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RECKSVILLE, Ohio — Get in, get a new knee, go home.

As treatments get less invasive and recovery times shrink, a new kind of hospital is cropping up — the “bedless hospital.”

They have all the capabilities of traditional hospitals: operating rooms, infusion suites, and even emergency rooms and helipads. What they don’t have is overnight space.

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“It reduces cost, and it reduces the risk of infection,” said Dr. Akram Boutros, CEO of MetroHealth System, which just opened a $48 million bedless hospital near Cleveland that he expects will serve about 3,000 people in the first year. “People go home to a less-risky environment, where they tend to get better faster.”

The growth in outpatient healthcare is a fundamental shift in US medicine. MetroHealth, which gets part of its funding from taxpayers and serves a large Medicaid population, has expanded outpatient visits from 850,000 to 1.2 million in the last four years, a 40 percent increase.

Outpatient visits, experts say, subsidize more expensive inpatient treatment.

But some observers worry that the development of bedless hospitals is part of a financial shell game hospitals must play to make the dollars match up with the care they offer. And they wonder if such facilities are diverting resources away from a large population of patients who still require more complex treatment.

“The untold story is what’s happening to all of those patients who do still need to be in the hospital,” said Harold Miller, chief executive of the Center for Health Care Quality and Payment Reform. “And are the places where they are going getting paid enough to support good care?”

Metrohealth
MetroHealth System’s new $48 million bedless hospital in Brecksville, Ohio has almost the same services as more traditional hospitals, but with no overnights. Dustin Franz for STAT

What’s driving the development of bedless hospitals, said several hospital executives, are changes in reimbursement, both from the federal government and private insurers.

At UCLA Medical Center, keeping patients out of the hospital — and delivery care in their communities — is a key part of the financial strategy. The health system operates about 160 clinics across the Los Angeles area, including several outpatient surgery centers. In many cases, said CEO Johnese Spisso, those facilities are needed because insurers will no longer pay for procedures to be performed in a regular hospital.

“Hospitals tend to be the highest-cost setting because of the intensity of services there,” she said. “You see a dramatic difference in the payment for inpatient and outpatient services.”

The rise of bedless hospitals has also tracked the development of streamlined treatments. Several years ago, doctors at  Memorial Sloan Kettering Cancer Center started brainstorming plans for more surgical space — an exercise that led to efforts to create standardize protocols for routine surgeries, such as mastectomies, that could be done without prolonged hospital stays.

The end result was the Josie Robertson Surgery Center, a 16-story building on Manhattan’s Upper East Side where doctors perform outpatient cancer surgeries. It has 28 short-stay beds, but most patients leave within hours of their procedures.

Dr. Brett Simon, director of the surgery center, said physicians now use standard sets of instruments and antibiotics during each procedure and order the same lab tests to monitor patients afterward. Not having to house patients for two or three days postsurgery saves them money.

“We can manage patients along what we know is an effective pathway,” Simon said.

And if problems arise, patients can quickly be stabilized and transferred to the inpatient hospital located nearby, the executives said.

Metrohealth
An isolation room in the emergency wing of the MetroHealth Brecksville Health and Surgery Center, part of the growing trend in bedless hospital care Dustin Franz for STAT

While none of the health systems could produce system-wide cost-saving data, the harder calculation, said Simon, is how much revenue will be generated. Payments to Josie Robertson come from Medicare, Medicaid, and commercial insurers. In prior years, when funding was based purely on the length of stay, moving patients through the hospital quickly would have been a money-loser. In its first year, the surgery center is expected to perform about 7,600 procedures, with that number to rise to about 12,000 over the next five years.

But under the Affordable Care Act and other reforms, reimbursement is linked more directly with the effectiveness of treatment, meaning providers are rewarded financially if they can deliver better care at a lower cost.

For MetroHealth, building and buying bedless hospitals is part of a strategy to compete with Cleveland Clinic and University Hospitals. While a helipad at its new building offers the capability to treat patients facing medical emergencies, most people will come for the convenience of having all medical services — primary care and specialty services — in one location near their homes.

”We know that convenience matters for patients,” Boutros said. “They would like to do the least amount of travel between themselves and the health care organization. The closer you are, the more likely you are to have a closer relationship with them.”

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  • As a current graduate student nurse, I specifically look forward to the health segments of the magazine where STAT is often referenced in authorship, to gain a sense of the information being shared with the population at large against the backdrop of the data our current research trends show.

    An article, titled “The Rise of the Bedless Hospital” by Casey Ross was particularly compelling given our current curriculum which includes a course on Health Policy. In this course, our focus has been toward understanding the current climate in health, reimbursements, and policies that enable the existing system. This article examines an important trend in healthcare which is the avoidance of overnight and particularly extended hospital stays as a means to control cost and improve patient outcomes.

    The article was well written and discussed practices I have personally experienced and have witnessed first-hand working in a hospital setting as a student. We are now seeing patients going in for same day surgeries that not too long ago required a several night stay. Patients arrive early in the morning for their surgeries, are provided the standard prophylactic antibiotic regimen and often see discharge by mid-afternoon. Health outcomes are indeed the new drivers to ensure maximum reimbursement by hospitals and providers. To the patient’s benefit, this approach in most cases has proved beneficial for a quicker recovery, avoidance of hospital acquired infections and unnecessary follow-up diagnostics.

    As a learning advocate for patient safety and health, I am pleased to see these changes in our healthcare system. I only wish these changes would have happened sooner and that the motivation would have been driven by doing the “right thing” for patients and their health and not for hospitals and their bottom line.

  • This method would have implications with Medicare and Health Insurance companies. Medicare will not pay the bills as there would be no hospital stay. Health insurance companies would pay part of the bill and the patient would be paying thousands of dollars. Future insurance premiums would rise accordingly.
    But, it might be a good practice as the total costs of healthcare might decrease.
    In developing countries, such a practice might allow for smaller hospitals and even mobile hospitals. In situations where homes are not suitable for post-operative care, small space-conditioned, monitored, connected units may be built and rented to keep patients near their homes for a couple of days post the procedure.

  • This has lawsuit written all over it. After all, it’s not really the people who you keep overnight that are healthy enough to go home that increase healt care costs; it’s the people who are sent home and have to be rushed back or don’t make it back who are really are driving up costs. And if there is pressure for turnaround on the few beds that are available, it won’t be those people’s fault they are the ones raising costs. If doctors are forced to send people home to save the health care system on costs, there will be more people sent home that should remain overnight. Doctors shouldn’t be forced to play Russian roulette with people’s lives like this. After all, you can have the space and beds to keep more people, but still send them home if you think they are better off recovering at home. However, you still need to be able to accommodate people in the event of an emergency.

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