Connecticut Hospitals Basics
There are many different categories of hospitals based on location, services provided, profit or non-profit status, government-run or independent, and whether they teach new clinicians. Hospitals are increasingly merging into large health systems. Connecticut has two very large systems, Hartford Healthcare and Yale-New Haven Health, and two smaller systems. As of 2022, there are six independent Connecticut hospitals.
Connecticut hospitals are increasingly merging into large health systems, which have been criticized for raising prices for care, with no improvement in quality, and closing services in rural areas. Hospital and health system costs are major drivers of rising healthcare spending in Connecticut. Uncompensated care, provided to patients who cannot pay their bills, is stable.
Key issues facing hospitals and health systems include rising labor costs and need for behavioral health services.
Connecticut Hospitals Deeper Dive
Hospitals in the United States can be categorized by size, location, demographics, finances, and affiliation. The American Medical Association divides hospitals into four major categories including community, federal government, nonfederal psychiatric care, and long-term care. Most hospitals provide acute (short-term) care for people experiencing illness, disease, injury, childbirth, trauma or who need surgery. Tertiary care centers are hospitals equipped to treat injuries or illnesses that require highly specialized care by teams of doctors, nurses, therapists, pharmacists, and other healthcare workers who are experts in a particular field. Trauma, burn, stroke, cancer, and heart and vascular conditions all require specialized care. There are also hospitals that only care for a specific population such as children or people with mental health conditions. It is important for patients and their caregivers to understand which hospitals in their community can meet their healthcare needs.
Community Hospitals — The American Hospital Association (AHA) defines a community hospital as one that provides general care or focused care, such as cancer or orthopedic care, to a local community and is not funded by the federal government. Community hospitals can have as few as six beds or more than 500 beds. Approximately 84% of hospitals in the U.S. are community hospitals and two thirds are located in cities.
Community hospitals can be teaching hospitals that train physicians and other healthcare professionals and participate in research. Academic medical centers are major teaching, tertiary care, community hospitals that are integrated with a medical school. These hospitals train medical students and resident physicians, conduct medical and academic research, and have access to cutting-edge technologies and therapies that other community hospitals may not have. Minor teaching community hospitals are not integrated with a medical school. Nonteaching hospitals do not train physicians and are staffed with fully trained board-certified physicians focused on meeting the general health and medical needs of the community.
Community hospitals can be differentiated by financial structure—for-profit or not-for-profit. The AHA reports that 58% of community hospitals are not-for-profit, 24% are for-profit, and the remainder are government owned. Not-for-profit hospitals need to generate revenue to keep the doors open for patients, however all their extra revenue, after covering costs, must be reinvested back into the hospital to develop patient programs, invested in technology and research, and to increase staff. For-profit hospitals function like a business. Investors expect a profit for their investment. This obligation places pressure on the hospital to be highly efficient, lower the cost of care, and focus on specialties or procedures that are profitable such as orthopedics.
Federal Government Hospitals — Federal government funded hospitals provide treatment for routine medical conditions and surgical care for specific groups such as active military and veterans. Veterans Administration (VA) hospitals and hospitals on military bases are two examples. The federal agencies that oversee these hospitals are the Veterans Administration, the Department of Defense, and the Department of Health and Human Services.
Nonfederal Psychiatric Care Hospitals — Nonfederal psychiatric hospitals are private hospitals that treat patients who need acute hospital care for a mental health condition such as depression or anxiety.
Long-term Care Hospitals — Patients who have severe chronic illnesses that do not need acute hospital care, but do need care that cannot be provided at home are transitioned to a long-term care hospital. These hospitals focus on rehabilitative care for extended periods of time such as weaning off a ventilator (breathing machine), rehabilitation for spinal cord paralysis, or extensive wound care.
Ambulatory Surgery Centers — An Ambulatory Surgery Center (ASC) is not a hospital, but rather a freestanding facility where same-day surgical procedures are performed on patients who do not need hospitalization or medical services for more than 24-hours. Eye surgeries, spinal injections, and many routine orthopedic surgeries can be performed at an ASC.
A health system is a network consisting of at least one hospital and one group of physicians, who provide comprehensive primary and specialty care to a community and are connected to each other and the hospital through joint management or ownership. The majority of health systems in the US are made of more than one hospital and include multiple primary care and specialty clinics and care facilities like surgery centers. Approximately 68% of community hospitals are part of a larger health system.
CT’s Hospital Landscape
In 2021 Connecticut health systems and hospitals provided a total of 7.4 million outpatient procedures, surgeries, tests, and visits to individuals, cared for 1.1 million patients in emergency departments, delivered 35,000 babies, admitted 337,000 patients, and aided 2.1 million people through community benefit programs.
Connecticut health care is dominated by large health systems. Over the last 20 years, hospitals have consolidated resulting in four health systems that dominate the market. In 2000, there were 27 independent hospitals; in 2022 there are only six. The two largest of Connecticut’s four health systems are Hartford Health and Yale New Haven Health. Together they own nearly half of the hospitals in the state. Nuvance and Trinity are the remaining systems who claim a smaller market share.
Large health systems have added to the stress on Connecticut hospitals. Large health systems have backed smaller health systems and independent hospitals into a corner as they struggle to hold onto their patients and staff. Earlier this year, St. Francis Hospital filed by a law suit against Hartford HealthCare claiming that the large health system used anticompetitive practices to create a monopoly on inpatient hospital services and charge higher rates.
Hartford Health is a nonprofit health system comprised of two tertiary-level teaching hospitals, an acute-care community teaching hospital, an acute-care hospital and trauma center, three community hospitals, a behavioral health network, a multispecialty physician group, a clinical care organization, a regional home care system, an array of senior care services, a mobile neighborhood health program, and a comprehensive physical therapy and rehabilitation network. The health system employs over 36,000 people, across over 400 locations, and provides care to approximately 17,000 people daily. Hartford Health is considered a center for excellence in cancer, heart and vascular, neuroscience, orthopedics, and urology care.
Yale New Haven Health is a nonprofit health system that includes five acute-care hospitals (three teaching and two community), the state’s only burn center, a medical foundation, several multispecialty centers and dozens of outpatient locations and ambulatory sites stretching from Westchester County, New York, to Westerly, Rhode Island. Yale New Haven Hospital is the primary teaching hospital for the Yale University School of Medicine. The health system employs over 29,000 people, operates across 360 locations, and provides care to over 15,000 people daily. U.S. News & World Report’s ‘America’s Best Hospitals’ nationally ranked Yale New Haven Hospital in 9 of 16 specialties including: Psychiatry (#8), Gynecology (#23), Geriatrics (#29), Pulmonology (#30), Diabetes and Endocrinology as well as Ear, Nose and Throat (both at # 32), Gastroenterology (#45), Urology (#47) and Neurology and Neurosurgery (#49).
Nuvance Health is a nonprofit health system that includes seven acute-care hospitals (three teaching and four community), a primary and specialty care practice network, two home care agencies, and a skilled nursing and rehabilitation facility. The system serves communities in the Hudson Valley region of New York and Western Connecticut. Nuvance Health offers specialized care in cancer, neuroscience, digestive health, and cardiovascular.
Trinity Health of New England is a nonprofit Catholic health system made up of three acute care hospitals (two teaching and one community), a rehabilitation hospital, and a medical group with 95 practice locations serving Connecticut and Springfield, Massachusetts.
Connecticut health systems have grown out of the mergers and acquisitions of hospitals, physician practices, and healthcare facilities throughout the state. In many situations, a larger health system acquired a smaller health system or independent hospital that was financially insecure and in danger of closing. The American Hospital Association claims that the consolidation of care through a merger or acquisition can result in decreased cost and increased quality of care, additional resources for patients, and highly trained providers.
However, this is not the case in Connecticut. Large health systems create monopolies resulting in reduced competition between hospitals. This empowers health systems to hike up their prices for services and negotiate higher prices from health insurance companies. In addition, health systems have centralized some rural services to their larger hospitals within the system to control cost. Labor and delivery services are one example. Rural hospitals often serve a substantial Medicaid population from diverse ethnic and racial backgrounds who live near or below the poverty level. Cutting rural labor and delivery services poses a safety risk for these mothers and babies and fails to address the ethnic, racial, and economic disparities that exist in many rural communities.
As of late 2022, Yale New Haven Health (YNHH) has applied to the state for permission to acquire three more hospitals in central Connecticut: Waterbury Hospital, Manchester Memorial Hospital and Rockville General Hospital. Prospect Medical Holdings, a private equity firm that owns the three hospitals put them up for sale and YNHH has agreed to purchase the operations. Connecticut’s Office of Healthcare Strategy (OHS) will determine if this acquisition is in the best interest of the consumers through the Certificate of Need process.
Certificate of Need (CON) is a regulatory process that requires state approval prior to making major changes like mergers, large financial investments in equipment or facilities like an MRI or an ambulatory surgery center, changing patients’ access to services, or suspending a medical service. between 2016 and 2017, OHS has approved 71 of 74 applications filed for service changes. The Federal Trade Commission recently stated “Many of the purported benefits of hospital mergers—including coordination of patient care, sharing information through electronic medical records, population health management, risk-based contracting, standardizing care, and joint purchasing—can often be achieved through alternative means that do not impair competition.”
Connecticut Healthcare System Performance
According to the Commonwealth Fund 2022 State Scorecard, Connecticut’s health system performance ranks third best in the nation. Health system performance is assessed using current data on the seven dimensions of performance including access and affordability; prevention and treatment; avoidable hospital use and cost; healthy lives; COVID-19; income disparity; and racial and ethnic equity. Connecticut fared well in access & affordability (#4) and prevention & treatment (#5).
However, Connecticut fell short on avoidable hospital use and cost despite the decline of Emergency Department (ED) visits from 1.6 million in 2016 to around 1.3 million in 2021. Overall Medicaid and Medicare beneficiaries, the uninsured, Black Non-Hispanics, and adults between ages 18 and 44 years old, remain more likely than other state residents, to seek care in an ED.
A substantial number of ED visits may have been avoided by timely, appropriate outpatient care from a primary care provider, urgent care center or federally qualified health center (FQHC). Patients’ misperceptions of the severity of their illness or were then advised by their primary care provider to go to the ED account for a portion of preventable visits. Unnecessary ED visits stress the health care system with their high cost and consumption of resources that higher acuity patients need. Improving patient access and education on when to seek emergency care, treatment for complicated patients, and development of short-term and long-term solutions could ease the stress on the health system.
Quality of Care
“Ensuring the Highest Standards of Patient Safety and Quality Care” is the mission of Connecticut Hospitals. Clinical collaboration of all hospitals throughout the state allows them to share information and experiences about patient safety and quality initiatives. Multiple initiatives coordinated by the Connecticut Hospital Association have produced impressive results. Over 75% of Connecticut hospitals are participating in the Institute for Healthcare Improvement’s 5 Million Lives campaign to decrease harm and preventable deaths.
America’s Health Rankings ranks Connecticut #6 for access to care, #4 for preventive clinical services, and #16 for quality among states.
The most recent federal National Healthcare Quality and Disparities Report from the Agency of Healthcare Research and Quality ranks the quality of care in Connecticut as average. Across 159 measures of quality, Connecticut was above the US average on 39, below average on 38, and average for the remaining 82. In addition, we aren’t getting any better. Compared with baseline years for each measure (which varies), we improved on just 13, got worse on 39, and 102 didn’t change.
How are Hospitals are Paid
Hospital services are paid through government insurance like Medicare and Medicaid private insurance including individual, small group, and employer plans, and out-of-pocket by patients. Care for those who do not have insurance or do not pay for medical services is partially reimbursed by state and federal governments; the rest is absorbed by the hospital as charity care/bad debt which is also called uncompensated care. In 2020, uncompensated care cost Connecticut hospitals $231.5 million. In general, Connecticut hospitals’ uncompensated care percent of total expenses ranking was fairly stable from 2020 to 2021.
CT Hospitals Key Issues
Mental Health America ranked Connecticut among the best five states in the nation in 2022 for low prevalence of mental illness and higher rates of access to mental health care for adults. However, Covid-19 has resulted in an increase in mental health and substance misuse conditions in Connecticut as in the rest of the US. While Connecticut residents may be better off than those in other states, behavioral health care access challenges still exist. A mid-September Household Pulse Census survey found that 361,729 Connecticut residents reported feeling anxiety nearly every day and 219,164 reported depressive thoughts nearly every day. Connecticut’s Department of Mental Health and Addiction Services (DMHAS) provides public health and addiction services in Connecticut. According to the federal Substance Abuse and Mental Health Services Administration (SAMHSA), the annual average percent of Connecticut youth aged 12 to 17 with a major depressive episode in the past year increased between 2004-2007 and 2016–2019. The annual average percentage of adults with serious thoughts of suicide in the past year did not significantly change between 2008–2010 and 2017–2019 illustrating that Connecticut still has work to do.
Workforce Recruitment & Retention
In Connecticut, healthcare labor costs are up about 15%, staff turnover hovers between 18% and 30%, and nurse vacancies are up 30%. Connecticut hospitals are working together to create solutions for shortages of doctors, nurses, and healthcare workers. Through higher wages, improved benefits, and schedules that improve work-life balance, hospitals hope to recruit and retain vital staff. Partnerships between academic institutions and hospitals are being forged to increase opportunities for clinical training, expanded workforce, employment, and retention.
Written by Stefanie Generao, APRN, DNP