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Mental Illness and Substance Use Hospitalizations in New Hampshire,
1997-2006
May, 2008
Part of the Access New Hampshire: Living with Disability in the Granite State Project
To learn more about the Access Project or to download the companion policy brief,
please visit us at www.iod.unh.edu. .
Questions / Comments:
Please contact:
Peter Antal, Ph.D. Melissa Mandrell, MSS, MLSP Institute on Disability/UCED
Tel/TDD: 603.228.2084 Fax: 603.228.3270
[email protected] The contents of this document were in part developed by grants from the U.S. Department of Health and Human Services, Administration on Developmental Disabilities (90DD0618), the New Hampshire Department of Education, and the New Hampshire Department of Health and Human Services, Bureau of Developmental Services (13H080). However, these contents do not necessarily represent the policies or the endorsement of the federal government or the New Hampshire state government. The Institute on Disability at the University of New Hampshire was established in 1987 to provide a coherent university-based focus to improve knowledge, policies, and practices related to the lives of persons with disabilities and their families and to promote the inclusion of people with disabilities into their schools and communities.
1Institute on Disability/UCED
Overview The intent of this paper is to develop an informed understanding of hospital care utilization among New Hampshire residents with mental illness or substance use conditions. We have relied upon the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code for the primary diagnosis, as well as the External Cause of Injury Code (E-Code) assigned by the hospital staff to identify hospital visits for patients with mental illness and/or substance use. Our review of data from 1997-2006 provided insights into the following areas:
• Changes in the demographics of hospital patients—including: an increase in youth 15-29 with mental illness or substance use who are hospitalized, and increases in certain conditions, including bipolar and anxiety disorders.
• Patterns of utilization—while repeat patients comprise only a small proportion of those seeking hospital care, repeat visitors were more likely to have co-occurring disorders of mental illness and substance use.
• Patterns of service—including hospital admitting and discharge practices for patients with primary diagnoses of mental illness or substance use and differences in access to acute care depending upon geography.
• Patterns of charges and coverage—rapidly escalating charges for hospital level care combined with a lack of increase in length of hospital stay, decreasing private insurance coverage for hospital visits for mental illness or substance use, and the long term financial impact for patients with co-morbid conditions of mental illness and substance use who repeatedly seek hospital care.
• Risks associated with a lack of health care coverage—repeat patients are more likely to be self pay and thus may not be able to obtain effective long-term mental health care.
• Patterns of identification—physicians at inpatient and ambulatory care facilities are more likely than they were 10 years ago to identify conditions related to mental illness or substance use as contributing factors for hospitalization.
Although the focus of the report is on hospital data, this analysis provides important information about trends for diagnosis and treatment of mental illness and substance use. The number of individuals who seek hospital care for mental illness or substance use has increased, and the number of hospitals available to provide specialty care has decreased. Insurance coverage for individuals seeking hospital care most frequently for mental health and substance use issues is shifting from private to public carriers. These and other conclusions drawn in this report indicate that much remains to be done if New Hampshire is to successfully address the changing needs of its residents.
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Mental Illness and Substance Use Hospitalizations in New Hampshire, 1997-2006
Topics of Interest Overview (p.2) Identifying hospital visits for mental illness or substance use (p.4) I. What are some of the characteristics of patients who are hospitalized for
mental illness or substance use conditions? (p.6) II. Since 1997, how have hospitalization rates changed for conditions related to
mental illness or substance use? (p.11) III. What are the charges incurred for mental illness and substance use hospital
visits? What has changed over time? (p.18) IV. What do the data tell us about those patients who have primary and secondary
conditions related to both mental illness and substance use? (p.24) V. To what extent are mental illness and substance use identified as contributing
factors for other medical conditions? (p.27) VI. How do hospitalization rates for mental illness or substance use vary across the
state? (p.30) Report Summary (p.34) Appendix A: List of Mental Illness and Substance Use Conditions (p.36) Appendix B: List of New Hampshire Hospitals (p.41)
Appendix C: Supplemental Tables for Figures (p.42)
Appendix D: Rate of Hospital Visits Per 10,000 Population, 2000-2003 Hospital
Discharge Data (p.46)
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Identifying Hospital Visits for Mental Illness or Substance Use This report focuses only on hospital utilization and does not address services or care provided in other settings. Information on other aspects of the state’s mental health service system is available from the Legislative Commission on Mental Health, NH Center for Public Policy Studies, NAMI NH, the NH Hospital Task Force, NH Council on Developmental Disabilities, NH Council for Children and Adolescents with Chronic Health Conditions, and Granite State Independent Living. In Fall 2008, the Institute on Disability will release a study on consumer perspectives of the services provided by New Hampshire’s Community Mental Health Centers. Unless otherwise noted, this report utilizes the primary diagnostic or E-Code field to define the reason for a particular hospital visit. Our decision to use the ICD-9 and E-codes to identify a mental illness or substance use visit was based on a review of the research literature, consultation with health statisticians, and input from the project’s Advisory Board. The reader should note that the data considered for this brief do not include cognitive and personality changes secondary to medical conditions (e.g., Alzheimer’s disease and other dementias, traumatic brain injury, hypothyroidism). Other areas commonly included in a set of DSM-IV criteria, such as sleep disorders, or conditions that may have a broader social interpretation (including a range of conditions related to sexuality), also are not included. The focus for this brief is on mental health conditions such as anxiety, depression, personality disorders, bipolar, paranoia, schizophrenia, other affective disorders, and substance use. Substance use includes conditions related to alcohol abuse and licit or illicit drug use, including alcohol dependence, alcoholic psychoses, drug dependence and psychoses, poisoning from drugs or alcohol, and toxic effects from alcohol. There is an overlap with certain codes used to identify mental illness (knowingly taking or overdosing on substances) or substance use (related to poisoning by opiates, sedatives, analgesics, psychotropic agents, and stimulants). This overlap, which accounts for 10% of ambulatory care visits for mental illness, does not have an appreciable effect on the larger context of co-occurrence of mental illness and substance use. A full list of the individual conditions and E-codes used to identify visits for mental illness or substance use are provided in Appendix A. Data Notes and Limitations Data presented in this report reflects information submitted to NH Department of Health and Human Services (NH DHHS) from the state’s inpatient, ambulatory, and specialty hospital care settings from 1997 through 2006. Our data set includes:
Inpatient data on patients at New Hampshire’s 26 acute care hospitals, 10 of which currently provide dedicated beds for patients with mental illness. Length of stay for these hospital visits can vary from one to 300+ days.
Ambulatory data primarily for users of emergency departments in New Hampshire hospitals. However, this also may include data on urgent care patients, patients seen for an outpatient service at a facility or who receive ambulatory surgery, as well as those admitted for inpatient observation. Length of stay for these visits is less than one day. Note that ambulatory care patients who are subsequently admitted for inpatient services are not included in this data.
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Specialty data on patients who receive specialized rehabilitative treatment at one of nine New Hampshire hospitals. Length of stay for these hospital visits can vary from one to 1000+ days. See Appendix B for a list of hospitals by type of setting.
Prevalence rates based on patient counts have been adjusted based on population growth estimates provided by the NH DHHS Health Statistics and Data Management Section, Bureau of Disease Control and Health Statistics, and Division of Public Health Services. Unless otherwise noted, when information on visits (rather than patients) is presented, these numbers are provided as a raw count of visits. Charges have been adjusted for inflation based on the Consumer Price Index – Urban (CPI-U-RS) with 2006=100. When reviewing the data, please note the following:
• The data do not offer a comprehensive assessment of the prevalence of mental illness or substance use in New Hampshire. The prevalence rate is much higher, as most mental illness and substance use treatment is provided at the community level by physicians, therapists, and mental health centers; data for community-based care is not captured in this report. Additionally, the stigma associated with mental illness and the cost of treatment may prevent many from seeking mental health care except in emergency situations.
• The data set includes visits by out-of-state patients who seek services in New Hampshire. In part, the inclusion of out-of-state patients offsets the number of in-state residents who go outside New Hampshire for their care. (Note that the data indicating town-based prevalence visit rates are only for patients who were able to be identified as New Hampshire residents.)
• Charge data do not reflect actual hospital care costs. The charge information provided on the hospital discharge files provides only a proxy indicator for costs which can be tracked over time. Based on work from the NH Public Policy Center, hospital charges were estimated to be more than double actual cost.1
• A number of files reviewed did not include a unique identifier or town name. For this reason, the true town prevalence hospitalization rate may be higher than what is presented here. Of note, visits with conditions related to mental illness or substance use were no more likely than all visits to be missing a unique identifier for their visit.
• Improved physician training resulting in better diagnosis of mental health conditions may account for some changes in how physicians code a particular condition over time. This may account for increased identification of secondary conditions.
In several instances, numerical data in this report have been rounded to the closest whole number for the reader’s convenience. Lastly, where there are graphical limitations on the number of data labels that can be placed on a particular graph, the underlying data tables are included within Appendix C.
1 New Hampshire Center for Public Policy Studies. (Mar. 2007). Financing New Hampshire Hospitals: Cost-Shifting in 2005. Concord, NH.
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I. What are some of the characteristics of patients hospitalized for mental illness or substance use?
This section provides an overview and comparison of patient characteristics based on whether the primary diagnosis related to the hospital visit was due to a mental illness, substance use, or all conditions. Areas of comparison include age, gender, admission source, primary payment source, and patient discharge information. Between 2004-2006, the combined ambulatory, inpatient, and specialty hospital visits that were associated with a primary diagnosis of mental illness or substance use were 74,531 and 30,077, respectively. For comparison, the total number of hospital visits in New Hampshire for this time period was 2.5 million. Age Group All Three Settings, Total Visits 2004-2006 Review of data by patient age indicates several differences in hospital visits for patients with mental illness or substance use conditions as compared to the total patient population. For example, the percentage of ambulatory, inpatient, and specialty visits for patients age 15-49 with mental illness or substance use conditions was greater than the general patient population. This was particularly true among 30 to 49 year olds; patients in this age group with a primary diagnosis of mental illness or substance use accounted for close to half of all inpatient care visits as compared to one in five of the general hospital population.
Fig. 1: Age Distribution by Condition Type, Percent of Visits: Inpatient, Ambulatory, and Specialty Care Hospitals, 2004-2006
0%10%20%30%40%50%60%70%80%90%
100%
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Mental Illness Substance Use All
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65+50 to 6430 to 4915 to 290 to 14
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Gender All Three Settings, Total Visits 2004-2006 Across all hospital settings and conditions, women represented a slightly higher proportion of visits than men. This gender disparity was greater among patients presenting with mental illness. However, for patients presenting with substance use, more men than women accounted for visits in all three hospital settings.
Fig. 2: Gender Distribution by Condition Type, Percent of Visits: Inpatient, Ambulatory, and Specialty Care Hospitals, 2004-2006
0%10%20%30%40%50%60%70%80%90%
100%
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Mental Illness Substance Use All
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MaleFemale
Source Of Admission to Hospital Inpatient Care Settings, Total Visits 2004-2006 Among visits with a mental illness condition admitted to inpatient care, 50% were transferred from an emergency department, 38% were physician referrals, 8% were hospital transfers, and 4% were from other sources. Among patients with a primary diagnosis of substance use, over three quarters of those admitted to inpatient care were transferred from the emergency department, 19% were physician referrals, 3% were hospital transfers, and 1% were from other sources. Among all visits, 48% were due to physician referral, 38% were transfers from the ER, 7% were due to clinic referral, 5% were a transfer from a hospital, and less than 2% were from other sources.
Table 1: Admission Source,Inpatient Care, 2004-2006
Admission Source Mental Illness
Substance Use All
N 18,093 7,516 371,293
Clinic referral 1.9% 0.6% 7.4%
HMO referral 0.0% 0.0% 0.8%
Not available 0.0% 0.0% 0.0%
Physician referral 38.4% 19.4% 47.9%
Transfer from ER 49.9% 76.3% 38.3%
Transfer from hospital 8.2% 3.3% 4.9%
Transfer from legal 0.4% 0.0% 0.0%
Transfer from other health facility 0.8% 0.3% 0.4%
Transfer from SNF 0.4% 0.2% 0.3%
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Specialty Care Settings, Total Visits 2004-2006 Data from specialty hospitals includes a broader array of admission sources than data available from inpatient hospitals. Among patients with a mental illness condition, 51% were referred by a mental health professional, 18% by an acute care hospital, 13% by a physician, 6% by a transitional house setting, 5% from a community mental health center, and 7% from other sources. Among patients presenting with a substance use condition, 24% were referred by a physician, 21% by a mental health professional, 20% from transitional housing setting, 19% from an acute care hospital, 7% from an HMO/PPO, 4% from family/friends, and 4% from other. Among all patient visits, 47% were admitted from an acute care hospital, 29% from mental health professionals, 10% from physicians, 5% from transitional housing settings, and 9% from other sources.
Table 2: Admission Source, Specialty Care, 2004-2006
Admission Source Mental Illness
Substance Use All
N 9,666 2,613 19,571
Acute care hospital 17.6% 18.8% 46.6%Community mental health center 5.5% 1.1% 3.0%
Court/police 0.5% 0.5% 0.4%Educational system 0.1% 0.0% 0.1%
Employer 0.0% 0.2% 0.0%Family/friend 1.9% 4.1% 1.5%
HMO/PPO 1.9% 7.3% 2.0%Media/advertisement 0.0% 0.2% 0.0%
Mental health professional 50.6% 21.4% 29.0%Nursing home 0.0% 0.0% 0.1%
Other 0.2% 0.3% 0.2%Other managed care 0.3% 1.0% 0.3%
Physician 13.1% 24.4% 10.0%Prison 0.6% 0.2% 0.4%
Psychiatric hospital 0.0% 0.0% 0.0%Self 0.2% 0.1% 0.1%
Transitional housing setting 5.7% 20.0% 5.5%Unknown 1.4% 0.3% 0.8%
Discharge Ambulatory Care Settings The majority of visits for patients with primary conditions related to mental illness (79%) or with substance use (88%) were discharged to home to manage their own care. In 12% of visits with mental illness and 4% of visits with a diagnosis of substance use, patients were transferred to another facility. The remaining eight categories account for the rest of the discharges. Note that visits for patients with mental illness or substance use conditions
Table 3. Discharges, Ambulatory Care, 2004-2006
Discharge Type Mental Illness
Substance Use All
Number of Visits 46,772 19,948 2,068,441 Against Medical Advice 1.1% 2.4% 0.4%
Assisted Living 2.0% 1.0% 0.1%Died 0.1% 0.0% 0.1%
Home Health Service 0.2% 0.2% 0.2%Home, self care 78.6% 87.6% 96.5%
Intermediate Care 3.8% 2.5% 1.3%Patient left before treatment 0.7% 0.6% 0.5%
Redirected to appropriate provider 0.1% 0.3% 0.0%Transfer to inpatient in same hospital 1.1% 1.0% 0.4%
Transfer to Other Facility 12.3% 4.5% 0.4%
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were three to six times more likely to result in a discharge against the medical advice of the attending physician than all visits. Discharge findings for patients with mental illness and substance use conditions contrast sharply with the general population where 96% of ambulatory care visits result in discharges to self care at home.2
Inpatient Settings Patients seeking inpatient care for mental illness were much more likely (78% vs. 63%) to be discharged to self care at home than all inpatient visits. Patients with a substance use condition were slightly more likely than all patients (64% vs. 63%) to be discharged to home. For both patients with mental illness and substance use, the next most likely source for discharges were transfer to another facility (8% of MI, 15% of SU) and Intermediate Care (6% of MI, 7% of SU). Patients with mental illness or substance use conditions were much more likely to be discharged against medical advice as compared to all conditions.
Table 4. Discharges, Inpatient Care, 2004-2006
Discharge Type Mental Illness
Substance Use All
Number of Visits 18,093 7,516 371,293 Against medical advice 3.5% 6.6% 0.7%
Assisted living 2.7% 1.8% 0.9%Died 0.3% 1.6% 2.2%
Home health service 2.3% 4.3% 16.2%Home, self care 77.6% 64.0% 63.0%
Intermediate care 5.9% 7.1% 14.2%Transfer to other facility 7.8% 14.7% 2.7%
Specialty Care Settings Among specialty care settings, patients with mental illness or substance use conditions were much more likely to be discharged to self care at home than all visits. Among patients with mental illness, 85% were discharged to home, 7% to assisted living, 2% to intermediate care or partial hospitalization, 2% were discharged against medical advice, and less than 1% were transferred to other facilities or home health services. Among patients with substance use conditions, 88% were discharged to home, 5% discharged against medical advice, 4% to assisted living, 2% to intermediate care, and less than 1% to partial hospitalization or home health services. Among all patients, this group was less likely to be discharged to self care at home (63%) and much more likely to be discharged to a home health service or to intermediate care.
Table 5: Discharges, Specialty Care, 2004-2006
Source Mental Illness
Substance Use All
N 9,666 2,613 19,571Against medical advice 2.5% 4.7% 2.2%
Assisted living 6.7% 3.8% 4.2%Died 0.0% 0.0% 0.1%
Home health service 0.2% 0.3% 16.4%Home, self care 85.5% 88.4% 63.5%
Intermediate care 2.4% 1.9% 11.9%Partial hospitalization 2.1% 0.1% 1.1%
Transfer to other facility 0.7% 1.0% 0.6%
2 Individuals who are discharged to self care at home may still seek mental health and substance treatment services through available community resources.
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Payment Source Payment Source, All Three Settings, Total Visits 2004-2006 Private payors (e.g. Anthem, Harvard Pilgrim) represented the largest payment source for patients with a diagnosis of mental illness or substance use. However, among ambulatory and inpatient care visits, the proportion of visits paid for by private payors was less than all visit types combined. Of note, inpatient visits that were categorized as self-pay made up one in four of substance use visits, one in six of mental illness visits, and only one in 20 visits among all patients.
Fig. 3: Payor Distribution by Condition Type, Percent of Visits: Inpatient, Ambulatory, and Specialty Care Hospitals, 2004-2006
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Self PayPrivateOtherMedicareMedicaid
Section Summary Compared to all patients, important differences were found among patients presenting with mental illness or substance use. In general, patients with these conditions were more likely to be admitted to inpatient care as a result of a transfer from the emergency department (rather than a physician or clinic referral) and to be discharged from ambulatory care settings to other services. Patients in this group were less likely than all groups combined to have their visits covered by private insurance. Patients with mental illness were more likely to be women and more likely than other groups to be transferred from another hospital to inpatient care, or referred by a mental health professional for specialized care. Additionally, they were more likely than other groups to be discharged from inpatient care to self care at home. Patients with substance use conditions were more likely to be men or were more likely to be admitted to specialty hospitals via referrals from physicians, transitional housing settings, HMO/PPO, or family and friends.
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II. Since 1997, how have hospitalization rates changed for conditions related to mental illness or substance use?
In this section we provide an overview of utilization rates across the three care settings—ambulatory, inpatient, and specialty—with a focus on considering what factors may be driving the changes in utilization rates. Areas reviewed include patient age, repeat visits, and specific conditions presenting at the time of admission. It is important to note that the closure of specialty hospitals has resulted in a substantial drop in the number of New Hampshire patients seen in specialty care settings. Over the past decade, the following specialty hospitals have closed: Seaborne Hospital (Dublin, CLOSED 1998), Seminole Point Hospital (Sunapee, CLOSED 1998), Charter Brookside Behavioral Health Systems (Nashua, CLOSED 2000), and Beech Hill Hospital (Dublin, CLOSED 2002). Hospitalizations for Mental Illness or Substance Use In New Hampshire the rate of all patients, regardless of condition, receiving services in an inpatient, ambulatory, or specialty care setting between 1997 and 2006 increased by 12%, from 2,622 to 2,943 per 10,000 people (accounting for over ¼ of the state’s population). During this same period, patients receiving care for a mental illness condition increased from 89 to 101 per 10,000 (+13%) and patients admitted for substance use appears to have decreased from 51 to 49 per 10,000 (-4%).
Fig. 4: Patients Hospitalized for Mental Illness or Substance Use, Inpatient, Ambulatory, and Specialty Hospital Settings,1997-2006
89.2 88.890.3 93.6 95.9 98.3 99.3
101.0
51.3 49.547.4 46.7 46.5
47.2 48.4 49.5
0
20
40
60
80
100
120
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
3 Year Average
Rate
Per
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000
Popu
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Mental Illness
Substance Use
Analyzing the data by hospital setting, we found a shift in the provision of care from the more intensive specialty and inpatient services to ambulatory care settings.
Fig. 5: Patients Hospitalized for Mental Illness by Hospital Setting
22.2 19.5 17.3 16.4 16.8 17.1 17.2 17.0
29.3 28.4 28.5 29.1 29.6 30.5 30.8 31.3
54.6 57.2 61.2
66.1 69.6 72.1 73.9
75.7
0
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40
60
80
100
1997-1999
1998-2000
1999-2001
2000-2002
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2002-2004
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3 Year Average
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Popu
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Specialty
Inpatient
Ambulatory
Between 1997 and 2006, hospital rates for mental illness held relatively stable among inpatient settings (averaging 30 per 10,000 residents) and dropped in specialty settings (from 22 to 17 per 10,000). Within ambulatory settings, however, the prevalence rate increased substantially, from 55 to 76 per 10,000 people.
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A similar pattern was found among patients with substance use conditions. Between 1997 and 2006, hospital rates for substance use held relatively stable among inpatient settings (averaging 15 per 10,000 residents) and dropped in specialty settings (from 15 to 5 per 10,000). Within ambulatory settings, the prevalence rate increased from 26 to 35 per 10,000 people.
Fig. 6: Patients Hospitalized for Substance Useby Hospital Setting
5.515.1 14.2 11.6 8.7 6.2 5.3 5.3
17.1 15.1 14.2 14.0 14.6 15.1 15.2 15.1
25.6 26.4 27.4 29.7 31.3 32.6 33.835.0
0
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1997-1999
1998-2000
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Inpatient
Ambulatory
A Look at Repeat Users of Hospital Services, All Three Settings
Fig. 9: Percent of Patients with Repeat Hospitalizations for Mental Illness or Substance Use, All Hospital Settings, 1997-2006
3.1% 1.9%
79.9%
17.1% 13.5%
84.6%
0%
20%
40%
60%
80%
100%
Low Incidence, (1-2 Visits) Medium Incidence (3-9 Visits) High Incidence (10+ Visits)1997-2006
Per
cent
of R
epea
t Vis
its
Mental Illness,N=85,028Subs tance Use,N=45,342
During the period 1997-2006, 80% of 85,028 patients with a primary diagnosis of mental illness and 85% of 45,342 patients with a primary diagnosis of substance use came in for ambulatory care only one to two times. 17% of patients with mental illness came in 3-9 times vs. 13% of patients with substance use conditions. Less than 5% in each group came in 10 or more times over this 10 year period.
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Over time, patients with mental illness conditions were not more likely to make repeated visits to ambulatory care settings. The number of patients in this category who made only one ambulatory care visit in a year increased by 1,406. The number of those who made two or more ambulatory care visits increased by 1,079.
Fig. 10: Patients with Mental Illness Conditions, Repeat Hospitalizations Per Year, All Hospital Settings
7,635 7,776 7,956 8,298 8,4818,740 8,801 9,041
1,744 1,718 1,820 1,974 2,129 2,206 2,316 2,379
1,7821,7321,6651,5641,4641,3861,3321,3390
2,000
4,000
6,000
8,000
10,000
1997-1999 1998-2000 1999-2001 2000-2002 2001-2003 2002-2004 2003-2005 2004-2006
3 Year Average
Num
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s
1 Vis it 2 Vis its 3+ Vis its
Those with substance use conditions who had two or more ambulatory care visits in a year increased by 55 patients vs. an increase of 241 patients who had only one ambulatory care visit in a year.
Fig. 11: Patients with Substance Use Conditions, Repeat Hospitalizations Per Year, All Hospital Settings
5,0604,9304,7734,6614,614
4,6234,7194,818
879831797770765749783808
540 527 489 476 468 485 498 5230
2,000
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1997-1999 1998-2000 1999-2001 2000-2002 2001-2003 2002-2004 2003-2005 2004-2006
3 Year Average
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s
1 Vis it 2 Vis its 3+ Vis its
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A Focus on Ambulatory Care Settings Differences by Age Group Even though the statewide prevalence rate for ambulatory care patients with diagnoses with mental illness increased from 55 to 76 per 10,000, there were marked differences in prevalence rates based on the age of patients. The greatest increase was among 15-29 year olds (+50 per 10,000) followed by 30 to 49 year olds (+24), 50 to 64 (+14), 0 to 14 (+6), and those over 65 (+2.4).
Fig. 7: Patients Hospitalized for Mental Illness, Ambulatory Care Per 10,000 Population by Age Group
7.3 8.6 10.1 11.8 13.0 13.7 13.9 13.5
90.097.0
106.4117.8
125.5 132.8 136.3139.7
74.8 76.8 80.8 86.9
92.1 94.6 96.7 98.8
39.9 42.5 45.9
49.1 49.9 50.852.3 54.1
44.9 46.1 47.2
46.9 45.9 45.5 45.8 47.3
0
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n0 to 14
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50 to 64
65+
Our findings were similar for patients with a primary diagnosis of substance use. The greatest increase was among 15-29 year olds (+22 per 10,000) followed by 30 to 49 year olds (+10), and 50 to 64 year olds (+9). Less then 2 points of increase was seen in those over 65 and those under 14 years of age.
Fig. 8: Patients Hospitalized for Substance Use, Ambulatory Care Per 10,000 Population by Age Group
1.8 1.6 2.0 2.2 2.7 2.7 2.8 2.5
43.0 44.8 47.252.2
57.0 61.0 63.8 65.2
39.9 40.8 41.7 44.8 46.0 47.2 48.150.4
17.8 19.1 20.3 21.9 23.1 23.9 25.5 26.7
10.6 10.9 11.5 11.7 12.0 12.0 12.1 12.2
0
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0 to 14
15 to 29
30 to 49
50 to 64
65+
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Differences in Conditions Tables 5 and 6 compare changes in ambulatory care visits for mental illness and substance use related conditions for the time period 1997-1999 and 2004-2006. In reviewing these tables, the reader should note that counts for emergency department visits that result in an inpatient admission are not included in this table. This is particularly relevant as 50% of mental illness and 76% of substance use inpatient admissions are transfers from hospital emergency departments. Table 5 Change in Ambulatory Care Mental Illness Visits, 1997-1999 vs. 2004-2006
Group 1997-1999 2004-2006
Change in Visits
Percent Change
Disturbance of Emotions—Childhood 195 480 285 146.2% Bipolar Affective Disorders 1,523 3,186 1,663 109.2%
Other Non-Organic Psychoses 961 1,738 777 80.9% Depressive Disorders 8,351 13,350 4,999 59.9%
Schizophrenic Disorders 1,271 2,000 729 57.4% Paranoid Delusional 166 258 92 55.4%
Personality and Anxiety Disorders 9,825 14,609 4,784 48.7% Poisoning by Substances 3,081 4,035 954 31.0%
Self Inflicted* 2,322 3,011 689 29.7% Disturbance of Conduct 601 772 171 28.5%
Adjustment Reaction 1,951 2,193 242 12.4% Physiological Malfunction Arising from Mental Factors 572 577 5 0.9%
Other** 454 563 109 24.0% Total 31,273 46,772 15,499
* Self Inflicted includes late effect of self injury. ** Other includes: special symptoms not specified, and psychoses with or specific to childhood
As shown in Table 5, visits for disturbance of emotions in childhood and bipolar affective disorders more than doubled since the 1997-1999 time period. Areas increasing by about 50% or more include: other non-organic psychoses (81%), depressive disorders (60%), schizophrenic disorders (57%), paranoid delusional (55%), and personality and anxiety disorders (49%). Other areas of increase include: poisoning by substances (31%), self inflicted injuries (30%), disturbance of conduct (28%), adjustment reaction (12%), and physiological malfunction arising from mental factors (1%). All other mental illness condition types increased by 24%. Table 6 documents that the greatest proportional change among substance use visits occurred among those identified with drug psychoses (169%). Close to a 50% increase was observed among conditions for drug use (55%), drug dependence (52%), and alcohol use (48%). Other areas of increase included alcoholic psychoses (29%), self-inflicted poisoning (16%), and other (43%). One category showed a drop in visits. Codings for alcohol dependence dropped by 19% (possibly as a result of being coded under the alcohol use category).
15
Table 6. Change in Ambulatory Care Substance Use Visits, 1997-1999 vs. 2004-2006
Group 1997-1999
2004-2006
Change in Visits
Percent Change
Drug Psychoses* 610 1,642 1,032 169.2%Drug Use 3,976 6,169 2,193 55.2%
Drug Dependence 582 884 302 51.9%Alcohol Use 4,860 7,175 2,315 47.6%
Alcoholic Psychoses 577 747 170 29.5%SI Poisoning 646 752 106 16.4%
Alcohol Dependence 3,077 2,499 -578 -18.8%Other** 56 80 24 42.9%
Total 14,328 19,868 5,540
* Of note, while ambulatory care settings demonstrated a substantial increase in Drug Psychoses over time, there was a drop in these visits within the inpatient and specialty care settings. ** Other includes: alcohol/drug pregnancy/fetus, poisoning by alcohol deterrents, and tobacco use disorder
Section Summary While the rate of hospitalization for mental illness has been on par with all conditions, the rates for substance use appear to have declined. Our data from the three hospital settings documents a shift in care. During the past 10 years, hospitalization rates for specialty care have dropped substantially, inpatient care has kept pace with population growth, and ambulatory care visits have increased dramatically, particularly among patients presenting with mental illness or substance use conditions. While ambulatory care rates across all conditions increased by 17%, the rate of patients with conditions related to mental illness or substance use increased by 39% and 37% respectively. A closer review of the ambulatory care data for patients presenting with mental illness or substance use shows that patient visits among most age groups have been consistent with population growth. However, ambulatory care visits among patients with mental illness or substance use age 15-29 and 30-49 have increased at a much faster rate. The data appear to indicate that repeat visitors are not the major driver in the increase in hospitalizations. In reviewing 10 years of data, 80% of patients with mental illness and 85% of patients with substance use conditions sought ambulatory care only 1-2 times during the ten year period (note however that this information is skewed as patients who are admitted to the emergency department but then transferred to inpatient care are not counted as ambulatory care patients).3 Less than 5% of patients with mental illness or substance use came in for care 10 or more times in the period studied. Our review found little change in the distribution of specific conditions that are subsets of mental illness and substance use. Over one in four of visits for patients with mental illness were related to either personality and anxiety disorders or depressive disorders. Among patients with substance use conditions, about one in three visits were for drug or alcohol use. Alcohol dependence accounted
3 Of the 9,025 inpatient visits transferred from ER between 2004-206: depressive disorders accounted for 35%, poisoning by drugs (21%), schizophrenic disorders (8%). All other categories were under 5%.
16
for 12% of visits while drug dependence accounted for 4%. Eight percent of visits involved drug psychoses compared to only 4% for alcohol psychoses. For the period between 1997-1999 and 2004-2006, the overall distribution of specific conditions did not change substantially. The exception to this was alcohol dependence, which made up 21.4% of visits in the 1997-1999 period and only 12.5% of visits in the 2004-2006 period. Of note, the actual number of ambulatory care visits increased by over 1,000 in the following areas: personality and anxiety disorders, bipolar disorder, depression, alcohol use, drug use, and drug psychoses.
17
III. What are the charges incurred for mental illness and substance use hospital visits? What has changed over time? In our study we looked at the fiscal impact of providing care for patients with mental illness or substance use conditions. The reader should note that there may be wide variation between the charge associated with a hospital visit and the actual cost. In an analysis of audited financial data4, Doug Hall of the NH Center for Public Policy Studies found the ratio of gross charges divided by total operating expenses had increased from 1.5 in 1997 to 1.9 in 2004. In other words, by 2004, total charges were nearly double that of operating expenses incurred by hospitals. In addition to variance by hospital, the charge vs. cost ratio may also vary widely based on the condition addressed. We reviewed changes in total charges over time and across hospital care settings. We analyzed charges for ambulatory and inpatient visits, focusing on coverage of total visits by payor type (private insurance, Medicare, Medicaid, self-pay, and other) and changes to the average charge per visit by payor type. Total Charges Over Time For primary diagnoses related to mental illness or substance use, total charges across the three hospital settings has dropped over 10 years, from $144 to $136 million among patients with mental illness and from $48 to $44 million among patients presenting with substance use conditions. During this same time period, hospital charges for all conditions have increased substantially, from $2 billion in 1997-1999 to $3.6 billion in the 2004-2006 period. Since the 1997-1999 period, specialty care hospital visits have dropped from 22 to 17 per 10,000 among patients with mental illness, and 15 to five per 10,000 among patients with substance use conditions. The change in charges for this population of patients is in large part driven by the cut in services offered through specialty care settings.
Fig. 9: Total Charges of Mental Illness Hospital Visits, by Setting 1997-2006
$0
$20,000,000
$40,000,000
$60,000,000
$80,000,000
$100,000,000
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
3 Year Average
Tota
l Cha
rges
Specialty
Inpatient
Am bulatory
Charges in specialty care settings for patients with mental illness have dropped by $35 million during this time period (-40%), while charges for inpatient care have increased by $17 million (+34%) and for ambulatory care, by $10 million (+165%).
4 Provided by NH Hospital Association of NH hospitals (does not include rehab hospitals or the NH State Hospital).
18
Specialty care charges for patients with a primary diagnosis of substance use have dropped by $20 million (-76%). During this period inpatient charges increased by $10 million (+55%) and ambulatory care increased by $6 million (+133%).
Fig. 10: Total Charges of Substance Use Hospital Visits, by Setting 1997-2006,
$0
$10,000,000
$20,000,000
$30,000,000
$40,000,000
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
3 Year Average
Tota
l Cha
rges
Specialty
Inpatient
Ambulatory
A Focus on Inpatient Care and Payor Source Mental Illness
Fig. 11: Total Mental Illness Visits by Payor, Inpatient Care Settings
1,790
1,0881,064959 902 890 917 946 1,018
1,8471,7121,7061,6951,758 1,742
1,886
8172565656544442
2,0032,0702,1152,0982,0672,050 2,102 1,967
1,010997979925843751680713
0
500
1,000
1,500
2,000
2,500
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
3 Year Average
Tota
l Vis
its
Medicaid
Medicare
Other
Private
Self Pay
While inpatient mental illness visits have been increasing over time, coverage of these visits by private payors has fallen. Between the time periods 1997-1999 and 2004-2006, total visits covered by private payors dropped from 2,050 to 1,967 (-4%), while all other groups experienced an increase: Medicare (+7%), Medicaid (+13%), self pay (+42%), and other (+91%).
Fig. 12: Average Charge Per Mental Illness Visit by Payor, Inpatient Care Settings
$0
$3,000
$6,000
$9,000
$12,000
$15,000
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
3 Year Average
Aver
age
Char
ge
Medicaid
Medicare
OtherPrivate
Self Pay
Average charges for mental illness inpatient visits have been steadily increasing among most payor types. Medicare received the highest average charge per visit ($14,879 for the 2004-2006 period). Other payor sources were more consistent, averaging $9,570 for the time period.
19
The difference in average charges may be attributed in part to the fact that Medicare patients typically have longer lengths of stay (8.8 days on average in 2004-2006) as compared to patients using other payors (5.1 days on average). Across all payor types, the average length of stay for inpatient care has been gradually decreasing, from 6.6 in 1997-1999 to 6.2 days in 2004-2006.
Fig. 13: Length of Stay for Mental Illness Visits by Payor,Inpatient Care Settings
0
2
4
6
8
10
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
1997-2006A
vera
ge L
engt
h of
Sta
y (D
ays)
Medicaid
Medicare
Other
Private
Self Pay
Fig. 14: Total Substance Use Visits by Payor, Inpatient Care Settings
365 364359310308 366331426
540530503515537
546525585
4541322819 483520
839824781808872853
810
993
692699639618619 692670693
0
500
1,000
1,500
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
3 Year Average
Tota
l Vis
its
Medicaid
Medicare
Other
Private
Self Pay
Substance Use Over 10 years, total inpatient visits for substance use conditions dropped slightly, from 2,717 to 2,505, and has been holding fairly steady for the past few years. During 2004-2006 private payors covered the most visits (853), followed by self pay (692), Medicare (546), Medicaid (366), and other sources (48).
Fig. 15: Average Charge Per Substance Use Visit by Payor,
Inpatient Care Settings
$0
$3,000
$6,000
$9,000
$12,000
$15,000
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
3 Year Average
Ave
rage
Cha
rge Medicaid
Medicare
OtherPrivate
Self Pay
Although total substance use visits did not change substantially, average charges rose between 53% and 76%, with the rate of increase relatively consistent among most groups. For the 2004-2006 period, Medicare had the highest yearly average charge ($12,724), followed by Medicaid ($11,900), other ($10,914), private ($10,469), and self pay ($9,814).
20
Patients with substance use conditions experienced a slight drop in average length of stay (from 3.75 in 1997-1999 to 3.72 in 2004-2006). For 2004-2006, Medicare patients had slightly longer inpatient stays, on average (4.6 days), followed by Medicaid (3.9), self pay (3.4), private (3.3), and other (3.2).
Fig. 16: Length of Stay for Substance Use Visits by Payor,Inpatient Care Settings
0
3
6
9
12
15
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
3 Year Average
Ave
rage
Len
gth
of S
tay
(Day
s)
Medicaid
Medicare
Other
Private
Self Pay
A Focus on Ambulatory Care and Payor Source Mental Illness Fig. 17: Total Mental Illness Visits by Payor,
Ambulatory Care Settings
2,180 2,317
5,557
2,172
2,7442,513
1,9951,8191,723
2,3182,9492,403
2,7782,573
2,081
2,4163,080
244221206185144127 221 257
5,9045,9785,0304,531
4,234
5,946 5,803
3,4653,362
2,8592,5392,3632,259
3,1273,502
0
2,000
4,000
6,000
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
3 Year Average
Tota
l Vis
its
Medicaid
Medicare
Other
Private
Self Pay
In comparing payor sources for ambulatory care charges for patients with mental illness, the greatest increase was in visits covered by private payors (increased by 1,568 visits), followed by self-pay (1,243), Medicaid (1,226), Medicare (998), and other (131). Between the 1997-1999 and 2001-2003 periods, the number of visits charged to private payors rose substantially. However, since 2001-2003, visits charged to private insurers dropped by 144. Since this period, visits covered by other payors increased: Medicare (+664 visits), Medicaid (+631), self pay (+375), and other (+37).
Fig. 18: Average Charge Per Mental Illness Visit by Payor, Ambulatory Care Settings
$300
$600
$900
$1,200
Aver
age
Char
ge
$01997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
3 Year Average
Medicaid
Medicare
OtherPrivate
Self Pay
For mental illness conditions, average charges increased by 77%, with most of the increase occurring since 2001 across all payor groups. In 2001, the average charge for a mental illness visit was $625; by 2006, average charges per visit had increased to $1,184.
21
Substance Use Over the ten year period studied, substance use ambulatory care visits increased for all payors: private (+643), self pay (+505), Medicaid (+347), Medicare (+313), and other (+48). Similar to visits for mental illness conditions, visits covered by private payors have flattened out since the 2003, increasing by only 4%. All other payors have experienced increased visits from 11% to 39%.
Fig. 19: Total Substance Use Visits by Payor, Ambulatory Care Settings
927837707673669639 742
986
728 789700663612570
704 882
1018972616262 79 110
2,2942,2862,151
1,931
1,7921,724
2,284 2,367
2,2352,1842,0001,841
1,8281,799
2,0712,304
0
500
1,000
1,500
2,000
2,500
3,000
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
3 Year AverageTo
tal V
isits
Medicaid
Medicare
Other
Private
Self Pay
Average charges for visits for substance use were only $956 during the 1997-1999 period but increased from $1,166 to $1,600 between the 2001-2003 and 2004-2006 periods.
Fig. 20: Average Charge Per Substance Use Visit by Payor, Ambulatory Care Settings
$0
$400
$800
$1,200
$1,600
$2,000
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
3 Year Average
Ave
rage
Cha
rge
Medicaid
Medicare
OtherPrivate
Self Pay
Section Summary Over the last few years, total charges for inpatient care for either mental illness or substance use conditions have continued to rise and have overtaken charges incurred by specialty hospital units (this is due primarily to a major decrease in the number of specialty care facilities in the state). For 2004-2006, yearly inpatient total charges for mental illness amounted to $67.2 million; inpatient charges for patients with substance use conditions were $27.6 million. During this same period, ambulatory care charges for patients with mental illness and substance use conditions were $16.7 million and $10.7 million respectively. While charges continued to increase across the board, average length of stay has tended to drop over time. Within inpatient settings, length of stay for mental illness visits dropped from 6.58 to 6.23 and for substance use there was a slight decrease from 3.75 to 3.72. For patients receiving care at
22
specialty hospitals, length of visits for mental illness dropped from 19.9 to 19.02 and for substance use, from 10.53 to 5.3. Average inpatient charges for patients with mental illness increased dramatically since 2001. The total number of inpatient and ambulatory care visits increased for all payor groups except private insurance since that time. The highest average charges per visit were for Medicare patients; this is not surprising given that this group had longer inpatient hospital stays than those covered by other payors. For inpatient hospitalizations among those with substance use conditions, total visits across all payor groups held relatively stable over the last five years; average charges for this group increased, while average lengths of stay dropped slightly. Within ambulatory care settings, there was a small proportional increase among number of charges to private payors; all other payor groups saw more substantial increases. The recent decrease in inpatient visits among individuals who are privately insured is concerning. Looking at data for 2006, across all hospital settings, 87,800 patients were covered by Medicare (187,251 visits), 54,438 by self pay (100,469 visits), 31,661 by Medicaid (75,172 visits), and 28,133 by other sources (37,784 visits). During 2006, private insurance covered 208,894 patients making 314,809 visits to hospital settings. Given the larger number of people covered under private insurance as well as the continuing population growth, we anticipated an increase in private insurance coverage to meet the needs of a growing population. Instead, we documented a drop in visits covered by private insurance for mental illness and only a slight increase in substance use visits between the 2001-2003 and 2004-2006 time periods. The substantial increase for mental illness or substance use charges in ambulatory care settings (+167% / +134%) was surprising since the total number of mental illness and substance use visits increased only by 50% and 40% respectively. Furthermore, our study found that over time an increasing number of patients were paying out of pocket for their health care (or were uninsured).
23
IV. What do the data tell us about those patients who have primary and secondary conditions related to both mental illness and substance use?
The Substance Abuse and Mental Health Services Administration (SAMHSA) research on co-occurrence of mental illness and substance use indicates 20-50% of those treated in mental health settings have a co-occurring substance use disorder and 50-75% of those with a substance use disorder have a co-occurring mental illness disorder.5 To determine if New Hampshire was in line with these national co-occurrence rates, we reviewed data across hospital settings for a 10-year period from 1997-2006. We found that 75% of patients with a primary diagnosis of mental illness who had at least 10 hospital visits over 10 years had substance use as a secondary or contributing diagnosis for one or more of these visits6 7. On average, 24% of all visits for patients with a primary diagnosis of mental illness included a secondary diagnosis of substance use.8
Table 8. Patients with Primary Diagnosis of Mental illness: Inpatient, Specialty and Ambulatory Care, 1997-2006
# Visits Patients
Total Visits
Total Charge
Avg. Charge
Incurred During Period
Per Visit
Avg. Charge
Incurred During Period
Per Patient
# Patients w/ Substance
Use Secondary in Any Mental Illness Visits by Patient
% of Patients
# Mental Illness Visits
with Substance Use Identified as Secondary Condition
% of All
Mental Illness Visits
1 49,851 49,851 $255,874,652 $5,133 $5,133 8,448 16.9% 8,448 16.9% 2 13,709 27,418 $158,728,380 $5,789 $11,578 4,468 32.6% 5,814 21.2% 3 5,464 16,392 $103,773,132 $6,331 $18,992 2,355 43.1% 3,859 23.5% 4 2,883 11,532 $74,354,851 $6,448 $25,791 1,399 48.5% 2,748 23.8% 5 1,694 8,470 $61,559,498 $7,268 $36,340 925 54.6% 2,092 24.7% 6 1,193 7,158 $54,007,613 $7,545 $45,270 702 58.8% 1,802 25.2% 7 738 5,166 $37,463,125 $7,252 $50,763 466 63.1% 1,350 26.1% 8 543 4,344 $32,038,639 $7,375 $59,003 356 65.6% 1,184 27.3% 9 448 4,032 $28,076,108 $6,963 $62,670 288 64.3% 1,030 25.5%
10+ 2,310 45,619 $319,507,545 $7,004 $138,315 1,737 75.2% 11,530 25.3%
5 Substance Abuse and Mental Health Services Administration, (2005, February 2). Many Patients Have Co-Occurring Disorders: Both Must Be Addressed for Successful Treatment. Retrieved March 23, 2008, from Join Together web site: http://www.jointogether.org/news/yourturn/announcements/2005/many-patients-have-co-both-be.html. 6 To avoid duplicate counts in Tables 8 and 9, the series of “poison codes” which were used to identify mental illness and substance use visits in other sections of this report were removed from the definition for a mental illness visit. 7 The percent of patients with mental illness and substance use may actually be higher. Tables 8 and 9 document secondary conditions only among those patients with a primary condition of mental illness. A patient with one primary visit for mental illness and who is seen on a different date for a primary visit for substance use, would not show up in our data as having a history of substance use. 8 For example, for the 1,193 patients who had 6 hospital visits during this period, an average of 1.5 of those visits included a secondary diagnosis of substance use.
24
Similarly, we found that 93% of repeat patients with a primary diagnosis of substance use have a co-occuring mental illness condition. On average, about 39% of all substance use hospital visits included a mental illness condition as a secondary diagnosis.
Table 9. Patients with Primary Diagnosis of Substance Use: Inpatient, Specialty and Ambulatory Care, 1997-2006
# Visits Patients
Total Visits
Total Charge
Avg. Charge
Incurred During Period
Per Visit
Avg. Charge
Incurred During Period
Per Patient
# Patients w/ Mental Illness Secondary in
Any Substance
Use Visits by Patient
% of Patients
# Substance Use Visits
with Mental Illness
Identified as
Secondary Condition
% of All Substance Use Visits
1 31,476 31,476 $152,890,873 $4,857 $4,857 10,630 33.8% 10,630 33.8% 2 6,884 13,768 $66,984,367 $4,865 $9,730 3,707 53.8% 5,197 37.7% 3 2,679 8,037 $38,480,975 $4,788 $14,364 1,689 63.0% 2,997 37.3% 4 1,343 5,372 $25,046,131 $4,662 $18,649 931 69.3% 2,119 39.4% 5 778 3,890 $17,525,868 $4,505 $22,527 584 75.1% 1,529 39.3% 6 548 3,288 $14,553,580 $4,426 $26,558 458 83.6% 1,378 41.9% 7 345 2,415 $10,566,441 $4,375 $30,627 294 85.2% 1,037 42.9% 8 246 1,968 $8,394,166 $4,265 $34,123 206 83.7% 790 40.1% 9 187 1,683 $7,228,499 $4,295 $38,655 158 84.5% 650 38.6%
10+ 856 14,880 $51,214,159 $3,442 $59,830 794 92.8% 5,924 39.8% In looking at the charges associated with hospital visits for mental illness or substance use, we found the overall and average charges among those who repeatedly use hospital services to be quite high. Over the 10-year period, 2,310 repeat patients accounted for a total of $320 million in hospital charges. This pattern also held true for patients with a primary diagnosis of substance use. Those 856 patients with repeated hospital visits for substance use incurred $51 million in charges over the course of 10 years. Of note, when comparing payment sources among patients with a high number of hospital visits (at least 10+ in the period studied), medium visits (3-9) and few visits (1-2), we found that payor sources changed as the frequency of hospital visits increased. As illustrated in Figs. 21 and 22, charges for low incidence patients are typically covered by private insurance (47% of all visits among patients with either mental illness or substance use conditions).
Fig. 21: Low, Medium and High Users of Hospital Services with Primary Diagnosis of Mental Illness by Payor,
1997-2006
2.8%
47.3%
11.9%
20.2%17.7% 19.4%
37.1%
3.7%
22.2%17.6%
11.1%
21.5%
4.1%
40.5%
22.9%
0%
20%
40%
60%
80%
100%
Medicaid Medicare Other Private Self Pay1997-2006
Perc
ent o
f Vis
its
Low Incidence (< 3 Visits) Medium Incidence (3-9 Visits)High Incidence (10+ Visits)
25
Fig. 22: Low, Medium and High Users of Hospital Services with Primary Diagnosis of Substance Use by Payor,
1997-2006
9.6%2.5%
46.7%
13.7%
27.5%
13.5%17.7%
2.2%
36.1% 30.6%
17.5%23.1%
2.1%
20.6%
36.7%
0%
20%
40%
60%
80%
100%
Medicaid Medicare Other Private Self Pay
1997-2006
Per
cent
of V
isits
Low Incidence (< 3 Visits) Medium Incidence (3-9 Visits)High Incidence (10+ Visits)
However, for repeated users of hospital services for mental illness, Medicare (40% of all visits) and Medicaid (23%) are the largest payors, followed by private (21%), self pay (11%), and other payors (4%). Among patients with substance use conditions, charges to self payors make up the majority (37%), followed by Medicare (23%), private (21%), Medicaid (17%), and other (2%). Section Summary In our review we found that the co-occurrence of mental illness and substance use was particularly high among those patients who were repeat hospital users. Of those patients with mental illness who visited at least 10 times over 10 years, 75% also had a substance use identified as a secondary condition. Similarly, 93% of patients with a primary condition of substance use had mental illness as a diagnosed secondary condition. High users of hospital services account for a disproportionate share of overall charges incurred. The 3% of patients with mental illness conditions who were hospitalized 10+ times over 10 years accounted for 25% of total visits for mental illness and 28% of total charges. The 2% of patients with substance use conditions who were high end users accounted for 17% of all visits and 13% of total charges. We also found that hospital services for repeat users were much less likely to be covered by private insurance (only 21% of patients with mental illness or substance use conditions) and much more likely to be covered by Medicare or Medicaid. For repeat hospital users with mental illness, 11% of visits were self pay; for repeat users with substance use conditions, 37% of visits were self pay.
26
V. To what extent are mental illness and substance use identified as contributing factors for other medical conditions?
As noted in the second section, the population prevalence rates based on a primary diagnosis or E-code across all hospital settings for mental illness has increased from 89 to 101 per 10,000 people. Among those presenting with a primary diagnosis or E-code of substance use, the rate declined slightly from 51 to 49 per 10,000 (again, in large part due to the in a decrease in specialty care services in our state). However, these rates are solely based on the primary diagnosis or E-code field and do not account for the role that mental illness or substance use conditions may have as a contributing factor for other hospital visits.
Fig. 23: Rate of Patients Hospitalized for Mental Illness by Hospital Setting, All Diagnostic & E-code Fields Reviewed
30.4 27.6 24.3 22.6 22.2 22.7 22.9 22.6
81.3 85.0 90.2 97.0 104.5 112.8118.0
121.095.9
112.1129.8 148.4
167.5188.1 203.1 220.2
0
50
100
150
200
250
300
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
3 Year Average
Rat
e P
er 1
0,00
0 Po
pula
tion
Specialty
Inpatient
Ambulatory
Figs. 23 and 24 illustrate the prevalence rate across hospital settings when the primary, E-code, and all secondary diagnostic fields are reviewed for conditions related to mental illness or substance use. While the specialty care hospital rate declines for both mental illness and substance use, rates for inpatient and ambulatory care have increased dramatically over time. For patients with conditions related to mental illness, inpatient rates increased from 81 to 121 per 10,000 and ambulatory care rates increased from 96 to 220 per 10,000. Among patients with substance use related conditions, inpatient rates increased from 87 to 105 per 10,000 and ambulatory care rates increased from 91 to 266 per 10,000.
Fig. 24: Rate of Patients Hospitalized for Substance Useby Hospital Setting, All Diagnostic & E-code Fields Reviewed
20.7 18.8 15.8 13.2 11.1 10.4 10.3 10.6
87.2 89.2 91.6 92.2 94.2 98.3 102.9 104.790.8
116.5136.2 152.9
169.4
192.2226.7
265.8
0
50
100
150
200
250
300
1997-1999
1998-2000
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
3 Year Average
Rat
e Pe
r 10,
000
Popu
latio
n
Specialty
Inpatient
Ambulatory
27
While the rate of increase in inpatient settings across all diagnostic fields shows a slight increase in rate vs. using only primary field and E-code, the ambulatory discharge data indicates a possible change in how physicians in ambulatory care settings are diagnosing mental illness and substance use. As shown in Fig. 25, physicians are much more likely to identify a secondary condition related to mental illness than they were 10 years ago. A similar pattern was found in the review of data for patients with a primary diagnosis of substance use.
Fig. 25: Rate of Patients Hospitalized with Mental Illness, Ambulatory Care Per 10,000 Population,
Comparison of Review Types
54.6 57.2 61.2 66.1 69.6 72.173.9 75.7
95.9112.1 129.8
148.4167.5
188.1203.1
220.2
0
50
100
150
200
250
300
1997-1999 1998-2000 1999-2001 2000-2002 2001-2003 2002-2004 2003-2005 2004-2006
3 Year Average
Rat
e Pe
r 10
,000
Pop
ulat
ion
Prim ary Diagnos is and E-Code OnlyPrim ary/SecondaryDiagnos is & Ecode
To better understand the interactions between mental and physical illnesses, we reviewed 2004-2006 inpatient9 care files to identify the secondary conditions that were most common among patients with either a primary diagnosis of mental illness or substance use. Tables 10 and 11 show the secondary health conditions for patients who were presenting with either a primary diagnoses of mental illness or substance use.10
Table 10. Primary Diagnosis of Mental Illness in Inpatient Settings, 2004-2006 Percent of Visits With Specified Secondary Condition
Secondary Diagnosis Condition Visits 18,093
Mental Disorders 83.3%Endocrine, nutritional and metabolic diseases, and immunity disorders 32.6%
Diseases of the circulatory system 26.0%Symptoms, signs, and ill-defined conditions 24.5%
Diseases of the respiratory system 18.8%Diseases of the musculoskeletal system and connective tissue 18.7%
Diseases of the digestive system 16.9%Injury and Poisoning 14.4%
Diseases of the nervous system 13.1%Diseases of the genitourinary system 8.1%
Infectious and parasitic diseases 5.7%
9 Ambulatory care files were not included in this review; ambulatory care staff are more likely to be focused on the presenting reason for a hospital visit while inpatient staff have additional time and resources to document a more complete case history of a patient and are more likely to consistently identify co-morbid conditions. 10 Does not account for patients who present at a different time with a primary condition other than mental illness or substance use.
28
Among the 18,093 visits by individuals with a primary diagnosis of mental illness, over 80% of those receiving services in an inpatient setting had secondary conditions related to a range of other conditions within the mental disorder ICD-9 grouping. One in three had conditions related to endocrine, nutritional, and metabolic diseases and immunity disorders. About one in four had conditions related to diseases and immunity disorders. About one in four had conditions related to diseases of the circulatory system or symptoms, signs, and other ill-defined conditions. Less than 20% had conditions related to: diseases of the respiratory, musculoskeletal, and digestive system, injury and poisoning, diseases of the nervous or genitourinary system, or infectious and parasitic diseases. Among the 7,516 visits with a primary diagnosis of substance use, most (87%) had secondary conditions which fell under the broad category of mental disorders. Approximately 42% had secondary diagnoses related to symptoms, signs, and ill-defined conditions; 36% had conditions related to endocrine, nutritional and metabolic diseases, and immunity disorders; and 34% had diseases of the circulatory system. About one in four had conditions related to diseases of the digestive or respiratory systems or conditions related to injury and poisoning. Less than 20% had conditions related to: diseases of the musculoskeletal system, diseases of the blood and blood forming organs, infectious and parasitic diseases, and diseases of the genitourinary system or nervous system.
Table 11. Primary Diagnosis of Substance Use in Inpatient Settings, 2004-2006 Percent of Visits With Specified Secondary Condition
Secondary Diagnosis Condition Visits 7,516
Mental Disorders 87.5%Symptoms, signs, and ill-defined conditions 41.8%
Endocrine, nutritional and metabolic diseases, and immunity disorders 36.4%Diseases of the circulatory system 33.8%
Diseases of the digestive system 26.9%Injury and Poisoning 25.3%
Diseases of the respiratory system 22.4%Diseases of the musculoskeletal system and connective tissue 14.1%
Diseases of the blood and blood-forming organs 14.0%Infectious and parasitic diseases 11.1%
Diseases of the genitourinary system 9.6%Diseases of the nervous system 8.4%
Section Summary Our research found that ambulatory care staff are increasingly likely to identify mental illness or substance use conditions as a secondary condition for an ambulatory care visit. This may indicate an increased awareness by health care providers of the interaction of mental and physical conditions. In looking at co-occurring conditions for patients with a primary diagnosis of mental illness or substance use receiving inpatient care, one quarter also presented with symptoms, signs, and ill-defined conditions and more than one in ten had conditions related to endocrine, nutritional and metabolic diseases, and immunity disorders; diseases of the circulatory system; and injury and poisoning. Patients with substance use disorders were even more likely to present with co-occurring conditions including diseases of the circulatory, respiratory, and digestive systems; and endocrine, nutritional and metabolic diseases, and immunity disorders. Findings indicate that further research using an expanded review of diagnostic fields to study the connection between mental illness or substance use and other health conditions is merited.
29
30
VI. How do hospitalization rates for mental illness or substance use vary across the state?
In order to develop town-by-town prevalence rates for hospitalizations for mental health and substance use conditions, we worked with the New Hampshire Bureau of Health Statistics to obtain hospitalization information not only for our own state, but also for residents who sought care in Maine, Vermont, and Massachusetts. The reader should note that the accompanying maps showing prevalence rates by town are based on number of hospital visits per 10,000 population, rather than a unique count of patients.11 Total visits are drawn from 2000-2003 hospital discharge data; in our review we looked at only the primary diagnostic and E-code fields. Data points for individual towns are included in Appendix D.12
The maps below illustrate the geographic distribution of hospitalizations for mental illness and substance use and include a listing of New Hampshire towns with hospitals with dedicated resources available to care for patients with mental illness conditions. We have divided prevalence rates for towns into quintiles, 20% of towns with the lowest rates are in the first quintile and 20% of towns with the highest prevalence rates are in the fifth quintile. Specialty hospitals are designated with an (S), hospitals which provide services for alcohol/drug treatment are indicated with a (D), and hospitals which provide alcohol/drug treatment only when there is a primary mental illness condition present are designated by (DP). Figs. 26 and 27 show the rate of visits per 10,000 population for primary diagnoses of mental illness in ambulatory care and inpatient settings. The highest rate for ambulatory care visits were found in towns that have a hospital providing mental health care and in eastern and northwestern regions of the state. These areas, as well as Keene and surrounding communities, also had high rates of inpatient care visits. Figs. 28 and 29 show the rate of visits per 10,000 population for primary diagnoses of substance use in ambulatory care and inpatient settings. Within ambulatory care settings, low versus high rate communities were scattered somewhat randomly across the state. Towns with higher rates of inpatient care included those in the Lakes Region, those in the eastern region of the state, and in Berlin and Gorham in the North Country.
11 Use of a visit count is due to a limitation in the data provided by surrounding states. Many of these hospital files lacked a unique ID for each patient, particularly for New Hampshire residents seeking services in either Vermont or Maine. As a result, findings would be skewed towards providing higher prevalence rates in the southern tier of the state than in the northern, eastern, or western regions. 12 Readers should interpret town level data with caution, particularly for areas with small population counts (e.g. under 1,000). Even though data is aggregated over a four year period in order to help address this issue, small changes in the count of visits can still result in major changes in the overall prevalence rate.
31
32
Section Summary Our town-by-town review of hospitalization rates highlight a number of areas of concern. First, while high incidence of ambulatory care visits for substance use appear to occur randomly across the state, high rates of mental illness ambulatory care as well as mental illness or substance use inpatient care do tend to cluster in certain geographic areas of the state. Even keeping in mind some of the limitations in utilizing town-based data, this clustering would seem to indicate a need for additional resources to better serve certain regions. Second, there does appear to be some connection between the availability of dedicated hospital resources for mental health care and higher rates of incidence as towns that have these resources tend to also have the higher prevalence rates. Third, certain town clusters, such as Claremont, Berlin, and their surrounding towns had consistently high rates of ambulatory and inpatient hospitalizations for patients presenting with either mental illness or substance use. This fact, combined with the historic lack of mental health and substance use treatment resources in rural areas is particularly concerning.
33
Report Summary This report draws upon patient data from 1997-2006 to provide an overview of hospitalization patterns for New Hampshire citizens with diagnoses of mental illness and/or substance use. In reviewing the data, the following limitations should be noted: this data set covers only one part of the overall continuum of care, prevalence of mental illness or substance use is likely much higher in the population; data on hospital charges do not reflect the total costs incurred; ambulatory patient data do not include information for patients who were seen by ambulatory care and then admitted for inpatient service; and, excepting for town hospitalization prevalence rates, the data do not include information about New Hampshire residents who receive hospital care out of state. Even though our research does not encompass the full continuum of mental health care, our review of hospital data indicates that New Hampshire may be losing ground in its ability to provide appropriate, accessible care for people diagnosed with mental illness and substance use conditions. For example:
• For patients diagnosed with mental illness or substance use conditions, ambulatory care utilization rates—especially in emergency departments—are on the rise. Between 1997-2006, ambulatory care admissions increased substantially, particularly among 15-49 year olds. While ambulatory care utilization for individuals over 65 did not increase substantially, this will likely change as the number of elders in New Hampshire is expected to double by 2020.
• Inpatient care utilization for patients diagnosed with mental illness and substance use conditions has kept pace with population growth. As a result, more hospital beds and trained health care providers will be needed.
• The co-occurrence of mental illness and substance use may be higher among certain segments of the population than previously thought. Addressing the needs of those who have co-occurring diagnoses of mental illness and substance use is particularly critical as these patients were far more likely to be repeat users of hospital services.
• For patients with a primary condition of mental illness who had on average at least one hospital visit a year, 75% had a co-occurrence of substance use as a contributing condition.
• Patients with mental illness or substance use conditions also presented with a range of secondary health conditions; the successful co-treatment of which will be critical to their long term health and well-being.
• New Hampshire’s specialty care facilities for mental illness and substance use treatment have been closing. This trend, as well as the general lack of resources that is often cited in rural areas of the state and the increased likelihood for patients with these conditions to be discharged against medical advice, is particularly troubling as may of these areas have the highest hospitalization rates for residents with mental illness and/or substance use conditions.
Our research also pointed to positive trends:
• Increasingly, ambulatory care patients with mental illness or substance use conditions were more likely to be discharged to other treatment sources rather than to self-care at home. This is a promising sign that the continuum of care is working to some extent.
34
• Within ambulatory care settings, we found that physicians are getting better at identifying mental illness or substance use as contributing conditions for patients in ambulatory care. This may be an indication that health care providers are developing a better understanding of the interaction between physical and mental health and will be able to provide treatment that meets the needs of the whole person.
In conclusion, our work raises questions about the state’s ability to meet the needs of citizens with mental illness or substance use conditions. Statewide, the availability of facilities that provide specialized mental health or substance use care is shrinking. Medicaid/Medicare reimbursement rates are failing to keep up with the rising costs of providing healthcare and private insurance coverage for mental illness and substance use treatment is declining. In much of the state there is a shortage of trained professionals to meet the needs of individuals with mental illness or substance use conditions. Lack of appropriate and ongoing treatment not only has consequences for patients; it also has a long-term negative impact on families, employers, and the community at large. Much remains to be done if New Hampshire citizens with mental illness and/or substance use conditions are to become and remain full participating members of their communities.
35
Identification of Hospital Visits for Mental Illness
Description Code Schizophrenic disorders 295 Simple schizophrenia 2950 Simpl schizophren-unspec 29500 Simpl schizophren-subchr 29501 Simple schizophren-chr 29502 Simp schiz-subchr/exacer 29503 Simpl schizo-chr/exacerb 29504 Simpl schizophren-remiss 29505 Hebephrenia 2951 Hebephrenia-unspec 29510 Hebephrenia-subchronic 29511 Hebephrenia-chronic 29512 Hebephren-subchr/exacerb 29513 Hebephrenia-chr/exacerb 29514 Hebephrenia-remission 29515 Catatonic schizophrenia 2952 Catatonia-unspec 29520 Catatonia-subchronic 29521 Catatonia-chronic 29522 Catatonia-subchr/exacerb 29523 Catatonia-chr/exacerb 29524 Catatonia-remission 29525 Paranoid schizophrenia 2953 Paranoid schizo-unspec 29530 Paranoid schizo-subchr 29531 Paranoid schizo-chronic 29532 Paran schizo-subchr/exac 29533 Paran schizo-chr/exacerb 29534 Paranoid schizo-remiss 29535 Ac schizophrenic episode 2954 Ac schizophrenia-unspec 29540 Ac schizophrenia-subchr 29541 Ac schizophrenia-chr 29542 Ac schizo-subchr/exacerb 29543 Ac schizophr-chr/exacerb 29544 Ac schizophrenia-remiss 29545 Latent schizophrenia 2955 Latent schizophren-unsp 29550 Lat schizophren-subchr 29551 Latent schizophren-chr 29552 Lat schizo-subchr/exacer 29553 Latent schizo-chr/exacer 29554 Lat schizophren-remiss 29555 Residual schizophrenia 2956 Resid schizophren-unsp 29560 Resid schizophren-subchr 29561
Residual schizophren-chr 29562Resid schizo-subchr/exac 29563Resid schizo-chr/exacerb 29564Resid schizophren-remiss 29565Schizoaffective type 2957 Schizoaffective-unspec 29570Schizoaffective-subchr 29571Schizoaffective-chronic 29572Schizoaff-subchr/exacer 29573Schizoaffect-chr/exacer 29574Schizoaffective-remiss 29575Schizophrenia NEC 2958 Schizophrenia NEC-unspec 29580Schizophrenia NEC-subchr 29581Schizophrenia NEC-chr 29582Schizo NEC-subchr/exacer 29583Schizo NEC-chr/exacerb 29584Schizophrenia NEC-remiss 29585Schizophrenia NOS 2959 Schizophrenia NOS-unspec 29590Schizophrenia NOS-subchr 29591Schizophrenia NOS-chr 29592Schizo NOS-subchr/exacer 29593Schizo NOS-chr/exacerb 29594Schizophrenia NOS-remiss 29595Affective psychoses 296 Manic dis, singl episode 2960 Manic disorder-unspec 29600Manic disorder-mild 29601Manic disorder-mod 29602Manic disorder-severe 29603Manic dis-severe w psych 29604Manic dis-partial remiss 29605Manic dis-full remission 29606Manic, recurrent episode 2961 Recur manic dis-unspec 29610Recur manic dis-mild 29611Recur manic dis-mod 29612Recur manic dis-severe 29613Recur manic-sev w psycho 29614Recur manic-part remiss 29615Recur manic-full remiss 29616Depr psych, singl episod 2962 Depress psychosis-unspec 29620Depress psychosis-mild 29621Depressive psychosis-mod 29622Depress psychosis-severe 29623Depr psychos-sev w psych 29624Depr psychos-part remiss 29625Depr psychos-full remiss 29626Depr psych, recur episod 2963
Recurr depr psychos-unsp 29630Recurr depr psychos-mild 29631Recurr depr psychos-mod 29632Recur depr psych-severe 29633Rec depr psych-psychotic 29634Recur depr psyc-part rem 29635Recur depr psyc-full rem 29636Bipolar affective, manic 2964 Bipol aff, manic-unspec 29640Bipolar aff, manic-mild 29641Bipolar affec, manic-mod 29642Bipol aff, manic-severe 29643Bipol manic-sev w psych 29644Bipol aff manic-part rem 29645Bipol aff manic-full rem 29646Bipolar affect, depress 2965 Bipolar aff, depr-unspec 29650Bipolar affec, depr-mild 29651Bipolar affec, depr-mod 29652Bipol aff, depr-severe 29653Bipol depr-sev w psych 29654Bipol aff depr-part rem 29655Bipol aff depr-full rem 29656Bipolar affective, mixed 2966 Bipol aff, mixed-unspec 29660Bipolar aff, mixed-mild 29661Bipolar affec, mixed-mod 29662Bipol aff, mixed-severe 29663Bipol mixed-sev w psych 29664Bipol aff, mix-part rem 29665Bipol aff, mix-full rem 29666Bipolar affective NOS 2967 Manic-depressive NEC/NOS 2968 Manic-depressive NOS 29680Atypical manic disorder 29681Atypical depressive dis 29682Manic-depressive NEC 29689Affect psychoses NEC/NOS 2969 Affective psychosis NOS 29690Affective psychoses NEC 29699Paranoid states 297 Paranoid state, simple 2970 Paranoia 2971 Paraphrenia 2972 Shared paranoid disorder 2973 Paranoid states NEC 2978 Paranoid state NOS 2979 Oth nonorganic psychoses 298 React depress psychosis 2980 Excitativ type psychosis 2981
Appendix A List of Mental Illness and Substance Use Conditions
36
Reactive confusion 2982 Acute paranoid reaction 2983 Psychogen paranoid psych 2984 React psychosis NEC/NOS 2988 Psychosis NOS 2989 Psychoses of childhood 299 Disintegrative psychosis 2991 Disintegr psych-active 29910 Disintegr psych-residual 29911 Early chld psychoses NEC 2998 Child psychos NEC-active 29980 Child psychos NEC-resid 29981 Early chld psychosis NOS 2999 Child psychos NOS-active 29990 Child psychos NOS-resid 29991 Neurotic disorders 300 Anxiety states 3000 Anxiety state NOS 30000 Panic disorder 30001 Generalized anxiety dis 30002 Anxiety state NEC 30009 Hysteria 3001 Hysteria NOS 30010 Conversion disorder 30011 Psychogenic amnesia 30012 Psychogenic fugue 30013 Multiple personality 30014 Dissociative react NOS 30015 Factitious ill w symptom 30016 Factitious ill NEC/NOS 30019 Phobic disorders 3002 Phobia NOS 30020 Agoraphobia with panic 30021 Agoraphobia w/o panic 30022 Social phobia 30023 Isolated phobias NEC 30029 Obsessive-compulsive dis 3003 Neurotic depression 3004 Neurasthenia 3005 Depersonalization synd 3006 Hypochondriasis 3007 Neurotic disorders NEC 3008 Somatization disorder 30081 Undiff somatoform disrdr 30082 Neurotic disorders NEC 30089 Neurotic disorder NOS 3009 Personality disorders 301 Paranoid personality 3010 Affective personality 3011 Affectiv personality NOS 30110 Chronic hypomanic person 30111
Chr depressive person 30112Cyclothymic disorder 30113Schizoid personality 3012 Schizoid personality NOS 30120Introverted personality 30121Schizotypal personality 30122Explosive personality 3013 Compulsive personality 3014 Histrionic personality 3015 Histrionic person NOS 30150Chr factitious illness 30151Histrionic person NEC 30159Dependent personality 3016 Antisocial personality 3017 Other personality dis 3018 Narcissistic personality 30181Avoidant personality 30182Borderline personality 30183Passive-aggressiv person 30184Personality disorder NEC 30189Personality disorder NOS 3019 Pedophilia 3022 Psychophysiologic dis 306 Psychogen musculskel dis 3060 Psychogenic respir dis 3061 Psychogen cardiovasc dis 3062 Psychogenic skin disease 3063 Psychogenic gi disease 3064 Psychogenic gu disease 3065 Psychogenic gu dis NOS 30650Psychogenic vaginismus 30651Psychogenic dysmenorrhea 30652Psychogenic dysuria 30653Psychogenic gu dis NEC 30659Psychogen endocrine dis 3066 Psychogenic sensory dis 3067 Psychogenic disorder NEC 3068 Psychogenic disorder NOS 3069 Anorexia nervosa 3071 Stereotyped movements 3073 Eating disorders NEC/NOS 3075 Eating disorder NOS 30750Bulimia 30751Pica 30752Psychogenic rumination 30753Psychogenic vomiting 30754Eating disorder NEC 30759Psychalgia 3078 Psychogenic pain NOS 30780Psychogenic pain NEC 30789Acute reaction to stress 308
Stress react, emotional 3080 Stress reaction, fugue 3081 Stress react, psychomot 3082 Acute stress react NEC 3083 Stress react, mixed dis 3084 Acute stress react NOS 3089 Adjustment reaction 309 Brief depressive react 3090 Prolong depressive react 3091 Adjust react/oth emotion 3092 Separation anxiety 30921Emancipation disorder 30922Adj react-anxious mood 30924Adj react-mixed emotion 30928Adj react-emotion NEC 30929Adjust react-conduct dis 3093 Adj react-emotion/conduc 3094 Other adjust reaction 3098 Prolong posttraum stress 30981Adjust react-phys sympt 30982Adjust react-withdrawal 30983Adjustment reaction NEC 30989Adjustment reaction NOS 3099 Depressive disorder NEC 311 Conduct disturbance NEC 312 Unsocialized aggression 3120 Unsocial aggress-unspec 31200Unsocial aggression-mild 31201Unsocial aggression-mod 31202Unsocial aggress-severe 31203Unsocializ, unaggressive 3121 Unsocial unaggress-unsp 31210Unsocial unaggress-mild 31211Unsocial unaggress-mod 31212Unsocial unaggr-severe 31213Socialized conduct dis 3122 Social conduct dis-unsp 31220Social conduct dis-mild 31221Social conduct dis-mod 31222Social conduct dis-sev 31223Impulse control dis NEC 3123 Impulse control dis NOS 31230Pathological gambling 31231Kleptomania 31232Pyromania 31233Intermitt explosive dis 31234Isolated explosive dis 31235Impulse control dis NEC 31239Mix dis conduct/emotion 3124 Other conduct disturb 3128 Cndct dsrdr chLDHd onst 31281
37
Cndct dsrdr adlscnt onst 31282 Other conduct disorder 31289 Conduct disturbance NOS 3129 Emotional dis child/adol 313 Overanxious disorder 3130 Misery & unhappiness dis 3131 Sensitivity & withdrawal 3132 Shyness disorder-child 31321 Introverted dis-child 31322 Elective mutism 31323 Relationship problems 3133 Oth emotional dis child 3138 Oppositional disorder 31381 Identity disorder 31382 Emotional dis child NEC 31389 Emotional dis child NOS 3139 Hallucinations 7801 Anorexia 7830 Nervousness 7992 Pois-analgesic/antipyret 965 Poisoning-opiates 9650 Poisoning-opium NOS 96500 Poisoning-heroin 96501 Poisoning-methadone 96502 Poisoning-opiates NEC 96509 Poisoning-salicylates 9651 Pois-arom analgesics NEC 9654 Poisoning-pyrazole deriv 9655 Poisoning-antirheumatics 9656 Pois-propionic acid derv 96561 Poison-antirheumatic NEC 96569 Pois-no-narc analges NEC 9657 Pois-analges/antipyr NEC 9658 Pois-analges/antipyr NOS 9659 Poison-sedative/hypnotic 967 Poisoning-barbiturates 9670 Poisoning-methaqualone 9674 Poisoning-glutethimide 9675 Poison-mix sedative NEC 9676 Pois-sedative/hypnot NEC 9678 Pois-sedative/hypnot NOS 9679 Poisoning-cns depressant 968 Poison-psychotropic agt 969 Poisoning-antidepressant 9690 Pois-phenothiazine tranq 9691 Pois-butyrophenone tranq 9692 Poison-antipsychotic NEC 9693 Pois-benzodiazepine tran 9694 Poison-tranquilizer NEC 9695 Poisoning-hallucinogens 9696 Poison-psychostimulants 9697
Poison-psychotropic NEC 9698 Poison-psychotropic NOS 9699 Poisoning-cns stimulants 970 Poisoning-analeptics 9700 Pois-CNS stimulants NEC 9708 Pois-CNS stimulant NOS 9709
E-Codes for Self-Inflicted Injury
Description ECODESuic/self-pois w/ sol/liq E950 Poison-analgesics E9500 Poison-barbiturates E9501 Poison-sedat/hypnotic E9502 Poison-psychotropic agt E9503 Poison-drug/medicin NEC E9504 Poison-drug/medicin NOS E9505 Poison-agricult agent E9506 Poison-corrosiv/caustic E9507 Poison-arsenic E9508 Poison-solid/liquid NEC E9509 Poison-piped gas E9510 Poison-gas in container E9511 Poison-utility gas NEC E9518 Poison-exhaust gas E9520 Poison-co NEC E9521 Poison-gas/vapor NEC E9528 Injury-hanging E9530 Injury-suff w plas bag E9531 Injury-strang/suff NEC E9538 Injury-strang/suff NOS E9539 Injury-submersion E954 Injury-handgun E9550 Injury-shotgun E9551 Injury-hunting rifle E9552 Injury-firearm NEC E9554 Injury-explosives E9555 Self inflict acc-air gun E9556 Injury-firearm/expl NOS E9559 Injury-cut instrument E956 Injury-jump fm residence E9570 Injury-jump fm struc NEC E9571 Injury-jump fm natur sit E9572 Injury-jump NEC E9579 Injury-moving object E9580 Injury-burn, fire E9581 Injury-scald E9582 Injury-extreme cold E9583 Injury-electrocution E9584
Injury-motor veh crash E9585 Injury-aircraft crash E9586 Injury-caustic substance E9587 Injury-NEC E9588 Injury-NOS E9589 Late eff of self-injury E959
38
Identification of Hospital Visits for Substance Use
Description Code Alcoholic psychoses 291 Delirium tremens 2910 Alcohol amnestic synd 2911 Alcoholic dementia NEC 2912 Alcohol hallucinosis 2913 Pathologic alcohol intox 2914 Alcoholic jealousy 2915 Alcoholic psychosis NEC 2918 Alcohol withdrawal 29181 Alcoholic psychosis NEC 29189 Alcoholic psychosis NOS 2919 Drug psychoses 292 Drug withdrawal syndrome 2920 Drug paranoid/hallucinos 2921 Drug paranoid state 29211 Drug hallucinosis 29212 Pathologic drug intox 2922 Other drug mental dis 2928 Drug-induced delirium 29281 Drug-induced dementia 29282 Drug amnestic syndrome 29283 Drug depressive syndrome 29284 Drug mental disorder NEC 29289 Drug mental disorder NOS 2929 Alcohol dependence syndr 303 Ac alcohol intoxication 3030 Ac alcohol intox-unspec 30300 Ac alcohol intox-contin 30301 Ac alcohol intox-episod 30302 Ac alcohol intox-remiss 30303 Alcohol depend NEC/NOS 3039 Alcoh dep NEC/NOS-unspec 30390 Alcoh dep NEC/NOS-contin 30391 Alcoh dep NEC/NOS-episod 30392 Alcoh dep NEC/NOS-remiss 30393 Drug dependence 304 Opioid type dependence 3040 Opioid dependence-unspec 30400 Opioid dependence-contin 30401 Opioid dependence-episod 30402 Opioid dependence-remiss 30403
Barbiturate dependence 3041 Barbiturat depend-unspec 30410 Barbiturat depend-contin 30411 Barbiturat depend-episod 30412 Barbiturat depend-remiss 30413 Cocaine dependence 3042 Cocaine depend-unspec 30420 Cocaine depend-contin 30421 Cocaine depend-episodic 30422 Cocaine depend-remiss 30423 Cannabis dependence 3043 Cannabis depend-unspec 30430 Cannabis depend-contin 30431 Cannabis depend-episodic 30432 Cannabis depend-remiss 30433 Amphetamine dependence 3044 Amphetamin depend-unspec 30440 Amphetamin depend-contin 30441 Amphetamin depend-episod 30442 Amphetamin depend-remiss 30443 Hallucinogen dependence 3045 Hallucinogen dep-unspec 30450 Hallucinogen dep-contin 30451 Hallucinogen dep-episod 30452 Hallucinogen dep-remiss 30453 Drug dependence NEC 3046 Drug depend NEC-unspec 30460 Drug depend NEC-contin 30461 Drug depend NEC-episodic 30462 Drug depend NEC-in rem 30463 Opioid/other drug depend 3047 Opioid/other dep-unspec 30470 Opioid/other dep-contin 30471 Opioid/other dep-episod 30472 Opioid/other dep-remiss 30473 Comb drug dependence NEC 3048 Comb drug dep NEC-unspec 30480 Comb drug dep NEC-contin 30481 Comb drug dep NEC-episod 30482 Comb drug dep NEC-remiss 30483 Drug dependence NOS 3049
Drug depend NOS-unspec 30490 Drug depend NOS-contin 30491 Drug depend NOS-episodic 30492 Drug depend NOS-remiss 30493 Nondependent drug abuse 305 Alcohol abuse 3050 Alcohol abuse-unspec 30500 Alcohol abuse-continuous 30501 Alcohol abuse-episodic 30502 Alcohol abuse-in remiss 30503 Tobacco use disorder 3051 Cannabis abuse 3052 Cannabis abuse-unspec 30520 Cannabis abuse-contin 30521 Cannabis abuse-episodic 30522 Cannabis abuse-in remiss 30523 Hallucinogen abuse 3053 Hallucinog abuse-unspec 30530 Hallucinog abuse-contin 30531 Hallucinog abuse-episod 30532 Hallucinog abuse-remiss 30533 Barbiturate abuse 3054 Barbiturate abuse-unspec 30540 Barbiturate abuse-contin 30541 Barbiturate abuse-episod 30542 Barbiturate abuse-remiss 30543 Opioid abuse 3055 Opioid abuse-unspec 30550 Opioid abuse-continuous 30551 Opioid abuse-episodic 30552 Opioid abuse-in remiss 30553 Cocaine abuse 3056 Cocaine abuse-unspec 30560 Cocaine abuse-continuous 30561 Cocaine abuse-episodic 30562 Cocaine abuse-in remiss 30563 Amphetamine abuse 3057 Amphetamine abuse-unspec 30570 Amphetamine abuse-contin 30571 Amphetamine abuse-episod 30572 Amphetamine abuse-remiss 30573 Antidepressant abuse 3058 Antidepress abuse-unspec 30580 Antidepress abuse-contin 30581 Antidepress abuse-episod 30582 Antidepress abuse-remiss 30583
39
Drug abuse NEC/NOS 3059 Drug abuse NEC-unspec 30590 Drug abuse NEC-contin 30591 Drug abuse NEC-episodic 30592 Drug abuse NEC-in remiss 30593 Alcoholic polyneuropathy 3575 Neuropathy due to drugs 3576 Alcoholic cardiomyopathy 4255 Alcoholic gastritis 5353 Alchl gastrtis w/o hmrhg 53530 Alchl gstritis w hmrhg 53531 Alcoholic fatty liver 5710 Ac alcoholic hepatitis 5711 Alcohol cirrhosis liver 5712 Alcohol liver damage NOS 5713 Cirrhosis of liver NOS 5715 Drug dependence in preg 6483 Drug depend preg-unspec 64830 Drug dependence-deliver 64831 Drug dependen-del w P/P 64832 Drug dependence-antepart 64833 Drug dependence-postpart 64834 Fetal damage d/t drug 6555 Fetal damg d/t drug-unsp 65550 Fet damag d/t drug-deliv 65551 Fet damg d/t drug-antepa 65553 Maternal alcohol aff NB 76071 Maternal narcotic aff NB 76072 Maternal hallucin aff NB 76073 Cocaine - nxs infl fetus 76075 Fts/NB afctd mtrnl des 76076 Noxious subst NEC aff NB 76079 NB drug withdrawal syndr 7795 Excess blood-alcohol lev 7903 Pois-corticosteroids 9620 Pois-analgesic/antipyret 965 Poisoning-opiates 9650 Poisoning-opium NOS 96500 Poisoning-heroin 96501 Poisoning-methadone 96502 Poisoning-opiates NEC 96509 Poisoning-salicylates 9651 Pois-arom analgesics NEC 9654 Poisoning-pyrazole deriv 9655 Poisoning-antirheumatics 9656 Pois-propionic acid derv 96561 Poison-antirheumatic NEC 96569 Pois-no-narc analges NEC 9657
Pois-analges/antipyr NEC 9658 Pois-analges/antipyr NOS 9659 Poison-sedative/hypnotic 967 Poisoning-barbiturates 9670 Poisoning-chloral hydrat 9671 Poisoning-paraldehyde 9672 Poisoning-bromine compnd 9673 Poisoning-methaqualone 9674 Poisoning-glutethimide 9675 Poison-mix sedative NEC 9676 Pois-sedative/hypnot NEC 9678 Pois-sedative/hypnot NOS 9679 Poisoning-cns depressant 968 Pois-cns muscle depress 9680 Poisoning-halothane 9681 Poison-gas anesthet NEC 9682 Poison-intraven anesthet 9683 Pois-gen anesth NEC/NOS 9684 Pois-topic/infilt anesth 9685 Pois-nerve/plex-blk anes 9686 Poison-spinal anesthetic 9687 Pois-local anest NEC/NOS 9689 Poison-psychotropic agt 969 Poisoning-antidepressant 9690 Pois-phenothiazine tranq 9691 Pois-butyrophenone tranq 9692 Poison-antipsychotic NEC 9693 Pois-benzodiazepine tran 9694 Poison-tranquilizer NEC 9695 Poisoning-hallucinogens 9696 Poison-psychostimulants 9697 Poison-psychotropic NEC 9698 Poison-psychotropic NOS 9699 Poisoning-cns stimulants 970 Poisoning-analeptics 9700 Poison-opiate antagonist 9701 Pois-CNS stimulants NEC 9708 Pois-CNS stimulant NOS 9709 Poisoning-dietetics 9770 Poison-alcohol deterrent 9773 Alcohol toxicity 980 Toxic eff ethyl alcohol 9800 Toxic eff methyl alcohol 9801 Toxic eff isopropyl alc 9802 Toxic effect fusel oil 9803 Toxic effect alcohol NEC 9808
Toxic effect alcohol NOS 9809 E-Codes for Self-Inflicted Injury, Substance Use
Description ECODESuic/self-pois w/ sol/liq E950 Poison-analgesics E9500 Poison-barbiturates E9501 Poison-sedat/hypnotic E9502 Poison-psychotropic agt E9503 Poison-drug/medicin NEC E9504 Poison-drug/medicin NOS E9505
40
Appendix B List of New Hampshire Hospitals
List of Hospitals included in Inpatient / Ambulatory Care Files
Alice Peck Day [Lebanon] Androscoggin [Berlin] (CAH) Catholic Medical Center (M –
Beds: 14 for >18-59; 5 for >60) (DP) [Manchester]
Cheshire (M --Beds: 12 for <11-18 YO; 12 for >18 YO) (D) [Keene]
Concord (M --Beds: 13 for >17 YO, 2 for >65 YO) (DP) [Concord]
Cottage [Woodsville] (CAH) DHMC (M --Beds: 21 for >18
YO) (DP) [Lebanon] DP Elliot (M –Beds Pathways: 12
for >18-65 YO; Beds GPU: 24 for >60 YO) [Manchester]
Exeter [Exeter] Franklin (CAH) [Franklin] Frisbee (M –10 beds for 65+,
younger if with dementia) [Rochester]
Huggins (CAH) [Wolfeboro] Lakes Region (M –Beds: 10 for
>65 YO) [Laconia]
Littleton (CAH) [Littleton] Memorial (CAH) [North
Conway] Monadnock (CAH)
[Peterborough] New London (CAH) [New
London] Parkland Medical Center
[Derry] Portsmouth (M –Beds: 22 for
> 18 YO) (D) [Portsmouth] St. Joseph (M –Beds: 18 for
>55 YO) [Nashua] Southern NH Regional
Medical Center (M –Beds: 30 total for >17 YO) (D) [Nashua]
Speare (CAH) [Plymouth] Upper Connecticut Valley
(CAH) [Colebrook] Wentworth-Douglas [Dover] Weeks (CAH) [Lancaster] Valley Regional (DP) (CAH)
[Claremont]
List of Hospitals included in Specialty Care Files
Beech Hill Hospital (D) [Dublin] (CLOSED, 2002)
Hampstead Hospital (M –Beds: 23>18 YO, 23 for 10-18 YO, 26 for Dev Disabled 6-30 YO) (D) [Hampstead]
Charter Brookside Behavioral Health Systems [Nashua] (CLOSED, 2000)
New Hampshire Hospital (M –Beds: 22 for 4-15 YO 200 for >15 IO) [Concord]
Northeast Rehabilitation Hospital (Salem)
Seaborne Hospital [Dublin] (CLOSED, 1998)
Portsmouth Pavilion [Portsmouth]
Healthsouth Rehabilitaion Hospital [Concord]
Legend: M = Mental health services available D = Some alc/drug txt DP = Alc/Drug treatment if primary psych condition exists CAH = Critical Access Hospital
41
Appendix C Supplemental Tables for Figures
Fig. 1 Data Table: Age Distribution by Condition Type, Percent of Visits: Inpatient, Ambulatory, and Specialty Care Hospitals, 2004-2006
Mental Illness Substance Use All Ambulatory Inpatient Specialty Ambulatory Inpatient Specialty Ambulatory Inpatient Specialty
N 46,772 18,093 9,666 19,948 7,516 2,613 2,068,440 371,293 19,571 0 to 14 7.6% 1.9% 14.3% 3.7% 1.3% 0.4% 13.7% 14.4% 8.0%
15 to 29 36.7% 24.1% 33.0% 35.9% 18.5% 24.3% 23.7% 11.1% 20.8%30 to 49 37.2% 45.3% 37.5% 42.9% 47.8% 55.4% 29.4% 20.2% 29.1%50 to 64 12.0% 17.3% 13.4% 14.0% 23.3% 18.3% 17.3% 17.6% 16.6%
65+ 6.5% 11.4% 1.8% 3.5% 9.2% 1.7% 15.9% 36.6% 25.4% Fig. 2 Data Table: Gender Distribution by Condition Type, Percent of Visits: Inpatient, Ambulatory, and Specialty Care Hospitals, 2004-2006
Mental Illness Substance Use All Ambulatory Inpatient Specialty Ambulatory Inpatient Specialty Ambulatory Inpatient Specialty
N 46,772 18,093 9,666 19,948 7,516 2,613 2,068,441 371,293 19,571 Female 58.3% 62.1% 56.7% 45.9% 47.5% 37.1% 53.3% 58.6% 53.5%
Male 41.7% 37.9% 43.3% 54.1% 52.5% 62.9% 46.7% 41.4% 46.5% Fig. 3 Data Table: Payor Distribution by Condition Type, Percent of Visits: Inpatient, Ambulatory, and Specialty Care Hospitals, 2004-2006
Mental Illness Substance Use All Ambulatory Inpatient Specialty Ambulatory Inpatient Specialty Ambulatory Inpatient Specialty
N 46,772 18,093 9,663 19,948 7,516 2,613 2,068,441 371,293 19,568 Medicaid 18.9% 18.0% 15.4% 14.8% 14.6% 5.7% 12.7% 11.5% 10.1%Medicare 19.8% 31.3% 25.0% 13.3% 21.8% 12.6% 19.0% 40.2% 40.2%
Other 1.7% 1.3% 14.9% 1.7% 1.9% 11.4% 5.6% 2.0% 9.7%Private 37.2% 32.6% 41.7% 35.6% 34.0% 59.9% 47.7% 40.9% 37.1%
Self Pay 22.5% 16.7% 2.9% 34.6% 27.6% 10.4% 15.0% 5.4% 2.9%
42
Fig. 9 Data Table: Total Charges of Mental Illness Hospital Visits, by Setting 1997-2006 (Average over 3 Years) Specialty Inpatient Ambulatory
1997-1999 $87,018,959 $50,323,962 $6,300,1471998-2000 $75,767,664 $47,657,020 $6,738,1021999-2001 $65,921,944 $50,367,185 $7,449,2372000-2002 $60,045,989 $53,073,640 $8,796,6112001-2003 $60,441,224 $57,590,696 $10,361,7812002-2004 $62,685,693 $61,214,679 $12,413,4712003-2005 $61,828,868 $64,797,421 $14,443,1362004-2006 $52,246,840 $67,202,445 $16,700,793
Fig. 10 Data Table: Total Charges of Substance Use Hospital Visits, by Setting 1997-2006 (Average over 3 Years) Specialty Inpatient Ambulatory
1997-1999 $25,816,454 $17,695,618 $4,585,0321998-2000 $22,689,795 $16,812,166 $4,986,9001999-2001 $17,295,323 $17,224,918 $5,294,5522000-2002 $11,519,005 $18,402,216 $6,081,6522001-2003 $7,018,002 $21,298,549 $6,867,4872002-2004 $5,564,930 $23,694,771 $8,020,5862003-2005 $5,687,048 $25,822,997 $9,306,7902004-2006 $6,086,961 $27,620,041 $10,662,306
Fig. 12 Data Table: Average Charge Per Mental Illness Visit by Payor, Inpatient Care Settings (Average over 3 Years) Medicaid Medicare Other Private Self Pay
1997-1999 $8,746 $12,523 $8,871 $7,281 $6,5011998-2000 $8,436 $12,624 $7,785 $6,726 $6,5021999-2001 $8,419 $13,090 $7,953 $7,144 $6,7922000-2002 $8,279 $13,385 $7,692 $7,589 $7,1552001-2003 $9,048 $13,948 $8,821 $8,071 $7,7962002-2004 $9,473 $14,324 $9,929 $8,365 $8,1422003-2005 $9,944 $14,735 $9,939 $8,870 $8,5692004-2006 $10,198 $14,879 $9,881 $9,305 $8,896
43
Fig. 13 Data Table: Length of Stay (Days) for Mental Illness Visits by Payor, Inpatient Care Settings (Average over 3 Years) Medicaid Medicare Other Private Self Pay
1997-1999 6.5 9.7 6.6 4.8 4.31998-2000 6.1 9.4 5.8 4.7 4.31999-2001 5.9 9.4 5.5 4.8 4.42000-2002 5.6 9.3 4.4 4.9 4.62001-2003 5.8 9.3 4.7 5.0 4.82002-2004 5.8 9.2 4.8 5.0 4.82003-2005 5.8 9.0 4.9 5.0 4.82004-2006 5.5 8.8 5.0 5.0 4.7
Fig. 14 Data Table: Total Substance Use Visits by Payor, Inpatient Care Settings (Average over 3 Years) Medicaid Medicare Other Private Self Pay
1997-1999 426 585 20 993 6931998-2000 365 537 19 872 6191999-2001 308 515 28 808 6182000-2002 310 503 32 781 6392001-2003 331 525 35 810 6702002-2004 359 530 41 824 6992003-2005 364 540 45 839 6922004-2006 366 546 48 853 692
Fig. 15 Data Table: Average Charge Per Substance Use Visit by Payor, Inpatient Care Settings (Average over 3 Years) Medicaid Medicare Other Private Self Pay
1997-1999 $6,842 $8,329 $6,760 $6,093 $5,5641998-2000 $7,327 $8,934 $7,893 $6,646 $5,6311999-2001 $8,534 $9,542 $9,299 $7,182 $5,8922000-2002 $8,707 $10,331 $9,858 $7,831 $6,3572001-2003 $9,432 $11,164 $10,482 $8,591 $7,3772002-2004 $9,734 $11,856 $11,142 $9,466 $8,0492003-2005 $10,937 $12,360 $11,094 $9,866 $9,2672004-2006 $11,874 $12,748 $10,920 $10,522 $9,814
44
Fig. 16 Data Table: Length of Stay (Days) for Substance Use Visits by Payor, Inpatient Care Settings (Average over 3 Years) Medicaid Medicare Other Private Self Pay
1997-1999 4.4 4.9 3.5 3.2 3.21998-2000 4.0 4.8 3.1 3.1 3.01999-2001 4.1 4.6 3.3 3.0 3.02000-2002 3.9 4.6 3.5 3.1 3.02001-2003 4.0 4.6 3.4 3.1 3.22002-2004 3.9 4.7 3.4 3.3 3.32003-2005 4.0 4.7 3.2 3.3 3.42004-2006 3.9 4.6 3.2 3.3 3.5
Fig. 18 Data Table: Average Charge Per Mental Illness Visit by Payor, Ambulatory Care Settings (Average over 3 Years) Medicaid Medicare Other Private Self Pay
1997-1999 $563 $632 $575 $624 $5731998-2000 $563 $646 $589 $626 $5821999-2001 $555 $651 $643 $638 $5902000-2002 $585 $704 $703 $686 $6432001-2003 $659 $810 $798 $743 $7172002-2004 $785 $949 $916 $832 $8262003-2005 $886 $1,087 $999 $934 $9252004-2006 $991 $1,187 $1,155 $1,072 $1,022
Fig. 20 Data Table: Average Charge Per Substance Use Visit by Payor, Ambulatory Care Settings (Average over 3 Years) Medicaid Medicare Other Private Self Pay
1997-1999 $963 $1,092 $927 $1,026 $8431998-2000 $1,016 $1,161 $974 $1,062 $8931999-2001 $1,008 $1,127 $1,057 $1,093 $9162000-2002 $1,045 $1,166 $989 $1,152 $9792001-2003 $1,140 $1,348 $1,154 $1,223 $1,0502002-2004 $1,312 $1,578 $1,256 $1,361 $1,1632003-2005 $1,448 $1,783 $1,509 $1,525 $1,2852004-2006 $1,577 $1,883 $1,740 $1,686 $1,407
45
Town
Mental Illness
Ambulatory Care Visit
Rate
Mental Illness
Inpatient Care Visit
Rate
Substance Use
Ambulatory Care Visit
Rate
Substance Use
Inpatient Care Visit
Rate State Median 158.3 36.1 37.5 22
Acworth 408.8 152.9 55.9 47.1 Albany 212.1 70.7 29.8 37.2
Alexandria 123.0 36.7 38.6 29.4 Allenstown 170.4 52.4 44.8 21.9
Alstead 183.1 72.5 25.4 30.5 Alton 173.4 38.3 35.6 23.4
Amherst 118.3 36.4 32.1 17.1 Andover 192.2 37.3 37.3 28.0
Antrim 189.2 52.3 36.2 17.1 Ashland 252.1 33.1 90.4 44.6
Atkinson 128.4 23.2 30.6 16.2 Auburn 85.4 30.6 28.5 15.5
Barnstead 179.4 45.5 32.7 30.3 Barrington 170.7 20.2 48.1 19.9
Bartlett 151.3 36.0 29.7 25.2 Bath 188.1 19.4 24.9 11.1
Bedford 99.1 40.0 24.8 14.4 Belmont 220.3 35.6 59.7 50.3
Bennington 163.4 45.7 28.1 8.8 Benton 119.8 31.9 39.9 8.0
Berlin 252.1 185.1 75.1 77.8 Bethlehem 149.2 42.3 47.9 22.3 Boscawen 161.2 54.2 36.1 19.4
Bow 114.4 33.1 22.3 17.5 Bradford 236.6 52.4 60.8 27.0
Brentwood 150.1 25.3 52.8 13.4 Bridgewater 121.4 14.9 24.8 22.3
Bristol 225.0 54.2 47.6 45.2 Brookfield 147.3 39.8 87.6 11.9 Brookline 126.6 30.9 32.7 17.8 Campton 184.9 23.7 41.9 31.0
Canaan 196.9 18.0 36.1 26.3 Candia 116.4 40.7 35.7 27.7
Canterbury 136.9 20.6 26.7 20.6 Carroll 180.8 43.4 79.5 28.9
Center Harbor 276.8 77.7 51.0 46.1 Charlestown 187.6 57.5 49.7 28.5
Chatham 392.0 57.4 47.8 9.6
Appendix D Rate of Hospital Visits Per 10,000 Population
2000-2003 Hospital Discharge Data
46
Chester 133.3 28.4 36.7 19.6 Chesterfield 101.0 50.5 30.4 19.4
Chichester 55.9 16.9 13.7 6.3 Claremont 342.2 115.5 106.6 47.8 Clarksville 85.2 25.6 0.0 51.1 Colebrook 274.3 94.3 75.0 33.2 Columbia 53.1 16.6 6.6 6.6 Concord 370.9 101.1 78.1 37.7 Conway 399.7 114.5 76.4 62.1 Cornish 127.6 29.3 38.1 19.1
Croydon 91.8 18.4 51.4 7.3 Dalton 192.1 81.2 35.2 29.8
Danbury 218.3 34.5 23.0 36.8 Danville 135.9 38.5 48.7 19.8
Deerfield 125.1 31.1 33.1 20.1 Deering 84.5 24.7 15.6 6.5
Derry 222.4 52.2 64.7 28.2 Dorchester 220.8 42.7 42.7 14.2
Dover 258.6 34.5 91.5 26.7 Dublin 115.0 31.7 31.7 10.0
Dummer 128.7 16.1 40.2 24.1 Dunbarton 99.8 26.5 15.9 15.9
Durham 108.9 13.7 30.5 9.4 East Kingston 126.5 25.3 57.3 17.3
Easton 75.8 9.5 0.0 9.5 Eaton 150.0 6.5 6.5 13.0
Effingham 161.3 49.9 30.7 26.9 Ellsworth 1416.2 86.7 115.6 202.3
Enfield 190.8 25.7 38.5 17.6 Epping 218.6 29.3 64.2 23.7 Epsom 240.1 57.5 55.1 30.8
Errol 228.0 50.7 25.3 109.8 Exeter 241.9 32.6 61.0 25.6
Farmington 291.8 43.1 68.2 24.3 Fitzwilliam 148.1 41.0 36.5 21.6
Francestown 124.2 19.6 19.6 9.8 Franconia 206.2 44.9 44.9 18.5
Franklin 409.6 89.9 87.3 57.9 Freedom 172.4 53.8 51.9 29.7 Fremont 167.7 22.8 41.4 20.7 Gilford 147.7 29.7 28.7 29.4
Gilmanton 199.2 34.1 31.8 18.6 Gilsum 134.9 72.2 25.1 37.7
Goffstown 110.9 32.5 30.5 15.6 Gorham 161.1 56.8 34.5 34.5 Goshen 180.3 85.2 81.9 49.2 Grafton 220.4 11.0 39.7 13.2
Grantham 131.4 21.0 39.8 16.6
47
Greenfield 201.3 52.9 32.3 5.9 Greenland 198.6 27.9 39.3 29.5 Greenville 206.4 80.3 77.0 43.5
Groton 177.1 10.7 37.6 16.1 Hampstead 147.4 28.5 33.8 13.6
Hampton 211.2 35.2 67.4 30.6 Hampton Falls 141.8 19.3 36.1 15.5
Hancock 124.2 32.5 25.4 22.6 Hanover 74.0 20.0 23.7 9.7
Harrisville 101.4 48.4 11.5 6.9 Hart's Location 0.0 0.0 0.0 0.0
Haverhill 271.1 34.4 49.6 23.7 Hebron 209.6 53.7 53.7 32.2
Henniker 141.1 39.3 32.8 15.1 Hill 203.1 36.7 36.7 24.5
Hillsborough 265.8 92.9 59.6 38.8 Hinsdale 149.3 51.8 32.5 21.7
Holderness 159.2 13.9 34.1 24.0 Hollis 103.9 41.5 24.7 16.5
Hooksett 120.4 33.8 45.6 21.4 Hopkinton 138.3 40.9 30.5 20.0
Hudson 186.1 59.8 59.8 33.7 Jackson 158.3 52.8 26.4 14.7 Jaffrey 204.0 65.0 60.0 28.9
Jefferson 219.5 29.6 32.1 27.1 Keene 246.8 103.1 65.9 36.2
Kensington 124.3 14.1 38.4 11.5 Kingston 143.4 25.2 52.9 15.7
Laconia 339.1 48.0 72.4 56.2 Lancaster 331.1 71.6 58.6 38.8
Landaff 146.5 33.3 20.0 20.0 Langdon 37.5 29.2 8.3 20.8 Lebanon 226.9 31.1 49.3 23.8
Lee 35.0 4.1 15.2 1.2 Lempster 139.0 47.2 39.7 22.3
Lincoln 147.7 37.4 41.4 25.6 Lisbon 237.8 46.9 53.2 31.3
Litchfield 134.3 28.2 43.1 26.9 Littleton 190.6 53.4 47.9 23.3
Londonderry 137.3 31.4 39.5 19.8 Loudon 155.9 45.8 29.8 13.3 Lyman 92.0 10.2 20.4 5.1
Lyme 112.5 22.2 11.8 13.3 Lyndeborough 142.2 40.8 30.3 13.6
Madbury 56.6 6.5 19.4 4.9 Madison 225.8 41.3 34.0 34.0
Manchester 246.6 82.6 95.2 38.8 Marlborough 147.5 73.7 36.9 35.6
48
Marlow 160.9 75.5 29.6 9.9 Mason 123.8 14.7 39.9 12.6
Meredith 181.9 33.6 46.1 36.0 Merrimack 137.6 49.5 39.1 23.2 Middleton 202.9 23.5 30.2 11.7
Milan 151.9 53.7 22.2 53.7 Milford 202.8 67.6 70.7 40.3 Milton 298.9 31.8 55.0 28.7
Monroe 96.8 28.1 37.5 21.9 Mont Vernon 130.3 50.7 38.1 33.4
Moultonborough 128.5 28.0 29.0 21.5 Nashua 257.1 83.1 99.0 51.8 Nelson 81.7 35.0 27.2 54.5
New Boston 99.5 22.6 31.1 17.0 New Castle 154.7 31.9 27.0 7.4
New Durham 193.5 31.4 38.9 16.2 New Hampton 135.4 25.6 23.2 28.1
New Ipswich 152.6 34.6 43.8 17.3 New London 189.7 46.4 33.5 20.6
Newbury 131.1 29.6 19.7 24.0 Newfields 123.7 12.7 30.1 9.5
Newington 225.0 66.5 76.0 0.0 Newmarket 188.8 20.1 56.4 19.2
Newport 283.7 74.5 103.6 51.2 Newton 157.5 30.5 50.8 20.3
North Hampton 163.6 22.4 61.6 20.2 Northfield 282.0 42.0 47.3 40.9
Northumberland 313.4 68.0 39.2 28.9 Northwood 179.2 36.3 47.0 17.5 Nottingham 146.0 23.2 29.6 13.5
Orange 139.8 0.0 32.9 16.4 Orford 126.8 16.1 13.8 13.8
Ossipee 340.0 94.4 95.0 60.8 Pelham 131.3 38.3 38.3 25.9
Pembroke 267.0 65.1 62.6 24.4 Peterborough 243.4 69.4 55.9 23.5
Piermont 185.0 24.9 56.9 32.0 Pittsburg 139.0 63.7 14.5 17.4 Pittsfield 281.0 74.8 68.1 41.4 Plainfield 110.2 18.4 32.4 11.9 Plaistow 158.3 44.8 49.9 19.8
Plymouth 166.9 28.0 36.2 24.7 Portsmouth 295.8 46.7 87.0 40.4
Randolph 95.6 36.8 36.8 14.7 Raymond 198.8 33.4 68.4 25.0
Richmond 94.5 42.8 24.8 20.3 Rindge 159.7 38.0 56.7 23.6
Rochester 351.5 42.8 78.5 29.2
49
Rollinsford 223.7 22.6 92.1 17.9 Roxbury 73.6 21.0 42.1 10.5 Rumney 263.7 18.7 45.9 37.4
Rye 175.1 32.4 30.4 21.9 Salem 157.1 46.7 41.7 25.2
Salisbury 169.2 42.3 33.8 29.6 Sanbornton 147.5 24.0 35.0 32.3
Sandown 129.0 26.3 51.6 16.9 Sandwich 113.0 21.1 21.1 26.8 Seabrook 260.6 62.6 87.7 39.4
Sharon 34.5 13.8 6.9 0.0 Shelburne 137.3 26.1 19.6 6.5
Somersworth 306.0 45.7 99.0 28.8 South Hampton 83.9 17.4 40.5 17.4
Springfield 162.9 53.5 48.4 35.6 Stark 151.9 39.2 4.9 14.7
Stewartstown 180.7 34.7 44.6 29.7 Stoddard 105.8 37.0 23.8 7.9 Strafford 121.8 25.8 31.8 10.6 Stratford 496.5 77.4 72.1 40.0 Stratham 120.7 18.3 33.1 16.8
Sugar Hill 87.8 13.2 35.1 4.4 Sullivan 177.1 66.8 26.7 30.1 Sunapee 152.8 27.1 28.6 18.3
Surry 115.1 40.8 29.7 18.6 Sutton 121.6 23.1 20.0 12.3
Swanzey 155.9 57.4 32.7 20.7 Tamworth 232.7 100.0 46.5 32.7
Temple 167.8 18.2 29.2 5.5 Thornton 118.7 9.3 13.3 14.7
Tilton 310.7 69.2 46.6 47.3 Troy 245.0 90.5 55.3 31.4
Tuftonboro 192.1 58.4 41.6 25.8 Unity 55.4 1.6 26.9 3.2
Wakefield 217.6 52.6 37.1 23.4 Walpole 134.6 74.5 28.3 23.5 Warner 186.5 44.0 30.8 32.5 Warren 214.3 28.2 47.9 47.9
Washington 118.4 13.2 13.2 15.8 Waterville Valley 105.6 19.2 48.0 9.6
Weare 143.6 39.9 30.6 17.0 Webster 60.2 22.6 22.6 7.5
Wentworth 116.6 18.9 22.1 22.1 Westmoreland 151.3 86.1 22.2 12.5
Whitefield 269.4 76.6 43.3 27.2 Wilmot 102.9 29.4 21.0 10.5 Wilton 197.7 47.6 56.9 29.1
Winchester 190.5 93.2 56.1 33.4
50
Windham 122.0 29.3 39.9 20.4 Windsor 108.0 0.0 0.0 12.0
Wolfeboro 258.4 60.6 49.4 28.7 Woodstock 111.1 34.9 69.7 28.3
51