prepared to care: the 24/7 role of america’s full- service hospitals
TRANSCRIPT
Prepared to Care:The 24/7 Role of America’s Full-
service Hospitals
The standby role of full-service is both unique and critical in the health care system.
Standby Role:
• Provide access to care 24 hours a day 7 days a week (24/7)
• Care for all patients regardless of ability to pay
• Be ready to respond to disasters
24/7 Role of Full-service Hospitals
Americans rely heavily on the 24/7 access to care provided by hospital EDs…
• One third of hospital care begins in the emergency department.
• The majority of ED patients require immediate care.
• More than half of ED care occurs outside of normal business hours.
Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006
Emergency Department Visits, 1997 – 2004, In Millions
Source: AHA Annual Survey, data for community hospitals.
…and that need is growing.
Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006
92.8 94.899.5 103.1 106.0 110.0 111.0 112.6
0
20
40
60
80
100
120
1997 1998 1999 2000 2001 2002 2003 2004
Em
erg
ency
D
epar
tmen
t V
isit
s
Meeting common emergency needs requires a wide array of resources be maintained 24/7.Example: Resource Needs for a Common Condition
Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006
Safety Net Role
Hospitals provide a medical safety net for the growing number of uninsured…
Number of Uninsured, 2000 – 2004, In Millions
39.8
45.0 45.843.6
41.2
2000 2001 2002 2003 2004
Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006
…serving proportionally more Medicaid and uninsured patients than physician offices…
Percent of Total Visits by Expected Source of Payment, Emergency Departments vs. Physician Offices, 2003
Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006
21%
14%16%
36%
5%
23%
56%
10%
Medicaid Uninsured Medicare Private Insurance
Emergency Department Physician Offices
…and taking an increasing role in the care of the behaviorally ill.
1,5071,349
467
662
1995 2004
Units of Hospitals Freestanding Facilities
Behavioral Health-Related Emergency Department Visits, 1994/95 – 2001/02
In Millions
Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006
Inpatient Psychiatric Facilities, 1995 – 2004
4.4
2.8
1994-95 2000-01
Disaster Readiness
A wide range of disasters hit communities annually…
Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006
Percent of Hospitals with Response Plans by Type of Incident, 2003
...and hospitals stand ready to respond.
Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006
97.3%
84.8%
77.2% 76.9%
85.5%
NaturalDisasters
Chemical Biological Nuclear orRadiologic
Explosive
Challenges in Maintaining the Standby Role
Hospitals face three major challenges in maintaining the standby role.
• Capacity constraints
• Financial challenges
• Competition for patients from facilities that don’t serve or contribute to the standby role
Capacity Constraints
Emergency Department Visits and Emergency Departments(1) in Community Hospitals, 1991 - 2004
(1)Defined as hospitals reporting ED visits.
As the number of patients seeking ED care has risen, the number of EDs has declined.
Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006
80
90
100
110
120
91 92 93 94 95 96 97 98 99 00 01 02 03 04
4,500
5,000
5,500
EmergencyDepartment Visits
EmergencyDepartments
Em
erg
ency
D
epar
tmen
ts
Em
erg
ency
D
epar
tmen
t V
isit
s (M
illi
on
s)
Capacity constraints have led to ED diversion in a majority of urban hospitals.
Percent of Hospitals Reporting Time on Diversionin Last 12 Months
42%
36%
67%
17%
64%
0% 10% 20% 30% 40% 50% 60% 70% 80%
All Hospitals
Non-teaching
Teaching
Rural
Urban
Source: AHA 2006 Survey of Hospital Leaders
Hospitals face a severe workforce shortage…
Vacancy Rates for Selected Hospital Personnel, December 2005
7.6%7.3%
6.3%5.9%
4.4%
8.5%
RegisteredNurses
NursingAssistants
LPNs LaboratoryTechnicians
ImagingTechnicians
Pharmacists
Source: 2006 AHA Survey of Hospital Leaders*118,000 vacancies is a national estimate created by extrapolating the vacancy rate to all 4,919 community hospitals in 2004.
118,000 RN Vacancies*
Registered Nurse FTEs: Supply and Demand, in Thousands, 2000 - 2020
Source: National Center For Health Workforce Analysis, Bureau of Health Professions, Health Resources and Services Administration, 2004.
…that is expected to worsen significantly over the coming decades.
FT
Es
in T
ho
usa
nd
s
Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006
1,600
1,800
2,000
2,200
2,400
2,600
2,800
3,000
2000 2005 2010 2015 2020
RN FTE Supply
RN FTE Demand
In 2020,
there will be a shortage of
1 million nurses
Financial Challenges
PrivatePayers
ElectiveCases
LessComplex
SurgicalCases
Well-funded
IndigentCare
24/7 CapacityUnfunded
Revenue from Service to Paying Patients
Medicareand
Medicaid
EmergentCases
MoreComplex
MedicalCases
Under-funded
DisasterReadiness
Hospitals support the standby role through revenues from patient care…
Hospital Payment Shortfall Relative to CostsFor Medicare and Medicaid Patients in Billions, 1997-2004
1997 1998 1999 2000 2001 2002 2003
Medicare
Medicaid
Bil
lio
ns
of
Do
lla
rs
2004
Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006
-1.9-2.6 -2.1
-2.3
-5.0
-15
-8.1
-3.4-2.4-1.4
4.32.3
-7.1
-1.6 -1.4
-$30
-$20
-$10
$0
$10
Total Shortfallin 2004: $22 Billion
…but hospitals face a growing shortfall from Medicare and Medicaid…
$18.5
$20.7$21.6 $21.5
$22.3
$24.9
$26.9
$19.0
1997 1998 1999 2000 2001 2002 2003 2004
Total Uncompensated Care Costs In Billions,1998 - 2004
Source: AHA Annual Survey
…and rising levels of uncompensated care.
Competition from Providers Not Serving the Standby
Role
0
20
40
60
80
100
120
140
2000 2001 2002 2003 2004 2005
2,500
3,000
3,500
4,000
4,500
5,000
Physician-owned Limited-service Hospitals Ambulatory Surgery Centers
Physician-owned Limited-service Hospitals and Ambulatory Surgery Centers, 2000 - 2005
Source: The Centers for Medicare & Medicaid Services
Ph
ys
icia
n-o
wn
ed
Lim
ite
d-
se
rvic
e H
os
pit
als
Am
bu
lato
ry s
urg
ery
Ce
nte
rs
Hospitals are losing patients to a growing number of limited-service providers…
Percent of Hospitals with an Emergency Department*, Physician-owned Limited-service Hospitals versus All Community Hospitals, 2003
*Hospitals treating more than 5% of cases in emergency department.
…that do not provide the 24/7 standby role…
Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006
91%
21%
Physician-owned Limited-serviceHospitals*
All Community Hospitals
…nor support the safety net role.
Medicaid as a Percent of All Patient Discharges, 2002
Physician-owned
Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006
15%
1%
4%
Heart Hospitals Orthopedic Hospitals Community Hospitals
Physician-owned
Est of
Well-funded services
Physician-ownedlimited-service
hospitals
Instead these facilities cherry-pick the well-funded services.
…relying on the economically motivated referral decisions of physician-owners...
• Behaviors associated with self-referral have been well documented, including:• Patient steering (physician-owners direct their patients to
their own facilities)
• Cherry-picking: • Offering well-reimbursed services
• Selecting healthier patients
• Avoiding low-income patients
…and leaving full-service hospitals without the means to subsidize the standby role.
Left forfull-servicehospitals
Unfunded and under-funded
services
• To maintain the standby role hospitals need:• Adequate payment from Medicare and Medicaid
• Support for uninsured populations
• Help in addressing the workforce shortage
• Fair competition• Ban self-referral to new limited-service hospitals• Payment systems that recognize standby costs
• Broad system support for the standby role
Without action, these services may not be there when we need them.