After some months of waiting, anticipating, and hand wrangling, President Obama's Healthcare Reform Bill was finally passed into law earlier this year, leading all corners of the healthcare industry to finally exhale and get on with the business of making America well again. But the questions haven't stopped; if anything, healthcare reform has simply created new ones.

So how will the healthcare design industry be affected by this new status quo? We asked some leading architecture, engineering, and construction firms what they thought would be coming down the pike. In responses to HEALTHCARE DESIGN and Healthcare Building Ideas' recent Corporate Profiles and Rankings poll (see the July issue of HEALTHCARE DESIGN and the Summer issue of Healthcare Building Ideas for results), we asked firms to answer this deceptively simple question: How do you think U.S. governmental healthcare reform will affect the healthcare design and construction industry in 2010 and beyond?

Optimism or wishful thinking?

Perhaps it is in the very nature of the average person who works in the healthcare industry-in design, construction, or otherwise-to stay positive and believe that outcomes will be generally good. We certainly had our share of respondents who felt that healthcare reform was a step in the right direction.

Payette, for example, simply state, “It will have a positive impact.” Walsh Construction Company also take a rosy view: “Healthcare reform will have a positive effect on the healthcare design and construction industry. More patients would overwhelm the current hospitals and medical facilities. This will generate a need for bigger, better, and more state-of-the-art hospitals, clinics, outpatient facilities, and so on. We are excited with the possibilities and take on the responsibility of building with the best value for the best quality for our clients.”

Some firms, like Burt Hill, see another building boom coming, just not immediately: “Reform will cause owners to delay projects until they fully understand the new rules; 2010 will be a slowly improving healthcare design year, while 2011-2015 will be very busy design years, as the industry tries to catch up for the work that was not done in 2008-2010.”

KMD Architects share the sentiment, framing the issue on a global scale: “For the past two years we have seen a rapid reduction and attrition in projects cancelled, delayed, and/or reduced in scope. Today there seems to be a glimmer of a return, but perhaps not to normalcy. There are many RFPs now appearing, but most are for master planning or relatively small architectural projects-all a result of the rebounding economy. For the reasons above we have made a greater effort overseas and have won several design competitions for large work in Korea, as well as new work in the Middle East. The new healthcare legislation has yet to bear fruit. Hospitals do not yet fully understand how new regulation will affect them momentarily and the vast majority are not yet ready to restart old projects or begin new ones.”

Regardless of how we get there, however, most agree that efficiency is of the upmost importance. As Perkins Eastman states, “The U.S. healthcare market will go slow on capital investment while they assess the impact of new legislation, focusing more on strategic planning than the immediate design of new capacity or renovations. The long-term focus will be on more efficiency and better use of facilities or updating of outdated facilities more than on expanded capacity.”

Facing the unknown

Some firms were decidedly more pessimistic in their thinking, and after all, who can blame them? This is uncharted water we're setting sail in, with the country divided on most issues right down the middle-including the very reform bill in question. Now that it's been passed into law, we can't simply assume those concerns will evaporate without a trace. While all involved clearly want to see America's healthcare system succeed, we clearly don't all agree on the best ways to make that happen. The order of the day, however, continues to be caution.

HDR Architecture, Inc.'s statement sums up the confusion, tempered with a desire to take on the new challenges that are certain to arise: “At this time, the issue of healthcare reform remains a big question mark. Our clients remain uncertain about the specific impacts the legislation will have on healthcare delivery. One certainty, though, is that the numbers of people accessing healthcare is going to increase. As a result, hospitals will need to focus on staffing and facility needs to accommodate these increased numbers of patients. Equally important will be their ability to contain costs, especially those related to inefficiencies in how a building facilitates the work of its users as well as how it functions from an operations standpoint. Additionally, as the economy recovers, facilities will once again become an investment tool, thus causing increases in construction activity. We believe it is our responsibility to effectively communicate how design exerts a powerful influence on both clinical outcomes and building performance.”

Regardless of political leanings, all the players in the healthcare design field surely recognize that change is coming whether we like it or not-protesting said change will likely not get you anything but left behind at this point.

Along those same lines, Flad Architecture points out that the economy will continue to be a big issue, regardless of how reform shakes out: “As the number of individuals with insurance increases, we anticipate additional need for certain services, such as Emergency Services and Women's Health. We are also seeing that funding sources are loosening, and money is becoming more available for construction-related projects, however, much of this money is still being spent on planning studies, as organizations continue to proceed with caution.”

ZGF Architects LLP bring up some interesting points in regards to the competitive market: “The well-positioned and efficient hospitals will continue to expand at the expense of the less efficient. There will be acquisitions and a new wave of mergers. Some ambulatory-only facilities [will be built] but not as many as most people think.”

The construction angle

Healthcare construction firms are affected by the reform bill in very different ways from healthcare architecture and engineering firms. But opinions are divided just as much in the construction field, where the economic downturn has been hitting quite hard indeed. As Suffolk Construction Company, Inc., succinctly put it: “Hospitals are still leery of the new bill and thus are reluctant to start their building programs again. They are all in a ‘wait and see’ mode.”

The issues, as Gilbane state them at least, are very much the same as those registering with their peers in the architecture and engineering world: “The primary benefit of governmental healthcare reform will be increased access to insurance coverage for many Americans. This increase in the potential number of patients may translate into greater demand for primary healthcare services, diagnostic testing services, and entry points for patients into the healthcare system. The impact of this greater demand will require healthcare institutions and systems to evaluate their ability to meet outpatient service needs through community health centers, medical office buildings, and ambulatory care centers and may necessitate investment into these types of facilities. The issues forcing improved inpatient environments of care due to advancing technology, higher acuity patients, and demand for private rooms will also probably not slow down. This will force some institutions to face a balancing act of where to invest in facilities depending on their patient demographics and looking at alternative strategies to fund investments in different settings.”

Looking forward

Annie Coull, AIA, NCARB, FACHA, Principal and Practice Director with Anshen+Allen, points out that at the end of the day, healthcare design is still all about patient outcomes, and firms must change with the times with that goal in mind. “As the economy and access to money has improved, it appears that more institutions are going forward with plans that they had temporarily put on hold. There is an enormous amount of competition for fewer projects, particularly large-scale replacement or new facilities,” says Coull. “Many design firms have expanded their services which bring value to healthcare providers such as upstream strategic planning, operational planning, equipment planning, or ‘downstream’ transition planning for institutions getting ready to move into new facilities. These are services that have traditionally been provided by specialty consultants, and not in the domain of design architects. Again, using new tools and processes to deliver projects in a more integrated and collaborative way with contractors and subcontractors is important for architects to embrace in order to continue to bring increased value to healthcare clients. Additionally, the patient and family experience must not fall victim to ‘rightsizing.’ The Press-Ganey satisfaction scores are still a priority for clients despite their cost-cutting mandates. So architects have to do ‘more with less’ by being creative with available resources and sheer ingenuity to create healing environments that respect people in the high stress circumstances of providing or receiving healthcare services.” HD

Healthcare Design 2010 August;10(8):52-56