Delayed Arrival The Domestic Hc Traveler Final 091108


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Delayed Arrival The Domestic Hc Traveler Final 091108

  1. 1. WHITE PAPER DelayeD arrival: the Domestic healthcare travelerCheryl Kassed, Phddavid lewandowsKi, MBalinda MaCCraCKen, MBaGary PiCKens, PhdGene ray, Msleah ray, MBasePteMBer 2008
  2. 2. Domestic travelfor healthcare:stanDby for takeoff?the phenomenon of patients bypassing local healthcareproviders to receive medical services outside of their localmarkets is gaining attention in professional literature.TRAvElIng gREATER DIsTAncEs foR HEAlTHcARE—DomEsTIc TREnDs AnD IssuEs HEAlTH TouRIsmsome trend-spotters forecast that american consumers will soon increase their globetrotting to find the bestprices for medical procedures. other industry-watchers remain uncertain about the transformative effects Use of medicalof growth in the consumer-driven healthcare market. a recent study by the healthcare business of thomson services abroad: thereuters found that more than 71 percent of surveyed adults were aware of the concept of medical tourism, practice of visitingand nearly a third of those who would consider medical tourism had annual incomes of $150,000 or more. other countriesMedical tourism is an increasingly common term and is predominantly associated with lower-cost healthcare specifically to benefitoverseas. But what about domestic travel for medical care? from the medical services availableMedical travel within the U.s. may have important implications for hospital revenue and quality of care. in there, often because they are cheapersome cases, residents will travel to hospitals farther away from home because the services they require are than at home.not available locally. other consumers travel for healthcare based on “survivability-related services;” that is,specialized services impacting life-threatening illness, recovery, and longevity. hospital quality indicators, source: encarta® worldincluding ratings and rankings, play an additional role. Consumers’ out-of-pocket costs, driven by payer english dictionarycoverage, are important factors, but their influence on patients’ willingness to travel for care is still evolving.some hospitals are demonstrating their commitment to transparency by posting costs for procedures ontheir web sites, which also offers a value proposition to consumers. this underscores specialization, location,and affordability as key factors in domestic healthcare travel, and likely all aspects of medical tourism.• Which consumers are likely to travel domestically for healthcare, and why?• How much hospital business is attributable to travelers?• What procedures and services are provided to traveling healthcare consumers? • Has domestic medical travel landed, or has its arrival been delayed?in many healthcare market dimensions, consumers are empowered by a growing availability of resourcesfor comparing physician and hospital ratings. these include postings of key metrics by quality-ratingorganizations, hospitals, and the federal government, with the notable addition of patient satisfaction inhospital Consumer assessment of healthcare Providers and systems (hCahPs). delayed arrival: the domestic healthcare traveler 3
  3. 3. Patient-satisfaction ratings support consumer empowerment in healthcare selection, joined by payer recognition through incentives for high satisfaction scores. on a growth basis, this also supports improved word-of-mouth promotion of providers and hospitals by satisfied patients. the effects of physician referrals and medical triage to critical care and specialty hospitals can work to drive healthcare delivery out of market when insured patients are referred due to medical necessity. Patients needing specialty services, such as organ transplants, are most often referred to hospitals where there are certified programs that have the requisite volumes and experience to provide that care. Book your service Medical travel service selection is motivated by expertise, location, and price considerations as more payers encourage the use of lower-cost services. although the domestic healthcare traveler has not substantially impacted the hospital economy, quality, payer restrictions, and other factors—including medical tourism road shows—are converging to make patient travel for medical care a trend for hospitals to watch. thomson reuters experts explored this issue by examining national hospital data and consumer information to understand the profile of the healthcare consumer who deliberately plans healthcare travel within the U.s. the analysis excluded emergency department visits as well as persons who live in northern locales in the summer and travel to southern climates in winter (“snowbirds”). sources included a national inpatient database and consumer research from the annual healthview Plus®/PUlse healthcare survey. KEy fInDIngs • N ine out of 10 adult healthcare consumers are willing to travel for life-threatening care, while fewer than one out of 10 (4 percent) are willing to travel for routine care—a trend that has remained constant for the last four years. • Nationally, 2 percent of average inpatient discharges originate from 100+ miles away. • A few hospitals providing specialized or expert services receive, on average, twice the revenue per traveling patient than per local patient. • D omestic travelers tend to be married, younger, affluent, and influenced by national hospital ratings, underscoring the importance of family support and means to afford higher costs associated with complex care. • M edical care with specialized services related to survivability drives the highest inpatient volumes for domestic healthcare travelers. Destinations: life-threatening illness broadens the healthcare map research shows that most consumers would not seek routine medical care beyond their local communities. however, life-threatening illness—or even the perception of it, is a strong motivator for domestic healthcare travel. Consumers consistently have expressed a strong willingness to travel for vital treatment compared to routine medical services (see Figure 1). the percentage of healthcare consumers willing to travel to a different community or state for these reasons has remained relatively unchanged throughout the study period. fIguRE 1: consistent Healthcare consumer Attitudes About mobility survey year Routine care (%) life-threatening Illness (%) 2004 3.7 88.3 2005 4.1 87.4 2006 4.2 87.6 2007 4.1 87.8 source: PUlse healthcare survey/healthview Plus®4 delayed arrival: the domestic healthcare traveler
  4. 4. according to the thomson reuters national database, 98 percent of a hospitals’ (nonemergent inpatient)discharges come from people who live within 100 miles of the hospital.1 Figure 2 shows the concentration ofhospitals per state, while the percent of nonemergent traveler discharges by county is illustrated in Figure 3. fIguRE 2: number of Hospitals Per state WASH. ME. MONT. N. DAK. MINN. ORE. WISC. N.Y. IDAHO S. DAK. MICH. WYO. PA. IOWA N.J. NEBR. OHIO MONT. IND. UTAH ILL. W. VA. COLO. VA. KAN. MO. CALI. KY. N.C. TENN. ARIZ. OKLA. S.C. N.M. ARK. HOSPITALS BY STATE MISS. ALA. GA. 10 TO 43 LOU. TEX. 44 TO 69source: Medicare Cost reports 70 TO 119 FLA. 120 TO 159 160 TO 540mARKET vARIAbIlITy AcRoss HosPITAl InPATIEnT busInEss lInEsacross the country, the impact of domestic healthcare travelers varies from market to market. elements ofconsumer selection and medical referrals drive this phenomenon. rural markets clearly depict more traveldue to their lack of proximity to specialty healthcare services. fIguRE 3: Traveler Discharges TRAVELER SHARE OF NON-EMERGENT ADMISSIONS >4% (513) 3% – 4% (270) 2% – 3% (469) 1% – 2% (793)source: thomson reuters inpatient database 0% – 1% (1096) delayed arrival: the domestic healthcare traveler 5
  5. 5. consumers travel Greater Distances for vital medical care the most-used hospital inpatient services by people who live more than 100 miles from the hospital are those related to survival. this is in contrast to local users, who will typically travel up to 15 miles for “bread and butter” hospital services. Figures 4 and 5 show the top hospital services provided to domestic travelers (who live more than 100 miles from the hospitals) and local patients (who live within 15 miles of hospitals), respectively. the clinical reporting groups2 with the most usage by domestic travelers are highly-specialized medical or surgical services. transplants and significant surgeries lead the list, followed by procedures for which provider experience and specialty are particularly critical. the propensity score is a measure of service use, where 1 is average and scores greater than 1 indicate a greater than average use of service. fIguRE 4: Top 10 clinical services Received by Patients Who Travel over 100 miles other organ transplant Bone marrow transplant Craniotomy (<17) Craniotomy (age 17+) except UST Pancreas, liver & shunt procedures other cardiothoracic procedures spinal procedures Periph & cranial nerve & other nervous system procedures Chemo w/ ac leuk as sdX or high dose chemo agent ECMO/TRACH w/ UV96+ or PDX X fac/mouth/nck w/ maj OR discharges Charges 0.0 2.0 4.0 6.0 8.0 10.0 12.0 Propensity score source: thomson reuters Projected inpatient database 2007 the top-volume clinical services for local service use (within 15 miles of residence) are shown in Figure 5. again, the propensity score is a measure of service use, where 1 is average and scores greater than 1 indicate a greater than average use of service. the majority are routine procedures or medical care. fIguRE 5: Top 10 clinical services Received by Patients Within 15 miles of Residence Propensity to travel for inpatient Care—top 10 Clinical services travel Up to 15 Miles normal newborn Bronchitis & asthma (age 17+) inpatient service Kidney infections & UTIs (age 17+) vaginal delivery w/o sterilization or o.r. procedure neonate w/ other significant problems Chronic obstructive pulmonary disease Cellulitis ( age 17+) Diabetes (age35+) ectopic pregnancy discharges Cesarean section Charges 1.0 1.05 1.1 1.15 1.2 1.25 1.3 Propensity score source: thomson reuters Projected inpatient database 20076 delayed arrival: the domestic healthcare traveler
  6. 6. nationally, data show that most healthcare is still local: 98 percent of inpatient hospital discharges arepatients who have traveled fewer than 100 miles to their treatment destination (see Figure 6). Patients mostoften seek treatment for common medical conditions closer to home. fIguRE 6: Average Distances Traveled for non-Emergent Healthcare Cumulative % of inpatient admissions By distance traveled for Care 100.0% 90.0% 80.0% 70.0%% of inpatient admissions 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 2.5 7.5 15 30 50 70 90 125 175 225 275 325 375 425 475 525 575 distance traveled source: thomson reuters Projected inpatient database 2007more revenue from Domestic healthcare traveler Dischargesalthough only 2 percent of hospital discharges originate from patients traveling more than 100 miles fromtheir residence, they contribute 4 percent of hospital charges.For the top 20 hospitals treating domestic healthcare travelers, 21 percent of discharges (on average) areattributable to these patients, with a range of 15 to 36 percent of the inpatient base. however, domestichealthcare travelers drive greater revenue percentage, with average revenue of 28 percent. the range ofrevenue contributed by domestic healthcare travelers varies widely (see Figure 7). fIguRE 7: Percent of Discharges, charges, and change Attributable to Domestic Healthcare Travelers Hospital Discharges (%) charges (%) Difference (%) Grace hospital 35.7 37.1 3.9 regional Medical Center 30.5 33.5 9.8 City Medical Center 27.7 31.3 13.0 Community hospital 27.4 40.3 47.1 shady Pines Memorial 17.4 33.9 94.8 General hospital 15.6 27.4 75.6 Clinic hospital 15.3 19.1 24.8 Average 21.0 28.0 33.3hospital names are fictitious; any resemblance to actual hospital names is coincidental. data has been blinded.source: thomson reuters Projected inpatient database delayed arrival: the domestic healthcare traveler 7
  7. 7. Who is the Domestic healthcare traveler? a healthcare-specific household segmentation system provides insights about relevant drivers of consumers in terms of clinical service needs, financial profiles, and likely behavioral responses. thomson reuters consumer market research examines the attitudes, behaviors, and utilization habits of consumer segments that are most and least likely to travel domestically for healthcare. this provides the ability to target and engage these groups. the top three consumer segments most willing to travel more than 100 miles for healthcare are Balancing act, settling down, and enjoying life (see Figure 8). fIguRE 8: most likely to Travel for life-saving care: most-Penetrated Household segments acute Conditions HoW To READ RADAR cHARTs non-traditional Media Chronic Conditions these charts show the relative influence of traveler characteristics traditional Media Use alternative Care and values on the decision to travel for life-saving medical Balancing act care. items plotted settling down enjoying life farther from the center Use internet for healthcare Use Preventive Care of the chart indicate higher importance research healthcare to the household source: healthview Plus® segment. details on the healthview Plus® segment attributes include marital status, age, gender, income, and presence or absence of children. consumer research (see Figure 8) tool are available from thomson reuters. highlights: • ost are upper-income households, indicating financial means to travel and bear related costs. M • Most are under age 54, suggesting a younger population is more likely to seek specialized care. • he majority are married, indicating financial and/or emotional support to travel and bear related costs. T • arketing approaches to best target the most highly penetrated segments should consider their distinct M profiles for service needs, information use, and media response. Who isn’t likely to travel Domestically for healthcare? the least-penetrated household segments indicate that they are far less likely to travel domestically for life-saving care (see Figure 9). fIguRE 9: less likely to Travel for life-saving care: least-Penetrated Household segments acute Conditions non-traditional Media Chronic Conditions traditional Media Use alternative Care Penny savers tee time Use Preventive Care earlybird specials Use internet for healthcare research healthcare source: healthview Plus®8 delayed arrival: the domestic healthcare traveler
  8. 8. WHo Is mosT lIKEly To TRAvEl foR lIfE-sAvIng cARE?the medical condition does not seem to have an impact on the willingness of a patient to travel for care.those most likely to travel have similar utilization of various services, but higher use of certain routine andpreventive care such as routine physicals, and oB/Gyn visits. Consumers in this group also:• Intensively seek healthcare information when making decisions for parents. • Are more discriminating consumers of physician services. • Are likely to switch providers due to service problems.• Select hospitals based on reputation. • Research hospital ratings but also value service attributes.• Value latest technology and will pay more for certain procedures.• Are more likely to have employer-sponsored and family insurance coverage. • Are more likely to use the Internet for research on medical conditions.implications: sunny skies or turbulence ahead?this research raises several considerations for the future of an increasingly consumer-drivenhealthcare is still localMost hospitals serve a local market comprised of patients within a 100-mile radius of the hospital. Publicposting of quality and satisfaction may increase consumers’ local comfort with their hospitals, decreasing theout-of-market hospital search except in certain circumstances. Medical triage and referrals indicate that mostcare can be obtained close to residence.domestic travel happens with specific driverssurvivability-related services matter. only a small segment of the population is traveling domestically fordeliberate inpatient care. this occurs more for survival-related services and originates from rural locations.while this also occurs in other markets, the mobile healthcare consumer may need more service packaging tosupport out of area, given the greater coordination of post-discharge home care, involvement of family/friendsin recovery, and growing travel costs. Most medical care in the country provides local access, but medical triagedoes occur for critical specialty care and this is shown in the data. hospitals can potentially engage the mobileconsumer who utilizes services that impact life-threatening care matters for the key servicesspecialty services and rural resources are partial drivers for the domestic healthcare traveler. Given these keyelements for payer coverage, this may be expected, and this data review substantiates common assumptions.specialty/critical care services generate more revenue. it appears that “draw factors” are due to both clinicalprogram expertise and, in some cases, location.Consumer segments are more or less ready to go out of marketadults who are more prepared to travel out of their market for healthcare tend to be younger, more affluent,and heavily influenced by top hospital when making their hospital selection. in addition to the role of referralsor medical triage, there are consumers who are more prepared and motivated to travel out of their market formedical care. delayed arrival: the domestic healthcare traveler 9
  9. 9. REfEREncEs liu JJ, Bellamy G, Barnet B, et al., “Bypass of local primary care in rural counties: effect of patient and community characteristics,” Annals of Family Medicine 6:124-30, 2008; Basu J, Mobley lr, “illness severity and propensity to travel along the urban-rural continuum,” health Place 13:381-99, 2007 doty Ca: “are Consumers embracing the Convergence of healthcare and Finance?” Forrester,7211,43154,00.html, 2007 thomson reuters, “Medical tourism: survey finds that well-educated, affluent people are driving the trend.” June 2008 Begg CB, Cramer ld, hoskins wJ, Brennan MF. “impact of hospital volume on operative mortality for major cancer surgery,” JaMa, 280:1747-51, 1998; Birkmeyer Jd et al. “hospital volume and surgical mortality in the United states,” new england Journal of Medicine, 346:1137-1144, 2002; dudley ra, Johansen, Kl, Brand r, rennie dJ, Milstein a, “selective referral to high-volume hospitals: estimating potentially avoidable deaths,” JaMa, 283:1159-66, 2000 “some hospitals seeking Fees Before surgery,” Omaha World Herald php?u_page=1219&u_sid=10293524, March 27, 2008 U.s. department of health and human services: hospital Compare web site: http://www., 2008 “hospital Charges here and elsewhere,”: reports/2008/05/01/hospital-charges-here-and-elsewhere.html, May 1, 2008 Zey M: “what Medical tourism teaches america,” The Providence Journal contributors/content/Ct_zey13_09-13-07_do72M9U.1aff7eb.html, 2007 thomson reuters, “the target Markets for top hospital ratings,” May 2008EnD noTEsthis is based on straight-line distances from the population-weighted center of the patient’s county of1origin to that of the hospital’s county.2 Clinical reporting groups (CrGs) are groupings of the Centers for Medicare and Medicaid’s diagnosis- related groups (drGs) that clinically related and have sufficient patient volume to support estimates of outcomes and resource use. the CrGs were invented and are maintained by thomson reuters clinicians.10 delayed arrival: the domestic healthcare traveler
  10. 10. THE PulsE HEAlTHcARE suRvEy AnD HEAlTHvIEW Plus® suRvEy AbouT THomson REuTERs the healthcare business ofdata for this analysis were gathered from the thomson reuters PUlse healthcare survey and healthview thomson reuters produces insights,Plus surveys. the PUlse healthcare survey is the largest privately funded household survey on health information, benchmarks and analysis that enable organizationsbehavior and utilization in the nation. More than 100,000 households participate on an annual basis, and to manage costs, improvesince 1988, the PUlse survey has provided insights into emerging trends and utilization patterns not performance, and enhance theavailable from other sources. Prior to 2008, both PUlse and the healthview Plus national healthcare quality of healthcare. thomson reuters is the world’s leadingconsumer survey were fielded by thomson reuters to help hospitals understand the attitudes, behaviors, source of intelligent information forand decision-making patters of healthcare consumers in local markets. in January 2008, the healthview businesses and professionals. wePlus survey was integrated into the PUlse healthcare survey, allowing analysis of richer, additional combine industry expertise with innovative technology to deliverhealthcare consumer data from a single consumer research tool. critical information to leading decision makers in the financial, legal, tax and accounting, scientific, healthcare and media markets,THomson REuTERs nATIonAl InPATIEnT DATA powered by the world’s most trusted news organization. withthomson reuters maintains the largest all-payer inpatient database in the healthcare industry. Updated headquarters in new york and major operations in london andquarterly, this database contains approximately 20 million discharges per year from more than 2,000 eagan, Minn., thomson reutersacute-care hospitals and includes data from various hospital system and state hospital associations, public employs more than 50,000 peopleand nonpublic state patient data, and individual hospitals contracting with thomson reuters. in 93 countries. thomson reuters shares are listed on the new york stock exchange (nyse: tri); toronto stock exchange (tsX: tri); london stock exchange (lse: tril); and nasdaq (nasdaQ: trin). thomson reuters 777 e. eisenhower Parkway ann arbor, Mi 48108 Usa Phone +1 800 366 7526 ©2008 thomson reuters. all rights reserved. Pro-5674 09/08 Ks