In Georgia, it might seem like we have a lot of choice when it comes to hospitals. There are many inpatient facilities, most of them privately owned and located close to each other. On the surface, that sounds like a good thing: more hospitals should mean better access and more options for patients. But in reality, having too many small, low-volume hospitals, facilities that treat and discharge very few patients per day, is creating serious problems. In these hospitals, doctors and nurses see fewer cases, which means they don’t get enough practice. Over time, this can lead to deskilling, where medical staff lose sharpness in their skills, especially for complex procedures. So instead of better care, patients may end up with lower-quality, less safe treatment, despite having many hospitals to choose from.
This study looked at how Georgia’s hospital system is structured and what effects that structure is having. What it found was worrying: our hospital system is deeply fragmented, meaning there are too many hospitals seeing only a small number of patients. This setup leads to poor coordination, lower quality of care, and makes it harder for the government to oversee and improve healthcare. It also wastes resources by spreading it too thin across too many facilities
What’s the Problem?
Georgia’s health system is dominated by a large number of small hospitals, many of them independently run. Most have low bed numbers and very few patients, with many averaging just 1–3 inpatient discharges per day. That’s incredibly low, especially when compared to hospitals in other countries. And yet, these hospitals are spread all over the country, often within 5–10 minutes of each other, so the competition is fierce.
What’s Going Wrong?
1. Wasting Resources
When hospitals sit half-empty, they still have to pay for electricity, staff, equipment, and maintenance. That’s a lot of wasted money, both for the hospitals and the government. Some facilities have invested in expensive machines that go unused most of the time, and many spend heavily on marketing to attract patients..
2. Pushing Unnecessary Treatments
Because hospitals are not making enough money from the Universal healthcare coverage program (government funded insurance), some are encouraging unnecessary treatments or hospital stays just to stay afloat. This means patients may end up being admitted when they don’t really need to be or may be overcharged or upcoded (billed for more expensive treatments than they received). All of this drives up costs for both patients and the health system.
3. Poor Quality Care
Small hospitals often can’t afford to hire enough trained staff or provide proper ongoing training. Many doctors and nurses work at multiple hospitals just to earn a decent wage, which can lead to exhaustion, mistakes, or poor continuity of care. In many cases, hospitals rely on pharmaceutical companies for staff training, raising questions about bias and quality.
Because patient numbers are so low, as mentioned above, doctors at these facilities may not get enough experience doing certain procedures, especially complex ones. Research in other countries shows that hospitals with more experience often have better outcomes for patients.
4. Weak Oversight and Regulation
With so many small, scattered hospitals, it’s nearly impossible for the government to properly monitor what’s happening. There’s not enough auditing, inspections, or follow-up to ensure that facilities meet basic standards. Almost any hospital that applies gets approved to work under UHC, regardless of quality. That means poor-performing hospitals are still getting public money, and patients have little way of knowing which hospitals provide safe, effective care.
Why Isn’t the Market Fixing Itself?
Normally, you’d expect the worst-performing hospitals to close, and stronger ones to grow. But that’s not happening in Georgia. In fact, the number of hospitals has stayed the same for years. That’s because:
- Even low-quality hospitals get paid by the UHC program
- Some rely on questionable practices to survive
Can This Be Fixed?
Yes, but not without strong action from policymakers. Here are a few things the government could do:
- Encourage hospitals to merge or join networks, so resources and staff can be shared
- Set minimum patient volume requirements for hospitals to stay in the UHC program
- Raise UHC reimbursement rates so hospitals don’t need to cut corners or push unnecessary care
- Set quality standards and regularly audit hospitals
- Educate patients about their healthcare rights and what they should or shouldn’t pay for
One positive example is how Georgia reformed its maternity care system. By requiring hospitals to meet certain standards and minimum delivery volumes, the number of maternity hospitals dropped significantly—leading to more focus on quality, though more research is needed to see if outcomes have improved.
Final Thoughts
Georgia’s hospital system may look accessible on the surface, but underneath it’s struggling. There are too many small hospitals, not enough patients in each, and too little oversight. This isn’t just a financial issue, it’s affecting patient safety, quality of care, and public trust.
Fixing this won’t be easy. But without change, the system will continue to waste resources, overburden patients, and fall short of what good healthcare should deliver. The solution isn’t just fewer hospitals, it’s better hospitals that are properly funded, well-regulated, and focused on patient care, not just survival.
Authors: Tvaliashvili Mari, Sulaberidze Lela, Goodman Catherine, Hanson Kara, and Gotua George.
https://ideas.repec.org/a/eee/socmed/v362y2024ics0277953624008827.html
