The burden of treating the poor and uninsured may be falling more to private hospitals as the urban public-hospital safety net grows weaker, a study released last week suggests.
The study shows that public hospitals -- especially in suburban areas -- are declining at a much faster rate than private hospitals. Public hospitals operated by the government are referred to as safety net hospitals because they serve a high proportion of low-income or uninsured patients.
"There's little attention paid to an area where there is so much movement," said Dennis Andrulis, author of the study and director of the Center for Health Equality at the Drexel University School of Health in Philadelphia. "Instead it's urban and rural; they skip over the suburbs."
The study, funded by the Robert Wood Johnson Foundation and released by the State University of New York Downstate Medical Center, used American Hospital Association data to examine hospitals in the nation's 100 largest cities and their suburbs.
The results showed that the number of public hospitals in cities dropped 16%, to 70 from 83, and fell 27% in their suburbs, to 98 from 134, from 1996 to 2002. The loss of private hospitals was 4% in suburban areas, as the total fell to 741 in 2002 from 772 in 1996, and 11% in the cities, as the total dropped to 575 from 647.
Despite the drop in public hospitals, there may not be fewer hospitals that have a mission to serve low-income or uninsured patients, said Skip Moskey, a spokesman for the National Association of Public Hospitals and Health Systems. Moskey said some public hospitals might have undergone governance changes but kept the same safety net mission.
He cited 910-bed Westchester Medical Center in Valhalla, N.Y., which is part of the growing trend of public hospitals changing to public-benefit corporations (June 21, 2004, p. 28). Moskey said that the association, which is made up of 120 public and private safety net hospitals, hasn't seen closure rates among its members close to those cited in the study. Andrulis said the study didn't look at why hospitals closed or if they changed governance models.
However, Caroline Steinberg, vice president of trend analysis for the AHA, said the results weren't surprising and as the public hospitals close, it puts a greater reliance on the not-for-profit and for-profit hospitals to treat the uninsured and Medicaid patients. "Private hospitals are taking a greater role," she said. "It does hurt the bottom line of hospitals."
The study did show that private hospitals are caring for a higher proportion of Medicaid patients, but those patients' average lengths of stay were relatively flat while lengths of stay were up at public hospitals. That means private hospitals are more efficient at treating Medicaid patients or more effective at recruiting healthier Medicaid patients than public hospitals, Andrulis said.
Medicaid patients' average length of stay at for-profit city and suburban hospitals was about five days in 1996, 1999 and 2002. The not-for-profits decreased to 6.2 days from 6.8 days in cities and to 5.7 days from 6.3 days in the suburbs. City public hospitals, meanwhile, saw an increase to 7.5 days from 6.8 days and the suburban public hospitals saw an increase to 7.7 days from 6.9 days.
The longer lengths of stay could be attributed to access problems. When there are fewer options for care, patients could be more likely to put off care. The patient's thinking is, "I'm just going to postpone this as long as I can then go to ER," Andrulis said.
The study concluded that large public hospitals in cities have more political clout and closing them is more likely to lead to "a careful assessment of impact, as well as a viable, alternative safety net plan."
The closing of a smaller suburban hospital may not trigger the same response.
"Suburban areas losing their public or primary safety net hospitals may be less likely to have the strong constituencies found in central cities," the study said. "As a result, there may be a less vocal and concerted effort to assure a viable alternative is available."
For additional public health coverage, read our profile of Georges Benjamin, executive director of the American Public Health Association (p. 52).