605: Hospitals Flashcards

1
Q

Hospitals

  • Before modern medicine
  • Earlly 1900s
  • After 1930
  • 1940s
  • 1965
  • 1970s -1980s
A
  • 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
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2
Q

Changes in hospital operations since 1960

A
  • 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)
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3
Q

Current and future challenges

A
  • 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
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4
Q

Hospital expenditures and sources of funding

A

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

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5
Q

Percent hospital expenditure: (changes since 1960)

A

Change from 39.3% in 1980 to 30.2% in 2000

  • Big change! (DRGs)
  • Has gone up slightly (to 32%) since 2000
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6
Q

Distribution of outpatient vs. inpatient revenues

A

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

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7
Q

How hospitals are classified (hospital classification)

A
  • 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)
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8
Q

Hospital ownership

A

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
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9
Q

Definition of “community hospitals”

A
  • Nonfederal, available to the public
  • Short term (avg LOS < 30 days)
  • Provide general acute services
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10
Q

Hospital Licensure and Accreditation

A
  • 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
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11
Q

% 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
A

% 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)
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12
Q

Distribution of hospitals and beds (what percent of hospitals have what percent of beds by size of hospital/bed size)

A

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

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13
Q

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
A
  • 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)
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14
Q

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)
A
  • 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)?
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15
Q

Integrated Health System (IDS)

  • Defintion
  • Why they arose
  • Integration strategies
A

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)
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16
Q

Number of hospitals that are in “health systems” (how has this changed from 2003 to 2013)

A

Major trend over past decade for hospitals to join health systems.

Increased from 53.6% to 63.2% of all community hospitals in 10 years (increased by about 10% over the decade)

17
Q

Triage status of ED patients (time pt should be seen in and % of pts that fall into each category)

Time pts spend in ED

A

Well over 3 of every 5 patients spends over 2 hrs in ED

18
Q

Percent of ED visits by age (comparing 2001 to 2011)

A
19
Q

% ED visits over a 12 month period: Medicaid vs. Uninsured vs. Private insurance (under 18 y.o. vs. 18-64 y.o.)

A

Medicaid beneficiaries are more likely to have at least one or more ED visits per year than uninsured or privately insured people.

20
Q

Hospital organization and management structure

  • Three management components and description of each
  • Definition of hospital governance
A

Three management components in organization of hospital:

  • Board of Trustees or Board of Directors
  • Hospital Administration
  • Medical Staff

*All three to some extent responsible to “community” (even if non-profit)

Hospital governance: How the 3 components interact to make decisions and operate hospital efficiently

  • Potentially conflicting goals (not uncommon)
    • MDs: provide highest quality of care w/o primary focus on cost
    • Hosp Admin: balance cost and quality
      • answer to community
      • possibly report profit (if proprietary)
    • Board: maintain positive reputation in community; long-term financial viability

Board of directors:

  • Operate hospital on behalf of owner(s)
    • community; shareholders (if for-profit)
  • Activities:
    • establish mission and overall policy
    • approve budgets
    • monitor performance of all operations, including finances and quality of services
    • Hire Chief Executive Officer (CEO)
    • Tries to satisfy needs of community
  • Membership
    • Donors, MDs, influential community members

Hospital administration:

  • Led by CEO
    • responsible for all operations; reports to board of directors
  • Others manage day-to-day operations
    • Chief Operating Officer (COO); Chief Financial Officer (CFO); Chief Information Officer (CIO); Chief Nursing Officer (CNO)
  • Vice presidents, department heads, supervisors, other administrators

Medical staff:

  • Medical staff organized according to bylaws approved by Board of Directors
    • independent group; reports to CEO and Board
    • headed by Chief of Medical Staff
  • Role of Medical staff:
    • assure quality of services provided
    • monitor and review MD performance
    • attempt to get MD behavior to coincide with hospital objectives and needs
    • serve on committees: quality assurance and improvement, safety, mortality review, infection prevention
  • MDs usually NOT employed by the hospital (with exception of hospitalists and sometimes radiologists and pathologists), but they are part of the medical staff
    • Granted admitting and treatment priveleges based on credentials, hospital’s needs, etc.
    • Despite not being employees, still play a role in the Medical Staff management structure
21
Q

Mission, Values, Goals - statements of hospitals

A

Mission Statement

  • Addresses hospital’s business; formal statement of goals and methods of achieving goals

Vision Statement

  • Often statement of what hospital would like to do and role it would like to play in community
    • Ideals
    • Philosophy of hospital

Values (sometimes combined with Vision)

  • Moral values & core beliefs of hospital