Massachusetts Community Hospitals - A Comparative Economic Analysis

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1 Massachusetts Community Hospitals - A Comparative Economic Analysis Rising Demand vs. Falling Profitability By Edward Moscovitch Prepared for the Massachusetts Council of Community Hospitals October

2 INTRODUCTION AND SUMMARY These are hard times for community hospitals in Massachusetts. The majority are losing money and have been for several years. Competing as they do with the near-by teaching hospitals in downtown Boston, the community hospitals are under pressure from their patients to provide the most modern equipment and facilities. The Massachusetts Council of Community Hospitals (MCCH) has asked Cape Ann Economics to update earlier studies that use data available for all U.S. hospitals to compare hospital utilization, costs, revenues, and capitalization in Massachusetts with comparable data for other states, and to use data over several years to identify important trends over time. The publicly available portion of the biannual survey of the American Hospital Association provides data on hospital beds, admissions, length of stay, outpatient procedures, and total costs for virtually all hospitals in the country. The Medicare cost reports include Medicare and non-medicare costs, charges, and revenues, as well as hospital capital ratios and annual profit and loss statements. To compare Massachusetts community hospitals with their counterparts elsewhere, the study separates teaching from community hospitals and then calculates aggregate data comparing Massachusetts community hospitals, taken as a whole, with community hospitals elsewhere. Key Findings Capacity utilization at Massachusetts hospitals is significantly higher than in the rest of the country The number of hospital beds (teaching and community) in Massachusetts in relation to state population is in line with national averages Projected increases in the population 65 and over will almost certainly to lead to a major increase in the need for hospital beds in Massachusetts over the next 25 years Over the last few years, the entire increase in hospital admissions in Massachusetts has occurred at teaching hospitals Roughly half of all admissions in Massachusetts are to teaching hospitals roughly 2 1/2 times the national average. Profitability at community hospitals in Massachusetts is markedly lower than at comparable hospitals in other states Unlike hospitals elsewhere in the country, Massachusetts hospitals make money on their Medicare business. 1

3 Medicare profits in Massachusetts are more than matched by losses on non-medicare business, primarily HMOs and Medicaid Adjusted for differences in wages and severity, community hospital costs per adjusted discharge in Massachusetts are significantly lower than costs elsewhere in the country. Despite these low costs, Massachusetts community hospitals lose money because non-medicare revenue per adjusted discharge is so much lower than in other states. Massachusetts community hospitals are under capitalized; assets per hospital day are lower than elsewhere in the country 2

4 PART 1 - HOSPITAL CAPACITY & UTILIZATION Beds, Admissions, and Length of Stay Massachusetts is not over-bedded; counting both teaching and community hospitals, Massachusetts has fewer beds per thousand population than the rest of the country 2.2 per thousand here as against 2.4 elsewhere, as shown in the chart below. Hospital Beds per 1,000 Population Trends since 1991, Community and Teaching Acute-Care Hospitals MA Rest of U.S. Beds per Thousand Source - AHA Surveys of U.S. Hospitals In the twelve years from 1991 to 2003, Massachusetts has experienced a greater reduction in hospital beds than other states, going from slightly above the nation in beds per capita to slightly below. The table below compares Massachusetts hospitals to those elsewhere in the U.S. for a variety of utilization measures. Since we re interested in overall utilization, the table includes teaching as well as community hospitals. 3

5 Hospital Utilization - MA vs. U.S. Change MA Relative to U.S Per Thousand Population Hospital Beds Massachusetts % -11.4% 3.6% -9.8% Rest of U.S % -11.2% In Patient Admissions Massachusetts % 2.1% 11.0% 1.5% Rest of U.S % 5.8% In Patient Days Massachusetts % 1.7% 15.2% 2.3% Rest of U.S % -0.7% Length of Stay Days Massachusetts % -0.3% 3.7% 0.8% Rest of U.S % -6.1% Occupancy Rate Per Cent All Hospitals Massachusetts 67.5% 66.3% 65.7% 64.5% 70.4% 72.0% 74.0% -4.6% 14.8% 11.2% 13.5% Rest of U.S. 60.7% 59.8% 58.8% 58.4% 60.6% 61.6% 65.2% -3.9% 11.8% Community Hospitals Massachusetts 62.4% 61.9% 61.4% 59.2% 64.5% 66.7% 68.0% -5.0% 14.8% 8.7% 8.7% Rest of U.S. 57.4% 56.4% 55.5% 55.4% 57.6% 58.6% 62.6% -3.5% 13.0% Source - U.S. Census Estimates of Population; AHA Surveys of American Hospitals The four columns at the right of the table summarize trends in each variable. The number of beds (per thousand population) fell by 27.6% in Massachusetts from 1991 to 1997, and by another 11.4% from 1997 to 2003, as against reductions of 17% and 11.2% elsewhere in the country. As a result, beds per capita in Massachusetts went from 3.6% above the country in 1991 to 9.8% below 12 years later. Inpatient admissions in Massachusetts have also fallen markedly down 10.6% from 1991 to 1997 (but up 2.1% since 1997) as against virtually no change elsewhere. As a result, hospital admissions in Massachusetts in 2003 (in relation to population) were only 1.5% above the national average, down from 11% above 12 years earlier. From 1991 to 1997, total inpatient days in Massachusetts fell 30.9% - a greater reduction than in admissions or in beds. As a result, length of stay and occupancy rates (shown in the lower portion of the chart) fell as well. Since 1997, length of stay has leveled off, the total number of days has risen slightly, while the number of beds has fallen. In 2003, admissions, days, and length of stay in Massachusetts were only barely above national levels. The perception that Massachusetts inpatient hospital utilization is out of line with national norms, then, is now about 10 years out of date. Hospital Occupancy Rates & Capacity Constraints The reduction in hospital beds continued after 1997, even while the number of inpatient days began to rise slightly. Fewer beds but more hospital days translate into higher occupancy 4

6 rates and capacity constraints. Looking only at community hospitals, occupancy rates have risen by 14.8% since While the increase in occupancy rates in Massachusetts is not out of line with the rest of the country, occupancy rates were already significantly higher here than the national average in 1991, so that occupancy rates are now reaching levels where availability of beds for medical emergencies is becoming an issue. Hospital Bed Occupancy Rate Trends since 1991, Community Hospitals InPatient Days per Staffed Bed 70% 65% 60% 55% 50% 45% 40% 62% 57% 62% 56% 61% 56% MA Rest of U.S. 59% 55% 64% 58% 67% 59% 68% 63% 35% 30% Source - Calculated from American Hospital Association Surveys The trend in occupancy rates (inpatient hospital days in relation to staffed hospital beds) is shown in the chart above. Occupancy rates by state are shown in the map below. 1 The increase is from an occupancy rate of 59.2% to a rate of 68%, or 8.8% of available bed-days. Expressed in terms of the initial rate of 59.2%, this translates into a 14.8% increase over the initial occupancy rate (68 is equal to 114.8% of 59.2). 5

7 Community Hospital Occupancy Rate InPatient Hospital Days Divided by 365 times staffed Hospital Beds Occcupancy Rate 0-50% 50% - 55% 55% - 60% 60% - 65% 65% - 70% > 70% Miles While Massachusetts occupancy rates aren t quite the highest in the country, 40 states have lower rates, and 32 states have significantly lower average occupancy rates below 60%. By contrast, only California, at 88%, has an occupancy rate much higher than Massachusetts. The other states with high rates range from Massachusetts 68% to Maryland s 72%. The average occupancy rate doesn t tell us how many hospitals are at uncomfortably high occupancy rates. As we see in the chart below, 60% of Massachusetts community hospitals in 2003 had occupancy rates of 60% or higher as opposed to only 30% of community hospitals elsewhere. 6

8 Hospital Capacity Utilization, MA and other U.S. Percent of Teaching and Community Hospitals at various capacity levels, % 45% 40% MA - Community MA - Teaching Other - Community Other - Teaching Percent of Hospitals in Group 35% 30% 25% 20% 15% 10% 5% 0% < 40% 40-50% 50-60% 60-70% 70-80% > 80% Source: - Calculated from AHA Hospital Capacity Utilization Hours per Month Diversion Diversion vs Hospital Capacity - MA Average Days per Month on Diversion vs Capacity Utilization Diversions - July 02 th N 03 Community Teaching Each bubble represents one hospital; bubbles are sized according to the number of hospital beds 30% 40% 50% 60% 70% 80% 90% 100% Percent of Beds Filled Sources: Diversions - MA Dept of Public Health; Occupancy - AHA Surveys We don t have national data on diversions, but the data from Massachusetts shows that when the occupancy rate reaches 60%, many community hospitals have to divert patients seeking emergency care, as shown in the chart at left. None of the hospitals with occupancy below 60% had any significant diversions, while several hospital with occupancy rates above 60% had to turn patients away several times each month. It is not unreasonable to conclude from this data that any further increase in occupancy rates if the number of beds continues to fall and hospital usage levels off or begins to rise risks 7

9 a significant increase in the number of times hospitals are unable to accept patients needing emergency treatment. 8

10 PART 2 - PROJECTING HOSPITAL DEMAND THE COMING MEDICARE BOOM Rising Medicare Demand as the Baby Boomers Reach 65 As we ve seen, the decline in hospital utilization (defined as inpatient days per thousand population), both in Massachusetts and around the country, came to an end in the late 1990s, and increased slightly from 1997 to Overall hospital utilization depends not only on medical practice, but also on the age composition of the population, since hospital utilization by people over 65 is roughly 6 times as high as amongst people under 65. The coming of age of the baby boom generation will increase dramatically the percentage of the population 65 and over. This, in turn, will almost certainly lead to a large increase in hospital days, both in Massachusetts and in the U.S. Massachusetts Population - Over & Under 65 Cenus Population Projections Thousands of Persons 6,000 5,000 4,000 3,000 2, Under 65 5,189 5,367 Actual 5,576 Projected 5,733 5,549 1, , , Census population figures for Massachusetts, with the population broken out between those over and under 65, are shown in the chart above. From 1991 to 2003, the population under 65 increased by 7.5%, while the population of seniors grew 3.3%. Census projections for Massachusetts population expect this pattern to reverse, with the under 65 population falling slightly by.5% - from 2003 to 2030, while the population over 65 increases by 71%, rising from 857,000 in 2003 to 1,463,000 by The AHA surveys separate Medicare hospital days from other hospitalizations; this effectively tells us how many hospital days are used by persons over and under 65. Comparing 9

11 this utilization with the population over 65 allows us to make projections of future hospital use that reflect the dramatically changing age composition of the population. Since 1997, hospital utilization days per thousand has been roughly constant, both for seniors and for those under 65. This has been true in Massachusetts and in the country generally. It is reasonable, then, to project future usage by assuming that these utilization rates remain unchanged over the next few years. Projections - Population by Age, Hospital Days Actual Projected % Inc Medicare MA Pop >65-000s ,025 1, % Medicare In Patient Days - 000s 1,773 1,614 1,875 1,890 2,261 3, % Days per Thousand Population 2,063 1,880 2,181 2,205 2,205 2, % Other U.S. Pop >65 - Mns % Medicare In Patient Days - Mns % Days per Thousand Population 2,206 2,097 2,216 2,214 2,214 2, % Non-Medicare MA Pop <65-000s 5,367 5,459 5,540 5,576 5,733 5, % Non-Medicare In Patient Days - 000s 1,808 1,967 1,911 1,875 1,927 1, % Days per Thousand Population % Other U.S. Pop <65 - Mns % Non-Medicare In Patient Days - Mns % Days per Thousand Population % Sources - Population Projection - U.S. Census; Hospital Days - AHA Survey Projections based on this assumption are laid out in the table above. The first set of rows gives data for Medicare utilization in Massachusetts. In 2003, the AHA survey reported 1,890,000 Medicare days in acute-care hospitals; this amounted to 2,205 days per thousand seniors in Massachusetts. This figure is virtually identical to the rest of the U.S. 2,214. This represents a slight increase since 1997 for Massachusetts, but there was almost no change in Massachusetts from 2001 to 2003, and almost no change in the rest of the U.S. from 1997 to Assuming this days-per-thousand ratio remains unchanged over the next 25 years, and applying it to the projected senior population, we can calculate a likely demand for Medicare hospital days of 3,226,000 by 2030 an increase of 70.7% over Similar calculations show virtually no change in the demand for non-medicare hospital days. Projecting the Increase in Hospital Days Overall hospital days in Massachusetts are shown in the chart below, broken out between community and teaching hospitals. 10

12 Massachusetts Total InPatient Hospital Days Trends since 1991 and projections to Teaching vs Community Thousands of Days 6,000 5,000 4,000 3,000 2,000 56% 3,013 59% 2,923 Community Additional Days Actual Teaching 53% Community Per Cent Hospital Days 54% 51% 51% 49% 2,141 1,939 1,946 1,841 1,860 Projected 1,860 1,860 1, ,000 2,377 2,067 1,929 1,641 1,739 1,839 1,904 1,904 1, Total hospital days in Massachusetts fell from 5.4 million in 1991 to 3.8 million in 2003 a drop of 30%. By 2030, hospital days will return essentially to 1991 levels 5.1 million days. The chart also shows that the community hospital share of total days peaked at 59% in 1993, and has since fallen to 49%. Since 1997, teaching hospitals have added 263,000 days, while community hospital volume has fallen by 79,000 days. Compared to 2003 levels, Massachusetts hospitals will have to find an additional 433,000 days by 2015 and an additional 1.3 million days by Since the entire increase in hospital volume over the coming 25 years will be in Medicare, we take a closer look at the trend in Medicare hospital days in the chart below. Seniors are more likely to be treated in community hospitals than are younger patients; nonetheless, the community share of Medicare hospital days fell from 63% in 1991 to 56% 12 years later and community hospital Medicare volume fell over this period by 56,000 days. The projected increase in Medicare days 1.3 million additional days per year far exceeds the current activity of either community or teaching hospitals (1.06 and.83 million, respectively). 11

13 Massachusetts Medicare InPatient Hospital Days Teaching vs Community Thousands of Days 3,500 3,000 2,500 2,000 1,500 1,000 63% 1,114 Community, Medicare Additional Days Teaching, Medicare 947 1,105 Actual Community Per Cent of Medicare Days 59% 56% 59% 1,056 Projected 1, ,056 1, How Many More Beds Will We Need? To provide these extra inpatient days, Massachusetts hospitals will have to build (and finance) thousands of new beds. From 1991 to 2003, 30% of Massachusetts hospital beds were closed, and the total fell from 20,300 to 13,900. To meet the rising Medicare demand, Massachusetts hospitals will have to add back almost all of the days lost 5,100 additional beds! These projections are laid out in the table below, and are made separately for community and teaching hospitals. The calculations start with the total number of hospital days, both Medicare and non-medicare, and translates these into bed requirements by looking at occupancy rates. The projected total days 4.2 million in 2015 and 5.1 million in 2030 are the same as shown in the chart on Page 9. The projections assume that the additional Medicare days are split evenly between community and teaching hospitals, which means little change in the market shares prevailing in

14 Actual Projected % Inc Projections - No change in 2003 occupancy rates Community Hospitals Days - 000s 1,939 1,841 1,946 1,860 2,077 2, % Occupancy Rate 59% 64% 67% 68% 68% 68% 0.0% Beds 8,970 7,825 8,000 7,496 8,368 10, % Teaching Hospitals Days - 000s 1,641 1,739 1,839 1,904 2,121 2, % Occupancy Rate 72% 78% 79% 81% 81% 81% 0.0% Beds 6,247 6,104 6,399 6,438 7,170 8, % Total Massachusetts Days 3,580 3,580 3,786 3,764 4,197 5, % Total Massachusetts Beds 15,217 13,929 14,399 13,934 15,538 18, % Community Hospitals Occupancy Rate 63% 63% -8.0% Beds 9,096 11, % Teaching Hospitals Occupancy Rate 77% 77% -4.7% Beds 7,521 9, % Total Massachusetts Beds 15,217 13,929 14,399 13,934 16,617 20, % Source - Calculated from AHA Surveys Projections - Massachusetts Hospital Beds Projections - Move to 2003 national occupancy rates The top half of the table assumes that occupancy rates remain at current high levels. At 68% occupancy, for example, community hospitals will need 10,196 beds by 2030 to accommodate 2,530,000 inpatient days an increase of 36% from current levels. 2 The lower half of the table assumes that we build enough beds to reduce occupancy rates to levels prevailing in the rest of the country in This would mean reducing community hospital occupancy from 68% to 63%, and teaching hospital occupancy from 77% to 74%. Under this assumption, Massachusetts will need 20,200 beds in 2030 the same total as we had in This would require an increase of almost 50% in community hospital beds 3,600 additional beds - and an increase of almost 42% at teaching hospitals. These trends are shown graphically in the chart below: 2 There are 365 days in the year; at 68% occupancy each bed provides 248 days a year. At this rate, it takes just over 10,000 beds to produce 2.5 million days. 13

15 Beds 22,000 21,000 20,000 19,000 18,000 17,000 16,000 15,000 14,000 13,000 12,000 20,314 Massachusetts Hospital Beds All Hospitals; Projections based on Projected Days 19,328 16,380 15,217 Occupancy Rates U.S. Occupancy Rates Actual 13,929 14,399 13,934 16,617 15,538 20, ,899 Accommodating the extra Medicare patients will require major increases at both community and teaching hospitals. This represents a particularly dramatic reversal for community hospitals, as shown in the chart below. Projected Massachusetts Hospital Bed Needs Teaching and Community Hospitals; Based on Lower Projections (74% Occupancy) Beds 14,000 12,000 10,000 8,000 6,000 4,000 5,721 14,593 4,916 14,412 5,215 Assumes increase in beds after 2003 split evenly between teaching and community 11,164 6,247 8,970 6,104 7,825 Teaching 6,399 8,000 Actual Community 6,438 7,496 Projected 7,170 8,368 8,703 10,196 2, Teaching hospitals have been adding beds since 1993, albeit at a much slower rate since Community hospitals lost almost half their beds from 1991 to 1999 and have been essentially level since; the sector has not added beds for a long time. In light of their low prof- 14

16 itability it s hard to see how community hospitals will be able to finance the capacity needed to accommodate projected Medicare demand, as we ll see below. How Much Will the Extra Capacity Cost? The Medicare cost reports provide a detailed accounting of hospital days, admissions, beds, and capital assets. By comparing larger with smaller hospitals (the extra capitalization of the larger hospital and the extra number of days), we can get a reasonable idea of how much additional investment hospitals would have to make to accommodate increased usage. Specifically, a cross-sectional regression was run on the most recent (2002) data for 3,452 community hospitals across the country. 3 It showed a statistically significant relationship between hospital assets on the one hand, and hospital days and discharges on the other. The regression analysis explained 47% of the variation in capital costs across hospitals quite a good fit for such a cross-section analysis of this kind. Interestingly, the statistical fit was better for hospital days and admissions than for hospital beds, which suggests that capital costs are associated more with all the equipment needed to meet patient needs than with the beds per se. Also, days and discharges have a roughly equal impact on capital needs, which means that a good deal of the capital requirement is related to the procedure or operation, regardless of how many days the patient stays in the hospital. The regression also shows that hospital capital needs depend on outpatient volume as well as inpatient days and admissions. 4 As we d expect, the impact of additional outpatient volume on capital needs is somewhat lower than the impact of additional inpatient business. All told, it costs the typical community hospital $11,500 in additional capital to accommodate one additional hospital stay (about 5 days for Massachusetts Medicare patients) per year. The regression results are applied to the projected increase in Massachusetts Medicare hospital volume to calculate the increase in investment required to accommodate the projected increase in Medicare demand. This is done in the table below. 3 The analysis here is cross-sectional that is, it compares larger hospital s capital with that of smaller hospitals, assuming implicitly that if the smaller hospitals grow over time their capital will have to expand to the levels of the larger hospitals. Ideally, we d use time-series analysis, looking at the increase in the capital of particular hospitals as their utilization rises over time. Unfortunately, I have data only for 2000, 2001, and 2002, and data for this period is distorted by changes in stock market prices (which affect total asset volume). The cross sectional analysis is a reasonable, although perhaps not exact, way to measure the underlying relationship. 4 Traditionally, outpatient volume is measured by looking at the ratio of total to inpatient charges. The Medicare data make clear not only that cost-to-charge ratios are different for inpatient and outpatient business, but also that the variation in Massachusetts is not the same as elsewhere in the country. An alternative to the traditional approach an alternative that uses Medicare cost-to-charge ratios is used throughout the paper and explained below in Part 3. 15

17 Capital Cost of Added Medicare Capacity Massachusetts Community Hospitals, Projected Capital Cost Change Per Unit Total Population 's 857 1, Hosp Days per 1, ,214 Medicare Hospital Days 000's 1,890 3,239 1,349 Community 50% Medicare Discharges - 000's Medicare LOS 5.59 Mdr OutP Disch Equivalent - 000s Pct of InPatient Discharges 32% Community Hosp Assets $Mns 4,342 1,689 1,689 Extra Debt 5%, 20 Yr $Mns Total Operating Profit $Mns Total Operating Revenue , As we projected earlier, the increase in Massachusetts elder population will mean an additional 1.35 million Medicare hospital days each year by Assuming that community hospitals provide half these days (roughly their share of current Medicare business), they will have to add capacity for an additional 675,000 days. At the current ratio of 5.59 days per Medicare discharge, this also means an additional 121,000 hospital stays. In 2003, for every 100 Medicare inpatient stays there was Medicare outpatient business equivalent to 32 discharges, so the hospitals would have to provide capacity for 39,000 outpatient discharge equivalents. The rightmost two columns of the table calculate the capital costs. From the regression analysis, we calculate additional capital requirements of $1,210 per additional hospital day, $5,470 per additional hospital discharge, and $5,390 per outpatient discharge equivalent. 5 Applying these unit costs to the projected increases in demand gives us an additional capital requirement of just under $1.7 billion (in 2003 dollars) an increase of roughly 40% over the current capitalization of Massachusetts community hospitals. At first glance, this seems manageable; spread over 25 years, it amounts to an increase of 1.5% per year. Looked at another way, however, the burden is enormous Financed with 5%, 20 year bonds, $1.7 billion of additional capital would require debt service of $135 million a year a large burden indeed when Massachusetts community hospitals as a whole have an operating loss of $28 million a year! Counting investment income and donations, Massachusetts community hospitals had a margin of $16.5 million, barely 10% of the required increase in debt service. The extra $135 million of annual debt service represents about 3% of overall 2002 operating revenues of $4.5 billion. It seems clear that under current financial conditions, Massachusetts community hospitals will be unable to borrow the funds they need to make the investments necessary to accom- 5 An additional hospital stay of five days requires $5,470 for the stay itself (presumably primarily for the procedures involved) plus $1,210 for each day (primarily for the bed and associated daily care), for a total of about $11,500. A shorter stay of, say, 3 days, would require about $9,000 ($5,470 plus $3,630). These figures are roughly twice the impact of an additional discharge equivalent of outpatient care, which requires about $5,390. It seems reasonable that this figure should be essentially identical to the procedure portion of an inpatient stay.

18 modate their half of the likely increase in Medicare business. (And, as we ll see in Part 4, Massachusetts community hospitals are already under-capitalized relative to their peers in other states, suggesting that they ll need to increase investment just to provide care for their current patients that reflects modern medical technology on top of any increase necessary to handle increased volume. At first glance, this may seem like a federal government problem the hospitals need to make a reasonable margin on Medicare business in order to make the investments necessary to handle the increase in Medicare patients. In practice, however, the Medicare and non- Medicare sides of the business are not easily separated. If hospitals fail to add capacity in the face of increased Medicare demand, the result will be higher and higher occupancy rates and lack of emergency room and extra bed capacity at periods of peak demand problems that will affect Medicare and non-medicare patients alike. In any case, lenders won t look separately at Medicare and non-medicare margins. If a hospital is losing money overall, it will have a hard time borrowing to finance additional capacity even if the capacity is for Medicare business and Medicare business by itself is profitable. In the next section, we turn to a discussion of the profitability of Massachusetts community hospitals, as compared to similar hospitals elsewhere in the country. 17

19 PART 3 HOSPITAL PROFITABILITY Medicare vs. Non-Medicare Profitability Massachusetts community hospitalizations are substantially less profitable than community hospitals in the rest of the U.S. The recent trend is shown in the chart below. Operating Profit Trend, 97 to 2002 Community Hospitals, Profit Pct of Operating Revenue 5% 4% 4.5% MA Rest of US 4.1% 4.0% 4.3% 3% 2% 2.1% 2.9% 2.9% 1% 0.3% 0% -1% -0.9% -1.2% -1.7% -0.6% -2% From 1997 to 2001, Massachusetts community hospital operating profits fell from 2.1% of operating revenues to a loss of 1.7%; they recovered slightly in 2002, but the overall operating margin remained at -.6% of operating revenues. 6 Operating profits elsewhere remained at about 4% of operating revenues. Massachusetts hospitals, then, were worse off relative to the rest of the country in 2002 than they had been 5 years earlier. 6 Operating profit is defined as operating revenues minus total costs. In addition to operating revenues, most hospitals have investment income and donated funds. Operating profit is used here as the basic measure of hospital fiscal health in the belief that hospitals should receive at least as much revenue from patient care as it costs to deliver. 18

20 Community Hospital Operating Profits Percent of Operating Revenues Total MA 2.1% 0.3% -0.9% -1.2% -1.7% -0.6% Other US 4.5% 2.9% 4.1% 2.9% 4.0% 4.3% Medicare MA 16.3% 12.2% 10.9% 5.1% 8.8% 6.0% Other US 11.9% 8.3% 6.6% 2.7% 3.4% -0.1% Non-Medicare MA -5.4% -5.1% -5.9% -3.8% -6.3% -3.5% Other US 1.1% 0.7% 3.1% 3.0% 4.3% 6.0% Percent of Hospitals with Profits < 2.5% MA 68% 70% 77% 78% 78% 78% Other US 51% 61% 62% 61% 56% 56% Percent of Hospitals with Profits < 0% MA 33% 46% 46% 63% 62% 52% Other US 37% 46% 47% 44% 40% 39% These results are spelled out in the table at left. The overall profit rates conceal some very important differences between Medicare and non- Medicare margins. Massachusetts hospitals had a positive margin of 6.0% on their Medicare business in 2002, but lost 3.5% on their other business. 7 This was in stark contrast to hospitals elsewhere, which essentially broke even on their Medicare business but had a positive 6.0% margin on non-medicare business. Trends in Medicare and non- Medicare profitability are illustrated graphically in the chart below. Operating Profit Trend, 97 to 2002 Community Hospitals, Medicare vs non-medicare 20% 15% 10% 5% 0% -5% 16% -5% 12% 1% 12% -5% 8% 1% 11% -6% 7% 3% 5% MA Medicare MA Other Rest of US - Medicare Rest of US - Other -4% 3% 3% 9% -6% 3% 4% 6% -4% 0% 6% -10% Massachusetts community hospitals have been losing money consistently on their non- Medicare business, with the losses essentially constant in the -4% to -6% range. The worsening of their overall profitability over time is the result of a fall in Medicare margins, from a very high 16% of Medicare revenues in 1997 to 6% in Medicare accounts for only 30% of total community hospital revenue in Massachusetts. 19

21 Medicare profitability in other states has been consistently lower than in Massachusetts, and has fallen from 12% in 1997 to 0% in Unlike hospitals here, however, community hospitals elsewhere have increased their margin on other business (HMOs, private insurers, and Medicaid) from only 1% in 1997 to 6% in The rising non-medicare margins have offset falling Medicare returns, so that as we ve seen overall margins have remained essentially constant. Community Hospital Operating Profit as Pct of Operating Revenue, 2002 Profit Pct < -1% -1% to 0% 0% to 2% 2% to 4% 4% to 6% 6% to 8% > 8% The extent to which Massachusetts community hospitals profitability falls below much of the rest of the country is shown in the map above. In only a handful of states are community hospitals as a whole losing money. State average profit rates conceal important differences between hospitals. Another important measure would show the percentage of hospitals that are making less than a modest 2.5% margin on operating revenues. The greater the percent of hospitals with such small margins, the greater the likelihood of hospital closings and overcrowded emergency rooms and hospital floors. 20

22 As shown in the dotted lines in the chart at right, the percent of community hospitals Community Hospitals Losing Money As Percent of All Community Hospitals in Region losing money in Massachusetts 65% was virtually the same MA - Hosps as in the U.S. as a whole 60% 62.7% 62.0% from 1997 through 1999 (just under half), but jumped 55% US - Hosps up to 62.7% in 2002 and remained substantially 50% higher in 2002 (52.2% of 46.3% 46.4% 47.3% Massachusetts community 45% 45.8% 44.1% hospitals vs. 39.4% elsewhere.) 40.0% Another way to 40% look at the data is that the percent of hospitals losing 35% money outside Massachusetts is up only slightly in 30% 36.7% 33.3% five years, while the percent in Massachusetts is up sharply (from 36.7% in 1997 to 52.2% in 2002). A more comfortable margin would be 2.5% or more. Few Massachusetts hospitals reach this level; fully ¾ of Massachusetts community hospitals (78%) have operating margins of 2.5% or less, up from 68% five years ago and higher than the national figure of 56%. 52.2% 39.4% Revenue and Cost per Adjusted Discharge It s helpful to understand hospital revenues and costs in relation to hospital volume that is, how much do hospitals spend per unit of service and how much revenue do they receive? The traditional measure of overall hospital volume is adjusted discharges, with adjusted referring to a calculation in which outpatient business is converted to inpatient discharge equivalents. The industry standard calculation of adjusted discharges takes inpatient discharges and adjusts them upward by the ratio of total hospital charges to inpatient charges. As indicated above, our analysis of Medicare cost to charge ratios indicates that this definition is misleading, particularly when comparing Massachusetts hospitals to those elsewhere in the country. Accordingly, we ve developed a modified definition of adjusted discharges, based on the ratio of total to inpatient costs, where Medicare cost-to-charge ratios for both inpatient and outpatient activity are applied to all charges to impute inpatient and outpatient costs. This process is described in more detail in Appendix Two; for now, we turn to an analysis of revenue and cost in relation to our modified definition of adjusted discharges. Revenue and cost per adjusted discharge are shown in the chart below, for community hospitals in Massachusetts and in the rest of the U.S. To make the data comparable between Massachusetts and other states, both revenues and cost numbers are indexed to reflect differences in wages and in severity. The severity adjustment is described in detail in Appendix three below; the calculation adjusts the raw data down slightly to compensate for higher than aver- 21

23 age Massachusetts wages and up slightly to compensate for the lower severity of illness of patients in Massachusetts community hospitals. 8 As we d expect given the prospective nature of the Medicare reimbursement system, Massachusetts and non-massachusetts Medicare revenue per adjusted discharge are practically identical, once account is taken of differences in wages and severity. Revenues, Costs per Adjusted Discharge Community Hospitals, Revised Discharge Calculation Dollars per Adjusted Discharge 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 7,236 6,638 6,824 8,382 7,705 7,326 Medicare Revenue non-med Revenue Cost 0 Mass Source: Calculated from Medicare Cost Reports Rest of US Non-Medicare revenue per adjusted non-medicare discharge, however, is strikingly lower in Massachusetts than elsewhere only $6,638 vs $8,382 elsewhere in the country. The revenue Massachusetts community hospitals receive for Medicaid, HMO, self-paying, and other insured non-medicare patients is some 21% below what hospitals elsewhere receive for comparable care (again taking into account differences in wages and severity). Contrary to the popular perception that Massachusetts hospitals are high cost, the chart also shows that Massachusetts community hospital costs are significantly lower 11% - than costs elsewhere. Massachusetts hospitals have responded to their very low non-medicare revenue by cutting their costs well below national levels. Since Medicare is a prospective reimbursement system, Massachusetts hospitals Medicare receipts are not cut back to reflect these reduced costs, and Medicare margins are therefore higher than in the rest of the country, as we ve 8 Unadjusted Medicare revenue per adjusted discharge is 9% lower in Massachusetts and elsewhere, but after adjustment to reflect the higher amount Massachusetts hospitals would have received had patient severity matched national levels (and reduced somewhat to reflect what labor costs in Massachusetts would have been at national wage rates), the Massachusetts and national Medicare unit revenues are practically identical 22

24 seen earlier. These lower costs are, however, higher than non-medicare revenues, so Massachusetts hospitals are losing money on their non-medicare business. Since non-medicare patients account for over 70% of community hospital volume, the positive margin on Medicare business is in most cases insufficient to overcome the losses on other business, so most Massachusetts hospitals are losing money despite their low costs. It s different elsewhere in the country; hospitals elsewhere are losing money on Medicare but are making money overall because their non-medicare revenues are higher than costs. 9 Percent of Medicare Revenue Revenues per Adjusted Discharge Non-Medicare as Pct of Medicare, Community Hospitals % Hospitals in most states 35% get substantially more revenue for non-medicare patients than 30% for Medicare 25% 20% 15% 10% 5% 0% -5% Massachusetts community hospitals -10% get 8% less for non-medicare -15% MA Other New Mid-Atlantic Great Lakes California Other U.S. England Source: Calculated from Medicare Cost Reports - Indexed for Severity and Wage Differences -8% 18% -3% 23% One way to understand hospital pricing is to think of Medicare revenues per unit of service as a kind of baseline price, and then to look at other prices in relation to Medicare. In Massachusetts, community hospitals are, in effect, giving an 8% discount to non-medicare payers relative to what Medicare pays. In almost all the rest of the country, however, hospitals charge more to non- Medicare payers, as shown in the chart above. In the rest of New England, the Great Lakes states, and California, for example, the premium charged to non-medicare payers varies from 18% to 42%; it s 17% in the remaining regions. Only in the 3 mid-atlantic states (NY, PA, and NJ) and, of course, Massachusetts, do non-medicare payers have lower rates than Medicare. This analysis underscores what we ve seen earlier community hospitals throughout the country have managed to remain profitable by charging more to non-medicare payers as Medicare rates have fallen. In Massachusetts (unlike the rest of the country), hospitals still make a comfortable margin on Medicare, but lose money overall because their losses on non- Medicare business are so high. The proximate cause of the crisis may be the drop in Medicare revenues, but since Medicare business is profitable in Massachusetts and non-medicare business is not (at least in 2002, the latest year for which comprehensive data is currently 42% 17% 9 In the chart on this page, I ve calculated only total costs per patient, not separating Medicare from non- Medicare costs. The profit margin analysis earlier in the report uses the Medicare accounting system to calculate Medicare from non-medicare costs. 23

25 available), the underlying problem is non-medicare rates substantially below costs and substantially below what is charged in other states. As we ll see below, these low non-medicare revenues have forced unit costs spending per patient - in Massachusetts significantly below national levels. Costs, Revenues per Adjusted Discharge Community Hospitals Indexed for Wages, Severity Massachusetts Medicare Revenue 6,569 6,484 6,485 6,253 6,778 7,236 Non-Medicare Rev 5,795 6,082 6,088 6,299 6,376 6,638 Overall Cost 5,910 6,171 6,247 6,357 6,591 6,824 Other U.S. Medicare Revenue 6,571 6,391 6,454 6,522 7,042 7,326 Non-Medicare Rev 6,902 6,990 7,188 7,427 7,813 8,386 Overall Cost 6,489 6,604 6,683 6,935 7,263 7,705 MA Pct U.S. Medicare Revenue 100% 101% 100% 96% 96% 99% Non-Medicare Rev 84% 87% 85% 85% 82% 79% Overall Cost 91% 93% 93% 92% 91% 89% Not Adjusted Massachusetts Medicare Revenue 6,353 6,075 6,066 5,891 6,360 6,711 Non-Medicare Rev 5,612 5,692 5,690 6,003 5,986 6,172 Overall Cost 5,726 5,790 5,850 6,042 6,199 6,365 Other U.S. Medicare Revenue 6,607 6,416 6,472 6,558 7,061 7,358 Non-Medicare Rev 6,891 6,990 7,191 7,420 7,815 8,384 Overall Cost 6,493 6,612 6,690 6,941 7,271 7,714 Inflation-Adjusted Cost per Discharge (not Adjusted) Massachusetts 7,485 7,109 6,810 6,658 6,463 6,365 Other U.S. 7,861 7,771 7,600 7,590 7,609 7,714 Calculated from Medicare Cost Reports Non-Medicare unit revenues in Massachusetts, however, have been consistently lower than elsewhere, and our hospitals have fallen even farther behind in the last few years (as shown by the green line in the chart). Our non-medicare revenue per adjusted discharge was 13% lower than the rest of the country in 1998; it was 21% lower in Massachusetts community hospitals spend less than hospitals Trends in unit revenues and costs are shown in the table at left. The table shows these unit revenues and costs two ways indexed for wage and severity differences (top half of the table), and unadjusted (bottom half). The indexed numbers are more appropriate when comparing Massachusetts to other states. 10 For all practical purposes, Medicare unit revenues in Massachusetts have been the same as the rest of the country throughout the period (the actual range is from a high of 101% to a low of 96%), as shown in the table, and also in the chart below. 100% 95% 90% 85% 80% 75% Massachusetts Pct of U.S. Revenue, Cost, per Adjusted Discharge - Community Hospitals 100.0% 101.5% 100.5% 87% 95.9% 93% 93% 91% 92% 84% 85% 85% Medicare Revenue non-medicare Revenue Expense 96.2% 91% 82% Indexed for Wages, Severity 98.8% 89% 79% Calculated from Medicare Cost Reports 10 As explained earlier, our unadjusted Medicare revenues are lower than other states, but this is because our case mix is less severe. Were we paying the same wages and treating the same patients, our revenues would have been $7,236 per adjusted discharge in 2002, instead of the $6,711 we actually received. 24

26 elsewhere, when account is taken of severity and wage differences. Actual spending was $6,365 per adjusted discharge, as shown in the table on the previous page. If our unit costs were reduced to reflect what we d pay at (lower) national wage rates, but increased to reflect the cost of (somewhat more seriously ill) patients with severity typical of community hospitals elsewhere, our spending would have been $6, This figure is some 11% less than the comparable national figure. The common perception of high Massachusetts hospital costs is based not on unit costs as we ve seen, hospitals here spend significantly less per patient but on the high utilization of outpatient services and teaching hospitals. These factors are explored in depth in Part 5 of the report. To understand trends in unit revenues or unit costs over time, it is best to look at the unadjusted numbers (that is, straight revenues and costs, with no adjustment for wage and severity differences). These appear in the bottom half of the table above, and show that non-medicare unit revenues rose twice as fast in the rest of the country than in Massachusetts (22% increase vs 10%) from 1997 to The increase in spending per patient was 65% higher in the rest of the country (19%, as against 11% in Massachusetts), while medical inflation rose faster in Massachusetts (the medical component of the Boston CPI was up 31% as against 21% elsewhere.) This result is shown graphically in the chart below. Massachusetts community hospitals were spending 15% less (in constant, 2002 dollars) per patient in 2002 than they had 5 years earlier, while spending elsewhere fell only 2%. On the one hand, everyone is in favor of efficiency and of spending dollars wisely. On the other hand, constant reductions in inflationadjusted spending must eventually lead to reduced quality of patient care. Inflation-Adjusted Expense per Patient Community Hospitals, Expense per Adjusted Discharge, 2002 Dollars 8,500 MA Oth U.S. 8,000 7,500 7,000 6,500 6,000 7,861 7,485 7,109 7,771 6,810 7,600 6,658 7,590 6,463 7,609 6,365 7,714 5,500 5,000 4,500 4, The net adjustment is upward, because, as explained in Appendix Three below, the impact of the severity adjustment is greater than the impact of the wage adjustment. 25

27 Per patient spending at Massachusetts community hospitals is substantially lower than in almost all other states, as shown in the map below. There are only five states Delaware, Utah, South Dakota, Alabama, and Arizona where per discharge community hospital spending (adjusted for severity and wage differences) is lower than in Massachusetts. But there are 37 states where spending is at least 10% higher than in Massachusetts! Community Hospital Spending per Adjusted Discharge, 2002 Indexed for Severity and Wage Differences Unit Cost 7,000 < 7,000 to 7,500 7,500 to 8,000 8,000 to 8,500 8,500 to 9,000 > 9,000 26

28 PART 4 HOSPITAL CAPITALIZATION A close look at data on hospital balance sheets, as reported in the Medicare cost reports, shows that Massachusetts community hospitals are already under capitalized, in comparison to hospitals elsewhere even before the need to expand facilities to accommodate growing numbers of Medicare patients. Comparing community hospitals in Massachusetts with those elsewhere, using traditional balance sheet measures, shows that hospitals here actually have a larger safety margin in terms of cash and short-term liabilities. Massachusetts hospitals had 46 days cash on hand in 2002, compared to only 34 days elsewhere in the country, as shown in the table below. Similarly, the overall quick ratio of Massachusetts hospitals was 72%, 39% above the 52% elsewhere. 12 In both of these measures of short-term safety margin, Massachusetts hospitals have improved their position since 1997, while hospitals elsewhere in the country have moved in the other direction. The long-term picture is just the reverse; Massachusetts hospitals capital position is worse than hospitals in the rest of the country. Our capital ratio is 57%, compared with 47% in the country at large. 13 Long-term debt which supports hospitals plant and equipment is 90% of total capital in Massachusetts but only 58% elsewhere. Community Hospital Capital Ratios The long-term ratios are defined in such a way that a lower number indicates a greater margin of safety exactly the reverse of the way the short-term measures are defined. For example, the longterm debt to capital ratio in Massachusetts was 56% higher than for other hospitals in 2002 meaning our hospitals are at greater risk. (This is shown in the lower right-hand corner of the table) If we look at the inverse of this ratio (shown in the bottom line of the table), hospitals elsewhere had a ratio only 64% of ours and we have a measure where a low score is a negative indicator for Massachusetts, comparable to the days cash on hand measure, where a low ratio relative to the U.S. is also unfavorable and a high ratio (136% of the US in 2002) is a positive sign Days Cash on Hand MA Other US MA % US 95% 91% 119% 141% 153% 136% Quick Ratio MA 42% 35% 44% 60% 71% 72% Other US 58% 52% 47% 45% 53% 52% MA % US 72% 67% 94% 134% 134% 139% Debt Ratio MA 57% 58% 57% 57% 54% 57% Other US 45% 45% 45% 45% 46% 47% MA % US 127% 131% 127% 126% 118% 121% US % MA 79% 77% 79% 80% 85% 83% Long-Term Debt / Capital MA 85% 88% 87% 90% 75% 90% Other US 56% 55% 56% 55% 55% 58% MA % US 151% 159% 155% 164% 135% 156% US % MA 66% 63% 65% 61% 74% 64% Source: Calculated from Medicare Cost Reports 12 The quick ratio is the ratio of liquid assets to current liabilities. The figures reported here are derived by assuming that all the Massachusetts community hospitals or all the hospitals elsewhere are one single entity; total liquid assets of all Massachusetts hospitals are divided by total current liabilities of these same hospitals. 13 The debt ratio is total liabilities as a percent of the sum of total liabilities and general fund balances. 27

29 MA Pct of US 160% 140% 120% 100% 80% 60% Key Capital Ratios Community Hospitals - MA Relative to Rest of U.S. Days Cash LT Debt Equity Debt Ratio Quick Ratio The chart at left shows Massachusetts capital ratios in relation to the U.S., inverting the long-term ratios so that a ratio above 100% means hospitals here have a greater safety margin than those elsewhere while a ratio below 100% indicates our hospitals are at greater risk. 40% 20% The 2 debt ratios have been inverted, so that values below 100% mean Massachusetts less favorable than rest of the U.S Source: Calculated from Medicare Cost Reports The chart shows how short-term positions have improved in recent years, while the long-term position of our hospitals has consistently been less favorable than our counterparts across the country. These traditional capital measures do not tell the whole story. They tell us about the financial safety of the hospital, but not whether its physical assets its plant and equipment are adequate to the hospital s patient care mission. To shed light on this, I ve compared hospital assets to hospital volume, as shown in the chart below. The results are striking. 28

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