Healthcare Business Market Research Handbook 2013-2014 [17 ed.] 1577831896

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Healthcare Business Market Research Handbook 2013-2014

Richard K. Miller & Associates

————— since 1972 —————

HEALTHCARE BUSINESS MARKET RESEARCH HANDBOOK 2013-2014 17th EDITION RKMA MARKET RESEARCH HANDBOOK SERIES

By: Richard K. Miller and Kelli Washington

Published by: Richard K. Miller & Associates 4132 Atlanta Highway, Suite 110 Loganville, GA 30052 (888) 928-7562 www.rkma.com

Richard K. Miller & Associates ————— since 1972 —————

HEALTHCARE BUSINESS MARKET RESEARCH HANDBOOK 2013-2014 17th EDITION RKMA MARKET RESEARCH HANDBOOK SERIES

Copyright © 2013 by Richard K. Miller & Associates All rights reserved. Printed in the United States of America. Use of the electronic edition of this publication is limited to internal use within the purchasing organization. The electronic edition may be stored on computers, Intranets, servers, and networks by organizations which have purchased this publication, and those for which an employee has made such purchase. Copies, including multiple copies, may be printed from the electronic edition for use within the purchasing organization. Libraries may store the electronic edition on an archival database or proxy server for access by library users. Governmental agencies purchasing this publication may share the content within the agency or department. Universities and colleges may share the information within their campus, but not with other universities. Membership associations may use the information within their internal organization, but may not distribute to their membership. This publication may not be stored on Internet websites, nor may it be file-shared through the Internet. This publication may not be resold or distributed without prior written agreement with the publisher. While every attempt is made to provide accurate information, the author and publisher cannot be held accountable for any errors or omissions.

ISBN Number: 1-57783-189-6

Richard K. Miller & Associates 4132 Atlanta Highway, Suite 110 Loganville, GA 30052 (888) 928-7562 www.rkma.com

CONTENTS PART I: AMERICA’S HEALTH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 1

GENERAL HEALTH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 National Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 State Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3 Metropolitan Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2

PERSONAL HEALTH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 2.1 Gallup Poll 2012. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

3

PREVALENCE OF DISEASE & ILLNESS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 3.1 Summary By Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 3.2 Causes of Death. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

4

STATE-BY-STATE ASSESSMENT.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 Alabama. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3 Alaska. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 Arizona. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5 Arkansas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.6 California.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.7 Colorado. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.8 Connecticut. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.9 Delaware.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.10 District of Columbia.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.11 Florida. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.12 Georgia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.13 Hawaii. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.14 Idaho. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.15 Illinois. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.16 Indiana. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.17 Iowa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.18 Kansas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.19 Kentucky. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.20 Louisiana. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.21 Maine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.22 Maryland. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.23 Massachusetts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.24 Michigan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.25 Minnesota. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.26 Mississippi.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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30 30 30 32

43 43 43 43 44 44 44 44 45 45 45 45 46 46 46 46 47 47 47 47 48 48 48 48 49 49 49

4.27 4.28 4.29 4.30 4.31 4.32 4.33 4.34 4.35 4.36 4.37 4.38 4.39 4.40 4.41 4.42 4.43 4.44 4.45 4.46 4.47 4.48 4.49 4.50 4.51 4.52

Missouri.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Montana. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nebraska.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nevada. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New Hampshire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New Jersey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New Mexico. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New York. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . North Carolina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . North Dakota.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ohio. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Oklahoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Oregon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pennsylvania.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rhode Island.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . South Carolina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . South Dakota. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tennessee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Texas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Utah. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vermont. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Virginia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Washington.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . West Virginia.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wisconsin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wyoming.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

49 50 50 50 50 51 51 51 51 52 52 52 52 53 53 53 53 54 54 54 54 55 55 55 55 56

5

STATE HEALTH RANKINGS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Rankings 2012. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3 Overall Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4 State-by-State Summary.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

57 57 57 58 59

6

METROPOLITAN MARKET PROFILES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 6.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 6.2 Healthcare Market Profiles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

PART II: HEALTHCARE SPENDING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 7

NATIONAL HEALTH EXPENDITURES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2 Spending.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3 Source Of Funds.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.4 Distribution of Expenditures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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81 81 81 82 82

8

GEOGRAPHIC VARIATIONS IN HEALTHCARE SPENDING. . . . . . . . . . . . . . . 8.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2 Dartmouth Atlas Project. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3 Hospital Care Intensity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.4 Regional Variations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

84 84 85 85 86

9

DEMOGRAPHICS OF HEALTHCARE SPENDING. . . . . . . . . . . . . . . . . . . . . . . 9.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.2 Healthcare Spending By Age. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.3 Healthcare Spending By Household Income. . . . . . . . . . . . . . . . . . . . . . . . . 9.4 Healthcare Spending By Household Type. . . . . . . . . . . . . . . . . . . . . . . . . . . 9.5 Healthcare Spending By Race And Ethnicity. . . . . . . . . . . . . . . . . . . . . . . . . 9.6 Healthcare Spending By Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.7 Healthcare Spending By Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

88 88 88 90 91 92 93 95

PART III: HOSPITALS & HEALTHCARE PROVIDERS. . . . . . . . . . . . . . . . . . . . . . . 96 10 ACCOUNTABLE CARE ORGANIZATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.2 Cost Savings Through Coordinated Care. . . . . . . . . . . . . . . . . . . . . . . . . . . 10.3 Largest ACOs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.4 Approved ACOs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

97 97 97 98 98

11 BEHAVIORAL HEALTH PROVIDERS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1 Behavioral Health Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.2 Largest Behavioral Health Providers.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.3 Community Hospital Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100 100 100 101 101

12 CHILDREN’S HOSPITALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.2 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.3 Largest Children’s Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

102 102 102 102 103

13 COMPLEMENTARY & ALTERNATIVE MEDICINE. . . . . . . . . . . . . . . . . . . . . . 13.1 CAM Use In America. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.2 Spending.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.3 Hospital CAM Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

104 104 105 105 106

14 CONVENIENT-CARE CLINICS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.1 Retail-Based Healthcare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.2 Patient Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.3 Patient Satisfaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

107 107 108 109

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14.4 Hospital-Operated Clinics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 14.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 15 DESIGN & CONSTRUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.2 Hospital Construction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.3 Largest Healthcare Design and Construction Firms. . . . . . . . . . . . . . . . . .

110 110 110 111

16 ECONOMIC CONTRIBUTION OF HOSPITALS. . . . . . . . . . . . . . . . . . . . . . . . . 16.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.2 Hospital Care and The U.S. Economy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.3 State-by-State Hospital Expenditures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

113 113 113 113 114

17 ELECTRONIC HEALTH RECORDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.1 Hospital and Physician Use of EHRs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.2 EHR Vendors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.3 Hospital-Physician Collaboration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.4 Physician Use of EHRs.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.5 Scribe Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.6 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

115 115 116 117 117 117 118

18 EMERGENCY DEPARTMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.1 Profile Of Emergency Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.2 Profile Of ED Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.3 Emergency Medicine In American Hospitals.. . . . . . . . . . . . . . . . . . . . . . . 18.4 Busiest Hospital Emergency Departments. . . . . . . . . . . . . . . . . . . . . . . . . 18.5 Overcrowding and Diversions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.6 Wait Times. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.7 ED Patient Satisfaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.8 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

119 119 119 121 122 122 123 123 125

19 FINANCIAL ISSUES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 19.1 Critical Financial Issues In Healthcare. . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 20 GROUP PURCHASING ORGANIZATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.1 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.2 Largest GPOs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.3 GPO Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.4 Satisfaction With GPO Relationships. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.5 Scrutiny Of GPO Operations.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.6 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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128 128 128 129 129 130 131

21 HOME CARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.2 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.3 Largest Home Healthcare Companies. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.4 Hospitals In The Home Care Market.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.5 Private Sector Home Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.6 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

132 132 132 133 133 134 134

22 HOSPICE & PALLIATIVE CARE.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.2 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.3 Hospice Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.4 Hospital Palliative Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.5 Quality Reporting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.6 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

135 135 135 135 136 137 138

23 HOSPITAL PATIENT DIAGNOSES, PROCEDURES & SPENDING. . . . . . . . . 23.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.2 Most Frequent Primary Diagnoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.3 Most Frequent Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.4 Spending For Most Frequent Procedures. . . . . . . . . . . . . . . . . . . . . . . . . .

139 139 139 139 140

24 HOSPITAL-ACQUIRED INFECTIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.1 Incidence and Mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.2 Antibiotic-Resistant Infections.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.3 Infection Control Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.4 Infection Prevention Practices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

141 141 142 142 142 145

25 HOSPITAL-PHYSICIAN RELATIONS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.2 Status and Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.3 Trends.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

146 146 146 147

26 HOSPITALS IN PURSUIT OF EXCELLENCE. . . . . . . . . . . . . . . . . . . . . . . . . . 148 26.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 26.2 Core Principals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 27 IMAGING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.1 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.2 CT Scans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.3 Magnetic Resonance Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.4 Positron Emission Tomography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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149 149 150 150 151

28 INFORMATION TECHNOLOGY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28.1 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28.2 Assessment of Healthcare IT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28.3 Executive Opinions On Key IT Issues.. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

152 152 152 155 155

29 LARGEST HEALTHCARE SYSTEMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 29.1 Largest Hospital Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 29.2 Largest Hospital Chains. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 30 LARGEST HOSPITALS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.1 Largest Community Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.2 Largest U.S. Military Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.3 Largest Academic Medical Centers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

159 159 159 160

31 MARKETING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.1 Marketing Budgets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.2 Advertising and Promotions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.3 Hospital Websites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.4 Provider Social Networking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.5 Virtual Tours. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.6 Community Outreach Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.7 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

161 161 161 162 164 164 165 165

32 MEDICAL LIABILITY.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.1 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.2 Professional Liability Insurance Carriers.. . . . . . . . . . . . . . . . . . . . . . . . . . 32.3 Liability and Defensive Medicine.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.4 Tort Reform.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.5 Claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.6 Malpractice Awards.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.7 Apologizing For Errors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.8 Frivolous Malpractice Lawsuits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.9 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

166 166 166 167 167 167 168 168 169 169

33 MEDICAL TOURISM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.1 Traveling Abroad For Medical Procedures. . . . . . . . . . . . . . . . . . . . . . . . . 33.2 Health Plans Encourage Medical Tourism. . . . . . . . . . . . . . . . . . . . . . . . . 33.3 Certified Foreign Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

170 170 170 171 171

34 MERGERS & ACQUISITIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 34.1 Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 34.2 Largest Deals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

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35 OUTSOURCING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.2 Outsourced Services.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.3 Largest Outsourcing Firms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

175 175 175 176

36 PARTNERSHIP FOR PATIENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.2 Pledged Organizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.3 Hospital Engagement Networks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.4 Improving Care Transitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

178 178 178 179 179 180

37 PATIENT COMMUNICATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37.1 Health Literacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37.2 Communications for Immigrant Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . 37.3 Communicating With Patients.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37.4 Hospital Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

181 181 181 182 182 184

38 PATIENT SATISFACTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 38.1 Patient Satisfaction Measurement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 38.2 Trends in Patient Satisfaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 39 PATIENTS FROM OVERSEAS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39.1 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39.2 Marketing Overseas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39.3 U.S. Hospitals Operating Abroad. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

188 188 188 188 189

40 PAY-FOR-PERFORMANCE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40.2 Background.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40.3 Outlook. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

190 190 190 191

41 POST-ACUTE & LONG-TERM CARE.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.1 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.2 Hospital Discharge To Long-Term Care. . . . . . . . . . . . . . . . . . . . . . . . . . . 41.3 Market Leaders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.4 Assisted-Living Facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.5 Long-Term Acute-Care Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.6 Rehabilitation Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.7 Skilled Nursing Facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.8 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

193 193 193 193 194 195 195 196 197

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42 PREPAREDNESS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42.2 Preparedness for Terrorists Threats. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42.3 Preparedness for Natural Disasters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42.4 Preparedness for a Influenza Pandemic.. . . . . . . . . . . . . . . . . . . . . . . . . . 42.5 Funding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

198 198 198 199 200 200

43 PREVENTABLE MEDICAL ERRORS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 43.1 Never Events. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 43.2 Non-Reimbursement.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 44 PRIMARY CARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44.1 Physician Visits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44.2 Efficient Use Of Primary Care.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44.3 Strengthening Primary Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44.4 Medical Homes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44.5 Concierge Physician Practices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44.6 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

204 204 205 205 206 207 208

45 PROFILE OF U.S. HOSPITALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.1 Data Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.2 Utilization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.3 Financial Performance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.4 Hospital Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.5 State-by-State. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

209 209 210 210 210 211

46 QUALITY & PATIENT SAFETY.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.1 The Toll of Adverse Events.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.2 Adverse Events.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.3 National Quality Strategy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.4 Healthcare Quality Initiatives.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.5 Quality Reporting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.6 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

214 214 214 215 215 217 217

47 READMISSIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47.1 The Cost Of Readmissions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47.2 Reducing Readmissions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47.3 Coaches For Post-Discharge Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

218 218 219 222

48 RURAL HEALTHCARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48.2 Staffing Challenges.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48.3 Medicare Reform Provisions For Rural Healthcare.. . . . . . . . . . . . . . . . . . 48.4 IT In Rural Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

223 223 223 224 225 225

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49 SHARED DECISION MAKING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49.2 Savings Potential. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49.3 Primary Care Demonstration Sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49.4 Breast Cancer Initiative.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

226 226 227 229 229 230

50 SPECIALTY HOSPITALS & CENTERS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.2 Specialty Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.3 Physician-Owned Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.4 Ambulatory Surgery Centers.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.5 Imaging Centers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.6 Standalone Emergency Centers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.7 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

231 231 231 232 232 235 235 236

51 STATE SPENDING FOR HOSPITAL CARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 51.1 Percentage of Total Spending For Hospital Care. . . . . . . . . . . . . . . . . . . . 237 52 TELEMEDICINE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52.2 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52.3 Telemedicine in Rural Healthcare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52.4 Telemedicine for Remote Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52.5 Electronic Intensive Care Units. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52.6 Telemedicine for Emergency Medical Care. . . . . . . . . . . . . . . . . . . . . . . . 52.7 Market Growth Through Telemedicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 52.8 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

239 239 239 239 240 241 241 242 242

53 TOP ISSUES CONFRONTING HOSPITALS. . . . . . . . . . . . . . . . . . . . . . . . . . . 53.1 ACHE Survey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53.2 Financial Challenges.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53.3 Healthcare Reform Implications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53.4 Patient Safety and Quality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

243 243 243 244 244

54 UNCOMPENSATED HOSPITAL CARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54.2 Cost to Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54.3 Bad Debt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

245 245 245 246

55 VALUE-BASED PURCHASING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55.2 Implementation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55.3 Measures For VBP Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

247 247 247 248

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55.4 Patient Experience of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 55.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 PART IV: AWARD-WINNING HOSPITALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 56 BEST PLACES TO WORK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 56.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 56.2 Top 100.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 57 CIRCLE OF LIFE AWARD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 57.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 57.2 Awards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 58 COMMUNITY VALUE AWARDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 58.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 58.2 Community Value 100 Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 59 CONSUMER CHOICE AWARDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 59.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 59.2 Award Winners. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 60 DESIGN AWARDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 60.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 60.2 Awards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 61 EMERGENCY MEDICINE EXCELLENCE AWARDS. . . . . . . . . . . . . . . . . . . . . 280 61.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 61.2 Awards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 62 HEALTHCARE ADVANTAGE AWARDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 62.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 62.2 Awards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 63 LANTERN AWARDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 63.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 63.2 Awards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 64 MISSION: LIFELINE AWARDS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64.2 Gold Plus Achievement.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64.3 Gold Achievement Award. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64.4 Silver Plus Achievement Award. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64.5 Silver Achievement Award. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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283 283 283 293 298 301

65 MOST-HIGHLY INTEGRATED HEALTHCARE NETWORKS.. . . . . . . . . . . . . . 305 65.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 65.2 IHN Ranking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 66 MOST WIRED HOSPITALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308 66.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308 66.2 Most Wired Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308 67 NATIONAL QUALITY HEALTHCARE AWARD. . . . . . . . . . . . . . . . . . . . . . . . . 315 67.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315 67.2 Award Winners. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315 68 NOVA AWARDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 68.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 68.2 Awards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 69 QUEST FOR QUALITY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 69.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 69.2 Awards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 70 SPIRIT OF EXCELLENCE AWARDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319 70.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319 70.2 Awards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319 71 TOP 100 HOSPITALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 71.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 71.2 Top Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 72 TOP CARDIOVASCULAR HOSPITALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324 72.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324 72.2 Top Cardiovascular Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324 73 TOP HEALTH SYSTEMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 73.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 73.2 Best-Performing Healthcare Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 74 TOP-RANKED HOSPITALS IN SPECIALITY FIELDS. . . . . . . . . . . . . . . . . . . . 74.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74.2 Ranking Of Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74.3 Ranking Of Children’s Medical Centers. . . . . . . . . . . . . . . . . . . . . . . . . . . 74.4 Ranking By Metropolitan Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

328 328 329 334 336

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75 AFFORDABLE CARE ACT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.2 Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.3 Impact. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.4 Mandate For Individuals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.5 Requirements for Employers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.6 Requirements For Private Health Insurance. . . . . . . . . . . . . . . . . . . . . . . . 75.7 Expansion of Public Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.8 Affordable Health Benefit Exchanges. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

338 338 338 338 339 339 339 340 340

76 AFFORDABLE HEALTH BENEFIT EXCHANGES. . . . . . . . . . . . . . . . . . . . . . . 342 76.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 76.2 Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 77 CHILDREN’S HEALTH INSURANCE PROGRAM. . . . . . . . . . . . . . . . . . . . . . . 77.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77.2 CHIP Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77.3 CHIP Spending. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

344 344 344 345

78 EMPLOYER-SPONSORED HEALTH INSURANCE. . . . . . . . . . . . . . . . . . . . . . 78.1 Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78.2 Premiums For Employer-Sponsored Plans.. . . . . . . . . . . . . . . . . . . . . . . . 78.3 Premiums For Families And Individuals. . . . . . . . . . . . . . . . . . . . . . . . . . .

347 347 348 349

79 INDIVIDUAL HEALTH INSURANCE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79.2 Adults With Individual Insurance.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79.3 Coverage Challenges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79.4 Out-Of-Pocket Spending.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

351 351 351 351 352

80 LARGEST HEALTH INSURERS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353 80.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353 80.2 Largest Insurers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353 81 LONG-TERM CARE INSURANCE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.2 Market Leaders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.3 Market Characteristics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

354 354 355 355 355

82 MEDICAL SPENDING FOR PPO-COVERED FAMILIES. . . . . . . . . . . . . . . . . . 82.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82.2 Average Annual Medical Spending. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82.3 Components of Spending. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82.4 Employee Share Of Spending. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

356 356 356 356 357 357

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83 MEDICAID. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83.1 Medicaid Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83.2 Medicaid Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83.3 State-by-State Medicaid Spending. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

358 358 358 359 361

84 MEDICARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84.1 Medicare Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84.2 Medicare Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84.3 State-by-State Medicare Spending. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84.4 Medicare Advantage Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

362 362 363 364 365 366

85 NATIONAL HEALTH INSURER REPORT CARD. . . . . . . . . . . . . . . . . . . . . . . . 367 85.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367 85.2 The 2012 NHIRC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368 86 PRE-EXISTING CONDITION INSURANCE PLANS. . . . . . . . . . . . . . . . . . . . . . 86.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86.2 Program Administration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86.3 State Assessments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

371 371 371 371

87 THE UNINSURED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373 87.1 Uninsured in the U.S.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373 87.2 Uninsured State-by-State. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373 PART VI: PHARMACEUTICALS & MEDICAL DEVICES. . . . . . . . . . . . . . . . . . . . . 375 88 DISTRIBUTION CHANNELS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88.1 Channel Distribution Spending. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88.2 Retail Sales.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88.3 Marketshare Leaders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

376 376 378 378 379

89 DRUG CLASSIFICATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89.1 ATC Classification System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89.2 Primary Drug Groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89.3 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

380 380 380 382

90 GENERIC DRUGS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90.1 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90.2 Market Leaders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90.3 Patent Expirations.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

383 383 383 384 385

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91 LARGEST BIOTECHNOLOGY COMPANIES.. . . . . . . . . . . . . . . . . . . . . . . . . . 386 91.1 Ranking By Worldwide Revenue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386 92 LARGEST PHARMACEUTICAL COMPANIES. . . . . . . . . . . . . . . . . . . . . . . . . . 92.1 Ranking By U.S. Revenue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92.2 Ranking By Global Revenue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92.3 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

387 387 387 388

93 MARKET OUTLOOK.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93.1 Global Pharmaceutical Sales. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93.2 Key Market Dynamics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93.3 Pharmerging Markets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

389 389 389 390 391

94 MEDICAL DEVICES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94.1 Categories Of Medical Technology Products. . . . . . . . . . . . . . . . . . . . . . . 94.2 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94.3 Market Leaders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94.4 In Vitro Diagnostics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

392 392 393 393 395 395

95 PROMOTIONAL SPENDING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95.1 Types of Promotions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95.2 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95.3 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

396 396 396 398

96 TOP-SELLING BRAND & GENERIC DRUGS. . . . . . . . . . . . . . . . . . . . . . . . . . 96.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96.2 Top Single-Source Brand Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96.3 Top Single-Source Generic Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

399 399 399 401 404

97 TOP-SELLING PHARMACEUTICAL PRODUCTS. . . . . . . . . . . . . . . . . . . . . . . 97.1 Ranked By U.S. Sales. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97.2 Ranked By Global Sales. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97.3 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

405 405 406 407

98 TOP-SELLING THERAPEUTIC DRUG CLASSES. . . . . . . . . . . . . . . . . . . . . . . 98.1 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98.2 Ranked By U.S. Sales. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98.3 Ranked By Number Of U.S. Dispensed Prescriptions. . . . . . . . . . . . . . . . 98.4 Ranked By Global Sales. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

408 408 408 408 409 410

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PART VII: GENOMIC & REGENERATIVE MEDICINE. . . . . . . . . . . . . . . . . . . . . . . 411 99 PERSONALIZED MEDICINE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99.2 The Potential Of Personalized Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . 99.3 Linking Genes To Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99.4 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99.5 Current Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99.6 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

412 412 412 413 414 415 416

100 GENE THERAPY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.2 Current Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.3 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

417 417 417 419

101 GENETIC TESTING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101.2 Current Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101.3 Direct-to-Consumer Genetic Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . 101.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

420 420 420 421 422

102 STEM CELLS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102.2 Stem Cell Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102.3 Stem Cell Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102.4 Bone Marrow and Blood Stem Cell Transplants. . . . . . . . . . . . . . . . . . 102.5 Cord Blood Storage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102.6 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

423 423 423 424 424 425 425

PART VIII: DISEASES & TREATMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427 103 ALCOHOL ADDICTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103.1 Prevalence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103.2 Medical Treatment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103.3 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

428 428 428 429

104 ALLERGIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104.1 Prevalence and Economic Impact. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104.2 Types of Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104.3 Allergy Capitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

430 430 430 431 432

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105 ALZHEIMER’S DISEASE & DEMENTIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105.1 Prevalence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105.2 Mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105.3 Cost of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105.4 Coexisting Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105.5 Early Detection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105.6 Research For Treatments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105.7 Genetic Influence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105.8 Influence of Physical and Mental Activity.. . . . . . . . . . . . . . . . . . . . . . . . 105.9 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

433 433 435 436 436 436 437 437 438 439

106 ARTHRITIS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106.1 Prevalence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106.2 Economic Impact. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106.3 Types of Arthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106.4 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

440 440 441 441 443 443

107 ASTHMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107.1 Prevalence and Mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107.2 Cost. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107.3 Asthma Capitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107.4 Asthma In Children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107.5 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107.6 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

444 444 445 445 446 446 447

108 BARIATRIC SURGERY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108.2 Impact On Obesity-Related Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . 108.3 Risks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108.4 Centers of Excellence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

448 448 448 449 449 449

109 BEHAVIORAL & MENTAL HEALTH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109.1 Prevalence And Economic Impact.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109.2 Mental Health Expenditures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109.3 Reimbursement Parity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

450 450 451 451 452

110 CANCER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110.1 Prevalence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110.2 Cancer In Men. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110.3 Cancer In Women. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

453 453 453 454

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110.4 110.5 110.6 110.7

Trends In Incidence And Mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Medical Treatment Marketplace. . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

454 455 456 457

111 CARDIOVASCULAR DISEASE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.1 Prevalence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.2 Cost. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.3 Trends In Cardiovascular Disease.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.4 Cardiac Surgery.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.5 Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.6 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

458 458 459 459 459 460 461

112 CHRONIC CONDITIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112.1 Prevalence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112.2 Healthcare Spending. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112.3 Financial Burden. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

462 462 463 464 464

113 CHRONIC OBSTRUCTIVE PULMONARY DISEASE. . . . . . . . . . . . . . . . . . . . 113.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113.2 Prevalence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113.3 Cost. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113.4 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113.5 Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113.6 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

465 465 465 465 466 466 466

114 COLDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114.1 Prevalence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114.2 Costs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114.3 Diagnosis And Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

467 467 467 468

115 COSMETIC & RECONSTRUCTIVE SURGERY. . . . . . . . . . . . . . . . . . . . . . . . 115.1 Market Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115.2 Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115.3 Assessment by Gender. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

469 469 469 470 470

116 DIABETES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116.1 Prevalence And Mortality.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116.2 Type I And Type II Diabetes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116.3 Economic Impact. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116.4 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

471 471 471 472 473 473

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117 END-OF-LIFE CARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117.2 Spending Disparities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117.3 Hospice And Palliative Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117.4 Psychological Support. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117.5 Advance Directives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117.6 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

474 474 475 476 476 476 477

118 HEADACHES & MIGRAINES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118.1 Prevalence And Cost. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118.2 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118.3 Headache Clinics.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

478 478 478 479 479

119 HIV & AIDS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119.1 Prevalence And Mortality.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119.2 Cost. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119.3 The AIDS Epidemic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119.4 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119.5 Prevention Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

480 480 480 481 481 482

120 INFECTIOUS DISEASES.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120.2 Prevalence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120.3 Mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120.4 Hepatitis C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120.5 Norovirus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120.6 Pneumonia And Pneumococcal Disease. . . . . . . . . . . . . . . . . . . . . . . . 120.7 Sexually Transmitted Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120.8 Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120.9 West Nile Virus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120.10 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

484 484 484 484 485 485 486 486 487 487 488

121 INFLUENZA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.2 Prevalence, Mortality and Cost. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.3 Flu Seasons.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.4 Flu Vaccination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.5 Threat Of A Flu Pandemic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

489 489 489 489 490 491

122 KIDNEY DISEASE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492 122.1 Prevalence And Expenditures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492 122.2 Kidney Transplants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492

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122.3 Renal Dialysis Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492 122.4 Daily At-Home Dialysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493 122.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493 123 OPHTHALMOLOGY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.1 Cost. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.2 Prevalence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.3 Eye Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.4 Myopia And Hyperopia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

494 494 494 494 496 497

124 ORGAN TRANSPLANTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124.2 Organ Transplant Centers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124.3 Transplants And Donors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124.4 Wait List.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124.5 Organ Procurement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124.6 Incentives For Organ Donation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124.7 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

498 498 498 498 499 499 501 502

125 ORTHOPEDICS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125.1 Orthopedic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125.2 Back Pain And Spinal Surgery.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125.3 Foot And Ankle Problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125.4 Hip Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125.5 Knee Surgery.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125.6 Implant Failures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125.7 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

504 504 505 506 506 507 508 509

126 OSTEOPOROSIS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126.1 Prevalence and Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126.2 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126.3 Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

510 510 510 511 511

127 PAIN MANAGEMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127.1 Prevalence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127.2 Economic Impact. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127.3 Pain Management In Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127.4 Pain Management In Children’s Hospitals. . . . . . . . . . . . . . . . . . . . . . . . 127.5 Pain Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127.6 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

512 512 512 513 514 514 515

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128 ROBOTIC SURGERY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128.2 Robotic Surgery Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128.3 Benefits Of Robotic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128.4 Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

516 516 516 517 517

129 SCREENING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519 129.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519 129.2 USPSTF Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519 130 SLEEP DISORDERS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130.1 Prevalence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130.2 Economic Impact. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130.3 Sleep And Overall Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130.4 Most Sleep-Deprived Cities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130.5 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130.6 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

527 527 528 529 530 530 531

131 SUBSTANCE ABUSE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131.1 Prevalence And Cost. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131.2 Medical Treatment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131.3 Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

532 532 533 534 534

132 SURGERY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132.2 Inpatient Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132.3 Quality Standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132.4 Elective Surgery.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

536 536 536 537 537 538

PART IX: HEALTHCARE PROFESSIONALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539 133 HEALTHCARE WORKFORCE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540 133.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540 133.2 Largest Employers.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540 134 HOSPITAL EXECUTIVE COMPENSATION. . . . . . . . . . . . . . . . . . . . . . . . . . . 542 134.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 542 134.2 Executive Compensation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 542 135 HOSPITAL EXECUTIVES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 544 135.1 Hospital CEO Turnover. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 544 135.2 Healthcare Executive Recruitment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546

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136 MEDICAL SCHOOLS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136.2 Largest Medical Schools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136.3 Teaching Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

547 547 547 548

137 NURSE PRACTITIONERS & PHYSICIAN ASSISTANTS. . . . . . . . . . . . . . . . . 137.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137.2 Nurse Practitioners. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137.3 Physician Assistants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137.4 Practice Settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

549 549 550 550 551 551

138 NURSES.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138.1 Licensed Registered Nurses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138.2 Nurses and Healthcare Quality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138.3 Nurse Shortages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138.4 Clinical Nurse Leaders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138.5 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

552 552 554 554 555 555

139 NURSING SCHOOLS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139.2 Largest Nursing Schools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139.3 Doctorate In Nursing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139.4 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

556 556 557 557 558

140 PHYSICIAN COMPENSATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140.2 Compensation For Physician Specialities. . . . . . . . . . . . . . . . . . . . . . . . 140.3 Salary Surveys.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

559 559 559 560

141 PHYSICIANS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.1 Physician Supply. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.2 Demographics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.3 Specialists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.4 Physician Shortages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.5 Group Practices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.6 Hospital-Employed Physicians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.7 Hospitalists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.8 Locum Tenens.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.9 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

562 562 563 563 564 565 566 567 567 567

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142 UNIVERSITY PROGRAMS IN HEALTH ADMINISTRATION. . . . . . . . . . . . . . 142.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142.2 Largest Master’s Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142.3 Market Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

569 569 569 570

PART X: HEALTHCARE ONLINE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571 143 CONSUMER USE OF ONLINE HEALTH INFORMATION. . . . . . . . . . . . . . . . 143.1 Use Of Online Information About Health Topics. . . . . . . . . . . . . . . . . . . 143.2 Online Sources For Health Information. . . . . . . . . . . . . . . . . . . . . . . . . . 143.3 Healthcare-Focused Social Networking.. . . . . . . . . . . . . . . . . . . . . . . . . 143.4 Online Patient Groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

572 572 572 573 574

144 DEMOGRAPHICS OF ONLINE HEALTH INFORMATION USERS.. . . . . . . . . 144.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144.2 Research About Specific Diseases or Medical Problems. . . . . . . . . . . . 144.3 Research About Medical Treatments or Procedures. . . . . . . . . . . . . . . . 144.4 Research About Fitness or Exercise. . . . . . . . . . . . . . . . . . . . . . . . . . . . 144.5 Research About Prescription and OTC Medicines. . . . . . . . . . . . . . . . . 144.6 Research About Health Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144.7 Research About Alternative Treatments and Medicines. . . . . . . . . . . . . 144.8 Research About Weight Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144.9 Research About Mental Health Issues. . . . . . . . . . . . . . . . . . . . . . . . . . 144.10 Research About Experimental Treatments or Medicines. . . . . . . . . . . 144.11 Research About Health During Overseas Travel.. . . . . . . . . . . . . . . . .

576 576 576 577 578 579 579 580 581 582 582 583

145 HEALTH INFORMATION EXCHANGE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585 145.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585 145.2 Guide To HIE Organizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585 146 MOBILE HEALTH APPS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146.2 Healthcare Professionals’ Use Of Health Apps. . . . . . . . . . . . . . . . . . . . 146.3 Consumer Use Of Health Apps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

593 593 593 594

147 PERSONAL HEALTH RECORDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147.2 Defining PHRs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147.3 Consumer Access To EMRs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147.4 Commercial PHR Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147.5 Compatibility Issues.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147.6 Pilot Projects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

595 595 596 596 596 597 598

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148 PHYSICIAN SERVICES ONLINE.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148.1 Types Of Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148.2 Virtual Visits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148.3 E-mail Communications With Doctors. . . . . . . . . . . . . . . . . . . . . . . . . . . 148.4 Remote Second Opinions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

599 599 599 601 601

149 PROVIDER RATINGS ONLINE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149.2 Hospital Compare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149.3 Quality Initiatives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149.4 State Healthcare Agency and Association Sites. . . . . . . . . . . . . . . . . . . 149.5 Consumer Reviews. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

603 603 603 604 604 605

150 SHOPPING ONLINE FOR HEALTHCARE PROVIDERS. . . . . . . . . . . . . . . . . 150.1 Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150.2 Use of Online Information About Hospitals. . . . . . . . . . . . . . . . . . . . . . . 150.3 Use of Online Information About Physicians. . . . . . . . . . . . . . . . . . . . . . 150.4 Use of Provider Ratings Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150.5 Use of Reviews. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150.6 Comparison Shopping For Healthcare Services. . . . . . . . . . . . . . . . . . . 150.7 Online Appointments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

606 606 606 607 608 608 609 610

PART XI: STATE & METROPOLITAN PREVALENCE DATA. . . . . . . . . . . . . . . . . 611 151 ARTHRITIS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151.1 National Assessment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151.2 State Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151.3 Metropolitan Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

612 612 612 613

152 ASTHMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152.1 National Assessment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152.2 State Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152.3 Metropolitan Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

619 619 619 620

153 CARDIOVASCULAR DISEASE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153.1 National Assessment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153.2 State Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153.3 Metropolitan Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

626 626 626 630

154 CHOLESTEROL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154.1 National Assessment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154.2 State Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154.3 Metropolitan Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

645 645 645 646

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155 DIABETES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155.1 National Assessment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155.2 State Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155.3 Metropolitan Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

652 652 652 653

156 DISABILITY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156.1 National Assessment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156.2 State Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156.3 Metropolitan Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

659 659 659 660

157 EXERCISE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157.1 National Assessment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157.2 State Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157.3 Metropolitan Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

666 666 666 667

158 HYPERTENSION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158.1 National Assessment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158.2 State Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158.3 Metropolitan Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

673 673 673 674

159 OVERWEIGHT & OBESITY.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159.1 National Assessment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159.2 State Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159.3 Metropolitan Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

680 680 680 681

160 TOBACCO USE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160.1 National Assessment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160.2 State Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160.3 Metropolitan Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

687 687 687 688

MARKET RESOURCES.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 694 REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 698

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PART I: AMERICA’S HEALTH

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1 GENERAL HEALTH

1.1 National Assessment According to the Behavioral Risk Factor Surveillance System, April 2013, (BRFSS, http://apps.nccd.cdc.gov/BRFSS/) of the Centers for Disease Control and Prevention (CDC, www.cdc.gov), adults rate their general health as follows: • Excellent: 18.6% • Very good: 32.8% • Good: 31.5% • Fair: 12.3% • Poor: 4.7%

_________________________________________________________________

“For people who report that they are in excellent health, average annual Medicare spending is $3,469; for those reporting poor health, spending is more than six times as high ($21,064).” American Hospital Association _________________________________________________________________

1.2 State Assessment According to the CDC BRFSS, adults, by state, rate their general health as follows: • • • • • • • •

Alabama: Alaska: Arizona: Arkansas: California: Colorado: Connecticut: Delaware:

Excellent

Very good

Good

Fair

16.6% 20.3% 19.9% 15.4% 21.5% 21.6% 22.8% 18.0%

28.3% 31.7% 30.2% 26.8% 30.7% 35.2% 33.5% 35.2%

31.9% 32.5% 32.5% 33.0% 29.1% 29.4% 28.9% 32.1%

15.6% 10.8% 12.5% 17.1% 14.6% 10.6% 11.1% 11.1%

Poor

7.6% 4.7% 4.9% 7.9% 4.1% 3.2% 3.7% 3.6%

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• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

District of Columbia: Florida: Georgia: Hawaii: Idaho: Illinois: Indiana: Iowa: Kansas: Kentucky: Louisiana: Maine: Maryland: Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:

26.8% 19.5% 18.5% 21.0% 20.3% 17.2% 15.5% 18.4% 17.7% 15.9% 16.9% 18.4% 21.9% 22.6% 16.2% 20.8% 14.2% 17.9% 18.8% 17.6% 20.7% 20.8% 22.0% 17.7% 19.0% 18.0% 17.9% 17.1% 15.5% 19.3% 18.6% 18.0% 18.1% 19.0% 17.9% 16.8% 22.9% 20.4% 21.7% 19.2% 13.4% 20.1% 19.5%

32.4% 29.1% 30.4% 27.1% 32.0% 32.8% 32.5% 36.8% 36.2% 29.7% 28.8% 35.3% 33.9% 34.4% 33.9% 37.5% 28.4% 30.9% 33.9% 35.8% 27.6% 36.7% 31.7% 28.1% 31.9% 31.5% 35.9% 33.4% 29.7% 34.1% 33.6% 33.4% 31.6% 34.5% 31.3% 28.8% 33.0% 37.4% 33.1% 33.3% 28.2% 34.9% 33.5%

27.1% 30.8% 32.2% 36.9% 32.2% 32.6% 33.1% 31.9% 31.1% 32.1% 31.4% 30.4% 30.1% 29.0% 32.7% 29.6% 33.4% 33.0% 30.1% 32.2% 31.5% 28.8% 30.2% 34.3% 32.2% 30.9% 31.5% 31.5% 34.6% 29.1% 31.0% 31.2% 31.3% 31.8% 29.8% 35.3% 30.6% 29.3% 28.5% 31.4% 33.4% 30.4% 31.6%

10.2% 14.7% 13.6% 11.1% 10.8% 13.3% 13.4% 9.9% 10.9% 14.7% 16.0% 11.8% 11.1% 10.5% 12.4% 9.0% 16.5% 12.7% 12.0% 11.0% 14.7% 9.9% 12.4% 14.1% 12.2% 14.0% 11.8% 13.4% 13.9% 12.9% 12.3% 12.6% 12.7% 11.7% 13.1% 14.0% 9.9% 9.8% 11.5% 12.0% 16.4% 10.9% 10.6%

3.6% 6.0% 5.3% 3.9% 4.6% 4.1% 5.5% 3.1% 4.1% 7.6% 6.9% 4.2% 3.1% 3.6% 4.8% 3.0% 7.5% 5.5% 5.3% 3.3% 5.6% 3.8% 3.8% 5.8% 4.7% 5.6% 3.0% 4.6% 6.3% 4.7% 4.5% 4.8% 6.4% 3.0% 7.8% 5.0% 3.6% 3.1% 5.2% 4.2% 8.7% 3.6% 4.8%

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The following states have the highest percentages of adults rating their personal health as excellent or good: 1. Connecticut: 88.1% 2. Minnesota: 88.0% 3. Vermont: 87.1% 4. Nebraska: 86.7% 5. Utah: 86.5% The following states have the highest percentages of adults rating their personal health as fair or poor: 1. West Virginia: 25.1% 2. Mississippi: 24.0% 3. Alabama: 23.2% 4. Kentucky: 22.3% 5. Tennessee: 20.9%

1.3 Metropolitan Assessment According to the CDC BRFSS, adults, by Metropolitan Statistical Area (MSA), Metropolitan Division (MD), or Micropolitan Statistical Area (ìSA), rate their general health as follows: • • • • • • • • • • • • • • • • • • • • • •

Akron, OH MSA: Albuquerque, NM MSA: Allentown-Bethlehem-Easton, PA-NJ MSA: Amarillo, TX MSA: Arcadia, FL ìSA: Asheville, NC MSA: Atlanta-Sandy Springs-Marietta, GA MSA: Atlantic City, NJ MSA: Augusta-Richmond County, GA-SC MSA: Augusta-Waterville, ME ìSA: Austin-Round Rock, TX MSA: Baltimore-Towson, MD MSA: Bangor, ME MSA: Barre, VT ìSA: Baton Rouge, LA MSA: Bethesda-Gaithersburg-Frederick, MD MD: Billings, MT MSA: Birmingham-Hoover, AL MSA: Bismarck, ND MSA: Boise City-Nampa, ID MSA: Boston-Quincy, MA MD: Bremerton-Silverdale, WA MSA:

Excellent

VG

Good

Fair

Poor

17.9% 25.8% 23.2% 18.2% 14.7% 22.7% 21.7% 21.0% 20.2% 23.5% 21.7% 22.1% 17.4% 31.2% 20.3% 25.5% 19.7% 18.7% 17.8% 22.8% 29.2% 23.9%

37.9% 30.0% 32.9% 29.9% 29.3% 33.2% 38.9% 28.5% 32.4% 34.7% 38.7% 34.4% 35.3% 38.0% 35.5% 37.4% 35.1% 31.6% 37.8% 34.6% 32.5% 37.3%

29.6% 27.8% 29.8% 35.1% 30.0% 27.6% 26.6% 30.4% 30.8% 28.5% 25.8% 29.8% 31.1% 21.3% 26.3% 28.1% 31.1% 32.0% 32.5% 27.3% 27.8% 27.6%

11.1% 12.0% 11.0% 11.0% 20.8% 10.9% 9.5% 14.9% 11.1% 8.4% 11.1% 10.5% 12.0% 6.7% 14.2% 7.5% 11.0% 12.4% 9.3% 10.7% 7.5% 7.8%

3.5% 4.3% 3.2% 5.8% 5.2% 5.5% 3.4% 5.2% 5.5% 4.9% 2.7% 3.2% 4.2% 2.8% 3.7% 1.5% 3.1% 5.3% 2.6% 4.6% 3.0% 3.4%

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• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Bridgeport-Stamford-Norwalk, CT MSA: 29.5% Buffalo-Cheektowaga-Tonawanda, NY MSA: 20.7% Burlington-South Burlington, VT MSA: 25.3% Cambridge-Newton-Framingham, MA MD: 28.4% Camden, NJ MD: 21.8% Canton-Massillon, OH MSA: 18.0% Cape Coral-Fort Myers, FL MSA: 20.1% Casper, WY MSA: 21.9% Cedar Rapids, IA MSA: 24.8% Charleston, WV MSA: 16.4% Charleston-North Charleston, SC MSA: 18.5% Charlotte-Gastonia-Concord, NC-SC MSA: 24.0% Chattanooga, TN-GA MSA: 10.3% Cheyenne, WY MSA: 20.0% Chicago-Naperville-Joliet, IL-IN-WI MSA: 20.1% Cincinnati-Middletown, OH-KY-IN MSA: 20.5% Cleveland-Elyria-Mentor, OH MSA: 20.5% Coeur d´Alene, ID MSA: 23.1% Colorado Springs, CO MSA: 22.6% Columbia, SC MSA: 18.8% Columbus, OH MSA: 17.8% Concord, NH ìSA: 21.4% Dallas-Plano-Irving, TX MD: 21.5% Dayton, OH MSA: 18.5% Del Rio, TX ìSA: n/a Deltona-Daytona Beach-Ormond, FL MSA: 15.0% Denver-Aurora, CO MSA: 25.3% Des Moines-West Des Moines, IA MSA: 20.2% Detroit-Livonia-Dearborn, MI MD: 13.9% Dover, DE MSA: 18.2% Durham, NC MSA: 26.7% Edison, NJ MD: 26.3% El Paso, TX MSA: 16.7% Eugene-Springfield, OR MSA: 20.1% Evansville, IN-KY MSA: 21.1% Fargo, ND-MN MSA: 20.5% Farmington, NM MSA: 21.1% Fayetteville-Springdale-Rogers, AR-MO MSA: 21.1% Fort Collins-Loveland, CO MSA: 30.4% Fort Wayne, IN MSA: 18.0% Fort Worth-Arlington, TX MD: 15.4% Gainesville, FL MSA: 28.5% Grand Island, NE ìSA: 14.9% Grand Rapids-Wyoming, MI MSA: 18.1%

38.1% 37.3% 41.6% 40.5% 35.6% 34.4% 34.0% 33.9% 32.1% 27.1% 33.7% 34.5% 38.4% 33.0% 33.4% 36.6% 35.9% 34.9% 39.2% 33.8% 35.5% 38.7% 33.4% 36.0% 19.4% 32.1% 39.0% 37.1% 33.4% 34.3% 32.5% 31.1% 20.3% 38.7% 31.4% 45.2% 27.6% 34.5% 41.4% 31.8% 34.1% 32.1% 36.7% 35.4%

22.9% 27.0% 24.4% 23.2% 28.3% 32.0% 29.4% 29.7% 34.4% 32.3% 32.5% 26.8% 30.6% 32.1% 30.9% 29.0% 28.9% 29.6% 25.6% 30.9% 31.0% 28.8% 31.9% 28.3% 35.0% 31.8% 25.8% 33.1% 34.2% 30.4% 27.7% 29.0% 40.3% 24.5% 29.4% 24.5% 36.0% 33.7% 20.2% 35.4% 36.1% 29.3% 32.3% 32.9%

7.5% 12.4% 6.0% 6.1% 10.1% 11.3% 11.4% 10.5% 7.4% 15.8% 11.1% 10.4% 13.3% 10.3% 11.6% 10.2% 10.8% 8.8% 9.6% 10.7% 12.4% 8.3% 10.1% 12.4% 16.0% 13.2% 7.5% 6.9% 14.0% 13.0% 10.6% 9.9% 16.4% 12.0% 12.1% 6.3% 10.8% 7.4% 7.1% 10.3% 10.8% 5.8% 13.0% 10.6%

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1.9% 2.6% 2.7% 1.8% 4.2% 4.3% 5.0% 3.9% 1.3% 8.3% 4.1% 4.3% 7.4% 4.6% 4.1% 3.8% 4.0% 3.6% 3.0% 5.7% 3.3% 2.8% 3.0% 4.7% 6.5% 7.8% 2.3% 2.7% 4.5% 4.2% 2.5% 3.7% 6.4% 4.7% 6.0% 3.4% 4.6% 3.2% 0.9% 4.5% 3.6% 4.3% 3.1% 3.1%

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Greensboro-High Point, NC MSA: Greenville, SC MSA: Hagerstown-Martinsburg, MD-WV MSA: Hartford-W. Hartford-E. Hartford, CT MSA: Hastings, NE ìSA: Helena, MT ìSA: Hickory-Morganton-Lenoir, NC MSA: Hilo, HI ìSA: Hilton Head Island-Beaufort, SC ìSA: Homosassa Springs, FL ìSA: Honolulu, HI MSA: Houston-Sugar Land-Baytown, TX MSA: Huntington-Ashland, WV-KY-OH MSA: Idaho Falls, ID MSA: Indianapolis-Carmel, IN MSA: Jackson, MS MSA: Jacksonville, FL MSA: Kahului-Wailuku, HI ìSA: Kalispell, MT ìSA: Kansas City, MO-KS MSA: Kapaa, HI ìSA: Kennewick-Richland-Pasco, WA MSA: Key West-Marathon, FL ìSA: Kingsport-Bristol, TN-VA MSA: Knoxville, TN MSA: Lake City, FL ìSA: Lakeland-Winter Haven, FL MSA: Laredo, TX MSA: Las Cruces, NM MSA: Las Vegas-Paradise, NV MSA: Lebanon, NH-VT ìSA: Lewiston, ID-WA MSA: Lewiston-Auburn, ME MSA: Lincoln, NE MSA: Little Rock-North Little Rock, AR MSA: Los Angeles-Long Beach-Glendale, CA MD: Louisville, KY-IN MSA: Lubbock, TX MSA: Manchester-Nashua, NH MSA: McAllen-Edinburg-Mission, TX MSA: Memphis, TN-MS-AR MSA: Miami-Ft. Lauderdale-Miami Beach, FL MSA: Midland, TX MSA: Milwaukee-Waukesha-West Allis, WI MSA:

19.1% 19.7% 16.3% 21.5% 19.5% 22.1% 16.7% 19.8% 21.3% 19.5% 19.2% 20.1% 12.7% 20.4% 19.6% 19.6% 23.4% 19.9% 22.6% 20.1% 21.8% 17.2% 29.0% 14.3% 16.3% 18.9% 19.1% 15.5% 16.5% 21.6% 23.3% 18.0% 24.0% 18.6% 22.1% 21.1% 16.6% 17.1% 24.4% 18.5% 18.9% 21.6% 21.0% 20.5%

35.3% 35.5% 34.1% 38.1% 40.1% 38.2% 29.6% 31.3% 39.2% 27.6% 29.6% 31.0% 27.0% 38.0% 36.4% 31.1% 34.6% 32.5% 35.4% 38.0% 30.0% 35.3% 31.1% 29.4% 34.2% 26.2% 28.3% 20.2% 29.3% 30.1% 38.4% 33.8% 36.0% 41.3% 31.6% 28.0% 33.9% 33.3% 42.7% 19.7% 37.1% 32.6% 36.8% 35.3%

28.3% 29.3% 35.0% 28.7% 26.9% 27.4% 31.2% 34.1% 26.4% 31.9% 37.3% 32.3% 32.5% 28.7% 29.9% 28.5% 25.0% 34.4% 27.5% 29.1% 32.0% 32.0% 27.2% 32.7% 32.4% 33.0% 33.2% 42.5% 30.8% 30.9% 27.3% 30.1% 24.4% 31.6% 29.8% 30.3% 32.1% 31.4% 22.7% 37.5% 25.8% 30.5% 26.8% 28.5%

12.9% 10.7% 7.6% 9.1% 11.3% 7.7% 16.1% 11.4% 10.2% 14.7% 11.3% 11.9% 18.6% 9.3% 9.6% 13.8% 12.1% 9.7% 10.4% 9.6% 12.0% 12.5% 8.8% 15.3% 10.4% 15.4% 13.4% 15.1% 17.1% 11.4% 7.8% 11.8% 11.9% 6.8% 11.9% 16.0% 11.8% 13.4% 7.3% 15.5% 13.2% 11.4% 10.5% 11.7%

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4.5% 4.8% 6.9% 2.6% 2.2% 4.7% 6.4% 3.5% 2.9% 6.4% 2.6% 4.6% 9.2% 3.6% 4.5% 6.9% 5.0% 3.5% 4.2% 3.2% 4.2% 2.9% 3.9% 8.3% 6.7% 6.4% 6.0% 6.7% 6.3% 6.0% 3.2% 6.3% 3.6% 1.6% 4.6% 4.6% 5.6% 4.9% 2.9% 8.8% 5.0% 3.9% 5.0% 4.0%

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Minneapolis-St. Paul, MN-WI MSA: Minot, ND ìSA: Mobile, AL MSA: Myrtle Beach-Conway, SC MSA: Naples-Marco Island, FL MSA: Nashville-Davidson--Murfreesboro, TN MSA: Nassau-Suffolk, NY MD: New Haven-Milford, CT MSA: New Orleans-Metairie-Kenner, LA MSA: New York-White Plains-Wayne, NY-NJ MD: Newark-Union, NJ-PA MD: Norfolk, NE ìSA: North Platte, NE ìSA: North Port-Bradenton-Sarasota, FL MSA: Ocala, FL MSA: Ocean City, NJ MSA: Ogden-Clearfield, UT MSA: Oklahoma City, OK MSA: Olympia, WA MSA: Omaha-Council Bluffs, NE-IA MSA: Orlando-Kissimmee, FL MSA: Palm Bay-Melbourne-Titusville, FL MSA: Panama City-Lynn Haven, FL MSA: Peabody, MA MD: Pensacola-Ferry Pass-Brent, FL MSA: Philadelphia, PA MD: Phoenix-Mesa-Scottsdale, AZ MSA: Pittsburgh, PA MSA: Port St. Lucie-Fort Pierce, FL MSA: Portland-South Portland-Biddeford, ME MSA: Portland-Vancouver-Beaver., OR-WA MSA: Providence-New Bedford, RI-MA MSA: Provo-Orem, UT MSA: Raleigh-Cary, NC MSA: Rapid City, SD MSA: Reno-Sparks, NV MSA: Richmond, VA MSA: Riverside-San Bernardino-Ontario, CA MSA: Rochester, NY MSA: Rockingham County-Strafford Co., NH MD: Rutland, VT ìSA: Sacramento-Arden-Roseville, CA MSA: Salt Lake City, UT MSA: San Antonio, TX MSA:

25.8% 18.9% 15.6% 18.0% 24.1% 21.6% 25.0% 22.8% 16.8% 22.1% 23.5% 21.5% 21.3% 22.0% 16.0% 26.2% 26.6% 18.0% 20.4% 20.9% 19.2% 15.6% 21.2% 28.1% 20.5% 24.0% 26.7% 19.4% 17.1% 26.1% 20.5% 22.4% 26.6% 21.8% 17.5% 21.1% 25.4% 19.8% 21.1% 20.5% 17.9% 26.4% 25.4% 24.7%

38.3% 36.8% 31.3% 40.2% 34.8% 37.6% 36.8% 33.8% 31.3% 32.4% 32.8% 32.7% 29.1% 33.7% 31.5% 30.7% 34.3% 33.2% 36.0% 37.8% 35.8% 34.1% 31.1% 34.9% 36.0% 35.4% 32.2% 36.4% 37.8% 38.5% 37.7% 35.4% 34.5% 37.6% 41.8% 36.1% 34.5% 30.7% 33.2% 42.3% 38.8% 34.5% 34.3% 28.5%

26.6% 31.0% 31.2% 26.4% 22.9% 28.2% 27.7% 31.8% 32.4% 29.7% 30.0% 32.6% 34.4% 32.0% 29.4% 29.0% 26.6% 30.6% 32.9% 30.6% 27.1% 32.3% 32.9% 23.6% 27.6% 25.9% 28.0% 29.4% 27.1% 24.0% 28.1% 28.9% 30.7% 30.8% 31.1% 27.6% 30.1% 30.2% 30.8% 27.1% 30.4% 25.9% 28.0% 30.7%

7.2% 11.2% 15.5% 11.4% 14.7% 7.6% 8.0% 9.1% 14.6% 12.1% 9.8% 9.8% 10.7% 9.2% 14.7% 11.0% 8.9% 12.4% 7.9% 7.8% 12.9% 10.0% 9.3% 10.6% 11.3% 11.0% 9.6% 11.1% 12.7% 8.6% 9.3% 9.9% 6.2% 7.6% 7.4% 10.8% 6.9% 15.4% 10.9% 6.6% 9.1% 8.8% 9.7% 12.2%

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2.1% 2.1% 6.4% 4.1% 3.5% 5.0% 2.6% 2.4% 4.9% 3.8% 3.8% 3.5% 4.5% 3.1% 8.4% 3.1% 3.6% 5.8% 2.9% 2.9% 4.9% 7.9% 5.5% 2.8% 4.6% 3.7% 3.5% 3.7% 5.3% 2.8% 4.3% 3.5% 2.0% 2.2% 2.3% 4.5% 3.0% 3.9% 4.0% 3.6% 3.9% 4.3% 2.6% 3.9%

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

San Diego-Carlsbad-San Marcos, CA MSA: San Francisco-Oakland-Fremont, CA MSA: San Jose-Sunnyvale-Santa Clara, CA MSA: Santa Ana-Anaheim-Irvine, CA MD: Santa Fe, NM MSA: Scottsbluff, NE ìSA: Scranton-Wilkes-Barre, PA MSA: Seaford, DE ìSA: Seattle-Bellevue-Everett, WA MD: Sebring, FL ìSA: Shreveport-Bossier City, LA MSA: Sioux City, IA-NE-SD MSA: Sioux Falls, SD MSA: Spokane, WA MSA: Springfield, MA MSA: St. Louis, MO-IL MSA: Tacoma, WA MD: Tallahassee, FL MSA: Tampa-St. Petersburg-Clearwater, FL MSA: Toledo, OH MSA: Topeka, KS MSA: Trenton-Ewing, NJ MSA: Tucson, AZ MSA: Tulsa, OK MSA: Tuscaloosa, AL MSA: Twin Falls, ID ìSA: Tyler, TX MSA: Virginia B.-Norfolk-N. News, VA-NC MSA: Warren-Troy-Farmington Hills, MI MD: Washington-Alexandria, DC-VA-MD-WV MD: Wauchula, FL ìSA: West Palm Beach-Boca Raton, FL MD: Wichita Falls, TX MSA: Wichita, KS MSA: Wilmington, DE-MD-NJ MD: Worcester, MA MSA: Yakima, WA MSA: Youngstown-Warren, OH-PA MSA:

24.5% 25.2% 24.7% 23.5% 23.9% 19.8% 19.2% 19.1% 22.8% 12.6% 16.1% 18.4% 19.8% 20.3% 23.4% 19.6% 20.1% 19.3% 18.3% 17.9% 16.4% 21.7% 20.5% 18.2% 19.8% 17.4% 20.9% 25.4% 21.1% 25.9% 17.7% 23.8% 19.0% 20.2% 21.6% 24.7% 14.2% 15.1%

33.1% 34.7% 31.8% 30.9% 32.8% 30.0% 30.6% 34.6% 36.5% 29.3% 32.5% 38.3% 45.4% 35.4% 36.8% 35.1% 33.3% 35.2% 32.7% 33.6% 38.9% 39.8% 29.0% 30.7% 27.9% 36.1% 31.7% 32.9% 38.9% 32.8% 26.8% 34.4% 31.4% 35.5% 36.1% 34.5% 31.2% 31.8%

28.0% 25.5% 28.7% 30.1% 28.1% 35.7% 32.4% 32.6% 29.3% 33.1% 30.7% 30.7% 26.5% 30.6% 28.0% 31.7% 30.7% 29.4% 31.9% 32.0% 28.6% 25.5% 34.8% 30.6% 34.0% 31.7% 33.1% 27.4% 29.1% 29.7% 31.6% 26.9% 30.6% 29.7% 28.9% 28.4% 33.5% 36.9%

10.4% 11.6% 11.5% 12.6% 11.7% 9.8% 12.6% 10.4% 8.5% 16.9% 15.1% 8.5% 6.7% 10.6% 8.9% 9.9% 11.9% 12.7% 12.4% 12.4% 12.3% 9.7% 10.0% 14.3% 14.0% 10.6% 8.0% 10.1% 8.1% 9.1% 18.3% 10.7% 13.4% 11.6% 10.1% 8.4% 15.4% 11.9%

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4.0% 3.0% 3.3% 2.9% 3.6% 4.7% 5.2% 3.4% 2.9% 8.1% 5.6% 4.1% 1.6% 3.2% 2.9% 3.7% 3.9% 3.4% 4.8% 4.0% 3.9% 3.3% 5.7% 6.2% 4.3% 4.2% 6.3% 4.2% 2.8% 2.5% 5.5% 4.2% 5.7% 3.0% 3.3% 4.0% 5.7% 4.3%

2 PERSONAL HEALTH

2.1 Gallup Poll 2012 A November 2012 poll conducted by Gallup (www.gallup.com) surveyed adults on personal health issues. The following are the results of this Gallup poll: 1. How would you describe your own physical health at this time? • Excellent: 32% • Good: 49% • Only fair: 14% • Poor: 6% 2.

How would you describe your own mental health or emotional well-being at this time? • Excellent: 48% • Good: 41% • Only fair: 9% • Poor: 2%

3.

Overall, how would you rate the quality of healthcare you receive? • Excellent: 40% • Good: 42% • Only fair: 12% • Poor: 6% • Not applicable: 1%

4.

Overall, how would you rate your healthcare coverage? • Excellent: 27% • Good: 40% • Only fair: 17% • Poor: 10% • Not applicable: 4%

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5.

Are you generally satisfied or dissatisfied with the total cost you pay for your healthcare? • Yes: 59% • No: 39% • No opinion: 2%

6.

Who pays the cost of premiums on your health insurance (based on adults with private health insurance)? • Self/household: 22% • Employer pays all: 10% • Costs are shared: 64% • None/other: 3%

7.

Over the past year, has the amount you paid for your and your family’s health insurance changed (based on adults who pay all or part of their health premiums)? • Gone up a lot: 29% • Gone up a little: 42% • Not changed: 22% • Gone down a little: 4% • Gone down a lot: 1% • No opinion: 2%

8.

Within the last 12 months, have you or a member of your family put off any sort of medical treatment because of the cost you would have to pay? • Yes, serious condition: 19% • Yes, non-serious condition: 13% • No: 68%

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3 PREVALENCE OF DISEASE & ILLNESS

3.1 Summary By Disease The following is a summary of the impact of major diseases and health conditions affecting the U.S. population: Alzheimer’s Disease • According to the Alzheimer’s Association (www.alz.org), an estimated 5.2 million Americans of all ages have Alzheimer’s disease. The course of the disease can be from two to 20 years. The cost of diagnosis, treatment, and long-term care for patients with AD is $203 billion annually in the United States, a number expected to rise to $1.2 trillion by 2050. Arthritis • Arthritis is the number one cause of disability in America, affecting an estimated 50 million people and costing the U.S. economy $128 billion per year in medical care and lost wages. It is responsible for 427 million days of restricted activity, 156 million days in bed, and 45 million days lost from work each year, according to the Arthritis Foundation (www.arthritis.org). Asthma and Allergies • According to the Asthma and Allergy Foundation of America (www.aafa.org), more than 60 million people in America have asthma or allergies, with a cost to the U.S. economy over $325 billion each year in hospitalizations, medical services, and lost productivity at work or school. Cancer • Cancer is the second-leading cause of death in the United States, exceeded only by heart disease. According to Cancer Facts and Figures, by the American Cancer Society (www.cancer.org), an estimated 1.64 million people in the U.S. were diagnosed with cancer in 2012, and an estimated 577,190 died of the disease. • In 2012, an estimated 848,170 new cancer cases among men were reported. The following are the leading sites: - Prostate: 241,740 - Lung and bronchus: 116,470 - Colon and rectum: 73,420 - Urinary bladder: 55,600 - Melanoma: 44,250

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- Kidney and renal pelvis: - Non-Hodgkin lymphoma: - Oral cavity and pharynx: - Leukemia: - Pancreas:

40,250 38,160 28,540 26,830 22,090

•

In 2012, an estimated 301,820 men died from cancer. The following were the leading sites: - Lung and bronchus: 87,750 - Prostate: 28,170 - Colon and rectum: 26,470 - Pancreas: 18,850 - Liver: 13,980 - Leukemia: 13,500 - Esophagus: 12,040 - Urinary bladder: 10,510 - Non-Hodgkin lymphoma: 10,200 - Kidney and renal pelvis: 8,650

•

In 2012, an estimated 790,740 new cancer cases among women were reported. The following were the leading sites: - Breast: 226,870 - Lung and bronchus: 109,690 - Colon and rectum: 70,040 - Uterine corpus: 47,130 - Thyroid: 43,210 - Melanoma: 32,000 - Non-Hodgkin lymphoma: 31,970 - Kidney and renal pelvis: 24,520 - Ovary: 22,280 - Pancreas: 21,830

•

In 2012, an estimated 275,370 women died from cancer. The following were the leading sites: - Lung and bronchus: 72,590 - Breast: 39,510 - Colon and rectum: 25,220 - Pancreas: 18,540 - Ovary: 15,500 - Leukemia: 10,040 - Non-Hodgkin lymphoma: 8,620 - Uterine corpus: 8,010 - Liver: 6,570 - Brain/nervous system: 5,980

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Cardiovascular Disease • According to 2012 Heart Disease and Stroke Statistics, by the American Heart Association (www.americanheart.org), 82.6 million Americans have one or more type of cardiovascular disease (CVD). Of them, 48% are male and 52% are female; 38% are age 65 or older. The following are incidences of specific CVDs: - Coronary heart disease, total: 16.3 million - Angina pectoris: 9.0 million - Myocardial infarction: 7.9 million - Stroke: 7.0 million - Congenital cardiovascular defects: 1.3 million to 650,000 •

The following is a breakdown of the 811,940 annual deaths in the U.S. attributed to CVD (source: 2012 Heart and Stroke Statistical Update): - Coronary heart disease: 50% - Stroke: 17% - High blood pressure: 8% - Congestive heart failure: 7% - Other: 16%

Diabetes • Nearly 26 million Americans have diabetes, and an estimated 79 million U.S. adults have prediabetes‚ according to the Centers for Disease Control and Prevention (CDC, www.cdc.gov). An estimated 7 million Americans with diabetes do not know they have the disease. • According to the American Diabetes Association (ADA, www.diabetes.org), annual direct medical expenditures related to diabetes treatment are $176 billion; approximately 44% of those costs are attributed to inpatient hospital stays. Headaches • According to the National Headache Foundation (www.headaches.org), as many as 50 million Americans suffer from chronic headaches. HIV and AIDS • The CDC estimates 1.2 million people in the U.S. are infected with human immunodeficiency virus (HIV); 490,696 have acquired immune deficiency syndrome (AIDS). A quarter of those with HIV are not aware that they are infected, and unaware carriers are responsible for half of the 48,000 new HIV cases each year. Infectious Diseases • According to the National Center for Infectious Diseases (www.cdc.gov/diseasesconditions), the following are the most fatal infectious diseases in the United States (typical mortality figures; exact numbers vary each year): - Influenza and pneumonia: 50,000 annual deaths

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- Septicemia: - Viral hepatitis: •

35,000 annual deaths 7,500 annual deaths

Americans get about 1.4 billion colds each year. Children typically get up to eight colds every year; adults catch an average of two to four colds each year.

Kidney Disease • According to the National Kidney Foundation (NKF, www.kidney.org), approximately 26 million Americans – or 1 in 10 adults – suffer from chronic kidney disease (CKD). Presently, another 20 million are susceptible due to risk factors such as diabetes, high blood pressure, cardiovascular disease, family history of kidney disease, and racial or ethnic heritage. Osteoporosis • The National Osteoporosis Foundation (www.nof.org) estimates that 9 million Americans (80% of whom are women) over the age of 50 have osteoporosis, another 48 million are at risk of developing the condition because of low bone mass, and 1.5 million Americans suffer an osteoporosis-related bone fracture every year. Pain • Chronic pain – commonly defined as pain persisting longer than six months – affects an estimated 76.5 million Americans and is a tragically overlooked public health problem, according to the National Center for Health Statistics (www.cdc.gov/nchs). Arthritis and back pain account for up to 60% of cases. Vision • According to the National Eye Institute (www.nei.nih.gov), blindness or low vision affects 4.2 million Americans. Of the 4.2 million vision-impaired Americans, 1.3 million are blind (0.8% of the population) and 2.4 million have low vision. In addition, 34.1 million people have myopia (nearsightedness) and 14.2 million have hyperopia (farsightedness).

3.2 Causes of Death According to the National Center for Health Statistics (www.cdc.gov/nchs), the leading causes of death in the United States are as follows: • Heart disease: 596,339 • Cancer: 575,313 • Chronic lower respiratory disease: 143,382 • Stroke: 128,931 • Accidents (unintentional injuries): 122,777 • Alzheimer’s disease: 83,494 • Diabetes: 73,282 • Influenza and pneumonia: 53,667 • Nephritis, nephrotic syndrome, and nephirsis: 45,731 • Intentional self-harm (suicide): 38,285 HEALTHCARE BUSINESS MARKET RESEARCH HANDBOOK 2013-2014

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4 STATE-BY-STATE ASSESSMENT

4.1 Overview Based on Health Care State Rankings, published by CQ Press (www.cqpress.com), with data from the National Center for Health Statistics (www.cdc.gov/nchs/), this chapter presents measures of consumer health in each of the 50 states and the District of Columbia. States ranked with the lowest incidences of disease are given the lowest ranking; the state with the most favorable attributes is ranked #1. For comparison with state data, national averages are as follows: • Rate of new cancer cases (estimated): 498.2* • Age-adjusted death rate, diseases of the heart: 190.9* • Adults aware they have diabetes: 8.3% • Adults with asthma: 8.8% • Rate of new AIDS cases annually: 12.2* • Adults reporting serious psychological distress: 11.1% * rate per 100,000 residents

4.2 Alabama • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

502.0* 235.5* 13.2% 8.0% 8.7* 11.5%

20 48 50 15 32 27

* rate per 100,000 residents

4.3 Alaska • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

409.5* 147.9* 5.3% 10.0% 3.2* 11.3%

3 4 1 41 13 23

* rate per 100,000 residents

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4.4 Arizona • New cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

451.5* 152.5* 9.0% 10.3% 9.1* 12.0%

7 6 30 44 33 33

* rate per 100,000 residents

4.5 Arkansas • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

530.2* 221.8* 9.6% 7.8% 5.3* 13.0%

33 44 34 11 20 46

* rate per 100,000 residents

4.6 California • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

425.6* 177.9* 8.6% 7.7% 13.2* 9.8%

6 23 24 10 42 4

* rate per 100,000 residents

4.7 Colorado • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

424.7* 145.3* 6.0% 9.2% 7.5* 11.2%

5 3 2 27 29 21

* rate per 100,000 residents

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4.8 Connecticut • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

588.8* 171.0* 7.3% 9.2% 10.1* 10.1%

47 18 11 27 36 6

* rate per 100,000 residents

4.9 Delaware • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

552.5* 200.2* 8.7% 10.0% 16.8* 10.5%

37 34 25 41 44 12

* rate per 100,000 residents

4.10 District of Columbia • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

460.2* 239.4* 8.3% 10.4% 93.3* 11.5%

* rate per 100,000 residents

4.11 Florida • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

577.2* 162.4* 10.4% 8.3% 26.0* 10.2%

44 11 44 16 49 7

* rate per 100,000 residents

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4.12 Georgia • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

411.8* 203.0* 9.7% 7.8% 19.7* 12.1%

4 37 35 11 46 35

* rate per 100,000 residents

4.13 Hawaii • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

515.0* 140.2* 8.3% 9.4% 3.0* 8.2%

26 2 20 31 12 1

* rate per 100,000 residents

4.14 Idaho • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

467.1* 164.1* 7.9% 8.8% 2.1* 11.5%

13 14 18 23 4 27

* rate per 100,000 residents

4.15 Illinois • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

494.9* 192.8* 8.7% 9.2% 10.1* 10.3%

19 30 25 27 36 8

* rate per 100,000 residents

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4.16 Indiana • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

514.1* 203.0* 9.8% 9.5% 6.5* 12.8%

25 37 37 32 25 44

* rate per 100,000 residents

4.17 Iowa • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

573.8* 174.8* 7.5% 7.8% 2.5* 11.4%

43 21 14 11 6 24

* rate per 100,000 residents

4.18 Kansas • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

480.7* 178.7* 8.4% 8.6% 3.9* 11.9%

15 25 21 21 14 29

* rate per 100,000 residents

4.19 Kentucky • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

561.9* 220.9* 10.0% 10.4% 6.9* 13.6%

40 42 39 45 26 47

* rate per 100,000 residents

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4.20 Louisiana • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

466.4* 230.0* 10.3% 6.7% 24.0* 12.7%

11 47 42 2 48 42

* rate per 100,000 residents

4.21 Maine • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

656.1* 172.9* 8.7% 10.0% 2.7* 12.5%

50 20 25 41 8 38

* rate per 100,000 residents

4.22 Maryland • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

486.0* 202.4* 9.3% 8.4% 27.6* 9.7%

18 35 32 19 50 3

* rate per 100,000 residents

4.23 Massachusetts • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

546.6* 165.5* 7.4% 10.4% 5.8* 10.4%

35 16 12 45 23 10

* rate per 100,000 residents

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4.24 Michigan • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

558.3* 221.5* 10.1% 10.5% 7.0* 12.0%

38 43 40 45 27 33

* rate per 100,000 residents

4.25 Minnesota • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

476.2* 129.8* 6.7% 7.6% 4.0* 10.9%

14 1 4 12 15 16

* rate per 100,000 residents

4.26 Mississippi • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

485.4* 266.5* 12.4% 7.2% 12.6* 12.0%

17 50 49 3 41 33

* rate per 100,000 residents

4.27 Missouri • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

520.4* 214.4* 9.4% 8.8% 8.5* 13.0%

29 40 33 33 31 46

* rate per 100,000 residents

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4.28 Montana • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

571.3* 163.1* 7.0% 9.1% 3.0* 11.3%

42 12 7 25 12 23

* rate per 100,000 residents

4.29 Nebraska • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

513.7* 165.3* 7.7% 7.8% 4.3* 12.1%

24 15 16 11 16 35

* rate per 100,000 residents

4.30 Nevada • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

462.7* 200.0* 8.5% 9.2% 12.4* 12.0%

10 33 22 27 39 33

* rate per 100,000 residents

4.31 New Hampshire • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

589.6* 174.9* 7.9% 10.4% 2.1* 11.2%

46 23 18 45 4 21

* rate per 100,000 residents

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4.32 New Jersey • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

552.4* 191.9* 9.2% 8.7% 17.6* 9.7%

36 29 31 22 45 3

* rate per 100,000 residents

4.33 New Mexico • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

458.3* 159.2* 9.7% 5.1% 12.7* 12.2%

8 9 22 37 19 42

* rate per 100,000 residents

4.34 New York • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

528.8* 225.1* 8.9% 9.8% 23.5* 11.0%

32 45 29 38 47 18

* rate per 100,000 residents

4.35 North Carolina • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

481.0* 191.0* 9.8% 7.5% 12.5* 10.9%

16 27 37 7 40 16

* rate per 100,000 residents

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4.36 North Dakota • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

510.2* 164.1* 7.4% 7.4% 2.4* 12.3%

23 14 12 5 5 37

* rate per 100,000 residents

4.37 Ohio • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

558.4* 204.8* 10.1 9.6% 5.8* 11.5%

39 39 40 35 23 24

* rate per 100,000 residents

4.38 Oklahoma • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

506.4* 241.6* 10.4% 9.5% 4.7* 14.0%

21 49 44 32 18 49

* rate per 100,000 residents

4.39 Oregon • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

542.4* 156.9* 7.2% 9.5% 5.6* 11.0%

34 7 9 32 21 18

* rate per 100,000 residents

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4.40 Pennsylvania • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

597.1* 199.4* 10.3% 9.9% 11.3* 10.5%

48 32 42 40 37 12

* rate per 100,000 residents

4.41 Rhode Island • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

566.8* 203.6* 7.8% 10.9% 7.4* 12.8%

41 38 17 49 28 44

* rate per 100,000 residents

4.42 South Carolina • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

509.5* 192.9* 10.7% 8.3% 15.5* 12.2%

22 31 46 16 43 36

* rate per 100,000 residents

4.43 South Dakota • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

519.5* 159.1* 6.9% 7.5% 1.4* 10.1%

28 8 6 7 1 6

* rate per 100,000 residents

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4.44 Tennessee • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

525.2* 220.6* 11.3% 6.0% 9.6* 13.7%

31 41 47 1 34 48

* rate per 100,000 residents

4.45 Texas • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

408.2* 191.9* 9.7% 7.4% 12.0* 10.7%

2 29 35 5 38 13

* rate per 100,000 residents

4.46 Utah • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

358.0* 152.1* 6.5% 9.1% 2.7* 12.6%

1 5 3 25 8 40

* rate per 100,000 residents

4.47 Vermont • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

598.3* 161.2* 6.8% 11.1% 1.8* 11.8%

49 10 5 50 2 28

* rate per 100,000 residents

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4.48 Virginia • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

461.9* 182.7* 8.7% 8.4% 8.2* 10.9%

9 26 25 19 30 16

* rate per 100,000 residents

4.49 Washington • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

517.7* 167.2* 7.6% 9.6% 6.2* 10.4%

27 17 15 35 24 10

* rate per 100,000 residents

4.50 West Virginia • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

583.0* 229.4* 11.7% 7.3% 4.5* 14.4%

45 46 48 4 17 50

* rate per 100,000 residents

4.51 Wisconsin • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

523.6* 171.9* 7.1% 8.3% 3.0* 11.1%

30 19 8 16 12 19

* rate per 100,000 residents

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4.52 Wyoming • Rate of new cancer cases (estimated): • Age-adjusted death rate, diseases of the heart: • Adults aware they have diabetes: • Adults with asthma: • Rate of new AIDS cases annually: • Adults reporting serious psychological distress:

Rank

466.7* 178.3* 7.2% 9.8% 2.9* 12.6%

12 24 9 38 9 40

* rate per 100,000 residents

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5 STATE HEALTH RANKINGS

5.1 Overview Since 1989, United Health Foundation (www.unitedhealthfoundation.org) has developed an annual healthcare index for each state; the District of Columbia is not included in the assessment. The annual assessment uses a composite of 17 criteria measuring demographic and lifestyle factors, access to healthcare, occupational safety, and disease/mortality rates. Ranking score is based on the weighted number of standard deviations a state is above or below the national average.

5.2 Rankings 2012 The following presents a summary of the 2012 assessment: R anking Score

1 2 3 4 5 6 7 8 9 10 11 12 13 (tie) 13 (tie) 15 16 17 18 19 20 21 22 23

Vermont: Hawaii: New Hampshire: Massachusetts: Minnesota: Connecticut: Utah: New Jersey: Maine: Rhode Island: Colorado: North Dakota: Oregon: Washington: Nebraska: Wisconsin: Idaho: New York: Maryland: Iowa: Virginia: California: Wyoming:

1.196 0.977 0.897 0.879 0.821 0.820 0.805 0.643 0.621 0.587 0.549 0.543 0.527 0.527 0.514 0.486 0.425 0.398 0.336 0.299 0.268 0.262 0.236

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24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 (tie) 49 (tie)

Kansas: Arizona: Pennsylvania: South Dakota: Alaska: Montana: Illinois: Delaware: New Mexico: North Carolina: Florida: Ohio: Georgia: Michigan: Nevada: Tennessee: Texas: Indiana: Missouri: Oklahoma: Kentucky: Alabama: South Carolina: West Virginia: Arkansas: Louisiana: Mississippi

0.152 0.139 0.104 0.091 0.083 0.037 -0.059 -0.063 -0.069 -0.105 -0.138 -0.245 -0.261 -0.269 -0.280 -0.317 -0.328 -0.341 -0.403 -0.464 -0.470 -0.521 -0.535 -0.655 -0.717 -0.938 -0.938

5.3 Overall Assessment The following is an overview of the 2012 assessment by United Health Foundation: • Obesity continues to be at epidemic levels and is one of the fastest-growing health challenges confronting the nation. The national median of obese adults is 27.8%; that means more than 66 million adults are obese, more than the entire population of the United Kingdom. In even the least obese state, Colorado, more than 20% of the population is obese. The combination of sedentary behavior and poor diet inevitably leads to increasing levels of obesity, which contributes to diabetes, cardiovascular disease, cancer, and other negative health outcomes. Additionally, the economic burden of obesity is worrisome. By 2030, medical costs associated with treating preventable obesity-related diseases are estimated to increase to $66 billion per year, and the loss in economic productivity could be between $390 billion and $580 billion annually, according to F as in Fat: How Obesity Threatens America’s Future 2012, a report released by Trust for America’s Health and the

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•

•

•

Robert Wood Johnson Foundation. Diabetes is also at epidemic levels. The percentage of adults with diabetes is as high as 12.0% in West Virginia, South Carolina, and Mississippi. The national median of adults with diabetes is 9.5%. A 2010 report from the United Health Center for Health Reform & Modernization indicates that if these rates are not reduced, diabetes and pre-diabetes will account for about 10% of total healthcare spending by 2020, at an annual cost of almost $500 billion. The 2012 Rankings saw stark differences between the five healthiest states (Vermont, Hawaii, New Hampshire, Massachusetts and Minnesota) and the f ive least healthy states (Mississippi, Louisiana, Arkansas, West Virginia, and South Carolina). In comparing the top five and bottom five states, it is evident that the least healthy states face formidable challenges related to behavioral determinants of health and to socioeconomic factors that influence health. While smoking rates in the five healthiest states range from 16.8% to 19.4% of the adult population, smoking rates are between 23.1% and 28.6% in the five least healthy states. Likewise, 27.2% to 36.0% of the population lead sedentary lives in the five least healthy states, compared to between 21.0% and 23.5% of the population in the five healthiest states.

5.4 State-by-State Summary Alabama • Overall Rank: 45 • Strengths include a low prevalence of binge drinking (11.3% of the population), high immunization coverage (92.6% of children ages 19-to-35 months receive immunizations), and high public health funding ($107 per person). Alabama ranks higher for determinants than for outcomes, indicating that overall healthiness may improve over time. • Challenges include a high prevalence of smoking (22.5% of the population), a high prevalence of obesity (31.6% of the population), a high percentage of children in poverty (25.8% of persons under age 18), many poor mental and physical health days per month (4.2 days and 4.3 days, respectively), a high rate of deaths from cardiovascular disease (347.9 deaths per 100,000 population), and a hig h infant mortality rate (9.5 deaths per 1,000 live births). Alaska • Overall Rank: 28 • Strengths include low levels of air pollution (7.3 micrograms of fine particulate per cubic meter), high public health funding ($189 per person), a low rate of preventable hospitalizations (56.8 discharges per 1,000 Medicare enrollees), few poor mental and physical health days per month (2.6 days and 2.7 days, respectively, in the previous 30 days), and a low rate of deaths from cardiovascular disease (231.8 deaths per 100,000 population).

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•

Challenges include a high rate of uninsured population (18.8%), low immunization coverage (85.9% of children ages 19-to-35 months receive immunizations), a high violent crime rate (633 offenses per 100,000 population), high geographic disparity within the state (19.4%), and a high occupational fatalities rate (9.4 deaths per 100,000 workers). Alaska ranks lower for determinants than for outcomes, indicating that overall healthiness may decline over time.

Arizona • Overall Rank: 25 • Strengths include a low prevalence of smoking (16.1% of the population), a low rate of preventable hospitalizations (50.7 discharges per 1,000 Medicare enrollees), and low rates of death from cancer and cardiovascular disease (168.4 deaths and 228.1 deaths per 100,000 population, respectively). • Challenges include a high percentage of children in poverty (31.3% of persons under age 18), a high rate of uninsured population (19.5%), limited availability of primary care physicians (91.7 primary care physicians per 100,000 population), low public health funding ($48 per person), and limited access to early prenatal care (77.6% of pregnant women receive prenatal care during the first trimester). Arizona ranks lower for determinants than for outcomes, indicating that overall healthiness may decline over time. Arkansas • Overall Rank: 48 • Strengths include a low prevalence of binge drinking (12.1% of the population), a low incidence of infectious disease (12.7 cases per 100,000 population), and moderate geographic disparity within the state (10.4%). • Challenges include a high prevalence of obesity (31.4% of the population), a high occupational fatalities rate (8.4 deaths per 100,000 workers), a high percentage of children in poverty (25.7% of persons under age 18), low immunization coverage (83.7% of children ages 19-to-35 months receive immunizations), a high rate of deaths from cardiovascular disease (327.4 deaths per 100,000 pop ulation), and a high rate of cancer deaths (213.1 deaths per 100,000 population). Arkansas ranks lower for determinants than for outcomes, indicating that overall healthiness may decline over time. California • Overall Rank: 22 • Strengths include a low prevalence of smoking (12.8% of the population), a low occupational fatalities rate (2.9 deaths per 100,000 workers), a low infant mortality rate (5.1 deaths per 1,000 live births), and a low rate of cancer deaths (173.9 deaths per 100,000 population). • Challenges include a high incidence of infectious disease (20.0 cases per 100,000 population), high levels of air pollution (15.2 micrograms of fine particulate per cubic meter), and a high rate of uninsured population (19.3%). California ranks lower for

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determinants than for outcomes, indicating that overall healthiness may decline over time. Colorado • Overall Rank: 11 • Strengths include a lower prevalence of obesity than other states (18.9% of the population), low levels of air pollution (7.4 micrograms of fine particulate per cubic meter), few poor physical health days per month (2.9 days in the previous 30 days), low rates of deaths from cancer and cardiovascular disease (166.8 deaths and 228.7 deaths per 100,000 population, respectiv ely), and a low rate of preventable hospitalizations (50.1 discharges per 1,000 Medicare enrollees). • Challenges include a high rate of uninsured population (15.6%), low immunization coverage (85.0% of children ages 19-to-35 months receive immunizations), and high geographic disparity within the state (15.8%). Colorado ranks lower for determinants than for outcomes, indicating that overall healthiness may decline over time. Connecticut • Overall Rank: 6 • Strengths include a low prevalence of smoking (15.4% of the population), a lower prevalence of obesity than other states (21.0% of the population), a low percentage of children in poverty (10.0% of persons under age 18), a low rate of uninsured population (11.0%), high immunization coverage (94.1% of children ages 19-to-35 months receive immunizations), ready availability of primary care physicians (162.7 primary care physicians per 100,000 population), low geographic disparity within the state (5.7%), and a low occupational fatalities rate (2.9 deaths per 100,000 workers). • Challenges include a high prevalence of binge drinking (17.8% of the population) and a high incidence of infectious disease (17.1 cases per 100,000 population). Delaware • Overall Rank: 31 • Strengths include a low rate of uninsured population (12.1%), high public health funding ($103 per person), few poor mental health days per month (3.1 days in the previous 30 days), and low geographic disparity within the state (4.3%). • Challenges include a high prevalence of binge drinking (18.2% of the population), a high violent crime rate (637 offenses per 100,000 population), a high incidence of infectious disease (19.6 cases per 100,000 population), and high levels of air pollution (12.6 micrograms of fine particulate per cubic meter). Delaware ranks lower for determinants than for outcomes, indicating that overall healthiness may decline over time.

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Florida • Overall Rank: 34 • Strengths include a low prevalence of binge drinking (13.9% of the population), high immunization coverage (91.9% of children ages 19-to-35 months receive immunizations), low levels of air pollution (8.3 micrograms of fine particulate per cubic meter), and low rates of deaths from cancer and cardiovascular disease (182.7 deaths and 240.8 deaths per 100,000 population, respectiv ely). • Challenges include a high incidence of infectious disease (30.7 cases per 100,000 population), a low high school graduation rate (65.0% of incoming ninth graders graduate within four years), a high rate of uninsured population (21.2%), a high violent crime rate (613 offenses per 100,000 population), and high geographic disparity within the state (21.5%). Georgia • Overall Rank: 36 • Strengths include a low prevalence of binge drinking (12.3% of the population) and few poor mental and physical health days per month (2.8 days and 3.0 days, respectively, in the previous 30 days). • Challenges include a low high school graduation rate (64.1% of incoming ninth graders graduate within four years), a high incidence of infectious disease (24.5 cases per 100,000 population), high levels of air pollution (12.9 micrograms of fine particulate per cubic meter), and a high rate of uninsured population (19.2%). Hawaii • Overall Rank: 2 • Strengths include a low prevalence of smoking (15.3% of the population), a lower prevalence of obesity than other states (22.9% of the population), low levels of air pollution (6.7 micrograms of fine particulate per cubic meter), a low rate of uninsured population (8.0%), strong public health funding ($235 per person), ready availability of primary care physicians (148.5 primary care physicians per 100,000 population), few poor mental and physical health days per month (2.6 days and 2.9 days, respectively, in the past thirty days), a low rate of preventable hospitalizations (28.6 discharges per 1,000 Medicare enrollees), and low rates of deaths from cancer and cardiovascular disease (159.0 deaths and 220.0 deaths per 100,000 population, respectively). • Challenges include low immunization coverage (86.1% of children ages 19-to-35 months receive immunizations), a high incidence of infectious disease (17.9 cases per 100,000 population), and a high prevalence of binge drinking (17.3% of the population). Idaho • Overall Rank: 17 • Strengths include a low incidence of infectious disease (3.6 cases per 100,000 population), a low violent crime rate (228 offenses per 100,000 population), high

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public health funding ($123 per person), a low rate of preventable hospitalizations (49.1 discharges per 1,000 Medicare enrollees), and a low rate of cancer deaths (176.9 deaths per 100,000 population). Idaho ranks hig her for determinants than for outcomes, indicating that overall healthiness should improve over time. Challenges include limited availability of primary care physicians (76.1 primary care physicians per 100,000 population), a high rate of uninsured population (15.4%), and a high percentage of children in poverty (19.7% of persons under age 18).

Illinois • Overall Rank: 30 • Strengths include a low occupational fatalities rate (3.5 deaths per 100,000 workers), ready access to early prenatal care (86.0% of pregnant women receive prenatal care during the first trimester), ready availability of primary care physicians (129.5 primary care physicians per 100,000 population), and a high rate of high school graduation (79.5% of incoming ninth graders graduate within four years). • Challenges include a high prevalence of binge drinking (18.5% of the population), a high rate of preventable hospitalizations (81.1 discharges per 1,000 Medicare enrollees), high levels of air pollution (12.5 micrograms of fine particulate per cubic meter), and a high violent crime rate (497 offenses per 100,000 population). Indiana • Overall Rank: 41 • Strengths include a low incidence of infectious disease (8.6 cases per 100,000 population), low geographic disparity within the state (8.5%), and a low rate of uninsured population (13.2%). • Challenges include a high prevalence of smoking (23.1% of the population), high levels of air pollution (13.4 micrograms of fine particulate per cubic meter), low public health funding ($39 per person), and a high percentage of children in poverty (26.3% of persons under age 18). Indiana ranks lower for determinants than for outcomes, indicating that overall healthiness may decline over time. Iowa • Overall Rank: 20 • Strengths include a high rate of high school graduation (86.5% of incoming ninth graders graduate within four years), a low rate of uninsured population (10.4%), high immunization coverage (93.3% of children ages 19-to-35 months receive immunizations), a low infant mortality rate (5.3 deaths per 1,000 live births), and few poor mental and physical health days per month (2.6 days and 2.7 days in the previous 30 days, respectively). • Challenges include a high prevalence of binge drinking (19.4% of the population) and limited availability of primary care physicians (84.0 primary care physicians per 100,000 population). Iowa ranks lower for determinants than for outcomes, indicating that overall healthiness may decline over time.

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Kansas • Overall Rank: 24 • Strengths include few poor mental and physical health days per month (2.9 days and 3.0 days in the previous 30 days, respectively), a low incidence of infectious disease (6.2 cases per 100,000 population), and ready access to early prenatal care (82.8% of pregnant women receive prenatal care during the first trimester). • Challenges include low public health funding ($47 per person), limited availability of primary care physicians (102.5 primary care physicians per 100,000 population), a high infant mortality rate (7.5 deaths per 1,000 live births), and a high occupational fatalities rate (5.7 deaths per 100,000 workers). Kentucky • Overall Rank: 44 • Strengths include a low prevalence of binge drinking (11.8% of the population), a low violent crime rate (259 offenses per 100,000 population). Kentucky ranks higher for determinants than for outcomes, indicating that overall healthiness may improve over time. • Challenges include a high prevalence of smoking (25.6% of the population), a high prevalence of obesity (32.3% of the population), a high rate of cancer deaths (227.0 deaths per 100,000 population), a high rate of preventable hospitalizations (102.0 discharges per 1,000 Medicare enrollees), and many poor mental and physical health days per month (4.6 days and 5.2 days, respectively, in the previous 30 days). Louisiana • Overall Rank: 49 (tie) • Strengths include ready access to early prenatal care (86.8% of pregnant women receive prenatal care during the first trimester), high immunization coverage (93.2% of children ages 19-to-35 months receive immunizations), and high public health funding ($95 per person). • Challenges include a high prevalence of obesity (33.9% of the population), a low high school graduation rate (61.3% of incoming ninth graders graduate within four years), a high incidence of infectious disease (23.8 cases per 100,000 population), a high rate of preventable hospitalizations (97.3 discharges per 1,000 Medicare enrollees), a high infant mortality rate (9.5 deaths per 1,000 live births), and high rates of cancer and cardiovascular deaths (220.1 deaths and 334.8 deaths per 100,000 population, respectively). Maine • Overall Rank: 9 • Strengths include a low violent crime rate (120 offenses per 100,000 population), a low rate of uninsured population (10.3%), low geographic disparity within the state (7.8%), a low incidence of infectious disease (6.1 cases per 100,000 population), and ready access to early prenatal care (87.4% of pregnant women receive prenatal

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care during the first trimester). Maine ranks higher for determinants than for outcomes, indicating that overall healthiness should improve over time. Challenges include a high rate of cancer deaths (210.4 deaths per 100,000 population).

Maryland • Overall Rank: 19 • Strengths include a low prevalence of smoking (15.1% of the population), ready availability of primary care physicians (179.4 primary care physicians per 100,000 population), a low percentage of children in poverty (12.3% of persons under age 18), and high immunization coverage (92.3% of children ages 19-to-35 months receive immunizations). Maryland ranks higher for determinants than for outcomes, indicating that overall healthiness should improve over time. • Challenges include a high incidence of infectious disease (32.8 cases per 100,000 population), a high violent crime rate (590 offenses per 100,000 population), and a high infant mortality rate (8.0 deaths per 1,000 live births). Massachusetts • Overall Rank: 4 • Massachusetts is among the top 10 states for 12 of the 22 measures. Strengths include a low prevalence of smoking (14.9% of the population), a lower prevalence of obesity than other states (21.8% of the population), a low occupational fatalities rate (3.0 deaths per 100,000 workers), a low rate of uninsured population (5.0%), high immunization coverage (93.4% of children ages 19-to-35 months receive immunizations), ready availability of primary care physicians (191.3 primary care physicians per 100,000 population), a low infant mortality rate (4.8 deaths per 1,000 live births), and low geographic disparity within the state (6.3%). • Challenges include a high prevalence of binge drinking (17.6% of the population) and a high rate of preventable hospitalizations (75.3 discharges per 1,000 Medicare enrollees). Michigan • Overall Rank: 37 • Strengths include a low occupational fatalities rate (3.2 deaths per 100,000 workers), high immunization coverage (93.7% of children ages 19-to-35 months receive immunizations), ready access to early prenatal care (85.4% of pregnant women receive prenatal care during the first trimester), and low geographic disparity within the state (9.0%). Michigan ranks higher for determinants than for outcomes, indicating that overall healthiness should improve over time. • Challenges include a high prevalence of obesity (30.3% of the population), low public health funding ($52 per person), and a high rate of deaths from cardiovascular disease (312.7 deaths per 100,000 population).

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Minnesota • Overall Rank: 5 • Minnesota is among the top 10 states for 13 of the 22 measures. Strengths include a high rate of high school graduation (86.5% of incoming ninth graders graduate within four years), a low occupational fatalities rate (2.8 deaths per 100,000 workers), a low rate of uninsured population (8.7%), a low premature death rate (5,382 years of potential life lost before age 75 per 100,000 population), a low rate of deaths from cardiovascular disease (206.3 deaths per 100,000 population), and few poor physical health days per month (2.9 days in the previous 30 days). • Challenges include low public health funding ($45 per person) and a high prevalence of binge drinking (20.0% of the population). Minnesota ranks lower for determinants than for health outcomes, indicating that overall healthiness may decline over time. Mississippi • Overall Rank: 49 (tie) • Strengths include a low prevalence of binge drinking (10.3% of the population), high immunization coverage (91.6% of children ages 19-to-35 months receive immunizations), and a low violent crime rate (281 offenses per 100,000 population). • Mississippi is among the bottom five states for 11 of the 22 measures. Challenges include a high prevalence of obesity (35.3% of the population), a high percentage of children in poverty (31.9% of persons under age 18), a low high school graduation rate (63.6% of incoming ninth graders graduate within four years), limited availability of primary care physicians (81.9 primary care physicians per 100,000 population), a high rate of preventable hospitalizations (97.8 discharges per 1,000 Medicare enrollees), a high infant mortality rate (10.3 deaths per 1,000 live births), and a high rate of deaths from cardiovascular disease (373.7 deaths per 100,000 pop ulation). Missouri • Overall Rank: 42 • Strengths include a high rate of high school graduation (81.9% of incoming ninth graders graduate within four years), a low incidence of infectious disease (10.4 cases per 100,000 population), and ready access to early prenatal care (86.4% of pregnant women receive prenatal care during the first trimester). • Challenges include a high prevalence of smoking (23.1% of the population), low public health funding ($45 per person), low immunization coverage (86.0% of children ages 19-to-35 months receive immunizations), and high preventable hospitalizations (77.3 discharges per 1,000 Medicare enrollees). Montana • Overall Rank: 29 • Strengths include a moderate prevalence of obesity (23.7% of the population), a low incidence of infectious disease (3.2 cases per 100,000 population), low levels of air pollution (8.0 micrograms of fine particulate per cubic meter), and a low rate of

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deaths from cardiovascular disease (240.6 deaths per 100,000 pop ulation). Montana ranks higher for determinants than for outcomes, indicating that overall healthiness should improve over time. Challenges include low immunization coverage (85.4% of children ages 19-to-35 months receive immunizations), a high occupational fatalities rate (8.9 deaths per 100,000 workers), and high geographic disparity within the state (18.6%).

Nebraska • Overall Rank: 15 • Strengths include a high rate of high school graduation (86.3% of incoming ninth graders graduate in four years), a low percentage of children in poverty (13.6% of persons under age 18), few poor mental health days per month (2.6 days in the previous 30 days), and low levels of air pollution (8.1 micrograms of fine particulate per cubic meter). • Challenges include a high prevalence of binge drinking (18.5% of the population), a high occupational fatalities rate (6.6 deaths per 100,000 workers), and moderate geographic disparity within the state (12.5%). Nevada • Overall Rank: 38 • Strengths include low levels of air pollution (9.0 micrograms of fine particulate per cubic meter), a low rate of preventable hospitalizations (57.4 discharges per 1,000 Medicare enrollees), a low percentage of children in poverty (17.9% of persons under age 18), and a low infant mortality rate (6.4 deaths per 1,000 live births). • Challenges include a low high school graduation rate (52.0% of incoming ninth graders graduate within four years), a high violent crime rate (702 offenses per 100,000 population), low immunization coverage (83.8% of children ages 19-to-35 months receive immunizations), low public health funding ($39 per person), and limited access to early prenatal care (73.3% of pregnant women receive prenatal care during the first trimester). Nevada ranks lower for determinants than for outcomes, indicating that overall healthiness may decline over time. New Hampshire • Overall Rank: 3 • Strengths include a low percentage of children in poverty (10.5% of persons under age 18), a low violent crime rate (160 offenses per 100,000 population), a low rate of uninsured population (10.4%), low geographic disparity within the state (5.7%), and a low premature death rate. • Challenges include moderate public health funding ($63 per person), a moderate prevalence of binge drinking (16.1% of the population), and a moderate rate of cancer deaths (196.2 deaths per 100,000 population).

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New Jersey • Overall Rank: 8 • Strengths include a moderate prevalence of obesity (23.9% of the population), a low infant mortality rate (5.3 deaths per 1,000 live births), a high rate of high school graduation (84.4% of incoming ninth graders graduate within four years), a low occupational fatalities rate (3.3 deaths per 100,000 workers), and ready availability of primary care physicians (143.1 primary care physicians per 100,000 population). • Challenges include a high incidence of infectious disease (19.4 cases per 100,000 population), limited access to early prenatal care (77.4% of pregnant women receive prenatal care during the first trimester), and a high rate of preventable hospitalizations (76.2 discharges per 1,000 Medicare enrollees). New Mexico • Overall Rank: 32 • Strengths include high public health funding ($130 per person), low levels of air pollution (6.1 micrograms of fine particulate per cubic meter), a low prevalence of binge drinking (12.2% of the population), a low rate of preventable hospitalizations (58.6 discharges per 1,000 Medicare enrollees), a low rate of cancer deaths (170.1 deaths per 100,000 population), and a low rate of deaths from cardiovascular disease (237.8 deaths per 100,000 population). • Challenges include a high rate of uninsured population (22.7%), a high percentage of children in poverty (29.2% of persons under age 18), a low high school graduation rate (59.1% of incoming ninth graders graduate within four years), a high violent crime rate (619 offenses per 100,000 population), limited access to early prenatal care (76.5% of pregnant women receive prenatal care during the first trimester), and high geographic disparity within the state (15.7%). New Mexico ranks lower for determinants than for outcomes, indicating that overall healthiness may decline over time. New York • Overall Rank: 18 • Strengths include ready availability of primary care physicians (168.1 primary care physicians per 100,000 population), high public health funding ($121 per person), low geographic disparity within the state (8.0%), a low infant mortality rate (5.6 deaths per 1,000 live births), a low occupational fatalities rate (3.2 deaths per 100,000 workers), and a low rate of cancer deaths (178.3 deaths per 100,000 population). • Challenges include a high incidence of infectious disease (32.4 cases per 100,000 population), a low high school graduation rate (68.8% of incoming ninth graders graduate within four years), a high percentage of children in poverty (25.0% of persons under age 18), and a high rate of deaths from cardiovascular disease (294.9 deaths per 1000,000 population). New York ranks lower for determinants than for outcomes, indicating that overall healthiness may decline over time.

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North Carolina • Overall Rank: 33 • Strengths include a low prevalence of binge drinking (12.9% of the population), high immunization coverage (91.4% of children ages 19-to-35 months receive immunizations), and a low occupational fatalities rate (4.2 deaths per 100,000 workers). • Challenges include a low high school graduation rate (68.6% of incoming ninth graders graduate within four years), a high percentage of children in poverty (24.5% of persons under age 18), and a high infant mortality rate (8.3 deaths per 1,000 live births). North Dakota • Overall Rank: 12 • Strengths include a low violent crime rate (201 offenses per 100,000 population), a low incidence of infectious disease (2.4 cases per 100,000 population), f ew poor mental and physical health days per month (2.4 days and 2.7 days in the previous 30 days, respectively), low levels of air pollution (5.6 micrograms of fine particulate per cubic meter), a high rate of high school graduation (83.1% of incoming ninth graders graduate within four years), and high immunization coverage (93.3% of children ages 19-to-35 months receive immunizations). North Dakota ranks higher for determinants than for outcomes, indicating that overall healthiness should improve over time. • Challenges include a high prevalence of binge drinking (21.5% of the population), a high occupational fatalities rate (5.6 deaths per 100,000 workers), and high geographic disparity within the state (17.7%). Ohio • Overall Rank: 35 • Strengths include a low rate of uninsured population (12.9%), a low occupational fatalities rate (3.5 deaths per 100,000 workers), a high rate of high school graduation (78.7% of incoming ninth graders graduate within four years), a low incidence of infectious disease (8.9 cases per 100,000 population), and low geographic disparity within the state (9.2%). Ohio ranks higher for determinants than for outcomes, indicating that overall healthiness should improve over time. •

Challenges include high levels of air pollution (13.1 micrograms of fine particulate per cubic meter), low public health funding ($41 per person), a high rate of preventable hospitalizations (79.1 discharges per 1,000 Medicare enrollees), many poor mental health days per month (3.8 days in the previous 30 days), and a high rate of cancer deaths (210.2 deaths per 100,000 population).

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Oklahoma • Overall Rank: 43 • Strengths include a low prevalence of binge drinking (12.5% of the population), high immunization coverage (91.3% of children ages 19-to-35 months receive immunizations), and high public health funding ($106 per person). • Challenges include a high prevalence of smoking (25.4% of the population), a high prevalence of obesity (32.0% of the population), limited access to early prenatal care (76.4% of pregnant women receive prenatal care in the first trimester), limited availability of primary care physicians (80.3 primary care physicians per 100,000 population), a high rate of preventable hospitalizations (88.7 discharges per 1,000 Medicare enrollees), many poor mental and physical health days per month (4.2 days and 4.2 days in the previous 30 days, respectively), and a high rate of deaths from cardiovascular disease (345.1 deaths per 100,000 population). Oregon • Overall Rank: 13 (tie) • Strengths include a lower prevalence of obesity than most other states (23.6% of the population), low levels of air pollution (7.7 micrograms of fine particulate per cubic meter), a low rate of preventable hospitalizations (46.1 discharges per 1,000 Medicare enrollees), a low occupational fatalities rate (3.5 deaths per 100,000 workers), and a low infant mortality rate (5.6 deaths per 1,000 live births). • Challenges include a high rate of uninsured population (17.0%), low immunization coverage (87.8% of children ages 19-to-35 months receive immunizations), low public health funding ($56 per person), and limited access to early prenatal care (78.3% of pregnant women receive prenatal care during the first trimester). Pennsylvania • Overall Rank: 26 • Strengths include a high rate of high school graduation (83.0% of incoming ninth graders graduate within four years), a low percentage of children in poverty (14.5% of persons under age 18), a low rate of uninsured population (10.6%), and low geographic disparity within the state (7.9%). • Challenges include high levels of air pollution (13.3 micrograms of fine particulate per cubic meter), low public health funding ($53 per person), low immunization coverage (87.8% of children ages 19-to-35 months receive immunizations), and a high incidence of infectious disease (16.8 cases per 100,000 popu lation). Rhode Island • Overall Rank: 10 • Strengths include a low prevalence of smoking (15.0% of the population), ready availability of primary care physicians (169.2 primary care physicians per 100,000 population), high public health funding ($113 per person), and low geographic disparity within the state (6.8%). Rhode Island ranks higher for determinants than for outcomes, indicating that overall healthiness should improve over time.

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Challenges include a high prevalence of binge drinking (17.9% of the population), a high percentage of children in poverty (22.2% of persons under age 18), and a high rate of preventable hospitalizations (74.1 discharges per 1,000 Medicare enrollees).

South Carolina • Overall Rank: 46 • Strengths include a low prevalence of binge drinking (12.5% of the population), a low percentage of children in poverty (17.6% of persons under age 18), and few poor physical health days per month (3.5 days in the previous 30 days). • Challenges include a low high school graduation rate (58.9% of incoming ninth graders graduate within four years), a high violent crime rate (671 offenses per 100,000 population), a high infant mortality rate (8.5 deaths per 1,000 live births), and a high incidence of infectious disease (20.0 cases per 100,000 population). South Dakota • Overall Rank: 27 • Strengths include a high rate of high school graduation (82.5% of incoming ninth graders graduate within four years), a low violent crime rate (186 offenses per 100,000 population), a low incidence of infectious disease (4.6 cases per 100,000 population), low levels of air pollution (7.2 micrograms of fine particulate per cubic meter), and few poor mental and physical health days per month (2.4 days and 2.8 days, respectively, in the previous 30 days). South Dakota ranks higher for determinants than for outcomes, indicating that overall healthiness should improve over time. • Challenges include high geographic disparity within the state (26.8%), a high prevalence of obesity (30.2% of the population), and a high prevalence of binge drinking (18.5% of the population). Tennessee • Overall Rank: 39 • Strengths include a low prevalence of binge drinking (8.8% of the population), high immunization coverage (94.1% of children ages 19-to-35 months receive immunizations), low geographic disparity within the state (9.5%), and ready availability of primary care physicians (121.2 primary care physicians per 100,000 population). Tennessee ranks higher for determinants than for outcomes, indicating that overall healthiness should improve over time. • Challenges include a high prevalence of obesity (32.8% of the population), a high rate of preventable hospitalizations (87.7 discharges per 1,000 Medicare enrollees), a high violent crime rate (668 offenses per 100,000 population), many poor physical health days per month (4.6 days in the previous 30 days), a high infant mortality rate (8.5 deaths per 1,000 live births), and a high rate of cancer deaths (215.3 deaths per 100,000 population).

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Texas • Overall Rank: 40 • Strengths include a low rate of cancer deaths (183.7 deaths per 100,000 population), a low infant mortality rate (6.3 deaths per 1,000 live births), and few poor physical health days per month (3.2 days in the previous 30 days). • Challenges include a high rate of uninsured population (25.6%), limited access to early prenatal care (59.7% of pregnant women receive prenatal care during the first trimester), a high percentage of children in poverty (25.6% of persons under age 18), a high incidence of infectious disease (20.4 cases per 100,000 population), and limited availability of primary care physicians (95.4 primary care physicians per 100,000 population). Texas ranks lower for determinants than for outcomes, indicating that overall healthiness may decline over time. Utah • Overall Rank: 7 • Utah ranks among the top10 states for 10 of the 22 measures. Strengths include a low prevalence of smoking (9.8% of the population), a low prevalence of binge drinking (8.6% of the population), a low rate of preventable hospitalizations (39.9 discharges per 1,000 Medicare enrollees), a low violent crime rate (213 offenses per 100,000 population), a low infant mortality rate (5.1 deaths per 1,000 live births), and a low rate of cancer deaths (142.0 deaths per 100,000 population). • Challenges include limited availability of primary care physicians (87.4 primary care physicians per 100,000 population), high geographic disparity within the state (16.0%), and low public health funding ($65 per person). Vermont • Overall Rank: 1 • Vermont ranks among the top 10 states for 14 of the 22 measures. Strengths include a high rate of high school graduation (88.6% of incoming ninth graders graduate within four years), ready access to early prenatal care (83.5% of pregnant women receive prenatal care in the first trimester), a low rate of uninsured population (9.6%), high public health funding ($177 per person), a low percentage of children in poverty (12.0% of persons under age 18), and ready availability of primary care physicians (170.7 primary care physicians per 100,000 population). • Challenges include a high prevalence of binge drinking (17.3% of the population) and moderate immunization coverage (89.8% of children ages 19-to-35 months receive immunizations). Virginia • Overall Rank: 21 • Strengths include a low violent crime rate (227 offenses per 100.000 population), few poor physical health days per month (3.0 days in the previous 30 days), a low percentage of children in poverty (14.8% of persons under age 18), and ready access to early prenatal care (83.9% of pregnant women receive prenatal care

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during the first trimester). Virginia ranks higher for determinants than for outcomes, indicating that overall healthiness should improve over time. Challenges include high levels of air pollution (11.2 micrograms of fine particulate per cubic meter), a high prevalence of smoking (19.0% of the population), low immunization coverage (86.7% of children ages 19-to-35 months receive immunizations), and high geographic disparity within the state (14.9%).

Washington • Overall Rank: 13 (tie) • Strengths include a low prevalence of smoking (14.9% of the population), a low occupational fatalities rate (2.9 deaths per 100,000 workers), a low infant mortality rate (4.8 deaths per 1,000 live births), and a low rate of preventable hospitalizations (46.5 discharges per 1,000 Medicare enrollees). • Challenges include limited access to early prenatal care (67.8% of pregnant women receive prenatal care during the first trimester), low immunization coverage (88.6% of children ages 19-to-35 months receive immunizations), a moderate high school graduation rate (74.8% of incoming ninth graders graduate within four years), and high geographic disparity within the state (12.5%). West Virginia • Overall Rank: 47 • Strengths include a low prevalence of binge drinking (9.0% of the population), high public health funding ($150 per person), ready access to early prenatal care (83.4% of pregnant women receive prenatal care in the first trimester), and a low incidence of infectious disease (9.5 cases per 100,000 population). W est Virginia ranks higher for determinants than for outcomes, indicating that overall healthiness should improve over time. • Challenges include a high prevalence of smoking (25.5% of the population), many poor mental and physical health days per month (4.1 days and 5.1 days, respectively, in the previous 30 days), a high rate of preventable hospitalizations (105.4 discharges per 1,000 Medicare enrollees), and high rates of cardiovascular and cancer deaths (329.8 deaths and 221.6 deaths, respectiv ely, per 100,000 population). Wisconsin • Overall Rank: 16 • Strengths include a high rate of high school graduation (88.5% of incoming ninth graders graduate within four years), a low occupational fatalities rate (3.3 deaths per 100,000 workers), a low incidence of infectious disease (5.0 cases per 100,000 population), a low rate of uninsured population (9.6%), high immunization coverage (93.5% of children ages 19-to-35 months receive immunizations), and few poor mental health days per month (2.8 days in the previous 30 days). • Challenges include a high prevalence of binge drinking (23.2% of the population) and low public health funding ($40 per person).

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Wyoming • Overall Rank: 23 • Strengths include low levels of air pollution (5.2 micrograms of fine particulate per cubic meter), a low violent crime rate (228 offenses per 100,000 population), a low percentage of children in poverty (10.5% of persons under age 18), a low incidence of infectious disease (3.5 cases per 100,000 population), and hig h public health funding ($118 per person). Wyoming ranks higher for determinants than for outcomes, indicating that overall healthiness should improve over time. • Challenges include a high occupational fatalities rate (11.2 deaths per 100,000 workers), limited availability of primary care physicians (92.7 primary care physicians per 100,000 population), and a high premature death rate.

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6 METROPOLITAN MARKET PROFILES

6.1 Overview The U.S. Census Bureau defines Metropolitan Statistical Areas (MSAs) as described at www.census.gov/population/www/metroareas/metrodef.html. There are 366 MSAs.

6.2 Healthcare Market Profiles For the 25 largest MSAs, Modern Healthcare provides the following market profile: New York-Northern New Jersey-Long Island, NY-NJ-PA • Population (2010 census): 18,897,109 • Number of hospitals: 111 • Number of physicians: 62,920 • Uninsured population (adults): 12.9% • Medicare population: 2,382,359 Los Angeles-Long Beach-Santa Ana, CA • Population (2010 census): 12,828,837 • Number of hospitals: 91 • Number of physicians: 23,970 • Uninsured population (adults): 21.5% • Medicare population: 1,329,072 Chicago-Joliet-Naperville, IL-IN-WI • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

9,461,105 75 25,560 14.4% 270,514

Dallas-Fort Worth-Arlington, TX • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

6,371,773 75 12,260 24% 288,117

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Philadelphia-Camden-Wilmington, PA-NJ-DE-MD • Population (2010 census): 5,965,343 • Number of hospitals: 52 • Number of physicians: 15,070 • Uninsured population (adults): 10% • Medicare population: 794,462 Houston-Sugar Land-Baytown, TX • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

5,946,800 52 12,150 24.6% 453,779

Washington-Arlington-Alexandria, DC-VA-MD-WV • Population (2010 census): 5,582,170 • Number of hospitals: 35 • Number of physicians: 16,488 • Uninsured population (adults): 11% • Medicare population: 443,573 Miami-Fort Lauderdale-Pompano Beach, FL • Population (2010 census): 5,564,635 • Number of hospitals: 46 • Number of physicians: 10,348 • Uninsured population (adults): 25.6% • Medicare population: 795,845 Atlanta-Sandy Springs-Marietta, GA • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

5,268,860 36 4,560 19.2% 515,702

Boston-Cambridge-Quincy, MA-NH • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

4,552,402 24 14,540 4.7% 234,291

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San Francisco-Oakland-Fremont, CA • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

4,335,391 43 12,170 11.9% 235,583

Detroit-Warren-Livonia, MI • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

4,296,250 34 10,898 12.9% 603,886

Riverside-San Bernardino-Ontario, CA • Population (2010 census): 4,224,851 • Number of hospitals: 32 • Number of physicians: 4,728 • Uninsured population (adults): 20.5% • Medicare population: 412,464 Phoenix-Mesa-Glendale, AZ • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

4,192,887 35 8,720 17.9% 451,870

Seattle-Tacoma-Bellevue, WA • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

3,439,809 25 7,050 12.1% 357,849

Minneapolis-Saint Paul-Bloomington, MN-WI • Population (2010 census): 3,279,833 • Number of hospitals: 29 • Number of physicians: 8,658 • Uninsured population (adults): 9.1% • Medicare population: 326,963

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San Diego-Carlsbad-San Marcos, CA • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

3,095,313 18 7,490 17% 338,579

St. Louis, MO-IL • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

2,812,896 25 6,880 10.5% 350,609

Tampa-St. Petersburg-Clearwater, FL • Population (2010 census): 2,783,243 • Number of hospitals: 25 • Number of physicians: 5,446 • Uninsured population (adults): 18.5% • Medicare population: 464,920 Baltimore-Towson, MD • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

2,710,489 20 11,046 10.1% 330,079

Denver-Aurora-Broomfield, CO • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

2,543,482 13 5,840 15.3% 234,135

Pittsburgh, PA • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

2,356,285 30 6,506 8.6% 435,502

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Portland-Vancouver-Hillsboro, OR-WA • Population (2010 census): 2,226,009 • Number of hospitals: 15 • Number of physicians: 8,608 • Uninsured population (adults): 14.8% • Medicare population: 229,032 Sacramento-Arden-Arcade-Roseville, CA • Population (2010 census): 2,149,127 • Number of hospitals: 15 • Number of physicians: 3,816 • Uninsured population (adults): 12.6% • Medicare population: 136,309 San Antonio-New Braunfels, TX • Population (2010 census): • Number of hospitals: • Number of physicians: • Uninsured population (adults): • Medicare population:

2,142,508 25 3,506 20% 233,628

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PART II: HEALTHCARE SPENDING

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7 NATIONAL HEALTH EXPENDITURES

7.1 Overview The Centers for Medicare & Medicaid Services (CMS, www.cms.gov) annually assesses and forecasts national health expenditures by type of service delivered (hospital care, physician services, nursing home care, etc.) and source of funding for the services (private health insurance, Medicare, Medicaid, out-of-pocket spending, etc.). This chapter provides a summary of historical data and CMS projections for national health expenditures.

7.2 Spending • • • • • • • • • • • • • • • • • • • • •

2000: 2001: 2002: 2003: 2004: 2005: 2006: 2007: 2008: 2009: 2010: 2011: 2012: 2013: 2014: 2015: 2016: 2017: 2018: 2019: 2020:

Spending (growth)

% of GNP

$1.35 trillion (7.0%) $1.47 trillion (8.6%) $1.60 trillion (9.1%) $1.73 trillion (8.0%) $1.85 trillion (6.9%) $2.02 trillion (6.9%) $2.15 trillion (6.5%) $2.28 trillion (6.2%) $2.39 trillion (4.7%) $2.49 trillion (3.8%) $2.58 trillion (3.9%) $2.71 trillion (3.9%) $2.82 trillion (4.2%) $2.98 trillion (3.8%) $3.23 trillion (7.4%) $3.42 trillion (5.7%) $3.63 trillion (6.3%) $3.85 trillion (5.9%) $4.08 trillion (6.2%) $4.35 trillion (8.5%) $4.64 trillion (6.7%)

13.8% 14.5% 15.3% 15.8% 15.6% 16.0% 16.1% 16.2% 16.6% 17.6% 17.9% 17.9% 17.9% 17.8% 18.2% 18.2% 18.3% 18.4% 18.6% 18.9% 19.2%

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_________________________________________________________________

“The growth of health spending has slowed substantially in the last few years, surprising experts and offering some fuel for optimism about the federal government’s long-term fiscal performance. Much of the slowdown is because of the recession, and thus not unexpected, health experts say. Still, the slowdown was sharper than health economists expected, and a broad, bipartisan range of academics, hospital administrators and policy experts has started to wonder if what had seemed impossible might be happening – if doctors and patients have begun to change their behavior in ways that bend the so-called cost curve.” The New York Times, 4/28/12 _________________________________________________________________

7.3 Source Of Funds The $2.82 trillion in health expenditures in 2012 was distributed by source of funds as follows (change from 2011 in parenthesis): • Private health insurance: $888.6 billion (3.8%) • Medicare: $590.8 billion (5.9%) • Medicaid: $458.9 billion (7.0%) rd • Other 3 party payers:* $450.8 billion (3.1%) • Out-of-pocket payments: $312.1 billion (2.5%) • Other health insurance: $107.7 billion (5.1%) * Includes worksite healthcare, other private revenues, Indian Health Service, workers’ compensation, general assistance, maternal and child health, vocational rehabilitation, other federal programs, Substance Abuse and Mental Health Services Administration, other state and local programs, and school health.

7.4 Distribution of Expenditures The $2.82 trillion in health expenditures in 2012 was distributed by type of expenditure as follows (change from 2011 in parenthesis):

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• • • • • • • • • • • • • • •

Hospital care: Physician and clinical services: Prescription drugs (retail outlet sales): Net cost of private health insurance: Nursing home care and continuing care retirement communities: Structures and equipment: Dental services: Other personal healthcare: Government public health activities: Home healthcare: Other professional services: Research: Non-durable medical products (retail outlet sales): Durable medical equipment (retail outlet sales): Government administration of health insurance:

$884.7 billion (4.2%) $549.6 billion (3.8%) $277.1 billion (2.9%) $162.6 billion (6.8%) $155.2 billion (2.6%) $105.0 billion (3.3%) $111.4 billion (3.3%) $143.3 billion (7.1%) $ 91.0 billion (5.0%) $ 77.5 billion (6.4%) $ 74.5 billion (5.0%) $ 48.7 billion (-3.0%) $ 47.8 billion (3.8%) $ 42.5 billion (7.2%) $ 37.5 billion (11.0%)

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8 GEOGRAPHIC VARIATIONS IN HEALTHCARE SPENDING

8.1 Overview Researchers have long documented variations in healthcare spending. Variations occur across geographic areas and among providers, and even among populations within a geographic area. Some researchers suggest that reducing spending in high-spending areas of the U.S. to the rates observed in the lowest spending regions could yield significant savings for the healthcare system without harming quality of care. Figure 8.1 shows variations in Medicare spending per beneficiary.

# # # # # #

< $7,000 $7,000 – $7,500 $7,500 – $8,000 $8,000 – $9,000 > $9,000 Not populated

Figure 8.1. Medicare spending per beneficiary (sources: The Dartmouth Atlas of Healthcare)

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8.2 Dartmouth Atlas Project For more than 20 years the Dartmouth Atlas Project has documented the glaring variations in how medical resources are distributed and used in the United States. T he project uses Medicare data to provide comprehensive information and analysis about national, regional, and local markets, as well as individual hospitals and their affiliated physicians. The Dartmouth Atlas Project uses the hospital care intensity index (HCI) for its assessment. The HCI reflects both the amount of time spent in a hospital and the intensity of physician services delivered in the hospital. Chronically ill patients living in states and regions or using hospitals with a high HCI are likely to spend more days in the hospital and see more physicians during hospitalizations.

8.3 Hospital Care Intensity Based on the HCI, New Jersey is the most aggressive in providing healthcare services (e.g., highest per capita spending); Utah is the most conservative (e.g., lowest per capita spending). States are ranked as follows: 1. New Jersey 2. New York 3. Louisiana 4. Hawaii 5. Nevada 6. Florida 7. California 8. Mississippi 9. Pennsylvania 10. Delaware 11. Texas 12. Illinois 13. Arkansas 14. Tennessee 15. Kentucky 16. West Virginia 17. South Carolina 18. Maryland 19. Alabama 20. Michigan 21. Oklahoma 22. Massachusetts 23. Missouri 24. Virginia 25. Rhode Island 26. Ohio

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27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50.

Connecticut Georgia Kansas North Carolina Indiana Arizona Nebraska South Dakota Iowa Alaska Wisconsin Colorado Maine New Hampshire Minnesota New Mexico Vermont North Dakota Wyoming Montana Washington Idaho Oregon Utah

8.4 Regional Variations Specific to Medicare, there are wide regional variations in elective surgery for patients with similar conditions. The following are examples (sources: Dartmouth Atlas Project and the Foundation for Informed Medical Decision Making): • Medicare patients with heart disease in Elyria, Ohio, are 10 times more likely to have a procedure such as angioplasty or stents than those in Honolulu, Hawaii. • In San Luis Obispo, California, men over 65 with early-stage prostate cancer are 12 times more likely to have surgery to remove their prostate than those in Albany, Georgia. • Women over 65 living in Victoria, Texas, are seven times more likely to undergo mastectomy for early-stage breast cancer than women in Muncie, Indiana.

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_________________________________________________________________

“These striking variations are the by-product of a doctor-centric medical delivery system. In highlighting the variation from community to community for elective procedures, we hope to shine a light on the fact that patients’ preferences are not always taken into account when medical decisions are made.” Shannon Brownlee, Acting Director New America Foundation Health Policy Program Dartmouth Institute for Health Policy and Clinical Practice _________________________________________________________________

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9 DEMOGRAPHICS OF HEALTHCARE SPENDING

9.1 Overview This chapter presents an analysis of consumer out-of-pocket healthcare spending. The assessment is based on the Consumer Spending Survey of the Bureau of Labor Statistics and is part of the 8th edition of Who’s Buying Health Care, published by New Strategist (www.newstrategist.com). The assessment focuses on health insurance (including Medicare), medical services (including physician, hospital, and dental services), and pharmaceuticals (including prescription and nonprescription). Total annual consumer out-of-pocket spending in these three areas is as follows: • Health insurance: $215.8 billion • Medical services: $ 89.0 billion • Pharmaceuticals: $ 58.8 billion Further assessment is made of each of the three healthcare areas for the following demographics: • Age of householder • Household income • Type of household • Race and ethnicity • Region • Education

9.2 Healthcare Spending By Age By age of householder, average annual household out-of-pocket spending for health insurance is as follows: • Under age 25: $ 381 • 25-to-34: $1,083 • 35-to-44: $1,436 • 45-to-54: $1,688 • 55-to-64: $2,017 • 65-to-74: $3,042 • 75 and older: $3,011 • Average household: $1,785

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By age of householder, average annual household out-of-pocket spending for medical services is as follows: • Under age 25: $ 167 • 25-to-34: $ 466 • 35-to-44: $ 650 • 45-to-54: $ 862 • 55-to-64: $1,054 • 65-to-74: $ 818 • 75 and older: $ 824 • Average household: $ 736 By age of householder, average annual household out-of-pocket spending for pharmaceuticals is as follows: • Under age 25: $ 97 • 25-to-34: $195 • 35-to-44: $335 • 45-to-54: $485 • 55-to-64: $679 • 65-to-74: $865 • 75 and older: $787 • Average household: $486

_________________________________________________________________

“Not surprisingly, older Americans are the biggest spenders on healthcare. Householders aged 55 or older spend more than younger age groups on health insurance and drugs. They account for 62% of out-of-pocket spending on prescription drugs. Householders aged 55-to-64 are the biggest spenders on medical services.” New Strategist _________________________________________________________________

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9.3 Healthcare Spending By Household Income By household income, average annual household out-of-pocket spending for health insurance is as follows: • Under $20,000: $ 987 • $20,000 to $39,999: $1,596 • $40,000 to $49,999: $1,705 • $50,000 to $69,999: $1,995 • $70,000 to $79,999: $2,019 • $80,000 to $99,999: $2,264 • $100,000 to $119,999: $2,048 • $120,000 to $149,999: $2,442 • $150,000 and above: $2,732 • Average household: $1,785 By household income, average annual household out-of-pocket spending for medical services is as follows: • Under $20,000: $ 322 • $20,000 to $39,999: $ 472 • $40,000 to $49,999: $ 607 • $50,000 to $69,999: $ 806 • $70,000 to $79,999: $ 974 • $80,000 to $99,999: $1,168 • $100,000 to $119,999: $1,152 • $120,000 to $149,999: $1,144 • $150,000 and above: $1,552 • Average household: $ 736 By household income, average annual household out-of-pocket spending for pharmaceuticals is as follows: • Under $20,000: $276 • $20,000 to $39,999: $457 • $40,000 to $49,999: $528 • $50,000 to $69,999: $507 • $70,000 to $79,999: $555 • $80,000 to $99,999: $573 • $100,000 to $119,999: $623 • $120,000 to $149,999: $636 • $150,000 and above: $715 • Average household: $486

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_________________________________________________________________

“Out-of-pocket spending on healthcare rises with income, in part because household size rises with income. Households with incomes of $100,000 or more spend 51% more than the average household on out-of-pocket healthcare expenses. High-income households spend only 27% more than average on prescription drugs, however. Low-income households spend the most on Medicare payments and Medicare prescription drug premiums because the elderly head a large proportion of them.” New Strategist _________________________________________________________________

9.4 Healthcare Spending By Household Type By household type, average annual household out-of-pocket spending for health insurance is as follows: • Married couples, no children: $2,802 • Married couples, oldest child under 6: $1,669 • Married couples, oldest child 6-to-17: $1,841 • Married couples, oldest child 18 or older: $2,200 • Single parent with child under 18: $ 743 • Single person: $1,169 • Average household: $1,785 By household type, average annual household out-of-pocket spending for medical services is as follows: • Married couples, no children: $1,034 • Married couples, oldest child under 6: $ 819 • Married couples, oldest child 6-to-17: $ 980 • Married couples, oldest child 18 or older: $1,080 • Single parent with child under 18: $ 381 • Single person: $ 446 • Average household: $ 736

By household type, average annual household out-of-pocket spending for

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pharmaceuticals is as follows: • Married couples, no children: • Married couples, oldest child under 6: • Married couples, oldest child 6-to-17: • Married couples, oldest child 18 or older: • Single parent with child under 18: • Single person: • Average household:

$820 $302 $408 $647 $194 $326 $486

_________________________________________________________________

“Married couples without children at home – most of them empty-nesters – are the biggest spenders on healthcare. They spend the most on health insurance, eye care services, nonprescription vitamins, and prescription drugs among other categories. Couples with adult children at home are the biggest spenders on medical services because they have the largest households.” New Strategist _________________________________________________________________

9.5 Healthcare Spending By Race And Ethnicity By race and ethnicity, average annual household out-of-pocket spending for health insurance is as follows: • Asian: $1,509 • Black: $1,133 • Hispanic: $ 848 • Non-Hispanic white and other: $2,033 • Average household: $1,785 By race and ethnicity, average annual household out-of-pocket spending for medical services is as follows: • Asian: $575 • Black: $294 • Hispanic: $418 • Non-Hispanic white and other: $736 • Average household: $727

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By race and ethnicity, average annual household out-of-pocket spending for pharmaceuticals is as follows: • Asian: $307 • Black: $279 • Hispanic: $241 • Non-Hispanic white and other: $556 • Average household: $486 _________________________________________________________________

“Asian, black, and Hispanic households spend less than non-Hispanic white households on out-of-pocket healthcare costs. Hispanics have larger households than non-Hispanic whites, and they are less likely to be covered by health insurance – two factors that should drive up their out-of-pocket healthcare costs. Although the younger average age of Hispanics lowers their healthcare needs, these statistics suggest that Hispanics receive less medical attention than non-Hispanic whites.” New Strategist _________________________________________________________________

9.6 Healthcare Spending By Region By region, average annual household out-of-pocket spending for health insurance is as follows: • Northeast: $1,916 • Midwest: $1,845 • South: $1,730 • West: $1,703 • Average household: $1,785

By region, average annual household out-of-pocket spending for medical services is as follows:

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• • • • •

Northeast: Midwest: South: West: Average household:

$625 $780 $672 $889 $736

By region, average annual household out-of-pocket spending for pharmaceuticals is as follows: • Northeast: $481 • Midwest: $508 • South: $521 • West: $414 • Average household: $486 _________________________________________________________________

“Spending on healthcare does not vary much by region, the index ranges from a low of 97 in the South to a high of 105 in the Midwest. On specific healthcare categories, however, there is more regional variation. Households in the West spend 25% more than average on services by medical professionals other than physicians and 30% more on physician’s as well as dental services. Midwestern households spend 29% more than average on hospital rooms and services. Households in the South spend 28% more than the average household on supportive and convalescent medical equipment.” New Strategist _________________________________________________________________

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9.7 Healthcare Spending By Education By education, average annual household out-of-pocket spending for health insurance is as follows: • Less than high school graduate: $1,215 • High school graduate: $1,712 • Some college: $1,635 • Associate degree: $1,660 • Bachelor degree: $2,121 • Masters, doctoral degree: $2,544 • Average household: $1,785 By education, average annual household out-of-pocket spending for medical services is as follows: • Less than high school graduate: $ 364 • High school graduate: $ 624 • Some college: $ 691 • Associate degree: $ 729 • Bachelor degree: $ 974 • Masters, doctoral degree: $1,177 • Average household: $ 736 By education, average annual household out-of-pocket spending for pharmaceuticals is as follows: • Less than high school graduate: $356 • High school graduate: $487 • Some college: $487 • Associate degree: $476 • Bachelor degree: $525 • Masters, doctoral degree: $591 • Average household: $486 _________________________________________________________________

“Out-of-pocket spending on healthcare rises with education, largely because income rises with education. The 29% of householders that are college graduates account for 38% of out-ofpocket healthcare spending overall, and the share rises above this level in a number of categories.” New Strategist _________________________________________________________________

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PART III: HOSPITALS & HEALTHCARE PROVIDERS

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10 ACCOUNTABLE CARE ORGANIZATIONS

10.1 Overview An Accountable Care Organization (ACO) refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that work together to coordinate care for the patients they serve with Medicare. The goal of an ACO is to deliver seamless, high-quality care for Medicare beneficiaries. ACOs create incentives for healthcare providers to work together to treat patients across care settings, including doctor’s offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program rewards ACOs that stabilize healthcare costs while meeting performance standards on quality of care. Participation in an ACO is purely voluntary.

10.2 Cost Savings Through Coordinated Care More than half of Medicare beneficiaries have five or more chronic conditions, such as diabetes, arthritis, hypertension, and kidney disease. These patients often receive care from multiple physicians, and uncoordinated care can lead to patients not getting the care they need, receiving duplicative care, and being at an increased risk of suffering medical errors. On average, one in seven Medicare patients admitted to a hospital has a harmful medical mistake during the course of their care. And nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days – a readmission many patients could have avoided if their care outside of the hospital had been aggressive and better coordinated. In addition to the pro blems incurred by patients, costs run higher because of these problems. _________________________________________________________________

“ACOs increasingly see insurance benefits as an opportunity to offer incentives promoting value-based decisions.” Modern Healthcare, 4/1/13 _________________________________________________________________

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By facilitating the coordination of patient care through ACOs, Medicare could potentially save $960 million over three years.

10.3 Largest ACOs The concept of ACOs dates to the mid-1990s, when the Bronx Accountable Healthcare Network (New York, NY) and Castle Health Group (Kailua, HI) launched the first of such organizations. The following are the largest among the organizations (source: Modern Healthcare): No. of Lives Participating Covered Physicians

• • • • • •

Advocate Physician Partners (Oak Brook, IL): Bronx Accountable Healthcare Network (New York, NY): Pendulum HealthCare Development Corp. (Rockford, IL): Southeast Texas ACO (Houston, TX): Blue Shield of California (San Francisco, CA): AnewCare Collaborative (Johnson City, TN):

350,000 140,000 100,000 60,000 41,500 10,000

3,900 3,000 500 30 520 1,500

10.4 Approved ACOs In March 2011, the Department of Health and Human Services (HHS) proposed new rules to help doctors, hospitals, and other providers better coordinate care for Medicare patients through ACOs. Following a six-month comment and review period, a final rule was published in October 2011. The initial ACOs approved by the HHS were designated ‘Pioneer ACO Organizations.’ The program launched in January 2012 with 32 Pioneer ACO Organizations, as follows: • Allina Hospitals & Clinics (Minnesota and Western Wisconsin) • Atrius Health (Eastern and Central Massachusetts) • Banner Health Network (Phoenix, AZ Metropolitan Area - Maricopa and Pinal Counties) • Bellin-Thedacare Healthcare Partners (Northeast W isconsin) • Beth Israel Deaconess Physician Organization (Eastern Massachusetts) • Bronx Accountable Healthcare Network - BAHN) (New York City and lower Westchester County, NY) • Brown & Toland Physicians (San Francisco Bay Area, CA) • Dartmouth-Hitchcock ACO (New Hampshire and Eastern Vermont) • Eastern Maine Healthcare System (Central, Eastern, and Northern Maine) • Fairview Health Systems (Minneapolis, MN Metropolitan Area) • Franciscan Alliance (Indianapolis and Central Indiana) • Genesys PHO (Southeastern Michigan) • Healthcare Partners Medical Group (Los Angeles and Orange Counties, CA) • Healthcare Partners of Nevada (Clark and Nye Counties, NV)

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• • • • • • • • • • • • • • • • • •

Heritage California ACO (Southern, Central, and Costal California) JSA Medical Group, a division of HealthCare Partners (Orlando, Tampa Bay, and surrounding South Florida) Michigan Pioneer ACO (Southeastern Michigan) Monarch Healthcare (Orange County, CA) Mount Auburn Cambridge Independent Practice Association - MACIPA (Eastern Massachusetts) North Texas ACO (Tarrant, Johnson and Parker counties in North Texas) OSF Healthcare System (Central Illinois) Park Nicollet Health Services (Minneapolis, MN Metropolitan Area) Partners Healthcare (Eastern Massachusetts) Physician Health Partners (Denver, CO Metropolitan Area) Presbyterian Healthcare Services – Central New Mexico Pioneer Accountable Care Organization (Central New Mexico) Primecare Medical Network (Southern California - San Bernardino and Riverside Counties) Renaissance Medical Management Company (Southeastern Pennsylvania) Seton Health Alliance (Central Texas - 11 county area including Austin) Sharp Healthcare System (San Diego County) Steward Health Care System (Eastern Massachusetts) TriHealth, Inc. (Northwest Central Iowa) University of Michigan (Southeastern Michigan)

The Centers for Medicare & Medicaid Services (CMS, www.cms.gov) approved the first 27 Accountable Care Organizations for the program in April 2012. In July, CMS announced the approval of an additional 88 organizations. These organizations are listed on the CMS website at www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/Downloads/MSSP-ACOs-List.pdf and www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/ Downloads/ACO-Contact-List.pdf.

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11 BEHAVIORAL HEALTH PROVIDERS

11.1 Behavioral Health Hospitals According the National Association of Psychiatric Health Systems (NAPHS, www.naphs.org), occupancy rates at behavioral health hospitals have been at record highs. The NAPHS Annual Survey, last published in April 2013, reports that inpatient behavioral hospital admissions average of 2,724 per hospital. Hospital occupancy averages 70.2%; lengths of stay average 9.7 days. Residential treatment admissions average 166. Residential treatment center occupancy averages 80.6%. NAPHS represents behavioral healthcare provider organizations that own or manage more than 600 psychiatric hospitals, general hospital psychiatric and addiction treatment units and behavioral healthcare divisions, residential treatment facilities, youth services organizations, and extensive outpatient networks. Behavioral health facilities scaled back beds for decades because of low occupancy rates. In Illinois, for example, there were as many as 55,000 behavioral health beds during the 1950s; now there are only 1,400. The numbers are now increasing in some areas. 11.2 Largest Behavioral Health Providers

The largest behavioral health providers, ranked by behavioral health net patient revenue, are as follows: (sources: Billian’s HealthData, American Hospital Directory, and Modern Healthcare, May 2013): • • • • • • • •

Universal Health Solutions (www.uhsinc.com): Devereaux (www.devereaux.org): Aurora Behavioral Health Care (www.aurorabehavioral.com): Sheppard Pratt Health System (www.sheppardpratt.org): Partners HealthCare System (www.partners.org): Texas Dept. of State Health Services (www.dhs.state.tx.us): Alexian Bros. Health System (www.alexianbroshealth.org): Sharp Healthcare (www.sharp.com)

# Hospitals

Beds

Revenue

103 2

9,947 193

$1.76 billion $ 397 million

8

615

$ 121 million

2

618

$ 109 million

1

328

$

94 million

9

2,377

$

67 million

1 1

233 149

$ $

58 million 57 million

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• • • • • •

HCA (www.hcahealth.com): AscendHealth Corp. (www.ascendhealth.net): Eastern Maine Healthcare Systems (www.emh.org): Haven Behavioral Healthcare (www.havenbehavioral.com): Albert Einstein Healthcare Network (www.einstein.edu): Iasis Healthcare (www.iasishealthcare.com):

4 2

223 223

$ $

55 million 49 million

1

74

$

49 million

4

189

$

47 million

1

147

$

38 million

1

124

$

37 million

11.3 Community Hospital Services According to the Agency for Healthcare Research and Quality (www.ahrq.gov), approximately 25% of all hospitalizations involve depression, bipolar, schizophrenia, substance abuse, or other behavioral health disorders as a primary or secondary diagnosis. Emergency departments have become the safety net for many patients with severe behavioral health disorders. Most general hospitals, however, are designed for short-stay medical-surgical patients. General hospitals that lack adequate psychiatric services generally attempt to move behavioral health patients to other facilities with such capabilities. Many community hospitals are not adequately prepared to provide services for patients with behavioral health problems. According to the American Hospital Association (www.aha.org), only 1,349 of 4,919 community general hospitals, or 27%, have an organized inpatient psychiatric unit.

11.4 Market Resources National Association of Psychiatric Health Systems (NAPHS), 900 17th Street NW, Suite 420, Washington, DC 20006. (202) 393-6700. (www.naphs.org)

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12 CHILDREN’S HOSPITALS

12.1 Overview According to the National Association of Children’s Hospitals and Related Institutions (NACHRI, www.childrenshospitals.net), there are approximately 200 children’s hospitals in the United States. These free-standing children’s hospitals serve about 12% of all hospitalized children, are responsible for 20% of the cost of treating children, and train about 25% of all pediatricians in the United States. More than 8.3 m illion outpatient visits are provided by children’s hospitals. Academic medical centers with children’s hospitals admit 18% of all inpatient children and garner 29% of the revenue in that area. There are 60 independent children’s teaching hospitals. According to the NACHRI, nearly two-thirds of the care given at children’s hospitals is for kids 5 and younger, with 25% for newborns. Compared with the 9% of general hospital beds allotted to intensive care, children’s hospitals devote 26% of their beds to the ICU.

12.2 Market Assessment According to a study by Rand Corp. (www.rand.com), 6.4 million children are hospitalized each year; 4.6 million are younger than one. The cost for children’s hospital stays is $33.6 billion.

12.3 Largest Children’s Hospitals The largest children’s hospitals, ranked by number of staffed beds, are as follows (sources: NACHR, Billian’s HealthData and Modern Healthcare [November 2012], and hospital websites): • • • • • • • •

Cincinnati Children’s Hospital Medical Center: Children’s Hospital of Atlanta: Texas Children’s Hospital (Houston): Children’s Hospital of Philadelphia: Nationwide Children’s Hospital (Columbus): Children’s Medical Center Dallas: Phoenix Children’s Hospital: Boston Children’s Hospital:

Beds

Admissions

512 496 491 469 451 442 425 395

17,844 22,868 21,661 28,401 20,434 26,558 13,404 17,173

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• • • • • • • • • • • • • • • • •

Miller Children’s Hospital (Long Beach): Akron Children’s Hospital: Children’s Hospital Central California (Madera): Children’s Hospitals and Clinics of Minnesota: Children’ Hospital Los Angeles: Arkansas Children’s Hospital (Little Rock): Lucile Packard Children’s Hospital at Stanford (California): Cook Children’s Medical Center (Ft. Worth): Children’s Hospital Colorado (Aurora) Children’s Hospital of Pittsburgh of UPMC: Children’s Hospital of Wisconsin (Milwaukee): Children’s Hospital of Alabama (Birmingham): Primary Children’s Medical Center (Salt Lake City, UT): Rady Children’s Hospital (San Diego): Children’s National Medical Center (Washington, DC): Miami Children’s Hospital: Children’s Mercy Hospitals and Clinics (Kansas City):

385 372 348 347 317 312 302 302 301 296 296 290 289 287 283 272 265

15,898 9,656 13,265 12,209 11,866 14,114 12,799 11,939 13,557 13,687 24,207 13,357 13,550 16,341 14,295 12,172 12,339

12.4 Market Resources National Association of Children’s Hospitals and Related Institutions, 401 W ythe Street, Alexandria, VA 22314. (703) 684-1355. (www.childrenshospitals.net)

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13 COMPLEMENTARY & ALTERNATIVE MEDICINE

13.1 CAM Use In America According the National Center for Complementary and Alternative Medicine (www.nccam.nih.gov), 38% of adults in the United States ages 18 years and over and 12% of children ages 17 years and under use some form of complementary and alternative medicine (CAM). The most commonly used CAM therapies among U.S. adults are as follows: • Non-vitamin, non-mineral, and natural products (most common of which are fish oil, omega 3/DHA, glucosamine, echinacea, flaxseed oil/pills, and ginseng): 18% • Deep breathing exercises: 13% • Meditation: 9% • Chiropractic or osteopathic manipulation: 9% • Massage: 8% • Yoga: 6% Adults use CAM most often to treat pain, including back pain or problems, neck pain or problems, joint pain or stiffness/other joint condition, arthritis, and other musculoskeletal conditions. CAM use is highest among the following demographic categories: • Women (43%, compared to men 34%) • Those ages 30-to-69 (30-to-39 years: 39%, 40-to-49 years: 40%, 50-to-59 years: 44%, 60-to-69 years: 41%) • Those with higher levels of education (masters, doctorate, or professional: 55%) • Those living in the West (45%) • Those who have quit smoking (48%) Overall, CAM use among children is nearly 12%, or about 1 in 9 children. Children are five times more likely to be treated by CAM if a parent or other relative uses CAM. Among children, CAM therapies are most often for back or neck pain, head or chest colds, anxiety or stress, other musculoskeletal problems, and attention deficit/hyperactivity disorder (AD/HD). The most commonly used CAM therapies among children are as follows: • Non-vitamin, non-mineral, and natural products: 4% • Chiropractic or osteopathic manipulation: 3% • Deep breathing exercises: 2% • Yoga: 2%

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13.2 Spending According to the National Center for Complementary and Alternative Medicine, adults spent $33.9 billion out-of-pocket annually on visits to CAM practitioners and on purchases of CAM products, classes, and materials. Eighty-one percent (81%) of CAM users pay for CAM services out-of-pocket. Nearly two-thirds of the total out-of-pocket spending by adults on CAM is for self-care purchases of CAM products, classes, and materials. Despite this emphasis on self-care therapies, 38 million adults make an estimated 355 million visits to practitioners of CAM each year. Distribution of CAM spending is as follows: • Non-vitamin, non-mineral, and natural products: $14.8 billion • Office visits: $11.9 billion • Classes (yoga, tai chi, etc.): $ 4.1 billion • Homeopathic medicine: $ 2.9 billion • Relaxation techniques: $ 0.2 billion

13.3 Hospital CAM Programs According to the American Hospital Association (www.aha.org), 21% of hospitals offer some type of CAM, a figure that has remained unchanged since 2006. A survey by Health Forum (www.healthforum.com), a subsidiary of the American Hospital Association (www.ama.org), found that among hospitals that offer CAM, the top therapies offered are as follows: Inpatient CAM Services • Massage therapy: 37% • Music/art therapy: 26% • Therapeutic touch: 25% • Guided imagery: 22% • Relaxation training: 20% • Acupuncture: 12% Outpatient CAM Services • Massage therapy: • Tai Chi, yoga, or qi gong: • Relaxation training: • Acupuncture: • Guided imagery: • Therapeutic touch:

71% 47% 43% 39% 32% 30%

The following are the key reasons hospitals offer CAM (source: Hospitals & Health Networks®):

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• • • • • • • • • •

Patient demand: Reflecting organizational mission: Clinical effectiveness: Attracting new patients: Physicians’ requests: Differentiation from competitors: Possible cost savings: Employee requests: Insurance coverage: Other:

87% 62% 61% 38% 37% 28% 14% 11% 4% 9%

13.4 Market Resources National Center for Complementary and Alternative Medicine, 9000 Rockville Pike, Bethesda, MD 20892. (888) 644-6226. (www.nccam.nih.gov)

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14 CONVENIENT-CARE CLINICS

14.1 Retail-Based Healthcare A rising number of pharmacy and retail chains are opening in-store health clinics. These retail health clinics – also referred to as convenient-care clinics – are creating a new model: quick but limited services at lower prices and almost always staffed by nurses or physician assistants. For many consumers the clinics are attractive because of the low cost: most charge less than $65 per visit. CVS, Duane Reed, Osco Drug, Rite Aid, and Walgreens are among the drug store chains offering in-store clinics. In other retail segments, Costco, Target, and Walmart also operate clinics at some locations. With 500 MinuteClinics operating in its stores in 25 states, CVS is the marketshare leader. There were 1,425 retail-based clinics in the U.S. as of May 2013, an increase from only 75 in 2006, according to the Convenient Care Association (www.ccaclinics.org). _________________________________________________________________

“One-third of Americans now live within 10 minutes of a retail clinic. Big pluses for the clinics are evening and weekend hours and no need for an appointment. Indeed, some doctors have opposed the expansion of the retail clinics. The American Academy of Family Physicians worries they will lead to care becoming more fragmented. The group also is concerned about the clinics treating anything more serious than a minor acute illness, saying that more serious medical problems could be missed. They argue that many doctors offices offer same-day scheduling and extended hours. Retail clinics stress that they are working in partnership with family doctors, not replacing them.” The Wall Street Journal, 4/16/13 _________________________________________________________________

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14.2 Patient Services An assessment by Rand Corporation (www.rand.org) and the University of Pittsburgh School of Medicine (www.medschool.pitt.edu) analyzing data from more than 1.3 million visits to retail clinics found the following: • Patients ages 18-to-44 account for 43% of the people visiting retail clinics, compared to 23% for primary care physician offices. Just 39% of the patients at retail clinics say they have a primary care physician; 80% of people surveyed nationally say they have a personal doctor. • When the concept of retail clinics first launched, most patients paid out-of-pocket. Now most use insurance for reimbursement, with only 16% of retail office visits paid for out-of-pocket. • About 90% of the visits to retail clinics are for preventive care and 10 simple acute conditions: upper respiratory infections, sinusitis, bronchitis, sore throat, immunizations, inner ear infections, swimmers’ ear, conjunctivitis, urinary tract infections, and either a screening test or a blood test. The same conditions account for 18% of visits to primary care physician offices and 12% of emergency department visits. _________________________________________________________________

“Retail medical clinics continue to grow rapidly and attract new segments of users. They remain just a small part of outpatient medical care, but appear to have tapped into patients’ needs.” Prof. Ateev Mehrota, M.D., Researcher Rand Corp. and UPMC, 8/27/12 _________________________________________________________________

A recent survey by Harris Interactive (www.harrisinteractive.com) found that 7% of households had a family member who visited a retail-based clinic during the prior 12 months. Among those patients, 16% were uninsured. Visits were for the following reasons: • Vaccination: 40% • Treatment for a common medical condition like an ear infection, cold, strep throat, skin rash, or sinus infection: 39% • Preventive screening tests for conditions like high blood pressure, high cholesterol, diabetes, or allergies: 24% • Physical exam for sports, school, camp, etc.: 10% • Received a referral from family physician or hospital emergency department: 8% • Other: 16%

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14.3 Patient Satisfaction Harris Interactive found that almost all convenient-care clinic patients are very/somewhat satisfied with the quality of the care (90%), cost (86%), and staff qualifications (88%). The biggest driver of satisfaction appears to be convenience, with 93% satisfied with the convenience of these clinics. Although an increasing number say they are satisfied with staff qualifications, 65% have concerns that serious medical problems might not be accurately diagnosed. CVS’ in-store MinuteClinics report a 95% customer satisfaction rating from the more than five million patient visits the clinics have generated.

14.4 Hospital-Operated Clinics Several healthcare systems have entered the retail market. Pennsylvania-based Geisinger Health System operates five clinics in Weis Market locations. Mayo Clinic opened a Mayo Express Clinic in a Minneapolis mall. Alegent Health operates nine clinics at Hy-Vee grocery stores in Nebraska. Houston-based Memorial Hermann and Sutter Health, in San Francisco, among others, also operate convenient-care clinics.

14.5 Market Resources Convenient Care Association, 260 South Broad Street, Suite 1800, Philadelphia, PA 19102. (215) 731-7140. (www.ccaclinics.org)

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15 DESIGN & CONSTRUCTION

15.1 Overview Modern Healthcare assesses the healthcare construction market annually. This chapter presents a summary of the 34th annual Construction & Design Survey, published in March 2013. _________________________________________________________________

“The grim uncertainty that froze the healthcare construction industry during the Great Recession appears to have lifted – only to be replaced with a new type of uncertainty. Healthcare organizations are still figuring out what facilities and services are best suited for healthcare payment reform and brave new worlds of accountable care, bundled payments, and patient satisfaction.” Modern Healthcare, 3/18/13 _________________________________________________________________

15.2 Hospital Construction The cost of hospital construction projects completed in 2012 totaled $33.0 billion. This represented 3,211 projects of all type (new facilities, expansions, and renovations) and 29,495 beds. The distribution by type of facility is as follows: Acute-care Hospitals • Entire facilities: $11.09 billion (161 projects) • Expansions: $ 4.22 billion (253 projects) • Renovations: $ 3.21 billion (1,343 projects) Rehabilitation Hospitals • Entire facilities: $ • Expansions: $ • Renovations: $

699 million (15 projects) 26 million (11 projects) 130 million (24 projects)

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Specialty Hospitals • Entire facilities: • Expansions: • Renovations:

$ 3.21 billion (57 projects) $ 770 million (49 projects) $ 243 million (108 projects)

Nursing Homes • Entire facilities: • Expansions: • Renovations:

$ $ $

142 million (9 projects) 73 million (7 projects) 142 million (22 projects)

Assisted-living • Entire facilities: • Expansions: • Renovations:

$ $ $

143 million (18 projects) 73 million (7 projects) 142 million (21 projects)

Outpatient Facilities • Entire facilities: • Expansions: • Renovations:

$ 1.65 billion (132 projects) $ 541 million (115 projects) $ 644 million (199 projects)

Medical Office Buildings • Entire facilities: • Expansions: • Renovations: • Research facilities: • Parking garages: • Other:

$ 1.02 billion (110 projects) $ 79 million (25 projects) $ 379 million (313 projects) $ 3.07 billion (95 projects) $ 460 million (35 projects) $ 564 million (78 projects)

Breaking ground in 2012 were 1,805 projects with 24,999 beds and projected construction costs of $37.2 billion. Representing 3,202 projects and 55,843 beds, in total, $54.9 billion in hospital projects were designed during 2012.

15.3 Largest Healthcare Design and Construction Firms Modern Healthcare’s 34th annual Construction & Design Survey identified the following as the largest design and construction firms in the healthcare market: Architectural Firms • HDR Architecture (www.hdrinc.com): $6.7 billion • Hellmuth, Obata + Kassabaum (www.hok.com): $4.3 billion • HKS (www.hksinc.com): $3.7 billion • AECOM Technology Corp. (www.aecom.com): $2.3 billion • Cannon Design (www.cannondesign.com): $2.1 billion • Stantec Architecture (www.stantec.com): $2.0 billion

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• •

Perkins & Will (www.perkinswill.com): Cathryn Bang & Partners Architects (www.cbparch.com)

$1.5 billion $1.1 billion

Construction Management Firms • Turner Construction Co. (www.turnerconstruction.com): • Gilbane Building Co. (www.gilbane.com): • Jacobs Engineering Group (www.jacobs.com): • Lend Lease (www.lendlease.com): • Skanska USA (www.skanskausa.com): • Whiting-Turner Contracting Co. (www.whiting-turner.com): • Power Construction Corp. (www.powerconstruction.net): • Mortenson Construction (www.mortenson.com): • J.E. Dunn Construction (www.jedunn.com):

$2.7 billion $2.4 billion $1.9 billion $1.3 billion $1.3 billion $1.2 billion $1.0 billion $ 892 million $ 620 million

Development Companies • Hammes Co. (www.hammesco.com): • Trammel Crow Co. (www.trammelcrow.com): • Navigant Consulting (www.navigantconsulting.com): • Balfour Concord (www.balfourconcord.com):

$1.53 billion $ 614 million $ 519 million $ 425 million

General Contractors • McCarthy Building Cos. (www.mccarthy.com): • Clark Construction Group (www.clarkconstruction.com): • Brasfield & Gorrie (www.brasfieldgorrie.com): • Robins & Morton Group (www.robinsmorton.com): • Layton Construction (www.laytoncompanies.com): • KBR Building Group (www.kbrbuildinggroup.com): • Walsh Group (www.walshgroup.com):

$1.26 billion $1.14 billion $1.05 billion $ 595 million $ 366 million $ 364 million $ 344 million

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16 ECONOMIC CONTRIBUTION OF HOSPITALS

16.1 Overview The American Hospital Association (www.aha.org) published The Economic Contribution of Hospitals in January 2013. This chapter sources data from this report.

16.2 Hospital Care and The U.S. Economy Hospital care is the largest component of the healthcare sector. This sector represents 17.8% of GDP, or approximately $3.0 trillion. Hospital revenue accounts for $885 billion of that total. Hospitals employ nearly 5.4 million people and are the second-largest source of private sector jobs. Hospitals pay over $350 billion in wages and salaries annually. Hospitals spend about $702 billion annually on goods and services.

16.3 State-by-State Hospital Expenditures By state, direct spending is as follows (source: The Economic Contribution of Hospitals, January 2013): • Alabama: $ 8.29 billion • Alaska: $ 1.75 billion • Arizona: $11.52 billion • Arkansas: $ 5.24 billion • California: $77.29 billion • Colorado: $10.05 billion • Connecticut: $ 9.56 billion • Delaware: $ 2.41 billion • District of Columbia: $ 3.76 billion • Florida: $36.01 billion • Georgia: $16.45 billion • Hawaii: $ 2.39 billion • Idaho: $ 2.79 billion • Illinois: $29.83 billion • Indiana: $16.08 billion • Iowa: $ 7.17 billion • Kansas: $ 5.96 billion • Kentucky: $10.05 billion

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• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Louisiana: Maine: Maryland: Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:

$ 9.70 billion $ 4.18 billion $12.73 billion $23.07 billion $25.24 billion $14.48 billion $ 5.80 billion $17.17 billion $ 2.48 billion $ 4.66 billion $ 4.07 billion $ 3.95 billion $18.24 billion $ 3.71 billion $58.54 billion $20.06 billion $ 2.23 billion $32.61 billion $ 6.78 billion $ 8.72 billion $35.25 billion $ 3.02 billion $ 9.71 billion $ 2.35 billion $12.77 billion $45.56 billion $ 4.68 billion $ 1.77 billion $15.34 billion $14.87 billion $ 4.72 billion $15.00 billion $ 1.05 billion

16.4 Market Resources American Hospital Association, 155 N. W acker Drive, Chicago, IL 60606. (312) 422-3000. (www.aha.org)

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17 ELECTRONIC HEALTH RECORDS

17.1 Hospital and Physician Use of EHRs The adoption of electronic health records (EHRs), also called electronic medical records (EMRs), is seen as an import effort in making the healthcare system more efficient. The federal government has set 2014 as the target for making interoperable EHRs available for all Americans. The American Recovery and Reinvestment Act (ARRA) of 2009 (P.L. 111-5), commonly known as the stimulus package, provided funding through the Centers for Medicare & Medicaid Services (CMS, www.cms.gov) to ensure widespread adoption and use of interoperable health information technology and meaningful use of EHRs. _________________________________________________________________

“As of November [2012], the feds had paid out $9.3 billion through a pair of EHR incentive programs. Three out of four hospitals and one in three physicians and other eligible professionals had been paid under the two programs, according to the CMS data.” Modern Healthcare, 12/24/12 _________________________________________________________________

• •

Meaningful use of EHRs is classified as follows: State 1: Data capture and sharing State 2: Advance clinical processes

The 24nd Annual Leadership Survey, published in March 2013 by the Healthcare Information and Management Systems Society (HIMSS, www.himss.org), reported the following status of EHR implementation among healthcare networks: • Have already attested to State 1: 66% • Expect to attest to Stage 1 by year-end 2013: 24% • Expect to qualify for State 2 in 2014: 75% • Expect to qualify for State 2 in 2015: 15% The goal of EHR implementation is not only to improve efficiency and patient

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safety but also to reduce healthcare costs. But, in reality, the move to electronic health records is contributing to billions of dollars in higher costs for Medicare, private insurers, and patients by making it easier for hospitals and physicians to bill more for their services, whether or not they provide additional care.

_________________________________________________________________

“Hospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier, at least in part by changing the billing codes they assign to patients in emergency rooms, according to a New York Times analysis of Medicare data from the American Hospital Directory. Regulators say physicians have changed the way they bill for office visits similarly, increasing their payments by billions of dollars as well.” The New York Times, 9/21/12 _________________________________________________________________

17.2 EHR Vendors According to HIMSS, the top vendors of acute-care EHR systems, ranked by total installations as of October 2012, are as follows: • Meditech (www.meditech.com): 1,155 • Epic Systems Corp. (www.epicsys.com): 678 • Cerner Corp. (www.cerner.com): 634 • McKesson Provider Technologies (www.mckesson.com): 471 • CPSI (www.cpsinet.com): 393 • Healthcare Management Systems Inc. (www.hmstn.com): 352 • Siemens Medical Solutions (http://medical.siemens.com): 310 • Healthland (www.healthland.com): 230 • Allscripts (www.allscripts.com): 178 Approximately 260 EHR systems have been developed by hospitals.

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17.3 Hospital-Physician Collaboration Most hospitals and health systems are collaborating with physicians on an integrated inpatient and outpatient medical record. According to Hospitals & Health Networks, 80% report subsidizing physician-office EMRs. Subsidy activity for physician-office EMRs was reported as follows: • Employed physician practices only: 48% • Both employed and independent physician practices: 30% • Independent physician practices only: 2% • Do not subsidize any physician-office EMR: 20%

17.4 Physician Use of EHRs According to a survey published in the New England Journal of Medicine, physicians who have used basic or fully functional (FF) EHRs reported the following benefits: • • • • • •

Alerted them to an important laboratory test: Prompted them to avoid a drug-allergy problem: Helped them prevent a potentially dangerous medication reaction: Helped them provide preventive care: Led them to order a critical test: Led them to order a genetic test:

Basic

FF

75% 66% 54% 41% 36% 8%

90% 80% 71% 69% 68% 17%

While the benefits of enhanced care are evident, EHRs have not provided the efficiencies that some doctors anticipated. In a survey of 4,279 physicians, conducted in 2013 by the American College of Physicians (www.acponline.org), 34% of respondents said they are very dissatisfied with the ability of their EHRs to decrease their workload.

17.5 Scribe Services According to a survey by Health IT Strategist, 35% of healthcare organizations using EHRs use scribes to aid physician documentation. Many hospitals use subcontractors to provide scribe services. Michael Murphy, CEO of ScribeAmerica (www.scribeamerica.com), estimates that the three largest companies in the field provide services for more than 150 hospitals, staffing them with about 2,000 scribes. About half of ScribeAmerica scribes are students in pre-med, pre-nursing, physician-assistant, or nurse-practitioner programs who go on to those professions after gaining invaluable, on-the-job educational experience working as scribes.

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17.6 Market Resources Hospital EHR Adoption Database, American Hospital Association, 2013. (www.ahadata.com/ahadata/html/EHRdatabase.html)

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18 EMERGENCY DEPARTMENTS

18.1 Profile Of Emergency Medicine According to Hospital Statistics 2013™, by the American Hospital Association (AHA, www.aha.org), the number of emergency department (ED) visits and total number of EDs have been as follows: • • • • • • • • • • •

2001: 2002: 2003: 2004: 2005: 2006: 2007: 2008: 2009: 2010: 2011:

Total ED Visits

# EDs

106.0 million 110.0 million 111.0 million 112.6 million 114.8 million 118.4 million 120.8 million 123.0 million 127.3 million 127.2 million 129.5 million

4,621 4,620 4,570 4,595 4,611 4,587 4,565 4,613 4,594 4,564 4,461

The American College of Emergency Physicians (ACEP, www.acep.org) provides the following profile of emergency medicine in the United States: • Emergency physicians in clinical practice: 31,797 • Emergency nurses: 89,300 • EMS providers (EMT basics, EMT intermediates paramedics, and first responders): 815,000 • Ambulance services: 17,000

18.2 Profile Of ED Patients According to the Agency for Healthcare Research and Quality (AHRQ, www.ahrq.gov), the following are the major reasons for hospitalizations through EDs: • Circulatory disorders: 26% • Respiratory disorders: 15% • Injuries: 11% • Mental health and substance abuse: 6% • Endocrine disorders: 5% • Genitourinary disorders: 5% • All other disorders: 18%

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• • • • •

The immediacy of care needed for ED visits is as follows: Urgent: 35% Emergent: 15% Semi-urgent: 20% Non-urgent: 13% No triage/unknown: 17%

According to Injury Facts 2012, published by the National Safety Council (www.nsc.org), the following numbers of injuries annually lead to trauma treatment in hospital EDs: • Falls: 8.8 million • Struck against or by an object or person: 4.4 million • Overexertion: 3.2 million • Motor vehicle occupant: 2.6 million • Cut or pierce: 2.0 million • Bites (other than dog bites) or sting: 1.1 million • Other specified: 925,000 • Unknown/unspecified: 755,000 • Poisoning: 708,000 • Other transport: 602,000 _________________________________________________________________

“35 million Americans are treated annually for trauma – one hospitalization every 15 minutes.” Hospitals & Health Networks, 10/12 _________________________________________________________________

Contrary to popular perception, individuals who are uninsured and who do not have a usual source of care are actually less likely to visit an emergency department than those who are insured and have a regular healthcare provider. According to the National Hospital Ambulatory Medical Care Survey (NHAMCS), by the National Center for Health Statistics (www.cdc.gov/nchs), only 17% of ED patients are uninsured. ACEP found that among frequent visitors (four or more visits a year) to EDs, 84% are insured; 81% have a primary source of care. Similar findings were reported by Ellen J. Weber, M.D., professor of clinical medicine in the division of emergency medicine at the University of California, San Francisco, whose research concluded that the biggest factor driving people to seek emergency care is poor physical and mental health. The University of California study, based on a sample of nearly 50,000 adults, found 83% of emergency department visits are made by people with a usual source of healthcare other than an emergency

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department. Moreover, 85% have medical insurance and 79% have incomes exceeding the poverty threshold. Individuals without health insurance are no more likely to have an emergency visit than those with private health insurance. Individuals without a usual source of care are 25% less likely to have an emergency visit than those with a private physician. The study also found 48% of emergency department visits are by adults who say they have poor physical health.

18.3 Emergency Medicine In American Hospitals HealthGrades (www.healthgrades.com) assesses annually Medicare patient records to evaluate emergency care provided at U.S. hospitals. The assessment focuses on 12 of the most common and life-threatening medical emergencies among that patient population, including heart attack, stroke, pneumonia, and chronic obstructive pulmonary disease (COPD). The Emergency Medicine in American Hospitals study, published in 2012 by HealthGrades, identified the following Top 10 Cities for Emergency Medicine, based on overall lowest mortality rate for patients admitted through the emergency department: 1. Cincinnati, OH 2. Phoenix, AZ 3. Milwaukee, WI 4. Dayton, OH 5. Cleveland, OH 6. West Palm Beach, FL 7. Tucson, AZ 8. Baltimore, MD 9. Houston, TX 10. Detroit, MI Providence, RI; Las Vegas, NV; Miami-Ft. Lauderdale, FL; and New York City had the highest percentage of admission through the emergency department (93.05%, 91.65%, 91.12% and 90.78%, respectively). Lincoln, NE; Sioux Falls, SD; Wichita, KS; and Omaha, NE, had the lowest percentage of admissions through the emergency department (48.06%, 53.72%, 54.84% and 62.32%, respectiv ely) for the 12 conditions studied. The 2012 assessment found that from 2008 to 2010, emergency admissions for heart attack decreased 1.7% for Medicare patients, but admissions for stroke increased by 2.2%. Heart attack and stroke were among the conditions with the highest mortality rates, with 10% of heart attack patients and 9% stroke patients dying after admission to a hospital. According to HealthGrades, 61% of hospital admissions among seniors begin in the emergency department, more than any other age group.

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18.4 Busiest Hospital Emergency Departments The following hospitals have the highest number of annual ED visits (sources: Modern Healthcare [April 2013] based on the AHA Annual Survey of Hospitals): • Florida Hospital (Orlando, FL): 407,439 • Montefiore Medical Center (New York, NY): 294,056 • Methodist Healthcare Memphis Hospitals (Memphis, TN): 281,831 • New York-Presbyterian Hospital (New York, NY): 261,513 • Methodist Hospital (San Antonio, TX): 258,058 • Orlando Regional Medical Center (Orlando, FL): 236,867 • Jackson Health System (Miami, FL): 219,113 • Memorial Hermann Northwest Hospital (Houston, TX): 208,710 • Nationwide Children’s Hospital (Columbus OH): 206,434 • Baptist Health System (San Antonio, TX): 206,172 • Christus Santa Rosa Health Care (San Antonio, TX): 203 681 • Cone Health (Greensboro, NC): 187,669 • Southcoast Hospitals Group (Fall River, MA): 181,205 • Harns County Hospital District (Houston, TX): 178,403 • Spectrum Health Butterworth Hospital (Grand Rapids, MI): 174,662 • Henry Ford Hospital (Detroit, MI): 172,498 • Baptist Medical Center (Jacksonville, FL): 169,885 • St. Luke’s-Roosevelt Hospital Center (New York, NY): 169,143 • Kaleida Health (Buffalo, NY): 169 076 • Christiana Care Health System (Wilmington, DE): 166,945 • St Joseph’s Regional Medical Center (Paterson NJ): 157,152 • Lakeland Regional Medical Center (Lakeland, FL): 156,630 • Lincoln Medical and Mental Health Center (New York, NY): 155,298 • Indiana University Health University Hospital (Indianapolis, IN): 151,674 • Children’s Medical Center (Dallas, TX): 149,046

18.5 Overcrowding and Diversions According to the AHA’s Hospital Statistics 2013™, the percentages of hospital EDs at or over capacity are as follows: • • • •

All hospitals: Urban hospitals: Rural hospitals: Teaching hospitals:

At

Over

21% 23% 20% 19%

17% 27% 11% 32%

When EDs exceed capacity, incoming patients are generally diverted to other EDs where they can be given more immediate care. According to the NHAMCS, 16.2 million patients annually arrive at emergency departments by ambulance; about 500,000 are diverted. According to Sg2 (www.sg2.com), hospital EDs spend 3% of their time in

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diversion status. The following percentages of hospitals reported time on ambulance diversion at least once a year (source: AHA Hospital Statistics 2013™): • All hospitals: 22% • Urban hospitals: 45% • Rural hospitals: 9% • Teaching hospitals: 38% The primary reason for diversion among EDs is as follows (source: AHA Hospital Statistics 2013™): • Lack of critical care or monitored beds: 42% • ED overcrowding: 27% • Staff shortages: 9% • Lack of general acute care beds: 8% • Lack of specialty physician coverage: 8% • Lack of psychiatric beds: 8%

18.6 Wait Times According to the NHAMCS, waits for emergency care have increased to an average of 56 minutes from 38 minutes a decade ago. The median wait is 31 minutes. A study by Harvard Medical School and researchers at Cambridge Health Alliance, published in Health Affairs, reports a similar finding. The study, which analyzed the time between patients’ arrivals in the ED and when they are first seen by a doctor, reports a 36% increase in wait time over the past seven years. For those whom a triage nurse classified as needing immediate attention, waits increased from 10 to 14 minutes, up 40%. Waits increased 150% for emergency patients suffering heart attacks, to 20 minutes. Some hospital EDs use check-in kiosks to streamline the admissions process. Besides offering patients more privacy, the kiosks can help nurses identify the most urgent cases. Many hospitals make their wait times available to the public.

18.7 ED Patient Satisfaction The Emergency Department Pulse Report, by Press Ganey Associates (www.pressganey.com), reports that patient satisfaction with care in the ED has increased since 2003. Still, patients admitted through the ED report lower satisfaction scores than those otherwise admitted to hospitals. The following are further findings of the report: • ED patients ranked the following as the most important contributors to their overall satisfaction: 1. How well they were kept informed about delays 2. How well their pain was controlled

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3. Degree to which staff cared about them as a person 4. Overall rating of care received during their visit 5. Nurses’ concern to keep them informed about their treatment • •

The average ED patient experience lasts four hours and seven minutes. Patient satisfaction drops based on amount of time spent in the ED, as follows: - < 1 hour: 88.9 - 1-to-2 hours: 89.0 - 2-to-3 hours: 86.3 - 3-to-4 hours: 83.4 - 4-to-5 hours: 81.0 - 5-to-6 hours: 79.0 - 6 hours or more: 76.9

•

Patient satisfaction was lowest during the evening shift, 3:00 p.m.-11:00 pm, and highest during the daytime, 7:00 a.m.-3:00 p.m. The average time spent in the ED increases by 30 minutes for every additional 10,000 patients seen annually. Patients who reported that they received “good” or “very good” information about delays reported nearly the same overall satisfaction whether they had spent over four hours or less than one hour in the ED.

• •

_________________________________________________________________

“Frequent, proactive communication – particularly about wait times and delays – is the most important determinant of patient satisfaction in hospital emergency departments.” Hospitals & Health Networks _________________________________________________________________

According to Hospitals & Health Networks, based on data from Press Ganey, EDs at hospitals in the following cities rank highest in patient satisfaction scores: Metro Areas - Population Over One Million • Miami-Ft. Lauderdale, FL: 87.0 • Hartford, CT: 86.8 • Indianapolis, IN: 86.5 • Columbus, OH: 86.4 • Milwaukee, WI: 86.2

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Metro Areas - Population Under One Million • Wichita, KS: 88.2 • Madison, WI: 87.4 • Grand Rapids, MI: 86.8 • Greenville, SC: 86.4 • Honolulu, HI: 86.2

18.8 Market Resources American College of Emergency Physicians, 1125 Executive Circle, Irving, TX 75038. (800) 798-1822. (www.acep.org) HealthGrades, 999 18 th Street, Suite 600, Denver, CO 80202. (303) 716-0041. (www.healthgrades.com) Press Ganey Associates, 404 Columbia Plaza, South Bend, IN 46601. (800) 232-8032. (www.pressganey.com)

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19 FINANCIAL ISSUES

19.1 Critical Financial Issues In Healthcare Based on discussions with health system chief financial officers (CFOs), Ernst & Young (www.ey.com) identifies the following as critical issues likely to reshape the hospital industry in years to come: Healthcare Affordability • Hospital finances are being eroded by the growing numbers of uninsured and underinsured. Aging populations, high-priced drugs and technology, and rising labor costs have combined to create a perfect storm for the industry. Stepping up workforce productivity is seen as the only last chance to improve margins. Access to Capital • Many hospitals have construction projects on hold because financing is not available. Lower credit ratings and tighter credit markets have both played a role. With few options, CFOs are seeking greater consolidation of resources and organizations. The merging of hospitals can bring savings, greater access to technology, more leverage with suppliers, and the power to negotiate with large insurance companies. Physician Relationships • CFOs are seeking to develop more mutually beneficial relationships with physicians. Workforce Issues • With the supply of nurses and other hospital workers falling far short of demand, the cost of labor is skyrocketing. While the number of qualified applicants to nursing schools is on the rise, the dwindling number of faculty means many applicants are turned away. Quality Initiatives • While pay-for-performance (P4P) proponents have argued that quality initiatives will drive dramatic reform in the delivery system, CFOs see goals falling short, with only incremental improvements at best. CFOs have invested significant sums toward efforts that improve quality measures, yet there are few measures to gauge longterm outcomes. The need is great, CFOs say, to involve doctors in the fabric of hospital leadership and to collectively take ownership for quality.

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The Race for New Technologies • CFOs observe that pressure on providers to invest in new clinical and information technologies is unprecedented. Yet CFOs say new technologies, often enormously expensive, do not always produce improved outcomes or a return on investment. Transparency and Community Benefit • The demand for transparency is great in areas of patient safety, quality of care, and costs and charges. Not-for-profit hospitals are required to disclose even greater detail on bad debts and collection policies, charitable care, and com munity benefit. CFOs point to a very full and growing compliance agenda that must be managed and integrated into business operations.

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20 GROUP PURCHASING ORGANIZATIONS

20.1 Market Assessment After personnel costs, the supply chain is the single largest expense center for U.S. hospitals. According to the 2012 Survey of Executive Opinions On Supply Chain Issues, conducted by Modern Healthcare, nearly three-quarters of hospitals spend as much as 40% of their expense budgets on medical/surgical supplies. Virtually all U.S. hospitals buy through group purchasing organizations (GPOs), cooperatives that marshal the collective buying power of their healthcare provider members to broker deep-discounted deals with suppliers and distributors. According to the 2012 Survey of Executive Opinions On Supply Chain Issues, the percentage of spending for medical/surgical supplies purchased through GPOs is as follows (percentage of respondents): • Less than 10%: 15.7% • 11% to 20%: 37.7% • 21% to 40%: 35.8% • 41% to 60%: 6.3% • 61% to 80%: 1.3% • 81% to 100%: 3.1% According to the Health Industry Group Purchasing Association (HIGPA, www.higpa.org), hospitals purchase over $275 billion in supplies annually, including over $30 billion in pharmaceuticals and $50 billion in medical and surgical equipment.

20.2 Largest GPOs The following are the largest GPO organizations, ranked by purchasing volume (source: Modern Healthcare): • Novation (www.novation.com): • Premier Purchasing Partners (www.premierinc.com): • MedAssets (www.medassets.com): • HealthTrust Purchasing Group (www.healthtrustpg.com): • Amerinet (www.amerinet-gpo.com): • Consorta (www.consorta.com): • GeriMed (www.gerimedgso.com): • Resource Optimization & Innovation (www.roiscs.com): • FirstChoice Cooperative (www.fccoop.org): • Hospital Purchasing Service (www.hpsnet.com):

estimated $35.9 billion $33.0 billion $24.0 billion $17.0 billion $ 7.0 billion $ 2.7 billion $ 2.0 billion $ 670 million $ 600 million $ 455 million

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20.3 GPO Services Most hospitals join GPOs because of the contract negotiations and pricing services. In recent years GPOs have expanded beyond their traditional roles to provide benchmarking data, consulting services, and quality monitoring. The following are the types of services being provided by GPOs (source: Modern Healthcare): • Clinical quality benchmarking • Clinical quality support • Contract management • Continuing medical education • Custom contracting • Electronic commerce • Energy-related services • Environmentally preferred contracting • Equipment repair • Insurance services • Management consulting • Market research • Marketing • Materials management consulting • Materials management outsourcing • Patient-safety services • Public policy • Revenue-cycle management • Supply-chain analysis • Technology assessment • Warehousing

20.4 Satisfaction With GPO Relationships In the 2012 Survey of Executive Opinions On Supply Chain Issues , respondents identified the following as very important for their healthcare organization (percentage of respondents): • Controlling the price paid for medical and surgical supplies: 84.3% • Accessing comparable performance data and information: 61.0% • Accessing supply-chain management tools: 41.9% • Participating in quality improvement and patient safety initiatives: 41.5% • Networking with other organizations: 25.9% Executives indicating that they were very satisfied with their GPO on the issue were as follows (percentage of respondents):

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• • • • •

Controlling the price paid for medical and surgical supplies: Accessing comparable performance data and information: Accessing supply-chain management tools: Participating in quality improvement and patient safety initiatives: Networking with other organizations:

25.8% 22.6% 23.9% 19.5% 22.8%

20.5 Scrutiny Of GPO Operations Because GPO companies are financed by the very manufacturers whose products they evaluate and select, questions have been raised about whose interests they really serve and about whether the contracts they negotiate really save hospitals money. Articles appearing in The New York Times in early 2002 examined the potential conflicts of interest at both hospitals and the GPOs that serve them. The business practices of GPOs were subsequently the subject of hearings by the Senate Judiciary Antitrust Subcommittee. Responding to challenges, the HIGPA and its GPO members adopted an industrywide code of conduct that set forth key principles for individual GPOs to embrace and incorporate into their internal business practices. Following the adoption of the Code of Conduct, HIGPA developed an initiative to ensure that members are coordinating their business practices to come into compliance with the code. Group Purchasing Organizations: Services Provided to Customers and Initiatives Regarding Their Business Practices, a 2010 report by the Government Accountability Office (GAO, www.gao.gov), assessed whether GPOs really save money for hospitals. The report concludes that GPOs often operate according to a compensation system that provides incentives to keep prices artificially high. Its findings suggest that when the hospital purchasing process is exposed to greater competition, hospitals are able to achieve a savings of up to 18% on average. Scrutiny of GPO operations continues. An April 2012 report f rom the GAO found no evidence of anti-competitive GPO behavior. _________________________________________________________________

“However, the report ... said the current system of oversight does not address all questions about GPO business practices, notably whether contract administrative fees create a financial incentive that is inconsistent with GPOs obtaining the lowest prices for their customers.” Modern Healthcare, 5/7/12 _________________________________________________________________

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20.6 Market Resources Health Industry Group Purchasing Association, 2025 M Street, Suite 800, W ashington, DC 20036. (202) 367-1162. (www.higpa.org)

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21 HOME CARE

21.1 Overview Home care is a cost-effective service not only for individuals recuperating from a hospital stay, but also for those who, because of a functional or cognitive disability, are unable to care for themselves. At any given time, 1.4 million Americans are receiving some form of healthcare at home for a period of one to three months. The following are characteristics of this market (sources: National Center for Health Statistics): • Receive skilled nursing services: 75% • Over age 65: 70% • Rely on Medicare as primary payment source: 52% • Heart disease: 11% • Diabetes: 8% • Congestive heart failure: 4% • Osteoarthritis: 4% • Fractures: 4% • Hypertension: 3% Some three million people over age 65 can only leave their homes with extreme difficulty, according to Joanne Schwartzberg, M.D., the American Medical Association’s director of aging and community health. Many suffer from a complex mix of chronic conditions that require constant attention. One solution is home care for this population. According to Retooling for an Aging America, 90% of those receiving care at home get help from family and friends; 80% rely solely on them.

21.2 Market Assessment According to The 2012 Market Survey of Long-Term Care Costs, by the MetLife Mature Market Institute (www.maturemarketinstitute.com), the average hourly rate for home health aides provided by a home care agency is $21 per hour; daily rates for adult day services are $70, figures that remain unchanged from the previous year. Costs range from an average of $30 per hour in Rochester, Minnesota, to $13 per hour in Shreveport, Louisiana. According to the Centers for Medicare and Medicaid Services (www.cms.gov), national expenditures for home healthcare in 2011 (most recent data available) were $75.7 billion, a 5.3% increase over the prior year.

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Home health industry expenditures are distributed as follows (sources: Deutsche Bank and Forbes): • Home nursing, excluding Medicare (including commercial, Medicaid and other): 38% • Equipment and other: 27% • Medicare home nursing: 25% • Hospice: 10% Under some reimbursement systems, insurers pay hospitals based on illness, giving hospitals an added incentive to get patients discharged as quickly as possible. Home care can assist in meeting this need by providing follow-up for patients who continue to need care but do not need to rem ain in the hospital. Studies indicate that home care reduces hospital inpatient days. Providing regular care in the home for certain conditions also reduces ED visits. Also, it frees resources for acute-care patients and more profitable procedures.

21.3 Largest Home Healthcare Companies The following are the largest home healthcare companies (source: Modern Healthcare [January 2013]): For-Profit • Apria Healthcare Group (Lake Forest, CA): $2,30 billion • Gentiva Health Services (Atlanta, GA): $1.80 billion • Amedisys (Baton Rouge LA): $1.47 billion • Chemed Corp. [dba Vitas Healthcare] (Cincinnati, OH): $1.36 billion • LHC Group (Lafayette, LA): $ 633 million • Addus Homecare Corp. (Palatine, IL): $ 273 million Not-for-Profit • Visiting Nurse Service of New York Home Care (New York, NY): • SSM Health Businesses (St. Louis, MO): • MJHS Home Care (New York, NY): • BayCare Home Care (Largo, FL): • Connecticut Community Care (Bristol, CT): • Christus Continuing Care (Houston, TX): • CPC Home Attendant Program (New York, NY):

$1.41 billion $ 161 million $ 134 million $ 113 million $ 110 million $ 104 million $ 93 million

21.4 Hospitals In The Home Care Market According to Hospital Statistics 2012, by the American Hospital Association (www.aha.org), 61% of community hospitals are direct providers of some aspect of home care service (nursing, physical therapy, occupational therapy, respiratory care, equipment, etc.).

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Of Medicare-certified agencies, free-standing proprietary agencies comprise 40%, and hospital-based agencies and public health agencies each make up 30%. This differs markedly from the industry composition in the early 1980s, when public health agencies dominated the ranks of certified agencies and proprietary and hospitalbased agencies combined accounted for only one-fourth of the total. The number of hospital-based and free-standing proprietary agencies has been growing faster than any other type of Medicare-certified agency, according to the National Association of Home Care and Hospice (www.nahc.org). The following are the 10 largest healthcare systems operating home care agencies (source: Modern Healthcare, June 2012): Visits

• • • • • • • • • •

Catholic Health East: Cox Health: Catholic Health Initiatives: Trinity Health: Hartford Healthcare System: Ascension Health: Adventist Health System: North Shore-Long Island Jewish Health System: Bon Secours Health System: University of Pittsburgh Medical Center:

1.95 million 1.14 million 701,400 699,100 554,100 546,785 534,200 508,600 499,200 450,000

Agencies Branches

30 4

41 5

n/a

n/a

37 2 14 20 4 5 2

43 10 21 22 9 n/a

5

21.5 Private Sector Home Care Excluding services provided by hospitals and their affiliates, Frandata (www.frandata.com) estimates the home care market at $55 billion. The sector includes more than 45,000 companies that provide home care services. This total includes 2,800 franchise operations from companies such as Accessible Home Health Care (www.accessiblehomehealthcare.com), BrightStar (www.brightstarcare.com), HomeWell (www.homewell.biz), and LivHome (www.livhomefranchise.com). Home-care companies are not regulated in about half of states and only a few states require licenses for companies that provide non-medical services. Even in states where there are regulations, enforcement is lax, according to Bloomberg Businessweek.

21.6 Market Resources National Association for Home Care & Hospice, 228 Seventh Street SE, Washington, DC 20003. (202) 547-7424. (www.nahc.org)

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22 HOSPICE & PALLIATIVE CARE

22.1 Overview Hospice and palliative services provide patient end-of-life care. The big difference between hospice care and hospital-based palliative care is that hospice care seeks to move end-of-life patients out of the hospital to a home environment.

22.2 Market Assessment Annual hospice and palliative care expenditures in the U.S. are estimated at $16 billion. Of this amount, Medicare pays about $13 billion. Spending is distributed by payer as follows (source: Modern Healthcare): • Medicare: 79% • Private insurance: 13% • Medicaid: 5% • Private sources: 2% • Self-pay: 1% Researchers at Duke University found that hospice reduced Medicare costs by an average of $2,309 per hospice patient. On average, hospice use decreased Medicare costs for cancer patients using hospice care for fewer than 233 days. For non-cancer patients, there were cost savings seen up to 154 days of hospice care. Health Affairs (March 2013) reports the following per patient savings for Medicare patients enrolled in hospice: • 1-to-7 days: $2,650 • 8-to-14 days: $5,040 • 15-to-30 days: $6,430

22.3 Hospice Care Hospice Care in America, published in 2012 by The National Hospice and Palliative Care Organization (www.nhpco.org), provides the following data on hospice care in the United States: Characteristics of U.S. hospice programs • 5,300 estimated operational hospice programs • 58% of hospices are not-for-profit, 36% are for-profit, and 6% are run by government agencies

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•

79% of hospices had fewer than 500 total admissions

Characteristics of patients served by hospice • An estimated 1.58 million patients were served by hospice programs. • The median time spent receiving hospice care is 19.7 days. • 56% of hospice patients are female; 44% are male • 67% are 75 years of age or older • Primary diagnosis of hospice patients: cancer (36%), heart disease (14%), and dementia (13%); 13% have unspecified debilities • 1.0 million patients die under hospice care each year; 41.6% of all deaths occurred under hospice care. Volunteer commitment • Approximately 468,000 hospice volunteers contribute 21 million hours to hospices each year, according to Hospice Foundation of America (HFA, www.hospicefoundation.org)

• • • • • •

The following are the largest providers of hospice care: Beverly Enterprises (www.beverlycares.com) Gentiva Health Services (www.gentiva.com) Manor Care (www.manorcare.com) Odyssey Healthcare (www.odyssey-healthcare.com) VistaCare (www.vistacare.com) Vitas (www.vitas.com)

22.4 Hospital Palliative Care In a palliative care program, attending to quality of life and cost-effective service are not mutually exclusive. Palliative care systems have been shown to enhance compliance with pain and quality accreditation standards and improved support for staff who deal with complex diagnoses and around-the-clock needs. Pain, nausea, f atigue, and weakness; depression or other psychological issues; family needs; and providerpatient communication – all of these interventions improve when a hospital puts a palliative care system in place. _________________________________________________________________

“More than 60% of U.S. hospitals with more than 50 beds report having a palliative care program.” Hospitals & Health Networks, 5/12 _________________________________________________________________

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In conjunction with the Center to Advance Palliative Care, The Robert Wood Johnson Foundation (www.rjwf.org) has funded Palliative Care Leadership Centers – model programs that offer hands-on technical assistance, training, and a year of mentoring to hospitals hoping to launch a palliative care program – at the following hospitals: • Fairview Health Services (Minneapolis, MN) • Massey Cancer Center of Virginia Commonwealth University Health System (Richmond, VA) • Medical College of Wisconsin (Milwaukee, WI) • Mount Carmel Health System (Columbus, OH) • Palliative Care Center of the Bluegrass (Lexington, KY) • The University of California (San Francisco, CA) _________________________________________________________________

“Once viewed as a service only offered to terminally ill patients, an increasing number of hospitals now offer palliative care to patients from the moment they enter the ED or ICU.” Hospitals & Health Networks, 2/12 _________________________________________________________________

22.5 Quality Reporting For fiscal 2013, the first year of its hospice quality-reporting program, the CMS requires hospices to report data on two measures: NQF 0209-Comfortable Dying Measure • Developed by the National Hospice and Palliative Care Organization and endorsed by the National Quality Forum, this indicator measures whether patients who reported being uncomfortable because of pain at their initial assessment after admission to hospice had their pain brought to a comfortable level within 48 hours. Structural/QAPI Measure • This measure reflects whether hospices have an internal quality assessment and performance-improvement program, or QAPI, in place during the fourth quarter of 2012. That QAPI program must include at least three patient care-related indicators.

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22.6 Market Resources Center to Advance Palliative Care, 1255 Fifth Avenue, Suite C-2, New York, NY 10029. (212) 201-2670. (www.capc.org) Hospice Foundation of America, 1710 Rhode Island Avenue NW, Suite 400, Washington, DC 20036. (202) 457-5811 (www.hospicefoundation.org) National Association for Home Care & Hospice, 228 Seventh Street SE, Washington, DC 20003. (202) 547-7424. (www.nahc.org) National Hospice and Palliative Care Organization, 1731 King Street, Suite 100, Alexandria, VA 22314. (703) 837-1500. (www.nhpco.org)

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23 HOSPITAL PATIENT DIAGNOSES, PROCEDURES & SPENDING

23.1 Overview The Healthcare Cost and Utilization Project (www.hcup-us.ahrq.gov), from the Agency for Healthcare Research and Quality (AHRQ, www.ahrq.gov), provides statistics for principal diagnoses, procedures, and spending for stays at community hospitals. Data for the most frequent diagnoses and procedures in 2010, published by AHRQ in December 2012, are presented in this chapter.

23.2 Most Frequent Primary Diagnoses The most frequent primary diagnoses are as follows: • Pregnancy, childbirth, and newborn infants: • Pneumonia: • Congestive heart failure: • Osteoarthritis: • Mood disorders: • Coronary atherosclerosis (coronary artery disease): • Septicemia (blood infection): • Cardiac dysrhythmias (irregular heart beat): • Trauma to vulva and perineum due to childbirth: • Chronic obstructive pulmonary disease and bronchiectasis:

4.16 million 1.16 million 1.02 million 921,000 873,000 832,000 831,000 807,000 751,000 733,000

23.3 Most Frequent Procedures The most frequent hospital procedures are as follows: • Blood transfusion: • Prophylactic vaccinations and inoculations: • Respiratory intubation and mechanical ventilation: • Diagnostic cardiac catheterization, coronary arteriography: • Cesarean section: • Repair of obstetric laceration: • Upper gastrointestinal endoscopy: • Circumcision: • Artificial rupture of membranes to assist delivery:

2.83 million 1.80 million 1.50 million 1.48 million 1.38 million 1.34 million 1.24 million 1.17 million 932,000

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• • • • • • • • • • •

Fetal monitoring: Hemodialysis: Echocardiogram: Percutaneous transluminal coronary angioplasty (PTCA): Knee arthroplasty: Enteral and parenteral nutrition: Colonoscopy and biopsy: Laminectomy, excision intervertebral disc: Hysterectomy: Incision of pleura, thoracentesis, chest drainage: Cholecystectomy and common duct exploration:

860,000 837,000 813,000 693,000 686,000 576,000 564,000 504,000 483,000 476,000 460,000

23.4 Spending For Most Frequent Procedures Spending for the most frequent hospital procedures is as follows: • Septicemia (blood infection): $15.4 billion • Osteoarthritis (degenerative joint disease): $13.6 billion • Coronary atherosclerosis (coronary artery disease): $13.4 billion • Liveborn (newborn infant): $11.6 billion • Acute myocardial infarction (heart attack): $11.5 billion • Complication of device, implant or graft: $11.4 billion • Congestive heart failure: $10.7 billion • Pneumonia: $10.5 billion • Spondylosis, intervertebral disc disorders, and other back problems: $ 9.9 billion • Respiratory failure: $ 8.1 billion • Cardiac dysrhythmias (irregular heart beat): $ 7.5 billion • Acute cerebrovascular disease (stroke): $ 7.4 billion • Complication of surgical procedures or medical care: $ 6.1 billion • Chronic obstructive pulmonary disease and bronchiectasis: $ 5.4 billion • Biliary tract disease (gall bladder disease): $ 4.8 billion • Rehabilitation care, fitting of prostheses, and adjustment of devices: $ 4.8 billion • Diabetes mellitus with complications: $ 4.6 billion • Fracture of neck of femur (hip fracture): $ 4.4 billion • Mood disorders: $ 4.3 billion • Heart valve disorders: $ 4.2 billion

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24 HOSPITAL-ACQUIRED INFECTIONS

24.1 Incidence and Mortality According to the Centers for Disease Control and Prevention (CDC, www.cdc.gov), approximately 1.7 million patients contract infections while being treated in a hospital for a non-susceptible illness or injury each year, and almost 88,000 die because of their infections. Many victims are elderly, with chronic conditions that weaken their immune systems. Trauma patients, like victims of car crashes or severe burns, are also especially vulnerable, as are cancer patients in for radiation or chemotherapy, as well as newborns. An additional 340,000 infections occur in home healthcare settings and another 100,000 in long-term care centers, according to the CDC. According to an April 2012 report from the CDC, healthcare-associated infections (HAIs) declined in 2010 as follows: • Central line-associated bloodstream infections: 33% • Number of people developing HAI invasive methicillinresistant staphylococcus aureus infections: 18% • Surgical-site infections: 10% • Catheter-associated urinary tract infections: 7% _________________________________________________________________

“The CDC says four of the most common HAIs declined in the last year.” Hospitals & Health Networks, 4/12 _________________________________________________________________

A recent study published in the Archives of Internal Medicine reported that healthcare-associated pneumonia affects about 250,000 U.S. hospitalizations a year. All-cause sepsis affects about 750,000 hospitalizations, about half of which may be healthcare-associated.

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24.2 Antibiotic-Resistant Infections Bacteria like staphylococcus aureus roam hospitals freely, spreading by contact with the hands, a stethoscope, or a bed railing. The more resistant to commonly used antibiotics the bacteria become, the greater the threat. In 1974, only 2% of staphylococcus aureus infections were MRSA (methicillin-resistant). That figure has now soared to over 70%, according to the CDC. Most troubling are ‘superbugs’ like vancomycin-resistant enterococcus (VRE) that are resistant to a wide range of antibiotics. Affecting some 26,000 hospital patients each year, according to the CDC, VRE infects the digestive system and urinary tract. No effective antibiotic targeting VRE has been approved. Another problematic superbug is clostridium difficile, or C. diff. For those affected, problems usually start when they are being treated with antibiotics for some other infection, which can kill off many of the healthful bacteria in the intestines, thus allowing C. diff to take over.

24.3 Infection Control Programs Hospitals must bear much of the responsibility for the failure to prevent hospitalborne infections. Though most hospitals now have infection-control programs, many do not include all optimal measures that might be employed to prevent infections. Five years ago, surveys by The Leapfrog Group (www.leapfroggroup.org) found 65% of hospitals did not have all of the recommended policies in place to prevent the most common hospital-acquired infections. Calling attention to these shortcomings has been effective, and recent annual surveys by The Leapfrog Group show increased compliance with guidelines. Some hospitals have implemented programs to aggressively screen for patients who may have problematic infections. And hospitals are also increasingly using diagnostic tests and automated surveillance systems to control infections. Hospital design plays a significant role in preventing the spread of infections. In a study reported by Modern Healthcare, private ICU rooms contributed to lower rates of hospital-acquired infections as follows: • Clostridium difficile reduced by 43% • Methicillin-resistant staphylococcus aureus infections reduced by 47% • Yeast infections reduced by 50%

24.4 Infection Prevention Practices The Infection Prevention & Hospital Cleaning Survey was conducted by the Association for the Healthcare Environment (www.ahe.org), the Association for Professionals in Infection Control and Epidemiology (www.apic.org), Health Facilities Management, and Materials Management in Health Care. Infection preventionists from 686 hospitals participated in the survey. The following are results of the survey: Cleaning Practices Cleaning practices and technologies hospitals routinely employ to disinfect patient

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rooms are as follows: • Quaternary ammonium disinfectant: • Disinfectant-impregnated wipes: • Sodium hypochlorite, household bleach: • Microfiber mops: • Change cubical curtains after discharge of patients placed under contact precautions: • Microfiber cloths: • Pour bottles to dispense disinfectant: • Copper and copper-alloy fixtures: • Hydrogen peroxide vapor decontamination system:

85% 77% 68% 68% 57% 46% 42% 4% 2%

Cleaning Verification Hospitals using chemicals (e.g., fluorescing markers) to verify cleaning of the following high-risk objects are as follows: • Bed rail: 16% • Tray table: 16% • Nurse call device: 16% • Bedside table: 15% • Bathroom doorknobs: 15% • Toilet seat: 15% • Patient telephone: 15% • Sinks: 14% • Toilet handle: 14% • Patient room doorknobs and cabinet pulls: 14% • Bathroom light switch: 14% • Restroom grab bars: 13% Staff Performance Optimization Hospitals have taken the following steps to optimize environmental services staff performance: • Hands-on training in cleaning protocols: 84% • Education on transmission of healthcare-associated pathogens and resultant infection: 81% • Ongoing performance feedback: 62% • Predefined performance targets for patient area cleaning: 31% • Patient interviews by supervisory staff: 27% • Well-defined quality management program for patient area cleaning: 24% • Use of visually observable feedback tool (e.g., black-light marker): 20% • Quality control assessments tied to compensation: 10% Measuring Compliance Hospitals measure compliance with cleaning standards in patient core areas as follows:

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• • • • • •

Observation-based audit: Patient satisfaction scores on cleanliness of room: Monitor compliance with performance targets: Risk-based audit: Environmental culture results: Measuring cleaning rates of high-risk objects in patient area:

87% 78% 34% 15% 14% 14%

Top Challenges The following are the top challenges to cleaning and disinfecting the patient environment: • Pressure to expedite room turns for incoming patients: 42% • Assigned responsibility for cleaning mobile objects: 41% • High hospital occupancy: 35% • Inadequate time to properly clean patient rooms and care areas: 32% • Reluctance to clean electronic equipment with saturated cloths: 32% • Inadequate staffing levels: 31% • Too busy/insufficient time allowed to consistently follow protocols: 28% • High turnover rates among environmental services technicians: 26% • Inadequate financial resources to invest in cleaning technologies and equipment: 26% • Lack of objective microbiologic standards for hospital cleaning: 20% • Lack of knowledge of the role specific high-risk objects play in transmitting healthcare-associated pathogens: 20%

_________________________________________________________________

“Several hospitals and health systems have deployed especially successful interventions to tackle the HAIs highlighted by the CDC. The common threads in each of the hospital’s success stories are: a multidisciplinary team dedicated to finding solutions; senior leaders who foster accountability as well as an alliance with care providers; vigilant adherence to infection prevention protocols; and, most importantly, a constant awareness that infection rates are more than just numbers – they are patients’ lives.” Hospitals & Health Networks, 4/12 _________________________________________________________________

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24.5 Market Resources Association for the Healthcare Environment of the American Hospital Association, 155 N. Wacker Drive, Chicago, IL 60606. (312) 422-3000. (www.aha.org) Association for Professionals in Infection Control and Epidemiology, 1275 K Street NW, Suite 1000, Washington, DC, 20005. (202) 789-1890. (www.apic.org) Committee to Reduce Infection Deaths, 185 East 85 th Street, Suite 35B, New York, NY 10028. (212) 369-3329. (www.hospitalinfection.org) The Leapfrog Group, 1660 L Street NW, Suite 308, Washington DC 20036. (202) 292-6713. (www.leapfroggroup.org)

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25 HOSPITAL-PHYSICIAN RELATIONS

25.1 Overview A 2012 survey conducted by the American College of Healthcare Executives (www.ache.org) found hospital-physician relations to be among the most important issues confronting hospitals, ranking ahead of issues such as patient satisfaction, personnel shortages, and technology.

25.2 Status and Issues The following are survey responses of hospital executives in the HospitalPhysician Relations Survey conducted by Press Ganey Associates (www.pressganey.com) and Modern Healthcare: Overall Relations Between Hospital and Physicians Hospitals with Employed Physicians

• • • • • • •

Outstanding: Very good: Good: Fair: Poor: Very poor: Unacceptable:

8% 37% 29% 17% 6% 3% 1%

Hospitals Without Employed Physicians

7% 19% 37% 22% 7% 6% 3%

Biggest Obstacles in Building Good Relations Between Hospitals and Employed Physicians • Trust: 39% • Compensation: 36% • Information technology: 29% • Reimbursement: 29% • Recruitment: 24% • Management: 23% • Governance: 22% • Compliance: 18% • Staffing: 18% • Quality measurement/reporting: 17% • Regulation: 16% • Clinical performance: 13%

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• • •

Medical technology: Legal issues: Credentialing:

12% 11% 6%

Governance Arrangements With Physicians • Physicians serve on governing board: • Physicians serve in other senior-level management positions: • Physician serves as president or CEO: • Hospital has co-ownership arrangement with physicians:

88% 61% 19% 16%

25.3 Trends The American Hospital Association (www.aha.org) reports a recent general improvement in hospital-physician relations. _________________________________________________________________

“In the last five years, we have seen a dramatic increase in the speed with which hospitals and physicians are coming together. Unlike the 1990s, when hospitals intentionally went out to try to acquire practices, it’s really the physicians who are driving a lot of this. They’re saying they want to be part of a larger organization, or maybe they want to get out of the business of care and focus on the provision of care. For whatever reason, physicians seem to be much more willing to work with hospitals. And hospitals, I think, are much more realistic about how to try to bring that together in a way that works for physicians as well. So we’ve seen a lot more employment, we’ve seen a lot more other forms of engagement and that’s only going to increase. Young, recent graduates are much more inclined to join a large group or a hospital.” Rich Umbdenstock, President and CEO American Hospital Association Hospitals & Health Networks, 1/12 _________________________________________________________________

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26 HOSPITALS IN PURSUIT OF EXCELLENCE

26.1 Overview The AHA Quality Center of the American Hospital Association (AHA, www.aha.org) has published a guide to support the ongoing efforts to improve the patient experience and outcomes in hospitals. Entitled Hospitals in Pursuit of Excellence (www.hpoe.org), the guide shows how hospitals can reduce waste and inefficiency, optimize the use of resources, and enhance their ability to deliver safe, high-quality, affordable patient care. Hospitals in Pursuit of Excellence focuses on four areas identified as common opportunities for improvement: healthcare-associated infections, patient flow, medication management, and patient safety (such as falls and pressure ulcers).

26.2 Core Principals Hospitals in Pursuit of Excellence recommends the following six core principles: Focus on the patient’s experience of care • Care must be respectful of, and responsive to, individual preferences, needs, and values. Create a culture of reliability • Culture defines the values and behaviors of organizations. Highly reliable cultures are known to be the safest organizations in the world. Manage organizational viability • Achieve consistency in structure and function of staff and units, where possible. Remove waste • Removing waste, including unnecessary steps, has a direct, positive impact on the bottom line. Eliminate defects • Finding and resolving problem points will result in greater efficiency and better health outcomes. Reduce process variation • Using quality tools and frameworks can increase consistency in processes of care and administration, thus reducing the risk of errors.

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27 IMAGING

27.1 Market Assessment Total annual spending on scans performed at imaging centers, including hospital departments, is estimated at more than $100 billion. Medicare’s annual spending for imaging increased from $6.6 billion in 2000 to $13.7 billion in 2006. After reimbursement rates were cut, spending dropped to $11.9 billion in 2010. Still, the number of advanced imaging tests continued to increase between 2006 and 2010. According to the Centers for Disease Control and Prevention (CDC, www.cdc.gov), the number of computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) scans tripled during the past decade to 12.6 scans ordered per 100 persons in physician office or outpatient visits. Many experts feel much of the increased testing now being performed is unnecessary. One such critic is H. Gilbert Welch, M.D., author of Should I Be Tested For Cancer? Maybe Not, And Here’s Why and a Professor at the Dartmouth School of Medicine. _________________________________________________________________

“We find that when we look for diseases we invariably find more people with them than we expected, but some of them may never develop into life-threatening diseases. The paradox is that we cast a net so broadly that we pick up diseases that don’t need treatment.” Prof. H. Gilbert Welch, M.D. Dartmouth School Of Medicine _________________________________________________________________

Still, it is not clear which scans are unnecessary.

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_________________________________________________________________

“A CT scan is the quickest and most definitive way to determine if something is going on. There is no good study which shows which scans shouldn’t have been ordered.” Prof. Stephen Amis, M.D., Chairman Department of Radiology Albert Einstein College of Medicine _________________________________________________________________

The National Council on Radiation Protection and Measurem ents (www.ncrponline.org) found medical imaging is responsible for about half the total radiation exposure to the typical U.S. resident, up from just 20% in the 1980s.

27.2 CT Scans An estimated 70 million CT scans are performed annually in the United States, an increase from 3 million in 1980. According to a study published in a recent issue of Radiology, the number of annual emergency room visits that included CT scans increased from 2.7 million to 16.2 million, or 500%, between 1995 and 2007. Researchers found that imaging procedures necessitating higher doses of radiation exposure increased at a faster rate than those requiring less radiation. Such high-dose scans include abdominal and pelvic scans, which deliver roughly seven times more radiation than head scans.

27.3 Magnetic Resonance Imaging Magnetic resonance imaging uses a powerful magnetic field to visualize soft tissues of the human body. It is useful in imaging the brain, muscles, the heart, and cancers. Approximately 26 million MRI procedures are performed each year. The cost of an MRI procedure typically ranges between $1,000 to $3,500. One advantage of an MRI scan is that it does not expose the patient to ionizing radiation as do CT scans and traditional X-rays.

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27.4 Positron Emission Tomography Positron emission tomography, a nuclear medicine imaging technique, produces a three-dimensional image or picture of functional processes in the body. The PET system detects pairs of gamma rays emitted indirectly by a tracer, which is injected into the body. PET scans are used most frequently in cardiology, neurology, and oncology. Approximately 1.7 million PET scans were performed in 2011, an increase from approximately 350,000 in 2002. On average, PET imaging costs are about $4,900 for a scan of the whole body, $6,700 for the brain, and $6,800 for the heart. As with all imaging procedures, costs vary widely by geographic location and type of provider; charges can be $20,000 or more.

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28 INFORMATION TECHNOLOGY

28.1 Market Assessment IDC Health Insights (www.idc-hi.com) estimates healthcare IT spending in 2012 at $45 billion. The estimate includes spending on hardware, software, and services for providers and payers. Spending is projected to increase to $54 billion by 2015.

28.2 Assessment of Healthcare IT The Healthcare Information and Management Systems Society (HIMSS, www.himss.org) has conducted an annual leadership survey since 1989. The following are results of HIMSS’ 24nd Annual Leadership Survey, conducted in 2013: Business Issue With Most Impact On Healthcare - Next Two Years • Healthcare reform: 37% • Financial considerations: 16% • Policy mandates: 14% • Health Information Exchange (HIE)/data interoperability: 8% • Shifting healthcare landscape: 7% • Technology considerations: 4% • Staffing issues: 2% Top IT Priority - Next Two Years • Achieving meaningful use: • Optimizing effective use of currently installed systems: • Leveraging information (e.g. data warehouse/business intelligence/ evidence-based medicine/clinical decision support): • Focus on clinical systems (e.g. CPOE/EHRs/ePrescribing): • Completing ICD-10 conversion: • Interoperability: Primary Clinical IT Focus • Ensuring the organization has a fully operational EHR in place: • Installing a CPOE application: • Focus on physician systems: • Certification of our EHR system and modules: • Focus on data warehouse/clinical analytics: • Creating continuity of care record: • Closed loop medication administration:

28% 20% 17% 11% 9% 6%

19% 10% 16% 2% 10% 3% 3%

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Primary Financial IT Focus • Implementing ICD10: • Upgrading financial analytics systems: • Upgrading the patient billing system: • Upgrading the patient access system (registration/ADT): • Enterprise scheduling system: Primary IT Infrastructure Focus • Servers and virtual servers: • Security systems (e.g. encryption/PCI/data loss prevention/ authentication): • Mobile devices (e.g. smart phones/iPhone/USB devices/PDAs): • Storage and backup (e.g. NAS/SAN/disk storage): • Desktops/laptops and virtual desktops/laptops: • Cloud computing: • Wired and wireless networking: • Telemedicine: Key Business Objective • Sustain financial viability or survival: • Improve patient care/quality of care/outcomes: • Improve operational efficiencies and lower operating costs via process reengineering (e.g. Six Sigma/CQI/TQM): • Accountable Care Organization: • Increase market share/ability to compete successfully in market: • Improve patient satisfaction: Most Significant Barrier To Implementing IT • Lack of staffing resources: • Lack of adequate financial support for IT/lack of budget: • Vendor’s inability to effectively deliver product or service: • Difficulty in achieving end-user acceptance or use: • Lack of time/availability of clinicians to help implement: • Lack of interoperable systems: • Difficulty in proving IT quantifiable benefits/return on investment: • Lack of a strategic IT plan/failure to execute an IT plan: • Lack of clinical leadership: • Constraints at a higher regional/policy/governmental level:

47% 15% 12% 4% 4%

18% 22% 16% 12% 10% 5% 3% 3%

21% 19% 17% 9% 9% 4%

21% 15% 13% 7% 6% 4% 4% 4% 4% 3%

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Area IT Can Have Most Impact On Patient Care • Improving clinical and quality outcomes: • Reducing medical errors/improving patient safety: • Standardize clinical care using evidence based medicine: • Supporting staff productivity: • Sharing information externally: • Enabling remote access of data: • Providing competitive advantage (i.e. improved patient satisfaction/improved reimbursement):

31% 25% 12% 8% 7% 5% 4%

Top Concerns - Security Of Electronic Medical Information • Securing information on mobile devices: security audits: • Internal breach of security: • Compliance with HIPAA security regulations and CMS • Data leakage (e.g. patient data inadvertently sent via e-mail): • External breach of security: • Inadequate funding/support for security process: • Limits of existing security technology: • Patient’s lack of confidence in the security of information: • Unauthorized use of data by third parties: • Inadequate security systems in place: • Connecting IT at hospital and remote clinics:

16% 10% 8% 8% 6% 5% 4% 4%

Security Breach • In last six months: • In last 12 months:

10% 19%

Role of Clinicians in IT • Participate in IT system evaluation/selection: • Act as project champions in educating and leading other clinicians: • Participate in the development of policies related to clinical information systems: • Involved in the development and implementation of clinical training: • We employ hospitalists who use our clinical applications to manage patient treatments/care: • Employed by the IS department to support existing clinical applications: • Act as business project leaders during clinical implementation: • Explore innovative ways to use IT in this clinical arena: • CMIO who orchestrates the clinical aspects of IT strategy: • Clinicians who are department managers may select the IT systems needed to support their departments: • No role:

36% 28% 27%

76% 74% 53% 54% 51% 45% 42% 38% 32% 14% 4%

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28.3 Executive Opinions On Key IT Issues Modern Healthcare has conducted an annual Survey of Executive Opinions On Key Information Technology Issues since 1990. The following are results of the 23rd annual survey, published in February 2013 (source: Modern Healthcare): Percentage of Organizations’ Total Operating Budget Allocated For Information Systems • 0.5% or less: 1.8% • 0.6% to 1.0%: 3.6% • 1.1% to 1.5%: 3.6% • 1.6% to 2.0%: 10.0% • 2.1% to 2.5%: 13.6% • 2.6% to 3.0%: 11.8% • 3.1% to 3.5%: 10.9% • 3.6% to 4.0%: 6.4% • 4.1% to 4.5%: 5.5% • 4.6% to 5.0%: 5.5% • 5.1% to 5.5%: 7.3% • 5.6% to 6.0%: 5.5% • More than 6.0%: 14.5% Top Issues in Health IT (respondents selected a maximum of three issues) • Achieve ICD-10 readiness: 44.5% • Achieve Stage 1 meaningful-use criteria: 29.1% • Adopt/upgrade financial and clinical systems for ACO or medical home readiness: 25.5% • Developing data warehouses: 23.6% • Electronic health records: 23.6% • Data privacy and security: 21.8% • Clinical communications infrastructure/links to physicians: 20.9% • Enabling patient access to selected data via the Internet: 20.9% • Adopt/extend ambulatory clinical lT systems: 16.4% • Consolidating all lT functions using common applications: 14.5%

28.4 Market Resources Healthcare Information and Management Systems Society, 230 East Ohio Street, Suite 500, Chicago, IL 60611. (312) 664-4467. (www.himss.org) Modern Healthcare, 150 North Michigan Avenue, 14th Floor, Chicago, IL 60601. (312) 649-5350. (www.modernhealthcare.com)

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29 LARGEST HEALTHCARE SYSTEMS

29.1 Largest Hospital Systems The 2012 Hospital Systems Survey, an annual ranking by Modern Healthcare, ranks the largest healthcare systems as follows: Largest Healthcare Systems (All Types) Ranked By Revenue • U.S. Veterans Affairs Department: $53.2 billion • HCA: $32.5 billion • Ascension Health: $14.7 billion • Community Health Systems: $13.6 billion • Dignity Health (formerly Catholic Healthcare West): $10.2 billion • Catholic Health Initiatives: $ 9.0 billion • Tenet Healthcare Corp.: $ 8.9 billion • New York-Presbyterian Healthcare System: $ 8.5 billion • Sutter Health: $ 7.8 billion • Trinity Health: $ 7.5 billion Largest Healthcare Systems (All Types) Ranked By Hospital Count • HCA: 163 • U.S Veterans Affairs Department: 152 • Community Health Systems: 127 • Catholic Health Initiatives: 72 • Ascension Health: 67 • Health Management Associates: 62 • LifePoint Hospitals: 54 • Tenet Healthcare Corporation: 50 • Dignity Health: 40 • Trinity Health: 36 Largest For-Profit Healthcare Systems Ranked By Staffed Acute-Care Beds • • • • • •

HCA: Community Health Systems: Tenet Healthcare Corporation: Health Management Associates: Vanguard Health Systems: LifePoint Hospitals:

Beds

Hospitals

41,482 19,695 13,453 10,330 6,201 6,048

163 127 50 62 18 54

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• • • •

Universal Health Services: Iasis Healthcare Corp.: Prime Healthcare Services: Ardent Health Services:

5,726 4,289 2,512 1,669

21 16 13 9

Largest Public Healthcare Systems Ranked By Staffed Acute-Care Beds Beds

• • • • • • • • • •

U.S Veterans Affairs Department: 17,141 Carolinas HealthCare System: 2,822 LSU Health System: 1,538 Broward Health: 1,378 Lee Memorial Health System: 1,303 Huntsville Hospital: 1,267 Memorial Healthcare System: 1,252 WellStar Health System: 1,144 West Tennessee Healthcare: 742 University of Mississippi Health Care: 615

Hospitals

152 14 10 4 4 5 4 4 6 2

Largest Catholic Healthcare Systems Ranked By Staffed Acute-Care Beds • • • • • • • • • •

Ascension Health: Catholic Health Initiatives: Catholic Health East: Trinity Health: Providence Health & Services: Christus Health: Mercy: Catholic Healthcare Partners: SSM Health Care: St. Joseph Health System:

Beds

Hospitals

12,544 7,916 6,171 6,125 5,577 4,994 3,393 3,309 2,926 2,673

67 72 25 36 27 27 23 23 12 12

Largest Secular Not-for-Profit Healthcare Systems Ranked By Staffed Acute-Care Beds Beds Hospitals • New York-Presbyterian Healthcare System: 8,278 21 • Dignity Health (formerly Catholic Healthcare West): 7,630 40 • North Shore-Long Island Jewish Health System: 5,621 15 • Sutter Health: 4,515 25 • Banner Health System: 4,039 23 • University of Pittsburgh Medical Center: 3,624 21 • BJC HealthCare: 3,445 12 • Mayo Clinic: 3,068 21 • Memorial Hermann Healthcare System: 3,025 10 • Meridian Health: 2,826 5

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Largest Non-Catholic Religious Healthcare Systems Ranked By Staffed Acute-Care Beds • • • • • • • • • •

Adventist Health System: Baylor Health Care System: Texas Health Resources: Advocate Health Care: Adventist Health: Baptist Memorial Health Care Corp.: OhioHealth: Methodist Hospital System: Baptist Healthcare System: Methodist Le Bonheur Healthcare:

Beds

Hospitals

6,883 3,534 3,237 2,989 2,759 2,319 1,802 1,585 1,521 1,311

33 21 23 10 17 11 8 5 5 3

29.2 Largest Hospital Chains The following are the largest for-profit hospital chains (sources: Truven Health Anaytics, CMS Medicare Hospital Cost Report, and Modern Healthcare, December 2012): • • • • • • • • • • • • • • • • • • • •

HCA Community Health Systems: Tenet’Healthcare Corp.: Health Management Associates: Universal Health Services: LifePoint Hospitals: Vanguard Health Systems: lasis Healthcare: Prime Healthcare Services: Ardent Health Services: AHMC Healthcare: Capella Healthcare: lntegrated Healthcare Holdings: Essent Healthcare: Merit Health Systems: United Surgical Partners Int’l: National Surgical Hospitals: Alta Hospitals System: Success Healthcare: Signature Hospital Corp.:

No. Hospitals

Staffed Beds

137 119 48 53 23 47 13 14 13 7 7 13 4 5 2 10 121 3 3 3

31,765 14,266 11,778 7,365 4,697 4,773 3,603 2,424 1,949 1,106 1,057 1,301 520 488 355 178 259 583 454 285

Operating Revenue

$28.06 billion $11.09 billion $ 7.91 billion $ 4.46 billion $ 3.74 billion $ 3.11 billion $ 2.79 billion $ 1.64 billion $ 1.36 billion $ 875 million $ 798 million $ 738 million $ 347 million $ 317 million $ 299 million $ 295 million $ 294 million $ 267 million $ 182 million $ 179 million

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30 LARGEST HOSPITALS

30.1 Largest Community Hospitals According to the American Hospital Association Guide, 2012 Edition, the following are the largest U.S. hospitals: • New York Presbyterian Hospital* (New York, NY): 2,261 staffed beds • Jackson Health System* (Miami, FL): 2,186 staffed beds • Florida Hospital* (Orlando, FL): 2,083 staffed beds • Central Texas Veterans Healthcare* (Temple, TX): 1,852 staffed beds • Indiana University Health* (Indianapolis, IN): 1,597 staffed beds • UPMC Presbyterian* (Pittsburgh, PA): 1,544 staffed beds • Patton State Hospital (Patton, CA): 1,517 staffed beds • Montefiore Medical Hospital* (New York, NY): 1,491 staffed beds • Orlando Regional Medical Center* (Orlando, FL): 1,464 staffed beds • Methodist Hospital* (San Antonio, TX): 1,409 staffed beds • Veterans Affairs Greater Los Angeles Healthcare System: 1,327 staffed beds • Baptist Health System* (San Antonio, TX): 1,313 staffed beds • Methodist Healthcare* (Memphis, TN): 1,305 staffed beds • Atascadero State Hospital (Atascadero, CA): 1,275 staffed beds • Lee Memorial Hospital* (Fort Myers, FL): 1,273 staffed beds • Cleveland Clinic Foundation* (Cleveland, OH): 1,239 staffed beds • Napa State Hospital (Napa, CA): 1,229 staffed beds • Kaleida Health* (Buffalo, NY): 1,161 staffed beds • Memorial Hermann Norhtwest Hospital (Houston, TX): 1,158 staffed beds • Barnes Jewish Hospital (St. Louis, MO): 1,150 staffed beds * includes multiple campuses

30.2 Largest U.S. Military Hospitals The following are the largest U.S. military hospitals (source: American Hospital Association Guide): • Naval Medical Center San Diego (San Diego, CA): 285 total beds • Wilford Hall Medical Center (San Antonio, TX): 284 total beds • Naval Medical Center Portsmouth (Portsmouth, VA): 274 total beds • National Naval Medical Center (Bethesda, MD): 240 total beds • Walter Reed Army Medical Center (Washington, DC): 236 total beds • Brooke Army Medical Center (Fort Sam Houston, TX): 226 total beds

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• •

William Beaumont Army Medical Center (El Paso, TX): Madigan Army Medical Center (Tacoma, WA):

209 total beds 205 total beds

30.3 Largest Academic Medical Centers The largest academic medical centers, ranked by number of residents and interns, are as follows (source: American Hospital Directory): • New York Presbyterian/Weill Cornell Medical Center (New York, NY): 1,324 • Monftefore Medical Center - Moses Division Hospital (New York, NY): 1,065 • University of Michigan Health System (Ann Arbor, MI): 840 • Johns Hopkins Hospital (Baltimore, MD): 820 • Cleveland Clinic (Cleveland, OH): 784 • UAB Hospital (Birmingham, AL): 750 • UPMC Presbyterian (Pittsburgh, PA): 731 • Mount Sinai Hospital (New York, NY): 727 • Hospital of the University of Pennsylvania (Philadelphia, PA): 672 • Jackson Memorial Hospital (Miami, FL): 668 • University of Virginia Medical Center (Charlottesville, VA): 639 • LAC/University fo Southern California Medical Center (Los Angeles, CA): 636 • Barnes-Jewish Hospital (St. Louis, MO): 636 • Ronald Reagan UCLA Medical Center (Los Angeles, CA): 625 • Indiana University Health Methodist Hospital (Indianapolis, IN): 616 • Massachusetts General Hospital (Boston, MA): 599 • Wake Forest University Baptist Medical Center (Winston-Salem, NC): 593 • Strong Memorial Hospital (Rochester, NY): 589 • Henry Ford Hospital (Detroit, MI): 588 • Thomas Jefferson University Hospital (Philadelphia, PA): 585 • Shands at the University of Florida (Gainesville, FL): 584 • Vanderbilt University Medical Center (Nashville, TN): 580 • Duke University Hospital (Durham, NC): 563 • UNC Health Care (Durham, NC): 555 • Parkland Health & Hospital System (Dallas, TX): 542

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31 MARKETING

31.1 Marketing Budgets Health systems and hospitals spend approximately 0.5% to 2% of their operating budgets on marketing. Betsy Gelb, Ph.D., professor of marketing and director of the Institute for Health Care Marketing at the University of Houston, estimates that about half of hospital marketing budgets go to advertising. The other half is spent on community relations/educational/PR activities, patient satisfaction, market research, and more. According to a recent survey by the 3,600-member Society for Healthcare Strategy and Market Development (SHSMD, www.shsmd.org), marketing budgets by healthcare organizations are distributed as follows: • Advertising: 48% • Publications: 17% • Collateral materials: 10% • Community events/giveaways: 9% • Marketing research: 6% • Website management: 5% • Call center: 2% • Other: 9%

31.2 Advertising and Promotions Hospitals have engaged in advertising since 1979, after the American Medical Association (AMA, www.ama-assn.org) was forced by a Supreme Court decision to drop its policy that discouraged most forms of healthcare ads. Though some ads are little more than public services messages, most are direct-to-patient marketing efforts aimed at creating demand. According to a survey of hospital executives by Modern Healthcare, the following methods are used by hospitals to increase marketshare: • Print ads: 97% • Alliances or partnerships: 77% • Direct mail: 74% • Billboard ads: 40% • Television ads: 34%

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Hospitals are large distributors of promotional items; for example, bee sting kits, first aid kits, and health education materials are often given free. Hospitals also focus on educational programs and health promotions to gain name recognition. Hospitalsponsored wellness and fitness programs within the workplace and in communities nationwide have become popular. Even shopping centers have become a place hospitals use to promote themselves to the public. Much healthcare advertising is driven by the fact that patients travel more for specialized care than in the past. The Mayo Clinic (Rochester, MN), for instance, reports that 25% of its patients come from 500 miles away or more. The Cleveland Clinic spends $8.5 million annually on advertising to attract patients nationally, according to Advertising Age. Similar to marketing efforts in other sectors, hospitals use demographic and personal data to target promotions to insured consumers most likely to need specific healthcare services. Targeted promotional programs have proven effective for many hospitals. Kaiser Health News estimates that 20% of hospitals use targeting tools in their marketing programs. The following are some examples (source: Kaiser Health News): • Provena’s six hospitals in Illinois mailed information about screenings and educational events to 293,000 people. The mailings led to more than 50,000 patient visits, a 17% response rate. After accounting for marketing costs, those visits netted the system $595,000. • During a 14-month period in 2010-2012, St. Anthony’s Medical Center (St. Louis, MO) spent $25,000 on targeted mailings to 40,000 women for mammogram screenings. The letters led 1,000 women to get screened and generated $530,000 in revenue from screenings, biopsies, and other related services. • The Henry Ford Health System promoted mammograms in mailings to 30,000 women ages 40 or older. More than 5,700 women responded to the mailings, generating $268,000 in profit and a return of more than four to one on the cost of the campaign.

31.3 Hospital Websites While virtually all hospitals have a website, they vary significantly in content and effectiveness. Many sites go beyond providing basic information about a hospital’s expertise to serve as an interactive extension of hospital services.

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_________________________________________________________________

“An important goal of hospital website design is a simple one: Help people find what they’re looking for quickly. Hospital websites are also starting to reflect innovation with interactive portals that give patients access to their test results, medical bills, and doctor’s schedules. Physicians can now introduce themselves via online videos and profiles.” Modern Healthcare _________________________________________________________________

According to William Rice, President of the Web Marketing Association (www.webmarketingassociation.org), hospital websites are perpetual works in progress. Some hospitals redesign their websites as frequently as once a year. _________________________________________________________________

“Early hospital websites could be classified as ‘brochure-ware’ that didn’t take advantage of the interactive features the Internet offers. A lot of hospitals didn’t see the immediate value of engaging visitors. Hospital websites have to avoid looking institutional and need to offer user-friendly functions such as posting items in English as well as other languages, especially in highly diverse communities.” William Rice, President Web Marketing Association Modern Healthcare _________________________________________________________________

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31.4 Provider Social Networking According to Social Media Resources For Health Care Professionals, by Ed Bennett (www.ebennett.org), director of web strategy at the University of Maryland Medical Center, 1,501 U.S. hospitals engage in social networking to communicate with their patients and the public. Combined, the hospitals have 6,379 social networking sites. Mr. Bennett’s list of hospital social networking activities is maintained online by Mayo Clinic at http://network.socialmedia.mayoclinic.org/hcsml-grid/. The following are numbers of hospitals using various social network tools at of June 2013: • Facebook: 1,264 • FourSquare: 1,116 • Twitter: 967 • YouTube: 695 • LinkedIn: 651 • Blogs: 185 Hospitals use Facebook, FourSquare, and LinkedIn to reach a patient base that is increasingly engaged in social networking. These networks allow hospitals to interact with the public as “friends” rather than as customers. This interpersonal online relationship can be an important part of the hospital experience for patients whose lives revolve around their online activities. Twitter, the micro-blog social-networking application that allows messages of up to 140 characters to be sent, or tweeted, onto a user’s personal feed in real time, is the most popular tool for hospitals that engage in social networking. Hospitals use Twitter to announce new treatments, support groups, health fairs, and various other newsworthy activities. Hospitals post video content on YouTube providing discussions of treatment options, patient education videos, presentations of health and wellness guidelines, visual displays of hospital facilities, and more. Some hospitals reserve space on their own website for bloggers.

31.5 Virtual Tours Taking advantage of leading-edge digital technology, some hospital websites offer virtual tours. The tours serve to reduce anxiety and relieve fears about procedures and admissions among patients, as well as to serve as a promotional tool for consumers searching for a hospital. A virtual tour on the website of the McLean Hospital, located just outside Boston, provides 360E panoramic views of the tree-lined, serene, and historic grounds of the hospital, as well as interior spaces. According to Nancy Hoines, director of business development and marketing at the Harvard-affiliated psychiatric hospital, the virtual tour is one of the most visited features on the McLean Hospital website.

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Palomar Medical Center West, near San Diego, moved to a new 653-bed facility in 2012. Small ponds and waterfalls grace the campus of the new hospital, and greenery adorns the atrium and terraces. The hospital began promoting the new facility with a virtual tour since construction began in December 2007. This engagement with the community made patients feel at home with the new facility even prior to the August 2012 opening. At Seattle Children’s Hospital, mini virtual tours use cartoon characters as guides, such as a little boy and friendly tiger in the MRI room. The tours help put families more at ease, particularly kids, according to Stephen Halsey, web services manager at the hospital.

31.6 Community Outreach Programs According to the AMA, the following percentages of hospitals offer selected community outreach programs: • Health screenings: 80% • Health fairs: 78% • Support groups: 67% • Patient education center: 60% • Health information: 49% • Enrollment assistance services: 45%

31.7 Market Resources Institute for Health Care Marketing, C.T. Bauer College of Business, University of Houston, 334 Melcher Hall, Houston, TX 77204. (713) 743-4600. (www.bauer.uh.edu/centers/ihcm) Society for Healthcare Strategy and Market Development, 155 North Wacker Drive, Suite 400, Chicago, IL 60606. (312) 422-3888. (www.shsmd.org)

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32 MEDICAL LIABILITY

32.1 Market Assessment A study by researchers from Harvard University, published in Health Affairs, estimated that medical liability-related costs in 2008 (most recent data available) were $55.6 billion, or 2.4% of total healthcare spending, and includes practicing defensive medicine or avoidance of high-risk patients in an effort to avoid being sued. Distribution of medical liability spending was as follows: • Defensive medicine: $45.6 billion (81.9% of total) • Economic, non-economic, and punitive damages: $ 5.7 billion (10.3% of total) • Defendant legal costs and administrative overhead: $ 4.1 billion (7.4% of total)

32.2 Professional Liability Insurance Carriers According to Modern Healthcare (February 2013) the largest insurance carriers, ranked by direct premiums written for medical professional liability, are as follows: • Doctors Cornpany Insurance Services: $857 million • Berkshire Hathaway Insurance Group: $845 million • Medical Liability Mutual Insurance Co.: $562 million • ProAssurance Corp.: $540 million • CNA Insurance Cos.: $496 million • American International Group: $419 million • Physicians’ Reciprocal Insurers: $383 million • Coverys Cos.: $367 million • NORCAL Mutual Insurance Co.: $286 million • ISMIE Mutual Insurance Co.: $284 million • MAG Mutual Group: $245 million • Hospitals Insurance Co.: $218 million • MCIC Vermont: $171 million • Allied World Assurance Co.: $165 million • State Volunteer Mutual InsuranceCo.: $164 million • Medical Mutual Liability Insurance Society of Maryland: $150 million • MMIC Group: $128 million • Mutual Insurance Company of Arizona: $126 million • Controlled Risk Insurance Company of Vermont: $112 million • Zurich Financial Services NA Group: $109 million • Medical Mutual Group: $105 million • W.R. Berkley Corp.: $104 million

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• • •

White Mountains Insurance Group: ACE INA Group: Markel Corp.:

$101 million $ 99 million $ 98 million

32.3 Liability and Defensive Medicine In a 2010 survey of 5,825 physicians by the American Medical Association (www.ama-assn.org), 42% of respondents said they had been sued at least once; more than 20% had been sued twice. According to Emily Carrier, M.D., a senior health researcher at the Center for Studying Health System Change (www.hschange.com), what frightens most physicians is the arbitrary nature of malpractice lawsuits and how evidence suggests that the quality of care is not a good predictor of lawsuits. Many people actually injured by negligence don’t go on to sue, while some liability actions are based on frivolous claims.

32.4 Tort Reform A number of states have instituted tort reform to limit the size of damage awards by juries in medical malpractice cases. However, it is not clear that tort reform has reduced healthcare spending. One reason that liability caps are ineffective in reducing medical spending is because physicians continue with the same defensive practices independent of the amount of their liability. Texas, for example, has not seen healthcare spending drop since instituting award caps in 2003 that limit non-economic damages against physicians to $250,000. Jackson Healthcare reported that 80% of doctors in Texas said they still practice defensive medicine, with 64% reporting no change in their behavior since caps went in effect.

32.5 Claims According to The 2012 Hospital Professional Liability and Physician Liability Benchmark Analysis, by Aon (www.aon.com), U.S.-based hospitals faced more than 44,000 claims arising from incidents occurring in 2011, with liabilities exceeding an estimated $8.6 billion. Two key hospital risk areas, the obstetrics unit and the emergency department, contribute more than $1.4 billion and $1 billion, respectively, to overall cost. The rate of hospital professional liability claims (HLCs) is growing at 1% annually. The rate of HLCs declined at a 5% annual rate from 2000 through 2006, then began to increase gradually through 2011 and 2012. According to the Handbook of Health Economics, 40¢ of every dollar spent on malpractice insurance premiums goes toward awards; insurers spend much of the rest on legal fees.

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32.6 Malpractice Awards More than $4 billion is estimated to be paid out annually to settle malpractice claims against doctors, according to The Wall Street Journal. An exact figure is very difficult to determine, however, since settlements are often kept confidential. The contingent fees charged by plaintiffs’ lawyers vary widely and are often limited by law, but a common rate is 33% of any payment. Ninety-seven percent (97%) of cases are settled out of court. The average malpractice award is about $325,000, according to the Kaiser Family Foundation (www.kff.org). According to David Barry Jr., a Partner at Corby & Demetrino, while large jury verdicts get media attention, the average award in malpractice claims has been flat since the late-1990s.

32.7 Apologizing For Errors In a recent survey by the American College of Physician Executives (www.acpe.org), almost 80% of doctors said physicians and hospitals that make mistakes should apologize for errors. In a survey of patients, 57% said they would be less likely to sue if the provider issued an apology after an error; only 25% indicated that they would be more likely to sue. Since 2001, prominent institutions – from the Dana-Farber Cancer Institute to Johns Hopkins Hospital – have made it a policy to urge their doctors to own up to mistakes and to apologize, according to The Wall Street Journal. Consultants are increasingly in demand for seminars on how best to deliver lawsuit-deflecting apologies. At some medical schools, including Vanderbilt University School of Medicine, courses in communicating errors and apologizing are mandatory for medical students and residents. Even some insurers are beginning to urge their clients to acknowledge errors and to apologize. Since launching a program in which doctors admit errors and offer payments out of court, the University of Michigan Health System has cut claims in half. The University of Illinois Medical Center at Chicago (UIMC) has seen a similar response. _________________________________________________________________

“Research has shown that these institutions ... have improved patient safety, lowered liability costs, reduced their number of claims, and improved patients’ experiences.” Modern Healthcare _________________________________________________________________

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32.8 Frivolous Malpractice Lawsuits Frivolous lawsuits have greatly diminished in number since 2002, which was the peak of the malpractice insurance crisis. One reason is the high cost of litigation. Most cases require experts from multiple specialities to establish cause and pre-trial costs often exceed $200,000. Frivolous malpractice cases have virtually disappeared because lawyers have become increasingly selective of the cases they will accept. The threat of countersuits to frivolous claims is another factor. Companies like Medical Justice Corp. (www.medicaljustice.com), for instance, assist doctors in minimizing ‘get rich quick’ lawsuits by countersuing when lawsuits are considered frivolous. The approach appears to be effective. Of the 1,500 physicians subscribing to the service, only 2% have been sued.

32.9 Market Resources 2012 Hospital Professional Liability and Physician Liability Benchmark Analysis, Aon Corporation (www.aon.com), 2012. American Society for Healthcare Risk Management, One North Franklin, 28 th Floor, Chicago, IL 60606. (312) 422-4580. (www.ashrm.org) Medical Liability Monitor, 1100 Lake Street, P.O. Box 680, Oak Park, IL 60303. (312) 944-7900. (www.medicalliabilitymonitor.com)

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33 MEDICAL TOURISM

33.1 Traveling Abroad For Medical Procedures A study by McKinsey & Co. (www.mckinsey.com) estimated 60,000 to 85,000 patients from the U.S. travel abroad annually for treatment at foreign hospitals. Taking into account travel for cosmetic and dental procedures, the number of U.S. patients traveling abroad is much higher than the McKinsey & Co. estimate. Josef Woodman, author of Patients Beyond Borders (2007, Healthy Travel Media), estimated that more than 150,000 Americans travel abroad annually for healthcare. The Deloitte Center for Health Solutions (www.deloitte.com) put the number as high as 750,000. Paul Mango, director of the healthcare practice at McKinsey & Co., projects the potential market for Americans seeking lower-cost care abroad at 710,000 procedures a year. These 710,000 procedures, currently bringing $35 billion of revenue to U.S. hospitals, could be done overseas at a savings of about $15,000 per procedure. The extent that the overseas healthcare market develops will depend upon whether insurers, employers, and the U.S. government begin encouraging treatment abroad. Cost is the primary driver attracting U.S. patients to other countries. Compared to $50,000 or more for a heart bypass performed in the U.S., the procedure costs $8,000 to $15,000 in Thailand or India, for example. In addition to excellent medical care, services in Asia typically include limo pick-up and convalescence in a hotel.

33.2 Health Plans Encourage Medical Tourism Some healthcare insurers have launched initiatives to eventually allow coverage for overseas medical care for policyholders. Blue Cross & Blue Shield of South Carolina, one of the first to launch such a program, has alliances through its Companion Global Healthcare subsidiary with Bumrungrad International Hospital (Bangkok), Parkway Group Healthcare (owner of three hospitals in Singapore), and hospitals in Turkey, Ireland, and Costa Rica. According to Ruben Toral, president of the International Medical Travel Association (www.intlmta.org), three areas of concern limit employers and insurers in adopting medical tourism as a solution to lower healthcare costs: quality, liability, and continuity of care. Payers typically ask three basic questions: • How do I know these hospitals offer the same quality services as U.S. hospitals? • What happens if something goes wrong? • Who is responsible for delivering aftercare when patients return from overseas?

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33.3 Certified Foreign Hospitals The Joint Commission International (www.jointcommissioninternational.org), a not-for-profit subsidiary of the Joint Commission, which accredits U.S. hospitals, has certified 465 hospitals and healthcare providers outside the U.S. The number of certified organizations by country (as of June 2013) is as follows: • United Arab Emirates: 65 • Germany: 3 • Saudi Arabia: 58 • Lebanon: 3 • Brazil*: 51 • Chile: 2 • Turkey: 48 • Costa Rica: 2 • Thailand: 45 • Kazakhstan: 2 • South Korea: 38 • Kuwait: 2 • China: 28 • Oman: 2 • India: 23 • Panama: 2 • Ireland: 22 • Slovenia: 2 • Italy: 22 • Bahamas: 1 • Taiwan: 22 • Bahrain: 1 • Singapore: 21 • Bangladesh: 1 • Spain**: 20 • Barbados: 1 • Denmark: 15 • Belgium: 1 • Jordan: 12 • Bermuda: 1 • Portugal: 11 • Ecuador: 1 • Indonesia: 9 • Ethiopia: 1 • Israel: 8 • Greece: 1 • Malaysia: 8 • Mauritius: 1 • Mexico: 8 • Modova: 1 • Qatar: 7 • Netherlands: 1 • Japan: 7 • Nicaragua: 1 • Philippines: 5 • Nigeria: 1 • Austria: 4 • Pakistan: 1 • Czech Republic: 4 • Peru: 1 • Egypt: 4 • Russia: 1 • Columbia: 3 • Vietnam: 1 * accredited jointly by Joint Commission International and the Consortium for Brazilian Accreditation ** accredited jointly by Joint Commission International and the Fundac i’n Avedis Donabedian

33.4 Market Resources International Medical Travel Association, P.O. Box 9, Prasarnmitr Post Office, Bangkok, Thailand 10114. (www.intlmta.org) International Society for Quality in Health Care, 2 Parnell Square East, Dublin 1, Ireland. +353 1 871 7049. (www.isqua.org)

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Joint Commission International, 1515 W est 22nd Street, Suite 1300W, Oak Brook, IL 60523. (630) 268-4800. (www.jointcommissioninternational.org) Medical Tourism Association, 10130 Northlake Boulevard, Suite 315, West Palm Beach, FL 33412. (561) 791-2000. (www.medicaltourismassociation.com)

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34 MERGERS & ACQUISITIONS

34.1 Assessment The number of recent hospital mergers and acquisitions are as follows (source: Modern Healthcare): • • • • • • • • • • •

2002: 2003: 2004: 2005: 2006: 2007: 2008: 2009: 2000: 2011: 2012:

Number of Deals

Facilities Involved

60 68 81 85 107 103 91 85 89 92 109

163 100 164 172 331 214 139 131 227 212 352

_________________________________________________________________

“In the name of getting ready for a healthcare reimbursement environrment that places more emphasis on quality and continuity of care and less on fee-for-service payment, hospital executives increasingly are seeking to buy or sell hospitals using less-common ownership structures, helping to boost the number of deals in 2012.” Modern Healthcare, 1/28/13 _________________________________________________________________

34.2 Largest Deals Among the 109 hospital mergers and acquisitions in 2012, terms of only 12 were

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publically disclosed. Among these, the following were the largest deals: • Highmark (Pittaburgh, PA) acquired five acute-care hospitals from West Penn Allegheny Health System: • Marian Health System (Tulsa, OK) acquired the 44-bed St. John Broken Arrow (Arrow, OK): • Prime Healthcare Foundation (Ontario, CA) acquired the 202-bed Knapp Medical Center (Weslaco, TX):

$475 million $152 million $100 million

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35 OUTSOURCING

35.1 Overview Modern Healthcare estimates that at least three-quarters of hospitals outsource at least one hospital function. _________________________________________________________________

“Whether it’s called outsourcing, partnering or another term, hospitals and health systems continue to use that approach as they realize that much of the expertise and resources they need, especially in the new era of value-based care, aren’t available in-house. Driven by the near-desperate need to reduce operating costs to cope with lower reimbursement rates, they’re increasingly turning to outside contractors for services such as construction, medical staffing, food services and information technology to bridge the gap in a more cost-effective manner. In turn, the companies providing the services are reporting double-digit growth in their clients.” Modern Healthcare, 9/3/12 _________________________________________________________________

35.2 Outsourced Services According to Modern Healthcare’s 34th Annual Outsourcing Survey (September 2012), the top hospital department management contracts, ranked by number of healthcare facilities outsourcing various functions, are as follows:

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• • • • • • • • • • • • • • • • • • • •

Laundry: Housekeeping: Clinical/diagnostic equipment maintenance: Emergency departments: Food Services: Pharmacy: Security: Anesthesia: Parking: Medical records: Information systems: Facility operations/equipment maintenance: Hospital call centers: Marketing: Surgery urgent: Psychiatric: Accounts receivable: Nursing staff: Radiology: Other (including hospitalists, materials management, laboratories, and more):

7,990 4,278 2,526 1,324 758 464 380 380 344 256 210 152 149 145 116 110 98 92 73 1,113

35.3 Largest Outsourcing Firms By category, the following are the largest providers of outsourced services to hospitals: Clinical/Diagnostic Equipment Maintenance • TriMedx • HSS • Crest Services • ABM Industries Emergency Department • EmCare • TeamHealth • Schumacher Group • ECI Healthcare Partners • CEP America • Emergency Medicine Physicians • ApolloMD • Premier Physician Services • Emergency Medical Associates • Emergency Service Partners

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Foodservice • Morrison Management Specialists • Healthcare Services Group • HHA Services Housekeeping • Healthcare Services Group • ABM Industries • HHA Services • ISS Facility Services Information Systems • Anthelio Healthcare Solutions • Computer Sciences Corp. • McKesson Technology Solutions • CareTech Solutions Laundry • Angelica Corp. • Healthcare Services Group • Unitex • HHA Services Pharmacy • Comprehensive Pharmacy Services • Pharmacy Systems • TeamHealth

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36 PARTNERSHIP FOR PATIENTS

36.1 Overview In 2011, the Obama Administration launched Partnership for Patients: Better Care, Lower Costs, a public-private partnership aimed at helping to improve the quality, safety, and affordability of healthcare for all Americans. Partnership for Patients brings together leaders of major hospitals, employers, physicians, nurses, and patient advocates, along with state and federal governments, in a shared effort to make hospital care safer, more reliable, and less costly. Partnership for Patients has two primary goals, as follows: Keep Patients from Getting Injured or Sicker • By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010. Achieving this goal would mean approximately 1.8 million fewer injuries to patients, with more than 60,000 lives saved over three years. Help Patients Heal Without Complication • By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010. Achieving this goal would mean more than 1.6 million patients would recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge. Achieving these goals will save lives and prevent injuries to millions of Americans, and it has the potential to save up to $35 billion across the healthcare system – including up to $10 billion in Medicare savings – over the next three years. Over the next 10 years, Partnership for Patients could reduce costs to Medicare by about $50 billion as well as yield billions in Medicaid savings.

36.2 Pledged Organizations As of June 2013, more than 7,700 partners, including over 3,300 hospitals as well as physicians and nurses groups, consumer groups, and employers, had pledged their commitment to Partnership for Patients. Pledged organizations are identified at http://partnershippledge.healthcare.gov.

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36.3 Hospital Engagement Networks As part of Partnership for Patients, hospitals across the country have been given resources and support to make healthcare safer and less costly by targeting and reducing the millions of preventable injuries and complications from healthcare-acquired conditions. In 2011, $218 million was awarded to 26 hospital system organizations to becoming Hospital Engagement Networks (HENs). These networks help identify existing solutions that reduce healthcare-acquired conditions. These best practices are sharing with other hospitals and healthcare providers. _________________________________________________________________

“The initiative and the HENs have two overarching goals: Reduce hospital-acquired conditions by 40% and preventable all-cause 30-day readmissions by 20% by the end of 2013, using data from 2010 as a baseline. Reaching those targets, HHS says, could result in 1.6 million fewer readmissions, 1.8 million fewer patient injuries and 60,000 [saved] lives over the next three years.” Modern Healthcare, 5/21/12 _________________________________________________________________

Hospital Engagement Networks work to develop learning collaboratives for hospitals and provide a wide array of initiatives and activities to improve patient safety. They are required to conduct intensive training programs to teach and support hospitals in making patient care safer, to provide technical assistance to hospitals so that hospitals can achieve quality measurement goals, and to establish and implement a system to track and monitor hospital progress in meeting quality improvement goals.

36.4 Improving Care Transitions One of the ways Partnership for Patients achieves its goal of reducing preventable hospital readmissions is by focusing on reducing complications during transitions from one care setting to another, particularly for patients with multiple chronic conditions. In April 2011, Center for Medicare and Medicaid Services announced the opportunity for Community-based Organizations to apply for the Community-based Care Transitions Program (CCTP), which was authorized by Section 3026 of the Affordable Care Act. This program allows a community of healthcare and social

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services providers to design and propose a Medicare fee for services benefit to receive payment for care transitions. Programs are tailored to the unique needs of each community.

36.5 Market Resources Partnership for Patients (www.healthcare.gov/compare/partnership-for-patients/index.html)

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37 PATIENT COMMUNICATIONS

37.1 Health Literacy The Institute of Medicine (www.iom.edu) describes health literacy as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. An estimated 80 million Americans navigate the complexities of the U.S. health system without sufficient literacy skills. A recent article published in the Annals of Internal Medicine, which assessed nearly 100 studies, found moderate to strong evidence that poor literacy skills can result in difficulties with understanding how to take medications properly. Patients with lower health literacy also are more likely to use the emergency room for non-urgent care, and these patients also typically have higher risk of poor health. Health literacy is one of two dozen objectives promulgated by Healthy People 2020 (www.healthypeople.gov/2020/), an initiative of the U.S. Department of Health and Human Services. The Joint Commission (www.jointcommission.org) has increased its focus on patient communication by piloting new and updated standards. Those standards, which involve verbal and written communication, are expected to influence accreditation decisions in the near future.

37.2 Communications for Immigrant Patients Approximately 50 million people in the U.S., or 18% of the population over five years old, speak a language other than English at home, a 46% increase since 1990. Several studies have shown that language barriers can negatively affect health outcomes, patient satisfaction, efficient use of resources, and quality of care. Explaining the proper dosage and mode of administering medication often can be challenging even with English-proficient patients; a language barrier presents more substantial difficulties. A recent report by the Center for Community Health Research and Action at Brandeis University revealed that more than one-fourth of limited-English patients without interpreters do not understand medication instructions. According to Modern Healthcare, 1,661 community hospitals engage outside services for foreign-language translation.

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37.3 Communicating With Patients The Institute for Healthcare Advancement (www.iha4health.org) has created a list of the 10 most common errors providers make when communicating with patients, as follows: • Literature that accompanies medications is written at an 11 th grade reading level, rather than fifth-grade or lower, the level at which the majority of the country’s population reads. • There is communication in medical jargon when it is not necessary, including using terms like “otitis media” and “myocardial infarction” instead of “ear ache” and “heart attack” when informing patients of their condition. • Reading materials are developed in a type size too small. (Providers are urged to use at least 12-point type with plenty of white space.) • When giving verbal directions, patients are not asked to repeat the instructions back in his or her own words to guarantee that he or she clearly understands the information. • Given that more than 90 million U.S. citizens read no higher than a third-to-fifth grade level, literature is not always provided that can be understood. • Recognizing that a patient’s response of “yes” or a simple nod might mean the patient is ashamed to admit he or she doesn’t understand what he or she has been told. • Mass-produced brochures and bulletins displayed and distributed in doctors’ offices and clinics are not always kept up to date, easy to read, or in line with that of their own medical policies and recommendations. • Talking too fast does not allow patients time to understand or ask questions in response. • Directions such as “take with food” should read, “swallow one pill with water and eat some food” for patients who take every direction literally. Some patients have interpreted “take with food” to mean that the medication should be folded into food before trying to swallow it. • Medical information is not provided in the patient’s primary language. The institute estimates that more than $73 billion is spent annually in unnecessary healthcare expenses because of the inability of patients to understand what medical providers say to them.

37.4 Hospital Programs Ask Me 3, developed by the National Patient Safety Foundation (www.npsf.org), is one tool commonly used by hospitals in patient communications. Ask Me 3 puts focus on a patient’s understanding of three questions: What is my main problem? What do I need to do? W hy is it important for me to do this? Another approach is “teach back,” in which patients are asked to explain what they’ve just heard in their own words. The following are examples of some hospital communications programs:

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•

•

Boston University Medical Center has implemented a host of patientcommunications strategies, from stripping medical jargon out of brochures and consent forms to revamping hospital signs. The initiative includes Project RED (Re-Engineered Discharge Project), which redesigned the discharge process to make sure every detail in all written materials is clear to all patients, including those with limited literacy skills. The Iowa Health System, frequently cited as a literacy leader, launched its Health Literacy Collaborative in 2003. Recent efforts have included boosting literacy and sensitivity training not just among clinicians, but among all hospital staffers. _________________________________________________________________

“Someone working a transportation job, for example, might hear a patient who is confused about medical instructions and could alert a nurse. Also, sometimes people may feel more comfortable asking or talking to somebody who is not as formal as a doctor or a nurse.” Mary Ann Abrams, M.D., Director Health Literacy Collaborative Iowa Health System _________________________________________________________________

•

Twin Rivers Regional Medical Center (Kennett, MO) launched an initiative to help patients better understand medical instructions at discharge. Patients are given a recorded message pertinent to their diagnosis and care responsibilities along with written discharge materials.

_________________________________________________________________

“When you look at the cost-benefit analysis, if, by doing this, you could reduce your readmission rates by 2% or 3%, that makes it all worthwhile.” Steve Pu, M.D., Medical Director Twin Rivers Regional Medical Center _________________________________________________________________

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37.5 Market Resources AHRQ Health Literacy Universal Precautions Toolkit, Agency for Healthcare Research and Quality. (www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf) An Overview of the ReEngineered Discharge (RED) Toolkit, Agency for Healthcare Research and Quality. (http://bit.ly/oKI2aD) National Action Plan to Improve Health Literacy, U.S. Department of Health & Human Services. (www.health.gov/communication/hlactionplan) The Health Literacy Environment Activity Packet, Harvard School of Medicine. (www.hsph.harvard.edu/healthliteracy/files/activitypacket.pdf)

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38 PATIENT SATISFACTION

38.1 Patient Satisfaction Measurement The Centers for Medicare & Medicaid Services (CMS, www.cms.gov) and The Joint Commission (www.jointcommission.org) require that hospitals measure patient satisfaction. According to Modern Healthcare (April 2012), the following are the largest patient-satisfaction measurement firms ranked by total number of annual engagements: • National Research Corp. (www.nationalresearch.com): 33,223 • Press Ganey Associates (www.pressganey.com): 27,304 • HealthStream Research (www.healthstreamresearch.com): 8,455 • Professional Research Consultants (www.prconline.com): 5,553 • Strategic Healthcare Programs (www.shpdata.com): 3,022 • Deyta (www.deyta.com): 2,500 • DSS Research (www.dssresearch.com): 2,005 • National Business Research Institute (www.nbri.com): 784 • Sullivan/Luallin (www.sullivan-lualin.com): 754 • Jackson Group (www.jacksongroup.com): 392 • Arbor Associates (www.arbor-associates.com): 385 • J.L. Morgan & Associates (www.jlmorganassociates.com): 342 • Surgical Outcomes Information Exchange (www.soix.com): 128 • Rural Comprehensive Care Network (www.rccn.info): 120

38.2 Trends in Patient Satisfaction According to Hospital Pulse Report, by Press Ganey Associates (www.pressganey.com), overall patient satisfaction at U.S. community hospitals has steadily increased for five consecutive years. The Press Ganey assessment is based on survey responses from over 2.8 million patients who had inpatient stays at over 2,000 U.S. hospitals. Patient satisfaction is measured as the average response to 38 standard questions related to admission, rooms, meals, nurses, tests and treatments, visitation, physicians, discharge, personal issues, and overall satisfaction. Responses are reported on a 100-point scale (very good = 100; good = 75; fair = 50; poor = 25; very poor = 0). The overall Patient Satisfaction Score reported in the Hospital Pulse Report for all hospitals surveyed is as follows: • Inpatient care: 86.1 • Outpatient care: 92.0

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Inpatient satisfaction scores by age and gender are as follows: • • • • • •

Under 18: 18-to-34: 35-to-49: 50-to-64: 65-to-79: 80 and older:

Female

Male

90.1 88.9 91.8 92.8 93.3 92.4

90.2 89.0 90.3 91.6 92.6 91.8

Patients surveyed by Press Ganey ranked their highest priorities with respect to overall satisfaction as follows: Inpatient • Response to concerns/complaints made during your stay • Degree to which hospital staff addressed your emotional needs • Staff effort to include you in decisions about your treatment • Promptness in responding to the call button • How well nurses kept you informed Outpatient • Response to concerns/complaints made during your stay • Sensitivity to patient needs • Staff concern for questions and worries • Overall rating of care received during your visit • How well staff worked together to provide care

• • • • • • • • • • • • • • • • •

Overall satisfaction scores for medical practice specialities are as follows: Oncology, medical: 93.8 Cardiology (interventional): 92.9 Cardiovascular disease: 92.9 Optometry: 92.5 Pulmonary disease: 92.4 Nephrology: 92.3 Surgery, general: 92.2 Rheumatology: 91.9 Surgery, vascular: 91.9 Podiatry: 91.8 Family medicine: 91.7 Internal medicine: 91.7 Dermatology: 91.5 Ophthalmology: 91.4 Urology: 91.4 Obstetrics/gynecology: 91.3 Pediatrics: 91.2

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• • • • • • • •

Surgery, orthopedic: Endocrinology: Otolaryngology: Surgery, neurological: Gastoenterology: Orthopedics: Physical medicine & rehabilitation: Neurology:

91.1 91.0 91.0 91.0 90.9 90.9 90.9 90.8

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39 PATIENTS FROM OVERSEAS

39.1 Market Assessment U.S. hospitals provide some of the best medical care in the world and have always attracted wealthy foreigners. Most hospitals do not disclose their international patient volumes, but analysts estimate the number of foreign patients admitted to U.S. hospitals in the tens of thousands each year. The annual market is estimated at $1.8 billion. Shannon O’Kelley, executive director of international and corporate care at New York-Presbyterian Hospital, estimates that about 3% of U.S. inpatient admissions at academic medical centers and other specialized facilities come from abroad. Since patients typically bring family with them, each dollar that foreign patients spend on inpatient care is estimated to generate another $3 of spending elsewhere in the U.S. economy, including spending for lodging, hospitality, and shopping. Until relatively recently, only a handful of high profile U.S. medical centers were active outside the U.S. market. Now several hospitals across the country attract foreign patients. Baptist Health South Florida, a seven-hospital system, for example, serves about 12,000 patients from Latin America annually. Its Gamma Knife Center, in Coral Gables, draws a large number of patients with inoperable brain tumors.

39.2 Marketing Overseas Nine hospitals in the Philadelphia area joined to establish Philadelphia International Medicine (www.philadelphiamedicine.com), a group that focuses on attracting foreign patients. The group’s international services center helps patients and their families with interpreters and travel arrangements to the U.S. The top medical centers continue to expand their reach overseas. The Cleveland Clinic, for example, has a Global Patient Services program that focuses on the markets in India and Japan. And Johns Hopkins Hospital has dev eloped consulting and referral relationships with providers in India, Japan, and Singapore.

39.3 U.S. Hospitals Operating Abroad Several U.S. hospital systems have partnered with local governments overseas to operate hospitals and clinics abroad. The following are some examples: • In 2011, Cleveland Clinic opened a 360-bed hospital in Abu Dhabi. It also m anages

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• • •

Sheikh Khalifa Medical City, a network of healthcare facilities, also in Abu Dhabi. Harvard Medical School, through Partners Harvard Medical International, collaborated with Dubai’s Healthcare City to build University Hospital. Johns Hopkins Medicine has a 10-year deal with the United Arab Emirates to manage Tawam Hospital in Abu Dhabi. The University of Miami Hospital Miller School of Medicine is negotiating to open clinics in both Colombia and in the Caribbean. The hospital also hopes for expansions in Egypt, Saudi Arabia, and Haiti.

39.4 Market Resources Partners Harvard Medical International, 100 Cambridge Street, Suite 2002, Boston, MA 02114. (617) 535-6400. (www.partners.org) Philadelphia International Medicine, 1835 Market Street, 10 th Floor, Philadelphia, PA 19103. (215) 563-4733. (www.philadelphiamedicine.com)

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40 PAY-FOR-PERFORMANCE

40.1 Overview Pay-for-performance (P4P) programs pay bonuses to providers based on quality and patient safety data. There are two types of P4P models: • Incentives paid by payers to organizations • Incentives paid by organizations to physicians According to Med Vantage (www.medvantageinc.com), there are approximately 160 active P4P programs in the U.S. Many providers use incentives to reward physicians for consistency with the system’s priorities. At Geisinger Health System, in Pennsylvania, for example, 20% of physician compensation is based on quality of care and other performance measures.

40.2 Background Several initiatives launched in the early 2000s have brought P4P incentives into the mainstream. The following are the major pioneering efforts in the P4P field: • Bridges to Excellence (www.bridgestoexcellence.org) launched in 2002 as a plan to pay bonuses to physicians who provide optimum care for diabetes patients. The program now serves as a model for other groups entering the pay-for-performance arena. Some Blue Cross and Blue Shield groups have licensed the Bridges to Excellence model, as have United Health and Cigna. • The Integrated Healthcare Association (IHA, www.iha.org) includes six California HMOs covering approximately 45,000 doctors and eight million patients. Insurers allied with IHA pay $50 million annually in bonuses to physicians. • In 2003, Centers for Medicare & Medicaid Services (CMS, www.cms.gov) and hospital alliance Premier (www.premierinc.com) launched the Hospital Quality Incentive Demonstration project, with 274 hospitals participating. Under the project, hospitals in the top 10% in five clinical areas – coronary artery bypass graft, heart attack, heart failure, hip and knee replacement, and pneumonia – received a 2% bonus Medicare payment based on outcomes. CMS followed this pilot project with a program focusing on a set of 10 hospital quality measures which, if complied with, increase the payments that hospitals receive for each discharge. Those hospitals that do not meet a threshold on quality are subject to reductions in payment.

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40.3 Outlook After a decade of experience with some proven successes, the future of P4P remains unclear. The concept of P4P is attractive when compared with traditional payment methods that may actually reward less-safe care, since some insurance companies will not pay for new practices to reduce errors, while physicians and hospitals can bill for additional services that are needed when patients are injured by mistakes. However, negative incentive models – eliminating payments for medical errors or increased costs – are gaining in popularity while P4P models linger as pilot programs. Among P4P programs there is little to no consistency. A study by PricewaterhouseCoopers (www.pwc.com) found great variation exists among commercial health plans’ P4P programs. Among nearly 60 indicators of physician performance being used by plans surveyed, no one indicator was used by all plans being studied. Also among the plans surveyed, no two reimbursement providers assessed performance in the same way, and all were administered differently. Critics of the P4P concept argue that care for patients with serious and complex illnesses is too complex to accurately attribute singular responsibility for the outcome of care for such patients. A study analyzing Medicare beneficiaries’ healthcare visits showed that a median of two primary care physicians and five specialists provide care for a single patient. _________________________________________________________________

“Pay-for-performance initiatives that provide incentives for good performance on a few specific elements of a single disease or condition may lead to neglect of other, potentially more important elements of care for that condition or a comorbid condition. The elderly patient with multiple chronic conditions is especially vulnerable to this unwanted effect of powerful incentives.” American College of Physicians Ethics _________________________________________________________________

Researchers from the Harvard School of Public Health found that performance measures used to evaluate and reward physicians and hospitals have shifted from a focus on processes of care to emphasis on patient outcomes, cost efficiency, and use of information technology. They found, for example, a sharp increase in use of outcome measures to reward physician and hospital behavior, with less focus on processes such as keeping rates of mammography screening high. Pay-for-

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performance adopters are now basing rewards on such things as whether diabetic patients have actually achieved healthy cholesterol levels and blood pressure rates, not just whether or not a doctor has prescribed pills.

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41 POST-ACUTE & LONG-TERM CARE

41.1 Market Assessment Post-acute care includes services at home health agencies, inpatient rehabilitation hospitals, long-term care hospitals, and skilled nursing facilities. In addition to skilled nursing facilities, long-term care is also provided by assisted living facilities. Home care is assessed in Chapter 21 of this handbook. This chapter assesses all other categories of post-acute and long-term care. According to the National Clearinghouse For Long-Term Care Information (www.longtermcare.gov), about 9 million Americans over the age of 65 needed long-term care services in 2012. By 2020, that number will increase to 12 million. While most people who need long-term care are age 65 or older, a person can need long-term care services at any age. Forty percent (40%) of people currently receiving long-term care are adults ages 18-to-64 years old. According to the Medicare Payment Advisory Commission (MedPAC, www.medpac.gov), annual Medicare spending on long-term care is over $55 billion.

41.2 Hospital Discharge To Long-Term Care According to Hospitals & Health Networks, 13% of hospital patient discharges, or about 5 million patients each year, are to long-term care or other post-acute facilities. Among these patients, the risk-adjusted rate of potentially avoidable re-hospitalization within 100 days is 18.5%, according to MedPAC.

41.3 Market Leaders According to Modern Healthcare (July 2012), the largest post-acute-care companies, ranked by annual net revenue, are as follows: • • • • • • • •

Kindred Healthcare: Select Medical Holdings Corp.: Golden Living: Genesis HealthCare Corp.: Brookdale Senior Living: Sun Healthcare Group: Amedisys: Sunrise Senior Living:

Type

Facilities

LTAC LTAC SNF SNF ALF SNF HHH ALF

465 1,073 320 231 650 199 529 269

States

46 45 21 13 36 47 41 31

Revenue

$5.52 billion $2.80 billion $2.80 billion $2.70 billion $2.46 billion $1.93 billion $1.47 billion $1.31 billion

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• • • • • • • • • • • • • • • • •

Five Star Quality Care: Emeritus Senior Living: Evangelical Lutheran Good Samaritan Society: Covenant Care: Vibra Healthcare: Alden Management Services: UPMC Community Provider Services: Athena Health Care Systems: Benedictine Health System: Apple Health Care: Cornerstone Affiliates: Acuity Healthcare: Christus Continuing Care: Good Shepard Rehabilitation Network: Silverado Senior Living: Front Porch: Ecumen:

ALF ALF

255 478

30 44

$1.28 billion $1.25 billion

SNF SNF LTAC SNF SNF SNF CCRC SNF CCRC LTAC LTAC RH ALF CCRC ALF

227 55 49 35 17 27 44 26 11 12 16 42 36 12 56

24 7 11 2 1 3 7 2 4 5 6 2 6 1 4

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $

958 million 514 million 443 million 352 million 328 million 298 million 215 million 203 million 200 million 189 million 189 million 187 million 167 million 160 million 142 million

ALF = Assisted-living facility CCRC = Continuing-care retirement communities HHH = Hospice/home health LTAC = Long-term acute-care hospitals OCF = Outpatient care facilities RH = Rehabilitation hospitals SNF = Skilled nursing facilities

41.4 Assisted-Living Facilities Assisted living is defined as a housing option for older adults that promotes independence and autonomy while also providing services to assist individuals with daily living. Facilities can range in size from a small house to a large apartment-style complex; most have between 25 and 125 units. According to the National Investment Center for the Seniors Housing & Care Industry (www.nic.org), more than 900,000 Americans live in approximately 39,500 assisted-living residences. The average age of an assisted-living resident is 86.9 years old. The average length of stay in an assisted-living facility is approximately 28.3 months. The senior assisted care business is an $18 billion to $20 billion annual industry , according to the Assisted Living Federation of America (ALFA, www.alfa.org). According to the 2012 Market Survey of Long-Term Care Costs, by the MetLife Mature Market Institute (www.metlife.com/mmi), the average monthly base price for assisted-living communities is $3,447, or $41,724 annually. The highest cost was reported in Washington, DC, at $5,757 per month. The lowest was in non-metropolitan areas of Arkansas, at $2,156. According to MetLife, 59% of assisted-living facilities offer dementia care; the additional costs for these services average $1,110 per month.

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41.5 Long-Term Acute-Care Hospitals Long-term acute-care hospitals (LTACHs) are designed to offer a post-acutecare transfer option for patients who need more care than is available at nursing facilities or rehab units and for longer periods of time than at short-term acute-care hospitals. LTACHs are designed to provide extended medical care and rehabilitation. Many patients at LTACHs are very sick. While usually in stable condition, they may be on dialysis, need a ventilator, or have wounds that will not heal. If those patients need surgery or suffer serious medical emergencies, they are usually transferred back to general hospitals. Certification of LTACHs has been required since the inception of the Medicare program in 1965. There are some 415 LTACHs across the U.S., with an average of about 60 beds per facility. Combined, they treat about 200,000 patients a year, including 130,000 Medicare patients. With 89 long-term hospitals, Select Medical Corporation (www.selectmedicalcorp.com) is the largest LTACH system. LTACHs are usually reimbursed at a higher rate than other post-acute settings. Given that reimbursement rates are highest for LTACHs, the CMS limits the number of patients that LTACHs located inside short-term acute-care hospitals can take from the host hospital. Since 2008, LTACHs have been permitted to accept only a maximum of 25% of patients from the host hospital. Rules exempt LTACHs that aren’t located inside a short-term acute-care hospital, and co-location within SNFs is allowed. Co-locating can achieve some economies of scale because of shared resources, such as caregivers used to treat patients in both settings. The symbiotic relationship can improve the bottom line for both units because it can make the LTACH more efficient and increase revenue at the SNF. The cost to retrofit a nursing home with an LTAC hospital is about $1 million to $3 million, compared with the $10 million to $20 million price tag to build a freestanding LTACH.

41.6 Rehabilitation Hospitals Rehabilitation providers treat a wide range of patients, such as those with spinal cord injuries, orthopedic problems, arthritis, or cancer. Some patients include those recovering from accidents and sports injuries. HealthSouth Corp. (www.healthsouth.com) is, by far, the largest rehabilitation facility operator. The following are other rehabilitation hospital systems (source: Modern Healthcare): • Allied Services (www.allied-services.org) • Baylor Institute for Rehabilitation (www.bhcs.com) • Brooks Rehabilitation (www.brookshealth.org) • Carolinas Rehabilitation (www.carolinasrehabilitation.org) • Casa Colina Centers for Rehabilitation (www.casacolina.org) • Doctor Robert L. Yeager Health Center (www.co.rockland.ny.us/Hospitals/)

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• • • • • • • • • •

Good Shepherd Rehabilation Network (www.gsmc.org) Madonna Rehabilitation Hospital (www.madonna.org) MedStar National Rehabilitation Network (www.nrhrehab.org) Rancho Los Amigos Medical Center (www.rancho.org) RehabCare Group (www.rehabcare.com) Select Medical Corporation (www.selectmedicalcorp.com) Spaulding Rehabilitation Network (www.spauldingnetwork.org) UPMC Community Provider Services (www.upmc.com) Vibra Healthcare (www.vibrahealthcare.com) Warm Springs Rehabilitation System (www.warmsprings.org)

41.7 Skilled Nursing Facilities According to the Nursing Facility Operational Characteristics Report, published in March 2013 by the American Health Care Association (www.ahcancal.org), there are 15,681 skilled nursing facilities in the United States, with a combined total of 1.67 million beds and 1.38 million patients. According to the Centers for Medicare and Medicaid Services (www.cms.gov), national expenditures for nursing home care in 2011 (most recent data available) were $145.6 billion. Medicare SNF spending, alone, totals about $25 billion. Approximately 75% of nursing homes are owned by for-profit chains. By comparison, only 15% of hospitals are owned by for-profit chains. The largest chains are as follows (source: Modern Healthcare [August 2012]): • • • • • • • • • •

Golden Living (www.goldenliving.com): HCR Manor Care (www.hcr-manorcare.com): Kindred Healthcare (www.kindredhealthcare.com): Genesis HealthCare (www.genesishcc.com): Sun Healthcare Group (www.sunh.com): Evangelical Lutheran Good Samaritan Society (www.good-sam.com): Covenant Care (www.covenantcare.com): Brookdale Senior Living (www.brookdaleliving.com): Five Star Quality Care (www.fivestarseniorliving.com): Alden Management Services (www.thealdennetwork.com):

Facilities

Beds

304 279 220 206 179

31,060 n/a 26,663 25,408 22,860

63 51 41 40 30

4,083 5,738 3,977 3,694 4,512

According to the 2012 Market Survey of Long-Term Care Costs, the average daily rate for a private room in a nursing home is $229, or $83,585 annually. Costs range from $655 per day in Alaska (statewide) to $141 per day in Baton Rouge and Shreveport, Louisiana. For semi-private rooms, the average daily cost is $205.

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41.8 Market Resources American Health Care Association, 1201 L Street NW , Washington, DC 20005. (202) 842-4444. (www.ahcancal.org) American Seniors Housing Association, 5225 Wisconsin Avenue NW, Suite 502, Washington, DC 20015. (202) 237-0900. (www.seniorshousing.org) Leading Age, 2519 Connecticut Avenue NW, Washington, DC 20008. (202) 783-2242. (www.leadingage.org) MetLife Mature Market Institute, 57 Greens Farms Road, Westport, CT 06880. (203) 221-6580. (www.metlife.com/mmi) National Center for Assisted Living, 1201 L Street NW, Washington, DC 20005. (202) 842-4444. (www.ahcancal.org/ncal) National Investment Center for the Seniors Housing & Care Industry, 1997 Annapolis Exchange Parkway, Suite 110, Annapolis, MD 21401. (410) 267-0504. (w ww.nic.org)

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42 PREPAREDNESS

42.1 Overview Major disasters and pandemic threats of the early-2000s have forced hospitals to increase their focus on emergency preparedness. Fortunately, preparing for one disaster essentially establishes preparedness for them all, as disaster preparedness planning relies on much of the same infrastructure and organizations. The development of a unified approach to disaster preparedness is based on a f undamental concept in disaster planning that cities and response organizations should deal with all disaster risks and contingencies at once by using the same preparedness and emergency response infrastructure. Even though any one disaster is unlikely, the number of possible catastrophes raises the likelihood that at least one w ill strike. The best preparedness approach, most experts say, is to plan for all hazards, concentrating on the common elements shared by most disasters, rather than planning separately for an individual event. It doesn’t matter whether it’s a hurricane, terrorist attack, or pandemic.

42.2 Preparedness for Terrorists Threats The federal government has implemented several major programs in bioterrorism-related homeland security efforts, including the following: • The HHS Command Center, which was planned shortly after the 9/11 attacks, opened in 2004. • Project Bioshield, launched in 2004, provides $5.6 billion through 2014 to help the government buy, develop, and deploy cutting-edge defenses against catastrophic attacks. The law allows the government to buy and stockpile vaccines and antidotes, accelerate, and, in an emergency, distribute the supplies before FDA approval. • The federal government has constructed 27 federal Centers for Public Health Preparedness across the U.S., each focusing on biological threats. The centers are as follows: - Columbia Mailman Center for Public Health Preparedness - Emory University - Emory Center for Public Health Preparedness - Harvard University Center for Public Health Preparedness - Johns Hopkins University Center for Public Health Preparedness - Loma Linda University Center for Public Health Preparedness - Saint Louis University Heartland Center for Public Health Preparedness - State University of New York at Albany Center for Public Health Preparedness

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-

Texas A & M Center for Rural Public Health Preparedness The Ohio State University - Ohio Center for Public Health Preparedness Tulane University - South Central Center for Public Health Preparedness University of Alabama at Birmingham - South Central Center for Public Health Preparedness University of Arizona, College of Public Health University of California at Berkeley-Center for Infectious Disease Preparedness University of California at Los Angeles - UCLA Center for Public Health and Disasters University of Illinois at Chicago - Illinois Public Health Preparedness Center University of Iowa - Upper Midwest Center for Public Health Preparedness University of Medicine and Dentistry of New Jersey - New Jersey Center for Public Health Preparedness at UMDNJ University of Michigan Center for Public Health Preparedness University of Minnesota Center for Public Health Preparedness University of North Carolina Center for Public Health Preparedness University of Oklahoma - Southwest Center for Public Health Preparedness University of Pittsburgh Center for Public Health Practice University of South Carolina Center for Public Health Preparedness University of South Florida - Florida Center for Public Health Preparedness University of Texas Center for Biosecurity and Public Health Preparedness University of Washington - Northwest Center for Public Health Practice Yale Center for Public Health Preparedness

The federal government has invested over $20 billion in bioterrorism preparedness. But with only $2 billion of this funding directed to assist healthcare providers at the local level, warnings persist about insufficient medications, vaccines, and distribution systems in the event of a chemical or biological attack. The American Hospital Association (AHA, www.aha.com) estimated that $11.3 billion is needed by U.S. hospitals for bioterrorism preparedness.

42.3 Preparedness for Natural Disasters For emergency planners, Hurricane Katrina challenged a long-held assumption: that help will arrive within 24-to-48 hours. After that disaster, most medical centers initiated new preparedness measures. Through years of dealing with hurricanes, disaster plans are well established in Florida. When hurricanes approach, the state activates its Emergency Operations Center in Tallahassee, and 67 county emergency coordinators have twice-daily telephone briefings. Hospitals and nursing homes have representatives in the state operation center before and during storms. The 240 hospitals in the state don’t rely on immediate outside help, according to Rich Rasmussen, a vice president at the Florida Hospital Association (www.fha.org). When hurricanes approach, Florida hospitals generally discharge patients who can

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safely go home, postpone elective surgeries, and determine if any patients should be evacuated. In California, hospital disaster planning includes seismic design or redesign of building structures. California law requires hospitals to ensure by 2013 that their buildings will withstand a major tremblor and to guarantee that by 2030 the buildings could continue operating after a quake. State officials have estimated that 40% of all hospital buildings need upgrades to meet the standards, which could cost the state’s hospitals up to $41 billion.

42.4 Preparedness for a Influenza Pandemic The threat of, and preparedness for, an influenza pandemic is discussed in Chapter 121 of this handbook.

42.5 Funding Funding grants through the Hospital Preparedness Program, administered by the HHS Office of the Assistant Secretary for Preparedness (www.phe.gov), totaled $353 million in FY2011, a decline from the peak funding of $398 million in FY2003 and FY2004. Funding through the Public Health Emergency Preparedness Cooperative Agreement, administered through the Centers for Disease Control and Preparedness (www.cdc.gov/phpr/coopagreement.htm), was $633 million, a decline from the peak of $970 million in FY2003.

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43 PREVENTABLE MEDICAL ERRORS

43.1 Never Events The National Quality Forum (NQF, www.qualityforum.org) has published a list of 28 so-called never events – errors that should never occur in a hospital. Payers have embraced the list and some now withhold payment if a never event happens. The NQF never events are as follows: Surgical Events • Surgery performed on the wrong body part • Surgery performed on the wrong patient • Wrong surgical procedure on a patient • Retention of a foreign object in a patient after surgery or other procedure • Intraoperative or immediately post-operative death in a normal-health patient Product or Device Events • Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility • Patient death or serious disability associated with the use or function of a device in patient care in which the device is used for functions other than as intended • Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility Care Management Events • Patient death or serious disability associated with a medication error • Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products • Maternal death or serious disability associated with labor or delivery on a low-risk pregnancy while being cared for in a healthcare facility • Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility • Death or serious disability associated with failure to identify and treat hyperbilirubinemia in neonates • Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility • Patient death or serious disability due to spinal manipulative therapy • Artificial insemination from the wrong donor

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Patient Protection Events • Infant discharged to the wrong person • Patient death or serious disability associated with patient elopement (disappearance) for more than four hours • Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility Environmental Events • Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility • Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances • Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility • Patient death associated with a fall while being cared for in a healthcare facility • Patient death or serious disability associated with the use of restraints or bed rails while being cared for in a healthcare facility Criminal Events • Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider • Abduction of a patient of any age • Sexual assault on a patient within or on the grounds of a healthcare facility • Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

43.2 Non-Reimbursement The Centers for Medicare and Medicaid Services (www.cms.gov) has taken action to reduce medical errors, including no longer paying hospitals for treating eight particular preventable medical errors. The following ‘complicating conditions’ have been deemed non-reimbursable: • Stage III and IV pressure ulcers • Falls or trauma resulting in fractures, burns, or other serious injuries • Foreign object accidentally left behind after surgery • Air embolism • Blood incompatibility • Vascular catheter-associated infections • Catheter-associated urinary tract infections • Mediastinitis after coronary artery bypass graft, a surgical site infection Reimbursement policies in several state Medicaid programs followed Medicare in not reimbursing for certain never events. Such state policies include the following:

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•

• • • •

The California Association of Health Plans passed a resolution in favor of no longer paying for the CMS’ list of eight conditions as well as three other preventable mistakes. Massachusetts officials announced the state would no longer pay for care related to the 28 serious reportable events as defined by the National Quality Forum. The New York State Medicaid program has stopped paying for the eight hospitalacquired conditions identified by Medicare. Maine and Pennsylvania passed laws that preclude hospitals from billing patients if an error occurs. The Tennessee Hospital Association approved a policy for hospitals not to seek payment from patients or their insurance companies for care related to serious preventable adverse events.

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44 PRIMARY CARE

44.1 Physician Visits According to the National Center for Health Statistics (www.cdc.gov/nchs), there are 465 million visits to doctors’ offices each year. Including visits to hospitals and clinics, the total number of medical visits is 1.1 billion. Approximately 350 million doctor visits are made each year for acute medical care. The number of doctor visits has increased 26% over the past decade, a rise attributed in large part to the growing elderly population. _________________________________________________________________

“Slightly more than 40% of U.S. physicians deliver primary care.” Modern Healthcare, 1/30/12 _________________________________________________________________

A national survey by Rand Corporation (www.rand.com) and the University of Pittsburgh School of Medicine found that 80% of people have a personal doctor. A survey by Gallup (www.gallup.com) found that 71% of American adults had been to a doctor, nurse practitioner, or physician assistant at least once in the previous six months. The following are percentages among individuals with specific healthrelated attributes: • Define their health status as “excellent” or “good”: 76% • Define health as “fair” or “poor”: 87% • Aged 50 and older: 81% • Very/somewhat overweight: 78% • Smoke every day: 71% According to IMS Health (www.imshealth.com), the following are the leading diagnoses by total number of patient visits for primary care: • Essential hypertension: 86 million • Diabetes mellitus without complications: 42 million • Hyperlipidemia: 32 million • Acute respiratory infection: 27 million • Otitis media: 22 million HEALTHCARE BUSINESS MARKET RESEARCH HANDBOOK 2013-2014

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• • • • •

Depressive disorder: Chronic sinusitis: Asthma: Esophagitis: Allergic rhinitis:

20 million 17 million 17 million 17 million 16 million

44.2 Efficient Use Of Primary Care Primary care generally provides the most efficient and cost-effective treatment for most conditions requiring medical attention. Yet for a variety of reasons, patients often go to a hospital emergency room or specialist for their ailments. Trips to the emergency room average $1,500 a visit, more than 10 times the cost of a typical office visit to a primary care physician. A study directed by Prof. Stephen R. Pitts, M.D., at the Emory University School of Medicine, published in Health Affairs, found that 28% of acute-care visits take place in emergency rooms, including almost all of the visits made on weekends and after office hours. More than half of acute-care visits made by patients without health insurance are to emergency rooms, which are required by federal law to screen any patient who arrives there.

44.3 Strengthening Primary Care Access to primary care physicians is critical to the healthcare system. According to the American College of Physicians (www.acponline.org), the proportion of primary care doctors in a community is relative to health outcomes and system costs. A study by researchers from the Johns Hopkins University School of Medicine published in the American Journal of Medicine assessed that a 15% increase in the number of primary care physicians in a metropolitan area would yield the following benefits: • Reduced emergency department visits by 10.9% • Reduced number of surgeries by 7.2% • Reduced inpatient admissions by 5.5% • Reduced outpatient visits by 5.0% In a metropolitan area with a population of 775,000, increasing the proportion of primary care physicians from 35% to 40% would yield the following: • Reduced emergency department utilization by 15,000 visits a year • Reduced surgery by about 2,500 cases a year • Reduced hospital admissions by 2,500 a year, saving an estimated $23 million According to Merritt Hawkins & Associates (www.merritthawkins.com), a physician search firm, primary care physicians are in greater demand today than any other type of doctor.

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_________________________________________________________________

“The health reform law means the demand for primary care will increase dramatically beginning in 2014. Even with growth in midlevels, provider supply will continue to be a challenge.” 2012 Environmental Scan American Hospital Association _________________________________________________________________

44.4 Medical Homes The ‘medical home’ concept is a model in which a physician receives compensation for coordinating patient care that enhances patient access to p hysicians and engages patients in their own care management. Patients suffering from one or more chronic disease often depend on several doctors who rarely communicate with one another. This lack of care coordination means it’s nearly impossible to arrange complementary treatments, cross-check prescriptions, and avoid ordering the same diagnostic tests over and over. The medical home model could reduce these duplications and f ollow-up care costs, saving an estimated $25 billion to $50 billion a year. The following are some pilot programs testing the medical home concept: • Nationwide, 27 of 39 Blue Cross Blue Shield insurers are testing some type of medical home pilot. • Bridges to Excellence (www.bridgestoexcellence.org) is testing the approach with an incentive plan that pays annual rewards of up to $125 per patient per year to physicians who demonstrate medical homes for patients connected to proven positive outcomes. • Six Pennsylvania insurers, including Independence Blue Cross and Aetna, are spending $13 million over three years to help doctors in 32 primary care practices set up medical homes. In the Healthcare Leaders Opinion Survey, conducted by The Commonwealth Fund (www.commonwealthfund.org) and Modern Healthcare, 84% of respondents supported providing supplemental payments to primary-care physicians – on top of fee-for-service payments – for delivering comprehensive, coordinated, and accessible care. The concept is supported by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association. The AARP and employers including IBM, Dow Chemical, and

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General Motors advocate medical homes. According to Modern Healthcare, the following are the largest medical home practices, ranked by number of annual patient visits: • Allina Hospitals & Clinics (Minneapolis, MN): 1.66 million • Fairview Health Services (Minneapolis, MN): 1.23 million • Open Door Family Medical Center (Ossining, NY): 196,303 • Care Network of the Children’s Hospital of Philadelphia (Philadelphia, PA): 83,660 • Sentara Healthcare (Norfolk, VA): 65,312 • Clarkstown Pediatrics (Nanuet, NY): 60,000 • Westchester Health Associates (Katonah, NY): 60,000 • Cambridge Health Alliance (Cambridge, MA): 43,456 • Southeast Texas Medical Associates (Beaumont, TX): 38,325 • Summit Medical Group (Berkeley Heights, NJ): 33,955 • Providence St. Peter Family Medicine Residency Program (Olympia, WA): 28,000 • Barry Pointe Family Care (Kansas City, MO): 17,975 • Belmar Family Medicine (Lakewood, CO): 10,000

44.5 Concierge Physician Practices Concierge practices provide retainer-based primary care to a limited group of patients. Limiting the number of patients they serve allows concierge physicians to spend more time with each person. _________________________________________________________________

“Services generally include enhanced access to physicians – sometimes even 24-7 – as well as lengthy, in-depth annual physical exams that include diagnostic testing as well as an extensive battery of screening tests. The practices, which can work in conjunction with Medicare and private insurance, often offer same-day or nextday appointments, ready physician access via e-mail and longer visits in general.” Modern Healthcare _________________________________________________________________

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Such practices typically cater to affluent clients, with typical retainer fees of $1,500 to $2,000 annually. At the high end, Guardian 24/7 (www.guardian247.com), founded by former White House physicians, charges from $6,000 to $12,000 a month, plus an additional $700,000 for one of the company’s top-of-the-line ‘ready rooms’ installed in a client’s home, yacht, or airplane. Concierge practices have been a growing niche in primary care since about 2000, but the concept is nothing new. In Florida some upper-middle-class retirees for years have paid extra fees for easy access to a doctor. Business models are evolving that make retainer-based care available to people who are not wealthy. In Seattle, for instance, Qliance Medical Group (www.qliance.com) charges monthly fees between $50 and $130, depending on age, for such access. Hybrid business models are also emerging, with some practices providing concierge-type services for patients who pay a premium along with traditional levels of care for the general public. Several chains serve the concierge market, the largest of which are MD2 (www.md2.com), with about 500 affiliated concierge physicians, MDVIP (www.mdvip.com), and Concierge Choice Physicians (www.choice.md).

44.6 Market Resources American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS 66211. (800) 274-2237. (www.aafp.org) American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, IL 60007. (847) 434-4000. (www.aap.org) American Academy of Private Physicians, P.O. Box 5129, Glen Allen, VA 23058. (877) 746-7301. (www.aapp.org) American College of Physicians, 190 North Independence Mall W est, Philadelphia, PA 19106. (800) 523-1546. (www.acponline.org) American Medical Association, 515 North State Street, Chicago, IL 60610. (800) 621-8335. (www.ama-assn.org) Medical Group Management Association, 104 Inverness Terrace East, Englewood, CO 80112. (303) 799-1111. (www.mgma.com) The Physicians Foundation, 77 Summer Street, 8th Floor, Boston, MA 02110. (617) 399-0417. (www.physiciansfoundation.org)

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45 PROFILE OF U.S. HOSPITALS

45.1 Data Summary Hospital Statistics 2012™, by the American Hospital Association (www.aha.org), provides the following data on U.S. hospitals: • Total number of all U.S. registered hospitals: 5,754 - U.S. community hospitals*: 4,985 - Non-government not-for-profit community hospitals: 2,904 - State and local government community hospitals: 1,068 - Investor-owned (for-profit) community hospitals: 1,013 - Non-federal psychiatric hospitals: 435 - Federal government hospitals: 213 - Non-federal long-term care hospitals: 111 - Hospital units of institutions (prison hospitals, college infirmaries, etc.): 10 •

Total staffed beds in all U.S. registered hospitals: - Staffed beds in community hospitals:

941,995 804,943

•

Total admissions in all U.S. registered hospitals: - Admissions in community hospitals:

• •

Number of urban community hospitals: Number of rural community hospitals:

2,998 1,987

• •

Number of community hospitals in a system**: Number of community hospitals in a network***:

2,941 1,508

36,915,331 35,149,427

* Community hospitals are defined as all non-federal, short-term general, and other special hospitals. Other special hospitals include obstetrics and gynecology; eye, ear, nose, and throat; rehabilitation; orthopedic; and other individually described specialty services. Community hospitals include academic medical centers or other teaching hospitals if they are non-federal short-term hospitals. Excluded are hospitals not accessible by the general public, such as prison hospitals or college infirmaries. ** System is defined by AHA as either a multi-hospital or a diversified single hospital system. A multihospital system is two or more hospitals owned, leased, sponsored, or contract managed by a central organization. Single, freestanding hospitals may be categorized as a system by bringing into membership three or more, and at least 25%, of their owned or leased non-hospital pre-acute or post-acute healthcare organizations. System affiliation does not preclude network participation.

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*** Network is a group of hospitals, physicians, other providers, insurers and/or community agencies that work together to coordinate and deliver a broad spectrum of services to their community. Network participation does not preclude system affiliation.

45.2 Utilization Inpatient, emergency department, and outpatient utilization in community hospitals is as follows (source: Hospital Statistics 2012): • Total inpatient admissions: 35,527,377 • Inpatient admissions per 1,000: 115.7 • Total inpatient days: 192,656,804 • Inpatient days per 1,000: 627.5 • Inpatient surgeries: 10,110,980 • Average length of stay: 5.4 • Emergency department (ED) visits: 127,300,000 • ED visits per 1,000: 415 • Outpatient visits: 641,953,442 • Outpatient visits per 1,000: 2,091.0 • Outpatient surgeries: 17,357,534

45.3 Financial Performance Hospital revenue and profit margins have been as follows (source: American Hospital Association): • • • • • • • • •

2002: 2003: 2004: 2005: 2006: 2007: 2008: 2009: 2010:

Total Revenue

Profit Margin

$435.8 billion $472.7 billion $507.5 billion $544.7 billion $587.1 billion $626.3 billion $643.6 billion $690.5 billion $730.9 billion

4.4% 4.8% 5.2% 5.3% 6.0% 6.9% 2.6% 5.0% 7.2%

45.4 Hospital Services The following percentages of U.S. community hospitals offer specialized healthcare services (source: American Hospital Association): • Birthing, labor, and delivery: 65% • Chemotherapy: 57% • Sleep center: 49% • Sports medicine: 40% • Ambulatory surgery center: 24%

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• • • • •

Dental services: Bariatric/weight control: Complementary medicine services: Alzheimer’s center: Free-standing emergency center:

23% 22% 21% 4% 4%

The following percentages of U.S. community hospitals provide services beyond traditional inpatient and outpatient care (source: Hospital Statistics 2012): • Home health service: 61% • Hospice: 62% • Skilled nursing facility: 39% • Meals on wheels: 21% • Assisted living: 15% • Other long-term care: 14%

45.5 State-by-State According to Hospital Statistics 2012, hospitals across the U.S. average 2.66 beds per 1,000 population. The average length of stay is 5.5 days. By state, these figures are as follows: • • • • • • • • • • • • • • • • • • • • • • •

Alabama: Alaska: Arizona: Arkansas: California: Colorado: Connecticut: Delaware: District of Columbia: Florida: Georgia: Hawaii: Idaho: Illinois: Indiana: Iowa: Kansas: Kentucky: Louisiana: Maine: Maryland: Massachusetts: Michigan:

Beds per 1,000

Avg. Stay

3.25 2.19 2.04 3.31 1.86 2.06 2.26 2.40 5.76 2.87 2.59 2.29 2.19 2.62 2.69 3.42 3.59 3.27 3.53 2.72 2.09 2.35 2.59

5.2 5.9 4.5 5.1 5.1 5.0 5.8 5.9 6.7 5.0 6.3 6.9 4.8 5.0 5.2 6.2 6.4 5.2 5.5 5.5 4.5 5.1 5.2

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• • • • • • • • • • • • • • • • • • • • • • • • • • • •

Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:

2.96 4.36 3.19 3.92 4.14 1.94 2.16 2.42 1.95 3.09 2.43 5.20 2.95 3.07 1.69 3.11 2.39 2.74 5.10 3.33 2.50 1.79 2.08 2.22 1.70 4.07 2.41 3.68

6.0 6.3 5.2 8.6 7.4 5.3 5.3 5.1 4.6 6.9 5.6 8.1 5.1 5.4 4.4 5.4 5.2 5.6 9.8 5.6 5.2 4.4 6.3 5.5 4.5 5.9 5.1 7.9

The total number of acute-care hospital discharges, by state, are as follows (source: Modern Healthcare [March 2012] based on data from the American Hospital Directory): • Alabama: 645,254 • Alaska: 40,782 • Arizona: 681,028 • Arkansas: 347,596 • California: 3,237,177 • Colorado: 413,802 • Connecticut: 386,734 • Delaware: 89,107 • District of Columbia: 115,136 • Florida: 2,397,688 • Georgia: 904,785 • Hawaii: 92,312

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• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Illinois: Indiana: Kansas: Kentucky: ldaho: Louisiana: lowa: Maine: Maryland: Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:

1,457,158 711,720 293,596 585,636 119,116 569,794 310,835 144,523 734,368 776,113 1,144,889 541,000 375,554 731,077 94,328 189,704 272,170 111,006 1,056,213 182,227 2,215,175 1,016,017 81,945 1,395,411 445,967 347,270 1,623,316 127,860 496,393 98,800 794,339 2,483,302 202,993 46,297 744,559 584,951 250,623 428,638 47,004

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46 QUALITY & PATIENT SAFETY

46.1 The Toll of Adverse Events The quality movement in healthcare was sparked, to a large extent, by the report To Err is Human: Building a Better Healthcare System, published in 1999 by the Institute of Medicine (IOC, www.iom.edu), which estimated that between 44,000 to 98,000 people die each year from medical errors – at a total national cost of up to $29 billion. The IOC study is now over a decade old, and in the absence of a similarly recognized report, the general feeling within the healthcare sector is that things have improved.

46.2 Adverse Events According to by the Centers for Medicare & Medicaid Services (CMS, www.cms.gov), the following adverse events occurred among patients during stays at 3,361 hospitals from October 2008 to June 2010: • • • • • • • •

Falls and trauma: Infection from vascular catheter: Urinary-tract infection from catheter: Pressure ulcer (stage 3 and 4): Foreign object retained after surgery: Poor glycemic control: Air embolism: Transfusion of incompatible blood:

Number

Rate per 1,000 Discharges

10,564 6,868 5,928 2,521 1,484 994 53 23

0.564 0.367 0.316 0.135 0.090 0.050 0.003 0.001

Approximately 2,000 wrong-site surgery events occur at hospitals each year, according to the CMS. Data from the Centers for Disease Control and Prevention (CDC, www.cdc.gov) published in November 2011 in the New England Journal of Medicine reported that almost 100,000 older adults are hospitalized annually for adverse drugs events after emergency room visits. Annual hospitalizations by type are as follows: • Hematologic: 42,104 • Endocrine: 22,726 • Cardiovascular: 9,800 • Central nervous system: 9,621

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46.3 National Quality Strategy The HHS released in March 2011 the National Strategy for Quality Improvement in Health Care. The 23-page plan presents three aims for the healthcare system, as follows: Better Care • Improve the overall quality by making healthcare more patient-centered, reliable, accessible, and safe. Healthy People and Communities • Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care. Affordable Care • Reduce the cost of quality healthcare for individuals, families, employers, and government. To achieve these aims, the National Quality Strategy established the following six priorities to help focus efforts by public and private partners: • Making care safer by reducing harm caused in the delivery of care • Ensuring that care engages each person and family as partners • Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease • Working with communities to promote wide use of best practices to enable healthy living • Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new healthcare delivery models

46.4 Healthcare Quality Initiatives There have been concerted efforts by U.S. hospitals to improve quality and patient safety. Several organizations and initiatives have spearheaded these efforts. The Leapfrog Group (www.leapfroggroup.org), a coalition of more than 100 member companies, works with its employer-members to encourage healthcare safety, quality, transparency, and easy access to healthcare information. Leapfrog’s consortium of companies, most of whom are in the Fortune 500, spend more than $56 billion annually for health benefits to their 33 million employees. The Leapfrog Group’s primary assessment of hospital quality is its Hospital Safety Score. The second round of Hospital Safety Scores, published in November 2012, assessed 2,618 hospitals. Hospital Saf ety Scores were distributed as follows:

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• • • • •

A: B: C: D: F:

30.2% 25.9% 37.3% 4.6% 1.0%

While the evaluation is generally well-received, some issues have been raised. Hospitals complain that grades can be disproportionally affected by outcomes of one or two patients. One major hospital, for instance, lost a letter grade because of one patient with an air embolism. Hospitals which do not complete the Leapfrog survey forms have also complained that they are sometimes graded incorrectly. HHS’ Partnership For Patients (see Chapter 36) is the largest among quality initiatives. _________________________________________________________________

“Adverse events affect as many as 1 in 3 patients, and the resulting harm causes tens of thousands of patient deaths each year and costs the healthcare system billions. Numerous large-scale initiatives have been undertaken in recent years to address the problem, including HHS’ Partnership for Patients, a $1 billion campaign launched in April 2011 that aims to reduce hospital-acquired conditions, improve transitions of care and reduce Medicare costs by up to $50 billion over 10 years.” Modern Healthcare, 9/3/12 _________________________________________________________________

There are several other quality initiatives and model quality guidelines. So many, in fact, that the need for the quality movement to coalesce around a strategy has become apparent. The IOM has called for the creation of a national qualitycoordination board to oversee existing initiatives and to develop clinical performance measures.

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46.5 Quality Reporting In 2005, the U.S. Department of Health & Human Services, along with several major hospital groups, launched Hospital Compare (www.hospitalcompare.hhs.gov), an online database that reports quality measures from more than 4,200 acute-care hospitals nationwide. Hospitals must provide data for the Hospital Compare assessment to receive full Medicare and Medicaid reimbursement from HHS. There are also quality reporting systems by non-governmental organizations. HealthGrades (www.healthgrades.com), for example, examines mortality and complication rates for 28 procedures and diagnoses. In addition, hundreds of hospitals post their own quality data for consumers.

46.6 Market Resources Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850. (301) 427-1364. (www.ahrq.gov) Association For Professionals In Infection Control and Epidemiology, 1275 K Street NW, Suite 1000, Washington, DC 20005. (202) 789-1890. (www.apic.org) Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138. (617) 301-4800. (www.ihi.org) Institute for Safe Medication Practices, 200 Lakeside Drive, Suite 200, Horsham, PA 19044. (215) 947-7797. (www.ismp.org) National Quality Forum, 1030 15th Street NW, Suite 800, Washington, DC 20005. (202) 873-1300. (www.qualityforum.org) The Henry J. Kaiser Family Foundation, 2400 Sand Hill Road, Menlo Park, CA 94025. (650) 854-9400. (www.kff.org) The Leapfrog Group, 1660 L Street NW, Suite 308, Washington DC 20036. (202) 292-6713. (www.leapfroggroup.org)

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47 READMISSIONS

47.1 The Cost Of Readmissions The Medicare Payment Advisory Commission (MedPAC, www.medpac.gov) reported that 17.6% of Medicare patients discharged from a hospital are readmitted within 30 days, costing Medicare more than $15 billion annually. Medicare spends an average of $7,200 for each readmission. Experts estimate that 76% of those readmissions are for reasons that may have been preventable. A similar finding was reported by researchers from the Centers for Medicare and Medicaid Services (CMS, www.cms.gov), published in The New England Journal of Medicine. The CMS reported cumulative re-hospitalizations as follows: • Within 30 days: 19.5% • Within 90 days: 34.0% • Within 365 days: 56.1% The CMS researchers found wide variation in re-hospitalization rates among states. The five states with the highest re-hospitalization rates (Maryland, New Jersey, Louisiana, Illinois, and Mississippi) had rates 45% higher than the five states with the lowest rates (Idaho, Utah, Oregon, Colorado, and New Mexico). According to MedPAC, seven conditions account for 30% of Medicare spending on readmissions. These conditions are as follows: • • • • • • •

Heart failure: COPD: Pneumonia: AMI: CABG: PTCA: Other vascular:

Admissions

Readmission Rate*

Avg. Medicare Payment

Total Spending

90,273 52,327 74,419 20,866 18,554 44,239 18,029

12.5% 10.7% 9.5% 13.4% 13.5% 10.0% 11.7%

$ 6,531 $ 6,587 $ 7,165 $ 6,535 $ 8,136 $ 8,109 $10,091

$590 million $345 million $533 million $136 million $151 million $359 million $182 million

* 15-day readmission rate COPD = chronic obstructive pulmonary disease AMI = acute myocardial infarcation CABG = coronary artery bypass graft PTCA = percutaneous transluminal coronary angioplasty

Another study, published in the September 2012 issue of the Journal of the American College of Surgeons, found that 11.3% of general surgery patients are readmitted within 30 days of discharge.

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Responding to federal initiatives, hospitals across the U.S. have made reducing readmission rates a top priority. The industry is being pushed, in part, by the CMS, which publishes 30-day readmission data on the Hospital Compare website. The Hospital Readmissions Reduction Program, part of the Patient Protection and Affordable Care Act, began in October 2012. Hospitals face a penalty for excessive readmissions of as much as 1% of their total Medicare billings in 2013. That fine will increase to 2% in 2014 and 3% in 2015. _________________________________________________________________

“Medicare penalties for healthcare delivery system failures will begin with avoidable readmissions in 2012 and expand to hospitalacquired conditions in 2015. These, together with growth of shared saving, and bundledpayment models, will shift more clinical and financial accountability to providers and will drive a greater focus on patient safety and coordination of inpatient and outpatient care.” 2012 Environmental Scan American Hospital Association _________________________________________________________________

47.2 Reducing Readmissions A key to reducing avoidable readmissions is better engagement of patients. According to an assessment by Stephen Jencks, M.D., published in the New England Journal of Medicine, 50.2% of Medicare beneficiaries readmitted within 30 days had not seen a physician between discharge and readmission. Engaging patients has been part of daily operating procedure at Mercy Clinics (Des Moines, IA) for about 15 years. At the forefront is their physician office-based health coach program, which allows Mercy to proactively manage the blood pressure, glucose levels, and immunization rates of more than 25,000 patients. Through the health coach and shared decision-making programs, patients are trained to become active participants in their care. Health coaches ask patients to set health behav ior goals versus outcome goals and together, coach and patient, develop a behavior-change plan with one- to two-week follow-up.

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_________________________________________________________________

“Any type of follow-up that needs to be done, we think we can get 95% to 97% of patients to do so.” Dave Swieskowski, M.D., CEO Mercy Clinics _________________________________________________________________

Nationally, about one-quarter of heart failure patients need to be readmitted within 30 days of discharge. The following are examples of health systems that have been successful in reducing cardiac patient readmissions: • Baylor University Medical Center has the lowest readmission rate for heart failure among all U.S. hospitals, 15.9%. The hospital’s success is attributed, in large part, to follow-up care. _________________________________________________________________

“One of the most important elements of Baylor’s program has been to jettison the notion that patients are ‘discharged’ from the hospital. Instead, hospital workers have begun to think of discharge as a transition from the hospital to care in the community.” Joel Allison, CEO Baylor University Medical Center _________________________________________________________________

•

•

•

Fuqua Heart Center at Piedmont Hospital, in Atlanta, reported a dramatic 75% reduction of 30-day readmission rates for heart failure through use of a telehealth program that monitors patient health status. Intermountain Health Care, in Salt Lake City, recorded a 40% decrease in heart failure readmissions after implementing Joint Commission quality measures across the system. Texas Health Arlington Memorial reduced its readmission rate among cardiac patients with a 12-week rehabilitation program. In 2007, the hospital remodeled and expanded its cardiac rehabilitation department – almost doubling the exercise area to more than 2,500 square feet – soon after the CMS expanded coverage for these services.

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_________________________________________________________________

“Many patients who start cardiac rehab come to us in wheelchairs or use walkers. They’re scared and often depressed. People of all ages and fitness levels support and encourage each other as they work together to improve their heart health. They make phenomenal progress.” Brenda Doughty, R.N. Cardiac Rehab Manager Texas Health Arlington Memorial _________________________________________________________________

The Florida Hospital Association (www.fha.org) has coordinated the Collaborative on Reducing Readmissions (CRR) since 2008. The group’s 108 member hospitals and health networks use face-to-face meetings and webinars to share best practices and interventions that have worked in their communities. Statewide, readmissions within 15 days of discharge fell by 11.1% from September 2008 to September 2010. That translated into 1,500 fewer readmissions and a savings of $12 million. At Orlando Health, which participates in the CRR, a readmission task force has implemented more than a half-dozen patient- and community-focused efforts that include a house calls program. _________________________________________________________________

“Fifty percent of our readmissions occur within 10 days of discharge, and we found one reason is that patients don’t get in to see their physicians soon enough. So, our house calls program bridges that first week to make sure patients understand their medications and when to take them.” David Sylvester, Vice President Orlando Health _________________________________________________________________

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47.3 Coaches For Post-Discharge Care Follow-up care is often provided through ‘coaches’ that work with patients personally or through virtual terminals to guide their care following discharge from a hospital. Model programs to guide patients’ post-hospital recovery have been developed by the University of Denver and Boston University. The Care Transitions Intervention (CTI, www.caretransitions.org) model was developed by Prof. Eric Coleman, M.D., at the University of Colorado at Denver. CTI is a four-week program aimed at promoting self-management among high-risk patients. Coaches visit high-risk patients in the hospital to establish a rapport, m eet with patients in their homes – ideally within 72 hours of discharge – and then follow up with them three times by phone. The result is a relatively short, low-cost, low-intensity intervention that can be deployed in a wide range of settings. As of July 2010, 309 sites in 38 states had implemented the model. The Re-Engineered Discharge (RED) program at the Boston University School of Medicine, led by Prof. Brian Jack, M.D., stresses patient education before discharge from the hospital. Project RED uses an electronic coach nam ed Louise, an animated character displayed on a touch screen mounted on a cart near the patient’s bed, f or providing post-discharge instruction. Louise, or the ‘virtual discharge advocate,’ as she is also known, talks to patients and reviews orders, and patients can respond using the touch screen. The Louise system also tests competency by asking questions such as, “What medications do you take?”

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48 RURAL HEALTHCARE

48.1 Overview According to Hospital Statistics 2012, by the American Hospital Association (www.ama.org), there are 1,987 rural hospitals in the U.S., representing 41% of all hospital locations. This number has declined by 10% over the past decade.

48.2 Staffing Challenges The rural population of the U.S. numbers about 20% of the total population, or 62 million people. However, less than 9% of physicians practice in non-metropolitan counties. In recent years, shortages of non-physician providers, including pharmacists, nurses, dentists, radiology and laboratory technicians, and mental health professionals, have also become more apparent. Physician rates in rural areas and, for comparison in urban areas, are as follows (source: WWAMI Rural Health Research Center, http://depts.washington.edu/uwrhrc): • Urban: 71 per 100,000 population • Large rural areas: 61 per 100,000 population • Small rural areas: 59 per 100,000 population • Isolated small rural areas: 36 per 100,000 population _________________________________________________________________

“... 77% of rural communities are facing a shortage of primary-care physicians and 8% don’t even have a single primary-care physician.” Modern Healthcare, 5/6/13 _________________________________________________________________

Rural doctors can be difficult to recruit. The primary reason is that rural doctors generally earn less than those in metro areas. Further, social and cultural isolation deters many physicians from locating in rural areas.

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_________________________________________________________________

“Many medical centers are staffing their clinics with mid-level providers such as nurse practitioners and physician assistants, but while they can relieve some of the burden, state rules vary when it comes to how much physician oversight is still required. With the need so dire, new physicians are being recruited as early as their second year of residency, often receiving dozens of glossy brochures advertising a town’s nature trails, festivals and short flights to major metropolitan areas. Starting salaries can seem tantalizingly high compared with specialty averages.” Modern Healthcare, 5/6/13 _________________________________________________________________

48.3 Medicare Reform Provisions For Rural Healthcare The Medicare Modernization Act of 2003 (MMA) authorized more than $25 billion through 2013 for the purpose of ensuring the long-term fiscal health of rural hospitals as well as addressing the physician shortage in small and outlying communities. The Medicare reform law boosts payments to rural hospitals and provides incentives aimed at enticing physicians to practice in underserved areas, such as 5% reimbursement bonuses to physicians and 15% bonuses to doctors performing outpatient services at critical-access hospitals. Additionally, Medicare has programs through which rural hospitals and medical centers can earn higher levels of reimbursement. These programs and the number of participating hospitals are as follows: • Critical-Access Hospitals: 25 or fewer beds and certain criteria to be met, including providing emergency services and nursing services 24 hours-a-day: 1,313 • Sole Community Hospitals: located more than 35 miles from other like hospitals: 460 • Medicare-dependent Hospitals: at least 60% of inpatient days attributable to patients covered by Medicare: 169

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Cost-based, efficiency-indifferent payments to critical-access hospitals totaled about $5 billion in FY2011, about $1.3 billion more than the prospective payment system (PPS) schedule, according to the Medicare Payment Advisory Commission (www.medpac.gov). Inpatient payments to critical-access hospitals that filed cost reports totaled $1 billion, about 1.1% of all Medicare payments for inpatient care.

48.4 IT In Rural Hospitals In 2010, the Secretary of Health and Human Services (HHS) announced $20 million in technical support assistance to help critical-access and rural hospital f acilities make the switch from paper-based medical records to certified electronic health-record systems. The funds are being distributed through regional extension centers, a program of HHS’ Office of the National Coordinator for Health Information Technology. Provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) allow that critical-access hospitals can fully depreciate costs of electronic health record systems in one year beginning in FY2011. ARRA, however, did not include rural health clinics among those providers that could receive meaningful-use incentive payments. Hospitals in some areas without good broadband service face an extreme challenge. _________________________________________________________________

“Many rural hospitals are still stuck with slow Internet service – even dial-up.” Hospitals & Health Networks, 10/12 _________________________________________________________________

48.5 Market Resources National Rural Health Association, 4501 College Boulevard, Suite 225, Leawood, KS 66211. (816) 756-3140. (www.ruralhealthweb.org) National Association of Rural Health Clinics, 2 East Main Street, Fremont, MI 49412. (866) 306-1961. (www.narhc.org)

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49 SHARED DECISION MAKING

49.1 Overview There is a growing effort among healthcare providers to encourage patients to become more informed about their diseases and to participate in m aking choices about intervention options. The concept is called shared decision making or informed decision making. _________________________________________________________________

“There’s nothing quite as personal and important to patients as their health. They are looking for the best care possible, and need help with the questions as much as the answers. One proven solution to arming patients with the right questions and answers is shared decision making. Shared decision making is a collaborative approach where patients are provided with evidence-based information on treatment choices and are encouraged to use this information to have an informed dialogue with their physicians to help them make the healthcare decisions that best align with their values, preferences, and lifestyle. lt has been gaining momentum in recent years, specifically as the healthcare industry strives to meet the requirements of the Patient Protection and Affordable Care Act and as payment reform has transitioned to paying for value creation instead of paying for services or procedures (i.e., fee for service).” Peter D. Goldbach, M.D., CMO Health Dialog Modern Healthcare, 4/8/13 _________________________________________________________________

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Shared decision making consists of three elements (source: Health Dialog): Shared Decision Making Aid • Shared decision making often involves written materials, online modules, and video to present information about treatment options that help the patient evaluate potential risks and benefits. Coaching From A Neutral Health Professional • A trained coach helps the patient clarify questions and concerns to discuss with their doctor. An Informed Discussion With The Treating Physician • After using aids, patients are better prepared to have a more informed discussion with their doctor about their options. Patients have always participated in decisions related to their care to some extent. Shared decision making goes even further by providing patients with aids to better guide them in the decision making process and by giving them an expanded role. The approach doesn’t take the doctor’s opinion out of the process; rather, it gives weight to the patient’s values when there is a choice. Insurers are embracing the concept as well. Highmark, part of the Blue Cross Blue Shield network, for instance, contacts patients who have had an MRI related to back pain to make certain they understand the treatment options that they may be presented with. In Minnesota, HealthPartners requires patients be offered a shared decision making experience before undergoing procedures such as spinal fusion. Health Net, in California, provides patients with decision making videos and consultation with a nurse or health coach. Scott & White Health Plan (Texas), one of the nation’s largest multi-specialty group practice systems, has implemented a shared-decision making program that provides decision aid tools and health coaching solutions to 160,000 members and plan physicians. Kaiser Permanente Southern California, Massachusetts General Hospital, and the Dartmouth Hitchcock Healthcare System also practice shared decision making.

49.2 Savings Potential Studies show that shared decision making leads patients to choose conservative options more often. Rates of angioplasty or prostate surgery, for example, have been reduced by 15% to 20% when there has been shared decision making. Group Health Cooperative (Seattle, WA) reports that after it began using video-based decision aids, patients opting for knee replacements fell by 38%, and those choosing to go ahead with a hip replacement fell by 26%. The cost of caring for those patients dropped by 12% to 21%.

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_________________________________________________________________

“Given the choice, patients opt for low-intensity care.” Hospitals & Health Networks, 1/13 _________________________________________________________________

Lewin Group (www.lewingroup.com) estimates that implementing shared decision making for the 11 conditions that account for 40% of Medicare spending could save $4 billion annually. A study published in the February 2013 issue of Health Affairs reported that patients who received shared decision making-based support had 5.3% lower overall medical costs than patients who received the usual level of support. Also, the enhanced support group had 12.5% fewer hospital admissions than the usual support group, and 9.9% fewer preference-sensitive surgeries, including 20.9% fewer preference-sensitive heart surgeries. _________________________________________________________________

“When shared decision making is applied to populations, quality and satisfaction go up while costs go down.” Modern Healthcare, 4/8/13 _________________________________________________________________

Health Dialog, a venture created by the Dartmouth Institute for Health Policy and Clinical Practice, reports the following results of shared decision making (source: Modern Healthcare, April 2013): Lower Utilization • 11.5% reduction in hospital admissions for patients with preference-sensitive conditions • 9.8% reduction in inpatient and outpatient pref erence-sensitive surgeries Reduced Costs • 16% reduction in medical costs associated with preference-sensitive conditions • Up to a 2.5% reduction in total medical costs

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High Patient Satisfaction and Knowledge • 94% of patients who viewed a decision aid would recommend the aids to family and friends • 99% of patients who viewed a decision aid said they understood the information presented

49.3 Primary Care Demonstration Sites To demonstrate the integration of shared decision making, the Foundation for Informed Medical Decision Making (www.informedmedicaldecisions.org) is funding demonstration projects at 12 primary care health centers, as follows: • Dartmouth-Hitchcock Medical Center, General Internal Medicine (Lebanon, NH) • Massachusetts General Hospital, John D. Stoeckle Center f or Primary Care Innovation (Boston, MA) • MaineHealth (Portland, ME) • Mercy Clinics Inc. (Des Moines, IA) • Oregon Rural Practice-based Research Network (Portland, OR) • Palo Alto Medical Foundation Research Institution (Palo Alto, CA) • Pittsburgh VA Health Care System (Pittsburgh, PA) • Stillwater Medical Group (Stillwater, MN) • University of California, Los Angeles (California) • University of California, San Diego (California) • University of North Carolina at Chapel Hill, The Sheps Center for Health Services Research (Chapel Hill, NC) • White River Junction VA Medical Center (White River Junction, VT)

49.4 Breast Cancer Initiative In 2012, the Foundation for Informed Medical Decision Making (www.informedmedicaldecisions.org) launched an initiative to support with funding shared decision making in breast cancer centers across the United States. T he programs, developed in collaboration with a nationally recognized team of breast cancer experts, cover all the major decisions faced by an individual with breast cancer in a comprehensive and easy-to-understand manner. The programs include women with breast cancer who talk about their experiences and the decisions they faced in the course of their treatments. The following sites are participating in the initiative: • Allegheny General Hospital (Pittsburgh, PA) • Blum Center for Patient and Family Education, Dana Farber Cancer Institute (Boston, MA) • Breast Health Center, Beverly Hospital (Beverly, MA) • Cancer Resource Room, Massachusetts General Hospital Cancer Center (Boston, MA) • Cancer Resource Center of Mendocino County (Ukiah, CA) HEALTHCARE BUSINESS MARKET RESEARCH HANDBOOK 2013-2014

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• • • • • • • • • • • • • • • • • • • • •

Christiana Care Breast Center Newark (Delaware) Community Medical Center (Toms River, CO) Dartmouth Hitchcock Medical Center (Hanover, NH) Department of General Surgery, Lahey Hitchcock Clinic (Burlington, MA) Flower Hospital (Sylvania, OH) Fox Chase Cancer Center (Philadelphia, PA) Fox Chase Virtual Health Cancer Center (Gibbsboro, NJ) Iowa Clinic (West Des Moines, IA) Kaiser Permanente (Oakland, CA) Mendocino Cancer Resource Center (Mendocino, CA) Marcell Community Library, Cleveland Clinic at Fairview (Cleveland, OH) Mile High Oncology (Denver, CO) Oncology Department, Wing Memorial Hospital (Palmer, MA) Outpatient Oncology Clinic, Sturdy Memorial Hospital (Attleboro, MA) Rose Medical Center (Denver, CO) Sally Jobe Breast Center (Greenwood, CO) South Suburban Oncology (Quincy, MA) Southcoast Oncology (North Dartmouth, MA) University of California, San Francisco (California) Wilshire Oncology Medical Group (Pomona, CA) Women’s Imaging Center, Berkshire Hospital (Pittsfield, MA)

49.5 Market Resources Foundation for Informed Medical Decision Making, 40 Court Street, Suite 300 Boston, MA 02108. (617) 367-2000. (www.informedmedicaldecisions.org) Prof. Annette O’Connor, Ph.D., at the University of Ottawa has assessed and rated more than 200 aids for health decision making, from prevention measures to surgery. The guide is viewable online at http://decisionaid.ohri.ca/decguide.html. Prof. Jeff Belkora, Ph.D., director of Decision Services at the University of California, San Francisco Breast Care Center, has developed a guide providing general direction and how to get informed when faced with a specific diagnosis. The guide is viewable online at www.guidesmith.org.

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50 SPECIALTY HOSPITALS & CENTERS

50.1 Overview The landscape of the U.S. healthcare system has been transformed in recent years with the emergence of specialty facilities. These include ambulatory surgery centers, specialty hospitals focusing on cardiac and orthopedic procedures, and diagnostic imaging centers. Hospitals generally view specialty facilities as competitors. Administrators of community hospitals say that losing patients to specialty competitors threatens their ability to provide unprofitable services like emergency care, which it subsidizes in part with profits from procedures like cardiac surgery. Hospitals in states with certificate-of-need laws are somewhat insulated from direct competition from niche providers, who are required to show a basis for qualification to get facilities built.

50.2 Specialty Hospitals There are approximately 500 specialty hospitals in the United States. According to the Medicare Payment Advisory Commission (MedPAC, www.medpac.gov), the following is the share of specialty hospitals owned by physicians: • All specialty hospitals: 60% • Heart hospitals: 35% • Orthopedic hospitals: 67% • Surgical hospitals: 73% A backlash against specialty hospitals, led by the American Hospital Association (AHA, www.aha.org), began in 2003, culminating with provisions that were incorporated in The Medicare Improvement Act of 2003, which effectively halted development or significant expansions of specialty hospitals. The moratorium on specialty hospitals expired in 2006 and physician-owned hospitals were again allowed to open. The Patient Protection and Affordable Care Act of 2010 again closed the door on physician-owned hospitals. New physician-owned hospitals are now barred from taking part in Medicare as well as other federal health programs. The restriction applies to all physician hospitals, even those that aren’t specialty facilities. It prohibits the approximately 300 existing institutions from expanding unless they meet stringent conditions.

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50.3 Physician-Owned Hospitals According to Physician Hospitals of America (www.physicianhospitals.org), 267 specialty hospitals are physician-owned. The number of physician-owned hospitals by state is as follows: • Alabama: 5 • Montana: 2 • Alaska: 0 • Nebraska: 6 • Arizona: 10 • Nevada: 1 • Arkansas: 4 • New Hampshire: 0 • California: 19 • New Jersey: 0 • Colorado: 2 • New Mexico: 3 • Connecticut: 0 • New York: 0 • Delaware: 0 • North Carolina: 1 • District of Columbia: 0 • North Dakota: 1 • Florida: 1 • Ohio: 13 • Georgia: 4 • Oklahoma: 17 • Hawaii: 0 • Oregon: 1 • Idaho: 3 • Pennsylvania: 9 • Illinois: 0 • Rhode Island: 0 • Indiana: 16 • South Carolina: 1 • Iowa: 0 • South Dakota: 7 • Kansas: 11 • Tennessee: 9 • Kentucky: 1 • Texas: 89 • Louisiana: 24 • Utah: 4 • Maine: 0 • Vermont: 0 • Maryland: 0 • Virginia: 0 • Massachusetts: 0 • Washington: 1 • Michigan: 4 • West Virginia: 2 • Minnesota: 0 • Wisconsin: 4 • Mississippi: 1 • Wyoming: 1 • Missouri: 0

50.4 Ambulatory Surgery Centers Ambulatory Surgery Centers (ASCs), which compete with hospital outpatient departments for procedures that don’t require overnight stays, like colonoscopies and some joint surgeries, are hollowing out hospitals as well. Four in five ASCs are at least partly owned by physicians, many in partnership with hospitals seeking to minimize losses. From the early 1980s to present, the share of outpatient surgeries performed in hospitals has declined from more than 90% to 45% as the result of ASCs. There was rapid growth in ambulatory surgery centers from 1996 through 2005; more recent growth has been moderate. According to Hospital Statistics 2013, by the American Hospital Association, there are 5,316 Medicare-certified freestanding ambulatory care surgery centers in the U.S.

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• • • •

The following companies are the largest ASC operators: AmSurg (www.amsurg.com) NovaMed (www.novamed.com) Surgical Care Affiliates (www.scasurgery.com) United Surgical Partners International (www.unitedsurgical.com)

In 2007, CMS issued a series of rules that set a new compensation rate of 65% of that which hospital outpatient departments get paid under Medicare. Previously, ASCs were reimbursed at 83% of the hospital rate. The new payment schedule was phased in over a period of four years, through 2011. The CMS also expanded the list of procedures ASCs could get paid for under Medicare. The CMS pays approximately $3 billion annually to ASCs, or an average of $580,000 per facility. The following are the most frequent ASC surgery procedures: Volume

• • • • • •

Gastrointestinal: Eye: Nervous system: Musculoskeletal: Skin: Genitourinary:

1.82 million 1.79 million 1.06 million 370,000 238,000 208,000

Pct. of Total Volume

32.7% 32.1% 19.0% 6.6% 4.3% 3.7%

The following states have the most ambulatory surgery centers (source: Ambulatory Surgery Center Association): • California: 761 • Florida: 406 • Texas: 361 • Maryland: 354 • Georgia: 287 • Pennsylvania: 236 • New Jersey: 233 • Washington: 220 • Ohio: 201 • Arizona: 152 The following are the largest ambulatory surgery centers, ranked by total number of annual procedures (source: Modern Healthcare, August 2012): • AtlantiCare Surgery Center (Egg Harbor Township, NJ; www.atlanticare.org): 19,153 • Northwest Michigan Surgery Center (Traverse City, MI; www.northwestmichigansurgerycenter.com): 17,954 • Stony Point Surgery Center (Richmond VA; www.stonypointsc.com): 16,010

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• • • • • • • • • • • • • • • • • • • • •

Lakeview Surgery Center (West Des Moines, IA www.lakeviewsurgerycenter.com): Allied Physicians Surgery Center (South Bend, IN; www.apsurgery.com): Seattle Orthopedic Center (Seattle, W A; www.proliancesurgeons.com): Evansville Surgery Center (Evansville, IN; www.evansvillesurgerycenter.com): St. Cloud Surgical Center (St Cloud, MN; www.stcsurgicalcenter.com): Prohance Highlands Surgery Center (Issaquah WA; www.proliancesurgeons.com): Village SurgiCenter (Erle, PA; www.vscerie.com): Gulf Coast Endoscopy Center of Venice (Venice, FL; www.gulfcoastendocenter.com): Edmonds Center tor Outpatient Surgery (Edmonds, WA; www.proliancesurgeons.com): Orthopaedic Center at Springhill (Mobile, AL; www.alortho.com/ambulatory.php): Valley Orthopedic Associates Ambulatory Surgery Center (Renton, WA; www.proliancesurgeons.com): Southgate Surgery Center (Southgate, MI; www.southgatesurgery.com): Murdock Ambulatory Surgery Center (Port Charlotte, FL; www.murdocksurgerycenter.com): Lakewood Surgery Center (Lakewood, WA; www.proliancesurgeons.com): Evergreen Orthopedic Surgery Center (Kirkland, WA; www.proliancesurgeons.com): Seashore Surgical Institute (Brick, NJ; www.seashoresurgical.com): Parkridge Surgery Center (Columbia SC; www.palmettohealth.org): Everett Bone and Joint Surgery Center (Everett, WA; www.proliancesurgeons.com): Central Minnesota Surgical Center (Sartell, MN; www.cmsurg.com): Surgery Center at Rainier (Puyallup, WA; www.proliancesurgeons.com): Summit View Surgery Center (Littleton, CO; www.summitviewsc.com):

12,398 11,711 11,611 10,748 10,070 8,924 6,948 6,879 6,667 6,190 6,155 5,184 4,932 3,808 3,642 3,551 3,372 3,236 3,217 3,142 2,972

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50.5 Imaging Centers According to SDI Health (www.sdihealth.com), there are about 6,200 freestanding imaging centers in the U.S., a number that has increased 80% from 3,300 in 2000. Imaging is further assessed in Chapter 27 of this handbook.

50.6 Standalone Emergency Centers Once confined to rural areas without hospitals, free-standing emergency centers have been opening in suburbs for the last decade. These centers now operate in at least 45 states, according to Bloomberg Businessweek. Unlike urgent care centers, which are equipped to treat only non-critical ailments, standalone ERs offer the same access to board-certified emergency-medicine specialists and complex technology found in traditional hospital emergency departments. Many are owned and operated by hospitals. The Centers for Medicare & Medicaid Services (CMS, www.cms.gov) allows hospital EDs to assess facility fees to cover overhead. Standalone emergency centers have adopted the same billing practice. They generally collect up to $500 per patient, compared with $135 at urgent care clinics, according to the Urgent Care Association of America (www.ucaoa.org). Standalone emergency centers typically cost more than 10 times that of an urgent care clinic to operate. Unlike hospitals, privately owned emergency centers are not bound by federal law to treat anyone with a critical emergency. _________________________________________________________________

“Among the fastest-growing areas of medical care, standalone ERs ... have begun drawing attention for whom they do and don’t treat. Many of the entrepreneur-owned ERs don’t take Medicare or Medicaid patients or people without insurance.” Bloomberg Businessweek, 4/15/13 _________________________________________________________________

Some states have imposed regulations. Delaware and Texas, for instance, now compel the facilities to provide critical care to everyone in a health emergency, regardless of their ability to pay. In Illinois and Idaho, private companies are not allowed to open free-standing emergency centers; only hospitals can build standalone emergency centers.

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50.7 Market Resources Ambulatory Surgery Center Association, 1012 Cameron Street, Alexandria, VA 22314. (703) 836-8808. (www.ascassociation.org) Physician Hospitals of America, 2025 M Street NW, Suite 800, Washington, DC 20036. (202) 367-1113. (www.physicianhospitals.org)

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51 STATE SPENDING FOR HOSPITAL CARE

51.1 Percentage of Total Spending For Hospital Care According to Health Expenditures by State, by the Centers for Medicare & Medicaid Services (CMS, www.cms.gov), spending for hospital care accounts for 36.5% of total U.S. healthcare spending. The percentage of total healthcare spending by residents in each state is as follows: • Alabama: 34.2% • Alaska: 40.2% • Arizona: 36.0% • Arkansas: 38.1% • California: 34.8% • Colorado: 35.1% • Connecticut: 31.7% • Delaware: 36.7% • District of Columbia: 49.2% • Florida: 33.1% • Georgia: 35.6% • Hawaii: 37.1% • Idaho: 37.1% • Illinois: 38.3% • Indiana: 38.7% • Iowa: 38.9% • Kansas: 35.0% • Kentucky: 36.6% • Louisiana: 30.4% • Maine: 35.3% • Maryland: 37.2% • Massachusetts: 39.2% • Michigan: 39.6% • Minnesota: 33.9% • Mississippi: 41.9% • Missouri: 41.5% • Montana: 41.3% • Nebraska: 40.3% • Nevada: 32.5% • New Hampshire: 35.7%

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• • • • • • • • • • • • • • • • • • • • •

New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:

33.8% 39.0% 36.1% 36.8% 41.5% 37.8% 38.4% 34.2% 36.4% 36.5% 38.8% 42.7% 33.4% 37.6% 36.1% 38.4% 37.1% 33.9% 41.1% 37.3% 41.1%

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52 TELEMEDICINE

52.1 Overview Telemedicine typically involves physicians using interactive video and/or storeand-forward consultations to diagnose or treat patients. Interactive video allows medical specialists to communicate with their patients who are in another location using television monitors and specially adapted equipment. Store-and-forward techniques include physicians sending pictures, x-rays, and other patient information directly to a remote specialist. After reviewing that information, the specialist then sends the diagnosis back to the local doctor, who treats the patients and provides follow-up care. Telemedicine is a valuable tool for real-time physical exams, consults, and education. And patients have responded well to the technology; they feel they are heard, have the physician’s undivided attention, and travel less.

52.2 Market Assessment Datamonitor (www.datamonitor.com) estimates the annual telemedicine market at $4.0 billion. The category includes a wide range of activities such as interactive patient consultation, interhospital and intrahospital m edical communications, monitoring devices in homes, and healthcare applications for smartphones. According to Hospitals & Health Networks, telemedicine services are provided by the following percentages of healthcare providers: • • • • •

Physician offices: Hospitals: Critical access hospitals: Rural health clinics: Federal health centers:

Consultation

Pharmacologic Mgt.

27% 42% 21% 19% 9%

13% 20% 14% 10% 6%

Psychotherapy

15% 26% 17% 14% 7%

52.3 Telemedicine in Rural Healthcare Telemedicine offers great potential for enhancing rural healthcare.

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_________________________________________________________________

“Telemedicine provides a means to improve the quality of life for the communities served. Patients in rural areas have access to appropriate specialists and enjoy a better experience because they and their families don’t have lengthy commutes. Ultimately this leads to better outcomes.” Stuart M. James, CIO University Health Systems of Eastern Carolina Hospitals & Health Networks _________________________________________________________________

The Rural Health Care Pilot Program of the Federal Communications Commission (www.fcc.gov), launched in 2007, provides $417 million for the construction and operation of 69 statewide or regional broadband telehealth networks in 42 states and three U.S. territories. One particular program receiving funding allows about 270 rural facilities in the Arkansas Delta region access to a network developed by the Center for Distance Health at the University of Arkansas. In California, the Telehealth Advancement Act, passed in October 2011, provides for improved access to healthcare services via telemedicine for rural and inner-city residents.

52.4 Telemedicine for Remote Patients Telemedicine is now considered essential for remote workplaces like offshore oil rigs, where flying a worker to a hospital by helicopter can cost $10,000 a trip. Some rigs have saved $500,000 or more a year using telemedicine, according to NuPhysicia (www.nuphysicia.com), which provides services for almost two dozen oil rigs around the world. NuPhysicia also offers video medical services to land-based employers with 500 or more workers at a site. In 2011, California launched a telemedicine system as part of a program to improve healthcare at state prisons. California spends more than $40 a day per inmate for healthcare, including expenses for guards who accompany prisoners on visits to outside doctors. This cost is more than four times the rate in Texas, and almost triple that of New Jersey, where telemedicine is used for mental healthcare and some medical specialties. University of California supervises the operation of the telemedicine and electronic medical record systems within its prison system. Texas has used a telemedicine program in state prisons since the mid-1990s, with more than 600,000 video visits conducted with inmates to date. Significant improvement has been seen in inmates’ health, including measures of blood pressure HEALTHCARE BUSINESS MARKET RESEARCH HANDBOOK 2013-2014

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and cholesterol, according to a report on the system published in the Journal of the American Medical Association.

52.5 Electronic Intensive Care Units Electronic intensive care units (eICU) allow intensivists, critical care nurses, and ancillary staff to monitor patients from a remote location through secure networks of cameras, monitors, and two-way communications links. They assist nurses in the unit by continuously monitoring patients’ vitals, reviewing test results, and alerting nurses when even the slightest change in condition occurs. Early adopters report an immediate improvement in patient outcomes and overall quality of care. According to a 2011 study by the Massachusetts Technology Collaborative (www.masstech.org) and the New England Healthcare Institute (www.nehi.net), telemedicine in intensive care units could save 350 lives and more than $122 million a year in Massachusetts alone. In a tele-ICU demonstration project at UMass Memorial Medical Center and a community hospital in the state, mortality dropped 20% and 36%, respectively. The hospitals recovered up-front investments for tele-ICUs in about a year; insurers saved $2,600 per patient treated via UMass’ tele-ICU. The community hospital was able to retain a substantial portion of patients that otherwise would have been transferred to another hospital. eICU systems complement, rather than replace, intensivist coverage. They do not involve outsourcing – eICUs are almost always staffed by the hospitals’ own physicians and nurses. The most widely used eICU system is eVantage by Visicu (www.visicu.com).

52.6 Telemedicine for Emergency Medical Care Several hospital systems use telemedicine to support emergency care at remote facilities. Such systems electronically link emergency physicians to rural clinics where emergency doctors are often unavailable. The physicians use videoconferencing cameras to help assess a patient’s condition, then advise on how to treat the patient based on the onsite staff’s preliminary physical exam and information from the remote examination. One of the first such systems was installed at the University of Mississippi Medical Center (UMMC). Called TelEmergency, the system allows nurse practitioners in 21 rural hospital emergency departments in the Delta Regional Health Network to consult with UMMC physicians on critical care cases using bedside videoconferencing systems.

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52.7 Market Growth Through Telemedicine While telemedicine is a sophisticated tool for advancing the medical reach of doctors and clinicians, for hospitals it is also a way to expand the mission of outreach. Providing telemedicine to a distant location can mean more patients for hospitals equipped with the technology. _________________________________________________________________

“If there’s a referral that needs to be made and a patient needs to come in for more specialized care, chances are they’re going to come into your facility. One of the big economic drivers for telemedicine is marketshare. You’re opening up markets for the major medical centers around the country.” Jonathan Linkous, Exec. Director American Telemedicine Association _________________________________________________________________

52.8 Market Resources American Telemedicine Association, 1100 Connecticut Avenue NW, Suite 540, Washington, DC 20036, (202) 223-3333. (www.americantelemed.org) Telemedicine Exchange, 433 N. Camden Drive, Suite 600, Beverly Hills, CA 90210. (800) 360-9827. (www.telemedicineexchange.com)

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53 TOP ISSUES CONFRONTING HOSPITALS

53.1 ACHE Survey A 2012 survey conducted by the American College of Healthcare Executives (ACHE, www.ache.org) found the following top issues confronting hospitals: 1. Financial challenges 2. Healthcare reform implementation 3. Patient safety and quality 4. Governmental mandates 5. Care for the uninsured 6. Physician-hospital relations 7. Patient satisfaction 8. Technology 9. Personnel shortages 10. Creating an Accountable Care Organization For the three top issues, the ACHE survey asked respondents about specific concerns. These responses are listed in the sections which follow.

53.2 Financial Challenges Specific concerns related to financial challenges are as follows (based on the percentage of survey respondents indicating that an issue is one of the top three concerns presently confronting their hospital): • Medicaid reimbursement: 88% • Government funding cuts: 88% • Medicare reimbursement: 78% • Bad debt: 71% • Decreasing inpatient volume: 54% • Increasing costs for staff, supplies, etc.: 51% • Inadequate funding for capital improvements: 43% • Managed care payments: 38% • Other commercial insurance reimbursement: 35% • Emergency department: 31% • Revenue cycle management (converting charges to cash): 28% • Competition from specialty hospitals: 13%

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53.3 Healthcare Reform Implications Specific concerns related to healthcare reform implications are as follows: • Reduce operating costs: 67% • Alignment of provider and payer incentives: 60% • Regulatory/legislative uncertainty affecting strategic planning: 55% • Align with physicians more closely: 54% • Develop information system integrated with primary care doctors: 51% • Study avoidable readmissions to avoid penalties: 45% • Obtain funding from the American Recovery and Reinvestment Act for electronic records: 40% • Hire one or more primary care physicians: 34% • Study avoidable infections to avoid penalties: 25%

53.4 Patient Safety and Quality Specific concerns related to patient safety and quality are as follows: • Engaging physicians in improving the culture of quality: 72% • Redesigning care processes: 58% • Pay for performance: 50% • Redesigning work environment to reduce errors: 43% • Non-payment for never events: 35% • Public reporting of outcomes data: 31% • Medication errors: 31% • Compliance with accrediting organizations (e.g., JCAHO, NCQA): 30% • Leapfrog demands (i.e., computerized physician order entry; ICU staffing by trained intensivists; and evidence-based hospital referral, or moving patients to facilities that perform numerous surgeries and high-risk neonatal conditions): 29% • Nosocomial infections: 21%

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54 UNCOMPENSATED HOSPITAL CARE

54.1 Overview The American Hospital Association (www.aha.org) defines ‘uncompensated care’ as an overall measure of hospital care provided for which no payment was received from the patient or insurer. It is the sum of a hospital’s bad debt and the charity care it provides. A hospital incurs bad debt when it cannot obtain reimbursement for care provided; this happens when patients are unable or unwilling to pay their bills. Uncompensated care excludes other unfunded costs of care, such as underpayment from Medicaid and Medicare. Charity care is care for which hospitals never expected to be reimbursed.

54.2 Cost to Hospitals Each year the American Hospital Association publishes aggregate information on the level of uncompensated care delivered in U.S. hospitals. National costs to hospitals for uncompensated care have been as follows: • • • • • • • • • • • •

2000: 2001: 2002: 2003: 2004: 2005: 2006: 2007: 2008: 2009: 2010: 2011:

Hospitals

Cost

4915 4908 4927 4895 4919 4936 4927 4897 5010 5008 4985 4973

$21.6 billion $21.5 billion $22.3 billion $24.9 billion $26.9 billion $28.8 billion $31.2 billion $34.0 billion $36.4 billion $39.1 billion $39.3 billion $41.1 billion

% of Total Expenses

6.0% 5.6% 5.4% 5.5% 5.6% 5.6% 5.7% 5.8% 5.8% 6.0% 5.8% 5.9%

An assessment by the U.S. Department of Health and Human Services (HHS, www.hhs.gov) put the 2011 figure even higher, at $49 billion a year. HHS found that, on average, uninsured families pay only about 12% of their hospital bills in full. Families with incomes above 400% of the poverty level, or about $88,000 a year for a family of four, pay about 37% of their hospital bills in full.

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54.3 Bad Debt Bad debt typically amounts to 3% to 4% of hospitals’ gross revenue, one of the highest rates among all industry sectors. Bad debt among California hospitals alone amounts to $8.0 billion, according to Kurt Salmon Associates (www.kurtsalmon.com). Denial of claims by health insurance companies for treatments that fall outside of coverage is a contributor to unpaid patient debt. _________________________________________________________________

“Insurance may provide patients little protection from catastrophic medical bills. Health insurers are very creative in how they can erode the actual value of a policy. Medical bills can escalate rapidly when patients need more than routine care and run into clauses that limit benefits or exclude certain spending from applying to deductibles.” Prof. Karen Pollitz, Ph.D. Health Policy Institute Georgetown University _________________________________________________________________

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55 VALUE-BASED PURCHASING

55.1 Overview Authorized by the Affordable Care Act, the Hospital Value-Based Purchasing (VBP) program is an initiative which rewards hospitals for the quality of care they provide to people with Medicare and measures taken to reduce healthcare costs. W ith the VBP initiative, 3,500 hospitals across the country will be paid for inpatient acute care services based on care quality, not just the quantity of the services they provide. The following are milestones in the development of the VBP initiative: • In April 2011, the Department of Health and Human Services (HHS, www.hhs.gov) launched the VPB with publication of proposed measures of assessment for FY2013. • In February and March 2012, CMS conducted a Dry Run of the FY2013 Hospital VBP Program. As part of the Dry Run, CMS created hospital-specific performance reports that simulate the FY 2013 Program for each hospital to review. The simulated reports employed hospital data from prior years to construct each hospital’s baseline period and performance period scores. • In November 2012, CMS released its final rule for the FY2014 Hospital VBP Program as part of the Agency’s Outpatient Prospective Payment System. _________________________________________________________________

“America’s hospitals firmly support the VBP program, which is designed to help hospitals improve patient care.” Richard Pollack, Exec. Vice President American Hospital Association _________________________________________________________________

55.2 Implementation For FY 2013, an estimated $850 million is allocated to hospitals based on their overall performance on a set of quality measures that have been shown to improve clinical processes of care and patient satisfaction.

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Hospitals will continue to receive payments for care provided to Medicare patients based on the Medicare Inpatient Prospective Payment System, but those payments are reduced across the board by 1% starting in FY2013 to create the funding for the new value-based payments. _________________________________________________________________

“The hospital value-based purchasing program pays hospitals based on their actual performance on quality measures, rather than just the reporting of those measures. The VBP program includes 12 clinical quality measures as well as the Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS] to assess patient experiences with care. The clinical measures account for 70% of a hospital’s VBP score and the HCAHPS survey for 30%.” American Hospital Association _________________________________________________________________

55.3 Measures For VBP Assessment The measures to determine quality in the Hospital Value-Based Purchasing Program focus on how closely hospitals follow best clinical practices and how well hospitals enhance patients’ experiences of care. The better a hospital does on its quality measures, the greater the reward it will receive from Medicare. The following measures were selected for the Hospital Value-Based Purchasing program in FY 2013: • Percent of heart attack patients given fibrinolytic medication within 30 minutes of arrival • Percent of heart attack patients given pci within 90 minutes of arrival • Percent of heart failure patients given discharge instructions • Percent of pneumonia patients whose initial emergency room blood culture was performed prior to the administration of the first hospital dose of antibiotics • Initial antibiotic selection for cap in immunocompetent patient • Prophylactic antibiotic received within one hour prior to surgical incision • Prophylactic antibiotic selection for surgical patients • Prophylactic antibiotics discontinued within 24 hours after surgery end time • Cardiac surgery patients with controlled 6am postoperative serum glucose • Surgery patients on a beta blocker prior to arrival that received a beta blocker during

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• •

the perioperative period Surgery patients with recommended venous thromboembolism prophylaxis ordered Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery

Hospitals will be scored based on their performance on each measure relative to other hospitals and on how their performance on each measure has improved over time. The higher of these scores on each measure will be used in determining incentive payments. By rewarding the higher of achievement or improvement on measures, Hospital Value-Based Purchasing gives hospitals the financial incentive to continually improve how they deliver care.

55.4 Patient Experience of Care As part of the VBP initiative, hospitals will be assessed on the experience of care provided to patients in addition to their adherence to q uality measures. This assessment is based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey system. Under HCAHPS, a random sample of patients discharged from hospitals across the country are surveyed and asked questions about their feelings and perceptions about their hospital stay. Patient satisfaction focuses on the following elements of their hospital stay: • How well nurses communicated with patients • How well doctors communicated with patients • How responsive hospital staff were to patients’ needs • How well caregivers managed patients’ pain • How well caregivers explained patients’ medications to them • How clean and quiet the hospital was • How well caregivers explained the steps patients and families need to take to care for themselves outside of the hospital (i.e., discharge instructions)

55.5 Market Resources A fact sheet on the Hospital Value-Based Purchasing program is provided online at www.HealthCare.gov/news/factsheets/valuebasedpurchasing04292011a.html. A primer on Hospital Value-based Purchasing is provided by the Centers for Medicare and Medicaid Services at www.cms.gov/HospitalQualityInits.

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PART IV: AWARD-WINNING HOSPITALS

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56 BEST PLACES TO WORK

56.1 Overview Modern Healthcare names the 100 Best Places To Work in Healthcare annually. The recognition program is sponsored by Studer Group (www.studergroup.com). The 2012 list, published in October 2012, includes 71 prov iders, 26 suppliers, and three payers.

56.2 Top 100 The following are providers receiving the Best Places To Work In Healthcare designation in 2012: • AllBetterCare Urgent Care Center (Mechanicsburg, PA) • Allegan General Hospital (Allegan, MI) • Bailey Medical Center (Owasso, OK) • Baptist Hospital East (Louisville, KY) • Baptist Memorial Health Care (Memphis, TN) • Baylor Jack and Jane Hamilton Heart and Vascular Hospital (Dallas, TX) • Black River Memorial Hospital (Black River Falls, WI) • Bon Secours Virginia (Richmond, VA) • Centegra Physician Care (McHenry, IL) • Central Illinois Endoscopy Center (Peoria, IL) • Cook Children’s Health Care System (Ft. Worth, TX) • Covenant Health (Lubbock, TX) • Doctors Hospital of Sarasota (Sarasota, FL) • Emergency Medical Associates of New Jersey (Parsippany, NJ) • EMP Management Group, Ltd. (Canton, OH) • Grundy County Memorial Hospital (Grundy Center, IA) • Hancock Regional Hospital (Greenfield, IN) • HaysMed (Hays, KS) • Health by Design (San Antonio, TX) • Henry County Hospital (Napoleon, OH) • Holy Name Medical Center (Teaneck, NJ) • Iatric Systems, Inc. (Boxford, MA) • Indiana University Health Goshen (Goshen, IN) • Jacksonville Medical Center (Jacksonville, AL) • JSA Healthcare (St. Petersburg, FL)

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King’s Daughters Medical Center (Brookhaven, MS) Laser Spine Institute (Tampa, FL) Louisiana Organ Procurement Agency (Metairie, LA) Lovelace Westside Hospital (Albuquerque, NM) Lovelace Women’s Hospital (Albuquerque, NM) Lowell General Hospital (Lowell, MA) Michigan Health & Hospital Association (Lansing, MI) Monroe County Hospital & Clinics (Albia, IA) Neosho Memorial Regional Medical Center (Chanute, KS) Orthopaedic Hospital of Wisconsin (Glendale, WI) Pikeville Medical Center (Pikeville, KY) PM Pediatrics (Lake Success, NY) Rainbow Hospice and Palliative Care (Mount Prospect, IL) Saint Francis Medical Center (Cape Girardeau, MO) Self Regional Healthcare (Greenwood, SC) Sheltering Arms Physical Rehabilitation Centers (Glen Allen, VA) South Baldwin Regional Medical Center (Foley, AL) Southern Ohio Medical Center (Portsmouth, OH) Southwest Medical Center, Inc (Charleroi, PA) St. Elizabeth Hospital (Gonzales, LA) St. Luke’s Lakeside Hospital (The Woodlands, TX) Stillwater Medical Center (Stillwater, OK) Sutter Center for Psychiatry (Sacramento, CA) Sutter Davis Hospital (Davis, CA) Texas Health Center for Diagnostics & Surgery (Plano, TX) Texas Health Harris Methodist Hospital Southlake (Southlake, TX) Texas Health Presbyterian Hospital Flower Mound (Flower Mound, TX) Texas Health Presbyterian Hospital Rockwall (Rockwall, TX) Texas Orthopedic Hospital (Houston, TX) The Women’s Hospital (Newburgh, IN) Thousand Oaks Surgical Hospital (Thousand Oaks, CA) Trilogy Health Services (Louisville, KY) USMD Hospital at Arlington (Arlington, TX) Valley Emergency Physicians Medical Group, Inc. (Walnut Creek, CA) Wamego City Hospital (Wamego, KS) Women & Children’s Hospital (Lake Charles, LA) Woman’s Hospital (Baton Rouge, LA)

The complete list of 100 Best Places To Work in Healthcare, which includes suppliers and payers as well as providers, is available online at www.modernhealthcare.com/article/20121010/info/310059999.

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57 CIRCLE OF LIFE AWARD

57.1 Overview The Circle of Life Award® honors innovation in palliative and end-of-life care. The award is sponsored by the American Academy of Hospice and Palliative Medicine (www.aahpm.org), the American Association of Homes and Services for the Aging (www.aahsa.org), the American Hospital Association (www.aha.org), the Archstone Foundation (www.archstone.org), the California Healthcare Foundation (www.chcf.org), the Catholic Health Association (www.chausa.org), the Hospice and Palliative Nurses Association (www.hpna.org), and the National Hospice and Palliative Care Organization (www.nhpco.org).

57.2 Awards The 2012 Circle of Life Award designations are as follows: 2012 WINNERS • Calvary Hospital (Bronx, NY) • Haslinger Family Pediatric Palliative Care Center, Akron Children’s Hospital (Akron, OH) • Sharp HealthCare (San Diego, CA) 2012 CITATIONS OF HONOR • Community PedsCare, Community Hospice of Northeast Florida (Jacksonville, FL) • St. Joseph Palliative Care Program (Orange, CA) • Unity (De Pere, WI) The website www.aha.org/aha/news-center/awards/circle-of-life/awardees.html presents a list of past award winners.

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58 COMMUNITY VALUE AWARDS

58.1 Overview Since 2004, Cleverley + Associates (www.cleverleyassociates.com) has evaluated hospitals using the Community Value Index® (CVI) as a tool for assessment. The CVI contains four core areas of evaluation, as follows: • Financial viability and reinvestment • Cost structure • Charge structure • Quality performance The 20 hospitals in five categories with the highest CVI scores are included in the annual Community Value 100 Hospitals list. Categories are as follows: • Teaching hospital - high intensity • Teaching hospital - medium intensity • Teaching hospital - low intensity • Non-teaching hospital - large • Non-teaching hospital - small

58.2 Community Value 100 Hospitals The following are the 2012 Community Value 100 Hospitals: • Adena Regional Medical Center (Chillicothe, OH) • American Legion Hospital (Crowley, LA) • Anna Jaques Hospital (Newburyport, MA) • Arnot Ogden Medical Center (Elmira, NY) • Baystate Medical Center (Springfield, MA) • Billings Clinic Hospital (Billings, MT) • Bronx-Lebanon Hospital Center (Bronx, NY) • Caritas Good Samaritan Medical Center (Brockton, MA) • Caritas Holy Family Hospital and Medical Center (Methuen, MA) • Carle Foundation Hospital (Urbana, IL) • Carolinas Medical Center (Charlotte, NC) • Carolinas Medical Center-Union (Monroe, NC) • Central Valley General Hospital (Hanford, CA) • Chinese Hospital (San Francisco, CA) • Citrus Valley Medical Center - IC Campus (Covina, CA)

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Cleveland Clinic Hospital (Weston, FL) Cookeville Regional Medical Center (Cookeville, TN) Covenant Medical Center (Waterloo, IA) Covenant Medical Center, Inc (Saginaw, MI) Danbury Hospital (Danbury, CT) Day Kimball Hospital (Putnam, CT) Dixie Regional Medical Center (St George, UT) Dubois Regional Medical Center (Dubois, PA) Falmouth Hospital (Falmouth, MA) Firsthealth Moore Regional Hospital (Pinehurst, NC) Flushing Hospital Medical Center (Flushing, NY) Forest Hills Hospital (Forest Hills, NY) Genesis Healthcare System (Zanesville, OH) Harns County Hospital District (Houston, TX) Hartford Hospital (Hartford, CT) Healthalliance Hospitals, Inc (Leominster, MA) Hennepin County Medical Center (Minneapolis, MN) Hollywood Community Hospital of Hollywood (Hollywood, CA) HolyCross Hospital (SilverSpring, MD) Houston Medical Center (Warner Robins, GA) Huntington Beach Hospital (Huntington Beach, CA) Immanuel-St. Josephs - Mayo Health System (Mankato, MN) Jackson-Madison County General Hospital (Jackson, TN) Kaleida Health (Buffalo, NY) Kootenai Medical Center (Coeur d’Alene, ID) Lakeland Hospital, St Joseph (St Joseph, MI) Lakeview Memorial Hospital (Stillwater, MN) Lawrence General Hospital (Lawrence, MA) Long Beach Memorial Medical Center (Long Beach, CA) Long Island Jewish Medical Center (New Hyde Park, NY) Lowell General Hospital (Lowell, MA) Lutheran Medical Center (Brooklyn, NY) Maimonides Medical Center (Brooklyn, NY) Maine Medical Center (Portland, ME) Mecosta County Medical Center (Big Rapids, MI) Memorial Hospital of Stilwell (Stilwell, OK) Memorial Mission Hospital And Asheville Surgery Center (Asheville, NC) MercyHealth Partners, Mercy Campus (Muskegon, MI) Mercy Medical Center (Springfield, MA) Mercy Medical Center Redding (Redding, CA) Mercy Medical Center-North lowa (Mason City, IA) Metro Heatth Medical Center (Cleveland, OH) Montefiore Medical Center (Bronx, NY) Morton Hospital & Medical Center (Taunton, MA)

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Mount Carmel St Ann’s Hospital (Westerville, OH) Mount Sinai Hospital (New York, NY) Mount St. Mars Hospital And Health Center (Lewiston, NY) Nebraska Heart Hospital, LLC (Lincoln, NE) New York Downtown Hospital (New York, NY) New York-Presbyterian Hospital (New York, NY) Ochsner Foundation Hospital (New Orleans, LA) Providence Milwaukie Hospital (Milwaukie, OR) Providence St Vincent Medical Center (Portland, OR) Rapid City Regional Hospital (Rapid City, SD) Richmond University Medical Center (Staten Island, NY) Robert Packer Hospital (Sayre, PA) Sacred Heart Hospital (Chicago, IL) Saint Francis Hospital, Inc (Tulsa, OK) Saint Mary’s Health Care (Grand Rapids, MI) Scotland Memorial Hospital (Laurinburg, NC) Signature Healthcare Brockton Hospital (Brockton, MA) Sisters of Charity Hospital (Buffalo, NY) Sound Shore Medical Center of Westschester (New Rochelle, NY) Southcoast Hospital Group, Inc (Fall River, MA) Southern Maryland Hospital Center (Clinton, MD) St Michaels Hospital (Stevens Point, WI) St Vincent’s Medical Center (Bridgeport, CT) St. Barnabas Hospital (Bronx, NY) St. Bernards Medical Center (Jonesboro, AR) St. Elizabeth Hospital (Appleton, WI) St. James Mercy Hospital (Hornell, NY) St. John Medical Center (Longview, WA) St. John West Shore Hospital (Westlake, OH) St. John’s Riverside Hospital (Yonkers, NY) St. Joseph Mercy Oakland (Pontiac, Ml) St. Josephs Hospital (Marshfield (WI) St. Josephs Hospital (Bellingham, WA) St. Joseph’s Hospital Yonkers (Yonkers, NY) Staten Island University Hospital (Staten Island, NY) The Moses H. Cone Memorial Hospital (Greensboro, NC) Thorek Memorial Hospital (Chicago, IL) Trinity Health System (Steubenville, OH) University of California San Diego Medical Center (San Diego, CA) Virginia Hospital Center - Arlington (Arlington, VA) West Anaheim Medical Center (Anaheim, CA) White County Medical Center (Searcy, AR)

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59 CONSUMER CHOICE AWARDS

59.1 Overview Since 1998, National Research Corporation (www.nationalresearch.com) has presented Consumer Choice Awards annually for the most-preferred hospitals in over 300 U.S. markets. Winners, named in Modern Healthcare each October, are selected based on responses in surveys of over 250,000 households.

59.2 Award Winners The 2012-2013 Consumer Choice Award winners are as follows: ALABAMA Birmingham, AL • UAB Hospital Daphne-Fairhope, AL • Thomas Hospital Huntsville, AL • Huntsville Hospital Mobile, AL • Providence Hospital Montgomery, AL • Baptist Medical Center - East Tuscaloosa, AL • DCH Regional Medical Center

ARIZONA Flagstaff, AZ • Yavapai Regional Medical Center West

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Phoenix, AZ • Mayo Clinic • St. Josephs Hospital & Medical Center

Prescott, AZ • Yavapai Regional Medical Center Tucson, AZ • University of Arizona Medical Center - University Campus

ARKANSAS Fayetteville-Springdale, AR • Washington Regional Medical Center Fort Smith, AR • Mercy Hospital Fort Smith Little Rock, AR • Baptist Health Medical Center-Little Rock

CALIFORNIA Bakersfield, CA • Bakersfield Memorial Hospital Chico, CA • Enloe Medical Center Fresno, CA • Saint Agnes Medical Center Los Angeles, CA • Cedars-Sinai Medical Center Modesto, CA • Memorial Medical Center Oakland, CA • John Muir Medical Center-Walnut Creek Orange County, CA • Hoag Memorial Hospital Presbyterian

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Redding, CA • Mercy Medical Center-Redding Riverside-San Bernardino, CA • Loma Linda University Medical Center Sacramento, CA • UC Davis Medical Center Salinas, CA • Community Hospital of the Monterey Peninsula • Salinas Valley Memorial Hospital San Diego, CA • Sharp Memorial Hospital San Francisco, CA • UCSF Medical Center San Jose, CA • Stanford Hospital & Clinics San Luis Obispo-Paso Robles, CA • French Hospital Medical Center Santa Barbara, CA • Santa Barbara Cottage Hospital Santa Cruz, CA • Dominican Hospital Santa Rosa, CA • Kaiser Foundation Hospital - Santa Rosa • Santa Rosa Memorial Hospital Vallejo, CA • Kaiser Permanente Vallejo Medical Center Ventura, CA • Community Memorial Hospital of San Buenaventura • Los Robles Hospital & Medical Center Visalia, CA • Kaweah Delta Health Care District

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COLORADO Boulder, CO • Longmont United Hospital Colorado Springs, CO • Penrose St. Francis Health Services • Memorial Hospital Central Denver-Aurora, CO • University of Colorado Hospital - Aurora Fort Collins, CO • Poudre Valley Hospital Grand Junction, CO • St. Mary’s Hospital Pueblo, CO • Parkview Medical Center

CONNECTICUT Bridgeport, CT • Yale-New Haven Hospital Hartford, CT • Hartford Hospital New Haven, CT • Yale-New Haven Hospital Norwich-New London, CT • Lawrence & Memorial Hospital

DELAWARE Wilmington, DE • Christiana Care Health System - Christiana Hospital

DISTRICT OF COLUMBIA Washington, DC • Inova Fairfax Hospital

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FLORIDA Daytona Beach, FL • Halifax Health Medical Center Fort Lauderdale, FL • Cleveland Clinic Hospital - Weston Fort Myers-Cape Coral, FL • HealthPark Medical Center Gainesville, FL • Shands at the University of Florida Jacksonville, FL • Mayo Clinic Jacksonville Lakeland, FL • Lakeland Regional Medical Center Melbourne, FL • Holmes Regional Medical Center Miami, FL • Baptist Hospital of Miami Naples, FL • NCH Healthcare System Ocala, FL • Munroe Regional Medical Center Orlando, FL • Florida Hospital - Orlando Panama City-Lynn Haven, FL • Bay Medical Center-Panama Pensacola, FL • Sacred Heart Health System Port St. Lucie, FL • Martin Memorial Medical Center

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Sarasota, FL • Sarasota Memorial Health Care System Tallahassee, FL • Tallahassee Memorial Healthcare Tampa, FL • Tampa General Hospital

GEORGIA Atlanta, GA • Emory University Hospital Augusta, GA • University Health Care System Columbus, GA • St. Francis Hospital Macon, GA • The Medical Center of Central Georgia Savannah, GA • Memorial Health • St. Joseph/Candler

IDAHO Boise, ID • St. Luke’s Regional Medical Center

ILLINOIS Bloomington, IL • Advocate BroMenn Medical Center Champaign-Urbana, IL • Carle Foundation Hospital Chicago, IL • Northwestern Memorial Hospital

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Lake County, IL & Kenosha County, WI • Northwestern Lake Forest Hospital Peoria, IL • OSF Saint Francis Medical Center Rockford, IL • St. Anthony Medical Center - Rockford Springfield, IL • Memorial Medical Center

INDIANA Elkhart-Goshen, IN • Elkhart General Hospital Evansville, IN • Deaconess Hospital Fort Wayne, IN • Lutheran Hospital • Parkview Regional Medical Center Gary, IN • The Community Hospital Indianapolis, IN • St. Vincent Hospitals and Health Services Lafayette, IN • Indiana University Health Arnett South Bend, IN • Memorial Hospital of South Bend

IOWA Cedar Rapids, IA • Mercy Medical Center - Cedar Rapids Davenport, IA • Genesis Health System • Trinity Medical Center

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Des Moines, IA • Mercy Medical Center - Des Moines Iowa City, IA • University of Iowa Hospitals and Clinics Sioux City, IA • St. Luke’s Regional Medical Center Waterloo-Cedar Falls, IA • Allen Memorial Hospital • Covenant Medical Center

KANSAS Topeka, KS • Stormont Vail Healthcare Wichita, KS • Wesley Medical Center

KENTUCKY Bowling Green, KY • The Medical Center Lexington, KY • Central Baptist Hospital • UK Albert B. Chandler Hospital Louisville, KY • Baptist Hospital East

LOUISIANA Alexandria, LA • CHRISTUS Hospital - St. Frances Cabrini • Rapids Regional Medical Center Baton Rouge, LA • Our Lady of the Lake Regional Medical Center

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Lafayette, LA • Lafayette General Medical Center • Our Lady of Lourdes Regional Medical Center New Orleans, LA • Ochsner Medical Center Shreveport, LA • Louisiana State University Hospital • Willis-Knighton Health

MAINE Bangor, ME • Eastern Maine Medical Center Portland, ME • Maine Medical Center

MARYLAND Baltimore, MD • Johns Hopkins Hospital Hagerstown, MD • Winchester Medical Center

MASSACHUSETTS Boston, MA • Massachusetts General Hospital Springfield, MA • Baystate Medical Center Worcester, MA • UMass Memorial Medical Center - University Campus

MICHIGAN Ann Arbor, MI • University of Michigan Health System

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Detroit-Livingston, Macomb, Oakland, St. Clair Counties, MI • Beaumont Hospital, Royal Oak Detroit-Wayne County, MI • Henry Ford Hospital • University of Michigan Hospitals Flint, MI • Genesys Regional Medical Center Grand Rapids, MI • Spectrum Health Holland-Grand Haven, MI • Spectrum Health Kalamazoo, MI • Bronson Methodist Hospital Lansing, MI • Sparrow Hospital Muskegon, MI • Mercy Health Partners - Hackley Campus Niles-Benton Harbor, MI • Lakeland HealthCare Saginaw-Saginaw Township, MI • Covenant Medical Center

MINNESOTA Duluth, MN • St. Luke’s • St. Mary’s Medical Center Minneapolis-Saint Paul, MN • Mayo Clinic St. Cloud, MN • St. Cloud Hospital

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MISSISSIPPI Biloxi, MS • Memorial Hospital at Gulfport Hattiesburg, MS • Forrest General Hospital Jackson, MS • Baptist Medical Center • St. Dominic - Jackson Memorial Hospital

MISSOURI Columbia, MO • Boone Hospital Center Joplin, MO • Freeman Hospital Kansas City, MO-KS • The University of Kansas Hospital Springfield, MO • Mercy Hospital Springfield St. Louis, MO • Barnes-Jewish Hospital

NEBRASKA Omaha, NE • The Nebraska Medical Center

NEW HAMPSHIRE Manchester-Nashua, NH • Elliot Hospital • Southern New Hampshire Medical Center

NEW JERSEY Atlantic City, NJ • AtlantiCare Regional Medical Center-Atlantic City Campus

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Bergen-Passaic, NJ • Hackensack University Medical Center Camden, NJ • Cooper University Hospital • Virtua Edison, NJ • Robert Wood Johnson University Hospital-New Brunswick Monmouth-Ocean, NJ • Jersey Shore University Medical Center Newark, NJ • Morristown Memorial Hospital • Saint Barnabas Medical Center Trenton, NJ • Robert Wood Johnson University Hospital-Hamilton

NEW MEXICO Albuquerque, NM • Presbyterian Hospital Las Cruces, NM • Memorial Medical Center-Las Cruces • Mountain View Regional Medical Center

NEW YORK Albany, NY • Albany Medical Center Binghamton, NY • Lourdes Hospital Buffalo, NY • Buffalo General Hospital Elmira, NY • Arnot-Ogden Medical Center

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Nassau-Suffolk, NY • Stony Brook University Medical Center New York - Bronx County • Montefiore Medical Center New York - Kings County • Maimonides Medical Center • New York Methodist Hospital New York - New York County • New York-Presbyterian Hospital New York - Queens County • Long Island Jewish Medical Center New York - Richmond County • Staten Island University Hospital New York - Westchester County • Westchester Medical Center • White Plains Hospital Center Poughkeepsie, NY • Vassar Brothers Medical Center Rochester, NY • Strong Memorial Hospital Syracuse, NY • St. Joseph’s Hospital Health Center Utica, NY • Faxton - St. Luke’s Healthcare • St. Elizabeth Medical Center

NEVADA Las Vegas, NV • Summerline Hospital and Medical Center • Sunrise Hospital and Medical Center Reno, NV • Renown Health

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NORTH CAROLINA Asheville, NC • Mission Health Charlotte, NC • Carolinas Medical Center Durham, NC • Duke University Medical Center Fayetteville, NC • Cape Fear Valley Medical Center Greensboro, NC • Moses H. Cone Memorial Hospital Hickory-Morganton, NC • Catawba Valley Medical Center • Frye Regional Medical Center Raleigh, NC • Rex Healthcare Wilmington, NC • New Hanover Regional Medical Center Winston-Salem, NC • Wake Forest University Baptist Medical Center

NORTH DAKOTA Fargo, ND • Sanford Medical Center Fargo

OHIO Akron, OH • Cleveland Clinic Foundation Canton, OH • Aultman Hospital Cincinnati, OH • The Christ Hospital

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Cleveland, OH • Cleveland Clinic Foundation Columbus, OH • Riverside Methodist Hospital Dayton, OH • Kettering Medical Center • Miami Valley Hospital Toledo, OH • The Toledo Hospital Youngstown, OH • St. Elizabeth Health Center

OKLAHOMA Lawton, OK • Comanche County Memorial Hospital Oklahoma City, OK • INTEGRIS Health • Mercy Health Center Tulsa, OK • Saint Francis Hospital • St. John Medical Center

OREGON Eugene-Springfield, OR • Sacred Heart Medical Center Medford, OR • Rogue Valley Medical Center Portland, OR • OHSU Healthcare • Providence St. Vincent Medical Center Salem, OR • Salem Hospital

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PENNSYLVANIA Allentown, PA • Lehigh Valley Hospital - Cedar Crest Altoona, PA • Altoona Hospital East Stroudsburg, PA • Pocono Medical Center Erie, PA • UPMC Hamot Harrisburg, PA • Penn State Milton S. Hershey Medical Center Johnstown, PA • Conemaugh Memorial Medical Center Lancaster, PA • Lancaster General Hospital Philadelphia, PA • Hospital of the University of Pennsylvania Pittsburgh, PA • Allegheny University Hospitals - Allegheny General • UPMC-Presbyterian Reading, PA • The Reading Hospital and Medical Center Scranton, Wilkes-Barre, PA • Geisinger Wyoming Valley Medical Center State College, PA • Geisinger Medical Center York, PA • York Hospital

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RHODE ISLAND Providence, RI • Rhode Island Hospital

SOUTH CAROLINA Charleston, SC • Medical University of South Carolina Medical Center Columbia, SC • Lexington Medical Center • Palmetto Health Baptist Florence, SC • McLeod Regional Medical Center Greenville, SC • Greenville Memorial Hospital Myrtle Beach, SC • Grand Strand Regional Medical Center Spartanburg, SC • Spartanburg Regional Medical Center

SOUTH DAKOTA Sioux Falls, SD • Sanford USD Medical Center

TENNESSEE Chattanooga, TN • Memorial Hospital Clarksville, TN • Vanderbilt University Medical Center Johnson City-Kingsport-Bristol, TN • Holston Valley Medical Center • Johnson City Medical Center

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Knoxville, TN • University of Tennessee Medical Center Memphis, TN • Baptist Memorial Hospital - Memphis Nashville, TN • Vanderbilt University Medical Center

TEXAS Amarillo, TX • Baptist St. Anthony’s Health System Austin, TX • Seton Medical Center Austin Beaumont-Port Arthur, TX • CHRISTUS Hospital-St. Elizabeth College Station-Bryan, TX • St. Joseph Regional Health Center Corpus Christi, TX • CHRISTUS Spohn Hospital - Shoreline Dallas, TX • Baylor University Medical Center at Dallas El Paso, TX • Sierra Providence Health Network Fort Worth, TX • Texas Health Harris Methodist Hospital Houston, TX • Memorial Hermann - Texas Medical Center • University of Texas, MD Anderson Clinic Longview, TX • Good Shepherd Medical Center

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Lubbock, TX • Covenant Medical Center - Lubbock • University Medical Center - Lubbock San Antonio, TX • Methodist Hospital Sherman - Denison, TX • Texoma Medical Center Temple, TX • Scott and White Memorial Hospital Tyler, TX • Trinity Mother Frances Waco, TX • Hillcrest Baptist Medical Center - Waco • Providence Health Center

UTAH Ogden, UT • McKay-Dee Hospital Center Provo-Orem, UT • Utah Valley Regional Medical Center Salt Lake City, UT • Intermountain Health Care • University Hospital - University of Utah Health Care

VIRGINIA Blacksburg, VA • Carilion New River Valley Medical Center Charlottesville, VA • Martha Jefferson Hospital • University of Virginia Medical Center Lynchburg, VA • Centra Lynchburg General Hospital

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Norfolk-Virginia Beach, VA • Sentara Norfolk General Hospital Richmond, VA • Bon Secours St. Mary’s Hospital of Richmond • Medical College of Virginia Hospital Roanoke, VA • Carilion Roanoke Memorial Hospital

WASHINGTON Bremerton, WA • Harrison Medical Center Kennewick, WA • Kadlec Regional Medical Center Olympia, WA • Providence St. Peter Hospital Seattle, WA • Evergreen Health • Swedish Medical Center Spokane, WA • Sacred Heart Medical Center & Children’s Hospital Tacoma, WA • St. Joseph Medical Center • Tacoma General Hospital Yakima, WA • Yakima Valley Memorial Hospital

WEST VIRGINIA Charleston, WV • Charleston Area Medical Center Huntington-Ashland, WV-KY-OH • Cabell Huntington Hospital

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Morgantown, WV • Ruby Memorial Hospital Parkersburg-Marrietta, WV-OH • Camden-Clark Medical Center • Marietta Memorial Hospital Wheeling, WV - OH • Wheeling Hospital

WISCONSIN Appleton, WI • ThedaCare Eau Claire, WI • Mayo Clinic Health System in Eau Claire Green Bay, WI • Bellin Memorial Hospital Janesville, WI • Mercy Health System • University of Wisconsin Hospital and Clinics La Crosse, WI • Gunderson Lutheran Hospital Madison, WI • University of Wisconsin Hospital and Clinics Milwaukee, WI • Froedtert Hospital Neenah, WI • Theda Clark Medical Center Racine, WI • Froedtert Hospital • Wheaton Franciscan Healthcare - All Saints

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60 DESIGN AWARDS

60.1 Overview Since 1985, Modern Healthcare’s annual Design Awards program has recognized excellence in the design and planning of new and remodeled healthcare facilities.

60.2 Awards The 2012 Design Awards are as follows: Award of Excellence - Built • UC San Diego Health System’s Sulpizio Cardiovascular Center (La Jolla, CA) • Vivian and Seymour Milstein Family Heart Center, New York-Presbyterian Hospital/ Columbia University Medical Center (New York, NY) Honorable Mentions - Unbuilt • Kaiser Permanente Small Hospital, Big Idea Project (Lancaster, CA) • King Abdullah Specialized Children’s Hospital (Jeddah, Saudi Arabia) • Sheikh Khalifa Medical City (Abu Dhabi, United Arab Emirates) Citations - Built • Ann & Robert H. Lurie Children’s Hospital (Chicago, IL) • Cooper University Hospital Roberts Pavilion (Camden, NJ) • Massachusetts General Hospital, The Lunder Building (Boston, MA) • Piedmont Newnan Hospital (Newnan, GA) • UCLA Medical Building (Santa Monica, CA) Citation - Unbuilt • Mercy Health-West Hospital (Cincinnati, OH)

• • • • • •

The following are recent Award of Excellence recipients: 2011: Memorial Sloan-Kettering (Brooklyn, NY) 2011: Miami Valley Hospital Heart and Orthopedic Centers (Dayton, OH) 2010: Swedish Orthopedic Institute (Seattle, W A) 2009: Grand Itasca Clinic & Hospital (Grand Rapids, MN) 2008: Banner Gateway Medical Center (Gilbert, AZ) 2008: The Weill Greenberg Center at Weill Medical College of Cornell University

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•

2007:

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2007: 2007:

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2007:

(Ithaca, NY) Peter and Paula Fasseas Cancer Clinic at University Medical Center North (Tucson, AZ) Providence Newberg Medical Center (Newberg, OR) Southwest Washington Medical Center, E.W. and Mary Firstenburg Tower (Vancouver, WA) U.S. Veterans Affairs Department,Long Beach Healthcare System, Blind Rehabilitation Center, Outpatient Clinic and Educational Resource Center (Long Beach (CA)

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61 EMERGENCY MEDICINE EXCELLENCE AWARDS

61.1 Overview HealthGrades (www.healthgrades.com) annually assesses Medicare patient records to evaluate emergency care provided at U.S. hospitals. The assessment focuses on 12 of the most common and life-threatening medical emergencies among that patient population, including heart attack, stroke, pneumonia, and chronic obstructive pulmonary disease (COPD). Those hospitals performing in the top 5% in the nation are designated as Emergency Medicine Excellence Award™ hospitals. The awards are based on analysis of more than seven million Medicare patient records. Emergency Medicine Excellence Award recipients had, on average, a 40% lower risk of death compared to patients treated at non-recipient hospitals.

61.2 Awards The list of hospital recipients of the 2012 Emergency Medicine Excellence Award™ is presented online at www.healthgrades.com/cms/ratings-and-awards/ 2012-Emergency-Medicine-Excellence-Award-Recipients.aspx.

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62 HEALTHCARE ADVANTAGE AWARDS

62.1 Overview The Advantage Awards, an annual recognition from Truven Health Analytics (www.truvenhealth.com) recognize hospitals, health plans, government agencies, and employers that use data analytics to improve the quality of care and business results.

62.2 Awards The following are provider recipients of the Healthcare Advantage Award: Overall Performance • ProHealth Care (Waukesha, WI) Consumer Outreach and Communications • Heartland Health (St. Joseph, MO) Health and Clinical Outcomes • IASIS Healthcare (Franklin, TN) • Tallahassee Memorial HealthCare (Tallahassee, FL) • United Regional Health Care System (Wichita Falls, TX) • Waukesha Memorial Hospital (Waukesha, WI) Performance Efficiency • Newton-Wellesley Hospital (Newton, MA) • St. Cloud Hospital (Saint Cloud, MN) • St. Elizabeth Hospital (Gonzales, LA) Strategy and Growth • BayCare Health System (Clearwater, FL) • Centegra Health System (Crystal Lake, IL) • Crozer-Keystone Health System (Springfield, PA)

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63 LANTERN AWARDS

63.1 Overview The Lantern Award is a recognition award given by the Emergency Nurses Association (www.ena.org) to hospital emergency departments that exemplify exceptional practice and innovative performance in the core areas of leadership, practice, education, advocacy, and research. The award serves as a visible symbol of an emergency department’s commitment to quality, presence of a healthy work environment and accomplishment in incorporating evidence-based practice, and innovation into emergency care.

63.2 Awards The 2012 Lantern Award recipients are as follows: • Advocate Good Shepherd Hospital Emergency Department (Barrington, IL) • Beaumont Health System - Grosse Pointe Emergency Center (Grosse Pointe, MI) • Boston Children’s Hospital Emergency Department (Boston, MA) • Cedars-Sinai Medical Center, Ruth and Harry Roman Emergency Department (Los Angeles, CA) • Chandler Regional Medical Center Emergency Department (Chandler, AZ) • Children’s Medical Center of Dallas, Seay Emergency Center (Dallas, TX) • Cincinnati Children’s Hospital Emergency Department - Burnet Campus (Cincinnati, OH) • Indiana University Health Methodist Hospital Emergency Medicine and Trauma Center (Indianapolis, IN)

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64 MISSION: LIFELINE AWARDS

64.1 Overview The American Heart Association (www.americanheart.org) and American Stroke Association (www.strokeassociation.org) have developed guidelines for the treatment of heart disease and stroke. Hospital teams that have demonstrated high rates of compliance with the guidelines are recognized annually by the associations. Gold Plus, Gold, Silver Plus, and Silver Award recognitions are listed in this chapter.

64.2 Gold Plus Achievement The following hospitals are recognized for 24 months of 75% or higher adherence on select quality measures in addition to at least 24 months of 85% or higher adherence on all achievement measures applicable to heart failure (HF) or stroke (S): • Abington Memorial Hospital (Abington, PA) - S • Advocate Good Samaritan Hospital (Downers Grove, IL) - S • Advocate Lutheran General Hospital (Park Ridge, IL) - S • Albany Medical Center (Albany, NY) - S • Alexian Brothers Medical Center (Elk Grove Village, IL) - S • Allegheny General Hospital (Pittsburgh, PA) - S • Alta Bates Summit Medical Center (Oakland, CA) - S • Altoona Regional Health System (Altoona, PA) - S • Arnot Ogden Medical Center (Elmira, NY) - S • Atlanta Medical Center (Atlanta, GA) - S • Atlantic General Hospital (Berlin, MD) - S • Aultman Hospital (Canton, OH) - HF, S • Aurora Sinai Medical Center (Milwaukee, WI) - S • Aurora St. Luke’s Medical Center (Milwaukee, WI) - HF, S • Aventura Hospital and Medical Center (Aventura, FL) - S • Avera Mckennan Hospital (Sioux Falls, SD) - S • Baptist Medical Center South (Jacksonville, FL) - S • Baylor University Medical Center at Dallas (Dallas, TX) - S • Baystate Franklin Medical Center (Greenfield, MA) - S • Beebe Medical Center (Lewes, DE) - S • Berkshire Medical Center (Pittsfield, MA) - HF, S

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Beth Israel Deaconess Hospital - Needham (Needham, MA) - S Bethesda Memorial Hospital (Boynton Beach, FL) - S Beverly Hospital (Beverly, MA) - S Billings Clinic (Billings, MT) - S Blake Medical Center (Bradenton, FL) - S Boone Hospital Center (Columbia, MO) - S Borgess Medical Center (Kalamazoo, MI) - S Boston Medical Center (Boston, MA) - S Brigham and Women’s Hospital (Boston, MA) - S Brookhaven Memorial Hospital Medical Center (Patchogue, NY) - S Butler Memorial Hospital (Butler, PA) - S California Pacific Medical Center (San Francisco, CA) - S Cape Canaveral Hospital (Cocoa Beach, FL) - S Capital Health (Trenton, NJ) - S Capital Regional Medical Center (Tallahassee, FL) - S Carney Hospital (Dorchester, MA) - S Carolinas Medical Center (Charlotte, NC) - S Carolinas Medical Center - NorthEast Inc. (Concord, NC) - S Caromont Health Gaston Memorial Hospital (Gastonia, NC) - HF Carondelet Neurological Institute - Carondelet St. Joseph’s Hospital (Tucson, AZ) - S Cedars-Sinai Medical Center (Los Angeles, CA) - S Centennial Medical Center (Frisco, TX) - HF Central Baptist Hospital (Lexington, KY) - S Central Carolina Hospital (Sanford, NC) - HF Central Dupage Hospital (Winfield, IL) - S Central Washington Hospital (Wenatchee, WA) - S Christus Hospital - St. Elizabeth (Beaumont, TX) - HF CHRISTUS Spohn - Shoreline (Corpus Christi, TX) - S Citizens Medical Center (Victoria, TX) - S CJW Medical Center (Richmond, VA) - S Cleveland Clinic (Cleveland, OH) - HF, S Cleveland Clinic Florida (Weston, FL) - HF, S Coliseum Medical Centers (Macon, GA) - S Community Hospital (New Port Richey, FL) - S Conroe Regional Medical Center (Conroe, TX) - S Cooper University Hospital (Camden, NJ) - HF Corpus Christi Medical Center (Corpus Christi, TX) - HF, S Cox Health (Springfield, MO) - S Crouse Hospital (Syracuse, NY) - S Crozer Chester Medical Center (Upland, PA) - S Cullman Regional Medical Center (Cullman, AL) - S Cypress Fairbanks Medical Center (Houston, TX) - S Dartmouth-Hitchcock Medical Center (Lebanon, NH) - S Decatur General Hospital (Decatur, AL) - S

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Delaware County Memorial Hospital (Drexel Hill, PA) - S Delray Medical Center (Delray Beach, FL) - HF, S Des Peres Hospital (St. Louis, MO) - HF Desert Springs Hospital Medical Center (Las Vegas, NV) - S DeTar Healthcare System (Victoria, TX) - S Detroit Receiving Hospital (Detroit, MI) - S Dixie Regional Medical Center (St. George, UT) - S Doctors Hospital of Manteca (Manteca, CA) - HF Doctors Hospital of Sarasota (Sarasota, FL) - S Doctors Medical Center of Modesto (Modesto, CA) - HF Duke University Hospital (Durham, NC) - HF, S East Cooper Medical Center (Mount Pleasant, SC) - S East Texas Medical Center (Tyler, TX) - S Eastern Maine Medical Center (Bangor, ME) - S El Camino Hospital (Mountain View, CA) - S Ellis Medicine - Ellis Hospital (Schenectady, NY) - S Elmhurst Hospital Center (Elmhurst, NY) - S Emory Eastside Medical Center (Snellville, GA) - S Emory University Hospital (Atlanta, GA) - S Englewood Hospital and Medical Center (Englewood, NJ) - S Enloe Medical Center (Chico, CA) - S Excela Health Frick Hospital (Mt. Pleasant, PA) - S Excela Health Latrobe (Latrobe, PA) - S Excela Health Westmoreland (Greensburg, PA) - S Exempla Lutheran Medical Center (Wheat Ridge, CO) - S Faith Regional Health Services (Norfolk, NE) - S Falmouth Hospital (Falmouth, MA) - S Faulkner Hospital (Boston, MA) - S Fawcett Memorial Hospital (Port Charlotte, FL) - S Florida Hospital Memorial Medical Center (Daytona Beach, FL) - S Floyd Medical Center (Rome, GA) - S Forest Hills Hospital (Forest Hills, NY) - S Forrest General Hospital (Hattiesburg, MS) - S Forsyth Medical Center (Winston-Salem, NC) - S Fort Walton Beach Medical Center (Fort Walton Beach, FL) - S Fountain Valley Regional Hospital (Fountain Valley, CA) - S Franklin Hospital (Valley Stream, NY) - S Froedtert Hospital (Milwaukee, WI) - S Frye Regional Medical Center (Hickory, NC) - S Geisinger Medical Center (Danville, PA) - S Geneva General Hospital (Geneva, NY) - S Glen Cove Hospital (Glen Cove, NY) - S Glendale Adventist Medical Center (Glendale, CA) - S Good Samaritan Hospital (San Jose, CA) - S

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Good Samaritan Medical Center (West Palm Beach, FL) - HF Good Samaritan Regional Medical Center (Corvallis, OR) - S Grady Memorial Hospital (Atlanta, GA) - S Grand View Hospital (Sellersville, PA) - S Grant Medical Center (Columbus, OH) - S Greater Baltimore Medical Center (Baltimore, MD) - S Greenville Memorial Hospital (Greenville, SC) - S Gundersen Lutheran Medical Center (La Crosse, W I) - S Guthrie Corning Hospital (Corning, NY) - S Gwinnett Hospital System (Lawrenceville, GA) - S Hamilton Medical Center (Dalton, GA) - S Harborview Medical Center (Seattle, WA) - S Hartford Hospital (Hartford, CT) - S Hazleton General Hospital (Hazleton, PA) - HF, S Henry Ford Hospital and Health Network (Detroit, MI) - S Henry Ford Macomb Hospital (Clinton Township, MI) - S Hialeah Hospital (Hialeah, FL) - HF Highland Hospital (Rochester, NY) - S Hoag Memorial Hospital Presbyterian (Newport Beach, CA) - S Holmes Regional Medical Center / Palm Bay Hospital (Melbourne, FL) - S Holy Cross Hospital (Fort Lauderdale, FL) - S Holy Cross Hospital (Silver Spring, MD) - S Holy Redeemer Hospital (Meadowbrook, PA) - S Holyoke Medical Center (Holyoke, MA) - S Houston Northwest Medical Center (Houston, TX) - HF Howard County General Hospital (Columbia, MD) - S Howard University Hospital (Washington, DC) - HF Huntington Hospital (Huntington, NY) - S Huntington Memorial Hospital (Pasadena, CA) - S Huntsville Hospital (Huntsville, AL) - S Integris Baptist Medical Center (Oklahoma City, OK) - S Intermountain Medical Center (Murray, UT) - S Jane Phillips Medical Center (Bartlesville, OK) - HF Jeanes Hospital - TUHS (Philadelphia, PA) - S Jersey Shore University Medical Center (Neptune, NJ) - S JFK Medical Center (Atlantis, FL) - S JFK Medical Center (Edison, NJ) - S John Muir Medical Center - Concord Campus (Concord, CA) - HF, S John Muir Medical Center - Walnut Creek Campus (Walnut Creek, CA) - HF, S Johns Hopkins Bayview Medical Center (Baltimore, MD) - S Jordan Hospital (Plymouth, MA) - S Kaiser Foundation Hospital Moanalua (Honolulu, HI) - HF Kaiser Foundation Hospital - San Rafael (San Rafael, CA) - S Kaiser Foundation Hospital San Francisco (San Francisco, CA) - S

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Kaiser Foundation Hospital Santa Rosa (Santa Rosa, CA) - S Kaiser Foundation Hospitals - Roseville/Sacramento (Roseville and Sacramento, CA) - S Kaiser Foundation Hospitals - San Jose (San Jose, CA) - S Kaiser Foundation Hospitals Santa Clara Medical Center (Santa Clara, CA) - S Kaiser Permanente Foundation Hospital - South San Francisco (South San Francisco, CA) - S Kaiser Permanente Redwood City Medical Center (Redwood City, CA) - S Kaiser Permanente South Sacramento (Sacramento, CA) - S Kaiser Permanente Walnut Creek Medical Center (Walnut Creek, CA) - S Kendall Regional Medical Center (Miami, FL) - S Kennedy University Hospitals - Cherry Hill (Cherry Hill, NJ) - S Kent Hospital (Warwick, RI) - S Kettering Medical Center & Sycamore Medical Center (Kettering, OH) - S Kingwood Medical Center - an HCA Affiliated Hospital (Kingwood, TX) - S Lahey Clinic (Burlington, MA) - S Lake Pointe Medical Center (Rowlett, TX) - HF Lankenau Medical Center (Wynnewood, PA) - S Lawnwood Regional Medical Center and Heart Institute (Fort Pierce, FL) - S Lee’s Summit Medical Center (Lee’s Summit, MO) - S Legacy Emanuel Hospital and Health Center (Portland, OR) - S Legacy Good Samaritan Medical Center (Portland, OR) - S Legacy Salmon Creek Medical Center (Vancouver, WA) - S Lehigh Valley Health Network - Cedar Crest (Allentown, PA) - S Lehigh Valley Hospital - Muhlenberg (Allentown, PA) - S Lexington Medical Center (West Columbia, SC) - S Lincoln Medical and Mental Health Center (Bronx, NY) - S Littleton Adventist Hospital (Littleton, CO) - HF, S Long Beach Memorial Medical Center (Long Beach, CA) - S Long Island College Hospital (Brooklyn, NY) - S Long Island Jewish Medical Center (New Hyde Park, NY) - S Los Alamitos Medical Center (Los Alamitos, CA) - HF, S Lowell General Hospital (Lowell, MA) - HF Loyola University Medical Center (Maywood, IL) - S Lutheran Medical Center (Brooklyn, NY) - S MacNeal Hospital (Berwyn, IL) - S Maimonides Medical Center (Brooklyn, NY) - S Manatee Memorial Hospital (Bradenton, FL) - S Marin General Hospital (Greenbrae, CA) - S Martha Jefferson Hospital (Charlottesville, VA) - S Mary Black Health System (Spartanburg, SC) - S Mary Washington Hospital (Fredericksburg, VA) - S Massachusetts General Hospital (Boston, MA) - S Mayo Clinic Hospital (Phoenix, AZ) - S

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McKay-Dee Hospital Center (Ogden, UT) - S Meadville Medical Center (Meadville, PA) - S Medical Center of Arlington (Arlington, TX) - S Medical Center of McKinney (McKinney, TX) - S Medical City Dallas Hospital (Dallas, TX) - S Medical University of South Carolina Medical Center (Charleston, SC) - HF, S Memorial Hermann Southwest Hospital (Houston, TX) - S Memorial Hermann The Woodlands (The Woodlands, TX) - S Memorial Hospital (Jacksonville, FL) - S Memorial Regional Hospital (Hollywood, FL) - S Memorial Stroke Center (Gulfport, MS) - S Mercy Fitzgerald Hospital (Darby, PA) - S Mercy Hospital (Miami, FL) - S Mercy Medical Center (Baltimore, MD) - S Mercy Medical Center (Canton, OH) - S Mercy Medical Center (Oshkosh, WI) - S Mercy Medical Center - Sioux City (Sioux City, IA) - S Mercy Medical Center Redding (Redding, CA) - S Mercy Philadelphia Hospital (Philadelphia, PA) - S Methodist Hospital of Southern California (Arcadia, CA) - HF MetroWest Medical Center - Leonard Morse Hospital (Natick, MA) - S MetroWest Medical Center Framingham Union Hospital (Framingham, MA) - S Middlesex Hospital (Middletown, CT) - S Midland Memorial Hospital (Midland, TX) - HF Millard Fillmore Gates Hospital (Buffalo, NY) - S Millard Fillmore Suburban Hospital (Williamsville, NY) - HF Mills-Peninsula Health Services (Burlingame, CA) - S Mission Hospitals (Asheville, NC) - S Morristown Memorial Hospital (Morristown, NJ) - S Mount Vernon Hospital (Mt. Vernon, NY) - S Nassau University Medical Center (East Meadow, NY) - S Nazareth Hospital (Philadelphia, PA) - S Nevada Neurosciences Institute at Sunrise Hospital & Medical Center (Las Vegas, NV) - S New York Downtown Hospital (New York, NY) - S New York Methodist Hospital (Brooklyn, NY) - S Newton-Wellesley Hospital (Newton, MA) - HF, S Noble Hospital (Westfield, MA) - S North Broward Medical Center (Deerfield Beach, FL) - S North Fulton Hospital (Roswell, GA) - HF, S North Shore Medical Center - FMC Campus (Fort Lauderdale, FL) - HF, S North Shore Medical Center Salem Hospital (Salem, MA) - S North Shore Medical Center Union Hospital (Lynn, MA) - S North Shore University Hospital (Manhasset, NY) - S

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Northern Westchester Hospital (Mt. Kisco, NY) - S Northside Hospital & Tampa Bay Heart Institute (St. Petersburg, FL) - S Northside Medical Center (Youngstown, OH) - HF Northwest Community Hospital (Arlington Heights, IL) - S Northwest Hospital & Medical Center (Seattle, W A) - S Northwest Medical Center (Margate, FL) - S Northwestern Memorial Hospital (Chicago, IL) - S Nyack Hospital (Nyack, NY) - S NYU Langone Medical Center (New York, NY) - S OakBend Medical Center (Richmond, TX) - S Ocala Health (Ocala, FL) - S Ocean Medical Center (Brick, NJ) - S O’Connor Hospital (San Jose, CA) - S Oconomowoc Memorial Hospital (Oconomowoc, WI) - S Orange Park Medical Center (Orange Park, FL) - S Orange Regional Medical Center (Middletown, NY) - S Oregon Health & Science University (Portland, OR) - S Osceola Regional Medical Center (Kissimmee, FL) - S OSF St. Joseph Medical Center (Bloomington, IL) - S Our Lady of Lourdes Medical Center (Camden, NJ) - S Our Lady of Lourdes Memorial Hospital (Binghamton, NY) - S Overlook Hospital (Summit, NJ) - S Palm Beach Gardens Medical Center (Palm Beach Gardens, FL) - S Palmetto General Hospital (Hialeah, FL) - HF Palmetto Health Richland (Columbia, SC) - HF Palms of Pasadena Hospital (St. Petersburg, FL) - S Parkland Health & Hospital (Dallas, TX) - S Pen Bay Medical Center (Rockport, ME) - S Penn State Hershey Medical Center (Hershey, PA) - S Pepin Heart Hospital University Community Health Systems Inc. (Tampa, FL) - HF Phelps Memorial Hospital Center (Sleepy Hollow, NY) - S Piedmont Medical Center (Rock Hill, SC) - HF Pikeville Medical Center (Pikeville, KY) - S Pitt County Memorial Hospital (Greenville, NC) - S Plainview Hospital (Plainview, NY) - S Pomona Valley Hospital Medical Center (Pomona, CA) - HF Presbyterian Intercommunity Hospital (Whittier, CA) - S Providence Healthcare Network (Waco, TX) - S Providence Hospital (Mobile, AL) - HF Providence Little Company of Mary Medical Center San Pedro (San Pedro, CA) - S Providence Memorial Hospital (El Paso, TX) - HF Providence Portland Medical Center (Portland, OR) - S Providence Regional Medical Center Everett (Everett, WA) - HF Providence Sacred Heart Medical Center and Children’s Hospital (Spokane, W A) - S

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Providence Saint Joseph Medical Center (Burbank, CA) - S Providence St. Vincent Medical Center (Portland, OR) - S Rapid City Regional Hospital (Rapid City, SD) - HF Regional Medical Center Bayonet Point (Hudson, FL) - HF, S Regional Medical Center of San Jose (San Jose, CA) - S Research Medical Center (Kansas City, MO) - HF, S Richmond University Medical Center (Staten Island, NY) - S Riverview Medical Center (Red Bank, NJ) - S Robert Wood Johnson University Hospital (New Brunswick, NJ) - S Robert Wood Johnson University Hospital Hamilton (Hamilton, NJ) - S Rochester General Hospital (Rochester, NY) - S Ronald Reagan UCLA Medical Center (Los Angeles, CA) - S Roper Hospital (Charleston, SC) - S Rush University Medical Center (Chicago, IL) - S Sacred Heart Health System (Pensacola, FL) - S Sacred Heart Hospital (Eau Claire, WI) - S Saint Agnes Hospital (Baltimore, MD) - S Saint Alphonsus Regional Medical Center (Boise, ID) - S Saint Clare’s Hospital - Denville (Dover, NJ) - S Saint Francis Hospital - Bartlett (Bartlett, TN) - HF Saint Francis Hospital and Medical Center (Hartford, CT) - S Saint Joseph’s Hospital of Atlanta (Atlanta, GA) - S Saint Louis University Hospital (St. Louis, MO) - HF, S Saint Luke’s Brain and Stroke Institute (Kansas City, MO) - S San Jacinto Methodist Hospital (Baytown, TX) - S San Joaquin Community Hospital (Bakersfield, CA) - S Sarasota Memorial Health Care System (Sarasota, FL) - S Scottsdale Healthcare Medical Center Osborn (Scottsdale, AZ) - S Scripps Green Hospital (La Jolla, CA) - S Scripps Memorial Hospital Encinitas (Encinitas, CA) - S Sequoia Hospital (Redwood City, CA) - S Seton Health / St. Mary’s Hospital (Troy, NY) - S Seton Medical Center (Daly City, CA) - S Sharon Hospital (Sharon, CT) - S Sharp Grossmont Hospital (La Mesa, CA) - S Sharp Memorial Hospital (San Diego, CA) - S Shasta Regional Medical Center (Redding, CA) - S Shawnee Mission Medical Center (Shawnee Mission, KS) - S Sierra Providence East Medical Center (El Paso, TX) - HF Sinai Hospital (Baltimore, MD) - S Sound Shore Medical Center of Westchester (New Rochelle, NY) - S South Jersey Healthcare - Elmer Hospital (Elmer, NJ) - S South Jersey Healthcare Regional Medical Center (Vineland, NJ) - S Southern Regional Health System (Riverdale, GA) - S

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Southside Hospital (Bay Shore, NY) - S Sparks Health System (Fort Smith, AR) - S Sparrow Hospital (Lansing, MI) - S St. Alexius Medical Center (Hoffman Estates, IL) - S St. Anthony Central Hospital (Denver, CO) - S St. Anthony’s Hospital (St. Petersburg, FL) - S St. Catherine of Siena Medical Center (Smithtown, NY) - S St. Charles Hospital (Port Jefferson, NY) - S St. David’s Medical Center (Austin, TX) - S St. Francis Hospital - The Heart Center (Roslyn, NY) - S St. Francis Hospital Inc. (Columbus, GA) - S St. John Medical Center (Tulsa, OK) - S St. John Medical Center (Westlake, OH) - S St. Joseph Hospital (Savannah, GA) - S St. Joseph Medical Center (Reading, PA) - S St. Joseph’s Hospital (Tampa, FL) - S St. Joseph’s Hospital and Medical Center / Barrow Neurological Institute (Phoenix, AZ) - S St. Joseph’s Regional Medical Center (Bryan, TX) - S St. Joseph’s Regional Medical Center (Paterson, NJ) - HF, S St. Jude Medical Center (Fullerton, CA) - S St. Lucie Medical Center (Port St. Lucie, FL) - S St. Luke’s Cornwall Hospital - Newburgh and Cornwall Campuses (Newburgh, NY) - S St. Luke’s Regional Medical Center (Sioux City, IA) - S St. Luke’s Roosevelt Hospital (New York, NY) - S St. Mark’s Hospital (Salt Lake City, UT) - S St. Mary Medical Center (Langhorne, PA) - S St. Mary’s Health Care System (Athens, GA) - S St. Mary’s Hospital and Medical Center (Grand Junction, CO) - HF St. Mary’s Medical Center (Huntington, WV) - S St. Vincent’s Medical Center (Bridgeport, CT) - S Staten Island University Hospital (Staten Island, NY) - S Stony Brook University Medical Center (Stony Brook, NY) - S Straub Clinic and Hospital (Honolulu, HI) - HF Sts. Mary and Elizabeth Hospital (Louisville, KY) - S Summa Akron City Hospital (Akron, OH) - S Swedish Medical Center (Englewood, CO) - S Swedish Medical Center (Seattle, WA) - S Syosset Hospital (Syosset, NY) - S Tampa General Hospital (Tampa, FL) - S Texas Health Presbyterian Hospital - WNJ (Sherman, TX) - S The Brooklyn Hospital Center (Brooklyn, NY) - S The Hospital of the University of Pennsylvania (Philadelphia, PA) - S

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The Johns Hopkins Hospital (Baltimore, MD) - S The Kingston Hospital (Kingston, NY) - S The Medical Center Inc. (Columbus, GA) - S The Medical Center of Aurora (Aurora, CO) - S The Medical Center of Plano (Plano, TX) - S The Memorial Hospital at Easton - Shore Health System (Easton, MD) - S The MetroHealth System (Cleveland, OH) - S The Miriam Hospital (Providence, RI) - S The Nebraska Medical Center (Omaha, NE) - S The Queen’s Medical Center (Honolulu, HI) - S The Reading Hospital and Medical Center (Reading, PA) - HF, S The University of Kansas Hospital (Kansas City, KS) - HF, S The University of Tennessee Medical Center (Knoxville, TN) - S The University of Toledo Medical Center (Toledo, OH) - S The Valley Hospital (Ridgewood, NJ) - S The Williamsport Hospital and Medical Center (Williamsport, PA) - S Theda Clark Medical Center (Neenah, WI) - S Thomas Jefferson University Hospital (Philadelphia, PA) - S Tri-City Medical Center (Oceanside, CA) - S Trident Medical Center (Charleston, SC) - HF Trinity Medical Center (Birmingham, AL) - HF Trinity Mother Frances Health System (Tyler, TX) - S Tucson Medical Center (Tucson, AZ) - S Tufts Medical Center (Boston, MA) - S Tulane University Hospital and Clinic (New Orleans, LA) - S Twin Cities Community Hospital (Templeton, CA) - HF UC Davis Medical Center (Sacramento, CA) - S UMass Memorial Medical Center - University Campus (Worcester, MA) - S Union Memorial Hospital (Baltimore, MD) - S United Regional Healthcare System (Wichita Falls, TX) - S Unity Hospital (Rochester, NY) - S University Hospitals Case Medical Center (Cleveland, OH) - S University Medical Center of Southern Nevada (Las Vegas, NV) - HF, S University of Colorado Hospital (Aurora, CO) - S University of Kentucky Chandler Hospital (Lexington, KY) - S University of Louisville Hospital (Louisville, KY) - S University of Michigan Health System (Ann Arbor, MI) - S University of Mississippi Health Care (Jackson, MS) - HF University of New Mexico Hospitals (Albuquerque, NM) - HF, S University of Rochester Medical Center - Strong Memorial Hospital (Rochester, NY) - S University of South Alabama Medical Center (Mobile, AL) - S University of Utah Health Care (Salt Lake City, UT) - S University of Wisconsin Hospital and Clinics (Madison, WI) - S

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UPMC Hamot (Erie, PA) - S UPMC McKeesport (McKeesport, PA) - S UPMC Mercy Pittsburgh (Pittsburgh, PA) - S UPMC Northwest (Seneca, PA) - S UPMC Passavant (Pittsburgh, PA) - S UPMC Shadyside (Pittsburgh, PA) - S UPMC St. Margaret (Pittsburgh, PA) - S UPMC Stroke Institute (Pittsburgh, PA) - S Upstate University Hospital (Syracuse, NY) - S USC University Hospital (Los Angeles, CA) - HF Utah Valley Regional Medical Center (Provo, UT) - S Valley Baptist Medical Center - Brownsville (Brownsville, TX) - S Valley Baptist Medical Center - Harlingen (Harlingen, TX) - S ValleyCare Medical Center (Pleasanton, CA) - HF Vassar Brothers Medical Center (Poughkeepsie, NY) - S Virginia Commonwealth University Medical Center (Richmond, VA) - S Virginia Mason Medical Center (Seattle, WA) - S Virtua Memorial Hospital (Mt. Holly, NJ) - S Wadley Regional Medical Center (Texarkana, TX) - HF, S Wake Forest University Baptist Medical Center (Winston-Salem, NC) - S WakeMed Health & Hospitals (Raleigh, NC) - S Washington Hospital Center (Washington, DC) - S Washington Hospital Healthcare System (Fremont, CA) - S Waukesha Memorial Hospital (Waukesha, WI) - S Wentworth-Douglass Hospital (Dover, NH) - S West Boca Medical Center (Boca Raton, FL) - HF West Florida Hospital (Pensacola, FL) - S West Virginia University Hospitals (Morgantown, WV) - S Westchester Medical Center (Valhalla, NY) - S White Plains Hospital Center (White Plains, NY) - S Winter Haven Hospital (Winter Haven, FL) - S Woodland Memorial Hospital - Woodland Healthcare (Woodland, CA) - S Wuesthoff Medical Center Rockledge (Rockledge, FL) - S Wyoming Medical Center (Casper, WY) - S

64.3 Gold Achievement Award The following hospitals are recognized for two or more years at 85% or higher adherence on all achievement measures applicable to heart failure (HF) or stroke (S): • Advocate BroMenn Medical Center (Normal, IL) - S • Advocate Christ Medical Center (Oak Lawn, IL) - HF, S • Advocate Good Samaritan Hospital (Downers Grove, IL) - HF • Albany Medical Center (Albany, NY) - HF • Alegent Health Bergan Mercy Medical Center (Omaha, NE) - HF

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Alegent Health Immanuel Medical Center (Omaha, NE) - HF Alegent Health Lakeside Hospital (Omaha, NE) - HF Alegent Health Mercy Hospital (Council Bluffs, IA) - HF Alegent Health Midlands Hospital (Papillion, NE) - HF Allegheny General Hospital (Pittsburgh, PA) - HF Alta Bates Summit Medical Center (Oakland, CA) - HF American Fork Hospital (American Fork, UT) - S Atlanta Medical Center (Atlanta, GA) - HF AtlantiCare Regional Medical Center (Pomona, NJ) - HF Bakersfield Memorial Hospital (Bakersfield, CA) - S Banner Good Samaritan Medical Center (Phoenix, AZ) - S Baptist Medical Center South (Montgomery, AL) - HF Bay Pines VA Healthcare System (Bay Pines, FL) - HF Bayhealth Medical Center - Kent General (Dover, DE) - HF Bayhealth Medical Center - Milford Memorial (Milford, DE) - HF Baylor Regional Medical Center at Grapevine (Grapevine, TX) - HF Beaufort Memorial Hospital (Beaufort, SC) - HF Borgess Medical Center (Kalamazoo, MI) - HF Boston Medical Center (Boston, MA) - HF Bronson Methodist Hospital (Kalamazoo, MI) - HF Brookwood Medical Center (Birmingham, AL) - HF Carondelet St. Mary’s Hospital (Tucson, AZ) - HF Christ Hospital (Jersey City, NJ) - HF Christiana Care Health System (Newark, DE) - HF Citizens Medical Center (Victoria, TX) - HF Columbia Memorial Hospital (Hudson, NY) - HF Columbia-St. Mary’s Hospital (Milwaukee, WI) - S Cooley Dickinson Hospital (Northampton, MA) - HF, S Coral Gables Hospital (Coral Gables, FL) - HF Creighton University Medical Center (Omaha, NE) - HF Cullman Regional Medical Center (Cullman, AL) - HF Cypress Fairbanks Medical Center (Houston, TX) - HF Decatur Memorial Hospital (Decatur, IL) - S Del Sol Medical Center (El Paso, TX) - HF Denver Health Medical Center (Denver, CO) - HF Desert Regional Medical Center (Palm Springs, CA) - HF Dixie Regional Medical Center (St. George, UT) - HF Doctors Hospital at White Rock Lake (Dallas, TX) - HF East Cooper Medical Center (Mount Pleasant, SC) - HF East Jefferson General Hospital (Metairie, LA) - HF Edward Hospital & Health Services (Naperville, IL) - HF, S Erie County Medical Center (Buffalo, NY) - HF F.F. Thompson Hospital (Canandaigua, NY) - S Fountain Valley Regional Hospital (Fountain Valley, CA) - HF

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Frye Regional Medical Center (Hickory, NC) - HF Gibson General Hospital (Princeton, IN) - HF Good Samaritan Medical Center (West Palm Beach, FL) - S Hahnemann University Hospital (Philadelphia, PA) - HF, S Hanover Hospital (Hanover, PA) - HF Heart Hospital of Lafayette (Lafayette, LA) - HF Hillcrest Medical Center - Oklahoma Heart Institute (Tulsa, OK) - HF Hilton Head Hospital (Hilton Head Island, SC) - HF Huntsville Hospital (Huntsville, AL) - HF Indian Path Medical Center (Kingsport, TN) - HF Indiana University Health Ball Memorial Hospital (Muncie, IN) - S Indiana University Health Methodist Hospital (Indianapolis, IN) - HF Iredell Memorial Hospital (Statesville, NC) - HF Jackson Hospital and Clinic Inc. (Montgomery, AL) - S Jackson Memorial Hospital (Miami, FL) - S JFK Memorial Hospital (Indio, CA) - HF John Randolph Medical Center (Hopewell, VA) - HF Johnson City Medical Center (Johnson City, TN) - HF King’s Daughters Medical Center (Ashland, KY) - HF Kona Community Hospital (Kealakekua, HI) - HF Lakewood Regional Medical Center (Lakewood, CA) - HF Lawrence & Memorial Hospital (New London, CT) - S LDS Hospital (Salt Lake City, UT) - HF LSUHSC W.O. Moss Regional Medical Center (Lake Charles, LA) - HF MacNeal Hospital (Berwyn, IL) - HF Marion General Hospital (Marion, OH) - HF Maryland General Hospital (Baltimore, MD) - S Maui Memorial Medical Center (Wailuku, HI) - HF Maury Regional Medical Center (Columbia, TN) - HF Memorial Hermann Southwest Hospital (Houston, TX) - HF Memorial Hospital (York (York, PA) - HF Memorial Hospital Miramar (Miramar, FL) - HF Menorah Medical Center (Overland Park, KS) - HF Memorial Medical Center of East Texas (Lufkin, TX) - HF Mercy Fitzgerald Hospital (Darby, PA) - HF Mercy Medical Center - North Iowa (Mason City, IA) - S Mercy Philadelphia Hospital (Philadelphia, PA) - HF Meriter Hospital (Madison, WI) - HF Methodist Hospitals Inc. (Gary, IN) - S Methodist Richardson Medical Center (Richardson, TX) - HF Milford Regional Medical Center (Milford, MA) - S Millard Fillmore Gates Hospital (Buffalo, NY) - HF Moses Taylor Hospital (Scranton, PA) - HF Mount Auburn Hospital (Cambridge, MA) - S

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MS Baptist Medical Center (Jackson, MS) - HF Nacogdoches Medical Center (Nacogdoches, TX) - HF New River Medical Center (Monticello, MN) - HF Newark Beth Israel Medical Center (Newark, NJ) - HF NewYork-Presbyterian Hospital/ Weill Cornell Medical Center (New York, NY) - S Niagara Falls Memorial Medical Center (Niagara Falls, NY) - HF North Adams Regional Hospital (North Adams, MA) - HF, S North Florida Regional Medical Center (Gainesville, FL) - S Northern Michigan Regional Hospital (Petoskey, MI) - S Northside Hospital (Johnson City, TN) - HF Ochsner Medical Center - New Orleans (New Orleans, LA) - S Ochsner Medical Center North Shore (Slidell, LA) - HF Ochsner Medical Center Westbank (Terrytown, LA) - HF Pali Momi Medical Center (Aiea, HI) - HF Palisades Medical Center (North Bergen, NJ) - HF Parker Adventist Hospital (Parker, CO) - HF Parkview Hospital Stanley Wissman Stroke Center (Fort Wayne, IN) - S Parkwest Medical Center (Knoxville, TN) - S Parkview Medical Center (Pueblo, CO) - HF Penrose-St. Francis Health Services (Colorado Springs, CO) - S Piedmont Hospital (Atlanta, GA) - HF Pinnacle Health Hospitals (Harrisburg, PA) - HF Pitt County Memorial Hospital (Greenville, NC) - HF Placentia-Linda Hospital (Placentia, CA) - HF Plaza Medical Center of Fort Worth (Fort Worth, TX) - S Poudre Valley Hospital (Ft. Collins, CO) - S Presbyterian / St. Luke’s Medical Center (Denver, CO) - HF Princeton Baptist Medical Center (Birmingham, AL) - HF, S Providence Alaska Medical Center (Anchorage, AK) - HF Rappahannock General Hospital (Kilmarnock, VA) - HF Raritan Bay Medical Center (Perth Amboy, NJ) - HF Renown Regional Medical Center (Reno, NV) - S Rome Memorial Hospital (Rome, NY) - HF Saddleback Memorial Medical Center (Laguna Hills, CA) - HF Saint Francis Hospital - Memphis (Memphis, TN) - HF Saint Francis Hospital and Health Centers (Poughkeepsie, NY) - S Saint Mary’s Health System (Waterbury, CT) - HF Saint Mary’s Regional Medical Center (Reno, NV) - S Sanford Medical Center - Fargo (Fargo, ND) - S Seton Health / St. Mary’s Hospital (Troy, NY) - HF Seven Rivers Regional Medical Center (Crystal River, FL) - HF Shands at the University of Florida (Gainesville, FL) - S Sharp Chula Vista Medical Center (Chula Vista, CA) - HF Sharp Grossmont Hospital (La Mesa, CA) - HF

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Shawnee Mission Medical Center (Shawnee Mission, KS) - HF Sherman Hospital (Elgin, IL) - HF Sierra Vista Regional Medical Center (San Luis Obispo, CA) - HF South Fulton Medical Center (East Point, GA) - HF South Jersey Healthcare Regional Medical Center (Vineland, NJ) - HF Southwest General Health Center (Middleburg Heights, OH) - HF Spalding Regional Medical Center (Griffin, GA) - HF Springs Memorial Hospital (Lancaster, SC) - HF St. Anthony Central Hospital (Denver, CO) - HF St. Clare Hospital and Health Services (Baraboo, WI) - HF St. David’s Round Rock Medical Center (Round Rock, TX) - S St. Elizabeth Health Center-HMHP (Youngstown, OH) - HF St. Joseph Medical Center (Reading, PA) - HF St. Joseph Medical Center (Tacoma, WA) - S St. Joseph Mercy Hospital Ann Arbor (Ann Arbor, MI) - S St. Luke’s Boise / Meridian Medical Center (Boise, ID) - HF St. Luke’s Hospital (Cedar Rapids, IA) - HF St. Mary Medical Center (Langhorne, PA) - HF St. Mary’s Medical Center (West Palm Beach, FL) - HF Stony Brook University Medical Center (Stony Brook, NY) - HF Swedish Medical Center (Englewood, CO) - HF Sycamore Shoals Hospital (Elizabethton, TN) - HF Texas Health Presbyterian Hospital - WNJ (Sherman, TX) - HF Texas Health Presbyterian Hospital Dallas (Dallas, TX) - HF, S The Good Samaritan Health System (Lebanon, PA) - HF The Heart Hospital Baylor Plano (Plano, TX) - HF The MetroHealth System (Cleveland, OH) - HF The University Hospital - UMDNJ (Newark, NJ) - HF The University of Tennessee Medical Center (Knoxville, TN) - HF Trinity Medical Center (Birmingham, AL) - S UCONN Health Center - John Dempsey Hospital (Farmington, CT) - HF University Hospitals Case Medical Center (Cleveland, OH) - HF University of Colorado Hospital (Aurora, CO) - HF University of Rochester Medical Center - Strong Memorial Hospital (Rochester, NY) - HF UPMC Hamot (Erie, PA) - HF Utah Valley Regional Medical Center (Provo, UT) - HF Valley Baptist Medical Center - Brownsville (Brownsville, TX) - HF Valley Baptist Medical Center - Harlingen (Harlingen, TX) - HF Valley Medical Center (Renton, WA) - HF Vanderbilt University Hospital (Nashville, TN) - S Vassar Brothers Medical Center (Poughkeepsie, NY) - HF WakeMed Health & Hospitals (Raleigh, NC) - HF War Memorial Hospital (Sault Sainte Marie, MI) - HF

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Waterbury Hospital (Waterbury, CT) - S West Valley Medical Center (Caldwell, ID) - HF Westchester Medical Center (Valhalla, NY) - HF Wilcox Memorial Hospital (Lihue, HI) - HF, S Wing Memorial Hospital and Medical Center (Palmer, MA) - HF Winthrop University Hospital (Mineola, NY) - HF Woodhull Medical and Mental Health Center (Brooklyn, NY) - HF

64.4 Silver Plus Achievement Award The following hospitals are recognized for 12 months of 75% or higher adherence on select quality measures in addition to at least 12 months of 85% or higher adherence on all achievement measures applicable to heart failure (HF) or stroke (S): • Aurora Sheboygan Memorial Medical Center (Sheboygan, WI) - S • Banner Baywood Medical Center (Mesa, AZ) - S • Baptist Health Medical Center - Little Rock (Little Rock, AR) - S • Barnes-Jewish Hospital (St. Louis, MO) - S • Bassett Medical Center (Cooperstown, NY) - S • Baystate Medical Center (Springfield, MA) - S • Benefis Health System (Great Falls, MT) - S • Bronx-Lebanon Hospital Center (Bronx, NY) - S • Broward General Medical Center (Ft. Lauderdale, FL) - S • Bryn Mawr Hospital (Bryn Mawr, PA) - S • Candler Hospital (Savannah, GA) - S • Cape Cod Hospital (Hyannis, MA) - S • Carondelet St. Mary’s Hospital (Tucson, AZ) - S • Centerpoint Medical Center (Independence, MO) - HF, S • Centra Lynchburg General Hospital (Lynchburg, VA) - S • CentraState Medical Center (Freehold, NJ) - S • Christiana Care Health System (Newark, DE) - S • Covenant Medical Center (Lubbock, TX) - S • Eden Medical Center (Castro Valley, CA) - S • Evergreen Hospital Medical Center (Kirkland, WA) - S • Faxton St. Lukes Healthcare (Utica, NY) - S • Fletcher Allen Health Care (Burlington, VT) - S • Flowers Hospital (Dothan, AL) - S • Franklin Square Hospital Center (Baltimore, MD) - S • Geisinger Wyoming Valley Medical Center (Wilkes-Barre, PA) - S • George Washington University Hospital (Washington, DC) - S • Georgetown University Hospital (Washington, DC) - S • Good Samaritan Hospital - Bon Secours Charity Health System (Suffern, NY) - S • Good Samaritan Hospital Medical Center (West Islip, NY) - S • Good Shepherd Medical Center (Longview, TX) - S

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Gulf Coast Medical Center (Fort Myers, FL) - S Hackensack University Medical Center (Hackensack, NJ) - S Harbor Hospital (Baltimore, MD) - S Harford Memorial Hospital (Havre de Grace, MD) - S Harlem Hospital Center (New York, NY) - S Hillcrest Baptist Medical Center (Waco, TX) - S Holy Name Medical Center (Teaneck, NJ) - S Inova Loudoun Hospital (Leesburg, VA) - S Jefferson Regional Medical Center (Pittsburgh, PA) - S Kaiser Permanente Antioch Medical Center (Antioch, CA) - S Kaiser Permanente Fremont Medical Center (Fremont, CA) - S Kings County Hospital Center (Brooklyn, NY) - S King’s Daughters Medical Center (Ashland, KY) - S Las Palmas Medical Center (El Paso, TX) - S Lawrence Hospital Center (Bronxville, NY) - S Leesburg Regional Medical Center (Leesburg, FL) - S Los Robles Hospital and Medical Center (Thousand Oaks, CA) - S Madigan Army Medical Center (Tacoma, WA) - S Mayo Clinic (Jacksonville, FL) - S Mayo Clinic - Rochester - Saint Mary’s Hospital (Rochester, MN) - S MCGHealth (Augusta, GA) - S Medical Center Hospital (Odessa, TX) - S Medical Center of Central Georgia (Macon, GA) - S Memorial Health University Medical Center (Savannah, GA) - S Menorah Medical Center (Overland Park, KS) - S Mercy Medical Center (Rockville Centre, NY) - S Meritus Medical Center (Hagerstown, MD) - S Methodist Hospital of Southern California (Arcadia, CA) - S Metropolitan Hospital Center (New York, NY) - S Miami VA HealthCare System (Miami, FL) - S Mount St. Mary’s Hospital and Health Center (Lewiston, NY) - S Mount Sinai Medical Center (Miami Beach, FL) - S Mountainside Hospital (Montclair, NJ) - S Nazareth Hospital (Philadelphia, PA) - HF NewYork-Presbyterian Hospital/ Columbia University Medical Center (New York, NY) - S Niagara Falls Memorial Medical Center (Niagara Falls, NY) - S North Mississippi Medical Center (Tupelo, MS) - S Northwest Hospital (Randallstown, MD) - S Ogden Regional Medical Center (Ogden, UT) - S Our Lady of Lourdes Regional Medical Center (Lafayette, LA) - S Palisades Medical Center (North Bergen, NJ) - S Palomar Medical Center (Escondido, CA) - S Paoli Hospital (Paoli, PA) - S

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PeaceHealth Sacred Heart Medical Center (Springfield, OR) - S Piedmont Medical Center (Rock Hill, SC) - S Pomona Valley Hospital Medical Center (Pomona, CA) - S Providence Little Company of Mary Medical Center - Torrance (Torrance, CA) - S Providence St. Peter Hospital (Olympia, WA) - S Rapides Regional Medical Center. Alexandria, LA) - S Redmond Regional Medical Center (Rome, GA) - HF, S Riddle Hospital (Media PA) - HF Riverside Methodist Hospital / Ohio Health (Columbus, OH) - S Riverside Regional Medical Center (Newport News, VA) - S Ronald Reagan UCLA Medical Center (Los Angeles, CA) - HF Saint Francis Hospital and Medical Center (Hartford, CT) - HF Saint Luke’s Hospital of Kansas City (Kansas City, MO) - HF Saint Peter’s University Hospital (New Brunswick, NJ) - S Saint Vincent Health Center (Erie, PA) - S Saint Vincent Hospital (Worcester, MA) - S Santa Barbara Cottage Hospital (Santa Barbara, CA) - S Scott and White Healthcare Round Rock (Round Rock, TX) - S Sierra Medical Center (El Paso, TX) - HF Signature Healthcare Brockton Hospital (Brockton, MA) - S Somerset Medical Center (Somerville, NJ) - S South Fulton Medical Center (East Point, GA) - S South Nassau Communities Hospital (Oceanside, NY) - S Southeast Alabama Medical Center (Dothan, AL) - S Southern New Hampshire Medical Center (Nashua, NH) - S Spring Valley Hospital Medical Center (Las Vegas, NV) - S St. Francis Hospital (Wilmington, DE) - S St. Joseph Hospital (Nashua, NH) - S St. Joseph Medical Center (Kansas City, MO) - S St. Luke’s Hospital (Cedar Rapids, IA) - S St. Mary’s Hospital and Medical Center (Grand Junction, CO) - S St. Mary’s Medical Center (West Palm Beach, FL) - S St. Mary’s of Michigan (Saginaw, MI) - S St. Vincent Charity Medical Center (Cleveland, OH) - S Tacoma General Hospital (Tacoma WA) - S Taylor Hospital (Ridley Park, PA) - S The Methodist Hospital (Houston, TX) - S The University Hospital - UMDNJ (Newark, NJ) - S The Washington Hospital (Washington, PA) - S Tuality Healthcare (Hillsboro, OR) - S University Hospital’s Geauga Medical Center (Chardon, OH) - S University Medical Center (Tucson, AZ) - S University of Arkansas for Medical Sciences (Little Rock, AR) - S University of California (Irvine Medical Center (Orange, CA) - HF

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University of Missouri Health Care (Columbia, MO) - S Valley Hospital Medical Center (Las Vegas, NV) - S Via Christi Hospital (Wichita, KS) - S West Boca Medical Center (Boca Raton, FL) - S Wuesthoff Medical Center - Melbourne (Melbourne, FL) - S

64.5 Silver Achievement Award The following hospitals are recognized for 12 consecutive months at 85% or higher adherence on all achievement measures applicable to heart failure (HF) or stroke (S): • Abington Memorial Hospital (Abington, PA) - HF • American Fork Hospital (American Fork, UT) - HF • Aspirius Wausau Hospital (Wausau, WI) - S • Aurora BayCare Medical Center (Green Bay, WI) - S • Banner Boswell Medical Center (Sun City, AZ) - S • Baptist Health System (San Antonio, TX) - HF • Baptist Hospital East (Louisville, KY) - S • Baptist Medical Center South (Montgomery, AL) - S • Baptist Medical Center (Jacksonville, FL) - S • Beaumont Hospital (Royal Oak, MI) - S • Buffalo General Hospital (Buffalo, NY) - HF • Calvert Memorial Hospital (Prince Frederick, MD) - S • Carle Foundation Hospital (Urbana, IL) - S • Carteret General Hospital (Morehead City, NC) - HF • Central Carolina Hospital (Sanford, NC) - S • Central Florida Regional Hospital (Sanford, FL) - S • Coastal Carolina Hospital (Hardeeville, SC) - HF • Columbia Hospital (West Palm Beach, FL) - S • Columbus Regional Hospital (Columbus, IN) - S • Doctors Hospital of Sarasota (Sarasota, FL) - HF • Doylestown Hospital (Doylestown, PA) - HF • DuBois Regional Medical Center (DuBois, PA) - S • Ephrata Community Hospital (Ephrata, PA) - HF • Forsyth Medical Center (Winston-Salem, NC) - HF • Good Samaritan Hospital Medical Center (West Islip, NY) - HF • Hamilton Medical Center (Dalton, GA) - HF • Hancock County Memorial Hospital (Britt, IA) - HF • Hawaii Medical Center East (Honolulu, HI) - S • Hoag Memorial Hospital Presbyterian (Newport Beach, CA) - HF • Ingalls Memorial Hospital (Harvey, IL) - S • Integris Baptist Medical Center (Oklahoma City, OK) - HF • Integris Southwest Medical Center (Oklahoma City, OK) - S • Intermountain Medical Center (Murray, UT) - HF

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Iredell Memorial Hospital (Statesville, NC) - S Jefferson Regional Medical Center (Crystal City, MO) - S Jersey City Medical Center (Jersey City, NJ) - S Jersey Shore University Medical Center (Neptune, NJ) - HF Jordan Valley Medical Center & Pioneer Valley Hospital Campus of JVMC (West Jordan, UT) - S Kaiser Permanente Los Angeles Medical Center (Los Angeles, CA) - S Lake Health (Concord, OH) - HF Lake Wales Medical Center (Lake Wales, FL) - HF Largo Medical Center (Largo, FL) - HF LDS Hospital (Salt Lake City, UT) - S Lenox Hill Hospital (New York, NY) - S Lewis Gale Medical Center (Salem, VA) - S Longview Regional Medical Center (Longview, TX) - S Manatee Memorial Hospital (Bradenton, FL) - HF Marquette General Health System (Marquette, MI) - S Mary Washington Hospital (Fredericksburg, VA) - HF Maui Memorial Medical Center (Wailuku, HI) - S McKay-Dee Hospital Center (Ogden, UT) - HF Mease Countryside Hospital (Safety Harbor, FL) - S Mease Dunedin Hospital (Dunedin, FL) - S Memorial Medical Center of East Texas (Lufkin, TX) - S Mercy General Hospital (Sacramento, CA) - S Mercy Hospital (Portland, ME) - HF Mercy San Juan Medical Center (Carmichael, CA) - S Methodist Richardson Medical Center (Richardson, TX) - S Middlesex Hospital (Middletown, CT) - HF Midland Memorial Hospital (Midland, TX) - S Morton Hospital and Medical Center (Taunton, MA) - HF, S Mount Nittany Medical Center (State College, PA) - HF Mountain View Hospital (Payson, UT) - S MountainView Hospital Medical Center (Las Vegas, NV) - S Newton Memorial Hospital (Newton, NJ) - HF North Cypress Medical Center (Cypress, TX) - S North Hawaii Community Hospital (Kamuela, HI) - HF North Shore University Hospital (Manhasset, NY) - HF North Suburban Medical Center (Thornton, CO) - S Northeast Georgia Medical Center (Gainesville, GA) - S Northern Michigan Regional Hospital (Petoskey, MI) - HF Ocean Medical Center (Brick, NJ) - HF Pali Momi Medical Center (Aiea, HI) - S Palm Beach Gardens Medical Center (Palm Beach Gardens, FL) - HF Parkland Medical Center (Derry, NH) - S Penn State Hershey Medical Center (Hershey, PA) - HF

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Pinnacle Health Hospitals (Harrisburg, PA) - S Porter Adventist Hospital (Denver, CO) - HF, S Providence Holy Cross Medical Center (Mission Hills, CA) - S Providence Rural Hospital Network (Portland, OR) - S Raritan Bay Medical Center (Perth Amboy, NJ) - S Regions Hospital (St. Paul, MN) - S Rockingham Memorial Hospital (Harrisonburg, VA) - HF Saint Joseph - London (London, KY) - HF Saint Mary’s Health System (Waterbury, CT) - S San Ramon Regional Medical Center (San Ramon, CA) - HF Schuylkill Medical Center East Norwegian Street (Pottsvile, PA) - HF Schuylkill Medical Center South Jackson Street (Pottsville, PA) - HF Sevier Valley Medical Center (Richfield, UT) - HF Sharon Hospital (Sharon, CT) - HF Sherman Hospital (Elgin, IL) - S Sierra Vista Regional Health Center (Sierra Vista, AZ) - HF SkyRidge Medical Center (Cleveland, TN) - HF Slidell Memorial Hospital (Slidell, LA) - HF South Baldwin Regional Medical Center (Foley, AL) - HF Southcrest Hospital (Tulsa, OK) - HF Southeast Missouri Hospital (Cape Girardeau, MO) - HF Spalding Regional Medical Center (Griffin, GA) - S St. Charles Health System Inc. (Bend, OR) - S St. Francis Hospital & Health Centers (Indianapolis, IN) - HF St. John’s Hospital (Springfield, IL) - HF St. Luke’s Episcopal Hospital (Houston, TX) - S St. Mary’s Medical Center- Evansville (Evansville, IN) - HF Stormont-Vail HealthCare (Topeka, KS) - HF Summa Akron City and St. Thomas Hospitals (Akron, OH) - HF Sutter Medical Center Sacramento (Sacramento, CA) - HF Sylvan Grove Hospital (Jackson, GA) - HF The Chester County Hospital and Health System (West Chester, PA) - HF The Christ Hospital (Cincinnati, OH) - HF The Hospital of the University of Pennsylvania (Philadelphia, PA) - HF Torrance Memorial Medical Center (Torrance, CA) - HF University Community Hospital / Florida Hospital (Tampa, FL) - S University of Mississippi Health Care (Jackson, MS) - S University of South Alabama Medical Center (Mobile, AL) - HF University of Virginia Health System (Charlottesville, VA) - HF Upstate University Hospital (Syracuse, NY) - HF Valley View Medical Center (Cedar City, UT) - HF VA Pittsburgh Healthcare System (Pittsburgh, PA) - HF Wake Med Cary Hospital (Cary, NC) - HF, S Walker Baptist Medical Center (Jasper, AL) - HF

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WellStar Kennestone Hospital (Marietta, GA) - S West Jefferson Medical Center (Marrero, LA) - HF, S Wheaton Franciscan Healthcare - St. Joseph (Milwaukee, WI) - S White County Memorial Hospital (Monticello, IN) - HF Winthrop University Hospital (Mineola, NY) - S Woodland Heights Medical Center (Lufkin, TX) - S Wuesthoff Medical Center Rockledge (Rockledge, FL) - HF Wyckoff Heights Medical Center (Brooklyn, NY) - S Yakima Valley Memorial Hospital (Yakima, WA) - HF, S York Hospital (York, ME) - HF, S

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65 MOST-HIGHLY INTEGRATED HEALTHCARE NETWORKS

65.1 Overview Since 1997, SDI (www.sdihealth.com) has ranked the 100 most-highly integrated healthcare networks (IHNs). The assessment evaluates each of the 570 non-specialty, local, and regional networks in the U.S. based on their ability to operate as a unified organization. IHNs are ranked based on scores in eight categories: integration, integrated technology, contractual capabilities, outpatient utilization, financial stability, services and access, hospital utilization, and physicians.

65.2 IHN Ranking The following is the 2012 ranking: 1. St. Johns Health System (Springfield, MO) 2. Geisinger Health System (Danville, PA) 3. Intermountain Healthcare (Salt Lake City, UT) 4. Sentara Healthcare (Norfolk, VA) 5. ProMedica (Toledo, OH) 6. WellStar Health System (Marietta, GA) 7. Providence Health & Services (Portland, OR) 8. Advocate Health Care (Oak Brook, IL) 9. St Johns Mercy Health Care (St. Louis, MO) 10. MultiCare Health System (Tacoma, WA) 11. Henry Ford Health System (Detroit, MI) 12. Sharp HealthCare (San Diego, CA) 13. Inova Health System (Falls Church, VA) 14. Alegent Health (Omaha, NE) 15. Baptist Memorial Health Care Corp (Memphis, TN) 16. Trinity Mother Frances Hospitals and Clinics (Tyler, TX) 17. MemorialCare (Fountain Valley, CA) 18. Franciscan Health System (Tacoma, WA) 19. Gundersen Lutheran Health System (La Crosse, WI) 20. University Hospitals Cleveland, OH) 21. Novant Health (Winston-Salem, NC)

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22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65.

Covenant Health (Knoxville, TN) Riverside Health System (Newport News, VA) Mercy Health System (Janesville, WI) Baylor Health Care System (Dallas, TX) OhioHealth (Columbus, OH) McLaren Health Care Corp (Flint, MI) Health First (Rockledge, FL) Community Health Network (Indianapolis, IN) OSF HealthCare (Peoria, IL) North Shore - LIJ Health System (Great Neck, NY) Wheaton Franciscan Healthcare (Glendale, W I) Banner Health (Phoenix, AZ) TriHealth (Cincinnati, OH) Scripps Health (San Diego, CA) Presbyterian Healthcare Services (Albuquerque, NM) Bon Secours Virginia Health System (Richmond, VA) MedStar Health (Columbia, MD) Aurora Health Care Inc (Milwaukee, WI) Broward Health (Fort Lauderdale, FL) Group Health Cooperative (Seattle, WA) Catholic Health System (Buffalo, NY) Saint Francis Health System (Tulsa, OK) Baystate Health (Springfield, MA) Beaumont Health System (Royal Oak, MI) UC Davis Health System (Sacramento, CA) Methodist Healthcare (Memphis, TN) Bassett Healthcare (Cooperstown, NY) Carolinas HealthCare System (Charlotte, NC) Texas Health Resources (Arlington, TX) WellSpan Health (York, PA) North Mississippi Health Services (Tupelo, MS) Lancaster General Health (Lancaster, PA) University of Michigan Health System (Ann Arbor, MI) Memorial Hermann Healthcare System (Houston, TX) Ochsner Health System (New Orleans, LA) Spectrum Health (Grand Rapids, MI) Fletcher Allen Health Care (Burlington, VT) Legacy Health (Portland,OR) Mountain States Health Alliance (Johnson City, TN) Greenville Hospital System (Greenville, SC) Palmetto Health (Columbia, SC) Rochester General Health System (Rochester, NY) Yale New Haven Health System (New Haven, CT) Carilion Clinic (Roanoke, VA)

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66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100.

Jackson Health System (Miami, FL) MaineHealth (Portland, ME) SwedishAmerican Health System (Rockford, IL) Meridian Health (Neptune, NJ) Park Nicollet Health Services (Saint Louis Park, MN) St John Providence Health System (Warren, MI) CaroMont Health (Gastonia, NC) Scott & White Healthcare (Temple, TX) Bon Secours St Francis Health System (Greenville, SC) Crozer - Keystone Health System (Springfield, PA) Renown Health (Reno, NV) Norton Healthcare (Louisville, KY) Eastern Maine Healthcare Systems (Brewer, ME) CoxHealth (Springfield, MO) Lahey Clinic (Burlington, MA) Monroe Clinic (Monroe, WI) Kaleida Health (Buffalo, NY) Cook Childrens Health Care System (Fort Worth, TX) JPS Health Network (Fort Worth, TX) Iowa Health System (Des Moines, IA) Affinity Health System (Menasha, WI) Appalachian Regional Healthcare (Lexington, KY) Genesis Health System (Davenport, IA) Heritage Valley Health System (Beaver, PA) Altru Health System (Grand Forks, ND) Akron General Health System (Akron, OH) Swedish Health Services (Seattle, WA) Cambridge Health Alliance (Cambridge, MA) Sanford Health (Sioux Falls, SD) Summa Health System (Akron, OH) Stormont - Vail HealthCare (Topeka, KS) Borgess Health (Kalamazoo, MI) Conemaugh Health System (Johnstown, PA) LifeBridge Health (Baltimore, MD) Memorial Health System (Springfield, IL)

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66 MOST WIRED HOSPITALS

66.1 Overview Hospitals & Health Networks, published by the American Hospital Association (www.aha.org), identifies annually the Most Wired™ Hospitals based on their use of IT in the following five areas: • Safety and Quality: Reducing errors in prescribing medications, monitoring changes in patient conditions and sending alerts to staff in real time, providing hospital clinicians with patients’ health records in electronic form, and more • Customer Service: Helping patients research illnesses and pre-registering them for hospital admissions • Business: Using software to streamline purchasing operations and to coordinate and track transactions with insurance companies, and similar upgrades • Workforce: Training physicians, nurses, and other clinicians; measuring staff performance, and related matters • Public Health: Safeguarding patient privacy with security measures, participating in cooperative health efforts with other institutions, and improving specific clinical practices

66.2 Most Wired Hospitals The following is the 2012 list of the most wired hospitals and healthcare systems: • Abington Health (Abington (PA; www.amh.org/abingtonhealth) • Acadia Hospital (Bangor, ME; www.acadiahospital.org) • Advocate Health Care (Oak Brook, IL; www.advocatehealth.com) • Alamance Regional Medical Center (Burlington, NC; www.armc.com) • Aleda E. Lutz VA Medical Center (Saginaw, MI; www.saginaw.va.gov) • Alfred I. duPont Hospital for Children; Wilmington, DE; www.nemours.org) • Altru Health System (Grand Forks, ND; www.altru.org) • AnMed Health (Anderson, SC; www.anmedhealth.org) • Ann & Robert H. Lurie Children’s Hospital (Chicago, IL; www.luriechildrens.org) • Arnot Ogden Medical Center (Elmira, NY; www.arnothealth.org) • Atlantic Health System (Morristown, NJ; www.atlantichealth.org) • Aurora Health Care (Milwaukee; www.aurorahealthcare.org) • Avera Health (Sioux Falls, SD; www.avera.org) • Banner Health (Phoenix, AZ; www.bannerhealth.com) • Baptist Health South Florida (Coral Gables, FL; www.baptisthealth.net)

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Battle Creek VA Medical Center (Battle Creek, MI; www.battlecreek.va.gov) Baystate Health (Springfield, MA; www.baystatehealth.org) Beaufort Memorial Hospital (Beaufort, SC; www.bmhsc.org) Beaumont Health System (Royal Oak, MI; www.beaumont.edu) Beckley VA Medical Center (Beckley, WV; www.beckley.va.gov) Berkshire Health Systems (Pittsfield, MA; www.berkshirehealthsystems.org) Beth Israel Deaconess Medical Center (Boston, MA; www.bidmc.org) Bon Secours Richmond Health System (Richmond, VA; www.bonsecours.com) Bothwell Regional Health Center (Sedalia, MO; www.brhc.org) Bronson Battle Creek (Battle Creek, MI; www.bronsonbattlecreek.com) Brooke Army Medical Center (Fort Sam Houston, TX; www.bamc.amedd.army.mil) Cancer Treatment Centers of America (Schaumburg, IL; www.cancercenter.com) Carilion Clinic (Roanoke, VA; www.carilionclinic.org) Carle (Urbana, IL; www.carle.org) Carolinas HealthCare System (Charlotte, NC; www.carolinashealthcare.org) Centra (Lynchburg, VA; www.centrahealth.com) CentraState Healthcare System (Freehold, NJ; www.centrastate.com) Charles George VA Medical Center (Asheville, NC; www.asheville.va.gov) Children’s Hospital Boston (Boston, MA; www.childrenshospital.org) Children’s Medical Center (Dallas, TX; www.childrens.com) Christ Hospital (Cincinnati, OH; www.thechristhospital.com) Cincinnati Children’s Hospital Medical Center (Cincinnati, OH; www.cincinnatichildrens.org) Citizens Memorial Hospital (Bolivar, MO; www.citizensmemorial.com) Columbia Memorial Hospital (Astoria, OR; www.columbiamemorial.org) Community Health Network (Indianapolis, IN; www.ecommunity.com) Concord Hospital (Concord, NH; www.concordhospital.org) Continuum Health Partners (New York, NY; www.wehealny.org) Crittenton Hospital Medical Center (Rochester, MI; www.crittenton.com) Crozer-Keystone Health System (Springfield, PA; www.crozer.org) Deaconess Health System (Newburgh, IN; www.deaconess.com) Denver Health and Hospital Authority (Denver, CO; www.denverhealth.org) Detroit Medical Center (Detroit, MI; www.dmc.org) Doctors Hospital (Columbus, OH; www.ohiohealth.com/doctors) Dublin Methodist Hospital (Dublin, OH; www.ohiohealth.com/dublinmethodist) Eastern Maine Medical Center (Bangor, ME; www.emmc.org) Eisenhower Medical Center (Rancho Mirage, CA; www.emc.org) Elliot Health System (Manchester, NH; www.elliothospital.org) Emory Healthcare (Atlanta, GA; www.emoryhealthcare.org) Exeter Health Resources (Exeter, NH; www.exeterhospital.com) FirstHealth of the Carolinas (Pinehurst, NC; www.firsthealth.org) Fisher-Titus Medical Center (Norwalk, OH; www.fisher-titus.org) Fletcher Allen Health Care (Burlington, VT; www.fletcherallen.org) Florida Hospital (Orlando, FL; www.floridahospital.com)

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Fort Madison Community Hospital (Fort Madison, IA; www.fmchosp.com) Franklin Memorial Hospital (Farmington, ME; www.fchn.org) Geisinger Health System (Danville, PA; www.geisinger.org) Genesis Health System (Davenport, IA; www.genesishealth.com) Grady Memorial Hospital (Atlanta, GA; www.gradyhealth.org) Grand View Hospital (Sellersville, PA; www.gvh.org) Greenville Hospital System University Medical Center (Greenville, SC; www.ghs.org) Gritman Medical Center (Moscow, ID; www.gritman.org) Gundersen Lutheran (La Crosse, W I; www.gundluth.org) Hackensack University Medical Center (Hackensack, NJ; www.hackensackumc.org) Hallmark Health System (Melrose, MA; www.hallmarkhealth.org) Hampton VA Medical Center (Hampton, VA; www.hampton.va.gov) Harris County Hospital District (Houston, TX; www.hchdonline.com) Hartford Hospital (Hartford, CT; www.harthosp.org) HCA (Nashville, TN; www.hcahealthcare.com) HealthAlliance Hospitals (Leominster, MA; www.healthalliance.com) HealthPartners (Bloomington, MN; www.healthpartners.com) Henry County Health Center (Mount Pleasant, IA; www.hchc.org) Hunter Holmes McGuire VA Medical Center (Richmond, VA; www.richmond.va.gov) Hunterdon Healthcare System (Flemington, NJ; www.hunterdonhealthcare.org) Indiana University Health (Indianapolis, IN; http://iuhealth.org) Inova Health System (Falls Church, VA; www.inova.org) Intermountain Healthcare (Salt Lake City, UT; www.intermountainhealthcare.org) Iowa Health System (Des Moines, IA; www.ihs.org) John D. Dingell VA Medical Center (Detroit, MI; www.detroit.va.gov) Kane Community Hospital (Kane, PA; www.kanehosp.com) King’s Daughters Medical Center (Ashland, KY; www.kdmc.com) Lafayette General Medical Center (Lafayette, LA; http://lafayettegeneral.com) Lake Chelan Community Hospital (Chelan, WA; http://lakechelancommunityhospital.com) Lawrence Memorial Hospital (Lawrence, KS; www.lmh.com) Lehigh Valley Health Network (Allentown, PA; www.lvhn.org) Lincoln Hospital & North Basin Medical Clinics (Davenport, WA; www.lincolnhospital.org) Lowell General Hospital (Lowell, MA; www.lowellgeneral.org) Loyola University Medical Center (Maywood, IL; www.loyolamedicine.org) Madigan Army Medical Center (Tacoma, WA; www.mamc.amedd.army.mil) Maimonides Medical Center (Brooklyn, NY; www.maimonidesmed.org) Main Line Health (Bryn Mawr, PA; www.mainlinehealth.org) Maine Medical Center (Portland, ME; www.mmc.org) Martin Health System (Stuart, FL; www.martinhealth.org) Mason General Hospital (Shelton, W A; www.masongeneral.com) Massena Memorial Hospital (Massena, NY; www.massenahospital.org) Mayo Clinic (Rochester, MN; www.mayoclinic.org)

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MedCentral Mansfield Hospital (Mansfield, OH; www.medcentral.org) MedCentral Shelby Hospital Shelby, OH; www.medcentral.org) Medical University of South Carolina (Charleston, SC; www.musc.edu) MedStar Health (Columbia, MD; www.medstarhealth.net) Memorial Healthcare (Owosso, MI; www.memorialhealthcare.org) Memorial Healthcare System (Hollywood, FL; www.mhs.net) Memorial Hermann (Houston, TX; www.memorialhermann.org) Memorial Sloan-Kettering Cancer Center (New York, NY; www.mskcc.org) Mercy Health (Chesterfield, MO; www.mercy.net) Mercy Medical Center (Cedar Rapids, IA; www.mercycare.org) Meridian Health (Neptune, NJ; www.meridianhealth.com) Meriter Hospital (Madison, WI; www.meriter.com) Methodist Health System (Dallas, TX; www.methodisthealthsystem.org) Methodist Medical Center of Illinois (Peoria, IL; www.mymethodist.net) Metro Health; Wyoming, MI (http://metrohealth.net) Middlesex Hospital (Middletown, CT (http://middlesexhospital.org) MidState Medical Center (Meriden, CT; www.midstatemedical.org) Ministry Health Care - St. Clare’s Hospital; Weston, WI; http://ministryhealth.org) Mission Hospital (Asheville, NC; www.missionhospitals.org) Montefiore (New York, NY; www.montefiore.org) Mountain States Health Alliance (Johnson City, TN; www.msha.com) MultiCare Health System (Tacoma, WA; www.multicare.org) Nationwide Children’s Hospital (Columbus, OH; www.nationwidechildrens.org) NCH Healthcare System (Naples, FL; www.nchmd.org) Nemaha County Hospital (Auburn, NE; www.nchnet.org) North Mississippi Health Services (Tupelo, MS; www.nmhs.net) North Shore University Hospital (Manhasset, NY; www.northshorelij.com) Northeast Georgia Medical Center (Gainesville, GA; www.nghs.com) Northern Michigan Regional Hospital (Petoskey, MI; www.northernhealth.org) NorthShore University HealthSystem (Evanston, IL; www.northshore.org) Northwest Community Hospital (Arlington Heights, IL; www.nch.org) Northwestern Memorial Hospital (Chicago, IL; www.nmh.org) Ohio State University Wexner Medical Center (Columbus, OH; www.medicalcenter.osu.edu) Oklahoma Heart Hospital (Oklahoma City; www.okheart.com Oklahoma Heart Hospital South Campus (Oklahoma City, OK; www.okheart.com) OSF Healthcare System (Peoria, IL; www.osfhealthcare.org) Othello Community Hospital (Othello, WA; www.othellocommunityhospital.org) Our Lady of Bellefonte Hospital (Ashland, KY; www.olbh.com) Palmetto Health (Columbia, SC; www.palmettohealth.org) Peninsula Regional Medical Center (Salisbury, MD; www.peninsula.org) Piedmont Fayette Hospital (Fayetteville, GA; www.piedmontfayette.org) Piedmont Hospital (Atlanta, GA; www.piedmonthospital.org) PinnacleHealth (Harrisburg, PA; www.pinnaclehealth.org)

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Poudre Valley Health System (Fort Collins, CO; http://pvhs.org) Providence Holy Family Hospital (Spokane, WA; www.holy-family.org) Providence Mount Carmel Hospital (Colville, WA; www.mtcarmelhospital.org) Providence Sacred Heart Medical Center & Children’s Hospital (Spokane, W A; www.shmc.org) Providence St. Joseph’s Hospital (Chewelah, WA; www.sjhospital.org) Pullman Regional Hospital (Pullman, WA; www.pullmanregional.org) Rady Children’s Hospital (San Diego, CA; www.rchsd.org) Richard L. Roudebush Veterans Affairs Medical Center (Indianapolis, IN; www.indianapolis.va.gov) Riverside Health System (Newport News, VA; www.riversideonline.com) Robert Wood Johnson University Hospital (New Brunswick, NJ; www.rwjuh.edu) Rush Oak Park Hospital (Oak Park, IL; http://roph.org) Rush University Medical Center (Chicago, IL; www.rush.edu) Saint Francis Care (Hartford, CT; www.stfranciscare.org) Saint Joseph Regional Medical Center (Mishawaka, IN; www.sjmed.com) Saint Peter’s Healthcare System (New Brunswick, NJ; www.saintpetershcs.com) Saint Vincent Hospital (Worcester, MA; www.stvincenthospital.com) Salem VA Medical Center (Salem, VA; www.salem.va.gov) Samaritan Healthcare (Moses Lake, WA; www.samaritanhealthcare.com) San Francisco VA Medical Center (San Francisco, CA; www.sanfrancisco.va.gov) Sarah Bush Lincoln Health System (Mattoon, IL; www.sarahbush.org) Sentara Healthcare (Norfolk, VA; www.sentara.com) Sharp HealthCare (San Diego, CA; www.sharp.com) South Shore Hospital (South W eymouth, MA; www.southshorehospital.org) Spooner Health System (Spooner, WI; www.spoonerhealthsystem.com) St. Clair Hospital (Pittsburgh, PA; www.stclair.org) St. Joseph’s Healthcare System (Paterson, NJ; www.stjosephshealth.org) St. Joseph’s Hospital Health Center (Syracuse, NY; www.sjhsyr.org) St. Luke’s Rehabilitation Institute (Spokane, W A; www.stlukesrehab.org) St. Vincent’s – Birmingham (Birmingham, AL; www.stvhs.com) Stanford Hospital and Clinics (Stanford, CA; www.stanfordhospital.org) Stony Brook University Medical Center (Stony Brook, NY; www.stonybrookmedicine.edu) Summa Health System (Akron, OH; www.summahealth.org) Texas Health Resources (Arlington, TX; www.texashealth.org) ThedaCare (Appleton, WI; www.thedacare.org) Tri-State Memorial Hospital (Clarkston, WA; www.tristatehospital.org) TriHealth (Cincinnati, OH; www.trihealth.com) Truman Medical Centers (Kansas City, MO; www.trumed.org) Tucson Medical Center (Tucson, AZ; www.tmcaz.com) Union Hospital (Terre Haute, IN; www.myunionhospital.org) Union Hospital Clinton (Clinton, IN; www.myunionhospital.org) Unity Health Center (Shawnee, Okla.; www.unityhealthcenter.com

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• University Health System (San Antonio, TX; www.universityhealthsystem.com) • University of Alabama at Birmingham Hospital (Birmingham, AL; www.uabmedicine.org) • University of California Davis Health System (Sacramento, CA; www.ucdmc.ucdavis.edu) • University of California, San Diego Health System (San Diego, CA; http://health.ucsd.edu) • University of Illinois Hospital & Health Sciences System (Chicago, IL; http://hospital.uillinois.edu) • University of Iowa Hospitals and Clinics (Iowa City, IA; www.uihealthcare.org) • University of Kansas Hospital (Kansas City, KS; www.kumed.com) • University of Missouri Health Care (Columbia, MO; www.muhealth.org) • University of New Mexico Hospitals (Albuquerque, NM; http://hospitals.unm.edu) • University of Pittsburgh Medical Center (Pittsburgh, PA; www.upmc.com) • University of Virginia Medical Center (Charlottesville, VA; www.healthsystem.virginia.edu) • University of Wisconsin Hospital and Clinics (Madison, WI; www.uwhealth.org) • UT Southwestern Medical Center (Dallas TX; www.utsouthwestern.edu) • UWHP Watertown Regional Medical Center (Watertown, WI; www.uwhpwatertown.com) • VA Northeast Region IV (Albany, NY; www.va.gov) • VA Palo Alto Health Care System (Palo Alto, CA; www.paloalto.va.gov) Small & Rural Hospitals • Ashe Memorial Hospital (Jefferson, NC; www.ashememorial.org) • Broadlawns Medical Center (Des Moines, IA; www.broadlawns.org) • Carson City Hospital (Carson City, MI; www.carsoncityhospital.com) • Coulee Medical Center (Grand Coulee, W A; www.cmccares.org) • Evergreen Medical Center (Evergreen, AL; www.evergreenmedical.org) • Kewanee Hospital (Kewanee, IL; www.kewaneehospital.com) • Kishwaukee Community Hospital (DeKalb, IL; www.kishhospital.org) • Magnolia Regional Health Center (Corinth, MS; www.mrhc.org) • Marshall County Hospital (Benton, KY; www.marshallcountyhospital.org) • Mid-Valley Hospital (Omak, WA; www.mvhealth.org) • Naval Hospital Lemoore (Lemoore, CA; www.med.navy.mil/sites/nhlem) • New London Hospital (New London, NH; www.newlondonhospital.org) • Newport Hospital and Health Services (Newport, WA; www.phd1.org) • Opelousas General Health System (Opelousas, LA; www.opelousasgeneral.com) • Osceola Medical Center (Osceola, WI; www.osceolamedicalcenter.com) • Pocono Medical Center (East Stroudsburg, PA; www.pmchealthsystem.org) • Ralph H. Johnson VA Medical Center (Charleston, SC; www.charleston.va.gov) • Samaritan Regional Health System (Ashland, OH; www.samaritanhospital.org) • Southampton Hospital (Southampton, NY; www.southamptonhospital.org) • Stone County Medical Center (Mountain View, AR;

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www.whiteriverhealthsystem.com) Sunnyside Community Hospital (Sunnyside, WA; www.sunnysidehospital.com) Syringa Hospital & Clinics (Grangeville, ID; www.syringahospital.org) Thayer County Health Services (Hebron, NE; www.thayercountyhealth.com) U.S. Air Force Hospital (Langley AFB, VA; www.jble.af.mil) Washington County Hospital & Nursing Home (Chatom, AL; www.wchnh.org)

Most Improved • Allegiance Health (Jackson, MI; www.allegiancehealth.org) • Care New England Health System (Providence, RI; www.carenewengland.org) • Chester County Hospital; west Chester, PA; www.cchosp.com) • Cook Children’s Medical Center (Fort Worth, TX; www.cookchildrens.org) • CoxHealth (Springfield, MO; www.coxhealth.com) • Guthrie Health (Sayre, PA; www.guthrie.org) • Heartland Health (Saint Joseph, MO; www.heartland-health.com) • Kaiser Permanente (Oakland, CA; www.kp.org) • Mary Greeley Medical Center (Ames, IA; www.mgmc.org) • Methodist Hospital System (Houston, TX; www.methodisthealth.com) • Munson Medical Center (Traverse City, MI; www.munsonhealthcare.org) • New York Presbyterian Hospital (New York, NY; www.nyp.org) • Norman Regional Health System (Norman, OK; www.normanregional.com) • North Kansas City Hospital (Kansas City, MO; www.nkch.org) • Robert Wood Johnson University Hospital (Hamilton, NJ; www.rwjhamilton.org) • Saint Vincent Health Center (Erie, PA; www.saintvincenthealth.com) • Sanford USD Medical Center (Sioux Falls, SD; www.sanfordhealth.org) • St. Elizabeth Hospital (Enumclaw, WA; www.fhshealth.org/stelizabeth) • Stormont - Vail HeathCare (Topeka, KS; www.stormontvail.org) • Susquehanna Health; williamsport, PA; www.susquehannahealth.org) • SwedishAmerican Health System (Rockford, IL; www.swedishamerican.org) • Tanner Medical Center (Carrollton, GA; www.tanner.org) • Thomas Jefferson University Hospitals (Philadelphia, PA; www.jeffersonhospital.org) • Trinitas Regional Medical Center (Elizabeth, NJ; www.trinitashospital.org) • Trinity Health (Minot, ND) (www.trinityhealth.org) Previous winners are listed online at www.hhnmostwired.com.

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67 NATIONAL QUALITY HEALTHCARE AWARD

67.1 Overview The National Quality Healthcare Award was created in 1993 to recognize outstanding quality-driven healthcare organizations. For 17 years, first through the National Committee for Quality Health Care and now through the National Quality Forum, the award has provided encouragement for improvements in quality through public recognition of organizations’ accomplishments.

67.2 Award Winners The following organizations have received National Quality Healthcare Awards: • 2012: Mountain States Health Alliance (Johnson City, TN) • 2011: Norton Healthcare (Louisville, KY) • 2010: North Shore-LIJ Health System (Great Neck, NY) • 2009: Memorial Hermann Healthcare System (Houston, TX) • 2008: Baylor Health Care System (Dallas, TX) • 2007: Health Partners (Bloomfield, MN) • 2006: Brigham and Women’s Hospital (Boston, MA) • 2005: Northwestern Memorial Hospital (Chicago, IL) • 2004: Trinity Health (Novi, MI) • 2003: Lehigh Valley Hospital and Health Network (Allentown, PA) • 2002: Carilion Health System (Roanoke, VA) • 2001: Catholic Health Initiatives (Denver, CO) • 2000: Munson Medical Center (Traverse City, MI) • 1999: BJC Health System (St. Louis, MO) • 1998: University of Pennsylvania Health System (Philadelphia, PA) • 1997: St. Luke’s Health System (Kansas City, MO) • 1996: Intermountain Health Care (Salt Lake City, UT) • 1995: Evanston (Illinois) Hospital Corp. • 1994: Henry Ford Health System (Detroit, MI)

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68 NOVA AWARDS

68.1 Overview Presented annually by the American Hospital Association (www.aha.org), NOVA Awards® honor hospitals and health systems that improve community health through healthcare, economic, or social initiatives – and do so in collaboration with other organizations.

68.2 Awards Winners of the 2012 NOVA Awards are as follows: • CARE Network: St. Joseph Health Queen of the Valley Medical Center (Napa, CA) • Fitness in the City: Boston Children’s Hospital (Boston, MA) • Puff City: Henry Ford Health System (Detroit, MI) • Rural Health Initiative: Shawano Medical Center of ThedaCare (Shawano, WI) • The Beth Embraces Wellness: An Integrated Approach to Prevention in the Community: Newark Beth Israel Medical Center and Children’s Hospital of New Jersey (Newark, NJ) Previous winners are listed at www.aha.org/aha/news-center/awards/NOVA.html.

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69 QUEST FOR QUALITY

69.1 Overview The American Hospital Association (AHA, www.aha.org) - McKesson Quest for Quality Prize®, given annually since 2002, aims to raise awareness of the need for a hospital-wide commitment to highly reliable, exceptional quality, patient-centered care; reward successful efforts to develop and promote a systems-based approach toward improvements in quality of care; inspire hospitals to systematically integrate and align their quality improvement efforts throughout the organization; and communicate successful programs and strategies to the hospital field. The prize honors hospitals that have committed in a systematic manner to achieving the Institute of Medicine’s six quality aims – safety, patient-centeredness, effectiveness, efficiency, timeliness, and equity.

69.2 Awards Quest for Quality Prize awards have been as follows: 2012 AWARDS • Winner: University Hospitals Case Medical Center (Cleveland, OH) • Finalist: Lincoln Medical and Mental Health Center (Bronx, NY) • Finalist: UNC Hospitals (Chapel Hill, NC) • Citation of Merit: Meriter Hospital (Madison, WI) 2011 AWARDS • Winner: Memorial Regional Hospital (Hollywood, FL) • Finalist: AtlantiCare Regional Medical Center (Atlantic City, NJ) • Finalist: Northwestern Memorial Hospital (Chicago, IL) • Citation of Merit: Providence Little Company of Mary Medical Center (Torrance, CA) • Citation of Merit: Virginia Mason Medical Center (Seattle, WA) 2010 AWARDS • Winner: McLeod Regional Medical Center (Florence, SC) • Finalist: Henry Ford Hospital (Detroit, MI) • Citation of Merit: Queens Hospital Center (Jamaica, NY)

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2009 AWARDS • Winner: Bronson Methodist Hospital (Kalamazoo, MI) • Finalist: Beth Israel Deaconess Medical Center (Boston, MA) • Citation of Merit: Duke University Hospital (Durham, NC) 2008 AWARDS • Winner: Munson Medical Center (Traverse City, MI) • Finalist: University of Michigan Hospitals and Health Centers (Ann Arbor, MI) • Citation of Merit: Avera McKennan Hospital & University Health Center (Sioux Falls, SD) • Citation of Merit: Saint Vincent Health Center (Erie, PA) 2007 AWARDS • Winner: Columbus Regional Hospital (Columbus, IN) • Finalist: Cedars-Sinai Medical Center (Los Angeles, CA) • Finalist: INTEGRIS Baptist Medical Center (Oklahoma City, OK) • Citations of Merit: Amarillo VA Health Care System (Amarillo, TX) • Citations of Merit: McLeod Regional Medical Center (Florence, SC) 2006 AWARDS • Winner: Cincinnati Children’s Hospital Medical Center (Cincinnati, OH) • Citation of Merit: Bronson Methodist Hospital (Kalamazoo, MI) • Citation of Merit: Baptist Memorial Hospital for Women (Memphis, TN)

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70 SPIRIT OF EXCELLENCE AWARDS

70.1 Overview Modern Healthcare and Sodexo Health Care Services have sponsored the Spirit of Excellence Awards since 1992, honoring organizations and individuals that go beyond what is expected in serving their patients and communities. Five awards are given as part of the program, as follows: • Service Spirit Award, which recognizes excellence in service and patient satisfaction • Quality Spirit Award, which recognizes quality, safety, and performance improvement • Community Spirit Award, which recognizes community education, support, and outreach • Team Spirit Award, which recognizes employee recruitment and retention • C.A.R.E.S. Spirit Award, which recognizes a team or group of individuals whose collective actions, attitudes, and behaviors personify compassion, accountability, respect, enthusiasm, and service

70.2 Awards The following are the 2012 Spirit of Excellence Award winners: Award for Community • Winner: Penn State Hershey Medical Center (Hershey, PA) • Honorable Mention: OSF St. Anthony Medical Center (Rockford, IL) Award for Patient Safety • Winner: Cullman Regional Medical Center (Cullman, AL) • Honorable Mention: Tri-City Medical Center (Oceanside, CA) Award for Process Improvement • Winner: Lake Cumberland Regional Hospital (Somerset, KY) • Honorable Mention: New England Baptist Hospital (Boston, MA) Award for Service • Winner: Good Samaratin Hospital, Cancer Center (Kearney, NE) • Honorable Mention: New England Baptist Hospital (Boston, MA)

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Award for Team • Winner: Fresenius Medical Care North America (Waltham, MA) • Honorable Mention: Mountain States Health Alliance - Sycamore Shoals Hospital (Johnson City, TN) The website www.modernhealthcare.com/section/spiritofex presents a list of past award winners.

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71 TOP 100 HOSPITALS

71.1 Overview Since 1992, Truven Health Analytics (www.truvenhealth.com) has developed an annual list of the 100 Top Hospitals (www.100tophospitals.com) based on a comparison of Medicare data for eight measures utilizing the Agency for Healthcare Research and Quality’s public-safety indicators. The assessment compares hospitals’ actual patient-safety performance with expected performance.

71.2 Top Hospitals The following is the 2013 list of 100 Top Hospitals: Major Teaching Hospitals • Advocate Christ Medical Center (Oak Lawn, IL) • Advocate Illinois Masonic Medical Center (Chicago, IL) • Advocate Lutheran General Hospital (Park Ridge, IL) • Baystate Medical Center (Springfield, MA) • Beth Israel Deaconess Medical Center (Boston, MA) • Christiana Care Health System (Newark, DE) • Froedtert & The Medical College of Wisconsin (Milwaukee, WI) • NorthShore University HealthSystem (Evanston, IL) • Northwestern Memorial Hospital (Chicago, IL) • Penn Presbyterian Medical Center (Philadelphia, PA) • Providence Hospital and Medical Center (Southfield, MI) • St. Joseph Mercy Hospital (Ann Arbor, MI) • The Methodist Hospital (Houston, TX) • UC San Diego Medical Center (San Diego, CA) • University of Michigan Hospitals & Health Centers (Ann Arbor, MI) Teaching Hospitals • Allen Hospital (Waterloo, IA) • Avera McKennan Hospital & University Health Center (Sioux Falls, SD) • Baptist St. Anthony’s Health System (Amarillo, TX) • Beaumont Hospital, Troy (Troy, MI) • Carolinas Medical Center-Mercy (Charlotte, NC) • Grant Medical Center (Columbus, OH) • Immanuel Medical Center (Omaha, NE)

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Kettering Medical Center (Kettering, OH) Lankenau Medical Center (Wynnewood, PA) McKay-Dee Hospital Center (Ogden, UT) Mercy Medical Center (Cedar Rapids, IA) Mission Hospital (Asheville, NC) North Colorado Medical Center (Greeley, CO) Poudre Valley Hospital (Fort Collins, CO) Presbyterian Intercommunity Hospital (Whittier, CA) Riverside Methodist Hospital (Columbus, OH) Rose Medical Center (Denver, CO) Saint Thomas Hospital (Nashville, TN) Saint Vincent Hospital (Worcester, MA) Scripps Green Hospital (La Jolla, CA) St. Luke’s Hospital (Cedar Rapids, IA) St. Vincent Indianapolis Hospital (Indianapolis, IN) Sutter Medical Center, Sacramento (Sacramento, CA) United Regional Health Care System (Wichita Falls, TX) Virginia Hospital Center (Arlington, VA)

Large Community Hospitals • Advocate Good Samaritan Hospital (Downers Grove, IL) • Banner Boswell Medical Center (Sun City, AZ) • Billings Clinic Hospital (Billings, MT) • Centinela Hospital Medical Center (Inglewood, CA) • Central DuPage Hospital (Winfield, IL) • Gaston Memorial Hospital (Gastonia, NC) • Good Shepherd Medical Center (Longview, TX) • Kendall Regional Medical Center (Miami, FL) • Lakeland Regional Medical Center (St. Joseph, MI) • Martin Health System (Stuart, FL) • Maury Regional Medical Center (Columbia, TN) • Mease Countryside Hospital (Safety Harbor, FL) • Memorial Hermann Memorial City Medical Center (Houston, TX) • Memorial Hospital West (Pembroke Pines, FL) • Northeast Georgia Medical Center (Gainesville, GA) • Ocala Regional Medical Center (Ocala, FL) • Providence Little Company of Mary Medical Center (Torrance, CA) • St. David’s Medical Center (Austin, TX) • St. David’s North Austin Medical Center (Austin, TX) • TriStar Skyline Medical Center (Nashville, TN)

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Medium Community Hospitals • Aurora Sheboygan Memorial Medical Center (Sheboygan, WI) • Baptist Medical Center East (Montgomery, AL) • Bon Secours St. Francis Hospital (Charleston, SC) • Chino Valley Medical Center (Chino, CA) • Doctors Hospital of Sarasota (Sarasota, FL) • Garden Grove Hospital Medical Center (Garden Grove, CA) • Gulf Coast Medical Center (Panama City, FL) • Holland Hospital (Holland, MI) • INOVA Fair Oaks Hospital (Fairfax, VA) • Lakeview Hospital (Bountiful, UT) • Lawrence Memorial Hospital (Lawrence, KS) • Licking Memorial Hospital (Newark, OH) • Logan Regional Hospital (Logan, UT) • McKee Medical Center (Loveland, CO) • Mercy Hospital Anderson (Cincinnati, OH) • Mercy Hospital Fairfield (Fairfield, OH) • Montclair Hospital Medical Center (Montclair, CA) • Ogden Regional Medical Center (Ogden, UT) • Shasta Regional Medical Center (Redding, CA) • West Anaheim Medical Center (Anaheim, CA) Small Community Hospitals • Alta View Hospital (Sandy, UT) • Desert Valley Hospital (Victorville, CA) • Dublin Methodist Hospital (Dublin, OH) • Gulf Breeze Hospital (Gulf Breeze, FL) • Hill Country Memorial Hospital (Fredericksburg, TX) • Lovelace Westside Hospital (Albuquerque, NM) • Major Hospital (Shelbyville, IN) • MedStar St. Mary’s Hospital (Leonardtown, MD) • Mercy Hospital Grayling (Grayling, MI) • Ministry Saint Clare’s Hospital (Weston, WI) • Payson Regional Medical Center (Payson, AZ) • Presbyterian Hospital Huntersville (Huntersville, NC) • Sacred Heart Hospital on the Emerald Coast (Miramar Beach, FL) • San Dimas Community Hospital (San Dimas, CA) • Sauk Prairie Memorial Hospital & Clinics (Prairie du Sac, WI) • Spectrum Health United Hospital (Greenville, MI) • St. Elizabeth Community Hospital (Red Bluff, CA) • Sutter Davis Hospital (Davis, CA) • Texas Health Harris Methodist Hospital Azle (Azle, TX) • Woodwinds Health Campus (Woodbury, MN)

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72 TOP CARDIOVASCULAR HOSPITALS

72.1 Overview Since 1998, Truven Health Analytics (www.truvenhealth.com) has conducted an annual study identifying the 50 U.S. hospitals that set the nation’s benchm arks for inpatient cardiovascular services. The assessment examines the performance of 971 hospitals by analyzing outcomes for patients with heart failure and heart attacks and for those who received coronary bypass surgery or percutaneous cardiovascular interventions (PCI) such as angioplasties. Compared with peer hospitals, performance of the 50 Top Cardiovascular Hospitals is as follows: • Spend an average $1,300 less per case • Have significantly better 30-day survival • Maintain lower 30-day readmission rates for heart attack and heart patients • Return patients to daily life half a day earlier, on average The following are projected outcomes if all cardiovascular providers performed at the level of the Top 50: • More than 7,500 additional lives could be saved • Nearly 12,000 additional patients could be com plication-free • Approximately $910 million could be saved The top performing hospitals perform over 50% more cardiac surgeries than peer hospitals.

72.2 Top Cardiovascular Hospitals The following is the 2013 List of Top Cardiovascular Hospitals: Teaching Hospitals with Cardiovascular Residency Programs • Baystate Medical Center (Springfield, MA) • Doctors Hospital (Columbus, OH) • Kettering Medical Center (Kettering, OH) • Lankenau Medical Center (Wynnewood, PA) • Mayo Clinic Hospital (Phoenix, AZ) • Mayo Clinic - Saint Marys Hospital (Rochester, MN) • Penn Presbyterian Medical Center (Philadelphia, PA) • Providence Hospital and Medical Center (Southfield, MI)

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Saint Vincent Hospital (Worcester, MA) Scripps Green Hospital (La Jolla, CA) St. Joseph Mercy Oakland (Pontiac, MI) Steward St. Elizabeth’s Medical Center (Boston, MA) The Christ Hospital (Cincinnati, OH) The University of Toledo Medical Center (Toledo, OH) UC San Diego Medical Center (San Diego, CA)

Teaching Hospitals Without Cardiovascular Residency Programs • Allen Hospital (Waterloo, IA) • Bethesda North Hospital (Cincinnati, OH) • Bon Secours St. Mary’s Hospital (Richmond, VA) • Bryan Medical Center (Lincoln, NE) • Decatur Memorial Hospital (Decatur, IL) • Mercy Medical Center (Canton, OH) • Mercy Medical Center - Des Moines (Des Moines, IA) • North Memorial Medical Center (Robbinsdale, MN) • Riverside Regional Medical Center (Newport News, VA) • St. Elizabeth’s Hospital (Belleville, IL) • St. John Medical Center (Westlake, OH) • St. John’s Hospital (Springfield, IL) • St. Joseph Medical Center (Reading, PA) • St. Joseph Mercy Hospital (Ann Arbor, MI) • St. Joseph’s Hospital (St. Paul, MN) • St. Luke’s Boise Medical Center (Boise, ID) • St. Luke’s Hospital (Cedar Rapids, IA) • Sutter General Hospital (Sacramento, CA) • The Jewish Hospital (Cincinnati, OH) • UPMC Hamot (Erie, PA) Community Hospitals • Advocate Good Shepherd Hospital (Barrington, IL) • Aurora BayCare Medical Center (Green Bay, WI) • Avera Heart Hospital (Sioux Falls, SD) • Banner Heart Hospital (Mesa, AZ) • Bellin Hospital (Green Bay, WI) • Blanchard Valley Hospital (Findlay, OH) • Dixie Regional Medical Center (St. George, UT) • French Hospital Medical Center (San Luis Obispo, CA) • Marion General Hospital (Marion, OH) • Mercy General Hospital (Sacramento, CA) • Nebraska Heart Institute & Heart Hospital (Lincoln, NE) • Providence St. Patrick Hospital (Missoula, MT)

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Shasta Regional Medical Center (Redding, CA) St. David’s Medical Center (Austin, TX) Trinity Hospital (Minot, ND)

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73 TOP HEALTH SYSTEMS

73.1 Overview Truven Health Analytics (www.truvenhealth.com) evaluated 255 healthcare systems on measures of clinical quality and efficiency. Performance measured used in the assessment are as follows: • 30-day risk-adjusted mortality rate • 30-day risk-adjusted readmission rate • Core measures mean percent • HCAHPS score (patient rating of overall hospital performance) • Risk-adjusted complications index • Risk-adjusted mortality index • Risk-adjusted patient safety index • Severity-adjusted average length of stay

73.2 Best-Performing Healthcare Systems The 2013 list of top-rated healthcare systems is as follows: Large Health Systems • Advocate Health Care (Oak Brook, IL) • Banner Health (Phoenix, AZ) • Memorial Hermann Healthcare System (Houston, TX) • OhioHealth (Columbus, OH) • Scripps Health (San Diego, CA) Medium Health Systems • Alegent Creighton Health (Omaha, NE) • Exempla Healthcare (Denver, CO) • Mission Health (Asheville, NC) • Prime Healthcare Services (Ontario, CA) • TriHealth (Cincinnati, OH) Small Health Systems • Asante (Medford, OR) • Cape Cod Healthcare (Hyannis, MA) • Mercy Health Southwest Ohio Region (Cincinnati, OH) • Poudre Valley Health System (Fort Collins, CO) • Roper St. Francis Healthcare (Charleston, SC)

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74 TOP-RANKED HOSPITALS IN SPECIALITY FIELDS

74.1 Overview Since 1989, U.S. News & World Reports has annually ranked the best U.S. hospitals in 16 specialty fields, as follows: • Cancer • Diabetes and Endocrinology • Ear, Nose & Throat • Gastroenterology • Geriatrics • Gynecology • Heart and Heart Surgery • Kidney Disorders • Neurology and Neurosurgery • Ophthalmology • Orthopedics • Psychiatry • Pulmonology • Rehabilitation • Rheumatology • Urology The assessment considers affiliation with a medical school, availability of key technologies such as robotic surgery, and performance of a minimum number of specified procedures on Medicare inpatients, reputation, death rate, and care-related factors such as nursing and patient services. U.S. News & World Reports also annually ranks the best U.S. children’s hospitals in 10 specialty fields, as follows: • Cancer • Diabetes and Endocrinology • Gastroenterology • Heart & Heart Surgery • Kidney Disorders • Neonatal Care • Neurology and Neurosurgery • Orthopedics • Pulmonology • Urology

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The annual assessment of children’s hospitals considers reputation, outcomes, and care-related indicators. The ranking is based on the assessment of almost 5,000 U.S. hospitals, including 170 children’s medical centers.

74.2 Ranking Of Hospitals The U.S. News & World Reports ranking of hospitals is viewable online at http://health.usnews.com/best-hospitals/rankings. The following are the 2012 topranked hospitals in each of the 16 specialty fields: Cancer 1. University of Texas M.D. Anderson Cancer Center (Houston, TX) 2. Memorial Sloan-Kettering Cancer Center (New York, NY) 3. Johns Hopkins Hospital (Baltimore, MD) 4. Mayo Clinic (Rochester, MN) 5. Dana-Farber/Brigham and Women’s Cancer Center (Boston, MA) 6. Cleveland Clinic (Cleveland, OH) 7. Massachusetts General Hospital (Boston, MA) 8. University of Washington Medical Center (Seattle, WA) 9. Ronald Reagan UCLA Medical Center (Los Angeles, CA) 10. Barnes-Jewish Hospital/Washington University (Saint Louis, MO) Cardiology and Heart Surgery 1. Cleveland Clinic (Cleveland, OH) 2. Mayo Clinic (Rochester, MN) 3. Johns Hopkins Hospital (Baltimore, MD) 4. New York-Presbyterian University Hospital of Columbia and Cornell (New York, NY) 5. Massachusetts General Hospital (Boston, MA) 6. Texas Heart Institute at St. Luke’s Episcopal Hospital (Houston, T X) 7. Duke University Medical Center (Durham, NC) 8. Ronald Reagan UCLA Medical Center (Los Angeles, CA) 9. Brigham and Women’s Hospital (Boston, MA) 10. Mount Sinai Medical Center (New York, NY) Diabetes and Endocrinology 1. Mayo Clinic (Rochester, MN) 2. Cleveland Clinic (Cleveland, OH) 3. Massachusetts General Hospital (Boston, MA) 4. Johns Hopkins Hospital (Baltimore, MD) 5. Yale-New Haven Hospital (New Haven, CT) 6. University of Washington Medical Center (Seattle, WA) 7. Brigham and Women’s Hospital (Boston, MA) 8. New York-Presbyterian University Hospital of Columbia and Cornell

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9.

UCSF Medical Center (San Francisco, CA) (New York, NY) 10. Ochsner Medical Center (New Orleans, LA) Ear, Nose & Throat 1. Johns Hopkins Hospital (Baltimore, MD) 2. Cleveland Clinic (Cleveland, OH) 3. Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital (Boston, MA) 4. UPMC-University of Pittsburgh Medical Center (Pittsburgh, PA) 5. University of Texas M.D. Anderson Cancer Center (Houston, TX) 6. Mayo Clinic (Rochester, MN) 7. Vanderbilt University Medical Center (Nashville, TN) 8. Hospital of the University of Pennsylvania (Philadelphia, PA) 9. Barnes-Jewish Hospital/Washington University (St. Louis, MO) 10. University of Iowa Hospitals and Clinics (Iowa City, IA) Gastroenterology 1. Mayo Clinic (Rochester, MN) 2. Cleveland Clinic (Cleveland, OH) 3. Johns Hopkins Hospital (Baltimore, MD) 4. Massachusetts General Hospital (Boston, MA) 5. UPMC-University of Pittsburgh Medical Center (Pittsburgh, PA) 6. Cedars-Sinai Medical Center (Los Angeles, CA) 7. Mount Sinai Medical Center (New York, NY) 8. Ronald Reagan UCLA Medical Center (Los Angeles, CA) 9. New York-Presbyterian University Hospital of Columbia and Cornell (New York, NY) 10. Ochsner Medical Center (New Orleans, LA) Geriatrics 1. Johns Hopkins Hospital (Baltimore, MD) 2. Mount Sinai Medical Center (New York, NY) 3. Ronald Reagan UCLA Medical Center (Los Angeles, CA) 4. Cleveland Clinic (Cleveland, OH) 5. Hospital for Special Surgery (New York, NY) 6. Massachusetts General Hospital (Boston, MA) 7. Mayo Clinic (Rochester, MN) 8. Duke University Medical Center (Durham, NC) 9. NYU Langone Medical Center (New York, NY) 10. UPMC-University of Pittsburgh Medical Center (Pittsburgh, PA)

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Gynecology 1. Mayo Clinic (Rochester, MN) 2. Brigham and Women’s Hospital (Boston, MA) 3. Cleveland Clinic (Cleveland, OH) 4. Johns Hopkins Hospital (Baltimore, MD) 5. Magee-Womens Hospital of UPMC (Pittsburgh, PA) 6. Massachusetts General Hospital (Boston, MA) 7. University of Texas M.D. Anderson Cancer Center (Houston, TX) 8. Duke University Medical Center (Durham, NC) 9. Memorial Sloan-Kettering Cancer Center (New York, NY) 10. Barnes-Jewish Hospital/Washington University (Saint Louis, MO) Nephrology (Kidney Disorders) 1. Cleveland Clinic (Cleveland, OH) 2. Mayo Clinic (Rochester, MN) 3. New York-Presbyterian University Hospital of Columbia and Cornell (New York, NY) 4. Johns Hopkins Hospital (Baltimore, MD) 5. Ronald Reagan UCLA Medical Center (Los Angeles, CA) 6. Brigham and Women’s Hospital (Boston, MA) 7. Massachusetts General Hospital (Boston, MA) 8. Barnes-Jewish Hospital/Washington University (St. Louis, MO) 9. University of Maryland Medical Center (Baltimore, MD) 10. UPMC-University of Pittsburgh Medical Center (Pittsburgh, PA) Neurology and Neurosurgery 1. Johns Hopkins Hospital (Baltimore, MD) 2. Mayo Clinic (Rochester, MN) 3. Massachusetts General Hospital (Boston, MA) 4. New York-Presbyterian University Hospital of Columbia and Cornell (New York, NY) 5. Cleveland Clinic (Cleveland, OH) 6. UCSF Medical Center (San Francisco, CA) 7. UPMC-University of Pittsburgh Medical Center (Pittsburgh, PA) 8. NYU Langone Medical Center (New York, NY) 9. Barnes-Jewish Hospital/Washington University (Saint Louis, MO) 10. Hospital for Special Surgery (New York, NY) Ophthalmology 1. Bascom Palmer Eye Institute at the University of Miami (Miami, FL) 2. Wilmer Eye Institute - Johns Hopkins Hospital (Baltimore, MD) 3. Wills Eye Hospital (Philadelphia, PA) 4. Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital (Boston, MA)

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5. 6. 7. 8. 9. 10.

Jules Stein Eye Institute, UCLA Medical Center (Los Angeles, CA) University of Iowa Hospitals and Clinics (Iowa City, IA) Duke University Medical Center (Durham, NC) Doheny Eye Institute (USC University Hospital (Los Angeles, CA) Cleveland Clinic (Cleveland, OH) New York Eye and Ear Infirmary, N.Y. (New York, NY)

Orthopedics 1. Hospital for Special Surgery (New York, NY) 2. Mayo Clinic (Rochester, MN) 3. Cleveland Clinic (Cleveland, OH) 4. Massachusetts General Hospital (Boston, MA) 5. Johns Hopkins Hospital (Baltimore, MD) 6. Hospital for Joint Diseases, NYU Langhone Medical Center (New York, NY) 7. Thomas Jefferson University Hospital (Philadelphia, PA) 8. Barnes-Jewish Hospital/Washington University (St. Louis, MO) 9. Duke University Medical Center (Durham, NC) 10. UPMC-University of Pittsburgh Medical Center (Pittsburgh, PA) Psychiatry 1. Johns Hopkins Hospital (Baltimore, MD) 2. McLean Hospital (Belmont, MA) 3. Massachusetts General Hospital (Boston, MA) 4. Menninger Clinic (Houston, TX) 5. New York-Presbyterian University Hospital of Columbia and Cornell (New York, NY) 6. Sheppard and Enoch Pratt Hospital (Baltimore, MD) 7. Mayo Clinic (Rochester, MN) 8. Resnick Neuropsychiatric Hospital at UCLA (Los Angeles, CA) 9. UPMC-University of Pittsburgh Medical Center (Pittsburgh, PA) 10. Austen Riggs Center (Stockbridge, MA) Pulmonology 1. National Jewish Health, University of Colorado Hospital (Aurora, CO) 2. Mayo Clinic (Rochester, MN) 3. Cleveland Clinic (Cleveland, OH) 4. Johns Hopkins Hospital (Baltimore, MD) 5. Duke University Medical Center (Durham, NC) 6. UPMC-University of Pittsburgh Medical Center (Pittsburgh, PA) 7. Massachusetts General Hospital (Boston, MA) 8. Barnes-Jewish Hospital/Washington University (St. Louis, MO) 9. Vanderbilt University Medical Center (Nashville, TN) 10. Brigham and Women’s Hospital (Boston, MA)

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Rehabilitation 1. Rehabilitation Institute of Chicago (Chicago, IL) 2. Kessler Institute for Rehabilitation (West Orange, NJ) 3. TIRR Memorial Hermann (Houston, TX) 4. University of Washington Medical Center (Seattle, WA) 5. Spaulding Rehabilitation Hospital (Boston, MA) 6. Mayo Clinic (Rochester, MN) 7. Craig Hospital (Englewood, CO) 8. Rusk Institute, NYU Langone Medical Center (New York, NY) 9. Moss Rehab-Albert Einstein Medical Center (Elkins Park, PA) 10. Shepherd Center (Atlanta, GA) Rheumatology 1. Johns Hopkins Hospital (Baltimore, MD) 2. Cleveland Clinic (Cleveland, OH) 3. Hospital for Special Surgery (New York, NY) 4. Mayo Clinic (Rochester, MN) 5. Brigham and Women’s Hospital (Boston, MA) 6. Massachusetts General Hospital (Boston, MA) 7. Hospital for Joint Diseases, NYU Langone Medical Center (New York, NY) 8. Ronald Reagan UCLA Medical Center (Los Angeles, CA) 9. UCSF Medical Center (San Francisco, CA) 10. Duke University Medical Center (Durham, NC) Urology 1. Cleveland Clinic (Cleveland, OH) 2. Johns Hopkins Hospital (Baltimore, MD) 3. Mayo Clinic (Rochester, MN) 4. Ronald Reagan UCLA Medical Center (Los Angeles, CA) 5. New York-Presbyterian University Hospital of Columbia and Cornell (New York, NY) 6. Vanderbilt University Medical Center (Nashville, TN) 7. Duke University Medical Center (Durham, NC) 8. Indiana University Health (Indianapolis, IN) 9. Barnes-Jewish Hospital/Washington University (Saint Louis, MO) 10. Memorial Sloan-Kettering Cancer Center (New York, NY)

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74.3 Ranking Of Children’s Medical Centers The 2012 U.S. News & World Reports ranking of children’s hospitals is viewable online at http://health.usnews.com/best-hospitals/pediatric-rankings. The following are the top-ranked hospitals in each of the 10 specialty fields: Cancer 1. Children’s Hospital of Philadelphia (Philadelphia, PA) 2. Dana-Farber Cancer Center/Boston Children’s Hospital (Boston, MA) 3. Cincinnati Children’s Hospital Medical Center (Cincinnati, OH) 4. Texas Children’s Hospital (Houston, TX) 5. Childrens Hospital Los Angeles (Los Angeles, CA) 6. St. Jude Children’s Research Hospital (Memphis, TN) 7. Seattle Children’s Hospital (Seattle, WA) 8. Children’s Hospital Colorado (Aurora, CO) 9. Children’s National Medical Center (Washington, DC) 10. Ann and Robert H. Lurie Children’s Hospital of Chicago (Chicago, IL) Cardiology & Heart Surgery 1. Boston Children’s Hospital (Boston, MA) 2. Children’s Hospital of Philadelphia (Philadelphia, PA) 3. Texas Children’s Hospital (Houston, TX) 4. University of Michigan C.S. Mott Children’s Hospital (Ann Arbor, MI) 5. Nationwide Children’s Hospital (Columbus, OH) 6. Children’s Healthcare of Atlanta (Atlanta, GA) 7. New York-Presbyterian Morgan Stanley-Komansky Children’s Hospital (New York, NY) 8. Cincinnati Children’s Hospital Medical Center (Cincinnati, OH) 9. Children’s Hospital of Los Angeles (Los Angeles, CA) 10. Lucile Packard Children’s Hospital at Stanford (Palo Alto, CA) Diabetes and Endocrinology 1. Children’s Hospital of Philadelphia (Philadelphia, PA) 2. Boston Children’s Hospital (Boston, MA) 3. Yale-New Haven Children’s Hospital (New Haven, CT) 4. Children’s Hospital Colorado (Aurora, CO) 5. Cincinnati Children’s Hospital Medical Center (Cincinnati, OH) 6. Children’s Hospital of Pittsburgh of UPMC (Pittsburgh, PA) 7. Children’s Hospital Los Angeles (Los Angeles, CA) 8. Johns Hopkins Children’s Center (Baltimore, MD) 9. Mattel Children’s Hospital UCLA (Los Angeles, CA) 10. New York-Presbyterian Morgan Stanley-Komansky Children’s Hospital (New York, NY)

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Gastroenterology 1. Children’s Hospital of Philadelphia (Philadelphia, PA) 2. Boston Children’s Hospital (Boston, MA) 3. Cincinnati Children’s Hospital Medical Center (Cincinnati, OH) 4. Texas Children’s Hospital (Houston, TX) 5. Nationwide Children’s Hospital (Columbus, OH) 6. Children’s Hospital of Pittsburgh of UPMC (Pittsburgh, PA) 7. Children’s Hospital Los Angeles (Los Angeles, CA) 8. Ann and Robert H. Lurie Children’s Hospital of Chicago (Chicago, IL) 9. Children’s Hospital Cleveland Clinic (Cleveland, OH) 10. Children’s Hospital Colorado (Aurora, CO) Neonatalogy 1. Cincinnati Children’s Hospital Medical Center (Cincinnati, OH) 2. Texas Children’s Hospital (Houston, TX) 3. Boston Children’s Hospital (Boston, MA) 4. Children’s Hospital of Philadelphia (Philadelphia, PA) 5. Rainbow Babies and Children’s Hospital (Cleveland, OH) 6. Children’s National Medical Center (Washington, DC) 7. Children’s Hospital Los Angeles (Los Angeles, CA) 8. Monroe Carell Jr. Children’s Hospital at Vanderbilt (Nashville, TN) 9. Children’s Hospital of Pittsburgh of UPMC (Pittsburgh, PA) 10. Johns Hopkins Children’s Center (Baltimore, MD) Nephrology (Kidney Disorders) 1. Boston Children’s Hospital (Boston, MA) 2. Children’s Hospital of Philadelphia (Philadelphia, PA) 3. Cincinnati Children’s Hospital Medical Center (Cincinnati, OH) 4. Seattle Children’s Hospital (Seattle, WA) 5. Texas Children’s Hospital (Houston, TX) 6. Children’s Mercy Hospitals and Clinics (Kansas City, MO) 7. Ann and Robert H. Lurie Children’s Hospital of Chicago (Chicago, IL) 8. Children’s Medical Center Dallas (Dallas, TX) 9. Nationwide Children’s Hospital (Columbus, OH) 10. Mattel Children’s Hospital UCLA (Los Angeles, CA) Neurology and Neurosurgery 1. Boston Children’s Hospital (Boston, MA) 2. Children’s Hospital of Philadelphia (Philadelphia, PA) 3. Children’s Hospital Cleveland Clinic (Cleveland, OH) 4. Cincinnati Children’s Hospital Medical Center (Cincinnati, OH) 5. Johns Hopkins Children’s Center (Baltimore, MD) 6. Texas Children’s Hospital (Houston, TX) 7. St. Louis Children’s Hospital-Washington University (St. Louis, MO)

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8. Seattle Children’s Hospital (Seattle, WA) 9. Children’s Memorial Hospital (Chicago, IL) 10. Nationwide Children’s Hospital (Columbus, OH) Orthopedics 1. Children’s Hospital of Philadelphia (Philadelphia, PA) 2. Rady Children’s Hospital (San Diego, CA) 3. Boston Children’s Hospital (Boston, MA) 4. Cincinnati Children’s Hospital Medical Center (Cincinnati, OH) 5. Children’s Medical Center-Texas Scottish Rite Hospital for Children (Dallas, TX) 6. Childrens Hospital Los Angeles (Los Angeles, CA) 7. Alfred I. duPont Hospital for Children (Wilmington, DE) 8. St. Louis Children’s Hospital-Washington University (St. Louis, MO) 9. Children’s Hospital Colorado (Aurora, CO) 10. Ann and Robert H. Lurie Children’s Hospital of Chicago (Chicago, IL) Pulmonology 1. Children’s Hospital of Philadelphia (Philadelphia, PA) 2. Cincinnati Children’s Hospital Medical Center (Cincinnati, OH) 3. Texas Children’s Hospital (Houston, TX) 4. Boston Children’s Hospital (Boston, MA) 5. Rainbow Babies and Children’s Hospital (Cleveland, OH) 6. Nationwide Children’s Hospital (Columbus, OH) 7. Children’s Hospital Colorado (Aurora, CO) 8. North Carolina Children’s Hospital at UNC (Chapel Hill, NC) 9. St. Louis Children’s Hospital-Washington University (St. Louis, MO) 10. Riley Hospital for Children Indiana University Health (Indianapolis, IN) Urology 1. Children’s Hospital of Philadelphia (Philadelphia, PA) 2. Boston Children’s Hospital (Boston, MA) 3. Riley Hospital for Children at Indiana University Health (Indianapolis, IN) 4. Cincinnati Children’s Hospital Medical Center (Cincinnati, OH) 5. Seattle Children’s Hospital (Seattle, WA) 6. Children’s Memorial Hospital (Chicago, IL) 7. Texas Children’s Hospital (Houston, TX) 8. Monroe Carell Jr. Children’s Hospital at Vanderbilt (Nashville, TN) 9. Rady Children’s Hospital (San Diego, CA) 10. Children’s Hospital of Pittsburgh of UPMC (Pittsburgh, PA) 74.4 Ranking By Metropolitan Area Rankings by metropolitan area are viewable online at http://health.usnews.com/best-hospitals/area.

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PART V: HEALTH INSURANCE

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75 AFFORDABLE CARE ACT

75.1 Overview The Patient Protection and Affordable Care Act, generally referred to as the Affordable Care Act, was signed into law in March 2010. The legislation is viewable online at www.healthcare.gov/law/full/index.html. This chapter provides a summary of key health coverage provisions in the law.

75.2 Objectives The following are the primary mandates of the Affordable Care Act: • Most individuals will be required to have health insurance beginning in 2014. • Individuals who do not have access to affordable employer coverage will be able to purchase coverage through a health insurance exchange with premium and costsharing credits available to some people to make coverage more affordable. Small businesses will be able to purchase coverage through a separate exchange. • Employers will be required to pay penalties if employees receive tax credits for health insurance through the exchange, with exceptions for small employers. • Regulations will be imposed on all health plans to prevent health insurers from denying coverage to people for any reason, including health status, and from charging higher premiums based on health status and gender. • Medicaid will be expanded to those under age 65 who are at 133% of the federal poverty level ($14,856 for an individual and $30,657 for a family of four in 2012).

75.3 Impact The Congressional Budget Office (CBO, www.cbo.gov) estimates that the legislation will reduce the number of uninsured people by 32 million by 2019 at a net cost of $938 billion over 10 years. During this time period the deficit will be reduced by $124 billion. According to CBO, by 2019, the legislation will have led to 24 million people obtaining coverage in the newly created state health insurance exchanges. In addition, 16 million more people would be enrolled in Medicaid and the Children’s Health Insurance Program. The cost of the legislation will be financed through a combination of savings from Medicaid and Medicare and new taxes and fees, including an excise tax on high-cost insurance plans.

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75.4 Mandate For Individuals All individuals will be required to have health insurance, with some exceptions, beginning in 2014. Those who do not have coverage will be required to pay a yearly financial penalty of the greater of $695 per person (up to a maximum of $2,085 per family), or 2.5% of household income, which will be phased in from 2014-2016. Exceptions will be given for those with financial hardship and religious objections; American Indians; people who have been uninsured for less than three months; those for whom the lowest cost health plan exceeds 8% of income; and individuals with income below the tax filing threshold ($9,350 for an individual and $18,700 for a married couple in 2009).

75.5 Requirements for Employers There is no employer mandate, but employers with 50 or more employees will be assessed a fee of $2,000 per full-time employee (in excess of 30 employees) if they do not offer coverage and if they have at least one employee who receives a premium credit through an exchange. Employers with 50 or more employees that offer coverage and have at least one employee who receives a premium credit through an exchange will be required to pay the lesser of $3,000 for each employee who receives a premium credit or $2,000 for each full-time employee (in excess of 30 employees). Large employers that offer coverage will be required to automatically enroll employees into the employer’s lowest cost premium plan if the employee does not sign up for employer coverage or does not opt out of coverage.

75.6 Requirements For Private Health Insurance New insurance market regulations will prevent health insurers from denying coverage to people for any reason, including their health status, and from charging people more based on their health status and gender. These new rules will also require that all new health plans provide comprehensive coverage that includes at least a minimum set of services, caps annual out-of-pocket spending, does not impose costsharing for preventive services, and does not impose annual or lifetime limits on coverage. Health plan premiums may vary based on the insured’s age (by a 3 to 1 ratio), geographic area, tobacco use (by a 1.5 to 1 ratio), and the number of family members. Health insurers will be prohibited from imposing lifetime limits on coverage and will be prohibited from rescinding coverage, except in cases of fraud.

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Young adults will be allowed to remain on their parent’s health insurance up to age 26. States will be allowed to form healthcare choice compacts that enable insurers to sell policies in any state that participates in the compact. Existing individual and employer-sponsored insurance plans will be allowed to remain essentially the same, except that they will be required to extend dependent coverage to age 26, eliminate annual and lifetime limits on coverage, prohibit rescissions of coverage, and eliminate waiting periods for coverage of greater than 90 days. Increases in health plan premiums will be subject to review.

75.7 Expansion of Public Programs Medicaid will be expanded to all individuals under age 65 with incomes up to 133% of the federal poverty level ($14,404 for an individual and $29,327 for a family of four in 2009) based on modified adjusted gross income. This expansion will create a uniform minimum Medicaid eligibility threshold across states and will eliminate a limitation of the program that prohibits most adults without dependent children from enrolling in the program today (though as under current law, undocumented immigrants will not be eligible for Medicaid). Eligibility for Medicaid and the Children’s Health Insurance Program (CHIP) for children will continue at their current eligibility levels until 2019. People with incomes above 133% of the poverty level who do not have access to employer-sponsored insurance will obtain coverage through the newly created state health insurance exchanges. The federal government will fully fund the costs of those who become newly eligible for Medicaid for years 2014 through 2016, fund 95% for 2017, 94% for 2018, 93% for 2019, and 90% for 2020 and subsequent years. States that have already expanded adult eligibility to 100% of the poverty level will receive a phased-in increase in the Federal Medical Assistance Program (FMAP) for non-pregnant adults without children. Medicaid payments to primary care doctors for primary care services will be increased to 100% of Medicare payment rates in 2013 and 2014, with 100% federal financing.

75.8 Affordable Health Benefit Exchanges States will create American Health Benefit Exchanges for individuals to purchase insurance and separate exchanges for small employers to purchase insurance. Premium and cost-sharing subsidies will be available to make coverage more affordable. Access to exchanges will be limited to U.S. citizens and legal immigrants. Small businesses with up to 100 employees will be allowed to purchase coverage through an exchange.

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Although there will not be a public plan option in the exchanges, the Office of Personnel Management, which administers the Federal Employees Health Benefit Program, will contract with private insurers to offer at least two multi-state plans in each exchange, including at least one offered by a non-profit entity. In addition, funds will be made available to establish non-profit, member-run health insurance co-ops in each state. Plans in the exchanges will be required to offer benefits that meet a minimum set of standards. Insurers will offer four levels of coverage that vary based on premiums, out-of-pocket costs, and benefits beyond the minimum required plus a catastrophic coverage plan. Premium subsidies will be provided to families with incomes up to 400% of the poverty level ($29,327 to $88,200 for a family of four in 2009) who do not have access to other coverage to help them purchase insurance through the exchanges. These subsidies will be offered on a sliding scale basis and will limit the cost of the premium to between 2% and 9.5% of income for eligible individuals. Cost-sharing subsidies will also be available to people with incomes between 100% and 250% of the poverty level to limit out-of-pocket spending.

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76 AFFORDABLE HEALTH BENEFIT EXCHANGES

76.1 Overview The Affordable Care Act requires each state to establish by 2014 a health benefit exchange where individuals and small businesses can purchase affordable health insurance plans. At the centerpiece of the reform law, exchanges will be the main portals for people without employer-sponsored or public insurance. In states that elect not to establish an exchange, the ACA requires the HHS to establish and operate one for the citizens of that state. This would also apply in the event HHS determines that despite state efforts to establish an exchange, the exchange has not made sufficient progress to become fully operational by January 1, 2014. HHS has begun laying the groundwork to establish what will become a federally facilitated exchange in 2014. Up to 30 million people are expected to enroll in health plans through their state exchange by 2020, either on their own or through their employer.

76.2 Status To establish an exchange, states must either pass enabling legislation or have an executive order signed by the governor. States have the option to decline to establish an exchange. As of January 2013, the following states had legislation signed into law establishing an exchange (source: National Conference of State Legislatures): • California • Colorado • Connecticut • Hawaii • Idaho • Kentucky • Maryland • Massachusetts* • Mississippi • Nevada • New Mexico • New York • Oregon

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• • • •

Rhode Island Utah* Vermont Washington

* Legislation passed prior to the Affordable Care Act

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77 CHILDREN’S HEALTH INSURANCE PROGRAM

77.1 Overview Created in 1997, the Children’s Health Insurance Program (CHIP) provides federally matched funds to states for health insurance to families with children. The program is intended to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid. States are given flexibility in designing their CHIP policies and eligibility requirements within broad federal guidelines. The federal government provides matching funds to states to provide CHIP coverage.

77.2 CHIP Enrollment Total CHIP enrollment in FY2012 was 7,977,203, distributed by state as follows: • Alabama: 109,255 • Alaska: 14,278 • Arizona: 20,043 • Arkansas: 103,693 • California: 1,765,893 • Colorado: 105,255 • Connecticut: 20,072 • Delaware: 15,443 • District of Columbia: 8,675 • Florida: 421,717 • Georgia: 248,536 • Hawaii: 30,584 • Idaho: 42,604 • Illinois: 336,885 • Indiana: 158,138 • Iowa: 75,133 • Kansas: 60,431 • Kentucky: 85,554 • Louisiana: 152,404 • Maine: 35,986 • Maryland: 119,906 • Massachusetts: 144,767 • Michigan: 83,004 • Minnesota: 5,164 • Mississippi: 91,470

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• • • • • • • • • • • • • • • • • • • • • • • • • •

Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:

93,734 24,365 52,852 29,760 10,801 198,283 9,635 552,068 254,460 7,115 280,650 120,501 112,165 272,492 24,815 72,084 16,623 96,028 972,715 59,698 7,054 182,118 44,322 37,631 172,451 8,586

77.3 CHIP Spending Total CHIP spending in FY2012 was $11.97 billion. Of the total, federal spending was $8.95 billion and spending by states was $3.51 billion, as follows: • • • • • • • • • • • •

Alabama: Alaska: Arizona: Arkansas: California: Colorado: Connecticut: Delaware: District of Columbia: Florida: Georgia: Hawaii:

Total

Federal

State

$ 200.8 million $ 30.4 million $ 31.6 million $ 124.8 million $1.918 billion $ 194.2 million $ 25.4 million $ 22.3 million $ 17.6 million $ 499.1 million $ 355.8 million $ 38.5 million

$ 156.7 million $ 19.8 million $ 24.4 million $ 99.2 million $1.246 billion $ 126.3 million $ 39.8 million $ 15.1 million $ 13.9 million $ 345.4 million $ 271.6 million $ 24.8 million

$ 44.1 million $ 10.6 million $ 7.2 million $ 25.6 million $671.5 million $ 68.0 million $ 14.4 million $ 7.1 million $ 3.7 million $153.7 million $ 84.2 million $ 13.8 million

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• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Idaho: Illinois: Indiana: Iowa: Kansas: Kentucky: Louisiana: Maine: Maryland: Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:

$ 43.7 million $ 407.6 million $ 181.3 million $ 122.7 million $ 76.3 million $ 178.2 million $ 226.9 million $ 40.7 million $ 237.5 million $ 489.7 million $ 66.2 million $ 19.6 million $ 207.6 million $ 158.9 million $ 74.9 million $ 58.5 million $ 43.9 million $ 20.1 million $ 947.2 million $ 151.6 million $ 858.0 million $ 385.7 million $ 24.0 million $ 431.7 million $ 146.1 million $ 187.0 million $ 429.0 million $ 57.2 million $ 119.2 million $ 26.2 million $ 252.0 million $1.200 billion $ 74.8 million $ 9.2 million $ 276.0 million $ 71.7 million $ 57.5 million $ 131.8 million $ 15.9 million

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

34.6 million 265.1 million 139.4 million 89.0 million 53.3 million 142.3 million 165.1 million 30.3 million 154.4 million 318.3 million 52.7 million 30.9 million 170.2 million 118.3 million 57.1 million 40.8 million 30.3 million 17.5 million 615.9 million 119.1 million 557.8 million 292.0 million 16.5 million 323.3 million 109.2 million 138.4 million 294.1 million 38.0 million 94.4 million 18.7 million 192.6 million 849.1 million 59.6 million 12.5 million 179.4 million 93.0 million 46.4 million 99.1 million 10.4 million

$ 9.1 million $142.5 million $ 41.9 million $ 33.8 million $ 23.0 million $ 35.9 million $ 61.8 million $ 10.4 million $ 83.1 million $171.4 million $ 13.5 million $ 11.2 million $ 37.4 million $ 40.7 million $ 17.8 million $ 17.8 million $ 13.6 million $ 2.6 million $331.3 million $ 32.5 million $300.2 million $ 93.7 million $ 7.5 million $108.4 million $ 36.9 million $ 48.5 million $134.9 million $ 19.1 million $ 24.8 million $ 7.5 million $ 59.3 million $351.6 million $ 15.2 million $ 3.4 million $ 96.6 million $ 21.3 million $ 11.0 million $ 32.7 million $ 5.5 million

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78 EMPLOYER-SPONSORED HEALTH INSURANCE

78.1 Coverage According to the Employer Health Benefits Survey, published by Kaiser Family Foundation (KFF, www.kff.org) and Health Research & Educational Trust (www.hret.org), employer-sponsored insurance is the leading source of health insurance, covering about 150 million people in the U.S. The Medical Expenditure Panel Survey - Insurance Component, published in 2013 by the Agency for Healthcare Research and Quality (www.ahrq.gov), reported that 35.7% of private-sector business establishments with fewer than 50 employees provided health insurance for their employees in 2011; 95.7% of businesses with 50 or more employees did so. The percentage of private-sector business establishments by state that provided health insurance were as follows: • • • • • • • • • • • • • • • • • • • • • •

Alabama: Alaska: Arizona: Arkansas: California: Colorado: Connecticut: Delaware: District of Columbia: Florida: Georgia: Hawaii: Idaho: Illinois: Indiana: Iowa: Kansas: Kentucky: Louisiana: Maine: Maryland: Massachusetts:

50 employees

37.5% 23.2% 28.8% 24.1% 37.9% 32.6% 43.7% 35.8% 49.6% 27.0% 28.6% 77.9% 25.7% 32.7% 27.4% 30.4% 39.6% 37.4% 33.2% 28.4% 39.1% 53.2%

97.5% 94.0% 94.8% 93.0% 93.4% 97.7% 97.0% 96.7% 97.3% 95.5% 96.7% 99.4% 93.9% 96.5% 97.6% 95.4% 96.7% 95.6% 94.2% 96.5% 97.3% 98.1%

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• • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:

36.9% 32.7% 25.8% 34.8% 30.6% 25.3% 35.8% 39.4% 46.7% 30.0% 44.5% 30.3% 35.3% 39.1% 32.4% 34.1% 46.7% 49.1% 31.2% 31.6% 37.1% 28.4% 27.7% 41.2% 37.8% 32.4% 33.1% 32.5% 29.8%

98.3% 93.9% 96.2% 94.9% 95.5% 93.9% 97.0% 97.3% 96.5% 93.4% 96.0% 96.1% 94.7% 96.7% 92.7% 95.2% 98.0% 97.9% 96.0% 94.4% 98.1% 92.3% 94.5% 98.9% 97.2% 94.4% 94.8% 96.7% 96.3%

78.2 Premiums For Employer-Sponsored Plans According to Aon Hewitt (www.aon.com), healthcare premiums for employersponsored plans have been as follows: Cost per Employee

• • • • • • •

2007: 2008: 2009: 2010: 2011: 2012: 2013:*

$ 7,874 $ 8,290 $ 8,703 $ 9,246 $10,034 $10,552 $11,188

Increase

Employee Premium Contribution

Employee Out-ofPocket Cost

5.3% 5.3% 5.0% 6.2% 8.5% 4.9% 6.3%

$1,567 $1,691 $1,797 $1,927 $2,090 $2,204 $2,385

$1,364 $1,508 $1,580 $1,761 $2,072 $2,200 $2,429

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In 2012, healthcare premium rate increases for U.S. companies and their employees were the lowest in six years. The average healthcare premium rate increase for large employers in 2012 was 4.9%, down from 8.5% percent in 2011 and 6.2% in 2010. In 2013, average healthcare premium increases are projected to increase up to 6.3%. On average, Aon Hewitt forecasts that companies will see 2013 cost increases of 7.0% for health maintenance organization (HMO) plans, 6.1% for point-of-service (POS) plans, and 6.1% for preferred provider organization (PPO) plans. Premium costs by plan type have been and are projected as follows: • • • • • • •

2007: 2008: 2009: 2010: 2011: 2012: 2013:*

HMO

POS

PPO

$ 7,680 $ 8,193 $ 8,693 $ 9,353 $10,103 $10,659 $11,405

$ 8,062 $ 8,403 $ 8,864 $ 9,557 $10,657 $11,062 $11,737

$ 8,050 $ 8,388 $ 8,764 $ 9,212 $ 9,965 $10,433 $10,069

78.3 Premiums For Families And Individuals According to KFF’s Employer Health Benefits Survey, average annual premiums for employee-sponsored health insurance have been as follows (total of employee and employer contributions): • • • • • • • • • • • • •

2000: 2001: 2002: 2003: 2004: 2005: 2006: 2007: 2008: 2009: 2010: 2011: 2012:

Single

Family

$2,471 $2,689 $3,083 $3,383 $3,695 $4,024 $4,242 $4,479 $4,704 $4,824 $5,049 $5,429 $5,615

$ 6,438 $ 7,061 $ 8,003 $ 9,068 $ 9,950 $10,880 $11,480 $12,106 $12,680 $13,375 $13,770 $15,073 $15,745

The distribution of premium payments in 2012 was as follows: • •

Employer contribution: Employee contribution:

Single

Family

$4,664 $ 951

$11,429 $ 4,316

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• • • • •

By type of plan, employee enrollment in 2012 was distributed as follows: Preferred provider organizations (PPOs): 56% Health maintenance organizations (HMOs): 16% High-deductible health plan/savings option (HDHP/SOs): 19% Point-of-service (POS) plans: 9% Conventional plans: 20 employees: 28% • Self-employed: 22% • Working for firms with