the state of america’s hospitals – taking the pulse a chart pack findings from the 2006 aha...
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The State of America’s Hospitals –
Taking the PulseA CHART PACK
Findings from the 2006 AHA Survey of Hospital Leaders
Executive Summary
• Hospitals face workforce shortages that are affecting patient care.• Hospitals had an estimated 118,000 registered nurse vacancies as of
December 2005.• Half of emergency departments (ED) are “at” or “over” capacity.
• A majority of urban hospitals experience time on diversion.• The most common reason for diversion is lack of staffed critical care
beds.• 42% of hospitals experienced gaps in specialty coverage in the ED.
• More than a third of hospitals now pay some physicians for specialty coverage.
• The majority of hospitals in “crisis states” face double-digit increases in the costs of medical liability coverage.• Nearly one-third of hospitals report the crisis is having a negative impact
on the hospital’s ability to provide services.• Obstetrics is the service most affected.
• Hospitals continue to face significant increases in the costs of pharmaceuticals and other supplies.
• Hospitals are taking a variety of actions to bolster disaster readiness including participation in large scale drills, establishing back-up communications plans and developing resource sharing plans with other hospitals.
Survey Methodology
• Survey was sent to approximately 4,900 community hospital CEO’s in late February 2006 via fax and Email.
• Data was collected through March 2006.• Unless otherwise specified, data reflects the above
mentioned time period.• A total of 1011 responses were received, a response
rate of 20%.
Overview
• Background• Workforce• Hospital Capacity, Emergency Department
Diversion and Specialty Coverage• Medical Liability• Health Care Costs• Disaster Readiness
Background
Inpatient Admissions and Outpatient Visits 1990 - 2004
Source: AHA Annual Survey
28
29
30
31
32
33
34
35
36
90 91 92 93 94 95 96 97 98 99 00 01 02 03 04
100
150
200
250
300
350
400
450
500
550
600
Outpatient Visits
Inpatient Admissions
Ou
tpat
ien
t V
isit
s (m
illi
on
s)
Ad
mis
sio
ns
(mil
lio
ns)
The demand for hospital care is rising.
Source: AHA Annual Survey
Total, Operating and Patient Care Margins1997 (pre-BBA) vs. 2004
Total Margin Operating Margin
Patient Care Margin
Hospital total margins are down 22 percent from pre-Balanced Budget Act levels…
6.7%
4.0%
-1.7%
5.2%
3.6%
-2.8%
1997
2004
33%
68%
67%
OperatingMargin
Medicaid
Medicare
Source: AHA Annual Survey
Percent of Hospitals Losing Money, 2004
…the majority of hospitals lose money serving Medicare and Medicaid patients while one-third lose money on operations.
-1.9-2.6
-2.1-2.3
-5.0
-15
-8.1
-3.4-2.4-1.4
4.32.3
-7.1
-1.6 -1.4
-$24-$22
-$20-$18
-$16-$14
-$12-$10
-$8-$6
-$4-$2
$0$2
$4$6
Hospital Payment Shortfall Relative to Costs Medicare and Medicaid, 1997 - 2004
(in billions of dollars)
1997 1998 1999 2000 2001 2002 2003
Medicare
MedicaidTotal 2004 Medicaid and Medicare Shortfall of $22.1 Billion
Source: AHA Annual Survey
Bill
ion
s o
f D
olla
rs
Growing government shortfalls put the financial health of hospitals at risk.
2004
Survey ResultsWORKFORCE
Chart 1:Vacancy Rates for Selected Hospital Personnel
December 2005
Hospitals face workforce shortages in key care-giving professions…
7.6%7.3%
6.3%5.9%
4.4%
8.5%
RegisteredNurses
NursingAssistants
LPNs LaboratoryTechnicians
ImagingTechnicians
Pharmacists
Source: 2006 AHA Survey of Hospital LeadersNote: 118,000 vacancies is a national estimate created by extrapolating the vacancy rate to all 4,919 community hospitals in 2004.
118,000 RN Vacancies*
..that are perceived to be getting worse…
IT Technologists
Housekeeping/ Maintenance
Nursing Assistants
LPNs
Billing/Coders
Laboratory Technicians
Imaging Technicians
Pharmacists
Registered Nurses
Chart 2:Percent of Hospitals Reporting Recruitment
More Difficult in 2005 vs. 2004
Source: 2006 AHA Survey of Hospital Leaders.
15%
15%
18%
19%
22%
36%
39%
45%
49%
0% 10% 20% 30% 40% 50% 60%
…and are affecting patient care.
5%
8%
11%
12%
17%
17%
21%
25%
38%
40%
52%
ED Overcrowding
Diverted ED Patients
Reduced Number of Staffed Beds
Increased Wait Times to Surgery
Discontinued Programs/ Reduced
Service Hours
Delayed Discharge/ Increased Length of Stay
Cancelled Surgeries
Curtailed Acquisition of New
TechnologyCurtailed Plans for Facility Expansion
Typ
e o
f Im
pa
ct
Source: 2006 AHA Survey of Hospital Leaders
Chart 3:Percent of Hospitals Reporting Service Impacts of
Workforce Shortage, 2005
Decreased Patient Satisfaction
Decreased Staff Satisfaction
Survey ResultsHOSPITAL CAPACITY,
EMERGENCY DEPARTMENT DIVERSON AND SPECIALTY
COVERAGE
25%
25%
28%
21%
29%
25%
20%
47%
10%
39%
0% 10% 20% 30% 40% 50% 60% 70% 80%
All Hospitals
Non-teaching Hospitals
Teaching Hospitals
Rural Hospitals
Urban Hospitals
ED is "At" Capacity ED is "Over" Capacity
Most EDs are “at” or “over” capacity…
Chart 4:Percent of Hospitals Reporting ED Capacity Issues by
Type of Hospital 2006
Source: AHA 2006 Survey of Hospital Leaders
68%
31%
75%
45%
50%
…and a majority of urban and teaching hospitals experience time on ED diversion…
Chart 5:Percent of Hospitals Reporting Time on Diversion
in Last 12 Months
42%
36%
67%
17%
64%
0% 10% 20% 30% 40% 50% 60% 70% 80%
All Hospitals
Non-teaching
Teaching
Rural
Urban
Source: AHA 2006 Survey of Hospital Leaders
4%
4%
10%
17%
19%
40%
0% 10% 20% 30% 40% 50%
…most often caused by a lack of staffed critical care beds.
Chart 6:Percent of Hospitals Citing Factor as Number One Reason
for Ambulance Diversion, January 2006
Source: AHA 2006 Survey of Hospital Leaders
Lack of Staffed Critical Care Beds
ED Overcrowded
Lack of General Acute Care Beds
Staff Shortages
Lack of Specialty Physician Coverage
Lack of Psychiatric Beds
Chart 7:Percent of Time on Diversion in January 2006
(Among Urban Hospitals Experiencing Diversion in the Last 12 Months)
18%
57%
16%
9%
0% 10% 20% 30% 40% 50% 60%
20% or More of Time
10-19.9% of Time
Up to 9.9% of Time
No Diversion Time
For urban hospitals reporting diversion, nearly one in six was on diversion more than 20 percent of the time.
Source: AHA 2006 Survey of Hospital Leaders
Percent of Urban Hospitals Experiencing Diversion
Percent of Timeon Diversion
45 percent of hospitals reported a moderate to significant increase in having to “board” behavioral health patients in the ED.
Chart 8:Percent of Hospitals Reporting Increases in “Boarding”
Behavioral Health Patients in the ED by Type of Hospital
Source: AHA 2006 Survey of Hospital LeadersNote: Boarding is a term used when patients that are in need of inpatient psychiatric or substance abuse services remain in the emergency department until a suitable placement can be found.
31%
32%
30%
28%
35%
14%
12%
19%
9%
18%
0% 10% 20% 30% 40% 50% 60% 70%
All Hospitals
Non-teaching Hospitals
Teaching Hospitals
Rural Hospitals
Urban Hospitals
Moderate Increase Significant Increase
53%
37%
49%
44%
45%
Chart 9:Percent of Hospitals Losing Specialty Coverage for Any
Period of Time in Last 24 Months and Number One Reason Cited
9%
11%
32%
42%
4%
2%
6%
9%
Specialists Lost to ASC
EMTALA Rule Changes
Specialists Lost to Limited-service Hospital
Physicians Retired or Left
Competition from Another Hospital
Liability Concerns
Uncompensated Care
Percent Losing Specialty Coverage
42 percent of community hospitals experienced gaps in specialty coverage in the ED.
Source: AHA 2006 Survey of Hospital Leaders
Percent of Above Citing
Reason as Number One
Factor
More than one-third of hospitals now pay some physicians for specialty coverage.
Chart 10:Frequency of Paying for Specialty Coverage
in Emergency Department
Source: AHA 2006 Survey of Hospital Leaders
62%
29%
5%4%
Pay for Coverage inSome Specialty Areas
Never Pay for Specialty Coverage
Pay for Coverage in Most Specialty Areas
Pay for Coverage in All Specialty Areas
Paying for specialty coverage has become more common over last few years.
Chart 11:When Hospital Began Paying for Specialty Coverage
(of those hospitals that reported payment for coverage)
Source: AHA 2006 Survey of Hospital Leaders
21%
54%
25%
More Than 2 Years Ago
1-2 Years Ago
Within Past Year
Survey ResultsMEDICAL LIABILITY
Chart 12:Percent of Hospitals in Crisis States* by Rate of Growth in
Medical Liability Expense over Past Two Years
The majority of hospitals in crisis states face double-digit increases in costs for medical liability coverage.
Source: AHA 2006 Survey of Hospital Leaders*Crisis states as identified by the American Medical Association as of January 2006 include: PA, WV, NV, MS, WA, OR, AR, MO, GA, FL, IL, NC, KY, OH, NY, CT, NJ, WY, RI, TN and MA.
Increase of Double or More
5%50 to 99.9%Increase
14%
Less than 10%Increase
46% 10-49.9%Increase
34%
The medical liability crisis is affecting hospitals and the patients they serve.
32%
13%
46%
100%
Significant Impact onAccess to Care in
Community
Negative Impact onHospital's Ability to
Provide Services
Community Lost MDs
Hospital Had to Takeon More Risk
Chart 13:Percent of Hospitals in Crisis States* Reporting Specific
Effects of Increased Professional Liability Expenses
Source: AHA 2006 Survey of Hospital Leaders*Crisis states as identified by the American Medical Association as of January 2006 include: PA, WV, NV, MS, WA, OR, AR, MO, GA, FL, IL, NC, KY, OH, NY, CT, NJ, WY, RI, TN and MA.
The service most affected is obstetrics.
33%
55%
18%
39%
19%
28%
Other
Primary andPreventive Care
Trauma
Emergency Care
Neurosurgery
Obstetrics
Chart 14:Percent of Hospitals in Crisis States* Reporting Negative Impact
on Ability to Provide Specific Services
Source: AHA 2006 Survey of Hospital Leaders*Crisis states as identified by the American Medical Association as of January 2006 include: PA, WV, NV, MS, WA, OR, AR, MO, GA, FL, IL, NC, KY, OH, NY, CT, NJ, WY, RI, TN and MA.
Hospitals are also taking on additional risk.
14%
16%
23%
45%
11%
9%
2%
4%
Allowing physicians to practice withoutcoverage
Opted not to purchase coverage
Increased stop-loss
Reduced level of coverage
Assumed a deductible
Created a captive
Became self-insured
Increased deductible
Chart 15:Percent of Hospitals in Crisis States* Reporting Taking on Additional Risk
Source: AHA 2006 Survey of Hospital Leaders*Crisis states as identified by the American Medical Association as of January 2006 include: PA, WV, NV, MS, WA, OR, AR, MO, GA, FL, IL, NC, KY, OH, NY, CT, NJ, WY, RI, TN and MA.
Survey ResultsHEALTH CARE COSTS
Hospitals face significant increases in the costs of pharmaceuticals and medical supplies.
9.3%
8.7%
9.0%
9.3%
10.3%
8.8%
Rural Hospitals
Urban Hospitals
All Hospitals
MedicalSupplies/DevicesPharmaceuticalproducts
Chart 16: Percent Change in Hospital Expenses for Pharmaceuticals
and Medical Supplies/Devices, 2004 to 2005
Source: AHA 2006 Survey of Hospital Leaders
Survey ResultsDISASTER READINESS
1%
4%
10%
86%
The majority of hospitals reported taking part in a large-scale drill with external response agencies.
Chart 17: Hospitals Participating in Large-scale Community-wide
Drills with External Response Agencies in 2005
Source: AHA 2006 Survey of Hospital Leaders
Yes, have already taken action
No, but plan to take action in 6-12 months
No, but plan to take action when resources permit
No action planned
2%
7%
11%
80%
80 percent of hospitals have established back up systems for communication with police, fire etc.
Chart 18:Percent of Hospitals Establishing Back-up Community-
wide Communications Ability in 2005
Source: AHA 2006 Survey of Hospital Leaders
Yes, have already taken action
No, but plan to take action in 6-12 months
No, but plan to take action when resources permit
No action planned
84 percent of hospitals have a formal or informal relationship with other hospitals for sharing resources.
17%
84%
YES NO
Source: 2006 AHA Survey of Hospital Leaders
Chart 19:Percent of Hospitals Reporting Relationships With Other
Hospitals for Sharing Resources in 2005
93 percent of hospitals have received federal or state assistance for disaster preparedness and planning.
7%
93%
YES NO
Source: 2006 AHA Survey of Hospital Leaders
Chart 20:Percent of Hospitals That Received Assistance (Financial or
In-Kind) for Disaster Preparedness and Planning in 2005
Hospitals vary in their ability to provide staffed beds in the event of a disaster.
14%
7% 7%
0-2 Hours 3-12 Hours More Than 12Hours
Chart 22:Average Number of Staffed Beds Hospitals With Surge Capacity Estimate Could Be Available in
the Following Time Periods
0-2 Hours 2-13 Hours More Than 12Hours
Chart 21:Percent of Hospitals Reporting
NO Capacity to Provide Additional Staffed Beds in the
Event of a Disaster
Source: 2006 AHA Survey of Hospital Leaders
14-15 beds
22-23 beds
28-29 beds
Time Period Time Period