tgba: Closing the Great Divide
The message is clear: “Healthcare must get cheaper.” We got it. Wherever I turn, I find articles and opinions by providers and administrators with the same basic theme.
No one likes to go to the hospital; it is a thing done mostly under duress. When falling off a roof (which I have done) or getting really sick (which I also have done), I’m glad the hospital is there. The rest of the time, I would prefer to take my doses of healthcare in smaller and friendlier venues. The medical profession agrees. Hospitals are immensely complex and expensive. They are really designed to deal with complex, emergent, and often life-threatening events.
I recently had an opportunity to tour a new major urban hospital expansion project. Because of its “essential facility” status, it has many redundant systems and a truly amazing seismically braced structure. The building was an engineering wonder to behold. As I walked around the building, I kept hearing my grandfather’s voice in the back of my head. He had this favorite saying: “There is no point in doing well, that which should not be done at all.” As I grow older, I understand his point: Sometimes we need to step back and consider the problem before us in a larger context.
Now, I’m not saying that we should not be building hospitals. What I am saying is that they are so fantastically expensive that we should be doing everything in our power to make sure that any medical services that can be provided elsewhere, are.
We have seen amazing technological advancements in the last few years that have allowed many diagnostics and procedures to be done away from the traditional hospital. Minimally invasive surgeries, advanced imaging equipment, and new drug regimens can be administered almost anywhere.
In the last 10 years, the majority of our work as healthcare architects has included the design of ambulatory care centers and medical office buildings in response to these advancements in medicine and technology. These buildings house ambulatory surgery centers, urgent care clinics, cancer care, and many other services and modalities. About half of our clients are private physician groups, and the other half are hospital organizations.
What is amazing to me is how different these two client cultures are.
Physicians have seen their reimbursements continue to erode, so they are working very hard to add new services and increase the operational efficiencies of their existing practices. On the other hand, hospitals come with a long tradition of responding to emergent needs and tend to approach outpatient services with a very holistic view of care.
To illustrate, we were recently hired by a community hospital to design an on-campus outpatient building with the stated goal of moving medical services into a non-acute medical setting. Their purpose is to better steward their financial resources and provide high-quality patient care. We were selected for this project, I think, because we had demonstrated our ability to design very lean and efficient outpatient facilities.
During the course of the design project, our clients made several requests: “What would be the cost implications if we landed a helicopter on the roof? If we provided emergency power to support the entire building? If we pushed the building into the side of a hill to preserve views from the existing ICU patient rooms?” It’s kind of like my friend who got a new Toyota Prius. He drove it a while before having a bicycle rack installed. As soon as that happened, his fuel efficiency dropped 20%. The car is so designed for fuel efficiency that if you ask it to do something more, it will fail in its primary purpose.
So what should be the new model for outpatient care facilities?
Both physician groups and hospitals have approached this question from such different perspectives. I am an optimist. I believe the answer will come from the best of both. Each group has corresponding strengths and weaknesses. Private physician groups are often much more lean and efficient in seeing and caring for patients, but they often do not offer a broad array of services. Hospital organizations, on the other hand, are better able to provide bundled and comprehensive services, which can be more convenient and effective for patients with multiple needs. Hospitals are usually better capitalized than private groups and so are better able to assemble equipment, space, and staff necessary to offer complete services.
When it comes to change, a little pain is a good thing. It helps us through the transition. Rising insurance premiums and healthcare reform may be just what we need to help us find a new model for partnerships between hospitals and physicians to provide better, more cost-effective care.