605: Hospitals Flashcards
Hospitals
- Before modern medicine
- Earlly 1900s
- After 1930
- 1940s
- 1965
- 1970s -1980s
- Before modern medicine
- Institutional warehouses for the poor, ill, homeless, mentally ill
- Little treatment, little hope
- Earlly 1900s
- Transformation began - assisted by development of medical technology
- Treatment possibilities were expanded
- Hospitals became centers for healing
- After 1930
- Greater availability of private insurance led to increased demand for hospital services
- 1940s
- Existence of hospital shortage was alleged
- Hospital Survey & Construction Act of 1946 (Hill-Burton Act)
- Provided federal grants to states for construction of new hospital or enlarged hospitals (more beds)
- 1965
- Medicare and Medicaid - increased availability of hospital insurance and demand for hospital care
- 1970s-1980s
- Hospital costs increased rapidly
- 1982 Tax Equity & Fiscal Responsibility Act (TEFRA) madated use of DRGs beginning in 1983
Changes in hospital operations since 1960
- New technologies; specialized services
- Growth of for-profit hospitals and corporations
- Vertical and horizontal integration - led to larger, more complex hospital organizations
- Managed care and reimbursement changes
- DRGs and prosepective reimbursement: shift of some care to ambulatory care settings > resulted in hospital cases being the more complex cases > increased costs
- Growth of information systems
- Focus on quality of care and accreditation (“Joint Commission” - formerly JCAHO)
- Larger uninsured population - EMTALA of 1986 (requires EDs to tx uninsured)
Current and future challenges
- Changing and competitive environment
- Mangaged Care and ACA - controlling readmissions
- Balancing cost increases and payment decreases
- Personnel shortages (will RN shortage return?)
- Unionization
- Increasing regulations (regulatory compliance)
- Focus on patient safety and medical errors (ACA has financial penalties for “errors”/readmissions)
- Earthquake building standards (will they be enforced?)
- Supposed to be done by 2008, pushed to 2013, then pushed to 2020
Hospital expenditures and sources of funding
Expenditures:
- Expenditures on hospital services represent 32.1% of total health expenditures in 2013
- Down from 39.3% in 1980
Sources of funding:
- 3.5% out-of-pocket
- 37.1% private insurance
- 25.9% Medicare
- 17.5% Medicaid
*Medicare + Medicaid equals about 44% of funding
Percent hospital expenditure: (changes since 1960)
Change from 39.3% in 1980 to 30.2% in 2000
- Big change! (DRGs)
- Has gone up slightly (to 32%) since 2000
Distribution of outpatient vs. inpatient revenues
27% of hospital revenues came from outpatient services in early 90s
45% of hospital revenues came from outpatient services in 2013
*** % of outpt revenue increased 18% in just 2 decades
How hospitals are classified (hospital classification)
- Length of stay:
- Short-term hospital: avg LOS < 30 days
- Long-term hospital: avg LOS > 30 days
- Type of major services:
- General (acute care)
- Specialty: psychiatric, rehabilitation, children’s
- Bed size
- How many beds does the hospital have
- Teaching status
- Teaching hospital: have residency program(s)
- Academic medical center: includes a medical school
- provide primary, secondary and tertiary care
- clinical medical research
- costs are often higher due to teaching and research
- revenue is often lower due to a higher uninsured population
- gov’t provides a little more funding for hospitals b/c of this (but under ACA additional funding might be removed)
- Urban vs. Rural (concern about financial viability of rural hospitals > if closed would result in access to care issues)
- Ownership (e.g. nonprofit, for profit, district, public)
Hospital ownership
Nonprofit
- Established as 501(c)(3) institution
- Satifies IRS code as nonprofit institution
- Exempt from federal, state, and local taxes
District
- Receive some (usually very small) amount of revenue from taxes levied on community in which they are located
- Otherwise look like non-profits
- Originally was a mechanism to get hospitals to locate in a community - people were willing to pay small tax amount to have a hospital in their area (this was more important in the past than now, but they still exist)
For-profit
- Proprietary; Investor-Owned
- Often part of multi-hospital chains
- Distribute profits to shareholders
Public; Government
- Federal, State, and Local hospitals
- “Providers of last resort”
- VA and military hospitals
Definition of “community hospitals”
- Nonfederal, available to the public
- Short term (avg LOS < 30 days)
- Provide general acute services
Hospital Licensure and Accreditation
- State Department of Health oversees licensure of hospitals
- Must be licensed to operate
- Meet certain minimum standards for space, equipment, personnel, safety, etc.
- Medicare certification
- Required if want to be reimbursed for Medicare and Medicaid pts
- Focuses on quality of care and patient safety
Hospital accreditation:
- Joint Commission accredits hospitals
- Private, nonprofit group formed in 1952
- Formerly Joint Commission for Accreditation of Healthcare Organizations (JCAHO)
- Sets performance standards
- Hospitals accredited by Joint Commission automatically satisfy Medicare certification
% of hospitals by ownership (comparing 1980, 1990, 2000, 2012)
- Nonprofit
- For-profit
- State and local
- Federal
% of beds by type of hospital/ownership (comparing 1980, 1990, 2000, 2012)
- Nonprofit
- For-profit
- State and local
- Federal
% hospitals by ownership
- Nonprofit: 53.7% in 1980 to 55.5% in 2012 (greater than half of hospitals are nonprofit)
- For-profit: 11.8% in 1980 to 20.5% in 2012 (# almost doubled)
- State and local: 28.7% in 1980 to 19.9% in 2012 (# dropped by almost 10% since 1980)
- Federal: 5.8% in 1980 to 4% in 2012 (small decrease)
# Beds
- Nonprofit: Hasn’t changed much since - currently have 65% of all hospital beds (tend to have more beds/hospital on avg - larger hospitals)
- For-profit: 7.9% of beds in 1980; 16% of beds in 2012 (doubled)
- State and local: 18.9% of beds in 1980; 14.3% in 2012 (big drop)
- Federal: 10.6% in 1980; 4.6% in 2012 (big drop)
Distribution of hospitals and beds (what percent of hospitals have what percent of beds by size of hospital/bed size)
33% of hospitals are very small (1-49 beds), but despite the large number of hospitals, they only have about 5.8% of all beds
Large hospitals (with 300+ beds) constitute 16% of hospitals, but >50% of beds
Hospital beds per 1000 population (U.S. distribution)
- Overall distribution (difference between regions)
- U.S. average (# beds/1000 pop.) since 1980 - how has number changed
- California: # of beds per 1000 pop. (states with lower # beds/1000 than CA)
- how has number changed since 1980
- Western states: lowest # of beds per capita
- East coast (with exception of DC): low # of beds per capita
- States in center of U.S.: ># of beds per capita (less populous states? health status?)
US averages: # of beds/1000 population
- 1980: 4.5
- 1990: 3.7
- 2000: 2.9
- 2012: 2.6
California: 1.8 beds per 1000 population (down from 1.9 2 years earlier)
- CA has fewer beds/1000 population as compared to U.S. overall (hasn’t changed much overall - avg in both U.S. and CA has decreased)
- Only three states have lower # beds/1000 than CA:
- Oregon 1.7
- Washington and Utah: 1.8
- Change in # since 1980:
- 1980: 3.6 (80% of U.S. avg)
- 1990: 2.7 (73% of U.S. avg)
- 2000: 2.1 (72.4% of U.S. avg)
- 2012: 1.9 (73.1% of U.S. avg)
Hospital readmissions
- What are readmissions a marker of?
- What impact does the ACA have on readmissions?
- Hospital readmissions in San Diego (and implications of this)
- Marker of quality care
- Higher readmission rates possibly indicative of lower quality of care (or at least pt outcomes)
- Affordable Care Act:
- Decreases payments (for all Medicare pts) to hospitals with “excessive” readmissions (began 10/2012)
- Initially is focusing on readmissions for: Acute MI, Heart Failure, Pneumonia
San Diego:
- 24% of all 30-day readmissions occur at different hospital than first admission
- 15% of all ED pts and 69% of “frequent fliers” seen at multiple hospitals
- **Implications for health information exchange (access to pt data by all hospitals in community)?
Integrated Health System (IDS)
- Defintion
- Why they arose
- Integration strategies
Growth in joint ventures, mergers, acquisitions
- Response to increasingly competitive environment
- Response to cost pressures (changes in reimbursement and regulation)
Integration strategies:
-
Horizontal integration:
- Combination/affiliation of similar units
- e.g. merger or aquisition of short-term acute hospitals in same geographic area (e.g. Grossmont Hospital became Sharp Grossmont; Mercy Hospital became Scripps Mercy)
- Objectives:
- Increase operational efficiences and economies of scale (larger scale operations can save costs - e.g. like buying in bulk)
- Enhance competitive posture (reduce competition since combining similar units in area)
-
Vertical integration:
- Combination/affiliation of different types and levels of services
- IDS includes different products to deliver services
- e.g. inpt, ambulatory care, mental health, home health, LTC, etc.
- Stimulated by contractual arrangements to have all services availables
- facilitates contracts with MCOs and other insurance companies if all services are provided by one organization (“one-stop shopping”); give negotiation advantage
- Patient feeder to other product lines (keep pts w/in the IDS)
- IDS includes different products to deliver services
- Combination/affiliation of different types and levels of services