The Economics of Biophilia: Healthcare

In today’s society, sectors across industry are reaping the economic benefits of biophilic design. By examining five of these sectors—workplaces, healthcare, retail stores, schools, and communities—we can begin to understand the fiscal implications of biophilic design across the economy. The numbers and percentages presented reflect powerful evidence that design and planning strategies informed by nature can lead to positive impacts on human health, child development, community safety, and worker satisfaction. These effects translate directly to increased profits.

Healthier Patients, Healthier Profits – Biophilic Design in Hospitals

Spending in the United States’ healthcare sector is at record levels and growing. In 2016, the U.S. spent $3.3 trillion on healthcare (U.S. Department of Health and Human Services (HSS), 2016) and that number is expected to rise to $5.7 trillion by 2026 (U.S. HSS , 2016a). Reducing these costs without sacrificing health outcomes is critical for the economic stability of the hospital system and its users. Biophilic design strategies can contribute to improved outcomes as an evidence-based solution.The process of evidence-based design for healthcare settings combines the best information from other fields, in this case current healthcare design research and the physiological and psychological needs of patients, doctors, and staff (Hamilton & Watkins, 2009).

Current research suggests that one of these needs is exposure to nature and natural systems, and that incorporating even small elements of biophilic design into the healthcare settings can improve patient outcomes, reduce the need for pain medication, reduce stress, and improve the working environment for those caring for patients. In 2017, the U.S. spent over $41 billion on healthcare construction (U.S. Department of Commerce, 2017). The contribution of biophilic design to improved outcomes are paired with financial savings. Over fifty published studies associate biophilic elements, such as healing gardens and controlled access to daylight, as primary influences for improved outcomes, which translate to cost savings.

Healthcare design can contribute to alleviating stress in both patients and care providers, which in turn can affect patient outcomes.  Patients may already be stressed, be it from acute or chronic trauma, recovery, or the anticipation of test results; they are therefore more susceptible to stress, which can affect the body psychologically, physiologically, biochemically, and behaviorally (Ulrich, 1999). A stressed body heals more slowly, is less resistant to infection, and may have heightened emotional reactions. Common sources of stress caused by the physical environment in hospitals include noise, poor control of lighting conditions, and confinement in a completely artificial environment (Ulrich et al., 2006).  While a healthcare facility itself does not directly affect treatment or recovery, it can be designed in a way that does not add to patient stress, and may possibly provide a source of distraction from pain or boredom.

Patient Health and Medical Expenses

In 1984, Roger Ulrich conducted what would become a seminal study, measuring the influence of a view of natural scenery on patients recovering from gallbladder surgery. Some patient rooms had views of a natural scene while others faced a brick wall. After accounting for other variables, his findings showed that patients who did not have a view of a brick wall had shorter postoperative hospital stays, a lower consumption of pain medications, and fewer negative evaluative comments from nurses. On average, the patients whose windows overlooked a scene of nature were released after 7.96 days, while patients with the view of the wall stayed 8.71 days —a decrease of 8.5% (Ulrich, 1984). In economic terms this is a significant cost reduction to the patient and the hospital at large. According to the Agency for Healthcare Research and Quality, the average expenditure per diem for a hospital stay after surgery in 2010 was $4,221 (Mirel & Carper, 2013). Applied to Ulrich’s study, the cost of patient care could have been reduced by over $145,000 if all 46 patients were released at the earlier time. While this is not an a precise calculation of cost savings, it may indicate the potential magnitude of savings that biophilic design elements in a hospital might contribute.

These seemingly small improvements in patient outcomes can still result in sizeable savings when spread across the 5,795 registered hospitals in the U.S. (American Hospital Association, 2018). In 2015, 51,430 major operational procedures took place in the United States, with resulting in hospital stays that averaged 4.8 days (U.S. HSS, 2010). Applying the same decrease in stay from Ulrich’s study, we estimate that the average length in hospital stay will decrease by roughly half a day (.41 days). Given that the national average expense per diem of a hospital stay after surgery is $4,221, and that the number of surgeries in the United States has remained relatively stable since 2010, we estimate that the nationwide savings per year due to reduced hospital stay associated with major surgery to be about $89 million (see Appendix). Again, the purpose of this calculation is not to pinpoint an exact industry cost savings, but rather to generate an idea of what the economic impacts of biophilic design are on the healthcare industry.

Subsequent studies built upon Ulrich’s findings (Kellert, 2008).  Examples from mental health research include a 1996 study conducted by Beauchemin and Hays (1996) who found a 2.6 day decrease in length of stay for bipolar disorder and depression patients in sunny, daylit rooms, when compared with those in dimmer rooms with only artificial lighting. A similar study conducted in 2001 found the  mean stay was 3.67 days shorter for patients with bipolar disorder in rooms with direct morning sunlight when compared with those who had none (Benedetti et al., 2001). Pharmaeconomists at the University of Texas Health Science Center in Houston estimated that each case of treated bipolar disorder costs a minimum of $11,720 (Begley et al., 1998). If one applies this number to the context of the work of Benedetti et al., and if a fraction of this value was deducted because of reduced treatment time, $271,904 could have potentially been avoided had the other 87 patients in this study also been released earlier as a result of recovering in naturally lit rooms.

Another example of the built environment’s effects on patient outcomes is the inclusion of daylight and windows for patients. These are important for two reasons: daylight for health, and views for relieving stress.  First, access to daylight, and conversely, darkness, can affect patient mood and sleeping habits. Second, patient and recovery rooms that have views of nature may help reduce patient recovery times. Everyone, not just those suffering from health issues, benefits from exposure to natural daylight cycles, which help set circadian rhythm.  Evidence shows there are benefits for exposing even newborns to sunlight (Barss and Comfort, 1985; Giunta and Rath, 1969). Both staff and patients who spend hours and days inside the hospital risk low vitamin D and disrupted sleep without exposure to daylight.  The benefits of providing windows to patients undergoing treatment or recovering have already been described.  By providing a distraction, a view of nature may also reduce perceived pain levels (Ulrich, 1999).  Distraction theory, taking a cue from gate control theory (Melzack and Wall, 1985, 1982), posits that positive views (e.g., of nature) can help lessen the perception of pain by diverting attention away from the source (Brewer and Karoly, 1989).  Views, like artwork and other visual distractions, should be interesting as well as safe and non-threatening (Kellert, 2008).  Previous studies shows that views of shadowy forests or art that is “abstract, emotionally negative, or surreal” had either no effect, or actually increased stress for those already in stressful positions (Ulrich, 1999; Ulrich et al., 2006).

In 2005, a study assessed the significance of sunlight in a hospital room on patients’ recovery from a cholecystectomy by measuring the quantity of analgesic medication and resulting costs. The patients were divided into rooms with varying sunlight. Patients in more brightly lit rooms  experienced 46% higher-intensity sunlight on average than those in dimmer rooms. The study determined that patients exposed to greater levels of sunlight perceived less pain, took 22% less analgesic medications per hour, and accrued 21% less in pain medication costs for the length of their stay (Walch et al., 2005). 

Healing Gardens

A growing body of evidence shows patients and visitors benefit greatly from access to healing gardens.  Including gardens in a healthcare facility for the benefit of both patients and staff is not a new idea, but often seems at odds with building closed-off and sterile places to house modern technology (Ulrich, 1999, 2002).  While the benefits of gardens have long been considered best practice, and the theory behind their potential benefits strongly supported, researchers and designers have recently begun to examine these benefits with more rigor.  Results from evidence-based design research have been so compelling that Dr. Naomi Sachs of the Therapeutic Landscapes Resource Center estimates that between 280-570 hospitals in America have incorporated large-scale healing gardens on into their grounds design layout in order to provide patients with a sense of control, physical movement, and access to nature as a positive distraction (Domke, 2008).  Evidence-based research supporting effective healing gardens is not about the creation of strict design rules, but rather the use of quality research to offer either a range of possible design responses to user needs or the establishment of environmental performance standards (Marcus, 2016). The benefits of nature in the hospital setting extend to family members and visitors. In a survey of four independent hospitals, 95% of hospital visitors who spent time in the hospitals’ gardens reported feeling more relaxed and calm after the visit. They also reported feeling less stressed and more able to cope with the situation (Marcus & Barnes, 1995).  For caregivers, having a access to a lush, green, outdoor area may make their already precious down time more restorative, something that benefits them and their patients.

Increases in stress in both patients and nursing staff arise when there is high responsibility and low control (i.e., the responsibility of recovering or the responsibility of patient well-being, and the inability to alter one’s surroundings or take a restorative break). Studies in horticulture therapy and healing gardens for patients have directly credited these activities with reducing patient and staff stress, reducing patient medication use, and increasing staff satisfaction (Sadler et al., 2008). There are many factors that influence and trigger stress, but the built environment can act as a stress reliever for outside stresses, as well as independently trigger positive physiological reactions. A  biophilic built environment can provide positive distractions. Positive distractions also promote well-being by evoking positive feelings that hold attention away from negative thoughts. Other interventions include the presence of natural elements such as water, plants, trees, and non-threatening animals. While not as impactful as dynamic types of nature, scenes of nature in artwork and murals have been shown to reduce anxiety and discomfort.