Health care delivery is evolving, for better or worse

While it is no surprise to anyone in the health care field, hospital mainframes are quickly evolving from the multilevel care model of yesteryear to one based strictly on acuity. And primary care isn’t just sitting around, either.

In the old days, if you got sick, you went to your family physician or a hospital-based clinic, or maybe a hospital emergency department. Now, there are so many choices, you almost don’t know where to go anymore. We’ve seen our rather clear-cut, family physician, primary care system, morph into impersonal, multichoice options of not only what Urgent Care Center to go to, but which medical office building with a general practice and maybe a hospital affiliation is closest to my home or workplace. We’re surrounded by options that are proliferating at lightning speed.

How did we get here, and what happens next from a facility perspective? How do we plan, design and build in an environment of evolution and change?

Simply, hospitals discovered that it was way too expensive to treat simple maladies in an expensive structure burdened by high carrying and specialty costs, where virtually every simple procedure becomes a cash drain on the bottom line, and that they needed volume in less expensive surroundings to make it work. In addition, your friendly family physician doesn’t want to do primary care anymore, nor are there enough of them to fulfill that role; it’s too demanding, with not enough reward. So, we see far more nurses (and technology such as that utilized by Forward) in play. But it’s not only the hospital’s mainframe’s cost to build and maintain that impacts the system. Physician and staff costs are also a drain on hospital reimbursement and insurance, which is geared toward minimizing or withholding treatment costs, rather than reasonably responding to acuity. And, without third-party payments to cover the basics, many patients simply won’t go to a local doctor; they’ll clog emergency departments.

The physical result of all of these changes is one in which there are Urgent Care outposts on seemingly every block, many run by chains or hospitals, as well as physician practice MOBs in multiple backyards. While the practices that occupy these MOBs may be owned by a particular health care system, they can now be located just around the corner from another health care system — a new twist on recent history, when these facilities were likely to be located solely within the catchment area of their associated or parent system. Now, because of their directly competing locations, everyone is poaching patients from one another.

What will happen with Urgent Care Centers? Well, we expect them to continue proliferating until the market is saturated, at which time some of them may in fact increase their capacity to deal with a greater acuity, or they will simply go out of business because of the saturation. This also raises the question, as acute care hospitals become more acute, as pressure on reimbursements continues, will a newer, simpler kind of “primary care hospital” re-emerge, perhaps one geared to specifically handle short length-of-stay procedures, and basic treatments on a profitable basis? We maintain that this shift is already underway.

Here at Kimmerle Newman, we see all of the above pressures generating projects. For example, the number of secondary and tertiary care hospitals that are purchasing and relocating physician practices to MOBs is enormous, along with inquiries and plans for tertiary care consolidations. We didn’t necessarily see that coming five years ago.

In the near term, say one to three years, we expect more of the same, with the medium term, four to six years, beginning to show some signs of strain and change. For example, we expect to see far more home health care staffed primarily by part-time nurses with extensive two-way telemedicine capabilities, as it’s more effective cost-wise (no one will be able to afford doctors or full-time nurses). And the long term, whatever it is, will be profoundly affected by the kind and extent of the health care system our society adopts, be it a more restricted system, or one that provides more services to all citizens. Or will it be some kind of hybrid delivery system to deal with the changes to come?

From our perspective, the design of inpatient and outpatient facilities must continue to respond to these changes, otherwise, health care institutions run the risk of essentially paying more for less, reducing their profitability and financial viability.

Michael Azarian is managing director for the Healthcare Studio at Kimmerle Group, a multispecialty architecture and real estate services firm.