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Week of 3 April 1998 Vol. I, No. 26 Feature Article SPH report: Worcester County hospitals BU study warns of reduced health care for Central Mass. suburbanites by Brian Fitzgerald In the past 25 years, hospital care in Worcester County has become increasingly concentrated within the city of Worcester, despite the fact that more of the county's residents live in its suburbs. This trend could lead to less access to health care for some of this non-city population, according to a recent study by the Boston University School of Public Health. "The patients are moving away from where health care is being given," says SPH Professor Alan Sager, lead author of the report, which was published in February. "If this is the wave of the future, it may mean more than just an inconvenience for patients. It might also pose a risk, especially for those who require a trip to the emergency room." In 1970, 60 percent of the patients admitted to a hospital in the county went to the city of Worcester. By 1996, this figure had risen to 73 percent. However, during the same time period Worcester's population fell by 3 percent while the population of the remainder of the county rose by 22.8 percent. "This bodes poorly for emergency care," says Sager, who wrote the report with SPH Researchers Jasprit Deol and Deborah Socolar. "And this could cause patients' personal physicians to play less of a role in their health care." The study points out that there were 17 hospitals in Worcester County in 1970, and 7 of them were located in the city. At present, there are just 11 in the county and only 3 of them within Worcester's borders. However, the city's share of the county's hospital admissions rose from three-fifths in 1970 to almost three-fourths in 1996. "Community hospital closings can undermine health care in many Worcester County towns," he says. "A hospital closing usually increases travel time not only to the emergency room, but also to outpatient clinics and where inpatient services are available." Faced with long trips to see their doctor, fewer people may seek services at a hospital, especially outpatient care, which is increasingly important in an era when hospital stays are becoming shorter, according to the report. Alan Sager Why would a clustering of health care in the city of Worcester undermine diagnosis and treatment by personal and family physicians? "Because doctors are likely to relocate their practices closer to the hospitals where they are sending their patients," says Sager. "One of the reasons one worries about hospital closings is that if a physician in private practice is in and out of a hospital once, twice, or three times a day, and the hospital closes, now he or she has to drive as much as 45 minutes each way to the hospital to see patients. The doctor might think it's a good time to relocate -- or even retire." Sager says that the predicament is not unique to Worcester County. A separate SPH study published last June looked at the shrinking number of acute-care hospitals in the state, which has fallen from 127 in 1970 to 81 today. While neither report provides anecdotal evidence of diminished patient care in Massachusetts, the later study points to a worse-than-usual flu season in December 1997 and early 1998 and its effect on some patients in California, Tennessee, and Florida, where hospital capacity has been cut in recent years. Hospitals in several parts of California, the Sacramento Bee reported, obtained the state's permission "to put patients in places other than licensed beds -- doctors' offices, hallways, outpatient areas . . ." In Nashville, Tenn., in early January, all hospitals but one were diverting ambulances from their emergency rooms. In Florida, hospitals in several counties recently were at or above capacity, with some emergency patients being diverted as far as 30 miles away. According to Sager, in Worcester County the number of hospital beds fell by 1,117 (39.7 percent) between 1986 and 1996. "This took place in part through the closing and merging of some hospitals, and in part through the downsizing of other hospitals," states the report. He says that this reduction of acute hospital capacity in the county can be expected to continue for a dozen years if the forces now at work in Massachusetts health care continue to exert themselves. In order to predict which hospitals would close, Sager, Socolar, and Deol developed a model, which suggests that Burbank, Clinton, Athol, and Hubbard hospitals are the most vulnerable. "In a worst-case scenario," says Sager, "if the rate of hospital care by two aggressive California HMOs were to prevail in Massachusetts by, say, the year 2010, there might be as few as 450 acute hospital beds still open in Worcester County. If this happens, we fear that one hospital might remain open throughout the county in 2010: the product of the merger between Memorial Medical Center of Central Massachusetts and the University of Massachusetts Medical Center." Sager suggests keeping many of these hospitals open and reforming them, which could require state legislation. "Elements of such legislation include provisions to identify which hospitals are needed," concludes the report, "to identify hospitals facing financial duress, to provide emergency aid to stabilize needed but endangered institutions, to reform methods of hospital payment so that hospitals that serve vulnerable patients are not exposed unfairly to financial harm, and to reform hospital governance. In the end, it is vital that the hospitals that are essential to protecting the health of the public have enough money to remain open if they are efficiently operated."