Healthcare providers in the U.S. have been consolidating rapidly, and the current coronavirus pandemic illustrates why this may be a very good thing for all of us.
Large multihospital health systems dominate the landscape in most urban areas. Independent community hospitals outside of rural areas are a vanishing breed, and the private practice of medicine is rapidly fading in favor of physician employment by hospitals and large medical groups.
The conventional explanation is that hospitals and doctors are seeking more economic power. Size, the argument goes, allows health systems to demand higher reimbursement rates from commercial payers, which have themselves merged into a handful of enormous national carriers. Several recent studies contend that provider consolidation, often undertaken under the banner of improved efficiency and quality, tends to raise the cost of care in local markets, without apparent improvements in outcomes. But there’s more to the story.
What that narrative doesn’t capture is the changing nature of clinical medicine. Hospitals are no longer places where patients get admitted electively for diagnostic testing or spend days or weeks recovering from surgery or an acute illness. Even before the COVID-19 pandemic, they were places filled with patients too sick to be anywhere else. Contemporary hospital care is labor-intensive, know-how-intensive, technology-intensive and capital-intensive; high-quality inpatient care now requires organizational scale to assemble and manage these resources.
Office-based medical practice has also radically evolved. The world of “Marcus Welby, M.D.”—a 1970s TV show about a fictional general practitioner who successfully treated everything that came his way—no longer exists. Because of advances in our understanding of human illness and the explosive growth in the array of treatments, we now have an expanding population of people with multiple chronic conditions that no one doctor can effectively manage. Medicine has become a team sport and, even in the outpatient arena, requires the close integration of multiple specialists who require technology and equipment that small-scale clinical practices can’t afford.
Simply put, improvements in biomedical science have driven healthcare delivery from the artisanal to the industrial.
That shift isn’t just a prerequisite for delivering evidence-based, high-quality care. It’s also a good thing when a crisis like the current COVID-19 pandemic hits. Large-scale healthcare delivery systems are much better equipped than independent community hospitals or small-scale medical practices to implement elements of an effective response. At Northwell Health, even before the first cases of COVID-19 appeared in New York, we were able to stand up an effective emergency management system, assemble the appropriate expertise across the organization, develop standardized treatment protocols that protect patients and staff, and marshal the necessary supplies and technology to care for a surge of sick patients. Once the disease spread in our communities, we created our own COVID-19 testing capability, implemented best practices, shifted resources and personnel to match local needs, and initiated clinical trials to identify new, effective treatments. We continue to manage complex supply chains and the impact of the pandemic on our own employees.
In a few short weeks, we have tested tens of thousands of patients, cared for thousands of hospitalized COVID-19 patients, redeployed hundreds of staffers, and moved hundreds of patients and vital pieces of equipment among our system’s hospitals. We have already enrolled scores of patients in cutting-edge clinical trials.
While public health departments are necessary, they’re insufficient; they can help study and coordinate but can’t deliver services at the scale needed. Small, independent hospitals and small physician offices lack the depth of expertise and the resources necessary to lead this effort. Collaborative, ad hoc consortia of independent providers can, theoretically, facilitate sharing of best practices, but they take time to create, lack the information exchange mechanisms of established systems, face barriers to sharing of physical assets and personnel, and suffer from a lack of clear mechanisms for making decisions so essential in a rapidly evolving situation.
Health systems didn’t grow to their current scale to address a public health crisis like COVID-19, but that scale may be just the thing that saves us.