Transcript Hospitals
Hospitals Introduction • History of Hospitals • Hospitals vs. Hospice Hospital Ownership • Public vs Private • Profit or Non-Profit • Type of care (primary, secondary, tertiary,…) • Type of services (ASC…) Number of Public Community Hospitals, 1990-2007 1,500 1,444 1,396 1,400 1,371 1,330 1,300 1,218 1,163 1,200 1,136 1,117 1,119 1,111 2004 2006 2007 1,100 1,000 900 800 700 1990 1992 1994 1996 1998 2000 2002 Notes: Includes nonfederal (i.e., state and local government), short-term general and specialty hospitals whose facilities are available to the public. Public community hospitals represent 23% of all community hospitals, and community hospitals represent about 85% of all hospitals. Federal hospitals, long term care hospitals, psychiatric hospitals, institutions for the mentally retarded, and alcoholism and other chemical dependency hospitals are not included. Source: American Hospital Association Annual Surveys: 1990-1998 data from Hospital Statistics, 2002, Table 1; 1999-2007 data from AHA Annual Surveys, Copyright 2009 by Health Forum LLC, an affiliate of the American Hospital Association, at http://www.ahaonlinestore.com. Principle Agent Problems • Owners versus Managers Market Structure • Monopolies • Monopolistically Competitive • Market Concentration – Herfindahl-Hirschman Index (sum of squared market shares measured in percentages) Monopoly = 10,000 ie. 100^2 • >1,400 subject to antitrust. • 5,000 two equal market shares. Effect of Competition on Prices • Until late 80s more competition meant higher prices. Competing on quality? • Medical Arms Race • Payer Driven Competition? HMOs lower prices Role of Government • Capital Assistance – Stimulus funds electronic records • Provision of Public Hospitals • Medicare and Medicaid Government Regulations of Hospitals • Certificate of Need (CON) – Wisconsin (ended 2011) • Effects of CON • Effects of CON on Nursing Homes 2004 Per Capita Hospital Expenses • • • • • • • • • • Hospital Expense Per Capita Massachusetts $2,357 North Dakota $2,229 New York $2,202 Missouri $2,009 Maine $1,936 Ohio $1,932 West Virginia $1,930 Rhode Island $1,929 Pennsylvania $1,925 • • • • • • • • • • • Delaware South Dakota Nebraska Minnesota Vermont Indiana Connecticut Michigan Iowa Wisconsin Illinois $1,908 $1,867 $1,862 $1,804 $1,775 $1,750 $1,745 $1,731 $1,720 $1,710 $1,709 • Con states in bold Hospitals and Medicare PPS • Prospective Payment System • http://www.cms.hhs.gov/ProspMedicareFeeS vcPmtGen/ Price Discrimination • Forms of Price Discrimination • Cost Shifting Role of Charity in Modern Hospitals • Hospital Altruism – Model of • Pure vs Impure – Evidence Declining Demand for Inpatient Care • http://www.statehealthfacts.org/comparetabl e.jsp?ind=397&cat=8 Capacity We analyze admission and discharge decisions when hospitals become capacity constrained on high-demand days, and develop a test for discrimination that, under certain circumstances, does not require controls for differences across patient groups. On high-demand days, patients are discharged earlier than expected compared to those discharged on low-demand days. High demand creates no statistically significant differences in hospitals' admission behavior. Thus, hospitals appear to ration capacity by hastening discharges rather than by restricting admissions. We could not reject a null hypothesis of no discrimination against Medicaid patients in discharges. Copyright (c) 2008, RAND. Hospitals’ Probability Of Offering Psychiatric Emergency Services, By Ownership Type, 1988– 2000. Horwitz J R Health Aff 2005;24:790-801 ©2005 by Project HOPE - The People-to-People Health Foundation, Inc. Hospitals’ Probability Of Offering Open-Heart Surgery, By Ownership Type, 1988–2000. Horwitz J R Health Aff 2005;24:790-801 ©2005 by Project HOPE - The People-to-People Health Foundation, Inc.