1. Prepared to Care: The 24/7 Role of America’s Full- service Hospitals

2. The standby role of full-service is both unique and critical in the health care system. Standby Role: Provide access to care 24 hours a day 7 days a week (24/7) Care for all patients regardless of ability to pay Be ready to respond to disasters

3. 24/7 Role of Full-service Hospitals

4. Americans rely heavily on the 24/7 access to care provided by hospital EDs… One third of hospital care begins in the emergency department. The majority of ED patients require immediate care. More than half of ED care occurs outside of normal business hours. Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006

5. Emergency Department Visits, 1997 – 2004, In Millions Source: AHA Annual Survey, data for community hospitals. …and that need is growing. Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006 Emergency Department Visits

6. Meeting common emergency needs requires a wide array of resources be maintained 24/7. Example: Resource Needs for a Common Condition Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006

7. Safety Net Role

8. Hospitals provide a medical safety net for the growing number of uninsured… Number of Uninsured, 2000 – 2004, In Millions Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006

9. …serving proportionally more Medicaid and uninsured patients than physician offices… Percent of Total Visits by Expected Source of Payment, Emergency Departments vs. Physician Offices, 2003 Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006

10. …and taking an increasing role in the care of the behaviorally ill. Behavioral Health-Related Emergency Department Visits, 1994/95 – 2001/02 In Millions Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006 Inpatient Psychiatric Facilities, 1995 – 2004

11. Disaster Readiness

12. A wide range of disasters hit communities annually… Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006

13. Percent of Hospitals with Response Plans by Type of Incident, 2003...and hospitals stand ready to respond. Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006

14. Challenges in Maintaining the Standby Role

15. Hospitals face three major challenges in maintaining the standby role. Capacity constraints Financial challenges Competition for patients from facilities that don’t serve or contribute to the standby role

16. Capacity Constraints

17. Emergency Department Visits and Emergency Departments (1) in Community Hospitals, 1991 - 2004 (1) Defined as hospitals reporting ED visits. As the number of patients seeking ED care has risen, the number of EDs has declined. Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006 Emergency Departments Emergency Department Visits (Millions)

18. Capacity constraints have led to ED diversion in a majority of urban hospitals. Percent of Hospitals Reporting Time on Diversion in Last 12 Months Source: AHA 2006 Survey of Hospital Leaders

19. Hospitals face a severe workforce shortage… Vacancy Rates for Selected Hospital Personnel, December 2005 Source: 2006 AHA Survey of Hospital Leaders *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*

20. Registered Nurse FTEs: Supply and Demand, in Thousands, 2000 - 2020 Source: National Center For Health Workforce Analysis, Bureau of Health Professions, Health Resources and Services Administration, 2004. …that is expected to worsen significantly over the coming decades. FTEs in Thousands Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006 RN FTE Supply RN FTE Demand In 2020, there will be a shortage of 1 million nurses

21. Financial Challenges

22. Private Payers Elective Cases Less Complex Surgical Cases Well-funded Indigent Care 24/7 Capacity Unfunded Revenue from Service to Paying Patients Medicare and Medicaid Emergent Cases More Complex Medical Cases Under- funded Disaster Readiness Hospitals support the standby role through revenues from patient care…

23. Hospital Payment Shortfall Relative to Costs For Medicare and Medicaid Patients in Billions, 1997-2004 1997199819992000200120022003 Medicare Medicaid Billions of Dollars 2004 Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006 Total Shortfall in 2004: $22 Billion …but hospitals face a growing shortfall from Medicare and Medicaid…

24. Total Uncompensated Care Costs In Billions, 1998 - 2004 Source: AHA Annual Survey …and rising levels of uncompensated care.

25. Competition from Providers Not Serving the Standby Role

26. Physician-owned Limited-service Hospitals and Ambulatory Surgery Centers, 2000 - 2005 Source: The Centers for Medicare & Medicaid Services Physician-owned Limited- service Hospitals Ambulatory surgery Centers Hospitals are losing patients to a growing number of limited-service providers…

27. Percent of Hospitals with an Emergency Department*, Physician-owned Limited-service Hospitals versus All Community Hospitals, 2003 *Hospitals treating more than 5% of cases in emergency department. …that do not provide the 24/7 standby role… Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006

28. …nor support the safety net role. Medicaid as a Percent of All Patient Discharges, 2002 Physician-owned Source: The Chartis Group, Prepared to Care: The 24/7 Role of America’s Full-service Hospitals, 2006 Physician-owned

29. Est of Well-funded services Physician-owned limited-service hospitals Instead these facilities cherry-pick the well- funded services.

30. …relying on the economically motivated referral decisions of physician-owners... Behaviors associated with self-referral have been well documented, including: Patient steering (physician-owners direct their patients to their own facilities) Cherry-picking: Offering well-reimbursed services Selecting healthier patients Avoiding low-income patients

31. …and leaving full-service hospitals without the means to subsidize the standby role. Left for full-service hospitals Unfunded and under-funded services

32. To maintain the standby role hospitals need: Adequate payment from Medicare and Medicaid Support for uninsured populations Help in addressing the workforce shortage Fair competition Ban self-referral to new limited-service hospitals Payment systems that recognize standby costs Broad system support for the standby role Without action, these services may not be there when we need them.