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The Changing Landscape of Hospital Capacity in Large Cities and Suburbs: Implications for the Safety Net in Metropolitan America

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An analysis of trends in hospital use and capacity by ownership status and community poverty levels for large urban and suburban areas was undertaken to examine changes that may have important implications for the future of the hospital safety net in large metropolitan areas. Using data on general acute care hospitals located in the 100 largest cities and their suburbs for the years 1996, 1999, and 2002, we examined a number of measures of use and capacity, including staffed beds, admissions, outpatient and emergency department visits, trauma centers, and positron emission tomography scanners. Over the 6-year period, the number of for-profit, nonprofit, and public hospitals declined in both cities and suburbs, with public hospitals showing the largest percentage of decreases. By 2002, for-profit hospitals were responsible for more Medicaid admissions than public hospitals for the 100 largest cities combined. Public hospitals, however, maintained the longest Medicaid average length of stay. The proportion of urban hospital resources located in high poverty cities was slightly higher than the proportion of urban population living in high poverty cities. However, the results demonstrate for the first time, a highly disproportionate share of hospital resources and use among suburbs with a low poverty rate compared to suburbs with a high poverty rate. High poverty communities represented the greatest proportion of suburban population in 2000 but had the smallest proportion of hospital use and specialty care capacity, whereas the opposite was true of low poverty suburbs. The results raise questions about the effects of the expanding role of private hospitals as safety net providers, and have implications for poor residents in high poverty suburban areas, and for urban safety net hospitals that care for poor suburban residents in surrounding communities.
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Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 84, No. 3
doi:10.1007/s11524-007-9163-9
* 2007 The New York Academy of Medicine
The Changing Landscape of Hospital Capacity
in Large Cities and Suburbs: Implications
for the Safety Net in Metropolitan America
Dennis P. Andrulis and Lisa M. Duchon
ABSTRACT An analysis of trends in hospital use and capacity by ownership status and
community poverty levels for large urban and suburban areas was undertaken to
examine changes that may have important implications for the future of the hospital
safety net in large metropolitan areas. Using data on general acute care hospitals
located in the 100 largest cities and their suburbs for the years 1996, 1999, and 2002,
we examined a number of measures of use and capacity, including staffed beds,
admissions, outpatient and emergency department visits, trauma centers, and positron
emission tomography scanners. Over the 6-year period, the number of for-profit,
nonprofit, and public hospitals declined in both cities and suburbs, with public
hospitals showing the largest percentage of decreases. By 2002, for-profit hospitals
were responsible for more Medicaid admissions than public hospitals for the 100
largest cities combined. Public hospitals, however, maintained the longest Medicaid
average length of stay. The proportion of urban hospital resources located in high
poverty cities was slightly higher than the proportion of urban population living in
high poverty cities. However, the results demonstrate for the first time, a highly
disproportionate share of hospital resources and use among suburbs with a low
poverty rate compared to suburbs with a high poverty rate. High poverty communities
represented the greatest proportion of suburban population in 2000 but had the
smallest proportion of hospital use and specialty care capacity, whereas the opposite
was true of low poverty suburbs. The results raise questions about the effects of the
expanding role of private hospitals as safety net providers, and have implications for
poor residents in high poverty suburban areas, and for urban safety net hospitals that
care for poor suburban residents in surrounding communities.
KEYWORDS Medicaid ALOS, Poverty, Safety net hospitals, Suburban hospital care,
Urban hospital care.
INTRODUCTION
The 100 largest U.S. cities and their surrounding suburbs are home to more than
half the nation_s population.
1
Among the greatest challenges for both urban and
suburban communities today is the growing difficulty hospitals face meeting the
needs of poor and uninsured residents while surviving economically in an ever-
competitive health care environment.
2
At the same time, federal, state, and local
Andrulis is with the Center for Health Equality, School of Public Health, Drexel University, Philadelphia,
PA 19102, USA; Duchon is with Health Management Associates, Washington, DC 20037, USA.
Correspondence: Dennis P. Andrulis, Center for Health Equality, School of Public Health, Drexel
University, 1505 Race Street, Mail Stop 1005 13th Floor, Bellet Building, Philadelphia, PA 19102, USA.
(E-mail: dennis.andrulis@drexel.edu)
400
governments are reassessing their financial commitments to safety net facilities as
political pressure mounts to contain or reduce costs associated with Medicaid and
charity care.
These market forces and government actions are creating significant shifts in
the composition of the safety net in large metropolitan areas across the country.
Research has documented a decline in the number of general acute care hospitals
across these areas since at least 1980.
3
As core components of the safety net, public
hospitals have been part of this trend, declining 14% in the 100 largest cities and
43% in their surrounding suburbs between 1980 and 1996. The decline in public
hospitals, whether through closure or conversion, has raised concerns about the
increasing role of the private sector in providing care to the poor and uninsured. In
areas where public hospitals have been privatized, evidence indicates that care for
the uninsured declines.
4
And because major urban safety net hospitals are more
likely to provide critical, high cost, and frequently unprofitable specialty care, such
as neonatal intensive care, and are more likely to care for uninsured and difficult to
treat patients, the closure or conversion of these facilities may, by implication,
reduce access significantly.
5
Concerns About Urban–Suburban Hospital Disparities
A small but growing literature has focused on urban–suburban hospital
Bdisparities.^ The Community Tracking Survey (CTS) has found a widening
disparity in high quality care found at the community level in Indianapolis, Seattle,
Phoenix, Greenville, Northern New Jersey, and Miami, in which physician
specialists and hospital systems are disproportionately investing resources in
wealthier suburban communities.
6
A recent CTS case study of Northern New
Jersey hospitals found that the largest hospital systems are Bcompeting aggressively
for market share in wealthy suburban areas^ that are experiencing population
growth, by expanding and upgrading facilities, whereas smaller hospitals serving
lower income and aging urban communities with stagnant or declining populations
are struggling, with several closing in recent years.
7
Our research from an
unpublished pilot study in 2003 found that relatively poor suburban areas that
are home to increasing numbers of diverse and immigrant populations, such as in
suburban Los Angeles, are struggling with inadequate access to hospital care,
particularly regarding a lack of emergency and specialty care, made worse by the
dispersion of populations and services across a large geographic area.
The Agency for Health Care Research (AHRQ), in noting the often distinctive
differences in demographics and population density between central cities and their
surrounding suburbs, has emphasized the importance of assessing the differences
between the needs and problems of safety nets in urban and suburban areas.
8
However, little research has systematically examined and compared urban and
suburban trends in hospital availability, capacity, and utilization across large
metropolitan areas.
This study analyzes indicators of hospital use and availability for urban and
suburban areas by focusing on two key dimensions: hospital ownership status and
the poverty level of the area where a hospital is located. First, we describe hospital
characteristics and volume of care by ownership status across cities and suburbs for
1996, 1999, and 2002. Secondly, we examine select measures of hospital use and
capacity of cities and suburbs by poverty level, which is positively correlated with
illness and health care need.
9
From these results, we consider how the delivery of
hospital care may be changing in urban and suburban areas, particularly for
THE CHANGING LANDSCAPE OF HOSPITAL CAPACITY 401
vulnerable populations, and the potential implications for the hospital safety net in
large metropolitan areas.
METHODS
The Social and Health Landscape of Urban and Suburban America project, from
which this study originated, documented the social and health improvements and
challenges occurring in the nation_s 100 largest cities and their suburbs between
1990 and 2000.
*
The selection of the 100 largest cities for both 1990 and 2000 was
based on population counts from the 2000 Census.
10
Although there is no standard
method for defining a suburban area, the counties are the federal government_s
standard building blocks for defining a metropolitan statistical area (MSA).
11
We
define the suburbs as the counties making up a primary MSA, excluding the central
city(ies). Over time, as traditionally Bsuburban^ cities have grown relatively rapidly
in recent years, many now appear on the list of 100 largest cities. Aurora, in the
Denver MSA and Plano, Garland, and Irving in the Dallas MSA are examples. In
these cases where more than one of the 100 largest cities are part of the same MSA,
the combined city data from that MSA were subtracted to define the suburban area.
Thus, the sampling represents 100 cities in 82 distinct metropolitan areas.
This method of selection from the 100 largest cities produces a different set of
cities and suburbs than a selection based on the 100 largest metropolitan areas. Our
method may somewhat lessen the differences found between city and suburban
averages compared to a method that selects the largest metropolitan areas first and
subtracts the Btraditional^ central city to define the suburban area.
We report 1996, 1999, and 2002 hospital data provided by Health Forum from
the American Hospital Association (AHA) annual surveys for general acute care
hospitals located in the metropolitan areas of the 100 largest cities. The
nonresponse rate was about 18% for all 3 years. At least one hospital from each
city participated in the survey each year. Eight suburban areas had no hospital data
included in the study.
We examined hospital data by three categories of ownership: public, nonprofit,
and for-profit, as reported by each institution. The hospital indicators included
number of hospitals, staffed beds, admissions, inpatient days, outpatient and
emergency department (ED) visits, Medicaid discharges, and Medicaid average
length of stay (ALOS). These data were grouped and analyzed by urban and
suburban location, as described above.
To examine the relationship between hospital capacity or utilization with
poverty, we categorized cities and suburbs each into three poverty groups and
compared their relative distribution of hospital services with their relative
distribution of population. Population size itself is not a perfect indicator of
demand because people can use hospitals in places where they do not live. However,
we note that other research has found that 75% of discharges among acute care
urban hospitals took place within a 10-mile radius.
12
Because hospital utilization
data were not available by patient address, we aggregated population and hospital
*
Reports and statistics for individual cities and suburban areas are available at www.downstate.edu/
healthdata. This report series was the successor to an earlier grant from Robert Wood Johnson
Foundation to examine health and socio-economic trends of the nation_s 100 largest cities, from 1980 to
1990.
ANDRULIS AND DUCHON402
resource and utilization data across all cities and across all suburbs. This allowed us
to make relative comparisons by poverty levels that minimize the effects of
variation of individual locations.
We defined levels of low, medium, and high poverty to create similarly sized
groups of cities and suburbs, based on poverty data from the 2000 Census.
13
Levels
were created separately for cities and suburbs because of the large difference in
average poverty rates (17.4% for cities, 9.3% for suburbs). For cities, low was
defined as less than 15%, medium as 15 to 20%, and high as greater than 20%. For
suburbs, low was defined as less than 7%, medium as 7 to 10%, and high as greater
than 10%. We calculated the percentage of total urban population that each
poverty group of cities comprises and the percentage of total suburban population
that each poverty group of suburbs comprises.
We aggregated the following hospital indicators, using 2002 data, by urban and
suburban poverty groups: staffed beds, admissions, inpatient days, outpatient and
ED visits, number of level 1 or 2 trauma centers, number of positron emission
tomography (PET) scanners, and number of neonatal intensive care unit (NICU)
beds. To analyze the relative availability or use of hospital resources by poverty
level for each indicator listed above, we compared each urban poverty group_s
percentage of the total to each poverty group_s percentage of total urban
population. The same method applied for the suburban poverty groups.
RESULTS
Utilization by Hospital Ownership
The suburbs, which have two thirds more population than the urban areas of the
100 largest cities, are home to many more acute care general hospitals than the
cities they surround. Urban hospitals, however, have more staffed beds and provide
a much larger volume of both inpatient and outpatient care, on average, compared
to suburban hospitals, regardless of ownership type.
All hospital ownership groups experienced moderate to substantial declines in
their numbers from 1996 to 2002 (Table 1). Proportionally, the greatest losses
occurred among public hospitals. Public hospitals declined by 16% in cities, from
83 to 70, compared with 11% for nonprofit and for-profit urban hospitals.
Suburban public hospitals declined by 27%, from 134 to 98 between 1996 and
2002 (Table 2). Suburban area nonprofit and for-profit hospitals decreased by 2 and
11%, respectively.
As the number of hospitals declined, the bed size per hospital increased over the
same 6-year period. For-profit hospitals had the largest average increase in bed size
in cities (14%), whereas public hospitals led in the suburbs (26%). Increases in
average bed size were associated with increases in utilization. Urban for-profit
hospitals consistently showed the greatest increases in several indicators, including
the average number of admissions (36%), inpatient days (30%), outpatient visits
(39%), and ED visits (61%) per hospital between 1996 and 2002.
With the largest average bed size, urban public hospitals had much higher
utilization per facility than nonprofit and for-profit urban hospitals. Across the
entire set of 100 largest cities, however, they were responsible for fewer total
admissions, inpatient days, and ED visits (but not outpatient visits) in 2002 than in
1996. In contrast, for-profit hospitals, as a group, saw double-digit growth on each
of these measures, and by 2002, had surpassed public hospitals in the total number
THE CHANGING LANDSCAPE OF HOSPITAL CAPACITY 403
TABLE 1 Urban hospital statistics by type of ownership
Hospital
ownership 1996 1999 2002
Percent change
1996–
1999
1999–
2002
1996–
2002
Number of
hospitals
For-profit 161 148 143
_
8.1
_
3.4
_
11.2
Nonprofit 486 454 432
_
6.6
_
4.8
_
11.1
Public 83 72 70
_
13.3
_
2.8
_
15.7
Total 730 674 645
_
7.7
_
4.3
_
11.6
Staffed beds
Per hospital For-profit 209 226 238
Total 33,727 33,459 34,004
_
0.8 1.6 0.8
Per hospital Nonprofit 372 381 394
Total 180,789 173,156 170,070
_
4.2
_
1.8
_
5.9
Per hospital Public 431 420 434
Total 35,805 30,265 30,381
_
15.5 0.4
_
15.1
Per hospital Total 343 351 363
Total 250,321 236,880 234,455
_
5.4
_
1.0
_
6.3
Admissions
Per hospital For-profit 7,496 8,969 10,208
Total 1,206,876 1,327,367 1,459,763 10.0 10.0 21.0
Per hospital Nonprofit 14,930 16,602 18,419
Total 7,255,948 7,537,279 7,956,852 3.9 5.6 9.7
Per hospital Public 17,321 17,861 18,613
Total 1,437,671 1,285,989 1,302,886
_
10.6 1.3
_
9.4
Per hospital Total 13,562 15,060 16,619
Total 9,900,495 10,150,635 10,719,501 2.5 5.6 8.3
Inpatient days
Per hospital For-profit 40,972 47,471 53,407
Total 6,596,463 7,025,670 7,637,232 6.5 8.7 15.8
Per hospital Nonprofit 91,617 96,441 103,603
Total 44,525,807 43,784,349 44,756,438
_
1.7 2.2 0.5
Per hospital Public 115,710 116,131 122,214
Total 9,603,959 8,361,430 8,554,979
_
12.9 2.3
_
10.9
Per hospital Total 83,187 87,791 94,494
Total 60,726,229 59,171,449 60,948,649
_
2.6 3.0 0.4
Outpatient visits
Per hospital For-profit 65,782 80,738 91,289
Total 10,590,903 11,949,217 13,054,346 12.8 9.2 23.3
Per hospital Nonprofit 181,449 214,040 248,214
Total 88,184,008 97,173,938 107,228,265 10.2 10.3 21.6
Per hospital Public 323,333 360,183 408,377
Total 26,836,659 25,933,162 28,586,419
_
3.4 10.2 6.5
Per hospital Total 172,071 200,380 230,805
Total 125,611,570 135,056,317 148,869,030 7.5 10.2 18.5
ED visits
Per hospital For-profit 17,077 21,980 27,507
Total 2,749,400 3,253,030 3,933,480 18.3 20.9 43.1
Per hospital Nonprofit 33,957 39,851 44,865
Total 16,503,073 18,092,234 19,381,719 9.6 7.1 17.4
Per hospital Public 60,176 63,166 70,167
Total 4,994,646 4,547,933 4,911,690
_
8.9 8.0
_
1.7
Per hospital Total 33,215 38,417 43,763
Total 24,247,119 25,893,197 28,226,889 6.8 9.0 16.4
Source: AHA Annual Survey of Hospitals, 1996, 1999, 2002
ANDRULIS AND DUCHON404
TABLE 2 Suburban hospital statistics by type of ownership
Hospital
ownership 1996 1999 2002
Percent change
1996–
1999
1999–
2002
1996–
2002
Number of
hospitals
For-profit 164 146 146
_
11.0 0.0
_
11.0
Nonprofit 608 603 595
_
0.8
_
1.3
_
2.1
Public 134 111 98
_
17.2
_
11.7
_
26.9
Total 906 860 839
_
5.1
_
2.4
_
7.4
Staffed beds
Per hospital For-profit 148 145 145
Total 24,301 21,152 21,219
_
13.0 0.3
_
12.7
Per hospital Nonprofit 204 203 201
Total 124,190 122,663 119,746
_
1.2
_
2.4
_
3.6
Per hospital Public 135 149 171
Total 18,156 16,513 16,738
_
9.0 1.4
_
7.8
Per hospital Total 184 186 188
Total 166,647 160,328 157,703
_
3.8
_
1.6
_
5.4
Admissions
Per hospital For-profit 5,412 5,861 6,680
Total 887,489 855,748 975,213
_
3.6 14.0 9.9
Per hospital Nonprofit 8,228 9,077 9,732
Total 5,002,332 5,473,212 5,790,584 9.4 5.8 15.8
Per hospital Public 5,149 6,048 7,468
Total 689,902 671,352 731,815
_
2.7 9.0 6.1
Per hospital Total 7,262 8,140 8,936
Total 6,579,723 7,000,312 7,497,612 6.4 7.1 14.0
Inpatient days
Per hospital For-profit 26,587 28,229 31,886
Total 4,360,344 4,121,392 4,655,293
_
5.5 13.0 6.8
Per hospital Nonprofit 45,541 47,160 48,757
Total 27,689,204 28,437,474 29,010,544 2.7 2.0 4.8
Per hospital Public 29,518 36,015 43,066
Total 3,955,393 3,997,678 4,220,449 1.1 5.6 6.7
Per hospital Total 39,741 42,508 45,156
Total 36,004,941 36,556,544 37,886,286 1.5 3.6 5.2
Outpatient visits
Per hospital For-profit 48,672 58,376 69,625
Total 7,982,232 8,522,945 10,165,240 6.8 19.3 27.3
Per hospital Nonprofit 117,154 136,517 149,959
Total 71,229,639 82,319,984 89,225,596 15.6 8.4 25.3
Per hospital Public 83,167 109,429 137,717
Total 11,144,417 12,146,647 13,496,252 9.0 11.1 21.1
Per hospital Total 99,731 119,755 134,550
Total 90,356,288 102,989,576 112,887,088 14.0 9.6 24.9
ED visits
Per hospital For-profit 16,433 19,524 22,624
Total 2,695,092 2,850,473 3,303,051 5.8 15.9 22.6
Per hospital Nonprofit 25,221 28,197 31,841
Total 15,334,310 17,002,859 18,945,393 10.9 11.4 23.5
Per hospital Public 19,338 22,367 27,502
Total 2,591,272 2,482,717 2,695,148
_
4.2 8.6 4.0
Per hospital Total 22,760 25,972 29,730
Total 20,620,674 22,336,049 24,943,592 8.3 11.7 21.0
Source: AHA Annual Survey of Hospitals, 1996, 1999, 2002
THE CHANGING LANDSCAPE OF HOSPITAL CAPACITY 405
of staffed beds (34,000 vs 30,400) and admissions (1.5 million vs 1.3 million) in the
largest urban areas.
Medicaid Utilization and Hospital Ownership
In cities, public hospitals maintained the highest average rate of Medicaid
discharges as a percentage of total admissions in 2002 (31.1%) compared to
nonprofit hospitals (18%) and for-profit hospitals (19.8%), but the differences
among the groups have narrowed since 1996. For-profit and nonprofit hospitals
increased their share of Medicaid discharges from 1996 to 2002, whereas the
reverse was true for public hospitals (Table 3). Total Medicaid discharges rose
nearly 39% among for-profit hospitals while declining more than 20% among
urban public hospitals. Medicaid discharges rose about 17% among nonprofit
hospitals over the same 6-year period.
Medicaid_s proportion of total admissions per hospital varied much less by
ownership type in the suburbs compared to urban areas, ranging from an average of
13.3% for nonprofit hospitals to 18.9% for public hospitals in 2002. In contrast to
urban hospitals, the Medicaid proportion of total discharges per hospital and the
total number of Medicaid discharges rose among suburban hospitals for all three
ownership types between 1996 and 2002. Suburban for-profit hospitals were
responsible for a larger total number of Medicaid discharges than public hospitals
for each of the three study years.
In both cities and suburbs, for-profit hospitals had the shortest Medicaid ALOS
and public hospitals had the longest. From 1996 to 2002, city and suburban public
hospitals both saw similar increases—between 11 and 12%—in their Medicaid
ALOS to 7.5 days for city public hospitals, and to 7.7 days among suburban public
hospitals. In contrast, the ALOS for Medicaid patients served in nonprofit hospitals
declined by 9% to 6.2 days in cities and declined by 8.5% to 5.7 days in suburban
areas. For-profit hospitals in cities and suburbs saw modest increases (about 3 and
8%, respectively) in their Medicaid ALOS to 5 days in 2002.
Hospital Utilization and Capacity by Poverty Level
in Cities and Suburbs
The cities and suburban areas, each grouped by low, medium, and high poverty
rates, as described in the Methods section, differ on a number of demographic
characteristics. On average, high poverty cities and high poverty suburbs are
relatively larger, have the lowest proportions of white residents and those without a
high school education, have the highest proportion of black residents, and have the
highest percentage of population that receives public assistance and is unemployed
(Table 4). Violent crime rates are also highest in high poverty cities and suburbs, as
are low birth weight rates, relative to their respective low and medium poverty
groups. Cities, overall, are more racially and ethnically diverse than their suburbs,
but vary less by poverty level on the percentage of Hispanic and foreign-born
residents compared with the suburbs.
We found that the proportion of hospital utilization and resources in high
poverty cities was modestly higher than their proportion of urban population. High
poverty cities had slightly higher proportions of beds, admissions, inpatient days,
and ED and outpatient visits relative to their proportion of the total urban
population (Figure 1).
By contrast, high poverty suburbs showed dramatically lower levels of
utilization relative to their share of the suburban population. These suburban
ANDRULIS AND DUCHON406
TABLE 3 Medicaid discharges and ALOS for urban and suburban hospitals
Hospital ownership 1996 1999 2002
Percent change
1996–1999 1999–2002 1996–2002
Urban hospitals
Medicaid discharges
Percent of total admissions For-profit 17.3 15.9 19.8
No. of discharges 208,574 211,548 289,347 1.4 36.8 38.7
Percent of total admissions Nonprofit 16.9 14.2 18.0
No. of discharges 1,227,919 1,073,857 1,431,585
_
12.5 33.3 16.6
Percent of total admissions Public 35.8 31.4 31.1
No. of discharges 515,129 403,748 405,326
_
21.6 0.4
_
21.3
Percent of total admissions Total 19.2 16.5 19.8
No. of discharges 1,896,137 1,669,811 2,124,729
_
11.9 27.2 12.1
Medicaid ALOS For-profit 4.9 5.1 5.0 4.4
_
1.1 3.2
Nonprofit 6.8 6.8 6.2
_
0.2
_
8.9
_
9.1
Public 6.8 7.4 7.5 8.6 2.2 11.1
Total 6.6 6.7 6.3 1.7
_
6.3
_
4.6
Suburban hospitals
Medicaid discharges
Percent of total admissions For-profit 17.2 14.4 17.9
No. of discharges 152,703 123,054 174,505
_
19.4 41.8 14.3
Percent of total admissions Nonprofit 12.5 10.6 13.3
No. of discharges 626,999 582,664 770,523
_
7.1 32.2 22.9
Percent of total admissions Public 17.8 22.1 18.9
No. of discharges 122,463 148,502 137,976 21.3
_
7.1 12.7
Percent of total admissions Total 14.2 12.8 14.8
No. of discharges 931,123 893,282 1,106,106
_
4.1 23.8 18.8
Medicaid ALOS For-profit 4.6 5.0 5.0 8.5
_
0.2 8.3
Nonprofit 6.3 6.3 5.7 0.8
_
9.2
_
8.5
Public 6.9 8.3 7.7 19.9
_
6.8 11.8
Total 6.1 6.4 5.9 5.8
_
8.7
_
3.4
Source: AHA Annual Survey of Hospitals, 1996, 1999, 2002
THE CHANGING LANDSCAPE OF HOSPITAL CAPACITY 407
TABLE 4 Characteristics of 100 largest cities and their suburbs by poverty rate levels,
a
2000
Cities by poverty level Suburbs by poverty level
Total Low Medium High Total Low Medium High
Total population
b
56,590,581 19,956,047 12,812,500 23,822,034 94,758,109 25,094,993 27,888,383 41,774,733
Average population size 690,129 623,626 557,065 882,298 1,184,461 815,347 1,237,728 1,562,885
Percent of population 65 and older 11.2 10.5 10.9 12.2 11.2 11.1 11.7 10.7
Percent of population non-Hispanic white 50.7 60.9 52.6 37.0 73.8 84.1 75.3 58.0
Percent of population non-Hispanic black 25.4 15.7 18.3 42.9 8.2 6.0 8.3 11.1
Percent of population Hispanic 16.3 13.0 21.9 15.3 12.5 5.3 9.4 26.4
Percent of population foreign-born 13.3 13.4 14.2 12.6 9.4 7.4 8.4 13.6
Percent of population on public assistance 5.1 3.4 5.1 7.2 2.7 1.8 2.5 4.1
Percent of population 25 and older with no high
school diploma
21.6 16.4 22.0 27.5 16.8 12.0 15.5 25.1
Unemployment rate (%) 7.6 5.5 7.3 10.4 4.9 3.6 4.6 7.1
Violent crime rate (per 100,000 pop.) 990.3 792.2 893.4 1307.7 323.0 216.9 337.5 448.4
Low birth weight rate (percent of live births) 8.9 7.8 8.2 10.6 7.1 6.6 7.1 7.6
Source: Demographic statistics tabulated from 2000 Census Bureau data; violent crime rates tabulated from 2000 FBI crime data; low birth weight rates tabulated from the 2000
Natality Data Set provided by the National Center for Health Statistics.
a
Categories for percentage of population living below federal poverty level are cities: low G15%, medium 15–20%, and high 920%; suburbs: low G7%, medium 7–10%, and high 910%
b
Suburban numbers exclude the population of suburban areas that were not represented by in the hospital data sets.
ANDRULIS AND DUCHON408
communities, which accounted for the largest proportion of the suburban
population—44% in 2000—represented about one fifth of all suburban hospital
beds, ED admissions, and inpatient days in 2002, and only 17% of the outpatient
visits (Figure 2). Low poverty suburbs, with just over one quarter (26%) of the total
FIGURE 1. One hundred largest cities by poverty level: Distribution of 2000 population compared
with distribution of hospital beds, utilization and specialty care, 2002 (percentages shown).
FIGURE 2. Suburbs of 100 largest cities by poverty level: Distribution of 2000 population
compared with distribution of hospital beds, utilization and specialty care, 2002 (percentages
shown).
THE CHANGING LANDSCAPE OF HOSPITAL CAPACITY 409
suburban population, accounted for 42% of suburban hospital beds and more than
40% of each of the other utilization measures.
We selected three high-cost hospital services to examine by community poverty
level: level 1 or 2 trauma care, PET scanners, and NICU beds. In cities, the overall
distribution and availability of these services across the three poverty groups
generally matched the distribution of the population across these groupings. For
example, high poverty cities, with 42% of the total urban population in 2000,
represented 43% of the urban level 1 and 2 trauma centers, 42% of the urban PET
scanners, and 39% of the urban NICU beds in 2002.
In suburban areas, distribution of these services by level of poverty was not
proportionate to the population distribution by poverty level. The low poverty
suburbs, with 26% of the total suburban population, accounted for 59% of these
trauma centers, 54% of the PET scanners, and 45% of the NICU beds. From 1996
to 2002, the number of PET scanners reported in hospitals located in low poverty
suburbs increased from 3 to 60 (data not shown). As with service utilization, high
poverty suburbs were significantly underrepresented by these capacity measures.
With 44% of total suburban population, they had only 17% of suburban trauma
centers and PET scanners and 34% of suburban NICU beds in 2002.
DISCUSSION
The results of our analysis of hospital data for urban and suburban areas of the 100
largest cities between 1996 and 2002 highlight two key themes. The first is that
while public hospitals remain as the major safety net providers in the communities
they serve, hospital inpatient care overall and for Medicaid patients in particular
appears to be shifting from the public to the private sector. These trends raise
questions about the long-term effects of a hospital safety net increasingly comprised
of nonprofit and for-profit institutions.
The second theme relates to the apparent disparities in the relative availability
of hospital resources between low poverty and high poverty suburban areas. In
contrast, for cities, there was only modest or little difference between the
percentage distribution of utilization or availability of select specialty care services
across low, medium, and high urban poverty areas, and the percentage distribution
of population across these three groups. The findings have implications for poor
residents in high poverty suburban areas, and also for urban safety net hospitals
and the role that they may play in caring for poor suburban residents in
surrounding communities. The appropriateness of the levels of hospital resources
concentrated in low poverty suburban areas also comes into question.
City–Suburban Differences by Ownership
The number of general acute care hospitals and staffed beds declined between 1996
and 2002, with public hospitals showing the largest percentage decreases in both
cities (16%) and suburbs (27%). These trends represent an acceleration in closings,
mergers, or conversions of public hospitals compared with the previous 16-year
period, between 1980 and 1996, noted earlier. The remaining urban public
hospitals continued to be relatively large facilities, as measured by their bed size,
but their presence across the urban landscape is diminishing. By 2002, for-profit
hospitals had eclipsed public hospitals in the volume of total and Medicaid
admissions in the largest cities. Whereas urban public hospitals still provided a
ANDRULIS AND DUCHON410
larger share of ED visits compared with urban for-profit hospitals, they were the
only group to see a decline in ED visits between 1996 and 2002.
These trends suggest a diminishing role for public hospitals in the provision of
inpatient care and a shift toward the private sector. This change has been
documented in New York City and Miami, for example, where the public hospital
systems are facing increasing competition from private hospitals for Medicaid
enrollees.
14,15
However, research on urban and suburban hospital care found that
private hospitals maintained a very consistent proportion of gross patient revenues
attributed to Medicaid and self-pay (i.e., a proxy for uninsured) patients during the
1990s, and that changes within one category were offset by relatively similar
amounts in the other.
16
This consistency suggests that private hospitals, in general,
may seek to stabilize a ceiling on the proportion of revenues dedicated to low
income populations to maintain their operating margins. To do so may require
decreasing charity care or increasing revenues through collections, or seeking
Medicaid patients who are more likely to generate positive income (e.g., women
giving birth). However, the threat of lawsuits and congressional hearings are
putting more pressure on nonprofit hospitals to show they have provided a
significant community benefit worthy of their tax-exempt status, particularly
regarding care for the uninsured and other vulnerable populations.
17,18
In suburbs, for-profit hospitals continued to have a larger share of total and
Medicaid inpatient volume compared to public hospitals. But unlike urban areas,
both inpatient and outpatient volume increased across suburban pubic hospitals. In
addition, average bed size for remaining public hospitals increased considerably,
suggesting that relatively smaller facilities closed or converted ownership, or
merged with other hospitals. It is also possible that new beds were added to
remaining hospitals as a result of hospital closings. One question, and an area for
future research, is whether the larger size of remaining suburban public hospitals,
combined with their increase in utilization across suburban areas, suggest that their
numbers and staffed beds will stabilize or continue to decline from continued
financial pressures.
We also found that public hospitals in urban and suburban areas had both the
longest Medicaid ALOS and the steepest rise in Medicaid ALOS between 1996 and
2002. These findings may indicate that, on average, public hospitals treat more
seriously ill Medicaid patients than for-profit or nonprofit hospitals, or that public
hospitals are performing fewer services such as deliveries, which are associated with
relatively shorter hospital stays. The results may also suggest that public hospitals
are less efficient in providing care or in their discharge planning, which could also
be related to patient circumstances beyond the hospitals_ control. Whether the
longer ALOS is related to inefficiencies or sicker patients or both, the financial
implications are ominous and worthy of additional study. Without adequate
revenues to cover the costs of care and to maintain infrastructure, many public
hospitals will continue to face an uphill battle for survival.
Hospitals in Low, Medium, and High Poverty Urban
and Suburban Areas
Our review of hospital capacity and utilization by community poverty levels
indicates that high poverty cities accounted for a slightly larger proportion of
hospital use relative to their proportion of the total urban population, whereas the
availability of specialty services such as trauma care, NICU beds, and PET scanners
across low, medium, and high poverty cities was generally in line with the
THE CHANGING LANDSCAPE OF HOSPITAL CAPACITY 411
population distribution across these groups. Among suburban areas, however, we
found that high poverty communities represented the greatest proportion of
suburban population in 2000 but had the smallest proportion of hospital use and
specialty care capacity, as indicated by the proportion of PET scanners, trauma care
centers, and NICU beds. The opposite was true of low poverty suburbs, which
represented the smallest proportion of total suburban population, but had the
largest proportions of suburban hospital use and specialty care capacity. This
lopsided distribution of hospital resources in favor of low poverty suburbs supports
other research documenting that hospitals have targeted expansion of specialty care
services to high-income markets.
6,19
The population characteristics of low poverty
suburban areas suggest that their residents are, on average, the most affluent in
metropolitan America, and likely are the best insured.
By the same token, hospital systems may be reluctant to expand into high
poverty suburbs. Although we do not have data on uninsured rates for these areas,
low income is highly associated with insurance status.
20
We also noted earlier that
the high poverty suburban areas averaged the largest percentages of Hispanic and
foreign-born populations. Surveys have documented these groups as having among
the highest uninsured rates in the country.
21
A lack of health coverage may be a
contributing factor in the relatively small proportion of hospital resources available
in high poverty suburbs.
For hospitals that do serve poor areas, the trends are troubling. We found that
between 1996 and 2002, high poverty areas had the greatest decline in the number
of suburban hospitals (data not shown). Such losses may further exacerbate access
problems, particularly for those with limited or no insurance and limited
transportation options.
6
These findings suggest other areas of inquiry of metropol-
itan safety net issues by raising questions about whether residents in high poverty
suburban areas, especially those who are poor or uninsured, will become
increasingly dependent on nearby city public hospitals. This contention has already
surfaced in Texas, where indigent or uninsured patients residing in surrounding
suburban counties of five urban county hospital districts accounted for 16% of the
$1.2 billion in uncompensated care provided by the public hospitals in these
districts in 2002.
22
The continued growth in the uninsured population in this country, which now
exceeds 46 million, is one of the most critical issues facing safety net hospitals
today, regardless of ownership status.
23
The responsibilities of each community to
care for its uninsured and other vulnerable populations fall on local hospitals and
other safety net providers. In the absence of state, regional, or national reforms to
significantly expand insurance coverage, hospitals will continue to search for ways
to limit their financial exposure from caring for uninsured patients, particularly as
the hospital industry becomes even more competitive in a global economy.
24
A limitation of this study is that we did not conduct a multivariate analysis.
Our aggregate analyses focus on poverty without considering other potentially
important factors that may influence hospital distribution, or supply and demand,
such as regional dynamics, local economics, political jurisdictional considerations,
uninsured rates and rates of disability.
25
At the same time, the results of our analysis
may offer direction for future research that takes these factors into account. The
results of this study also do not allow us to assess whether a group of cities or
suburbs provides too much or too little hospital care, nor do they address critical
concerns about the distribution of hospital services within individual cities or
suburban areas.
ANDRULIS AND DUCHON412
CONCLUSIONS
What do these results by ownership and poverty say about the future of hospital
care in urban and suburban areas? The continued losses of public hospitals in both
cities and suburbs, at the very least, inject uncertainty about a changing hospital
safety net that increasingly involves the private sector. The fallout from this
transition in cities may differ significantly from the suburbs. In large central cities,
the size of public and other primary safety net institutions, their constituency, their
presence as an employer, and the political issues surrounding their status suggest
that communities are likely to demand a careful assessment of impact, as well as a
viable alternative safety net plan.
4
Suburban areas with growing numbers of poor,
or those losing their public or primary safety net hospitals, may be less likely to
have the strong constituencies found in central cities. As a result, there may be a less
vocal and concerted effort to assure that viable options are available, with the
consequences falling on the most vulnerable. Ultimately, more regional cooperation
may be required to ensure adequate financing and access to hospital care for the
poor and uninsured in large metropolitan areas.
ACKNOWLEDGEMENT
Funding for the Social and Health Landscape of Urban and Suburban America
project, upon which this study was based, came from the Robert Wood Johnson
Foundation.
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