1. Estimates of the Uninsured from Hospital Emergency Department and Inpatient Data Susan Forbes, DrPH Jill Miyamura, Ph.D. R. Scott Daniels, Ph.D. Hawaii Health Information Corporation Hawaii Coverage for All Project Technical Workshop VI September 17, 2004

2. 3 Data Sets for Hospital Data Emergency Department (ED) Visits from 15 out of 17 hospitals with EDs Inpatient Discharges from 23 out of 23 acute care hospitals Financial Data—relied on both DataBank, survey data reported to AHA, and cost reports analyzed by E&Y Collected by HHIC in concert with our mission to collect, analyze and disseminate statewide health information to support efforts to continually improve the quality and cost- efficiency of health care services provided to the people of Hawaii.

3. Questions to be answered with hospital data: Emergency Department (ED) Data: What does ED data tell us about the uninsured? Is there any difference between the insured and uninsured in the nature of ED visits? What is the insurance status of patients admitted to the hospital from the ED, and how has this changed over time? For patients admitted to the hospital from the ED, is there a difference in principal diagnosis by insurance status?

4. Questions to be answered with hospital data—continued: Preventable Hospitalizations: What proportion of total hospitalizations are “[potentially] preventable”? Do [potentially] preventable hospitalizations vary by payer? How have [potentially] preventable hospitalizations changed over time?

5. Questions to be answered with hospital data—continued: Financial Impacts How do charges for emergency department visits vary by insurance status? What are the total charges for each payer type (private, government, uninsured)? How does hospital care of the uninsured impact the financial health of a hospital? How has bad debt changed over time?

6. Emergency Department What does ED data tell us about the uninsured?

7. Uninsured ED Visits by Sex

8. Uninsured ED Visits by Sex and Age, 2002

9. Uninsured ED Visits by Island, 2002

10. ED Data--Continued Is there any difference between the insured and uninsured in the nature of ED visits?

11. Top 10 Reasons for ED Visit by Insured Status, 2002

12. Top Reasons for ED Dental

13. Top Reasons for ED Infectious Disease

14. From ED to Inpatient What is the insurance status of patients admitted to the hospital from the ED, and how has this changed over time? …is there a difference in principal diagnosis by insurance status?

15. Inpatient Admissions from ED by Insurance Status

16. Top Ten Reasons for Admission from ER by Status, 1995-2003

17. Potentially Preventable Hospitalizations What proportion of total hospitalizations are potentially preventable? Do potentially preventable hospitalizations vary by payer? How have potentially preventable hospitalizations changed over time?

18. Preventable Hospitalization by Insurance Status

19. Preventable Hospitalizations by Payer

20. Preventable Hospitalizations Charges by Payer

21. Preventable Hospitalizations ALOS by Payer

22. Preventable Hospitalizations by County

23. Preventable Hospitalizations by County and Insured Status

24. Financial Impacts How do charges for emergency department visits vary by insurance status?

25. ED Charge per Visit by Insured Status

26. ED Charge per Visit by Payer

27. Financial Impacts--continued How does hospital care (ED and inpatient) impact the financial health of a hospital? How has bad debt changed over time?

28. Burden to the Hospitals In 2002, charges to the uninsured were over $50 million for ED and inpatient combined

29. U.S. Hospitals Charity and Bad Debt 2001 – Sept. 2003 U.S. hospitals uncompensated care to total charges gap increasing from 4.8% in 2001 to 5.3% in 2003 Larger hospitals (400 – 500+ beds) had larger uncompensated care to total charges of 4.6% in 2001 to 8.1% in 2003. Hospitals with 300 – 399 beds had lower uncompensated care to total charges of 3.1% - 3.6% from 2001 to 2003 Uncompensated Care – Charity & Bad Debt Source: DATABANK Healthcare Association of Hawaii Report, 2003

30. Hawaii Charity Care & Bad Debt, 1998 - 2003 The average annual charity care 1998 – 2003 for the Hawaii hospitals was $79.3 million with a total of just over $476 million for the six year period “Queen’s Medical Center absorbed $23 million in bad debt and charity care for the fiscal year ended June 30, 2003” 12/21/2003 Rix Maurer, Queen’s Health System CFO “For Hawaii Pacific Health, when all the shortfalls are added from various programs and under-reimbursements are included, the losses move closer to $47 million for the fiscal year ended June 30, 2003” 12/21/2003 Dave Heywood, Hawaii Pacific Health VP Source: Healthcare Association of Hawaii Report, November 2003 Honolulu Star Bulletin Hawaii’s hospitals see continuing losses as reimbursements tumble, December 21, 2003

31. Uncompensated Care – Charity Care and Bad Debt Increased charity care (43.7 million U.S. uninsured), will likely cause hospital revenue to grow at a slower pace than expenses, causing moderate decline in profitability Hawaii hospitals provide services regardless of ability to pay resulting in bad debt expense and charity care As the percentage of uninsured in Hawaii increases, bad debt and charity care increase Source: Healthcare Association of Hawaii Report, November 2003

32. Questions? Mahalo!