After a hospital closes, a community's health can improve

After the abrupt closure of 160-year-old St. Vincent's Hospital in New York City in 2010, dislocated patients flooded nearby hospitals. 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 other 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, speeded up physician credentialing, added triage and patient-care units, and placed patients in beds in the hallways.

Hospital closures typically cause upheaval among the patients, communities and other providers in the market. It is less clear, however, whether the closures result in worse health outcomes for the community.

Now, an ambitious new study in Health Affairs by other researchers suggests that based on broad measures of quality and access, patients collectively may be no worse off—and some types of patients may fare better with different providers.

The Health Affairs researchers, who examined 195 hospital closures between 2003 and 2011, found the death rate for Medicare beneficiaries in affected communities was no different following the closures, even among people who were recently discharged from a hospital. The cost of care and the length of hospital stay also were no different. That was largely true even when the researchers looked at patients who needed immediate medical attention, such as patients with trauma, stroke or heart attack.

Remarkably, fewer patients in communities with closed hospitals died from heart attacks. Beyond that, fewer Medicare patients 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.

These findings suggest that patients 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, said study co-author Dr. Karen Joynt, an assistant professor at Harvard University and senior adviser in HHS' Office of the Assistant Secretary for Planning and Evaluation.

Other studies, however, have shown that closures are particularly hard on the most vulnerable and acutely ill patients. Joynt cautioned that her study looked at the average results across multiple years and nearly 200 hospital closures. The research also looked only at results for patients covered by Medicare. That excluded the uninsured. This is a critical point because hospitals that provided more care to poor patients were more likely to close. “I don't want it to be interpreted as it's totally fine if a hospital closes,” she said.

The closed hospitals studied by the researchers were more likely to be safety net providers in urban areas owned by for-profit companies. They also tended to be small, with 64 beds on average, compared with an average of 94 beds among hospitals that remained open. They also were in terrible financial shape, running an average operating loss of 20%.

For patients served by St. Vincent's in New York, the void in care was addressed by nearby hospitals' stepped-up capacity, an expansion of existing safety net capacity and an influx of competing commercial providers.

But a year after St. Vincent's closed, former patients with the greatest medical needs reported anxiety, longer wait times and greater distances to access care, researchers from the City University of New York reported. “They didn't know where their doctors were,” said Diana Romero, a CUNY associate professor in community health, one of the study's authors.

Safety net clinics received state funding to increase capacity, which the Callen-Lorde Community Health Center used to expand its hours and hire more clinicians, said Wendy Stark, executive director of Callen-Lorde, a community health center that specializes in care for lesbian, gay and transgender patients. Meanwhile, the city's major health systems opened new clinics and specialty services.

On the other hand, St. Vincent's psychiatric services have never been replaced, Stark said. In addition, new competition for insured patients and profitable services has widened the gap between private providers and safety net providers following the hospital's closure, she added.

Joynt said the research might be useful as hospital operators and communities consider which inpatient facilities are necessary, given that hospital consolidation is continuing in the face of rate squeezes, flat or declining admissions and a general shift toward outpatient care.