Big Med's Spread

What explains the growth in hospital assets from 2000 through 2019? A decomposition analysis

Understanding disparities in hospital finances is essential for ensuring equitable systems of care. One understudied element is total assets, which include both financial and capital resources that hospitals acquire. We evaluated changes and drivers of variation in US hospital assets from 2000 through 2019 using data from the Centers for Medicare and Medicaid Services and American Hospital Association Annual Survey. We decomposed overall variation in total assets to determine the level (hospital, health system, or health care market) that contributed most to variation, and examined the extent to which asset growth was associated with changes in common inputs to hospital wealth vs changing relationships with these inputs or other unmeasured factors. Total assets held by US hospitals increased from $750 billion in 2000 to $1.6 trillion in 2019. Most variation occurred between hospitals, such that high-asset hospitals tended to remain high-asset and low-asset hospitals remained low-asset. Most of the increase in assets was due to unmeasured factors (ie, not patient revenue). We conclude that hospital wealth in the form of assets has grown substantially over time and accrued primarily to wealthy hospitals. Policymakers should consider broader measures of hospital wealth when targeting financial resources and efforts to strengthen data on hospital financing.

Gluing Together a Fragmented Healthcare System for Geriatrics Will Be Hard. It's Time for United Action

"Gluing" together integrated Geriatric Clinical Service lines (GCSL) within the US healthcare system is a significant challenge. Reasons encompass health professional workforce shortages, inconsistent requirements for geriatric educational competencies among the health professional disciplines, preconceived ageist attitudes about older adults with complex illnesses, and a US healthcare system infrastructure that is not aligned with longitudinal and interdisciplinary care needs for older adults. This review focuses on three major characteristics of the US healthcare system that have impeded widespread dissemination of GCSLs: 1) the US's historical fee for service (FFS) reimbursement system; 2) increasing reliance upon disease specific specialty care services for older patients that have resulted from advances in medicine; and 3) rising consolidation of US healthcare systems over the last 30 years. Three specific options are also provided that might help change the current and future trajectories of GCSLs: 1) local political advocacy to implement health policy legislation; 2) expand geriatric physician and health professional workforce by nontraditional means; and 3) reprioritize expansionist healthcare systems corporate behavior. Each of these interventions will be hard to achieve, but it is time to unite if GCSLs are to thrive as pathways to improve care outcomes for older adults with complex medical, cognitive and neuropsychiatric disorders.