The New Hospitals: House Specialties

Two years after builders broke ground, an immense concrete and glass structure towers over the grounds at OhioHealth Riverside Methodist Hospital, dwarfing parking garages and office buildings and even a nearby apartment high-rise. While making your way around the bend on the stretch of state Route 315 that runs alongside its perimeter or approaching from North Broadway, you feel for a moment that you might be swallowed, too-absorbed into its broad face. The Neuroscience Center is a behemoth, a stunning building with curved edges that soften its hulking facade. When it opens next fall, the tower will be the unifying centerpiece of a collection of hospital buildings, connecting Riverside's heart center to its cancer center to the towers that house other patients and their caregivers.

The $321 million project is just one among a slew of expansion projects in which OhioHealth has invested in the last few years, but it represents only a piece of the collective $2.7 billion Central Ohio's hospital systems have pumped into expansions and renovations since 2009. One by one, new hospitals, many built to treat specific diseases or body systems, began to replace old ones, and health systems sprouted standalone emergency departments in the suburbs. Slowly but surely, patterns emerged. Health care systems are investing in the care they are good at providing-the specialty care that makes Columbus home to hospitals ranked among the best in the country. But what's truly driving these investments, and who might be missing out in the process?

Some say competition drives investments in specialty care. "What I see is a duplication of services-the building of competing heart hospitals, cancer treatment hospitals," says Cathy Levine, executive director of Universal Healthcare Action Network (UHCAN), an Ohio-based nonprofit that advocates for quality, affordable health care. "It's happening, and I haven't seen objective data analysis that convinces me that this duplication of services is happening because of community need and not competition for market share. I'm concerned that it's driven by competition for market share."

The 9-story neuroscience tower at Riverside includes an imaging and radiology unit and an open, naturally lit waiting area with computers and interactive displays to help families of patients learn about neurological diseases and treatment. It'll even have a classroom where specialists will lecture about illnesses such as dementia and Parkinson's disease. A surgical floor holds eight new operating rooms twice as large as the ones they're replacing, as well as interventional radiology suites, where aneurisms are coiled and blood clots are removed. The tower's 224 patient rooms will be completely private, each with a view facing either outward from the hospital or into an interior atrium garden.

OhioHealth built the hospital to give more patients access to the hospital's leading neuroscience program, says chief medical officer Dr. Bruce Vanderhoff. Riverside is one of the largest stroke centers in the nation, and OhioHealth leads Central Ohio by volume in stroke treatment. "It's clear that as our population ages and our medical capabilities expand, the need for advanced neurological care will continue to grow," he says. "It is incumbent upon us to continue to lead this community where we are already established as a leader."

While the new patient tower won't allow Riverside to treat a dramatically larger amount of patients in house-the addition will create only 42 new beds, as about half of the hospital's rooms had been shared before-it'll allow the hospital to expand on technology that has earned it credibility in interventional stroke care.

It's the middle of the night when a man in Dublin wakes up to find his arm numb. He slurs a few jumbled words to his spouse before he's rushed to his local hospital. After being admitted, a high-definition camera transmits his image to Riverside hospital via OhioHealth's eICU system, which was originally designed to allow doctors to monitor multiple ICU patients in the same building. Now, the technology is being applied to stroke treatment, which is particularly time sensitive. The patient in one of OhioHealth's regional hospitals can hear and speak to a specialist in Columbus. The doctor can even scan the patient remotely-assessing his motor and sensory skills, seeing his eyes respond to the glare of a flashlight-and speak with the nurses about his labs and progress. "The optics are so good, the physician can read the person's fingerprint," Vanderhoff says. From here, neurological experts can make life-saving decisions, Vanderhoff says, such as determining whether it's appropriate for the patient to undergo treatment at his local hospital or whether he should be transferred to Riverside or Grant Medical Center, which specialize in stroke treatment.

Riverside and Grant have earned credibility in the field of neuroscience and attracted an army of experts; it wouldn't be possible to recruit an equivalent crew to work at every facility in the 40-county region they serve, Vanderhoff says. The Neuroscience Center is like a mothership to the network of hospitals, concentrating the experts in one place with the resources to treat everyone.

"We can take that expertise and make it immediately available throughout the community we serve," he says. "[Regional hospitals] are able to keep more of their patients than they were before. It helps us satisfy our goal of keeping care local and improving access to care."

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Just down the road, less than three miles as the crow flies, the Ohio State University Wexner Medical Center is also in the midst of a campus-wide expansion-this one with a $1.1 billion price tag.

The anchor is a new $750 million James Cancer Hospital and Solove Research Institute and Critical Care Center, as well as a new emergency department. When it opens at the end of this year, the 21-story tower will replace the current cancer hospital, a brick building built in the '90s with a mix of private and shared rooms. The medical center initially announced a new brain and spine center would replace the old cancer hospital, but it will probably be used for general medicine, surgery and organ transplants, says CEO Dr. Steven Gabbe.

Instead, OSU will open the new comprehensive brain and spine hospital on the western side of University Hospital, next to the new neurological critical care unit in the Critical Care Center. While they're spread across the campus now, all of OSU's neuroscience services-including research, epilepsy, Parkinson's and Alzheimer's treatment and stroke rehabilitation, but excluding neurological oncology, which will be located in the James-will be consolidated there. It'll increase inpatient beds for neurological patients from 70 beds to about 125, Gabbe says.

OSU's focus on neuroscience is not a response to OhioHealth's recent investment in the same specialty, Gabbe says. Neuroscience has long been one of OSU's signature programs (along with cancer, cardiology, critical care, transplants and imaging), he says.

"It's not anything we woke up and decided to do yesterday," Gabbe says. "It's always been a part of our strategic plan. We know, given the number of patients who come not only from Franklin County but from all over the country, that it's something we need to grow and have more space for."

The same could be said of OSU's nationally recognized cancer program.

Since the current James Cancer Hospital opened more than 20 years ago, its 160 beds have been either fully or nearly fully occupied every day. "It was very clear soon after [the James] opened that there would be a greater need for inpatient and ambulatory care," Gabbe says. "We recognized a great need for a new cancer hospital given the changing demographics in this country and the state and in Franklin County. People are getting older and experiencing more chronic diseases, particularly cancer."

The new hospital will feature 276 beds for cancer treatment and an additional 144 beds in the attached Critical Care Center, which will treat all patients in critical condition. Thirty of these critical-care beds will be reserved just for cancer patients. Admissions continue to increase among both cancer patients and patients experiencing other critical illnesses, and the new facilities will enable OSU to meet both needs. The James is one of only seven cancer centers in the country that offers both phase one and phase two clinical trials (the first two steps in a process of testing and approving new treatments), another reason the hospital is in high demand. Patients come to the James because it offers therapies other centers can't.

When Gabbe visits the 17 area hospitals in OSU's network, he hears the same thing: "'Please be sure that when one of our patients needs critical care, or cancer care there's a bed for them in the James.' We need more beds available for transfers, for new patients, for surgery," he says.

The Ohio State University Wexner Medical Center expansion also included the addition of two floors and 60 beds to the Ross Heart Hospital, doubling the size of electrophysiology labs there. Some of OhioHealth's cardiac services, housed now in the McConnell Heart Hospital at Riverside, will expand into the connected Neuroscience Center. An entire floor of the new tower will be dedicated to open-heart surgery recovery rooms. Earlier this year, Mount Carmel

Health Systems completed a $110 million expansion on St. Ann's hospital in Westerville, which included a new patient tower with 60 beds, a heart hospital and a general surgery, orthopedic and spine unit. The expansion enabled Mount Carmel to begin performing open-heart surgeries for the first time this spring.

Some in the health advocacy realm ask what's truly motivating these investments.

"If you look at population health needs, do we need more tertiary care or do we need more comprehensive primary care?" says patient advocate Levine.

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The top two leading causes of death in Ohio in 2010 were heart disease and cancer, respectively, according to the state health department. Third was chronic lower respiratory diseases (like COPD, most common in former or current smokers) followed by stroke, accidents and Alzheimer's disease.

Suicide is the 11th leading cause of death in Ohio, which begs another question: Why hasn't mental health care been included in recent hospital expansions?

It's a question Rachelle Martin asks herself daily. Martin is the executive director of the National Alliance for Mental Illness (NAMI) of Franklin County, a nonprofit organization that provides free classes, organizes support groups and refers people suffering from mental illness to treatment facilities.

"There isn't a day that goes by that we don't receive calls from family members wanting to get their loved ones treatment," Martin says. "And there are just not enough treatment beds in hospitals, and there are not enough clinicians that can work with the populations that we serve."

She says it's common for people to spend multiple days in emergency rooms waiting for an inpatient bed to become available. By law, a hospital doesn't need to immediately admit a patient unless she is a threat to herself or others. Compared to other regions, Central Ohio comes up short on inpatient psychiatric treatment, says Dr. Natalie Lester, medical director of the psychiatric department at the Ohio State University Wexner Medical Center.

"We have fewer beds per capita than the rest of the state," she says. "In fact, we have half as many as, say, the Cleveland area." This has been true historically, she says, but the problem becomes worse as the demand for behavioral health care increases.

Her department treats 450 psychiatric patients per month in the emergency room at the medical center and an additional 50 at University Hospital East, and Lester says that number has been steadily increasing for the past several years. Ohio State has 73 inpatient psychiatric beds-53 for adults and 20 for children and adolescents. While that total hasn't increased since 2011, the department recently introduced a new program with an eye toward reducing the demand for hospitalization.

Last October, OSU opened the Crisis Assistance Linkage and Management (CALM) unit in Harding Hospital. It has eight tranquil observation rooms that are designed much like traditional psychiatric care rooms. Patients who have suicidal thoughts, suffer severe depression or hear voices, among other symptoms, are taken to one of these rooms, which are removed from the bright, noisy and all-around over-stimulating emergency rooms.

"The traditional approach to treating [these patients] is we either hospitalize them or they go home," Lester says. "Often these are complex problems, and with a more thorough investigation or evaluation they might be able to be stabilized. We built the CALM unit to admit patients for stabilization with the goal to avoid inpatient hospitalization."

While Ohio State has hired more behavioral health providers-the size of the department has doubled in the last three years, and the residency program has grown-the demand for services outpaces the supply of caregivers. Whether it's the emotionally draining nature of the work or other factors like schedule or pay, psychiatry just isn't attracting new doctors.

Historically, high-paying specialties-radiology, ophthalmology, plastic surgery, neurology-have attracted the most medical residents. But that's no longer the case, says Dr. Bryan Martin, associate dean for graduate medical education at Ohio State.

"For a time, [students] were coming out of medical school with big debt, and they were concerned about going into specialties that would help to pay off their debt," Martin says. "Those are still very, very popular, but some of the other programs like internal medicine are becoming more popular." Of last year's graduating class of medical students, nearly half chose primary care specialties focused on preventing chronic illnesses in the first place.

The health care industry is following this trend, too, providing incentives to hospitals that emphasize preventive care. Private insurers, as well as Medicaid and Medicare, offer financial incentives to hospitals when they meet the recommended number of preventive tests for patients with certain illnesses, as well as control "unnecessary" hospital admissions and readmissions.

"That certainly pushes us toward primary care and preventative medicine," Martin says. "That's part of that whole global shift-making primary care more important."

These trends are also driving a surge in the number of outpatient and primary-care facilities in the suburbs, closer and more convenient to patients who live outside the city.

OhioHealth's Vanderhoff acknowledges the shift to preventive care will eventually decrease the need for inpatient beds and increase the need for outpatient care. Central Ohio is beginning to see that shift now in suburbs like New Albany and Grove City, where both OhioHealth and Mount Carmel have facilities. Outpatient, primary care and even standalone emergency centers are being built to meet the needs of a growing suburban population and the demand for more preventive care.

"When do we reach a point where we won't see anymore bed count [increases]?" Vanderhoff says. "I don't know, but I can say the focus of health care providers needs to be the right care at the right time at the right place.

"We're not focused on building hospitals," he continues. "We're focused on bringing those resources to the community where they're needed, when they're needed. Sometimes that's a multidisciplinary practice building, a primary care building or an urgent care. In other communities, it's putting in ambulatory campuses and emergency rooms or enhancements to hospitals we have like the neuroscience tower. We're not just adding incremental beds for the sake of, 'If you build it, they will come.' Those days are gone."