After the abrupt closure of St. Vincent's Hospital in New York City five years ago, dislocated patients flooded nearby hospitals in such numbers that it mimicked the surge of demand after a bioterrorist attack.
The disruption made the community an appealing case study for researchers at the UPMC Center for Health Security in Baltimore who examined the Manhattan hospital's closure for clues into how a sustained swell in demand might affect hospitals.
Hospitals near St. Vincent's—a Level 1 trauma center and safety net hospital—scrambled to find space and staff. Hospitals added workers in psychiatry; rushed physician credentialing; converted space into triage and patient-care units and placed patients in beds in the hallways.
Hospital closures typically cause upheaval among the patients, communities and other healthcare providers in the market. It can be extreme, as was the case with St. Vincent's and is often the case in communities that lose their only hospital. Studies have shown that closures are particularly hard on the most vulnerable and acutely ill patients.
It is less clear, however, whether the closures actually mean worse health outcomes for the community at large. New research published this week in the policy journal Health Affairs suggests that, by broad measures of quality and access, patients collectively may be no worse off. Surprisingly, they may even be better off in some cases.
The results, however, have a few critical caveats. “I don't want it to be interpreted as it's totally fine if a hospital closes,” said study author Dr. Karen Joynt, an assistant professor at Harvard University and senior adviser in HHS' Office of the Assistant Secretary for Planning and Evaluation.
Joynt cautioned that the study looked at the average results across multiple years and nearly 200 hospital closures. The research also exclusively looked at results for patients covered by Medicare. That excludes the uninsured, a vulnerable population. This is a critical point because hospitals that provided more care to poor patients were more likely to close.
The researchers studied which hospitals were more likely to close, and they looked at what actually happened to community health outcomes for Medicare patients after they did.
The death rate was no different, even among people who were recently discharged from a hospital. The cost of care and the length of hospital stays were also no different.
That was largely true even when the researchers looked at patients who needed immediate medical attention—those suffering with trauma, stroke or heart attack.
There was one significant exception: Fewer patients died from heart attacks. That suggests the patients actually found better care than what was offered in the hospital that failed.
“We suspect that to some degree the market is doing a decent job” determining which hospitals remain open, Joynt said.
Indeed, the study found other possible indicators that patients managed to find access to better care. Overall, fewer returned to the hospital within 30 days of leaving. And when the only hospital to serve a community closed, death within 30 days of hospitalization in that community declined.
Hospital consolidation has accelerated since the passage of the Affordable Care Act, and many of the same pressures compelling hospitals to join forces—such as flat or declining admissions, a general shift toward outpatient care and pressure to provide more coordinated care under new payment models—are causing many to close.
Joynt said the research might be useful as hospital operators and communities consider which inpatient facilities are necessary.
The study examined 195 hospital closures between 2003 and 2011. They were more likely to be in urban areas, owned by for-profit companies and serve as safety net providers. They also tended to be small. They had 64 beds, on average, compared with an average of 94 beds among hospitals that remained open. However, the hospitals that closed generally had more beds per 1,000 people in the communities they served.
They also were in terrible financial shape, running an average operating margin of -20%.
St. Vincent's Catholic Medical Center, which owned the 160-year-old hospital in lower Manhattan, struggled for roughly three years after emerging from bankruptcy before closing the facility's doors under the burden of $700 million in debt.
According to a survey one year later, most residents living near the hospital said they had used St. Vincent's in the previous five years—primarily the emergency room—and most had a doctor affiliated with the hospital. Most also said finding care was more difficult after it closed. Nearly half the respondents said there were fewer services in the community, but a few said they'd gained access to services they didn't have at St. Vincent's.
When St. Vincent's closed, the expanding North Shore-Long Island Jewish Health System saw an opportunity—but not to replace the hospital.
A year ago, the Great Neck, N.Y.-based system opened a free-standing emergency room and ambulatory center across the street from the St. Vincent's site. Demand for its emergency services has been greater than expected, said Alex Hellinger, executive director of the Greenwich Village facility, called Lenox Hill HealthPlex. Patients in the emergency room topped 90 per day recently, up from the initial projection of 50. Some transfer to Lenox Hill Hospital, which North Shore-LIJ acquired in May 2010.
NorthShore-LIJ is also adding orthopedic and ambulatory surgery on one floor and an imaging center on another, which Hellinger said local doctors identified as an area of need.
The HealthPlex is also seeking to attract insured patients who didn't use St. Vincent's, he said. Still, the new facility cares for a “higher than normal” number of patients who pay bills without insurance and it invested to replace the forensic and medical services St. Vincent's offered to victims of sexual assault.
Still, Hellinger acknowledged the frustration from the community at the loss. “They wanted a hospital,” he said.
There was a similar sense of frustration in Quincy, Mass., after Steward Health Care System closed Quincy Medical Center in December last year.
“It was almost like the loss of a good friend for the community,” said John Holiver, CEO of Manet Community Health Center, which operated a federally qualified health center in the Quincy hospital and elsewhere in the area. “I saw first the doubt, and then the anger, and then the grieving process that went on from the community.”
Manet has since relocated its clinic to a renovated facility and offers free shuttle service to another Steward hospital roughly 2 miles away.
The Manet clinics treated 50,000 people last year. “We've seen that go up precipitously since the closing of Quincy,” Holiver said.