MEDICINE : Prognosis for Hospitals: Fewer Patients, Reduced Surgeries

Major technological, economic and social forces are rapidly changing the face of medicine and reshaping the structure and functions of hospitals.

In the future, there will be many fewer reasons to be hospitalized. By the end of the 1990s, today’s typical hospital patient may well be cared for at an outpatient clinic, a nursing home or even at home. Sophisticated and complex diagnostic imaging procedures will be conducted mostly outside of hospitals. Hospitals will be smaller and will concentrate on patients who need intensive care.

BACKGROUND: Hospitals traditionally have been large, sprawling, ever-growing complexes where patients must go for a broad range of diagnostic, surgical and medical services. They have been the places where doctors gather to do the things they cannot do in their offices because only hospitals had the facilities required by patients in need of round-the-clock care.

Early signs of change began about a decade ago when the federal government altered restrictions which had discouraged hospitals and the rest of the health sector from competing with one another. A driving force was the need to cut the rising cost of health care.

Simultaneously, entrepreneurs seized upon the opportunity to compete with hospitals for patients by opening diagnostic and imaging centers that offer CT scans and other procedures outside the control of hospitals. Also, advances in surgical technology enabled surgeons to perform several procedures on an outpatient basis instead of in a hospital operating room.

The net result of these trends, as well as of cost-cutting efforts by Medicare and insurers and the proliferation of health maintenance organizations, has been for hospitals to close wings as patient admissions fell.

Hospitals began using previously unheard of marketing methods to maintain their patient loads. A favorite has been to vie with competitors for the title of the community’s best center for various kinds of care, such as heart surgery or cancer treatment.

Another method has been to attract patients by creating specialized clinics for sports medicine, drug and alcohol treatment, AIDS or sexually transmitted diseases.

OUTLOOK: Hospitals, of course, will survive--although possibly not all of them. But by the year 2000 they will become different places, experts at the American Hospital Assn. believe.

Within this decade, says Douglas Henderson-James, a Duke University health care futurist, only 15% of the 20 million surgeries performed in the United States annually will be done in hospital surgical suites. A major reason is advances in “keyhole surgery,” a minimally invasive technique which enables surgeons to do more operations on an outpatient basis than are possible today. Experts predict most gallbladder operations, hernia repairs, kidney removals and 80% of all abdominal surgery will be done in this way.

New devices which make possible the infusion of chemicals and drugs outside of a hospital will sharply increase the number of patients who can be treated at home or in a nursing home. Included will be patients needing postsurgical care, cancer chemotherapy, nutrition therapy, antibiotics, and control of pain.

Another major factor is that the day is rapidly dawning when technology also will provide many new medical approaches that will have profound effects on hospitals and the kinds of medical problems they can deal with. Advances in molecular biology and genetic engineering may involve hospitals deeply by providing new early diagnostic tests and treatments for cancer. Much more aggressive treatments will be developed for neurological diseases and disorders and will require more intensive hospital care.

Advances in genetic research are expected to lead to gene manipulation and therapy for a number of psychiatric disorders, including alcoholism, manic depression and schizophrenia. Community hospitals, says the AHA, are designing programs to integrate physical medicine and psychiatry.

But whether the high overhead expenses of hospitals will allow them to compete cost-wise with free-standing single-purpose facilities, which are certain to enter the field as new possibilities open, is an open question.