We should welcome the advances that are making hospitals less important | Hacker News Reader

We should welcome the advances that are making hospitals less important

nytimes.com

173 pointsdr_48 comments

Hospitals aren't becoming obsolete, but their role is changing. Hospitals were once a place where patients were kept for extended periods of time; now for reasons of cost, sanitation, improved surgical techniques, and patient preference they're increasingly places where patients go for medical treatment but unless they're on the verge of death (and thus may need further treatment in very short order) patients then return to the community.

More surgeries; less meals and laundry. Rather than becoming obsolete, I'd say that hospitals are gaining an increased focus.

What’s the relative cost of in-patient vs. out-patient care?

I don't have an answer to your question, but I recently spent some time at the hospital taking care of my daughter, and my understanding is that a lot of it comes down to the fact that hospitals are able to provide good enough care to be comfortable discharging patients earlier.

It used to be more common to keep patients at the hospital just in case, but they now send patients home in many of those cases. In my (unprofessional) opinion, this is a good thing. Recovery is much easier in the comfort of our own home, without the stress of being woken up at all hours of the night for tests. We're also completely avoiding a huge risk -- hospital borne infections.

> What’s the relative cost of in-patient vs. out-patient care?

They're not directly comparable, because the care delivered is fundamentally different, but inpatient care is about two orders of magnitude more expensive.

That's not to say that reduction of inpatient care is always a goal, though, because it's only a good tradeoff when the outpatient care actually would provide equivalent or better clinical outcomes. Sometimes that's true, sometimes it's not.

Are the costs 100x or are the chargemaster prices 100x?

What are a couple of the major factors driving such a huge difference?

To give you a very round number it is several $k per day depending on where in the country ($2-5k) and what hospital for a bed in a two person room with 24h nursing floor care. That does not include doctors, meals, medications, tests, etc. If you're in an ICU or surgery it is easily 2-20x higher than that so you can't compare it. A skilled nursing facility or hospice can be less than $1k per day.

In home care even with 8 to 24h nursing can be had for a similar price or lower than a skilled nursing facility ($50-100/hr) with much better quality of life and lower risk of infection if you go to reasonable efforts to keep it clean.

This doesn't make sense to me. Please correct me if I'm wrong.

A hotel can easily provide room and board (essentially the services of a hospital's basic in-patient care) for <$100 a night. The hospital also has a ton of equipment and staff that are additional, but how can it possibly be as much as $1900-$4900? I feel like in-patient care is similar to a hotel but with extra stuff that might increase the cost by a factor of (perhaps) 2-5. But not 10-25. That would suggest that there's some major inefficiency in hospitals causing the cost bloat. You said the price is before doctors, medications, tests, etc. so the service is essentially just accomodation. How can it be so expensive?

Hospitals have needs that hotels don't from the ground up. They have different architecture, interior design, and HVAC needs, they have different real estate needs, they need to be robust to natural disasters, they maintain services like ambulances and a vast records and bookkeeping system. Sanitation requirements are much higher, there's no reason to assume costs there scale linearly - think about night shifts. Hospital workers usually are more unionized than hotel workers (should a hotel room be <$100 a night?). I believe nurses do a lot of work that lower trained/skilled/paid workers would do in a hotel.

Then you can start throwing in the inflated costs due to the American insurance system, the higher liability hospitals have compared to hotels, and other factors. I'm sure people more familiar with the medical profession could add even more exacerbating factors that I don't know about. All of this isn't to say that the hospital or healthcare system isn't inefficient, but simply that hospitals and hotels are apples and oranges.

I am also curious. For further reference, the NHS has a reference cost of £1,489/£3,366 for non-elective and elective inpatient stays respectively (figures date from 2012/13).

As a side question, does anyone know how to convert 2012-GBP into 2018-USD under PPP?

Here in Japan, the health insurance system only covers a basic shared room with other 4 patients. If you want a private room, you have to pay out of pocket. For my wife when she stayed in the clinic for a week after a C-section, the highest grade of room (with your own mini-fridge, etc - comparable to a midrange hotel room) cost 15,000 yen/night ($140/night), which is maybe 2x as much as an actual hotel would cost. Obviously that doesn't include any actual medical (nurse calls etc)

I recently stayed in a Japanese hospital in central Tokyo that's part of a chain used by celebrities. The most expensive rooms were over 1000USD a night, but free rooms are also available (if in limited quantities).

http://mita.iuhw.ac.jp/hospitalization/room/index.html#01

Few hotels at the $100 mark has any staff to speak off onsite during the night. A night porter, and a single guy in the kitchen, if there's overnight room service. These people, while probably nice, will be fairly limited in their ability to perform more than the most rudimentary services for you.

You're in hospital because your condition is such that you might need emergency high-grade medical attention on moments notice. If you don't, you're better off going home (or, indeed, checking in to a hotel).

Try to work out what a hotel would cost that would serve you and ten guests en eight course haute cuisine tasting menu from your choice of five different cuisines at 15 minutes notice at any point during the day or night, and you're closer to the answer.

One factor could be that hospitals get reimbursed differently depending on treatment. "Observation" status is low-paying but reliable, whereas "Inpatient" pays higher, but may be deemed unnecessary by an insurance company and thus not paid out. https://www.advisory.com/daily-briefing/2012/08/09/observati...

"Many patients are never informed of their hospital status, and physicians say the care provided does not depend on status. However, the status change can have a major impact on patient costs:

- Hospital stay costs: Medicare pays significantly more for inpatient stays—which fall under Part A of the federal program—than for observation stays—which fall under Part B. As such, much of the cost of a Part B hospital stay fall to the patient.

- Post-discharge care costs: Medicare does not cover post-discharge care for Part B observation stays. As such, a patient who is placed on observation status for a broken bone will have to pay the full cost of rehabilitation. In comparison, Medicare pays for skilled nursing care following an inpatient stay that lasted at least three consecutive days. However, patients who are shifted into inpatient status after spending days in observation status must spend three full days in inpatient status to receive the benefit (the time spent in observation status does not count toward the three-day requirement)."

https://www.unitedmedicareadvisors.com/inpatient-and-outpati...

FWIW In the US in 2010, the average overall hospitalization cost was $9700. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb146.pdf

>patient preference

As a patient, I'm always suspicious when I see this. When I'm in a bad enough shape to go to the hospital, going home is not my priority, getting better is.

As someone who also work in an hospital, pushing patients out as quickly as possible has more to do with financial objectives than anything else. (e.g. we were told that our hospital should have 25% less beds by 2020)

how and why would you plan to have less beds in the future? Is that backed by population growth and average hospital utilisation per person or some other metric?

If you can do more outpatient work, you can reduce the bed count, the cost of having a patient taking up a bed in a hospital is very high, even if they are as close to perfect health as possible and are just waiting to be discharged. This is money that could employ another doctor or buy another piece of health-giving equipment.

The sooner you can kick a patient out of hospital, the sooner they become someone else's problem, coming out of someone else's budget. In a publicly-funded system, the local authority may pay for in-home care visits and the patient's GP may be responsible for post-hospital outcomes.

Stupid PFI deals can mean that the cost-per-bed is ludicrous, and that money that could be going towards patient care is being funnelled to failing companies like Carillion.

In an insurance-funded system, the relationship between costs and fees comes down to negotiation between the hospitals and the insurance companies, rather than from the hospital simply coming up with the fees and the insurance companies paying them. This may mean that the income per-bed-per-night is less than it costs, whilst the income per procedure is higher than it costs. Even if the hospital is still responsible for post-discharge care, they may be able to make more profit out of expensive home visits by low-paid carers than in-ward rounds by higher-paid nurses.

>> patient preference > As a patient, I'm always suspicious when I see this.

There are many practices in medicine that exist only because of patient perference and despite their harm.

I think this is because of ongoing poor health education amongst the general public, physicians who are worn out and choose their battles and that private health care systems (at least in Aus) reward practitioners who get good feedback from patients better than those who have the best health outcomes.

In general this is true, but I would guess it's least true in hospitals?

They have a lot of throughput and are generally over-burdened, so 'driving away' patients isn't much of a risk. Beyond that, a lot of their patients are there because it's the nearest hospital and aren't actually choosing where to go.

At least anecdotally, my impression is that PCPs and clinics worry about satisfying patient demands (e.g. antibiotics for colds) to maintain revenue, while hospitals mostly worry about how to get more patients who can pay and fewer who can't.

In Thailand, where medical care is both cheap and good, most of it takes place in hospitals. You can still find clinics, but people usually go to a full-blown hospital when they have health-related issues.

Inpatient treatment is much more common here than in the US, in fact from my American perspective it sometimes feels like they overtreat (lots of tests, prescriptions, IVs, and overnight stays for minor ailments).

I would have thought that treatment at a hospital would generally be better--they're larger than clinics, they have more equipment and more specialists. Though I wouldn't be surprised if clinics had certain advantages like a more personal relationship with your doctor.

All this is to say that in a market where health care is both cheap and good, hospitals aren't going away and people are spending more time in them. I wouldn't be surprised if the decline of hospitals in the US was about costs like you say.

Most simple things can be dealt with at a clinic in less time (in-the-door to out-the-door) than you'd spend merely filling out the initial hospital paperwork.

When I'm in a bad enough shape to go to the hospital, going home is not my priority, getting better is.

I'm not saying that patients want to go home before they're ready to be discharged. But for non-emergency procedures, patients will almost always opt for a minimally-invasive surgery which allows them to go home sooner rather than a more invasive surgery even if the minimally-invasive surgery is less effective.

As a physician, one of the things not touched on in this discussion and only briefly mentioned in this article is the harm associated with hospitalization. For many of my patients discharge planning is one of the toughest conversations to have. Patients are often reluctant to leave the hospital and I have to tell them why its better that they continue care at home. The reasons they want to stay are many and varied, but include the long emergency department wait times (if they get sick again and have to come back they don't want to deal with that again), clean sheets on a comfortable bed with 3 meals a day for my poorest patients, staff to take care of their needs and that they probably feel safer in the hospital because of all the beeps and bops and scurrying about of the staff. But, they can't see all the patients who had bad outcomes from staying in the hospital too long: they get confused or delirious, there is a medication error, they fall getting out of bed in the middle of the night, they get a new infection, etc.

Trying to get people to see those risks is hard, especially since they shouldn't happen, so no one expects them to happen.

For those in the industry, the continued consolidation and increasing power of hospital systems seems a given, despite the problems that entails. It is refreshing to see this perspective voiced

As I said in another thread, hospitals are the largest component of US healthcare cost. They make money by increasing the number of hospital visits, especially for surgeries. Even non profits have been consolidating and seeking profit, and the largest non profit systems have dramatically increased their incomes over the last few decades

Hospitals are devouring outpatient clinics to get their patient volume into the hospital system. These practices are loss leaders for the hospital profit centers in many cases

Sadly, many hospital systems fight improvements in care that decrease inpatient admissions by making people healthier, because fewer admissions means less hospital revenue.

Having hospitals in charge of US healthcare is like having the fox in charge of the henhouse

What is the thing about hospitals that distinguishes them from other facilities?

Is it just that they have beds and everything else is a clinic?

Why is having beds such a big factor? Is it just that they are a large fixed cost which makes it hard to turn a profit?

I don't particularly like hospitals, but the healthcare system in the US is hugely fragmented and piecing together all the providers you need is a pain in the ass, why are hospitals unable to capitalize on their broad experience and expertise to help?

ER. In most areas hospitals are the only facilities providing emergency care. (And boy is it expensive)

Given how many people go there with a minor fever or stomach ache, it isn't expensive enough.

Some hospital systems triage those people into an urgent care style pipeline and charge them less.

The horror.

Having had 3 stays last year in the UK hospitals have a large number or nurses, support staff and normally a junior doctor for a relatively small number of patients.

Also all Doctors admit that hospitals are not healthy places and that getting people home as quick as possible is always good

Not to mention the utter evil in the way billing practices drive care. Many hospitals will perform unnecessary procedures on patients as soon as they know they will be covered by insurance. This leads to unnecessary catheterizations, blood draws, etc.

Over treatment incentivized by fee for service.

I advocate for the capitation model, rewarding wellness. Though it’s not a silver bullet (eg trauma, acute conditions).

Bad headline, but the article itself gives some nice insights into the current trajectory of medical care in the US. Important to note that the trend is not the same in all countries though. In Japan, where hospital stays are frequently used as a stopgap measure in cases where elderly patients can't afford or can't find a long term assisted living facility, hospitalization shows only moderate declines from historic highs in the 90s.

"Hospitals are no longer seen as therapeutic." That's putting it mildly! I think we generally do a piss poor job of providing truly therapeutic environments as a service.

"Hospitals will also continue consolidating into huge, multihospital systems. They say that this will generate cost savings that can be passed along to patients, but in fact, the opposite happens. The mergers create local monopolies that raise prices to counter the decreased revenue from fewer occupied beds. Federal antitrust regulators must be more vigorous in opposing such mergers."

This interrupted the flow of the piece for me...it has nothing to do with hospital visits diminishing overall and it's an empirical claim that would have benefited from a citation. It seems that Times op-eds often go for these sorts of flourishes at the end.

I learned some interesting facts/stats from this piece and enjoyed it overall.

It is absolutely relevant as these hospital networks are gobbling up medical practcies, nursing facilities, and other providers (acute rehab, pt, hospice, etc).

The results are predictable. Prices are going up and medical providers are marketing funnels.

In my little area (Albany-Schenectady-Troy NY), 90% of the providers are now affiliated with two medical systems. One is a former Catholic medical system that was absorbed by a national system and the other is a federation of joint ventures headlined by the local trauma/teaching hospital. 10 years ago, we had 5 networks in the region. Even as an outsider looking in, you can see the monopolist behaviors. Nursing and other medical staff are taking 20% salary haircuts, doctors are forced to sell practices or lose referrals and go out of business, and the quality and costs are not moving the right way.

Seeing as how the infant/mother mortality rate is so high in the US compared to other developed nations, I don't think home births should be encouraged as much in non-rural areas. Birthing Centers are better than home births though not suitable for high-risk cases.

> Seeing as how the infant/mother mortality rate is so high in the US compared to other developed nations

6.2 in the US versus 5.7 in the EU doesn't really back that statement up.

https://www.infoplease.com/world/health-and-social-statistic...

> Through the 19th century, most Americans were treated in their homes. Hospitals were a last resort, places only the very poor or those with no family went. And they went mainly to die.

Sort-of related: Why would anyone ever think putting "memorial" in a hospital name was a good idea? "A place to go to die" is the first thing that has always popped into mind when I see that.

If 'memorial' bothers you, you are going to love the an archaic French term: 'Hôtel-Dieu', or hotel of God.

And yet a hospital chain is in the works to build a $1 billion facility mere 3 miles from their current one. [1]

Carmel (pop 90,000) has 2 hospitals already pluz a gazillion medical centers.

[1] https://www.indystar.com/story/news/local/hamilton-county/20...

Here's all you need to know at the bottom of the article:

"Ezekiel J. Emanuel is ....a partner at Oak HC/FT, a health care investment company."

Shabby nonsense from the Times.

So someone with enough expertise to manage investments in the area is automatically disqualified from having and sharing an opinion about it?

Ezekiel Emanuel was also one of the architects of Obamacare, which hey, lots of people will hold that as an even bigger point against him. But he may have an interesting opinion about health care policy.

The title should be: We should welcome the advances that are making hospitals less important in US.

There is nothing wrong with hospitals in EU.

I'm sure there is something wrong with hospitals in the EU. They're run by humans, after all.

I came here prepared to walk away from this article being reminded once again of Betteridge's Law[1], but then I got to thinking once I did finish it...

...decoupling certain aspects of healthcare from gigantic, expensive hospital systems may actually work for patients and medical care providers couldn't it? Article points out how we do to an extent already, and paints an interesting argument for why we could see more of it. I think I'm on the "want to see more of it", but unsure what the drawbacks would be aside how the expected parties would like to see those traditionally centralized services remain so.

I am not a medical professional, the article just got me thinking on the topic...which means, Betteridge be damned-if a piece of writing gets you thinking about something you wouldn't ordinarily think about, article succeeded.

---

[1] https://en.wikipedia.org/wiki/Betteridge%27s_law_of_headline...

For those, like me, confused by this comment, the article's real title, which I guess was changed on HN after this comment is "Are Hospitals Becoming Obsolete?".

As opposed to?

Is there a framework that could communicate the most appropriate role of a given hospital for those trying to evaluate their care options? For example, "given the individual's parameters X and Y and Z, the hospital in question is in quadrant N of the individual's sphere of care options. This implies a role of [e.g. emergency use only, etc]."

It just seems like we need a more objective idea of _what a given hospital really is and can be_ for a given individual. Such a model would naturally expose economic opportunities for providers who have the resources to open small competitor clinics, while conserving resources like money, energy, etc. for care seekers who can only be excused for thinking "sick = hospital".

If we can't get needed anti-monopoly regulators to do their job, we can at least start to find points of leverage with which to educate the public on the cost-benefit and alternatives in a more straightforward way.

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