Health Care Institutions - Types Of Hospitals
public poor emergency medical
There are more than sixty-five hundred hospitals in the United States that are described as short-stay or long-term, depending on the length of time a patient spends before discharge. Short-stay facilities include community, teaching, and public hospitals. Sometimes short-stay hospitals are referred to as acute care facilities because the services provided within them aim to help resolve pressing problems or medical conditions, such as a heart attack, rather than long-term chronic conditions such as the need for rehabilitation following a head injury. Long-term hospitals are usually rehabilitation and psychiatric hospitals or facilities for the treatment of tuberculosis or other pulmonary (respiratory) diseases.
Hospitals also are distinguished by their ownership, scope of services, and whether they are teaching hospitals with academic affiliations. Hospitals may be operated as proprietary (for-profit) businesses, owned either by corporations or individuals such as the physicians on staff, or they may be voluntary—owned by not-for-profit corporations, religious organizations, or operated by federal, state, or city governments. Voluntary, not-for-profit hospitals are usually governed by a board of trustees, selected from among community business and civic leaders, who serve without pay to oversee hospital operations.
Most community hospitals offer emergency services as well as a range of inpatient and outpatient medical and surgical services. There are more than one thousand "tertiary" hospitals in the United States, which provide highly specialized services such as neonatal intensive care units (for care of sick newborns), trauma services, or cardiovascular surgery programs. The majority of tertiary hospitals serve as teaching hospitals.
Teaching hospitals are those community and tertiary hospitals affiliated with medical schools, nursing schools, or allied-health professions training programs. Teaching hospitals are the primary sites for training new physicians where interns and residents work under the supervision of experienced physicians. Nonteaching hospitals also may maintain affiliations with medical schools and some also serve as sites for nursing and allied-health professions students as well as physicians-in-training.
The most common type of hospital in the United States is the community, or general, hospital. Community hospitals, where most people receive care, are typically small, with fifty to five hundred beds. These hospitals normally provide quality care for routine medical and surgical problems. Since the early 1980s, many smaller hospitals were closed down because they were no longer profitable. The larger ones, usually located in cities and adjacent suburbs, are often equipped with a full complement of medical and surgical personnel and state-of-the-art equipment.
Some community hospitals are nonprofit corporations, supported by local funding. These include hospitals supported by religious, cooperative, or osteopathic organizations. In the 1990s, increasing numbers of not-for-profit community hospitals have converted their ownership status, becoming proprietary hospitals that are owned and operated on a for-profit basis by corporations. These hospitals have joined investor-owned corporations because they need additional financial resources to maintain their existence in an increasingly competitive industry. Investor-owned corporations acquire not for-profit hospitals to build market share, expand their provider networks, and penetrate new health care markets.
Most teaching hospitals, which provide clinical training for medical students and other health care professionals, are affiliated with a medical school and may have several hundred beds. Many of the physicians on staff at the hospital also hold teaching positions at the university affiliated with the hospital, in addition to teaching physicians-in-training at the bedsides of the patients. Patients in teaching hospitals understand that they may be examined by medical students and residents in addition to their primary "attending" physicians.
One advantage of obtaining care at a university-affiliated teaching hospital is the opportunity to receive treatment from highly qualified physicians with access to the most advanced technology and equipment. A disadvantage is the inconvenience and invasion of privacy that may result from multiple examinations performed by residents and students. When compared with smaller community hospitals, some teaching hospitals have reputations for being very impersonal; however, patients with complex, unusual, or difficult diagnoses usually benefit from the presence of acknowledged medical experts and more comprehensive resources available at these facilities.
Public hospitals are owned and operated by federal, state, or city governments. Many have a continuing tradition of caring for the poor. They are usually located in the inner cities and are often in precarious financial situations because many of their patients are unable to pay for services. These hospitals depend heavily on Medicaid payments supplied by local, state, and federal agencies or on grants from local governments. Medicaid is a program run by both the state and federal government for the provision of health care insurance to persons younger than sixty-five years of age who cannot afford to pay for private health insurance. The federal government matches the states' contribution to provide a certain minimal level of available coverage, and the states may offer additional services at their own expense.
Well-known public hospitals include Bellevue Hospital Center (New York City), Parkland Memorial Hospital (Dallas, Texas), Truman Medical Center (Kansas City, Missouri), University of Southern California Medical Center (Los Angeles, California), and Temple University Hospital (Philadelphia, Pennsylvania). Many public hospitals are also university-affiliated teaching hospitals.
TREATING SOCIETY'S MOST VULNERABLE MEMBERS. Increasingly, public hospitals must bear the burden of the weaknesses in the nation's health care system. The major problems in U.S. society are readily apparent in the emergency rooms and corridors of public hospitals—poverty, drug and alcohol abuse, crime-related and domestic violence, and infectious diseases such as acquired immunodeficiency syndrome (AIDS) and tuberculosis.
LOSING MONEY. The typical public hospital provides millions of dollars in health care, and fails to recoup those costs from reimbursement by private insurance, Medicare (a program run by the federal government through which persons age sixty-five and older receive health care insurance), or Medicaid. The National Association of Public Hospitals and Health Systems (NAPH) estimated that nearly half of all public hospital charges are not ultimately paid. This figure has grown sharply as the number of uninsured Americans has also increased. State and local governments provide subsidies to help offset these expenses. However, even with the subsidies, the unpaid costs incurred by the nation's public hospitals add up to billions of dollars' worth of care each year.
PROVIDING NEEDED SERVICES. The NAPH believes that the mission of public hospitals is to respond to the needs of their communities. As a result, most provide a broad spectrum of services. Although the need for trauma care exists across all socioeconomic levels, the American Hospital Association reported that NAPH members are twice as likely to have trauma centers as other community hospitals.
Almost half of NAPH-member hospitals provide prison services, and some hospitals have dedicated beds for prisoners. County and city revenues provide most, if not all, of the funds available for prison services. Many of the NAPH-member hospitals are also major academic centers, training medical and dental residents as well as nursing and allied health professionals.
MORE THAN THEY CAN HANDLE. For many Americans, the public hospital emergency room has replaced the physician's office as the place to seek health care services. With no insurance and little money, many people go to the only place that will take them without question. Insurance companies and health care planners estimate that more than half of all emergency room visits are for nonemergency treatment.
Poor or near poor children up to eighteen years of age of all races were more likely to visit emergency rooms (25.2% and 22.1%, respectively) in 2001 than
|Emergency department visits within the past year among children under 18, by selected characteristics, selected years 1997–2001|
|[Data are based on household interviews of a sample of the civilian noninstitutionalized population]|
|Under 18 years of age||Under 6 years of age||6–17 years of age|
|Percent of children with 1 or more emergency department visits|
|Black or African American only||24.0||22.5||22.6||33.1||32.3||29.2||19.4||18.2||19.7|
|American Indian and Alaska Native only||*24.1||33.3||27.0||*24.3||*29.5||*||*24.0||*36.2||*26.5|
|Native Hawaiian and other Pacific Islander only||—||*||*||—||*||*||—||*||*|
|2 or more races||—||23.3||31.1||—||28.7||33.7||—||*19.7||29.2|
|Hispanic origin and race2|
|Hispanic or Latino||21.1||15.9||19.4||25.7||21.4||26.1||18.1||12.6||15.4|
|Not Hispanic or Latino||19.7||18.3||20.9||24.0||23.8||24.7||17.6||15.7||19.2|
|Black or African American only||23.6||22.5||22.6||32.7||32.5||28.8||19.2||18.2||19.8|
|Hispanic origin and race and poverty status2,3|
|Hispanic or Latino:|
|Not Hispanic or Latino:|
|Black of African American only:|
|Health insurance status4|
|Poverty status and health insurance status3|
|Location of residence|
those who were not poor (19.5%). (See Table 3.1.) About 28.5% of children on Medicaid visited emergency rooms at least once in 2001, as opposed to 18.6% of children who were privately insured and 17.4% of uninsured children. In the eighteen and older age group, 27.5% of poor persons made one or more emergency department visits and 26.2% of the near poor made one or more visits. Of adults age eighteen to sixty-four, 17.2% of people who were privately insured made one or more emergency room visits during 2001, as opposed to 39.7% of those who had Medicaid and 18.9% of those who were uninsured. (See Table 3.2.)
|*Estimates are considered unreliable.|
|— Data not available.|
|1Includes all other races not shown separately, unknown poverty status, and unknown health insurance status.|
|2The race groups, white, black, American Indian and Alaska Native (AI/AN), Asian, Native Hawaiian and Other Pacific Islander, and 2 or more races, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Starting with data year 1999 race-specific estimates are tabulated according to 1997 Standards for federal data on Race and Ethnicity and are not strictly comparable with estimates for eariler years. The five single race categories plus multiple race categories shown in the table conform to 1997 Standards. The 1999 race-specific estimates are for persons who reported only one racial group; the category "2 or more races" includes persons who reported more than one racial group. Prior to data year 1999, data were tabulated according to 1977 Standards with four racial groups and the category "Asian only" included Native Hawaiian and Other Pacfic Islander. Estimates for single race categories prior to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race. The effect of the 1997 Standard on the 1999 estimates can be seen by comparing 1999 data tabulated according to the two Standards: Estimates based on the 1977 Standard of the percent of children under 18 years of age with 1 or more emergency department visits are: 0.1 percentage points higher for white children; 0.2 percentage points higher for black children; 2.1 percentage points lower for AI/AN children; and 2.0 percentage points higher for Asian and Pacific Islander children than estimates based on the 1997 Standards.|
|3Poor persons are defined as below the poverty threshold. Near poor persons have incomes of 100 percent to less than 200 percent of the poverty threshold. Nonpoor persons have incomes of 200 percent or greater than the poverty threshold. Poverty status was unknown for 17 percent of children in the sample in 1997, 21 percent in 1998, 24 percent in 1999, 23 percent in 2000, and 23 percent in 2001.|
|4Health insurance categories are mutually exclusive. Persons who reported both Medicaid and private coverage are classfied as having private coverage. Starting in 1997 Medicaid includes state-sponsored health plans and State Child Health Insurance Program (SCHIP). The category "insured" also includes military, other state, and Medicare coverage.|
|5MSA is metropolitan statistical area.|
|SOURCE: "Table 75. Emergency Department Visits within the Past 12 Months among Children under 18 years of Age, according to Selected Characteristics: United States, Selected Years 1997–2001," in Health, United States, 2003, National Center for Health Statistics, 2003, http://www.cdc.gov/nchs/data/hus/tables/2003/03hus075.pdf (accessed June 22, 2004)|
|Location of residence|
Public hospitals are frequently underfunded and understaffed, and service can be exceedingly slow. All-day waits in the emergency room for initial treatment are not uncommon. A NAPH survey found that the average wait to get a hospital bed upon admission from the emergency room was 5.6 hours, although waits of three to four days were not unusual. Seriously ill patients could wait an average of 3.2 hours to be admitted into intensive care units.
PUBLIC HOSPITALS IN PERIL OF CLOSING. According to the California Department of Health Services, since the early 1990s, sixty hospitals in the state have closed while twenty-six have opened. Many urban public hospitals are located in inner cities and are often the only resources for twenty-four-hour standby emergency and trauma care. As a result, they care for a disproportionate number of victims of violence. Between 1983 and 1999, ten of the original twenty-three hospitals with designated trauma centers in Los Angeles closed their trauma units, causing severe overcrowding in those that remained. During the 1992 Los Angeles riots, King/Drew Medical Center treated ninety-four lacerations, fifty-four gunshot wounds, eighty-seven assaults, and nineteen stab wounds over the course of six days.
During 2002 Los Angeles faced another public hospital crisis with the threatened closure of two more county hospitals, Harbor-UCLA Medical Center and Olive View-UCLA Medical Center, facilities that provide trauma and emergency care and are considered "lifelines" for the working poor. Though both remain open, the county's public hospitals operate under continuing threats of closure. Three quarters of the Los Angeles county health system's patients are uninsured, and some industry observers believe that the remaining three hospitals that form the core of the county health system would be unable to accommodate them.
In 2003 the NAPH urged Congress to take immediate steps to relieve the financial crisis that threatened to close more public hospitals, further compromising the nation's "safety net"—its essential role in the provision of care for uninsured Americans. Citing economic uncertainty and heightened awareness about matters of national security, NAPH called upon the administration of President George W. Bush to reverse Medicaid and Medicare cuts that went into effect in fiscal year 2003; remove regulatory obstacles to enable public hospitals to negotiate lower pharmaceutical drug prices; expand access to health insurance coverage; and ensure adequate financing for emergency preparedness.