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What’s Driving Hospital Sprawl?

Photo: Cleveland Clinic

In the greater Cleveland area, hospitals are fleeing urban neighborhoods for car-dependent locations. It's a troubling trend that's not limited to northeast Ohio.

Over the last few decades, the Cleveland Clinic has shuttered hospitals in inner-ring suburbs like East Cleveland and Lakewood. The process has been very painful for the affected communities.

Meanwhile, the healthcare giant has opened hospitals -- always LEED certified! -- in greenfield sprawl locations by highway interchanges in wealthier Avon and Twinsburg. Even its remaining main campus, which is in Cleveland, has sprawled out over city neighborhoods, creating tensions with the low-income black communities surrounding it.

Monte Castleman at says you'll find the same pattern in the Twin Cities and around the nation. He explains the factors that are leading the industry to close urban hospitals and open new ones in cornfields. Trends in hospital design, like the preference for private rooms, are propelling the change:

You may have seen old pictures of hospitals with mammoth open wards. Over time these wards have gotten smaller and smaller until finally the standard was only two to a room, or “semi-private,” common in most postwar construction. And now the standard has reached the ultimate low, one person per room. More and more services are being done on an outpatient basis, surgery is becoming simpler and minimally invasive. This means only the most seriously ill and injured patients are kept inpatient. Also, with scares like MRSA and SARS are popping up on an almost routine basis, cross infection is becoming a serious concern.

Patient expectations have changed too. Our culture has increasingly demanded space and privacy. Much has been written about the shift from transit to private cars and from the city to the suburbs. More recently, kids sharing bedrooms is becoming uncommon and communal showering after gym was going out by my time in school. (I only recall a someone taking one a couple of times my entire school career, and when my school rebuilt the gym after my time they included private stalls for the boys.)  And patients in hospitals are demanding privacy too, or as much as is possible in that setting.

Obviously someone taken away by ambulance after a stroke isn’t in a position to ask to go to a certain hospital they like better; such a person is going to go wherever the paramedics decide to take them. But hospitals are in a stiff competition with each other for a certain type of patient for elective and semi-elective procedures, to the point they go as far as buying advertising. These are not Medicaid patients, on whom hospitals lose money, nor are they Medicare patients on whom hospitals might make a little or lose a little, depending. These are certainly not the uninsured, whose bills are often sold to collection agencies for pennies on the dollar or written off entirely as charity care. But I’m talking about patients with private insurance.

Such a privately insured patient seeking elective care is apt to like lots of free parking, plenty of shiny windows and granite, and most of all private rooms. Insurance will only pay for a semi-private room unless medically necessary, or a semi-private room is unavailable, so newer hospitals make sure semi-private rooms are not available by simply not having them.

Why not just remodel? It doesn't pencil out, says Castleman.

Unfortunately it’s not as simple as busting out a couple of interior walls. The optimal sizes for semi-private and private rooms are completely different and not even multiples of each other. The figures I could find were for Canadian hospitals which are a bit smaller than US hospitals, but are still useful in comparison. Generally speaking a private hospital room is 165 square feet, or 13.25 X 20, and an semi-private is 265 square feet, or 15 X 22.

So suppose you have a hospital wing with 12 rooms on each side for a total of 48 patients, and a nursing station at the end. That’s 180 feet long. You could only fit 13 private rooms in that space, so chances are you wouldn’t even bother to try to reconfigure it with all the work of moving all the walls, windows, and bathrooms. But between the extra length and width you don’t need, you’ve now wasted over 1000 square feet for each wing of each floor. Plus the nursing station, which has a fixed space and minimum staffing, is only serving half the patients it could. Plus you still need to find a place to build 24 new rooms on your property. Even if you move to super-expensive structured parking (and Lakeview already is using structured parking), finding room on your cramped existing site could be problematic.

You can’t just build up because hospitals need to be horizontal to some degree. You need a nursing station serving a number of rooms, all with windows, on the same floor. At some point it becomes attractive to tear the whole thing down and start over from scratch on a new site.

Around Minneapolis, Castleman says, many hospitals that are moving to new greenfield sites weren't located in very walkable areas to begin with.

But in Cleveland, urban neighborhoods are losing convenient access to healthcare facilities, expanding inequality and reducing job access.

More recommended reading today: The Transport Politic reports that the Trump administration has been withholding promised funds from shovel-ready transit projects all over the country. And Pricetags shares a time-lapse video showing how Seattle has grown denser over the last three years alone.

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