Hospitals plan for lasting declines in admissions

In earnings reports released this year, some of the biggest U.S. hospital operators are blaming weak performance on flagging hospital volumes. That highlights a persistent shift in where patients are receiving care because of major changes in payment and delivery and continued weakness in the overall economy, analysts say.

Hospital systems are setting their strategic plans with the assumption that inpatient care will continue to decline.

One of the nation's largest hospital chains, Community Health Systems in Franklin, Tenn., reported last week that nearly 5% fewer patients were admitted to its hospitals last year. The news followed announcements by LifePoint Hospitals, Brentwood, Tenn., and HCA, Dallas, that hospital visits in the fourth quarter dropped 3.9% and 1%, respectively. Not-for-profit Partners HealthCare in Massachusetts recently announced that 3.6% fewer patients were admitted across its dozen hospitals in 2013.

Those declines are not unique or surprising, given changes to healthcare payment and delivery, prolonging a trend that began with the Great Recession, hospital leaders and consultants say. “The majority of hospitals and health systems are seeing a flattening of their inpatient volumes,” said Jeff Jones, a managing director for Huron Consulting Group. “Some are beginning to see a sustained decline.”

An important driver is that more Americans are covered by health plans with high deductibles, copayments and coinsurance, dampening demand for elective procedures that require hospitalization, analysts said.

Meanwhile, a growing number of procedures can be performed outside the hospital in less-costly outpatient settings.

Also, new Medicare policies have boosted the financial incentives for hospitals to strengthen management of chronic diseases and keep patients out of the hospital. Those policies have been mirrored to some extent by private payers, which increasingly offer bonuses to hospitals and doctors for curbing costs.

The slow economic recovery is also a factor, though its influence is uncertain as the recovery continues. “Nobody can really say how much of the weak trends are explained by the economy,” said Megan Neuburger, a senior director for Fitch Ratings.

Slack demand has hospital operators reducing their costs and looking for ways to expand revenue. Some have pursued deals in growth markets, such as LifePoint Hospitals' recent acquisitions in Michigan's Upper Peninsula, Neuburger said.

Ascension Health, St. Louis, the nation's largest not-for-profit health system, told Moody's Investors Service analysts that it would improve its financial position by $170 million through expense cuts and new revenue initiatives, after inpatient volumes fell below expectations last year.

Not-for-profit Bon Secours Health System, Marriottsville, Md., projects declines of 1% to 2% in coming years after two years of flat admissions gave way to a decline of 3% in recent months, said Janice Burnett, the system's senior vice president and chief financial officer.

She attributed the bulk of recent declines to the growing number of Medicare patients held on observation status rather than being admitted, which results in lower Medicare payments. The rest is due to pressure to reduce unnecessary admissions.

The continued shift of care from hospitals to ambulatory settings is expected to drive fewer hospital visits for the next two years.

Bon Secours moved to cut expenses as hospital admissions began to flag nearly three years ago. The system has slashed $110 million from operating costs during the past two years and will squeeze another $40 million from expenses by the end of its fiscal year in August. That amounts to an annual reduction in operating expense, including labor and supplies, of 1.7% a year.

To offset its continued admissions declines, Bon Secours' strategic plan calls for another $150 million in cuts during the next three years. That's in addition to $30 million in savings annually from efforts to increase its clinical efficiency.

Follow Melanie Evans on Twitter: @MHmevans