What’s Driving Hospital Sprawl?

Photo:  Cleveland Clinic
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 Streets.mn 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.

  • TakeFive

    Interesting read and ofc economics is always a driving factor. But as trends have changed and there’s a lot more than just ‘privacy’ that has changed then building new hospitals closer to where your ‘customers’ are only made for good common sense.

  • noktulo

    Mount Carmel in Columbus is dismantling its West hospital (in the urban Franklinton neighborhood), and retaining its nursing school and ER there while moving all its inpatient facilities to a new hospital south of suburb Grove City, which is pretty far out. It’s really sad that a facility that I’m sure helps support local businesses in Franklinton is moving out, and it’s moving from a more easily transit-accessible location to somewhere that is impossible to get to via transit. Sucks for transit-dependent relatives of long-term patients 🙁

  • Michael

    I’ll be a bit contrarian and say, good riddance. 1) Hospitals, Injured Soldier Homes, etc. have always been put at the urban edge; it’s only our horizontal growth over the last century that has absorbed into so many of them. It seems like they can provide a more comfortable experience and higher standard of care outside the city, which is something our ancestors recognized as well. 2) Hospitals provide about as much to urban life as a medium security prison. 3) I don’t think family physicians are necessarily leaving cities; rather mostly outpatient surgery so I don’t really buy into the various “health justice” arguments.

    I get the temptation among urbanists to see massive developments outside the city and wonder why it can’t be in the CBD, but the giant hospitals have huge costs: 1) often times they don’t pay property taxes, 2) they require huge amounts of public infrastructure like timed, signalized intersections, 3) bring in tons of cars – most of which switch in 20 minute crushes creating artificial rush hours, and 4) the employees & patients don’t really leave for lunch or anything, so it doesn’t do much to catalyze the area economically.

  • Jeff

    How are people supposed to get to a hospital to visit friends and family that’s in a car-dependent suburb? Your comparison to a prison isn’t too crazy, but I think a more accurate comparison would be to a jail. And this is exactly why the city is looking to close Rikers and replace it with a series of smaller jails throughout the boroughs–so that the incarcerated aren’t completely isolated from their communities. Same could be said for patients.

  • Same in Fresno. Over a 15 year period, 4 hospitals moved away from downtown to greenfield sites in the north part of town where the rich suburbs are. Only “Fresno Community Hospital” was left to serve the bottom half of the city.

  • Michael

    I’ll clarify that I am referring specifically to these massive destination hospital campuses – Mayo Clinic, Cleveland Clinic, “University of [State] Medical Center.” Certainly community hospitals are indispensable.

  • SDGreg

    Some of this thinking is just backwards and not tethered to reality. Hospitals should be closer to the people they serve and not farther away without a mix of transportation options for reaching them. With good reason, we don’t put fire stations or police stations on the edges of cities. They are integrated within them. Proximity is just as important for urgent medical issues.

    Staff and visitors can and do leave for meals, if a hospital is integrated into the community. If it’s on the edge in the middle of nowhere, then that won’t happen much. And the public infrastructure argument is a smoke screen. The public infrastructure costs to reach sprawl locations is more expensive because of the distances involved.

    If one were to use the argument of not paying taxes and not catalyzing the area economically, then schools should be put on the edge too. That’s a poor idea as well.

  • Sean

    I worked on the mapping for this report in 2011. It found that in the Bay Area only 10% of the operations cost of a hospital is rent. http://dot.ca.gov/hq/tpp/offices/orip/Grants/final_products/2011/Transit_Accessible_Locations_for_Health_and_Social_%20Svcs_2011.pdf

  • Andy Chow

    Old hospitals had big wards because it helps nurses and doctors monitor patients. Today, there are electronic devices that help monitor patients so they don’t have to be within visible range. Today’s hospital rooms have to be wired because of electronic health records.

  • Michael

    A preface: of all things that have been relocated out of cities, suburban hospital complexes are fairly reasonable in my mind. Plus, the treated population is often pretty immobile necessitating cars or ambulance.

    1. There’s a difference between cleveland clinic type hospitals as discussed in the article that attract statewide and beyond for planned treatments and community hospitals.
    2. We’ll disagree on meals. I lived for a long time by a massive urban medical complex (longwood medical in Boston). Choices were pretty much fast food, in an area where average wages were six figures. Same pattern in DC by washington medical center.
    Re: infrastructure, agreed. The point is that there’s a lot of costs to whatever city hosts them.
    3. Not having a cleveland clinic type complex does not mean not having health care. Not every city hosts a land grant- type University.

  • Walking NPR

    Also employees. Speaking as one who works at a medical campus that relocated to the ‘burbs it suuuucks. Not only does it make me more car dependent, but it limits where within the city I can live and still have a reasonable commute. So you’re affecting a large working population as well.

  • Guy Ross

    Be careful what you wish for, folks. The alternative in the U.S. is the expansion of the urban hospital. Unless this happens in extremely expensive real estate markets, it means destroying multiple city blocks to make way for surface parking. Here is Duluth Minnesota, a formerly wonderful are of the city is now a field of parking lots. Where the streets 1st, 2nd, 3rd and 4th are labeled, there exist two hospital complexes – the majority of the area is full block surface lots. https://uploads.disquscdn.com/images/105c352129d27043c5e52cbbd445743a29ad0313730b2be821820e7d659cd6f2.gif

  • ohnonononono

    Should probably note that hospital consolidation is going on even in big cities like NYC where the result is not necessarily more sprawl but fewer, larger hospitals that draw patients from further away, complemented by smaller satellite facilities that are affiliated with those hospitals. There were once 50 hospitals in Manhattan and over the past decades they’ve dwindled to about a dozen. Along with the trend toward patients having their own rooms, small community hospitals that aren’t affiliated with a larger institution and a good medical school often can’t survive anymore, and large health systems provide more opportunities for cross-subsidy of money-making activities with money-losing activities, while also allowing the systems to take advantage of state and federal funding provided to hospitals serving the exact right amount of indigent/Medicaid/Medicare patients while also attracting those affluent choice customers seeking elective procedures.

    These larger hospitals today rank as the largest single employers in most cities, with a major class division between the huge numbers of low and moderate-income healthcare workers, many of whom can’t afford cars, and the doctors and other highly paid professional staff who disproportionately drive to work even in neighborhoods where car ownership/use is relatively low. Because most hospitals are non-profits that usually don’t have to pay property taxes, they have less incentive to use their land efficiently and many provide free subsidized parking to employees. The kicker is that because hospitals are 24/7 facilities, so many people work long, odd hours outside the traditional 9-to-5 transit schedules that many transit agencies are built on. But these facilities are now so big that there are major opportunities for local transit agencies to work with them to identify how to better serve their needs. Transit agencies need to be proactive about trying to partner with these behemoth institutions because otherwise the incentives will continue to work toward them eating entire neighborhoods to replace them with parking.

  • qatzelok

    You’re forgetting *visitors* and *patients going outside*, in your dismissal of the ability of urban hospitals to generate urban activity.

    I have lived near an urban hospital complex for many years and it generates lots of pedestrian activities because it’s so near mass transit. Its urban location encourages patients to venture outside and experience the daily hustle of normal, non-sick life, something suburban hospital patients can only dream of by turning on their televisions or surfing the Internet.

    Going outside is very therapeutic, and the lawns and contrived green-spaces of suburban sprawl (hospital or otherwise) don’t tempt humans to go outside the same way that ordinary urban life does.

  • mattaudio

    Why does Duluth permit surface parking lots as an allowed land use?

  • Guy Ross

    Healthcare takes up nearly 20% of the economy nationally. Duluth is a healthcare hub for a massive geographic area. The northernmost rust-belt city is extremely reliant on these two hospitals for jobs and public revenue. Like many cities in its class, people want to live on a two acre property and have a fast drive in with free parking at the destination.

  • Joe R.

    Why can’t they build multi-story parking facilities, or better yet put these multistory parking garages under the hospital buildings? If the city made them pay property taxes on the land used for parking lots, which they should, there would be a strong financial incentive to do exactly that. In your example above the parking lots could have been located on landfill in that lake or river if they didn’t want to put them under the hospital buildings.

  • Joe R.

    2 acres? Why the f*ck does anyone need even 1/10th of that? Unless these people are growing all their own food, 1/10th or 1/20th acre lots are more than sufficient.

  • Joe R.

    Exactly. There’s little incentive for anybody to go outside when a facility is built in the middle of nowhere as there is nothing of interest. If you have a bustling urban area nearby, it’s certainly very therapeutic for both patients and staff.

  • Joe R.

    So if you don’t drive, and don’t own a car, you have to pay $$$ for a car service and more $$$ for a hotel to do something you could do for free, or at worst for a mass transit fare, if the place was located in a city.

  • Joe R.

    Cities could give more incentive for hospitals to work with local transit agencies by charging them property taxes on any land used for parking. At the very least this might shift the paradigm from eating entire neighborhoods for parking to building garages under the hospital buildings. Since such parking would be very expensive, the hospital likely would only build as much as is really needed. There might also be a strong incentive to provide dormitories for staff.

  • Michael

    I am sympathetic to economic access arguments. However, I think urbanists discount the scale of these destination hospitals. For example, 8 miles west of Milwaukee is the Medical College of Wisconsin – the largest complex in Wisconsin – which if placed on the city grid would be 50 blocks. Suppose we could move it downtown AND scale it down 50%, it would still be 25 city blocks. Even in a city like Milwaukee that has industrial brownfields & redevelopment opportunities, there’s no way to accommodate developments of that scale without displacing a ton of people and businesses. If spread across the downtown, the core would become a sprawling disconnected medical center – all of which would need extensive car infrastructure given the population being served.

    Would I prefer to have my city’s core be a giant hospital complex with related parking garages – which in my experience creates essentially an urban dead zone – or spend $30-50 dollars every time a relative gets elective surgery, I would choose the latter every time.

  • Stephen Simac

    more likely riding (or hiring someone) their lawn mower around their acreage

  • Joe R.

    It’s more like spend $30 to $50 every time you want to visit a relative who has had elective surgery. Or the same thing if they start putting nursing or rehab facilities in the middle of nowhere. As An example, my mother has been in a rehab place for about 9 weeks. I visit her 2 to 3 times a week. I walk there as it’s about 1.3 miles away. So in my case we’re talking about spending upwards of $100 a week to see her if the place was located in a greenfield, along with the inconvenience of calling and waiting for a car service both ways. I’d be in the hole for over $1000 now, which is money I frankly don’t have. The end result would more likely have been I don’t see her at all, or maybe once a month.

    Why can’t they build these things vertically if they put them in cities? That includes putting any parking under the facility? We’ve been building everything else vertically in cities for centuries. There’s these newfangled inventions called steel and concrete which let you go as high as you want.

  • Joe R.

    Probably, which makes having all that land even more ridiculous. You’re destroying natural habitat to grow something ugly and pointless like grass.

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