The Transformation of the American Hospital, 1965–2015

Over the last fifty years, the hospital has been technologized, corporatized, and bureaucratized due to demographic, political, economic, and scientific developments. The demographic shift has led to the greying of the population, with an associated increase in chronic disease, resulting in hospitalized patients becoming sicker and more complex. Legislative changes such as the introduction of Medicare led to a surge in the number of hospitalizations of older individuals; the subsequent move to prospective payment led to shorter hospital stays—and increased reliance on the skilled nursing facility. A change in the economic climate produced consolidation, with the resulting growth of hospital chains and hospital systems. Scientific advances, fuelled in many cases by generous research grants from the National Institutes of Health, led to new, non-invasive imaging techniques such as computerized tomography and magnetic resonance imaging. Advances in biology and epidemiology led to new approaches to the hospital’s management of diseases as disparate as heart attacks and cancer.

The March of Time, 1965–2015

This chapter traces the evolution of office-based care from the small, intimate, low-tech practice of the 1960s to the multi-physician, rule-driven, computerized practice of 2015. The changes are attributed to scientific advances in medicine (such as new treatments for hypertension and diabetes), social trends (for example, the women’s movement and the corporatization of medicine), and legislative milestones (principally the passage of Medicare, the introduction of Medicare hospice, new home care coverage).

Finale

The evidence suggests that medical care for frail, old people should be interdisciplinary, coordinated, and accessible. Analysis of the current system suggests it should begin with comprehensive assessment of the individual, including physical function, emotional state, degree of social engagement, support system, and medical insurance. Next, the ideal interdisciplinary team should determine the person’s goals of care. Finally, a plan of care should be developed, taking both goals and needs into account. Implementing the plan will require a robust home care program as well as family support. Achievement of such a system will necessitate reforming the complex adaptive system that makes up American health care today. The most promising change agent is the Medicare program itself, which could introduce requirements into medical training programs to assure competence in geriatric medicine and communication skills. With appropriate legislative changes, Medicare could also negotiate with drug companies over price and set reimbursement for medical technology based on cost-effectiveness. Medicare could also develop a new benefit plan for frail elders that offered more intensive home care and other services in exchange for decreased coverage of invasive, expensive, and often non-beneficial hospital-based technology.

The Hospital through Other Eyes

The patient’s experience of hospitalization is affected by device manufacturers, the pharmaceutical industry, government regulators, and Medicare as well as by physicians and hospital administrators. For example, the hospital is the largest consumer of medical devices and the site for intensive lobbying to purchase the newest, most sophisticated equipment; medications taken by patients in the hospital are likely to be continued after discharge, resulting in drug company pressure to influence the hospital formulary.

The Varieties of Hospital Experience

American hospitals come in a variety of flavors: teaching and non-teaching, for profit and not-for-profit, large and small, government and private, urban and rural. While the patient’s experience varies slightly depending on the type of hospital, all hospitals could be improved to better serve the needs of older patients if they implemented basic geriatric principles.

Entering the Palace of Technology

Hospitals are both potentially life-saving and dangerous. For vulnerable older people, the hospital poses the risk of developing acute confusion, adverse drug reactions, falls, and loss of independence. It is a technologically-intensive, unfamiliar environment that is often disorienting to elderly patients.

Different SNFs, Different Miffs

Skilled nursing facilities vary in quality, with for-profit facilities offering, on average, poorer care. Not-for-profit facilities are at the forefront of the culture change movement that promotes patient-centered care. However, substandard care is common in both types of facility, with a recent Office of Inspector General report finding high rates of adverse events, many of them dangerous.

From the Outside In

The interests of various groups--physicians, hospital administrators, drug companies, device manufacturers, and Medicare—affect the older patient’s experience in the office. Physicians avoid home visits in the interest of achieving work/life balance; hospitals buy medical practices to maximize admissions; drug companies use point-of-care marketing to sell pharmaceuticals; device manufacturers lobby physicians to order tests; and Medicare mandates medication reviews and after-visit summaries.

Now and Then

The Skilled Nursing Facility (SNF) is largely a creation of Medicare: the institution of prospective payment for hospital care in 1983 led to early discharge of patients from the hospital. For frail, old people who were not ready to go home so quickly, the SNF evolved as an intermediate site of care. Social trends and scientific developments also affected the development of the SNF over the past fifty years. Changes in family structure as well as unprecedented geographic mobility weakened the ability of families to take care of older people after a hospital stay. The growth of mega-corporations and of mergers and acquisitions led to the development of SNF chains. In medical science, the development of hip and knee joint replacement surgery, along with the aging of the population, led to the rise in popularity of these procedures, with a concomitant need for post-surgical rehabilitation. The development of the intensive care unit and advances in anaesthesia resulted in a steady rise in the age of patients undergoing complex surgery, further stimulating the need for skilled nursing facility care.

Movers and Shapers

Nursing home administrators, physicians, hospitals, drug companies, and Medicare are among the major influences on the patient’s experience of skilled nursing facility (SNF) care. Administrators are concerned with selecting patients with high levels of Medicare reimbursement; physicians tend to regard SNF care as low status and unrewarding; hospitals use the SNF as a safety valve allowing for early discharge; drug companies work with regional medical distributors to influence physician prescribing; and Medicare tries to promote quality by using an elaborate system of quality indicators, mandating state inspections or surveys, and reimbursing care so as to encourage maximal use of physical therapy.