Malls and Hospitals

A recent “1A” podcast about malls, plus the article Why Major Hospitals Are Losing Money By The Millions, sent me into fortune teller mode. I’ve a hunch there are parallels between the evolution of malls and hospitals. And if so, then for anyone considering building or buying a hospital, I’d think twice.

Before malls there were city centers, markets, corner stores and the like. Malls arrived and sucked customers into the ‘burbs. Some vendors followed, some struggled, and others croaked. I remember the Oakdale mall as a little kid, and I spent many hours during my high school years loitering in the Poughkeepsie mall.

Then the internet and Amazon landed. Ever since, malls have been closing at a remarkable rate. When did you last visit one? Who needs them when you can shop and get a date online?

Moving on to hospitals, for many years they were the place you went to die. But as medical and surgical treatments improved, that changed drastically. During my med school days in St. Louis, I remember wondering how there could be so many giant hospitals in such a relatively small space. How could there possibly be that much sickness, and money to house it?

In parallel, many quaint private practices closed shop. As complexity and bureaucracy entered medicine, medical professionals who may have considered private practice (like me), instead followed the relative simplicity and security of hospital groups and big buildings.

Like many friends in med school I chose ER, largely because it was interesting and different every shift; but also because I hated the idea of running a business, carrying a pager and chasing patients and insurers for payments. “Work an hour, get paid an hour, and no overhead” was my mantra … until Pre-R. The word “hospitalist” emerged a few years after I graduated, which came from internists also seeking shift work serenity. Today there are obstetric hospitalists as well. Opening a private practice in this political/medical climate still just seems nutty.

But the internet and the “gig economy” are threatening disrupters that should make hospital owners and workers nervous. Cost conscious patients with high deductibles who are fearful of massive bills are a real threat to hospital bottom lines now. I’d never heard the word “chargemaster” a decade ago, but today the smoke is clearing and price transparency has become a hot topic. Massive unpredictable bills combined with a wacky insurance industry are just chasing many patients away.

Don’t get me wrong though. I’m not anti buildings. I’m anti waste. So my questions are these:

  1. How much do the bricks and mortar of hospitals actually make people healthier?
  2. How best should the existing bricks and mortar being used in this new internet age? For efficiency pre-internet, hospitals made great sense. They help make good use of limited resources and they improve the efficiency of caregivers. (Why pay docs to drive around?)

Many admissions, however, are simply for prudence and close monitoring of problems likely to resolve on their own. A large fraction could easily be managed with home health services. And regarding infectious disease, hospitals may actually serve as illness amplifiers instead.

Of course if you ask patients, most would prefer to convalesce in the comfort of home… unless they’re homeless or indigent. Actually, in my preferred world, these would be the patients most likely to be admitted. Instead we have to grovel and call them “social admits” which sticks in my craw every time. But that’s for another post.

Sure it’s hard to do in-home surgeries, but more and more are being done outpatient or in high dollar surgicenters. Many other medical problems can be dealt with outside of hospitals as well now. Diabetes is a useful example. It used to be a death sentence. Then it turned it into something needing prolonged admission. Today, we admit mainly complications related to poorly controlled diabetes. Patients with diabetes are often the experts nowadays. Actually, if you have diabetes, do yourself a favor and find a nurse who also has it and grab dinner. They’re the real gurus. Other illnesses are following similar outpatient routes.

Today Pre-R and many other tech based medical companies pose a real threat to buildings in general. But that’s ok. It’s evolution. More interesting is how will those in charge react and what will be done with the vacant structures? Instead of resenting or firing docs like me I hope they’ll adapt and embrace tech themselves.

When I worked on cruise ships, I didn’t bemoan my tiny 2-4 bed infirmaries. To me every guest room was a hospital bed. Similarly, if those running hospitals offered telemedicine and house calls, then no longer would they be constrained by physical bed counts. Hospital beds could then be used for the least fortunate, rather than patients most likely to have “reimbursable” conditions.

Any time a clerk answers the phone and says “we can’t give advice over the phone, you’ll have to come in to be seen,” to me that’s a lost opportunity and a failure. Why not offer telemedicine from ERs as well? Any night that a hospital has an open bed while someone with mental illness spends a night in the adjacent creek, that’s another “F” in my book for hospital, town and country.

While I think there are many ways to make great use of so much brick and mortar, unfortunately I fear many hospitals will sink rather than adapt. We’ll see.

Anyways, if you do choose to invest in a hospital, please let me know in a decade how you made out.

P.S. Does your ER still take crackly, often dropped, ambulance calls over a red or black 1980s phone? My wife makes prolonged video Facetime calls from the passenger seat of our car with her family in Venezuela, and only occasionally do the calls get dropped… while they drive as well! Someone square that for me please.

ER, House Calls

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