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June 2010

Hospital Inpatient and Emergency Department Utilization Trends Fiscal Years 2004-2008. June 2010. Deval L. Patrick, Governor Commonwealth of Massachusetts Timothy P. Murray Lieutenant Governor. JudyAnn Bigby, M.D., Secretary Executive Office of Health and Human Services

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June 2010

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  1. Hospital Inpatient and Emergency Department Utilization TrendsFiscal Years 2004-2008 June 2010 Deval L. Patrick, GovernorCommonwealth of Massachusetts Timothy P. MurrayLieutenant Governor JudyAnn Bigby, M.D., SecretaryExecutive Office of Health and Human Services David Morales, CommissionerDivision of Health Care Finance and Policy

  2. Table of Contents Executive Summary: Focus of this Analysis 2 Executive Summary: Major Findings 3 Trends in Hospital Inpatient Utilization 4 Trends in Hospital Emergency Department Utilization 11 Appendix 19 Data Sources and Methods Teaching and Community Hospitals in Massachusetts Disproportionate Share Hospitals (DSH) in Massachusetts Massachusetts Emergency Medical Services (EMS) Regions

  3. Executive Summary: Focus of this Analysis • To evaluate trends in hospital inpatient utilization in Massachusetts from FY04 through FY08 and the differences in utilization: • Between teaching and community hospitals • Between disproportionate share hospitals (DSH) and non-DSH hospitals • Among the five regions of Massachusetts • To evaluate trends in hospital emergency department (ED) utilization, mainly hospital outpatient ED visits, in Massachusetts from FY04 through FY08 and the differences in utilization: • Between teaching and community hospitals • Between DSH and non-DSH hospitals • Among the five regions of Massachusetts

  4. Executive Summary: Major Findings Inpatient Utilization • The number of discharges in Massachusetts hospitals remained relatively stable from FY04 through FY08. The total number of hospital inpatient discharges fluctuated by less than 1% (approximately 6,000 discharges) during this period. The most substantial change in the rate of inpatient discharges was a decrease of 1.2% from FY07 to FY08, after adjusting for population changes. • There was little change in the proportion of discharges at teaching hospitals versus community hospitals from FY04 through FY08. Although there was a slight increase in the number of discharges at teaching hospitals and a slight decrease in discharges at community hospitals between FY04 and FY08, the proportion of discharges at teaching hospitals remained stable at 44% to 45% during this period. Larger shifts into teaching hospitals occurred during the 1990s when the percentage of discharges in teaching hospitals increased from 36% to 43%. • Most regions of the state, with the exception of the Central region where discharges declined, experienced modest increases in inpatient hospitalization from FY04 to FY08. The largest increase (1.7%) in inpatient discharges occurred in the Southeast region, while the Central region experienced a 4.5% drop. • Most patients chose hospitals located in the same region where they live, however, one-third of patients residing in the Northeast and Southeast went to Metro Boston area hospitals for inpatient care. Emergency Department (ED) Utilization • The total number of ED visits in Massachusetts increased 9% from FY04 to FY08, reaching about 3 million by FY08. After adjusting for population changes, ED visits increased between 1.5% and 2.4% each year between FY04 and FY08. • Several national and local studies indicate that the volume of ED visits are not necessarily expected to decrease as insurance coverage expands. This is due in large part to the fact that the uninsured do not account for a larger share of preventable or avoidable ED visits than the insured and that reliance on the ED may be due to outpatient capacity constraints, which may be exacerbated by increased insurance coverage. • The percentage increase in outpatient ED visits was the same among teaching and community hospitals from FY04 through FY08. Teaching hospitals accounted for roughly 30% of outpatient ED visits during this period. This is a lower percentage than found for inpatient discharges (45%). • Outpatient ED visits increased at the same rate in both DSH hospitals and non-DSH hospitals. In FY08, DSH hospitals accounted for about 35% of outpatient ED visits. • Increases in outpatient ED visits were observed in all regions of the state from FY04 through FY08 with the largest increase (20%) found in the West. The rate of increase in the Western region was more than double the increase in most other regions. Northeast region hospitals experienced a 3% increase in outpatient ED visits during this period. • As expected, most patients went to hospital emergency rooms located in the same region as their residence. However, about 21% and 12% of residents in the Northeast and Southeast regions, respectively, chose or were sent to a Metro Boston area hospital.

  5. Trends in Hospital Inpatient Utilization

  6. Volume of Inpatient Discharges Relatively Stable FY04 to FY08Annual Number of Inpatient Discharges in MA The total number of hospital inpatient discharges in Massachusetts fluctuated by less than 1% each year between FY04 and FY08. During the last two decades, the number of hospital discharges reached the peak of over 900,00 in 1992 and went down to the bottom of about 760,000 in 1996. It gradually increased since 1996. +0.7% -0.7% +0.8% -0.4% Source: DHCFP Massachusetts Hospital Discharge Data.

  7. After Adjusting for Population Changes, Volume of Inpatient Discharges Remained Relatively Stable FY04 to FY08Number of Inpatient Discharges Per 1,000 Population in MA After adjusting for population changes, the largest change in the volume of inpatient discharges was a decrease of 1.2% from FY07 to FY08. This decrease followed a period of increase in the previous two years. Discharges per 1,000 population +0.3% -1.2% -0.4% +0.6% Source: DHCFP Massachusetts Hospital Discharge Data.

  8. Teaching Hospitals Accounted for 44% of All Inpatient Hospitalizations FY04 to FY08Number of Inpatient Discharges by Hospital Teaching Status in MA Teaching hospitals made up roughly 44% of the discharges from FY04 to FY08. This is substantially higher than the national rate of 19%. More substantial increases in the share of discharges to teaching hospitals occurred during the 1990s, when the share of discharges in teaching hospitals went from 36% in FY90 to 43% by FY00. Source: DHCFP Massachusetts Hospital Discharge Data. List and map of teaching and community hospitals is included in the Appendix.

  9. Share of Inpatient Hospital Discharges at DSH Hospitals Decreased FY04 to FY08Number of Inpatient Discharges by Hospital DSH Status in MA The number of inpatient discharges in DSH hospitals decreased by 3.7% from FY04 to FY08 and discharges in non-DSH hospitals increased by 1.9% during the same period. DSH inpatient discharges make up about 27%-28% of discharges in each year of the study. DSH: disproportionate share hospitals. Sixty-three percent or more of patient charges attributed to Medicare, Medicaid, other government payers, and free care. List of DSH hospitals is included in the Appendix. Source: DHCFP Massachusetts Hospital Discharge Data.

  10. Distribution of Inpatient Discharges Among Hospital Regions Relatively Stable FY04 to FY08Number of Inpatient Discharges by Regions of Hospital Location in MA The number of inpatient discharges increased between 0.4% and 1.7% from FY04 to FY08 in all regions except the Central region, which experienced a decline of 4.5% over the same period. Hospitals in the Southeast region had the highest increase (1.7%) from FY04 to FY08. All regions experienced a decrease from FY07 to FY08. Source: DHCFP Massachusetts Hospital Discharge Data.

  11. About a Third of Patients in the Northeast and Southeast Chose a Metro Boston Area Hospital for Inpatient CareDistribution of Inpatient Discharges among Regions of Hospital Location in MA, FY08 Most patients went to the hospitals located in the same region as their residence. However, about one-third of residents in the Northeast and Southeast regions chose a Metro Boston area hospital. About 14% of residents in the Central region used Metro Boston hospitals. This pattern has been fairly stable since FY04. Note: Non-Massachusetts residents and the discharges with missing residence information are excluded (5.5% of total inpatient discharges in 2008). Source: DHCFP Massachusetts Hospital Discharge Data.

  12. Trends in Hospital Emergency Department Utilization

  13. Number of ED Visits Increased between 1.4% and 2.5% Each Year FY04 to FY08Volume of ED Visits in MA 2.1% Between FY04 and FY08 the total number of ED visits in Massachusetts increased between 1.4% and 2.5% each year. Eighty-two percent of ED visits result in a discharge from the ED. The distribution of ED visits among those that result in discharge versus inpatient or observation stay was stable during this period. Future DHCFP analyses will evaluate the change in outpatient ED visits for emergent versus ambulatory care sensitive conditions. 2.5% 2.5% 1.4% 2,928,036 2,868,781 2,799,680 2,730,252 2,692,407 3% 3% 15% 15% 82% 82% Notes: Due to the reported data errors from two hospitals for 2004 and 2005, their data are excluded from all years ED data for accuracy in trends. These hospitals make up roughly 5% of total ED visits. The total ED visits for 2008 with these hospitals included is 3,086,940. Data include ED visits to Massachusetts hospitals by Massachusetts and out-of-state residents.Source: DHCFP Massachusetts Hospital Discharge Data; DHCFP Hospital Outpatient ED Data; DHCFP Hospital Observation Data.

  14. ED Visits per 1,000 Population Gradually Increased between FY04 and FY08Volume of Total and Outpatient ED Visits Per 1,000 Population in MA After adjusting for population changes, the growth in ED visits was somewhat slower from FY06 through FY08 compared to the unadjusted growth rate. The rate of growth of ED visits per 1,000 population was 1.6% from FY07 to FY08 compared to the unadjusted change of 2.1% from FY06 to FY07. 1.6% 2.1% 2.4% 1.5% Source: DHCFP Massachusetts Hospital Discharge Data; DHCFP Hospital Outpatient ED Data; DHCFP Hospital Observation Data.

  15. Research Finds ED Use Not Expected to Decline with Expanded Coverage Several national and local studies have found that the volume of ED visits should not be expected to decrease as insurance coverage expands and in fact indicate that increases may occur for the following reasons: • The uninsured do not account for a larger share of avoidable ED visits • Reliance on the ED may be due to outpatient capacity constraints which may be exacerbated by the newly insured seeking to establish primary care relationships Among the studies and articles cited:What Accounts for Difference in the Use of Hospital Emergency Departments Across U.S. Communities? Peter J. Cunningham; Health Affairs. 25 no.5 (2006) w324-w336 (published online 18 July 2006) DOI: 10.1377/hlthaff.25.w324 Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? Results of a national population-based study Ellen J. Weber, Jonathan A. Showstack, Kelly A. Hunt, David C. Colby, Michael L. Callahan; Annals of Emergency Medicine – January 2005 (Vol. 45, Issue 1, Pages 4-12, DOI 10.1016/j.annemergmed.2004.06.023) Myths and Facts: Would expanding health coverage ease emergency department overcrowding and reduce spending?http://callhealthreform.org/contents/view/39/ Emergency Department Visits in Massachusetts: Who Uses Care and Why? A Massachusetts Health Reform Survey Policy Brief, Sharon K. Long; Karen Stockley: Urban Institute, Blue Cross Blue Shield Foundation, The Commonwealth Fund, The Robert Wood Johnson Foundation, September 2009 Health Insurance Transitions and Emergency Department Utilization Mortensen K, McLaughlin C; AcademyHealth. Meeting (2005: Boston, MA) Abstr AcademyHealth Meet.2005; 22:abstract no. 3015 Massachusetts universal coverage does not reduce ED visits, polls say; Susan Landers, AMA, published online amednews.com; http://www.ama-assn.org/amednews/2009/10/19/prsf1020.htm

  16. Volume of Outpatient ED Visits Grew at Similar Rates for Teaching and Community HospitalsNumber of Outpatient ED Visits by Hospital Teaching Status in MA, FY04-FY08 The percentage increase in outpatient ED visits was roughly equal between teaching and community hospitals and relative shares remained fairly stable. The percentage of outpatient ED visits at teaching hospitals was 30%, compared to 45% of inpatient discharges. **Two hospitals excluded from this analysis are both community hospitals, therefore, the percentage share is slightly distorted. With the inclusion of these two hospitals, the teaching hospital share is slightly lower at 29% and the community hospital share is slightly higher at 71%. Note: Due to the reported data errors from two hospitals for 2004 and 2005, their data are excluded from all years ED data for accuracy in trends. These hospitals make up roughly 5% of total ED visits. The total outpatient ED visits for 2008 with these hospitals included is 2,500,069. Data include ED visits to Massachusetts hospitals by Massachusetts and out-of-state residents.

  17. Outpatient ED Visits Increased at the Same Rate in Both DSH and Non-DSH Hospitals Number of Outpatient ED Visits by Hospital DSH Status in MA, FY04-FY08 The percentage of ED visits at DSH hospitals remained at 35% throughout the period FY04 to FY08. This distribution is slightly higher than that for inpatient discharges, where DSH hospitals represent roughly 27% of all discharges. **The two hospitals excluded from this trend analysis are each a DSH and non-DSH hospital. As a result, the proportions are relatively unchanged when these hospitals are included. The DSH and non-DSH hospital shares are 35.6% and 64.4%, respectively. Note: Due to the reported data errors from two hospitals for 2004 and 2005, their data are excluded from all years ED data for accuracy in trends. These hospitals make up roughly 5% of total ED visits. The total outpatient ED visits for 2008 with these hospitals included is 2,500,069. Data include ED visits to Massachusetts hospitals by Massachusetts and out-of-state residents. DSH: disproportionate share hospitals. 63% or more of patient charges attributed to Medicare, Medicaid, other government payers, and free care.Source: DHCFP Hospital Outpatient ED Data.

  18. Hospitals in the West Region Experienced a 20% Increase in Outpatient ED Visits FY04 to FY08 Number of Outpatient ED Visits by Hospital Regions in MA, FY04-08 Outpatient ED visits increased in all hospital regions. However, hospitals in the West region had the highest increase (20%) between FY04 and FY08, more than double the increase found in other regions. The increase was just 3% for the hospitals located in the Northeast region. The greatest proportion of ED visits (34%) is found in the Metro Boston area followed by the Southeast region (22%). Note: Due to the reported data errors from two hospitals for 2004 and 2005, their data are excluded from all years ED data for accuracy in trends. One of the excluded hospitals is from the Metro Boston area and the other is from the Northeast. These hospitals make up roughly 5% of total ED visits. The total outpatient ED visits for 2008 with these hospitals included is 2,500,069. Data include ED visits to Massachusetts hospitals by Massachusetts and out-of-state residents.Source: DHCFP Hospital Outpatient ED Data.

  19. More than 20% of Patients Residing in the Northeast Went to a Metro Boston Area EDDistribution of Outpatient ED Visits among Regions of MA, FY08 Not surprisingly, most ED patients went to hospitals located in the same region where they live. However, 21% of those living in the Northeast region and 12% of those in the Southeast region chose, or were sent to, a Metro Boston area hospital. These include those transported by ambulance. Note: Non-Massachusetts residents and the visits with missing residence information are excluded (6.4% of total outpatient ED visits in 2008).Source: DHCFP Hospital Outpatient ED Data.

  20. Appendix

  21. Data Sources and Methods Hospital Inpatient Utilization • Massachusetts Division of Health Care Finance and Policy (DHCFP), Hospital Inpatient Discharge Database, FY04-FY08. This dataset is created based on data submissions from all Massachusetts acute hospitals. The hospital fiscal year is generally October 1 through September 30 of each year. Hospital Emergency Department Utilization • DHCFP, Outpatient Emergency Department Database, FY04-FY08. Includes visit-level information for those ED patients who were discharged from the ED as outpatients and were not transferred to either hospital observation or hospital inpatient. • DHCFP, Hospital Inpatient Discharge Database, FY04-FY08. Includes those ED patients who were admitted for inpatient care after an ED visit. • DHCFP, Hospital Outpatient Observation Database, FY04-FY08. Includes those ED patients who were admitted for observation after an ED visit. • These ED datasets are created based on data submissions from all Massachusetts acute hospitals. Population Adjustments • Population data are from U.S. Census Bureau, “Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico: April 1, 2000 to July 1, 2008” (NST-EST2008-01). Data Adjustments • Due to reported data errors from two hospitals for 2002 through 2005, their data are excluded from all ED visit data related to the trends. These hospitals make up roughly 5% of ED visits. These two hospital data are included in the regional analyses which are based only on FY08 data.

  22. Teaching and Community Hospitals in Massachusetts • In this analysis, teaching hospitals are defined according to the Medicare Payment Advisory Commission’s (MedPAC) definition of a major teaching hospital: at least 25 full time equivalent medical school residents per one hundred inpatient beds. • The Division of Health Care Finance and Policy analyzed the most current available hospital cost reports to determine which hospitals met this criteria. For the purposes of this analysis, the 15 hospitals meeting this criteria were assigned to the teaching cohort for all the years of this analysis.

  23. Disproportionate Share Hospitals (DSH) in Massachusetts • In this analysis, the Division of Health Care Finance and Policy defines disproportionate share hospitals (DSHs) as those hospitals with a large percentage (63% or more) of patient charges attributed to Medicare, Medicaid, other government payers, and free care. • Based on this definition and using a 2007 base year, the 18 hospitals listed below were assigned to the DSH cohort for all the years of this analysis.

  24. Massachusetts Emergency Medical Services (EMS) Regions Note: Emergency Medical Services (EMS) regions are designated by the Massachusetts Department of Public Health Office of Emergency Medical Services (OEMS). Massachusetts Division of Health Care Finance and Policy - 23

  25. Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Phone: (617) 988-3100 Fax: (617) 727-7662 Website: www.mass.gov/dhcfp Publication Number: 10-181-HCF-02

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