At (To) we talk a lot about the importance of location for individual well-being. However, we rarely discuss the effects hospital systems have on place choices and the central role hospitals play in organizing, stimulating and maintaining healthy economies – for both those they employ and those they serve. With an increasing majority of newly minted physicians going to work for hospitals (only one in three physicians remained independent at the end of 2016), this blog post will examine the changes "big-box" hospitals are currently experiencing, as well as the future of physician jobs as a result of: (1) the shifting climate from independent physician practices to hospital-centric models; (2) technology; and (3) patient service needs.
This "new" model shouldn’t be a surprise; a similar scenario occurred in the 1990s when “hospitals and other entities bought practices and employed physicians as a way for achieving efficiencies associated with system-wide integration, management of large population groups, and better positioning for value-based or bundled payments” (from "The Physician Employment Trend: What You Need to Know"). However, today's scenario is very different because the hospital model has been updated to also factor in WHERE services are located and how they are delivered to meet the lifestyles of growing, shifting populations who require care. Why does this change matter to physicians or recruiters working to facilitate placement of physicians to their best locations? Because it acknowledges the critical role geography plays for delivering both care and practitioner choice, requiring recruiters, agencies and hospitals to be able to accurately communicate a physician lifestyle related not only to a hospital's brand but also its neighborhood. If you’re a recruiter but don't consider yourself a relocation expert, you’re behind the times based on the current climate. For modern medicine to be successful, hospitals and their communities must successfully compete for providers, particularly those in primary care. Thus location, including the neighborhoods where future physicians will live, the grocery stores where they will shop and the day care their children will have, is just as important as the services and work environment provided by the hospital itself (so we should get it right!). Location, no less than a medical specialty, is unique to individuals and requires focused attention to achieve positive, measurable outcomes; it’s the next dimension of the "value-based care" we need to be talking about.
The Floating Hospital
While not new, the Floating Hospital is an excellent example of how patient services can adapt and scale to all types of communities in parallel with changes in medicine and the environments that support care delivery. If you haven’t heard of the Floating Hospital, here’s a brief history:
Established in 1866 with the guidance of St. John’s Guild of the Trinity Church, the Floating Hospital was a vessel outfitted to serve the medical needs of sick, poor children plagued by diseases that were largely the result of environmental conditions in New York City, primarily those associated with poor air quality. It was designed to be a literal floating hospital, providing healthy food, drink and fresh sea air to impoverished children: “a temporary, restorative escape from crushing heat, filth and diseased conditions of a New York City summer” (from "The Floating Hospital History Timeline"). Its practical model at the time was a response to a pervasive problem: poor children were dying by the hundreds during the summer from intestinal diseases that were rampant in crowded slums. Its model was conceived not by a physician but by a Congregational minister “who had the imagination and vision to understand that a healthy atmosphere and medical care could be combined on a hospital boat that could venture out onto the water and expose its passengers to cool breezes and sea air.” How astonishing – to use geography as a health solution!
Over time, the Floating Hospital grew in its successes, transforming itself from what was considered primarily a “quarantine vessel” for diseases such as cholera to a fleet of five ships serving as outpatient centers that welcomed the poor, sick and famous. New York City mayor Rudy Giuliani, Elizabeth Taylor and David Rockefeller were among their notable passengers. In the 1980's, the Floating Hospital became a resource for community health care, offering free medical and dental screenings, health and education workshops, free lunches, entertainment and fitness classes.
Following the attacks on September 11, 2001, the Floating Hospital embraced a land-based model, eventually anchoring its main clinic in Long Island City, NY. It continues to expand its fleet and community-focused mission, including through clinics and a state-of-the-art transportation network that makes more than 100 trips every day, reaching patients at more than 200 family shelters, domestic violence safe house and public housing complexes in all five boroughs of the city. In 2012, the Queensbridge Community Health Center was opened as part the Floating Hospital, strategically positioned to be within a short walk for more than 7,000 residents (once again using geography, needs and lifestyle characteristics to determine optimal access to patient care).
Over time, the Floating Hospital has expanded its brand to include other land-based locations in Massachusetts, bridging gaps in patient care and services throughout the eastern portion of the state. As explained through the graphic below, the Floating Hospital for Children along with Tufts Medical Center supports seven affiliated hospitals and a network of almost 1,800 physicians to deliver high-quality, community-based care. Of course, those are only numbers until you examine the benefits of local care. With models like the Floating Hospital for Children, individuals requiring care can experience state-of-the-art treatment close to home, resulting in quick access to specialized expertise and top-notch facilities in their backyard. This sort of location-based model (keeping care in the community) makes life easier on families, while also driving down health care costs for patients, employers and insurance providers .
Perhaps unintentionally, the Floating Hospital established a precedent for geography and location as part of a solution to address individual care concerns. It is only one example of whole communities organizing and orienting public health toward more positive, locally focused outcomes, with providers playing a critical role in the process. The Floating Hospital also indirectly acknowledged the need to deliver care under various business models and relationship networks. Not all care, and actually very little, requires a patient to visit a state-of-the-art facility. In fact, most services can be administered through small, local clinics or even mobile units. Of course, all of these services rely on transportation by providers to be successful, and thus networks to support them. We mention this because from a lifestyle perspective as a physician, nurse or health practitioner delivering services, where you work, how you see patients and which resources are available to help deliver your expertise can vary depending on your location and its supported infrastructure, as well as on the local hospital’s business model for care. “Health is driven by health care, but it is also driven as much by everything that is not health care – all the social factors, economic factors and demographics,“ says Maulik Joshi, senior vice president and CEO of the American Hospital Association’s Health Research & Education Trust (from "Hospital of Yesterday: The Biggest Changes in Health Care"). “Hospitals are getting into the culture of health; it’s not just health care.”
A New Frontier for Care Delivery
Certainly by now you’ve heard of telemedicine. Below are a few examples of hospitals and locations adapting their business models to meet growing geographically focused population demands. When combined with technology and the realities of specific service types, physicians of the future can live anywhere they want or move as often as they like. This offers an opportunity for nontraditional practice that historically has not been available. It may also help provide a solution for physicians considering early retirement who want to have greater location flexibility and spend less time in the hospital. There are currently a number of exciting pilot programs in the United States designed to distribute the value of centralized specialists across a wider geographic area.
Virtual Medical Centers
Mercy Hospitals is pioneering this field with a new virtual care center in Missouri intended to serve a four-state area. “Described as a ‘hospital without beds,’ the Virtual Care Center is home to a large medical team, but with no patients. Using highly sensitive two-way cameras, online-enabled instruments and real-time vital signs, clinicians 'see' patients where they are. That may be in one of Mercy’s traditional hospitals, a physician office or in some cases, the patient’s home.”
Inova Health Systems is trying out a more modest program in Northern Virginia, where telemedicine facilities allow a group of intensivists to deliver their services to 122 ICU beds located all over the state.
New Remote Clinical Services
New remote clinical services and opportunities are growing by the numbers. Since radiology has proven to be an optimal field for outsourcing via telemedicine, many hospitals are now looking at the possibility of splitting off many other specializations. Psychiatry, neurology and many other disciplines are ripe for decentralization employing telehealth practices. Several vendors already provide remote care in the fields of dermatology, mental health and stroke care. Hospitals themselves are also looking to get into the action, leading to a volatile and competitive (but rapidly expanding!) market.
Some final thoughts
But, what else must be considered? Not surprisingly, we can turn to geography to answer that question. Certain populations have resources that make access to cutting-edge, convenient delivery possible (or not). For example, lack of a high-speed internet connection or access to a major transportation network defines what some refer to as a "digital divide" in the United States, which affects community health care just as much as education or jobs. If you don’t have access to technology services to facilitate care, then you must either seek care at a centralized location or care must come to you. This map by Esri was created for the White House Connecting America initiative, and it highlights some of the issues associated with broadband access, particularly in poor communities. So where does that leave us with telemedicine? Does it overlook the needs of those who require services the most, catering to convenience and wealthier areas? Our observation is that it's too early to tell.
Increased, rapid communication can have major benefits, transforming the way people live and move. For a physician this may be communicating “from the inside out” or “the outside in.” With other major moving pieces of technology advancement, and investment in rural communication infrastructure for agricultural applications, there may be a means for facilitating increased development and technology services (and thus health services) through a packaged system that decreases the digital divide, provides necessary services for those who have yet to realize their benefits and directly addresses the need for physicians in areas that need them most. This change may come more rapidly for urban dwellers and medical specialties well positioned for remote care due to types of services being administered, but most likely that will not always be the case.
Hospitals are a major piece of this puzzle – they can take the lead in services and location (and thus re-location) of physicians to meet population demands. By recognizing the value of location intelligence for operational decision-making, business growth strategy and community connectivity, hospitals represent a catalyst for community growth and prosperity. Understanding where hospitals are located and the expanse of their networks, combined with knowledge of the populations they serve (including how and where individuals are living) and their technology infrastructure, gives physicians a clear picture of what work-life balance may be like for a first or next job. For recruiters focused on employee placement, location information can prove a major advantage for communicating opportunity and lifestyle happiness, ensuring that a position meets expectations for all aspects of a physician’s life. Technology platforms that make use of location-based information can be a driving force behind better, more efficient health care delivery and better opportunities for physicians. This is the model that largely drives (To) at scale, as it uncovers deeper views and connections to communities that are of high value for both doctors and patients – using the geography we all share. This location-based model represents a new horizon for finding and developing integrated health solutions that serve hospital business objectives in parallel with the needs of physicians and communities.