92.8 94.899.5 103.1 106.0 110.0 111.0 112.6
0
20
40
60
80
100
120
1997 1998 1999 2000 2001 2002 2003 2004
Chart 1:Emergency Department Visits, 1997 – 2004, In Millions
Source: AHA Annual Survey, data for community hospitals.
Demand for emergency access to care is rising.E
mer
gen
cy
Dep
artm
ent
Vis
its
Chart 2:Emergency Department Visits by Level of Urgency, 2003
35% Urgent (should be seen in 15-6 minutes)
Semi-urgent 20%(should be seen in 61-120 minutes)
Non-urgent 13%(should be seen in
121 minutes to 24 hours)
15% Emergent (should be seen in less than 15 minutes)
Most emergency department patients have immediate health care needs.
Source: Centers for Disease Control and Prevention, National Ambulatory Medicare Care Survey: 2003 Emergency Department Summary.
No Triage/Unknown 17%
Emergency care demand is highly unpredictable and can vary greatly by time of day…
Source: New Britain General Hospital, New Britain, CT.
Chart 3:Emergency Department Visits by Hour of Day, October 1–31, 2004
0
5
10
15
20
25
30
Mid
nig
ht
1:00
AM
2:00
AM
3:00
AM
4:00
AM
5:00
AM
6:00
AM
7:00
AM
8:00
AM
9:00
AM
10:0
0 A
M
11:0
0 A
M
No
on
1:00
PM
2:00
PM
3:00
PM
4:00
PM
5:00
PM
6:00
PM
7:00
PM
8:00
PM
9:00
PM
10:0
0 P
M
11:0
0 P
M
Minimum Average Maximum
…and day of week, raising management challenges for hospitals.
Source: New Britain General Hospital, New Britain, CT.
Chart 4:Emergency Department Visits by Day of Week, November 17–30, 2004
201
186
170 166
141
181
148
127
172167
195
157
222
186
Da
y 1
Da
y 2
Da
y 3
Da
y 4
Da
y 5
Da
y 6
Da
y 7
Da
y 8
Da
y 9
Da
y 1
0
Da
y 1
1
Da
y 1
2
Da
y 1
3
Da
y 1
4
Figure A: Inpatient Psychiatric Facilities, 1995–2004
Decreasing resources for behavioral health care have led more patients to turn to the ED for care.
1,5071,349
467
662
1995 2004
Units of Hospitals Freestanding Facilities
Source: AHA Annual Survey of Hospitals, 1995-2004.
2169
1816
Figure B:Behavioral Health-Related Emergency Department Visits, 1994/95–2001/02In Millions
Source: Gregory Luke Larkin et al., Trends in U.S. Demand in U.S. Emergency Department Visits for Mental Health Conditions, 1992 to 2001; Psychiatric Services 56:671-677, June 2005.
4.4
2.8
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
1994-95 2000-01
Common patient conditions require a wide variety of resources to be available 24/7.Chart 5:Example: Resource Needs for Common Condition
Source: King’s Daughter Medical Center, Brookhaven, MS.
Rural hospitals often serve large geographic areas.Figure C:Geographic Region Served by King’s Daughter Medical Center
Source: King’s Daughter Medical Center, Brookhaven, MS.
Population
Full-service hospitals are equipped to respond to over 1000 unique conditions.
Source: New Britain General Hospital, New Britain, CT.
Chart 6: Emergency Visits and Conditions TreatedExample: New Britain General Hospital, FY 2005
In 2005, New Britain General Hospital
Treated over 63,000 patients with over
1,690 unique conditions
48,430
1,210
1,280
1,300
1,380
1,430
1,450
1,500
1,560
1,720
1,730
Other
Pneumonia
Open Wound of Finger
Acute Pharyngitis
Acute Bronchitis
Alcohol Abuse
Abdominal Pain
Asthma
Ear Infection
Viral Infection
Upper Respiratory Tract Infection
Chart 7:Accidents Cared for at Level I Trauma Centers, 2001 – 2004
Victims of accidents or violent crimes often are transported to Level I trauma centers…
201,774
103,002
34,879 31,72825,976
20,57810,975 6,899 6,132
47,201
Motor Vehicle/Traffic
Fall Firearm Struckby/against Object
Cut/Pierce Non-motorVehicle
Transportation
Fire/Burn Machinery Accident
Pedal Cyclist,Other
Other
Source: National Trauma Data Bank, 2004.
…where extensive and highly specialized resources are available 24/7.
Source: American College of Surgeons: Resources for Optimal Care of the Injured Patient, 1999.
AnesthesiaCardiac surgeryCritical care medicineGeneral surgeryHand surgeryMicro vascular/replant
surgeryNeurosurgeryObstetrics/GynecologyOphthalmic surgeryOral/maxillofacial surgeryOrthopedic surgeryPlastic surgeryRadiologySurgical ICU service with
physician in-house 24/7Thoracic surgery
Radiology Services 24/7-X-Ray-Angiography-Sonography-CT-MRI
Operating room personnel in-house 24/7
Post-anesthetic recovery room nurses 24/7
Intensive/critical care nurses with trauma education
Respiratory therapy services 24/7
Clinical laboratory serviceHemodialysisPhysical, occupational and
speech therapy
Operating Room EquipmentOperating microscopeThermal control equipmentRadiology C-ArmEndoscopes/bronchoscopeCraniotomy instrumentsEquipment long bone and
pelvic fixationRapid infuser system
ED EquipmentResuscitation equipmentStandardized IV fluids and
administration setsLarge-bore intravenous setsArterial catheters
Clinical capabilities immediately available…
…supported a wide array of caregiver resources…
…and specialized equipment
Chart 8:Selected Resource Requirements for Level I Trauma Centers
77% 76%
69%65%
59%
48%
40%
14%
HealthScreenings
Health Fair CommunityOutreach
SupportGroups
PatientEducation
Center
HealthInformation
Center
EnrollmentAssistanceServcies
Meals onWheels
Chart 9:Percentage of Community Hospitals Offering Selected Community Services, 2004
Source: Health Forum, Hospital Statistics, 2006.
Hospitals provide many community services for low-income populations and the community at large.
Medicaid beneficiaries use more ED care than other populations.
Chart 10:Emergency Department Visits per 100 Population by Immediacy of Patient Condition, 2003
5.6 3.5 3.2
7.67.3 5.7
19.8
12.7 16.7
9.6
4.6
10.8
3.9
8.9
12.5
6.9
0
10
20
30
40
50
60
Medicaid Uninsured Medicare PrivateInsurance
Emergent
Urgent
Semi Urgent
Non Urgent
Source: Chartis Group Analysis of National Hospital Ambulatory Medical Care Survey, 2003.
Vis
its
pe
r 1
00
P
op
ula
tio
ns
0
5
10
15
20
25
30
35
40
45
50
55
60
1990 1995 2000 2004
Other Title XIX
Adults
Children
Blind/Disabled
Aged
Source: Centers for Medicare & Medicaid Services; 2004 data, CBO March 2005 Baseline.
(1) Does not include S-CHIP Enrollees
Chart 11:Medicaid Enrollees(1), 1990 – 2004 (In Millions)
Mil
lio
ns
25.3 M
36.3 M
44.5 M
57.3 M
The number of Medicaid beneficiaries has more than doubled since 1990.
71.5%
68.2%
76.3%
1996-97 2000-01 2004-05
Chart 12:The Percent of Physicians Providing Office/Clinic Based Charity Care, 1996/97 – 2004/05
Source: Center for Studying Health System Change, A Growing Hole in the Safety Net: Physician Charity Care Declines Again, Tracking Report No. 13, March 2006.
The proportion of physicians providing office/clinic-based charity care is declining.
21%
14%16%
36%
5%
23%
56%
10%
Medicaid Uninsured Medicare Private Insurance
Emergency Department Physician Offices
EDs serve proportionally more Medicaid and uninsured patients than physician offices.Chart 13:Percent of Total Visits by Expected Source of Payment, Emergency Departments vs. Physician Offices, 2003
Source: Centers for Disease Control and Prevention, National Ambulatory Medical Care Survey; National Hospital Ambulatory Medical Care Survey.
97.3%
84.8%
77.2% 76.9%
85.5%
NaturalDisasters
Chemical Biological Nuclear orRadiologic
Explosive
Chart 14:Percent of Hospitals with Response Plans by Type of Incident, 2003
Source: Centers for Disease Control and Prevention, Bioterrorism and Mass Casualty Preparedness in Hospitals: United States, 2003.
Hospitals plan for multiple types of disasters.
Chart 15:Selected Recent U.S. Disasters
Hospitals in all regions must be prepared for a range of natural and manmade disasters.
Source: National Hurricane Center; Wikipedia; FEMA: Taking Shelter from the Storm: Building a Safe Room Inside Your House; The National Coalition For School Bus Safety; National Transportation Safety Board; Michigan Tech (http://www.geo.mtu.edu/UPSeis/area.html)
Disaster response in hurricane zones can last for days and require hospitals to play many different roles.
Day 1 Day 2 Day 3 Day 4 Day 5+
• Hurricane alert – hurricane expected to hit land in two days
• Hospital begins to procure supplies, including gas, food, lumber and water
• Hospital prepares ancillary power generators, sets up extra cots, installs portable toilets and boards windows
• Elective surgical and ancillary procedures are postponed and some patients well enough to return home are discharged
• Sunny day but clouds roll in quickly and winds begin to gust
• Hospital continues preparation activities
• Hospital develops emergency staffing schedules and sets up daycare for employees’ children
• In the evening, community members arrive at the hospital’s front door with pillows, blankets, bags and pets in tow; Many are pregnant or elderly – no one is turned away
• Torrential rain• and gusting winds
• Occasionally the sound of broken glass or objects hitting the building can be heard
• Care provided for the injured
• Shelter provided for hundreds of people and their pets
• Daycare is provided for employees’ children
• Hospital kitchen continues to operate and feeds the hungry
• Light rain with occasional sunshine
• Roads are littered with branches and trees, electricity is out, and there is no running water
• Hundreds remain sheltered, and daycare and kitchen operations continue
• Cleanup of the hospital’s grounds begins – can’t get cars out until the roads are cleared
• Community members flock to the hospital cafeteria – the only place providing food in town
• Sunny day
• Roads are reopening but many are closed
• Utilities come back online throughout the day
• Many of those seeking shelter do not leave because the roads to their homes are impassible or their homes are severely damaged
• Cleanup of the hospital’s grounds continues
• Elective procedures continue to be postponed
Pre
pa
red
ne
ss
/Re
sp
on
se
Ac
tiv
itie
sC
on
dit
ion
s
Figure D:Hurricane Response: Baptist Hospital, Pensacola
Source: Baptist Medical Center, Pensacola, FL.
Chart 16:Vacancy Rates for Selected Hospital Personnel, December 2005
Hospitals currently face workforce shortages in key care-giving professions…
7.6%7.3%
6.3%5.9%
4.4%
8.5%
RegisteredNurses
NursingAssistants
LPNs LaboratoryTechnicians
ImagingTechnicians
Pharmacists
Source: AHA Survey of Hospital Leaders, 2006.
1,500
1,700
1,900
2,100
2,300
2,500
2,700
2,900
2000 2005 2010 2015 2020
Chart 17:Registered Nurse FTEs: Supply and Demand, 2000 – 2020
Source: National Center For Health Workforce Analysis, Bureau of Health Professions, Health Resources and Services Administration, 2004.
In 2020, there will be a shortage of
1 million nurses
By 2020, demand will outstrip supply by 1 million for registered nurses…
RN FTE Demand
RN FTE Supply
FT
Es
in
Th
ou
sa
nd
s
Chart 18:Physician Supply and Demand, 2000 – 2020
Source: College of Graduate Medical Education, Physician Workforce Policy Guidelines for the United States, 2000-2020.
275
300
325
350
375
400
2000 2005 2010 2015 2020
Generalist Physicians Specialist Physicians
In 2020, there will be a
shortage of 84,000
physicians
…and 84,000 physicians.
Generalist Demand
Generalist Supply
475
500
525
550
575
600
625
650
675
700
2000 2005 2010 2015 2020
Specialist Demand
Specialist Supply
Th
ou
sa
nd
s
Th
ou
sa
nd
s
80
90
100
110
120
91 92 93 94 95 96 97 98 99 00 01 02 03 04
4,500
5,000
5,500
EmergencyDepartment VisitsEmergencyDepartments
Chart 19:Emergency Department Visits and Emergency Departments(1) in Community Hospitals, 1991 – 2004
Source: The Lewin Group analysis of American Hospital Association Annual Survey data, 1991 – 2004, for community hospitals.(1)Defined as hospitals reporting ED visits.
Em
erg
ency
D
epar
tmen
t V
isit
s (M
illio
ns)
Em
erg
ency
D
epar
tmen
ts
As the number of patients seeking ED care has risen, the number of EDs has declined.
-1.9-2.6 -2.1
-2.3
-5.0
-15
-8.1
-3.4-2.4-1.4
4.32.3
-7.1
-1.6 -1.4
-$30
-$20
-$10
$0
$10
Chart 20:Hospital Payment Shortfall Relative to Costs for Medicare and Medicaid Patients in Billions, 1997 – 2004
1997 1998 1999 2000 2001 2002 2003
Medicare
Medicaid
Source: AHA Annual Survey, data for community hospitals
Bil
lio
ns
of
Do
lla
rs
2004
Total Shortfallin 2004: $22 Billion
Hospitals face a growing payment shortfall from Medicare and Medicaid.
91%
21%
Physician-owned Limited ServiceHospitals*
All Community Hospitals
Chart 21:Percent of Hospitals with an Emergency Department*, Physician-owned Limited-service Hospitals versus All Community Hospitals, 2003
Source: Centers for Medicare & Medicaid Services, Study of Physician-owned Specialty Hospitals Required in Section 507(c)(2) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, 2005. AHA Annual Survey, 2003. *Hospitals treating more than 5% of cases in emergency department.
The majority of physician-owned limited-service hospitals do not provide the 24/7 standby role…
…and provide relatively less care to low income populations.
Chart 22:Medicaid as a Percent of All Patient Discharges, 2002
15%
1%
4%
Heart Hospitals Orthopedic Hospitals Community Hospitals
Source: Medicare Payment Advisory Commission, Physician-owned Specialty Hospitals, March 2005.
Physician-owned
Source: Verispan’s Diagnostic Imaging Center Profiling Solution, 2004.*2005 values are estimated based upon current trends.
Chart 23:Percent of Outpatient Surgeries by Facility Type, 1981 – 2005
0%
20%
40%
60%
80%
100%
81 83 85 87 89 91 93 95 97 99 01 03 05*
Hospital-based Facilities 45%
FreestandingFacilities 38%
Physician Offices 17%
Outpatient surgical care is shifting from hospitals to other settings.
