Yesterday we talked about how the nature of the community hospital will be changing in the next half generation. The combination of the push towards quality and bundled payments will lead to general hospitals and general specialists becoming more specialized.
the combination of bundled payments and quality accrual due to specialization is that the general surgeon and the general specialist will be declining in importance. Instead, hospitals will have emergency departments that can handle stabilization of patients and then they’ll ship the patients out to county or regional centers of excellence. If someone has a broken hip, there will be two or three hospitals in a metro area with a dozen surgeons who just do hips and nothing else. If there is a need to do a bypass, a hospital will have two bypass surgeons who do 90% of those procedures between the two of them.
A new article in JAMA lays out a framework to think about what types of non-emergency surgeries should be performed locally and which ones should be shipped out.
— Karan Chhabra (@krchhabra) July 27, 2016
Low risk, high volume surgeries should be performed locally while high risk surgeries should be sent to the specialized specialists.
How does that actually work?
Does it even work in areas where the two most tightly community hospitals are forty miles apart by air and seventy by ambulance? Does it work when a patient would need to travel a day or more for the surgery?
I think it could work in reasonable proximity to major metro areas. The central academic and flagship specialty hospitals would be able to handle the extreme cases like they do now while St. Tabatha’s develops a specialization in gastric bypass but they concede colectomies to Northern Community General which does that and complex knee replacements as its core special services. At the same time Big City Hospital Chain Southern Campus gets a focus on CABG. They’ll ship patients half an hour into the city for transplants, complex and rare diseases but the community hospitals could have initial diagnosis ability, broad spectrum critical capability that is enough to get a person stabilized and then a lot of moving between facilities for the middle to high end care. System wide net utilization may be the same with significant redistribution of particular patients with particular needs compared to today’s system of everyone trying to be everything.
Does that work in Wyoming? Does that model make sense in the Dakotas? Is it feasible along most of the Appalachian spine? Does this work in areas where there is low proider density and great distances to current specialists much less in a future where specialists are even more tightly clustered?
I don’t know what that answer is. I don’t think this simple model works as well outside of major metropolitan areas but I don’t know where those critical access facilities and doctors fit in a world where specialization on procedure class produces increasing quality returns and payment reform models are driving towards comprehensive bundling where low volume systems are at a distinct disadvantage due to their inherent inability to accumulate significant experience and significant specialization to capture gains by learning.