HOSPITALS

HOSPITALS. Hospitals are institutions in which illnesses, injuries, and disabilities are diagnosed and treated. Deploying advanced medical technology, modern American hospitals are capable of providing medical services beyond those available in physicians' offices or outpatient facilities. In the United States, hospitals are operated either privately or by government entities. Some private hospitals operate for profit; others are operated by religious or secular charitable organizations on a nonprofit basis. Hospitals may function independently or participate in multihospital systems or networks.

The first American hospital was established in 1752. Subsequently, sustained growth in the quantity and quality of American hospitals has been fostered by technological and educational advances, government policies, and public and private health insurance mechanisms that have generally shifted the burden of paying for hospital services away from the individual patient.

The development of American hospitals may be traced through five historical stages. In the formative stage (1750–1850), private charitable organizations established voluntary hospitals that treated patients free of charge while, at the same time, public almshouses (which also provided nonmedical social services to poor, mentally ill, dispossessed, and disabled individuals) were gradually transformed into public hospitals. Next, the era of specialization (1850–1890) gave rise to specialized hospitals (for example, children's hospitals) and nursing emerged as a trained profession. The subsequent era of surgery (1890–1930) was spurred by the introduction of anesthesia and aseptic practices, which facilitated rapid growth in surgical practice, and thereby expanded the role of for-profit hospitals. In the era of insurance and expansion (1930–1975), the emergence of hospital insurance, Medicare, and Medicaid changed the way hospital care was financed. These programs, along with expanded federal assistance for the construction of new community hospitals and Veterans Administration hospitals, financed a proliferation of new and expanded hospitals. Finally, in the era of cost containment (1975–2000), earlier trends toward expansion and deployment have been largely reversed and replaced by countervailing trends towards hospital consolidation, diversification, and integration.

1750–1850: The Formative Era

Traditionally, care for the sick was one of many social services that public almshouses provided to the poor and dispossessed. In the eighteenth century, certain public almshouses evolved into public hospitals by focusing on caring for the sick. In this manner, Philadelphia Almshouse became Philadelphia General Hospital, New York Alms-house became Bellevue Hospital, and Baltimore County Almshouse became part of Baltimore City Hospitals.

In 1752, the Pennsylvania Hospital became the first permanent general hospital specifically chartered to care for the sick. In 1791, New York Hospital followed; in 1821 came Massachusetts General Hospital. These voluntary hospitals did not generally charge fees, but instead were supported by charitable donations. Although most patients admitted for treatment in voluntary hospitals were poor, the admissions process was selective. Patients deemed contagious, immoral, or otherwise undesirable (alcoholics, for example) were transferred to almshouses. Such selectivity was designed to reduce the hospital's mortality rate and to improve its reputation. Despite these efforts towards respectability, however, people of means generally stayed away from hospitals.

1850–1890: The Era of Specialization

For several reasons, the ability of hospitals successfully to treat illness and injury substantially improved during the mid-nineteenth century. First, Florence Nightingale's success in promoting cleanliness and proper ventilation on hospital wards improved hospital mortality rates years before germ theory explained why. Second, nursing schools were established during this period, graduating trained professional nurses who made indispensable contributions to hospital care. Third, in the 1870s, Johns Hopkins University adopted systematic clinical instruction and investigations. Consequently, hospitals became central to medical education and scientific training as well as treatment.

As hospitals became more successful at treating illness and injury, they gradually transformed from storehouses where the impoverished could convalesce (or die) into medical treatment centers of choice for individuals from across the social spectrum. As part of this transformation, specialty hospitals emerged. Some were developed to pull children, mentally ill, and disabled people out of almshouses and into institutions dedicated to serving their particular needs. In addition, specialized religious and ethnic hospitals were established by certain religious and immigrant groups. These hospitals arose in response to actual discrimination and also to satisfy certain unique needs of group members—last rites among Catholics and kosher meals among Jews, for example.

During this time, ward-style hospitals in which relatively poor patients were attended by the hospital's on-staff physicians remained the norm. Slowly, however, private rooms were added, attracting middle-class and wealthy patients who retained their choice of physician.

1890–1920: The Era of Surgery

The groundwork for the era of surgery was laid by two important mid-nineteenth-century developments. First, in 1846, Dr. William Morton introduced anesthesia at Massachusetts General Hospital. Then, in 1867, Dr. Joseph Lister demonstrated antiseptic surgery in London. These two demonstrations set the stage for the emergence of surgery, which would thrust hospitals into their central role in treating illness and injury.

Dr. Lister's method of performing antiseptic surgery was soon superseded by aseptic surgery, which involves creating a sterile surgical field rather than sterilizing at various points during a procedure. As aseptic surgery proliferated, surgical mortality rates plummeted. However, sterile surgical fields required a more complex environment than most home kitchens or doctors' offices could provide. Consequently, by 1900, almost all surgery was performed in hospitals. Pressure on hospital bed space caused by the increase in surgical admissions forced hospitals to admit sick patients only during the acute phase of their illness rather than for their entire treatment. With sicker patients in residence for shorter periods, the costs of providing hospital care predictably increased.

As mortality rates fell and positive results emerged, more people were willing to pay for surgery. Accordingly, patient fees gradually replaced charitable donations as hospitals' primary source of revenue. This shift generally enabled physicians to wrest control over hospital admissions away from hospital board members. However, not every physician was able to obtain hospital admitting privileges. In response, some physicians built their own hospitals or increased pressure on existing hospitals to open their facilities to all physicians.

1930s–1960s: The Era of Insurance and Expansion

Until 1929, private hospitals were financed exclusively by charitable contributions, patient fees, or both. In 1929, however, Baylor University Hospital successfully introduced prepaid hospital care when it offered fifteen-hundred schoolteachers the opportunity to purchase up to twenty-one days of hospital inpatient care per year (whether used or not) for six dollars per person. Other hospitals followed suit, some issuing joint offerings that allowed subscribers to preserve greater choice among hospitals and physicians.

The need for prepaid hospital care became more acute during the Great Depression, when private voluntary hospitals faced a crisis of declining occupancy and decreased charitable contributions while public hospitals swelled with nonpaying patients. To survive this crisis, in 1932 a number of private hospitals agreed to provide certain hospital services for a fixed payment regardless of the cost of delivering the services. These prepaid services plans, which functioned like hospitalization insurance, provided blanket coverage for a list of services rather than reimbursing the hospital for each service provided. The plans, known as Blue Cross Plans, remained under the control of the voluntary hospitals.

Blue Cross Plans charged standard rates without regard to a policyholder's income. Not surprisingly, the plans attracted mainly middle-class subscribers. Yet Blue Cross Plans proved viable, and kept the voluntary hospitals viable too. Indeed, the financial success of Blue Cross Plans induced commercial indemnity insurers to offer similar hospitalization coverage to groups and individuals. By the 1950s, more Americans obtained hospitalization coverage from commercial insurers than from Blue Cross. Even while Blue Cross plans and private hospitalization insurance proliferated, however, many poor and elderly Americans who were the most vulnerable to sickness and its costs remained uninsured.

Beginning in the late 1940s, public and private hospitals began to receive additional financial support from Congress. In 1946, the Hospital Survey and Construction Act (Hill-Burton Act) funded the construction of many new community hospitals nationwide. In 1965, Congress authorized the federal Medicare program, which pays for hospital and medical care for individuals aged sixty-five or older and those with long-term disabilities. Shortly thereafter, Medicare was supplemented by Medicaid, a joint federal-state program that provides medical and hospital insurance to low-income people under sixty-five and to those who have exhausted their Medicare benefits.

1975–2000: The Era of Cost Containment

The introduction from the 1930s through the 1960s of Blue Cross Plans, private health insurance, Medicare, and Medicaid all contributed to pushing consumer demand for medical and hospital care to unprecedented levels. As the overall demand for health services escalated, so did overall costs, which consumed 15 percent of the gross domestic product in 2001.

Insurers responded to escalating health care costs by creating new mechanisms, including managed care, to control costs and access to services. Some managed care plans employ utilization review, require pre-authorization of hospitalization, or negotiate for reduced fee payments to participating providers in exchange for patient volume. Alternatively, to discourage excess medical services, other managed care plans pay participating physicians a fixed monthly fee per patient, regardless of the services used. These new insurance mechanisms have reduced average hospital lengths of stay and occupancy levels. By moving health services from hospitals to outpatient settings wherever possible, managed care plans have diminished the role of hospitals in the American health care system.

Hospitals have responded to these changes by diversifying their activities, increasing on-site outpatient services or even providing outpatient services off-site. Hospitals also have affiliated with one another to create multihospital systems and networks, and have vertically integrated with physicians through a variety of organizational structures. These organizations were intended to offset the negotiating power of the insurers, but have met with only limited success, if that.

At the start of the twenty-first century, hospitals continue to play an unparalleled role in providing essential medical services, facilitating medical research, and training new physicians. However, whether hospitals will retain their central role in American medical care is open to question.

BIBLIOGRAPHY

Starr, Paul. The Social Transformation of American Medicine. New York: Basic Books, 1982.

LindaDynan

Hospitals. The first hospitals in America were makeshift: military hospitals during the Colonial Era, and the Revolutionary War, and quarantine and inoculation hospitals during epidemics. By the early nineteenth century, the sick poor were often relegated to alms houses, many of which ultimately became tax‐supported municipal hospitals run by local governments. The first permanent institutions for the general care of the sick were organized in northeastern cities in the eighteenth and early nineteenth centuries and included Pennsylvania Hospital in 1751, New York Hospital in 1771, and Massachusetts General Hospital in 1821. These were not intended for the general public; popular opinion regarded medical treatment in an institution by strangers as a last resort, appropriate only for those who had no other choice.

The Nineteenth Century.

The number of hospitals increased during the Antebellum Era, partly in response to growing optimism about the recuperative powers of a regulated moral and physical environment. The new institutions included general‐care hospitals as well as a host of specialty hospitals or asylums: mental hospitals, lying‐in hospitals usually associated with foundling homes, and hospitals for the care and treatment of the blind. The link between poverty and hospitalization remained strong; whether municipally or privately owned, hospitals were primarily charity institutions.

After the Civil War, the number of hospitals increased dramatically, reaching approximately fourteen hundred by 1900. This rapid growth resulted as much from social upheaval as from medical advances. Amid surging immigration and rapid urbanization, local governments, benevolent groups, and churches organized hospitals for the growing ranks of the needy sick. Religious and ethnic groups founded hospitals for religious and cultural reasons. Mullanphy Hospital in St. Louis, the first Roman Catholic hospital in the United States, was founded by the Sisters of Charity in 1828; German Jews in New York City organized Mount Sinai Hospital in 1852. Hospitals mainly cared for the chronically ill, for whom the cultural aspects of daily hospital life were central. Religious hospitals rarely administrated distinctive therapeutics, but they did provide a comfortable and familiar environment—and gave visible proof that a denomination was caring for its own. Hospitals were also organized to provide treatment and clinical training for groups excluded or discriminated against elsewhere. Female physicians founded the New York Infirmary for Women and Children (1860) and the New England Hospital for Women and Children (1862). African Americans organized Provident Hospital in Chicago (189) and Douglass Hospital in Philadelphia (1895). In addition to bed care, many hospitals maintained outpatient facilities, or dispensaries. For the poor, these often represented the only professional medical care available.

By the late nineteenth century, three types of hospitals had evolved: municipal, proprietary, and voluntary. Municipal hospitals, typically larger than the others, were supported by public funds and managed by public authorities; many developed reputations for grim conditions and poor care. For‐profit proprietary hospitals, often owned by physicians, relied on patient payments. Voluntary hospitals derived most of their financial support from private philanthropy, supplemented in some cases by public funding. As expanding hospital populations outpaced traditional sources of funding, patients increasingly paid for their hospital stays. Ultimately this helped remove the stigma of hospitalization as a last resort for paupers.

Early Twentieth Century.

Hospital growth continued unabated in the early twentieth century with the number soaring to more than six thousand by the mid‐1920s. As the hospitals’ image as a charity institution faded, they advertised comfortable private rooms to attract patients. Unlike nineteenth‐century institutions, which mostly provided chronic care and treatment, these new hospitals typically welcomed the acutely ill as well as surgical and obstetrical cases. The number of women delivering their babies in hospitals increased, especially after 1914, when the introduction of the sedative scopolamine to induce “twilight sleep” offered the promise of painless childbirth. The professionalization of nursing proved crucial to the emergence of the modern hospital. Hospital nursing schools, which provided a supply of unpaid student nurses to staff wards, became essential components of the hospital economy. Hospital training for medical students also became the rule in this period. Efficiency, professionalization, and standardization came to dominate hospital development. Institutional and professional groups such as the American Hospital Association and the American College of Surgeons worked to modernize all aspects of hospital life, from record‐keeping to laundry practices. During World War I, the military relied on hospitals to provide medical services in Europe, with American hospitals and medical schools sending teams of physicians and nurses to replicate facilities at home.

By the end of the 1920s, deliveries and abortions, adenoidectomies, appendectomies, tonsillectomies, and the treatment of accident victims accounted for 60 percent of hospital admissions. By 1935, a third of Americans were born in and died in a hospital, but regional and class differences persisted. Rural areas and the South had relatively few hospitals. In an ironic twist, high fees now increasingly excluded the hospitals’ traditional patients, the poor. Proposals for compulsory national health insurance stirred powerful opposition, but voluntary hospital‐insurance plans, such as Blue Cross, flourished. Although hospital lobbyists were unsuccessful in efforts to include federal funding for privately managed hospitals among the New Deal's programs, the 1946 Hill‐Burton Act sought to improve hospital care and availability through federal grants to states for hospital construction. The federal government had provided health care for veterans since shortly after the Civil War, when the first soldiers’ homes were established for disabled veterans, but World War II spawned a vast new system of veterans’ hospitals.

Post–World War II Developments.

In the postwar era, hospitals assumed an ever‐greater medical and cultural role. The availability of antibiotics improved the safety and sophistication of hospital treatment and stirred optimism about the future promise of medical research. Technological developments expanded hospital services and altered hospitals’ physical organization, creating, for example, intensive‐care, coronary, and neurosurgery units. Hospital admissions in 1960 were double those of 1930. Hospitals even played a prominent role in twentieth‐century popular culture, as evidenced by a series of television programs extending over several decades, from Dr. Kildare, Marcus Welby, M.D., and the long‐running soap opera General Hospital to St. Elsewhere and the enormously popular E.R.

Hospitals employed huge numbers of workers, skilled and unskilled. Excluded from the gains made by other workers under New Deal labor laws, hospital workers, despite opposition from hospital administrations, began to organize in the 1950s. In 1974, federal prohibitions on striking by hospital workers were lifted.

Financial issues were central to further hospital development. Greater federal involvement in hospital finances resulted from the Medicare and Medicaid programs established in 1965, which reimbursed hospitals for the care of the elderly and the poor. In the 1970s and 1980s, as hospital costs climbed, many voluntary hospitals merged in efforts to cut costs, creating regional and national chains. The number of for‐profit hospitals rose from 414 in 1977 to 797 in 1997. The 1990s found America's hospitals in a state of flux and financial crisis. As they tried to economize, patient stays were shortened, surgery was more frequently performed on an ambulatory basis, medical testing was contracted out, and recuperating patients shifted to less‐expensive venues. Further, more medical care was delivered outside the hospital: in physicians’ offices, patients’ residences, nursing homes, and long‐term care facilities. Increasingly, the institution that had developed in the late nineteenth and early twentieth centuries known as the modern hospital seemed the product of specific historical circumstances, and one that might well evolve in radically different ways. For all their problems, however, America's more than six thousand hospitals (as of 1998), with over a million beds and 4.4 million staff and employees, remained fundamental to the nation's health‐care system and an integral feature of U.S. life.
See also Cancer; Childbirth; Death and Dying; Disease; Heart Disease; Medical Education; Medicine; Mental Health Institutions; New Deal Era, The; Philanthropy and Philanthropic Foundations; Roman Catholicism; Strikes and Industrial Conflict; Veterans Administration.

Bibliography

Gerald N. Grob , Mental Institutions in America: Social Policy to 1875, 1973.
Morris J. Vogel , The Invention of the Modern Hospital: Boston, 1870–1930, 1980.
Harry F. Dowling , City Hospitals: The Undercare of the Underprivileged, 1982.
David Rosner , A Once Charitable Enterprise: Hospitals and Health Care in Brooklyn and New York, 1888–1915, 1982.
Charles E. Rosenberg , The Care of Strangers: The Rise of America's Hospital System, 1987.
Diana Elizabeth Long and Janet Golden, eds., The American General Hospital: Communities and Social Contexts, 1989.
Rosemary Stevens , In Sickness and in Wealth: American Hospitals in the Twentieth Century, 1989.
Vanessa Northington Gamble , Making a Place for Ourselves: The Black Hospital Movement, 1920–1945, 1995.
Joel D. Howell , Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century, 1995.
Christopher J. Kauffman , Ministry and Meaning: A Religious History of Catholic Health Care in the United States, 1995.
Guenter B. Risse , Mending Bodies, Saving Souls: A History of Hospitals, 1999.

Bernadette McCauley

hospital institution for the care of the sick, maintained by private endowment or public funds or both. General hospitals minister to all types of illness, while special hospitals are concerned with only one disease or group of diseases. Many hospitals are maintained solely for the treatment of military personnel and veterans. Once a pesthouse for the care of the indigent and the friendless, with a quality of treatment and nursing from which few emerged alive, the hospital has flourished with the progress of medicine and surgery. Toward the end of the 19th cent. hospital care was revolutionized by the discovery of anesthesia, improvement in sanitation, establishment of hospital nursing schools, and other advances. Hospitals in large cities have become huge medical centers equipped not only to treat the ill but also to further the education of the medical staff, train a nursing staff, perform vital research into the cause and cure of disease, and help the patient with convalescent and social problems.

hospital (hist.) hostel, hospice XIII; asylum for the destitute or infirm XV; institution for the care of the sick XVI. — OF. hospital (mod-.hôpital) — medL. hospitāle, sb. use of n. of hospitālis, f. hospit-; see prec. and -AL1.
So hospitality XIV. hospitable XVI. f. medL. hospitāre receive as a guest. hospitaller member of certain charitable religious orders XIV; spiritual officer of a hospital XVI. — OF. hospitalier — medL. hospitālārius.

hospital originally, a house for the reception and entertainment of pilgrims, travellers, or strangers; any of the establishments of the Knights Hospitallers. Also, a charitable institution for the housing and maintenance of the needy; an asylum for the destitute, infirm, or aged (now chiefly in surviving proper names).
hospital blues a name for the uniform worn by wounded soldiers in the wars of 1914–18 and 1939–45.
Hospital Sunday the Sunday nearest to St Luke's day (18 October).

hospital (hos-pi-t'l) n. an institution providing medical or psychiatric care and treatment of patients. community h. a small hospital, which may be staffed by general practitioners, providing care for patients for whom home care is not practicable. day h. a hospital at which patients are under medical supervision during the day but do not stay overnight. district general h. a hospital that provides sufficient basic services for the population of a health district. See also trust.

hos·pi·tal / ˈhäˌspitl/ • n. 1. an institution providing medical and surgical treatment and nursing care for sick or injured people. 2. hist. a hospice, esp. one run by the Knights Hospitallers.

hospitals. Christian hospitals were founded from the 4th cent. onwards and became numerous in the Middle Ages, when they were commonly associated with monastic orders. Most medieval hospitals in England were almshouses for the aged.

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