Health Economics Program

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1 Health Economics Program Issue Brief February 2006 Health Conditions Associated With Minnesotans Hospital Use Health care spending by Minnesota residents accounts for approximately 12% of the state s economy and about twenty percent of total health care spending goes to purchase hospital inpatient care for state residents. This issue brief broadly describes the mix of health conditions that were associated with Minnesotans hospital use in Among the primary findings: Eight of the 25 major groups of health conditions, or major diagnostic categories (MDCs), were associated with 76% of hospital claims during 2003 and 73% of all patient days of care provided. The top five MDCs accounted for 50% of all 2003 patient days of care provided to Minnesotans: Diseases and disorders of the circulatory system were associated with 12% of total patient days; Mental diseases and disorders were 10%; Just under 10% of all patient days were provided to newborns and sick neonates; Diseases and disorders of the digestive system were responsible for 9%; 9% of all patient days were associated with musculoskeletal problems. linked to the presence of complicated or preexisting comorbid diagnoses. Average length of stay ranged from 2.6 days for conditions related to pregnancy and childbirth to 7.7 days for those diagnosed with a mental health condition. Patients with complicated diagnoses had longer average lengths of stay than those without them. Methods For this analysis, we used Minnesota resident insurance claims billed by 119 hospitals operating in the state during calendar year Claims were categorized into major diagnostic categories (MDCs), which is a way of grouping the discrete ICD9-CM diagnosis codes used for hospital billing and utilization analysis that appear upon each claim. The diagnoses in each MDC generally correspond to a single major organ system within the human body. 2 Health Conditions Responsible for Hospital Inpatient Utilization Table 1 ranks the top eight broad medical conditions (MDCs) associated with the bulk of hospital patient days of care used by Minnesota residents during These eight categories were responsible for 76% of all claims, and 73% of the patient days of care Across all major diagnosis categories, 26% of the total patient days of care provided were h ealth e conomics p rogram Minnesota Department of Health

2 provided. The first five condition categories alone were responsible for half of the total patient days. Patients with complicated and/or comorbid diagnoses 3 accounted for 26% of all patient days (Table 2) and stayed in the hospital longer, on average, than patients without complex conditions, 4.5 versus 3.7 days (Table 3). Table 1 Number of Inpatient Claims and Patient Days by Major Diagnostic Category, 2003 Major Diagnostic Category Number of Claims Number of Days Claims Days Circulatory System 75, , % 11.7% Mental Diseases & Disorders 27, , % 10.2% Newborns & Neonates with Problems 63, , % 9.6% Digestive System 47, , % 9.4% Musculoskeletal & Connective 54, , % 9.3% Respiratory System 42, , % 8.8% Pregnancy & Childbirth 68, , % 8.6% Nervous System 27, , % 5.3% All Else (17 categories) 130, , % 27.0% Total 537,463 2,094, % 100.0% Source: Minnesota Hospital Discharge Dataset of participating hospitals CY 2003, Minnesota residents only Care provided to Minnesota residents with circulatory system conditions accounted for nearly 12% of all patient days and 14% of all claims during 2003, ranking first in Table 1. Average length of stay for Minnesota patients in this MDC without complications or comorbidities was 3.1 days compared to 3.7 days to those with them (Table 3). Table 2 shows that patients with complicating diagnoses and/or comorbidities were associated with 24% of the patient days within this category. Among the numerous surgical services provided within this first ranked MDC were percutaneous cardiovascular interventions, cardiac device implants, coronary artery bypass surgeries, and valve replacements, for example. The most prevalent medical condition (non-surgical) within this MDC was a diagnosis of heart failure and cardiogenic shock, which accounted for 16% of all the circulatory system-related patient days of care. Table 2 Share of Inpatient Claims and Patient Days with Complications and/or Comorbidities, 2003 With Complications and/or Comorbidities Major Diagnostic Category Claims Days Circulatory System 20.5% 23.7% Mental Diseases & Disorders n.a* n.a* Newborns & Neonates with Problems n.a* n.a* Digestive System 58.6% 74.3% Musculoskeletal & Connective 18.8% 22.1% Respiratory System 43.3% 46.2% Pregnancy & Childbirth 5.5% 9.8% Nervous System 25.4% 31.4% All Else (17 categories) 31.0% 29.3% Total 22.9% 26.3% Source: Minnesota Hospital Discharge Dataset of participating hospitals CY 2003, Minnesota residents only * n.a. = not applicable. Some MDCs by definition contain no DRGs with complications and/or comorbidities 2

3 Table Average Length of Stay (ALOS) by Major Diagnostic Category: Patients With and Without Complications and/or Comorbidities Major Diagnostic Category Complications and/or Comorbidities (CC) ALOS Without CC Source: Minnesota Hospital Discharge Dataset of participating hospitals CY 2003, Minnesota residents only n.a. = not applicable. ALOS With CC Overall ALOS Total Circulatory System Mental Diseases & Disorders 7.7 n.a 7.7 Newborns & Neonates with Problems 3.2 n.a 3.2 Digestive System Musculoskeletal & Connective Respiratory System Pregnancy & Childbirth Nervous System All Else (17 categories) Total Mental diseases and disorders, ranked second in Table 1, were associated with slightly over 10% of the patient days provided by Minnesota hospitals to state residents in While the patient day volume was high, this MDC accounted for only 5% of all claims. The overall average length of stay for the MDC was 7.7 days (Table 3). Psychoses accounted for nearly 79% of total patient days associated within this MDC and lengths of stay averaged around 8.7 days (not shown). Ranking third, Table 1 shows that conditions specific to newborns and neonates with problems were associated with over 9% of all Minnesota resident patient days and nearly 12% of all claims. This category includes all newborns, from normal full-term neonates, to full-term neonates with major problems, and premature neonates as well as those at low birthweight. 5 While the number of patient days ranks high in this category due to the large volume of births within the state, it is also important to recognize that the care provided included some of the most intensive, high tech, and expensive hospital care available, especially at facilities equipped with neonatal intensive care units. It is this combination of the number of births and need for neonatal intensive care that accounts for the patient day volume. Normal newborns accounted for 74% of the claims in this MDC and 49% of patient days. Neonates with various gestational age, respiratory, or delivery-related problems were associated with 26% of claims and 51% of MDC patient days. The average length of stay for normal newborns was 2.1 days in 2003 versus 6.2 days for neonates with problems (not shown). Diseases and disorders of the digestive system ranked fourth in Table 1, accounting for slightly more than 9% of total patient days in 2003, and just under 9% of all claims. Of the patient day total within the category, the largest shares were for major small and large bowel procedures; followed by treatment of esophagitis, gastroenteritis, and other miscellaneous digestive disorders; and gastrointestinal hemorrhage with complications and/or comorbidities. Table 2 shows that cases including complications and/or comorbidities were associated with 74% of the patient days within the category. Average lengths of stay for Minnesota patients without complex diagnoses in this MDC were 2.6 days compared to 5.2 days for those with them (Table 3). 3

4 In fifth rank on Table 1 were diseases and disorders of the musculoskeletal system and connective tissue. These conditions were associated with 10% of the claims Minnesota hospitals filed on behalf of state residents and 9% of all patient days. Thirty one percent of the MDC patient day volume was a result of major joint and limb reattachments of the lower extremities (in other words, joint replacements, or revisions, to patients hips, knees, and ankles), a share that was four times higher than the next ranked DRG, medical back problems. According to Table 3, average length of stay for patients in this MDC without complications and/or comorbidities was 3.5 days versus 4.2 days for patients with the complex conditions. Table 2 shows that only 22% of the MDC patient days resulted from patients with complicating diagnoses and/or comorbidities. Nearly 9% of all patient days and 8% of all claims in 2003 were associated with the treatment of respiratory system conditions, the MDC occupying the sixth rank on Table 1. Patients without complications and/or comorbidities in this MDC stayed in the hospital an average of 4.1 days while those with the greater clinical complexity remained 4.6 days (Table 3). Patients with more clinical complexity were responsible for 46% of the patient days consumed within the MDC (Table 2). Two conditions were responsible for the largest shares of the hospital stays in this category. Simple pneumonia and pleurisy among adults was responsible for 25% of category patient days, followed by patients suffering from chronic obstructive pulmonary disease 12%. Services provided to women during pregnancy, childbirth, and recovery ranked seventh in patient day volume during Table 1 shows that this MDC was associated with just under 9% of all patient days and almost 13% of all claims. The claim and patient day volumes associated with this category are high, not only due to the large number of pregnancies in the state, but also due to the care provided women experiencing high-risk pregnancies, complications of pregnancy (e.g. gestational diabetes or hypertension), those receiving Cesarean sections, and assorted postpartum conditions. Vaginal delivery without a complicating diagnosis accounted for nearly 46% of the patient days in this MDC, followed by C-Sections at over 22% of the MDC volume. Average length of stay displayed in Table 3 for noncomplex cases was 2.5 days compared with 4.7 days for women with complicating diagnoses and/or comorbidities. The average hospital stay for a normal vaginal delivery without complicating diagnoses was 2.1 days while women receiving C-sections without additional complications and/or comorbidities stayed 3.7 days. Complicated and/or comorbid diagnoses accounted for just under 10% of MDC patient days. Nervous system conditions, which included diagnoses of stroke, coma, viral meningitis, headache, and concussion, for example, were ranked eighth in Table 1. They accounted for 5% of the patient days provided to Minnesota residents during 2003 and 5% of all claims. Within this MDC, three more specific conditions were responsible for nearly 39% of the category s patient day count. They were: intracranial hemorrhage and stroke with infarction; craniotomy for persons over age 17 with complications and comorbidities; and degenerative nervous system disorders. The stroke category accounted for 18% of the MDC s patient day total. Table 3 reveals that patients with no complicating diagnoses and/or comorbidities stayed in the hospital an average of 3.8 days while those with the more complex conditions remained an average of 5.1 days. Thirty-one percent of patient days in this category resulted from complex diagnoses (Table 2). Conclusions Overall inpatient hospital utilization and spending are influenced by several factors: The prevalence of common clinical conditions; The length of time patients stay in the hospital; The presence or absence of preexisting comorbid conditions; 4

5 Unexpected complications that may occur during a hospital stay; The level of technology employed in treatment. The combination of all of these factors determines overall inpatient hospital utilization and spending. Endnotes 1 Admissions to these 119 out of 134 acute care hospitals represent 89% of all patient admissions in the state. Two subacute hospitals, Bethesda and Valley Hospital at Hidden Lakes, all federal hospitals (VA and PHS Indian facilities), the state hospital in St. Peter, state regional treatment centers, and the Shriners Hospital for Children are excluded from the total count. 2 A few MDCs, however, depart from this schema to reflect specific types of injury, multiple significant trauma, burns, HIV infection, substance abuse, miscellaneous contacts with the health care system, and categories for invalid diagnosis codes. 3 The Centers for Medicare and Medicaid Services (CMS) define comorbidity as a preexisting condition, which because of its presence increases the length of hospital stay by at least one day in approximately 75% of the cases. A complication is a condition that occurs during the hospital stay, adding at least one day in approximately 75% of the cases. 4 All newborns delivered in hospitals are counted as inpatients from delivery until discharged. Insurance claims are generated for each infant and include nursery charges, plus any therapies or procedures performed, such as circumcision or bilirubin light therapy, for example. 5

6 The Health Economics Program conducts research and applied policy analysis to monitor changes in the health care marketplace; to understand factors influencing health care cost, quality and access; and to provide technical assistance in the development of state health care policy. For more information, contact the Health Economics Program at (651) This issue brief, as well as other Health Economics Program publications, can be found on our website at: Minnesota Department of Health Health Economics Program 85 East Seventh Place, P.O. Box St. Paul, MN (651) Upon request, this information will be made available in alternative format; for example, large print, Braille, or cassette tape. Printed with a minimum of 30% post-consumer materials. Please recycle.