Urban Hospitals Under Stress, 1993 Study Finds
The National Public Health and Hospital Institute in Washington examined the current status of large urban hospitals and the impact on them as a result of recent changes in the U.S. health care system.
One purpose of the study was to bring up to date a study published in 1978 by the Commission on Public General Hospitals that detailed the status of large, urban hospitals at that time.
The investigators gathered data on 851 hospitals in the 100 largest US cities. Investigators also expanded their data collection to include information from national, public sources on the number of female-headed families, children in poverty, and foreign-born populations.
In a report to RWJF, investigators noted the following findings:
- The urban environment changed from 1980 to 1990 in ways likely to increase the burden on public hospitals.
- In the 1980s, urban hospitals witnessed a shift away from patients with private health insurance and toward low-income patients (either uninsured or covered by Medicaid).
Investigators disseminated findings in Urban Social Health: A Chartbook Profiling the Nation's 100 Largest Cities (1995), published under a subsequent RWJF grant (see Grant Results on ID# 022724).
The Robert Wood Johnson Foundation (RWJF) supported the study with a grant of $247,797 that took place between September 1991 and June 1993.
Historically, urban public hospitals have been a primary source of health care for low-income populations. A comprehensive examination of these institutions was conducted in the mid-1970s by the Commission on Public General Hospitals (an independent body created by the Hospital Research and Education Trust, an affiliate of the American Hospital Association), which included representatives from health, government, and community groups. The commission's study, issued in 1978, found these hospitals under stress because of insufficient government funding, lack of cost-effective measures to care for low-income populations, and the sheer number of those needing care.
They recommended financing, service, and organizational changes to ensure the viability of public general hospitals. In the years since the commission's report, no formal effort had been made to reassess the status of public general hospitals. In the decade after this study, major changes took place both in the health care system and in the urban environment in which these hospitals operate.
The increase in AIDS, drug abuse, trauma, and the uninsured population as well as changes in health care financing and a lesser commitment by private hospitals to serve the medically disenfranchised, placed additional burdens on public hospitals. This made a new look at the hospitals serving large cities a timely idea.
This grant from RWJF supported NPHHI to develop a descriptive analysis of the current condition of urban public hospitals in the 100 largest US cities, and, specifically, to examine the impact on public hospitals of recent changes in the health care system. Among such changes were the growth of managed care, new trends in medical education, and new technology.
The investigators planned to profile trends on financial viability and service delivery at these hospitals and compare these trends with the experience of private institutions in the same communities. They also planned to examine the extent to which the problems identified in the mid-1970s had been dealt with and identify the major challenges public hospitals now faced.
The investigators established a comprehensive database of 851 hospitals in the 100 largest US cities: 64 public general hospitals, 745 private general hospitals, 21 public university hospitals, and 21 private university hospitals.
These data were gathered in collaboration with the National Association of Public Hospitals, which represents 90 public hospitals in major urban areas, and the Association of American Medical Colleges' Council of Teaching Hospitals, which represents over 400 major public and private teaching institutions.
The investigators also gathered data from the American Hospital Association and the federal Health Care Financing Administration (HCFA) on hospital use and Medicaid and Medicare payments for poor and elderly patients.
Initially, the investigators intended to rely on information from the databases of other associations, interviews, and a survey of NPHHI's own membership. But as the project unfolded, they decided that some of these data were not as reliable or complete as data from existing national public sources, such as HCFA and the US Census. Public data allowed the investigators to include information on female-headed households, children in poverty, foreign-born populations, and other factors that indirectly, but often powerfully, affect the public hospitals in cities.
In a report to RWJF, the investigators noted two categories of trends that they believed held implications for the development of solutions to health care problems of the cities:
- The urban environment changed from 1980 to 1990 in ways likely to increase the burden on public hospitals. For example, whereas the average unemployment rate for the United States declined 3.1 percent during that time period, unemployment in the largest 100 cities increased 11.6 percent. Similarly, the poverty rate grew about 67 percent faster in the 100 largest cities than in the nation as a whole. Cities also suffered increases in violent crime and (especially in the latter half of the 1980s) a variety of diseases, including syphilis, tuberculosis, AIDS, measles, mumps, and chicken pox.
- In the 1980s, urban hospitals witnessed a shift away from patients with private health insurance and toward low-income patients (either uninsured or covered by Medicaid). As a result, the share of hospital revenues from Blue Cross/Blue Shield and other private insurers declined, while the Medicaid share increased.
The investigators compiled preliminary data in an unpublished, draft report. Specific findings appeared in Urban Social Health: A Chartbook Profiling the Nation's 100 Largest Cities (1995), published under a subsequent RWJF grant (see Grant Results on ID# 022724). The project director made a presentation and submitted a report on public hospitals and health care reform to the Kaiser Commission on the Future of Medicaid. See the Bibliography for details.
AFTER THE GRANT
In May 1994, RWJF made another grant to NPHHI (see Grant Results on ID# 022724) for further analyses and for dissemination of a report on health and sociodemographic factors in urban areas. In August 1996 RWJF made a third grant to NPHHI in this area, for a study comparing the largest cities with their surrounding counties on demographic and hospital data (ID# 029644), which was expected to be of use to administrators and policymakers dealing with access to health care in cities and their surrounding suburbs.
GRANT DETAILS & CONTACT INFORMATION
Report on the Status of Public Hospitals in Major Cities
National Public Health and Hospital Institute (Washington, DC)
Dates: September 1991 to June 1993
Dennis P. Andrulis, M.P.H., Ph.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Books and Reports
Health Indicators and Urban Change in the Nation's Largest Cities, 19801990: An Update on the Commission on Public General Hospital's Report, Part I: Key Findings. Washington, D.C.: National Public Health and Hospital Institute, 1993. Forthcoming.
Public Hospitals and Health Care Reform. Washington, D.C.: National Public Health and Hospital Institute. Submitted to Kaiser Commission on the Future of Medicaid on June 1, 1993. Forthcoming.
Presentations and Testimony
Dennis P. Andrulis, "Public Hospitals and Health Care Reform," to the Kaiser Commission on the Future of Medicaid, February 26, 1993, Washington, D.C.
Report prepared by: Sybil Stokes
Reviewed by: Janet Heroux
Reviewed by: Robert Narus
Program Officer: Nancy L. Barrand