Article
As lower-acuity procedures move outpatient and complex care spreads across health systems, leaders need a clearer view of which patients will consume tomorrow’s beds.
If a CEO asked me whether their health system will have enough beds in 2036, my first inclination would be to question what “enough” really means.
The answer depends on which patients those beds will serve, how complex their needs will be, and how long they will remain in the hospital. It also depends on whether the system has the right capacity in the right place, with the right clinical support required to use it well.
A simple inpatient volume forecast can’t answer those questions.
And that’s exactly the central challenge in capacity planning today, where health systems have become accustomed to looking at discharge volume as a proxy for demand. To be clear, it’s a perfectly understandable place to start. After all, discharges are visible, familiar, and relatively easy to compare over time.
| Quaternary | Tertiary | Shifting tertiary |
|---|---|---|
| Niche services anchored at research AMCs (e.g., CAR T-cell therapy) | Services historically linked to AMC hubs (e.g., brain/ skull surgery) | Services shifting to intrasystem or intersystem spokes (e.g., thoracic surgery) |
| High acuity | Medium acuity | Low acuity |
|---|---|---|
| Surgeries done at most inpatient facilities (e.g., large bowel resection) | Minor procedures, critical care, and high-volume medical (e.g., mechanical ventilation) | Medical and potentially avoidable admissions (e.g., diabetes-related admission) |
But a discharge is only the end of the story. It tells us that a patient moved through the hospital but not how much capacity that patient required along the way. And that’s a distinction that matters more with every passing year.
Think about two patients who each generate one discharge. One may have a planned, complex procedure, supported by a coordinated surgical team, and a carefully prepared discharge plan while the other may arrive through the emergency department with several chronic conditions and nowhere safe to go after hospitalization.
On paper, they’re equal in that each is counted once. But operationally, they can have very different consequences.
Their care may require different teams, technology, and levels of nursing support, and their lengths of stay may look nothing alike. One might move through a predictable pathway while the other remains in the hospital as the care team works through medical, functional, and social barriers. This is where discharge volume begins to lose its explanatory power. It captures movement. Inpatient days capture occupation.
When the patient mix changes, the relationship between those measures changes with it.
Some of the lower-acuity procedures that once required an inpatient stay are moving into ambulatory settings (a shift that has been underway for years and will continue).
The reality is that the hospital is becoming a more concentrated place, one shaped by age, complexity, and clinical risk. A smaller share of care may be delivered there, while the patients who remain represent a greater share of the system’s complexity. That creates an uncomfortable possibility for leaders: inpatient discharges may grow modestly while the pressure on beds remains intense.
The reason is simple: A change in the number of patients does not necessarily produce the same change in the number of days those patients spend in the hospital.
I see this as one of the most important issues in future capacity planning. Leaders can watch procedures migrate outpatient and assume that inpatient pressure will ease. But medical admissions continue to arrive, complex patients require longer stays, and the capacity released by one part of the portfolio is quickly consumed by another.
The hospital can look quieter in one measure and fuller in another.
There’s another shift underway, and it’s changing the competitive landscape.
Quaternary care remains closely associated with highly specialized services anchored by research-oriented academic medical centers, and tertiary care has traditionally followed those same hubs. Increasingly, however, certain services are moving into capable community hospitals and broader health system networks (I call this the “shifting tertiary landscape.”)
The change is being driven by several forces. Community systems are gaining scale by recruiting specialized physicians and building programs that once would have been difficult to support outside an academic setting. Academic systems, meanwhile, are expanding their footprints and competing for a wider range of high-acuity procedural care.
The old map—with the academic center at the top and community hospitals serving primarily as feeders—is becoming less reliable.
Care may still move toward an academic hub for the most specialized cases. Other patients may be treated closer to home, within a system spoke or at a competing community facility. Those movements affect more than referral patterns. They shape access, market share, revenue, and the ability to sustain other parts of the enterprise.
A system cannot compete for complex care if it can’t accept the patient, nor can a hospital grow a destination program if its capacity is constantly occupied by demand that could have been managed elsewhere.
The future inpatient portfolio is already taking shape. Lower-acuity procedures will continue to move outward, and higher-acuity patients will account for a greater share of demand. Tertiary and quaternary services will evolve across academic and community settings, while aging and rising medical complexity will put additional pressure on hospitals that are already operating close to their limits.
Leaders who want to be fully prepared headed into the next decade will need to know which populations are consuming capacity, which services are vulnerable to displacement, and where care can be delivered safely and effectively. It’s critical to understand the relationship between inpatient and outpatient growth and make decisions about capacity before a full bed forces the decision for you.
That’s why I would frame the issue this way:
Will we have enough capacity for the patients we want—and need—to serve?
The answer begins with understanding what a discharge really represents.
Now in its fifth year, the Vizient inpatient portfolio organizes inpatient hospitalizations into acuity-based cohorts using diagnosis-related groups, providing a common way to examine the difference between highly specialized care, core inpatient activity, and potentially avoidable demand. The work is informed by Vizient’s ability to compare the relative distribution of care across academic medical centers and non-academic hospitals, using data that spans patient populations and payer types. Each year, Vizient clinicians, data scientists, and statisticians review the underlying data and refine the framework.
That process creates a practical starting point for discussions that can otherwise become highly subjective. Individual systems can still adapt the definitions to reflect their own clinical realities, but the portfolio allows them to have a consistent, data-informed view of the inpatient landscape.
Associate Principal, Vizient Strategy Intelligence
In his role as associate principal on the Vizient Strategy Intelligence team, Justin Cassidy serves as a trusted adviser to strategy leaders at more than a third of the nation’s hospitals, including more than 70 academic medical centers. He collaborates with healthcare managers to convene stakeholders and facilitate discussions between clinical, financial, and administrative leaders. During his tenure at Vizient...
