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Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
Hospitals Components of the Care Care Premium Payment
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Hospitals Components of the Care Care Premium Payment

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    • 1. Hospitals
    • 2. Components of the Care Care Premium Payment HIAA Issue Brief: “Why Do Health Insurance Premiums Rise?” Sept 2002 Physicians and Other Health Providers 41% Hospitals 30% Drugs and Medical Supplies 14% Nursing and Home Health Care 3% Claims and Consumer Services 12%
    • 3. Estimated Medicare Benefit Payments, by Type of Service, 2002 Source: CBO, March 2002 Baseline: Medicare. Total = $247 Billion
    • 4. National Expenditures for Health Services and Supplies (1) by Category 1980 and 2001 Source: Centers for Medicare & Medicaid Services, Office of the Actuary (1) Excludes medical research and medical facilities construction (2) “Other” includes net cost of insurance and administration, government public health activities, and other personal health care (3) “Other professional” includes dental and other non-physician professional services Prescription Drugs - 5.2% Trends in the Overall Health Care Market Physician Services - 20.2% Hospital Care - 43.5% Nursing Home Care - 7.6% Other (2) - 9.5% Other Medical Durables and Non-durables - 5.9% Home Health Care - 1.0% Other Professional (3) - 7.3% $233.5 B $1372.6 B Other Medical Durables and Non-durables – 3.7% Prescription Drugs – 10.2% Home Health Care - 2.4% Other Professional (3) - 7.9% Physician Services - 22.9% Hospital Care - 32.9% Other (2) - 12.9% Nursing Home Care - 7.2% 10
    • 5. Percent Change in National Expenditures for Selected Health Services and Supplies 1992 - 2001 Rx Drugs Premiums Hospital Nursing home Home health Source: The Lewin Group analysis of American Hospital Association Annual Survey data, 1980 – 2001, for community hospitals
    • 6. Evolution of Hospitals <ul><li>Institutions of social welfare </li></ul><ul><li>Built specifically to care for the sick </li></ul><ul><li>Institutions of medical practice </li></ul><ul><ul><li>growth </li></ul></ul><ul><li>Institutions of medical training </li></ul><ul><li>Institutions of health service consolidation </li></ul>
    • 7. Types of Hospitals <ul><li>Community / General Medical (Surgical) </li></ul><ul><ul><li>Acute Care </li></ul></ul><ul><li>Specialty Hospital </li></ul><ul><li>Mental Illness / Psychiatric </li></ul><ul><li>Rehabilitation </li></ul><ul><ul><li>Chronic disease </li></ul></ul>
    • 8. Types of Hospitals <ul><li>Community Hospital </li></ul><ul><li>Nonfederal, short stay </li></ul><ul><ul><li>< 30 days, acute </li></ul></ul><ul><li>Services available to the general public </li></ul><ul><ul><li>Examples of non-community hospitals? </li></ul></ul>
    • 9. Types of Hospitals <ul><li>Specialty Hospital </li></ul><ul><li>Admits only certain types of patients </li></ul><ul><ul><li>Women </li></ul></ul><ul><ul><li>Children </li></ul></ul><ul><ul><li>Cardiac care </li></ul></ul><ul><ul><li>Rehabilitation </li></ul></ul><ul><ul><li>Tuberculosis </li></ul></ul><ul><ul><li>Etc </li></ul></ul>
    • 10. Hospitals can be distinguished by: <ul><li>Ownership </li></ul><ul><li>Public (government owned) </li></ul><ul><ul><li>Federal </li></ul></ul><ul><ul><ul><li>Military, VA </li></ul></ul></ul><ul><ul><li>State </li></ul></ul><ul><ul><ul><li>Mental, TB </li></ul></ul></ul><ul><ul><li>Local </li></ul></ul><ul><ul><ul><li>Community hospitals </li></ul></ul></ul><ul><ul><ul><li>Serve urban areas, indigent </li></ul></ul></ul><ul><ul><ul><li>May be teaching hospital </li></ul></ul></ul>
    • 11. Hospitals can be distinguished by: <ul><li>Ownership </li></ul><ul><li>Private </li></ul><ul><ul><li>Voluntary </li></ul></ul><ul><ul><ul><li>Non-profit (tax-exempt) </li></ul></ul></ul><ul><ul><ul><ul><li>Make profit, but cannot be distributed to individuals </li></ul></ul></ul></ul><ul><ul><ul><li>Assets belong to community </li></ul></ul></ul><ul><ul><ul><li>Among all private hospitals, ~80% are nonprofits </li></ul></ul></ul><ul><ul><li>Proprietary (investor-owned) </li></ul></ul><ul><ul><ul><li>Owned by individuals, partners, or corporations </li></ul></ul></ul><ul><ul><ul><li>Operated for the financial benefit of stockholders </li></ul></ul></ul>
    • 12. Major Distinguishing Features of Non-profit Hospitals <ul><li>Exist primarily for some public good </li></ul><ul><li>Profits are not distributed to any individuals </li></ul><ul><ul><li>No shareholders </li></ul></ul><ul><li>Exempt from income tax, sales tax, and property tax </li></ul><ul><ul><ul><li>They deliver benefits that exceed the subsidy? </li></ul></ul></ul>
    • 13. Hospitals can be distinguished by: <ul><li>Affiliation </li></ul><ul><li>Independent </li></ul><ul><li>Multi-unit chains (hospital systems) </li></ul><ul><ul><li>Advantages </li></ul></ul><ul><ul><ul><li>Reduced administrative overhead </li></ul></ul></ul><ul><ul><ul><li>Provide broad scope of services </li></ul></ul></ul><ul><ul><ul><li>Reach variety of markets </li></ul></ul></ul><ul><ul><ul><li>Access to capital </li></ul></ul></ul><ul><ul><ul><li>Access to management resources, expertise </li></ul></ul></ul>
    • 14. Hospitals in RI <ul><li>Lifespan </li></ul><ul><li>Rhode Island Hospital </li></ul><ul><li>Bradley Hospital </li></ul><ul><li>Hasbro Children’s Hospital </li></ul><ul><li>The Miriam Hospital </li></ul><ul><li>Newport Hospital </li></ul><ul><li>Care New England </li></ul><ul><li>Women & Infants </li></ul><ul><li>Butler Hospital </li></ul><ul><li>Kent County Hospital </li></ul><ul><li>Unaffiliated </li></ul><ul><li>Roger Williams Medical Center </li></ul><ul><li>South County Hospital </li></ul><ul><li>Westerly Hospital </li></ul><ul><li>Partners Healthcare System </li></ul><ul><li>Memorial Hospital of RI </li></ul><ul><li>Department of Mental Health </li></ul><ul><li>Retardation and Hospitals </li></ul><ul><li>Eleanor Slater Hospital </li></ul><ul><li>St. Joseph Health Services </li></ul><ul><li>Our Lady of Fatima Hospital </li></ul><ul><li>St. Joseph Hospital for Specialty Care </li></ul><ul><li>Landmark </li></ul><ul><li>Landmark Medical Center </li></ul><ul><li>Rehabilitation Hospital of Rhode Island </li></ul>
    • 15. Types of Hospitals <ul><li>Teaching or Non-Teaching </li></ul><ul><ul><li>AMA approved residency programs for MDs </li></ul></ul><ul><ul><li>Affiliation with medical school or other health discipline </li></ul></ul><ul><ul><li>24 hr Access to MD care </li></ul></ul><ul><ul><li>Technology </li></ul></ul><ul><ul><li>Residents, interns </li></ul></ul><ul><ul><li>Major or minor </li></ul></ul><ul><ul><ul><li>Member of Council of Teaching Hospitals </li></ul></ul></ul><ul><li>Osteopathic hospitals </li></ul>
    • 16. Hospital Governance <ul><li>Board of Trustees (governing body) </li></ul><ul><ul><ul><li>Define the mission </li></ul></ul></ul><ul><ul><ul><li>Set long-term direction </li></ul></ul></ul><ul><ul><ul><li>Relationship with community </li></ul></ul></ul><ul><ul><ul><li>Operational policies </li></ul></ul></ul><ul><ul><ul><li>Appoint and evaluate the CEO </li></ul></ul></ul><ul><ul><ul><li>Approve MD appointment </li></ul></ul></ul><ul><li>Chief Operating Officer (CEO) </li></ul><ul><ul><ul><li>Responsible for day-to-day activities </li></ul></ul></ul><ul><li>Medical Director (chief of staff) </li></ul><ul><ul><ul><li>Clinical oversight </li></ul></ul></ul><ul><ul><ul><li>Medical staff </li></ul></ul></ul><ul><ul><ul><ul><li>Chiefs of service </li></ul></ul></ul></ul><ul><ul><ul><li>Medical staff Committees </li></ul></ul></ul>
    • 17. Licensure, Certification, Accreditation <ul><li>Licensure (State function; Mandatory) </li></ul><ul><ul><li>Condition : </li></ul></ul><ul><ul><ul><li>Compliance with state laws, building codes, fire safety, sanitation standards </li></ul></ul></ul><ul><li>Certification (Federal function; non-mandatory per se) </li></ul><ul><ul><li>Condition : </li></ul></ul><ul><ul><ul><li>Satisfy conditions of participation </li></ul></ul></ul><ul><ul><ul><li>Compliance with standards </li></ul></ul></ul><ul><li>Accreditation (Private function, voluntary) </li></ul><ul><ul><li>Condition : </li></ul></ul><ul><ul><ul><li>Joint Commission for Accreditation of Healthcare Organizations (JCAHO) </li></ul></ul></ul>
    • 18. Regulation <ul><li>State </li></ul><ul><ul><li>License from Department of Public Health </li></ul></ul><ul><ul><li>May restrict to Not-For Profit </li></ul></ul><ul><ul><li>Mix of Services </li></ul></ul><ul><ul><ul><li>Medicine, pathology, radiology, pharmacy, ED, etc. </li></ul></ul></ul><ul><ul><li>Minimum Standards </li></ul></ul><ul><ul><ul><li>Physical plant </li></ul></ul></ul><ul><ul><ul><li>Staffing </li></ul></ul></ul><ul><ul><ul><li>Infectious disease controls </li></ul></ul></ul><ul><ul><ul><li>Quality assurance </li></ul></ul></ul>
    • 19. Key Law: A. The Hill-Burton Free Care Program <ul><li>1946 - Modernize after Depression, WWII </li></ul><ul><ul><li>In return for funds, hospitals must provide free care (not bad debt) </li></ul></ul><ul><li>1975 Title XVI Public Health Service Act </li></ul><ul><ul><li>must provide uncompensated services in perpetuity </li></ul></ul><ul><ul><li>Govt. can recover funds after institution sold </li></ul></ul>
    • 20. B. Emergency Medical Treatment and Active Labor Act (EMTALA) <ul><li>1986 - Forbids Medicare participating hospitals from dumping patients out of EDs </li></ul><ul><ul><li>patients may be transferred after screened and stabilized only if at no risk </li></ul></ul><ul><ul><li>must attempt to communicate with non-English speaking patients </li></ul></ul><ul><li>Non-compliance = $50,000 penalty/pt + lawsuit </li></ul><ul><li>Most states have legislation requiring some degree of ED care </li></ul>
    • 21. C. Sherman Antitrust Act <ul><li>Section I. Every contract… in restraint of trade or commerce among the several states…is declared to be illegal </li></ul><ul><ul><li>If ‘market power’ possessed </li></ul></ul><ul><li>Section II. Every person who shall monopolize or ATTEMPTS to monopolize …any part of trade or commerce shall be deemed guilty of a felony </li></ul>
    • 22. D. Patient Rights <ul><li>Informed Consent </li></ul><ul><li>Advance Directives </li></ul><ul><ul><li>Do not resuscitate orders </li></ul></ul><ul><ul><li>Living will </li></ul></ul><ul><ul><li>Durable owner of attorney </li></ul></ul><ul><li>Hill-Burton notice </li></ul>
    • 23. <ul><li>Is the hospital industry growing or retrenching? </li></ul>
    • 24. Number of Beds and Number of Beds per 1,000 Persons 1980 - 2001 Source: The Lewin Group analysis of American Hospital Association Annual Survey data, 1980 – 2001, for community hospitals
    • 25. Hospital Expansion 1960-1980 <ul><li>Factors: </li></ul><ul><li>Advances in medical science/service </li></ul><ul><li>Development of specialized technology </li></ul><ul><li>Advances in medical education </li></ul><ul><li>Development of professional nursing </li></ul><ul><li>Growth of health insurance </li></ul><ul><li>Role of government </li></ul>
    • 26. Hospital Expansion <ul><li>Role of government: </li></ul><ul><li>Hill-Burton Act (1946) provided federal construction and repair grants to states </li></ul><ul><li>Medicare and Medicaid </li></ul><ul><ul><li>Cost-plus reimbursement </li></ul></ul><ul><li>Between 1965-1980 hospital beds increased by ~33% </li></ul>
    • 27. Hospital Downsizing 1980s  <ul><li>Factors: </li></ul><ul><li>Reimbursement </li></ul><ul><ul><li>DRG (1983) </li></ul></ul><ul><li>Economic constraints </li></ul><ul><ul><li>Small rural </li></ul></ul><ul><li>Technology </li></ul><ul><ul><li>Move to outpatient services </li></ul></ul><ul><li>Utilization controls </li></ul><ul><li>Social factors </li></ul>
    • 28. Shift to Outpatient Services <ul><li>Technology </li></ul><ul><ul><li>reduces inpatient days </li></ul></ul><ul><ul><li>reduces need for inpatient services </li></ul></ul><ul><li>Homecare, outpatient services, and neighborhood clinics </li></ul><ul><li>Influence of prospective payment </li></ul><ul><ul><li>MCO’s and Govt. reduced length of stay </li></ul></ul>
    • 29. Total Hospital Outpatient Visits in Community Hospitals 1980 - 2001 Millions Source: The Lewin Group analysis of American Hospital Association Annual Survey data, 1980 – 2001, for community hospitals
    • 30. Number of Freestanding Ambulatory Care Surgery Centers 1996, 1998, 2000, and 2002 Source: SMG Marketing Group
    • 31. Percentage Share of Inpatient vs. Outpatient Surgeries 1980 - 2001 Inpatient Surgeries Outpatient Surgeries Source: The Lewin Group analysis of American Hospital Association Annual Survey data, 1980 – 2001, for community hospitals
    • 32. Integration <ul><li>Vertical </li></ul><ul><ul><ul><li>expand rage of services </li></ul></ul></ul><ul><li>Horizontal </li></ul><ul><ul><ul><li>mergers and affiliations </li></ul></ul></ul>
    • 33. Current Economic Pressures <ul><li>Increasing demand </li></ul><ul><li>Rising input costs </li></ul><ul><ul><li>Labor </li></ul></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><li>Medical devices </li></ul></ul><ul><li>Medical liability insurance crisis </li></ul><ul><li>New requirements for disaster readiness and HIPAA </li></ul><ul><li>Recession </li></ul>
    • 34. Inpatient Admissions in Community Hospitals 1980 - 2001 Source: The Lewin Group analysis of American Hospital Association Annual Survey data, 1980 – 2001, for community hospitals. Millions
    • 35. Total Inpatient Days in Community Hospitals 1980 - 2001 Millions Source: The Lewin Group analysis of American Hospital Association Annual Survey data, 1980 – 2001, for community hospitals
    • 36. Average Length of Stay in Community Hospitals 1980 - 2001 Source: The Lewin Group analysis of American Hospital Association Annual Survey data, 1980 – 2001, for community hospitals DAYS
    • 37. Share of Growth in Spending on Hospital Care 1997 to 2001 (~84B) Source: PricewaterhouseCoopers calculations, February 2003 . Population Growth 21% Utilization Rate 34.4%
    • 38. Share of Growth in Spending on Hospital Care 1997 to 2001 (~84B) Wages 32% Benefits 7% Drugs 3.5% Supplies and Services 21% Other: -18.3% efficiencies
    • 39. Aggregate Hospital Payment-to-Cost Ratios for Private Payers, Medicare and Medicaid 1980 - 2001 Source: The Lewin Group analysis of American Hospital Association Annual Survey data, 1980 – 2001, for community hospitals (1) Includes Medicaid Disproportionate Share payments Private Payer Medicare Medicaid (1)
    • 40. Local Economic Influence <ul><li>Hospital as Purchaser </li></ul><ul><li>Hospital as Employer </li></ul><ul><li>Provider of Discounted and Uncompensated Care </li></ul><ul><li>Provides Health Education and Promotion Programs </li></ul>
    • 41. For-Profit versus Not-for-Profit
    • 42. <ul><li>... As you can see, Dr. Rawlings and the Terrace Heights Hospital are not prejudiced. Anyone can get in, regardless of race, color, or creed - they just have to be able to pay! Their admission does not depend upon the degree of the their illness, but on the right insurance card. </li></ul><ul><li>That's a far cry from the sign in front of Albert Schwitzer's Jungle Hospital, which reads, 'Here, at whatever hour you come, you will find light and help and human kindness.' What a rotten business man Schweitzer must have been, but what a magnificent doctor and humanitarian he was. When the only consideration of the hospital is concern for the profit margin, humanity goes out the window. And without humanity, you cannot have good medicine. &quot; </li></ul>
    • 43. “ There's nothing wrong with running a health-care enterprise for profit. After all, doctors, nurses and drug companies work for profit.” Uwe Reinhardt, professor of health economics - Princeton ``If we don't have a sound bottom line, we can't keep the quality there, we can't provide the technology, we can't pay the best people.'’ Columbia HCA's chief executive officer, Thomas Frist Jr
    • 44. ``There's never been a study showing that for-profit hospitals do any better or worse job taking care of patients than nonprofits,'’ Judy Feder, health care researcher Georgetown University . ``It has no place in the health care system. For-profit hospitals will self destruct because they'll get too greedy. Rep. Pete Stark (D., Calif.).
    • 45. For-Profit vs Not-for-Profit <ul><li>Administrative costs: Higher administrative costs as a percentage of all costs at for-profit hospitals </li></ul><ul><ul><li>Woolhandler and Himmelstein (NEJM, 3/13/97) </li></ul></ul><ul><li>Technology: Possible incentive for teaching public hospitals to invest in newer technologies (= quality?) </li></ul>
    • 46. For-Profit Hospitals <ul><li>For-Profit hospitals 3-11% more expensive than NFPs </li></ul><ul><ul><li>Shorten stays </li></ul></ul><ul><ul><li>Up-coding of DRGs </li></ul></ul><ul><li>For-Profit spend less on personnel </li></ul><ul><li>Avoid charity care? </li></ul><ul><li>Seek areas where little competition </li></ul>
    • 47. For-Profit Hospitals <ul><li>Spend more on ancillary services and administration </li></ul><ul><ul><li>Highly paid executives </li></ul></ul><ul><ul><li>Ensure profitability </li></ul></ul><ul><li>Investors expect returns of 10- 15% or more </li></ul><ul><li>FPs must pay taxes on their profits </li></ul>
    • 48. Concerns about For-Profit Hospitals <ul><li>Loss of local control of a valued community resource and employer, often one of the biggest in town </li></ul><ul><li>Allegations that they buy troubled nonprofit hospitals at bargain prices and don't adequately reimburse states and cities for years of the hospitals’ tax-free status </li></ul><ul><li>Concern that hospital chains are building local health care empires that wield too much clout against competitors. </li></ul><ul><li>Unease about the quality and amount of free care to poor and uninsured patients. </li></ul>
    • 49. <ul><li>Change in ownership quick and clandestine </li></ul><ul><li>Extent to which charitable assets are repaid </li></ul><ul><li>Golden parachute for former hospital CEO </li></ul><ul><li>Reduction in unprofitable segments </li></ul><ul><li>Intangibles </li></ul><ul><ul><li>transportation, teen pregnancy prevention program, school health clinic </li></ul></ul>Concerns about For-Profit Hospitals (cont.)
    • 50. LARGEST FOR-PROFIT, PUBLICLY TRADED HOSPITAL COMPANIES (ranked by number of licensed beds) <ul><li>1. HCA INC. (based in Nashville) 175 hospitals 40,056 licensed beds </li></ul><ul><li>2. TENET HEALTHCARE CORP . (Santa Barbara, CA) 113 hospitals 27,748 licensed beds </li></ul><ul><li>3. TRIAD HOSPITALS INC. (Dallas) 45 hospitals 7,816 licensed beds </li></ul><ul><li>4. COMMUNITY HEALTH SYSTEMS INC. (Brentwood, TN) 70 hospitals 7,020 licensed beds </li></ul><ul><li>5. UNIVERSAL HEALTH SERVICES INC. (King of Prussia, PA) 25 hospitals 5,846 licensed beds </li></ul><ul><li>6. HEALTH MANAGEMENT ASSOCIATES INC. (Naples, FL) 41 hospitals 5, 769 licensed beds </li></ul><ul><li>7. PROVINCE HEALTHCARE COMPANY (Brentwood, TN) 20 hospitals 2,315 licensed beds </li></ul><ul><li>8. LIFEPOINT HOSPITALS INC. (Brentwood, TN) 23 hospitals 2,196 licensed beds </li></ul>http://www.corp-research.org/jan03.htm
    • 51. The short term outlook <ul><li>Inpatient  Outpatient </li></ul><ul><li>Integration </li></ul><ul><ul><li>Vertical (expand rage of services) </li></ul></ul><ul><ul><li>Horizontal (mergers and affiliations) </li></ul></ul><ul><li>Payment: Power balance </li></ul><ul><li>Regulation </li></ul><ul><li>Safety </li></ul><ul><li>Labor shortages </li></ul><ul><li>Information technology / HIPAA </li></ul><ul><li>Consumerism </li></ul>

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