare admissions, and hospitals surrounded by competitor hospitals may lead to less financially secure hospitals (a predictor from 1990 to 1997, but not from 1980 to 1990).
Predictors of Hospital Closings, 1980-1997
| 1980-1990 | 1990-1997 |
| Hospitals with fewer beds | Hospitals with fewer beds |
| Hospitals in minority neighborhoods | Less financially secure hospitals |
| Hospitals surrounded by competitor hospitals | Less financial resources relative to patient volume |
| Patients' length-of-stay longer | |
| Low occupancy rates | |
| Low Medicare admissions |
In the "CGE&Y 2002 Hospital Executive Survey," top executives of healthcare facilities nationwide listed the following as the major obstacles to running a thriving hospital. Phrases in bold are terms from the survey.12
Inadequate reimbursement levels. Some insurance companies delay payments on valid claims, more uninsured patients are seeking care, and government and managed care reimbursements are inadequate to meet health care costs. In Massachusetts, hospitals say "the single biggest problem" is the reimbursement for Medicaid patients. The state reimburses the hospital at 71 cents on the dollar, which causes a $200 million a year loss to hospitals in that state (LeBlanc).
Severe staffing shortages. Nursing shortages have been a problem for at least 5 years. But, recently shortages in laboratory, information technology, and business office staff have been causing problems in all areas of health care by "driving up costs and threatening patient safety and health" (Lisi).
Unwieldy regulatory requirements. Hospital costs are rising due to more and more government regulation. Hospital officials fear that the new regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that will take effect in 2003 will just add to the burden.
Rapidly changing patient demands. The aging population will require more specialized care, time with hospital staff, and Medicare/Medicaid resources. "Better informed patients are demanding more specialty services, greater convenience, and additional options for services" (Lisi).
Constrained capacity. Hospital closures and an increasing population are causing more people to be serviced by fewer facilities.
Encroaching specialty facilities. Full-service hospitals are serving more and more of the uninsured and lower income patients, while more of those with health insurance and higher incomes go to specialty hospitals for their care.
Growing liability issues. Malpractice insurance premiums have skyrocketed in the last few years, causing a financial burden on hospitals as well as doctors. In some cases, even when hospitals did not close, certain departments within hospitals did due to an inability to pay for malpractice insurance. In 2002, Methodist Hospital and Mercy Hospital in Philadelphia, PA announced that they were closing their obstetrics departments. In 1999, there were 2,940 maternity units. That is 463 fewer than in 1991. For more information on this topic, see the panel entitled Is Malpractice Litigation Hazardous to Our Health? in Chapter 15.
Endangered capital investments. "Constraints on revenue and rising costs make it tougher for hospitals to buy new technology and infrastructure. Hospitals often need state-of-the-art technology to remain competitive and keep up with patient demands" (Lisi). But, not all hospitals see this as an obstacle to becoming financially viable. Newton-Wellesley Hospital, in Massachusetts, recorded losses of $23 million in 1998. Despite this, it invested in new radiology equipment and expanded its emergency, women's health, and pediatric departments. In 2001, it still reported a loss, but only of $5 million. Union Hospital, also in Massachusetts, invested in a new emergency room after reporting losses of $2 million in 1997. In 2001, it recorded a surplus of $5 million.
Sources: The Henry J. Kaiser Family Foundation. "State Health Facts Online." Retrieved September 4, 2002 from http://www.statehealthfacts.kff.org. U.S. Census Bureau. United States Census 2000 Summary File 3. Retrieved September 6, 2002 from http://www.census.gov. U.S. Census Bureau. Statistical Abstract of the United States, 2001. American College of Emergency Physicians. "Emergency Medicine Statistical Profile," July 2001. Retrieved September 6, 2002 from http://www.acep.org/. American Hospital Association. "Fast Facts on U.S. Hospitals from Hospital Statistics ®." Retrieved September 4, 2002 from http://www.hospitalconnect.com/. Tim Bonfield. "Ohio hospitals face stress." The Cincinnati Enquirer, August 20, 2000. Retrieved September 6, 2002 from http://enquirer.com/. Robert Wood Johnson Foundation. "Research to Update Information on Urban Hospital Closings, Mergers, and other Reconfigurations," January 2001. Retrieved September 6, 2002 from http://www.rwjf.org. U.S. Department of Health and Human Services. "HHS Issues First Major Protections for Patient Privacy." Retrieved September 10, 2002 from http://www.hhs.gov/. New Jersey Hospital Association. "NJHA Supports Physician Call for Action on Medical Malpractice Crisis," June 13, 2002. Steve LeBlanc. "State beset by hospital closings," March 10, 2002. Retrieved September 6, 2002 from The Ad Hoc Committee to Defend Health Care web site at http://216.36.252.42/news_state_beset.htm. Chris Lisi. "Top Hospital Executives Identify Leading Trends, Worry About Future in New National Survey," May 9, 2002. Retrieved September 10, 2002 from http://www.us.cgey.com/news/. Massachusetts Medical Society Online. "MMS Trustees Create Task Force on Hospital Closings-Vital Signs," February 25, 2002. Retrieved September 10, 2002 from http://www.massmed.org. John Seewer. "Small-town maternity wards give way to high costs, heavier competition." The Review, April 26, 2002. Retrieved September 10, 2002 from http://www.the-review.com. Marie McCullough. "High costs shrink maternity care." The Philadelphia Inquirer, July 7, 2002. Retrieved September 10, 2002 from http://www.philly.com/.
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