Hospitals Race to the Cornfields

Previously on this site there was a post on the phenomenon on schools relocating from urban neighborhoods to areas with more space on the fringes of town. Schools have their issues, like parking spaces in the case of high schools for students arriving by car, and space for athletic fields, but the fundamental model of students in the classroom hasn’t changed much. Until they were destroyed in that gas explosion the 1912 and 1922 buildings – with some cosmetic remodeling and technology updates – still served my old high school Minnehaha Academy just fine.

But hospitals face issues more serious than those faced by schools. With hospitals the fundamental models of patient care and patient expectations have changed a lot. MRI machines are more difficult to retrofit in a hospital than WiFi and flat screen TVs in a classroom, and the buildings are in use 24 hours a day, 365 days a year. This means any hospital not built in the last 25 years is functionally obsolete, and those 50 years or more are at the end of their service life. Recently Lakeview Hospital of Stillwater joined the trend and announced they were moving to this plot of land at a future interchange off Highway 36.

Standards of Care and Patient Expectations

You may have seen old pictures of hospitals with mammoth open wards. Over time these wards have gotten smaller and smaller until finally the standard was only two to a room, or “semi-private”, common in most postwar construction. And now the standard has reached the ultimate low, one person per room. More and more services are being done on an outpatient basis, surgery is becoming simpler and minimally invasive. This means only the most seriously ill and injured patients are kept inpatient. Also, with scares like MRSA and SARS are popping up on an almost routine basis, cross infection is becoming a serious concern.

Patient expectations have changed too. Our culture has increasingly demanded space and privacy. Much has been written about the shift from transit to private cars and from the city to the suburbs. More recently, kids sharing bedrooms is becoming uncommon and communal showering after gym was going out by my time in school. (I only recall a someone taking one a couple of times my entire school career, and when my school rebuilt the gym after my time they included private stalls for the boys.)  And patients in hospitals are demanding privacy too, or as much as is possible in that setting.

Obviously someone taken away by ambulance after a stroke isn’t in a position to ask to go to a certain hospital they like better; such a person is going to go wherever the paramedics decide to take them. But hospitals are in a stiff competition with each other for a certain type of patient for elective and semi-elective procedures, to the point they go as far as buying advertising. These are not Medicaid patients, on whom hospitals lose money, nor are they Medicare patients on whom hospitals might make a little or lose a little, depending. These are certainly not the uninsured, whose bills are often sold to collection agencies for pennies on the dollar or written off entirely as charity care. But I’m talking about patients with private insurance.

Such a privately insured patient seeking elective care is apt to like lots of free parking, plenty of shiny windows and granite, and most of all private rooms. Insurance will only pay for a semi-private room unless medically necessary, or a semi-private room is unavailable, so newer hospitals make sure semi-private rooms are not available by simply not having them.

(There’s of course questions we could ask about macro health care policy and costs in general, but this isn’t the time and place for that discussion. I’m just explaining the reasons behind the current moving frenzy.)

The Trouble with Remodeling.

One might ask, “can’t they just remodel?”

Sometimes that’s an option, but unfortunately it’s not as simple as busting out a couple of interior walls. The optimal sizes for semi-private and private rooms are completely different and not even multiples of each other. The figures I could find were for Canadian hospitals which are a bit smaller than US hospitals, but are still useful in comparison. Generally speaking a private hospital room is 165 square feet, or 13.25 X 20, and an semi-private is 265 square feet, or 15 X 22.

So suppose you have a hospital wing with 12 rooms on each side for a total of 48 patients, and a nursing station at the end. That’s 180 feet long. You could only fit 13 private rooms in that space, so chances are you wouldn’t even bother to try to reconfigure it with all the work of moving all the walls, windows, and bathrooms. But between the extra length and width you don’t need, you’ve now wasted over 1000 square feet for each wing of each floor. Plus the nursing station, which has a fixed space and minimum staffing, is only serving half the patients it could. Plus you still need to find a place to build 24 new rooms on your property. Even if you move to super-expensive structured parking (and Lakeview already is using structured parking), finding room on your cramped existing site could be problematic.

You can’t just build up because hospitals need to be horizontal to some degree. You need a nursing station serving a number of rooms, all with windows, on the same floor. At some point it becomes attractive to tear the whole thing down and start over from scratch on a new site.

I will note a few exceptions to the rule. This include hospitals at Faribault, which has already had a spacious site at the edge of town for decades, and Waseca and Mankato, which have expanded at their existing sites by gobbling up adjacent residential neighborhoods.

What about Abbott Northwestern?

One might ask how the big city hospitals, which also have mostly shared rooms, get by?

For one thing being a large facility allows you more options and to take enough rooms offline at once to economically remodel. Secondly, Abbott Northwestern has some of the best oncology services and surgical suites in the region, sometimes you just can’t get the services you need at a hospital that has all private rooms. (I recall a consult with a spine surgeon who told me “I like to operate at Abbott because the operating suites are so much better equipped there, but I know they don’t have private rooms so don’t worry, you won’t have to spend the night).

The hospitals in the worst spot are probably those in older suburbs like Fairview Ridges or Fairview Southdale, which have both obsolete facilities on cramped sites and little to attract patients. I can’t think of a single reason why I would want to go there instead of the better services at Abbott or the U or the private rooms at St. Francis in Shakopee.  They need to survive on patients taken there on an emergency basis, referrals by doctors, or patients that don’t have the means to go to either a high-tech inner-city hospital or a more modern outer-suburban hospital.

That said, Fairview Southdale did recently open a new maternity wing with all private rooms, branded “The Birthplace”,  and is offering U of M branded cardiology services. Allina has been opening “Mother Baby” centers. Maternity centers are attractive to hospitals because in this day and age it might be the mother’s first experience in a hospital, and they might keep coming back for future care for themselves and their kid. But they still remain stuck with a lot of obsolete semi-private rooms.

Sometimes, too, when hospitals merge they reduce the number of services available at each facility, making the buildings easier to remodel by requiring fewer services to be housed in each building.  For example Austin and Albert Lea have both been bought out by Mayo. There is a proposal to cease most medical services at Albert Lea and psychiatric services at Austin. Instead Albert Lea would have most of the psychiatric services, and Austin most of the medical services.

Similarly when Mercy and Unity Hospitals in the northern suburbs both became controlled by Allina, Unity eventually became mostly a psychiatric facility and Mercy the medical facility. (In both cases they keep the ER open, but if you need psychiatric treatment at Mercy / Austin or medical services at Unity / Albert Lea . , you have to be transferred. ) But this is only possible with hospitals reasonably close together, and results in even more travel by patients than relocating both facilities to new campuses would.

Speaking of psychiatric hospitals… Psychiatric wards are one area where shared rooms are still the standard, since spreading infection isn’t as big of issue and there’s safety and social benefits to shared rooms in that setting. And much has been written about the shortage of psychiatric beds in Minnesota.  One might ask why some of the shared rooms can’t just be converted to psychiatric beds.

Ultimately though, again, fiscal aspects come into play. Hospitals tend not to make much money on psychiatric services since they can’t bill a bunch of expensive procedures and tests, so they’re not eager to provide more beds. And the number of people hospitalized has fallen over time with new medications, better outpatient care, and reluctance for insurers to pay for long term hospitalizations. And it doesn’t solve the problem of where you build more private medical beds on your existing property.

The Impact to the Neighborhood.

Finally, one might ask if we really want these type of facilities in a “walkable” neighborhood. And it should be noted that a lot of these existing locations aren’t especially “walkable” anyway. At least it has a sidewalk, but Lakeview’s existing location here doesn’t seem too urban, and has a Walk Score of 42. Cannon Falls had a Walk Score of 20. I have no idea why but the trend in the 1950s through1970s was to put hospitals in the middle of quiet residential neighborhoods not particularly near anything else.

Maybe staff being able to walk to work if they lived nearby would be a plus, but with a rural hospital drawing patients from hundreds of square miles, even in the most walkable neighborhood the number of patients that would walk would be few. Do we want huge hospital campuses in downtown business district instead of a coffee shop and grocery store, in hopes that passerby might decide to have a cardiac catheterization between stopping for ice cream and mailing a letter? Do we want them in a residential neighborhood with all the car traffic from staff. patients, visitors, and and the occasional ambulance screaming by or helicopter noise at all hours of the day and night? How many complaints have we heard about the number of people in cars on 26th and 28th Streets in South Minneapolis? Much of this discussion probably comes from patients, staff, and visitors shuttling from Abbott to the freeway.

You can’t take only the best elements of having a hospital in a crowded urban setting while ignoring the drawbacks.

Disclaimer: I am an employee in the claims operations division of a health insurance company in Minnesota. Views and opinions are my own and not of my employer, and facts and statistics are from independent research and not internal information