Texas Hospitals: Utilization and Financial Trends

Texas Department of State Health Services Texas Hospitals: Utilization and Financial Trends 1997-2006 Financial and Utilization Data from the Cooperative DSHS/ AHA/THA Annual Survey of Hospitals Center for Health Statistics - HSU December 2007 i Prepared by: Center for Health Statistics - HSU, Texas Department of State Health Services, December 2007

For additional information or suggestions on this report, please contact: Texas Department of State Health Services Center for Health Statistics - HSU 1100 West 49th Street, Suite M660 Austin, TX 78756-3199 Phone: (512) 458-7261 Fax: (512) 458-7344 Email: feedback.opp@dshs.state.tx.us http://www.dshs.state.tx.us/chs/hosp ii Prepared by: Center for Health Statistics - HSU, Texas Department of State Health Services, December 2007

Table of Contents Executive Summary... v I. Beds and Ownership...1 Count of Texas Acute Care Hospitals and Licensed Beds, 1997-2006, Figures 1 & 2... 2 Texas Acute Care Hospitals and Staffed Beds by Ownership, 2006, Figures 3 & 4... 3 Count of Texas Psychiatric Care Hospitals and Licensed Beds, 2006, Table 1... 4 Texas Psychiatric Care Hospitals by Ownership, 2006, Figure 5... 4 II. Hospital Utilization Trends... 5 Texas Acute Care Hospitals: Staffed Beds Occupancy Rate and Licensed Beds Occupancy Rate, 1997-2006, Figure 6... 6 Texas Acute Care Hospitals: Total Inpatient Days, Admissions, and Average Length of Stay (ALOS), 1997-2006, Figure 7... 7 Texas Acute Care Hospitals: Outpatient Visits and Emergency Room Visits, 1997-2006, Figure 8... 8 Texas Acute Care Hospitals: Inpatient and Outpatient Surgical Operations, 1997-2006, Figure 9... 9 Texas Acute Care Hospitals: Utilization Ratio by Public Health Region, 2006, Figure 10... 10 III. Hospital Financial Trends... 11 Texas Acute Care Hospitals: Total Uncompensated Care Adjusted for Inflation, 1997-2006, Figure 11... 12 Comparison of Uncompensated Care Figures for Seven Most Populous States, 2006, Table 2... 13 Texas Acute Care Hospitals: Uncompensated Care by Public Hospitals, 2006, Figure 12... 14 Texas Acute Care Hospitals: Bad Debt and Charity Charges by Ownership, 1997-2006, Table 3... 15 Psychiatric Care Hospitals: Bad Debt, Charity, and Total Uncompensated Care by Ownership, Tables 4 & 5, Figure 13... 16 IV. Hospital Utilization and Financial Data - Supplemental Information... 17 Texas Acute Care Hospitals: Reported Beds Set Up and Staffed by Service, 2006, Table 6... 18 Texas Acute Care and Psychiatric Care Hospitals: Utilization by Type of Service, 2006 Table 7... 19 Texas Acute Care and Psychiatric Care Hospitals: Uncompensated Care by Type of Service, 2006, Table 8... 20 iii Prepared by: Center for Health Statistics - HSU, Texas Department of State Health Services, December 2007

Table of Contents V. Hospital Utilization and Financial Date - Supplemental Information (continued) Texas Acute Care Hospitals Reporting the Highest Uncompensated Care, 2006 Table 9... 21 Texas Acute Care Hospitals: Uncompensated Care by Public Health Region, 2006, Table 10... 22 Texas Acute Care Hospitals by County, November 2007, Map 1... 23 VI. Appendix... 24 Hospital Data Planning Staff Roster... 25 Texas Department of State Health Services Public Health Regions Map, Map 2... 26 Texas Department of State Health Services Public Health Regions by County, Table 11... 27 iv Prepared by: Center for Health Statistics - HSU, Texas Department of State Health Services, December 2007

Executive Summary Hospitals are classified as either Acute Care or Psychiatric. Between 1997 and 2006, the number of acute care hospitals increased by 12 percent, from 474 to 530 hospitals. During the same period, the number of psychiatric hospitals decreased by 28 percent, from 58 to 41 hospitals. Acute care hospitals are divided into three categories of ownership: For-Profit (45 percent) - 242 hospitals Non-Profit (30 percent) - 157 hospitals Public (25 percent) - 131 hospitals In 2006, the state hospital utilization rate was 589 inpatient days per 1,000 population, a decline of 4 percent since 1997. According to the 11 public health regions in Texas, Region 7 (Austin, Travis County area) had the lowest utilization rate at 434 inpatient days per 1,000 population. Region 1 (Northwest Texas, including Lubbock County) had the highest utilization rate with 766 inpatient days per 1,000 population. Uncompensated care is comprised of Bad Debt Expense(s) and Charity Charges. In 2006, public acute care hospitals reported the highest amount of charity charges with $4.21 billion. Nonprofit acute care hospitals reported the highest bad debt expenses with $2.00 billion. During the same period, public psychiatric hospitals reported the highest amount of total uncompensated care with bad debt expenses of $6.28 million and charity charges of $166.66 million. In 2006, the most number of patient admissions (2,611,271) was for general medical and surgical services, the staffed occupancy rate was 61 percent, and the number of inpatient days was 13,723,748. Ben Taub General Hospital in Houston reported the highest total uncompensated care with $960 million. Thirteen hospitals reported no uncompensated care. v Prepared by: Center for Health Statistics - HSU, Texas Department of State Health Services, December 2007

I. Beds and Ownership 1 Prepared by: Center for Health Statistics - HSU, Texas Department of State Health Services, December 2007

Count of Texas Acute Care Hospitals and Licensed Beds 1997-2006 Figure 1: Number of Acute Care Hospitals, 1997-2006 540 Number of Hospitals 520 500 480 460 440 420 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Total 474 473 467 469 471 492 502 509 526 530 * Due to the tracking of hospitals 2006 ownership numbers are as of November 2007 Figure 2: Number of Acute Care Licensed Beds, 1997-2006 Licensed Beds 80,000 78,000 76,000 74,000 72,000 70,000 68,000 66,000 64,000 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Total 70,871 71,087 70,754 69,991 71,821 70,939 73,285 71,710 74,253 78,135 DEFINITIONS: Licensed Beds is defined as the number of beds licensed by the Department of State Health Services (DSHS), Health Facilities Licensing. STATISTICS: The number of acute care hospitals in Texas, licensed by DSHS, increased 11.8 percent from 1997 to 2006 (Figure 1). The number of DSHS licensed beds increased by 10.2 percent from 1997 to 2006 (Figure 2). A specific hospital s Licensed Beds can be found in the Hospital Tracking Database as variable TDHLIC. 2 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of and State Hospital Health Tracking Services, Database December 2007

Texas Acute Care Hospitals and Staffed Beds by Ownership, 2006 Reporting Hospitals by Ownership, November 2007 Staffed Beds by Ownership Public 25% (131) For-Profit 45% (242) Public 17% (10,686) For-Profit 38% (23,717) Non-Profit 30% (157) Non-Profit 45% (27,470) * Due to the tracking of hospitals 2006 ownership numbers are as of November 2007 Figure 3 Figure 4 DEFINITIONS: Public Hospital: Hospitals owned by an agency of city, county or state government and includes hospital districts, hospital authorities, county and city facilities and state-operated facilities. Non-Profit Hospital: Hospitals owned by not-for-profit organizations, such as religious organizations, community hospitals, cooperative hospitals or fraternal societies. For-Profit Hospital: Hospitals owned on a for-profit basis by an individual, a partnership or a profit-making corporation. Staffed Beds is defined as the number of beds set up and staffed for use at the end of the hospital s reporting period. This number will be less than or equal to the hospital s licensed beds. STATISTICS: The ownership of Texas acute care hospitals is composed of approximately one-half for-profit hospitals. Less than one out of five staffed beds are in public hospitals, the remaining beds being divided between for-profit and non-profit hospitals. A specific hospital s Ownership can be found in the Hospital Tracking Database as variable OWNCODE or on the AHA/ DSHS survey under variable F1. Staffed beds can also be found in the AHA/DSHS survey as variable E1b1. 3 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of and State Hospital Health Tracking Services, Database December 2007

Count of Texas Psychiatric Care Hospitals and Licensed Beds & Texas Psychiatric Care Hospitals by Ownership, 2006 Year Number of Hospitals Number of Beds Admissions Psychiatric Hospitals by Ownership, November 2007 1997 58 6,654 64,993 1998 55 6,324 69,446 Public 24% (10) 1999 55 6,127 61,559 2000 40 4,924 66,711 2001 40 4,976 78,490 2002 38 4,876 76,870 For-Profit 48% (20) 2003 36 2,986 75,709 2004 38 3,398 80,033 2005 38 4,399 80,244 2006 41 5,065 86,072 Table 1 Figure 5 Non-Profit 29% (12) * Includes nine state owned psychiatric hospitals and their 2,476 beds. DEFINITIONS: Psychiatric Hospital: A hospital that provides diagnostic and therapeutic services to patients with mental or emotional disorders. STATISTICS: Between 1997 and 2006 the number of psychiatric hospitals in Texas decreased 29 percent and the number of beds decreased 26 percent (Table 1), while admissions increased 24 percent. Psychiatric admissions can be found in the AHA/DSHS survey in Section H1 a-e. 4 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of and State Hospital Health Tracking Services, Database December 2007

II. Hospital Utilization Trends 5 Prepared by: Center for Health Statistics - HSU, Texas Department of State Health Services, December 2007

Texas Acute Care Hospitals: Staffed Beds, Occupancy Rate and Licensed Beds Occupancy Rate, 1997-2006 Percentage 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Staffed Beds Occupancy Rate Licensed Bed Occupancy Rate 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Staffed Beds Occupancy Rate (%) Licensed Bed Occupancy Rate (%) 56.8 57.0 58.7 60.2 62.2 64.7 63.9 61.8 61.3 61.1 45.9 44.9 46.2 48.0 50.7 56.6 52.4 51.1 50.9 51.1 Figure 6 DEFINITIONS: Staffed Occupancy Rate = inpatient days days open staffed beds x 100 Licensed Occupancy Rate = inpatient days for Texas Department of State Health Services licensed hospitals days open licensed beds x 100 STATISTICS: From 1997 to 2006, the staffed occupancy rate for Texas acute care hospitals increased 7.6 percent and the licensed occupancy rate for Texas acute care hospitals increased 11.3 percent. (Figure 6) Licensed beds can be found in the Hospital Tracking Database under variable TDHLIC. Staffed beds can be found on the AHA/DSHS survey on page 15 E1a1. 6 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of State Health Services, December 2007

Texas Acute Care Hospitals: Total Inpatient Days, Admissions, and Average Length of Stay (ALOS), 1997-2006 DEFINITIONS: Millions of Visits/Day 16.00 14.00 12.00 10.00 8.00 6.00 4.00 2.00 0.00 Inpatient Days ALOS Admissions 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Admissions 2.17 2.23 2.29 2.35 2.45 2.48 2.56 2.57 2.59 2.61 Inpatient Days 11.9 12.1 12.3 12.4 13.0 13.4 13.6 13.5 13.7 13.7 ALOS 5.5 5.4 5.4 5.3 5.3 5.4 5.3 5.3 5.3 5.3 Figure 7 Inpatient Days: The number of adult and pediatric days of care rendered during the reporting period. Includes neonatal and swing days. Does not include days of care rendered for normal infants born in the hospital, but does include those for their mothers. Includes days of care for infants born in the hospital and transferred into a neonatal care unit. Also includes swing bed inpatient days. Inpatient day of care (also commonly referred to as a patient day or a census day, or by some federal hospitals as an occupied bed day) is a period of service between the census-taking hours on two successive calendar days, the day of discharge being counted only with the patient was admitted the same day. Admissions: Defined as all patient accepted for inpatient service during the reporting period. Includes adult, pediatric, neonatal and swing admissions. Excludes newborns. Average Length of Stay: The average number of days a patient stays in the hospital. Average length of stay = inpatient days admissions. STATISTICS: Inpatient days increased 9.24 percent between 1997 and 2001 and 6.53 percent from 2001 to 2006. The number of admissions increased by 20 percent between 1997 and 2006. The average length of stay decreased by 3.6 percent during the same period. Inpatient days can be found on the AHA/DSHS annual survey on page 15 E1f1 and admissions as E1e1. 7 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of and State Hospital Health Tracking Services, Database December 2007

Texas Acute Care Hospitals: Outpatient Visits and Emergency Room Visits, 1997-2006 30.0 Number of Visits (Millions) 25.0 20.0 15.0 10.0 5.0 Outpatient Visits Emergency Room Visits 0.0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Outpatient Visits 20.3 21.0 21.4 21.4 22.9 24.5 24.3 24.7 24.4 23.9 Emergency Room Visits 6.4 6.7 7 7.2 7.7 8 8.3 8.1 8.5 8.5 Figure 8 DEFINITIONS: Outpatient Visit: A visit by a patient who is not lodged in the hospital while receiving medical, dental or other services. Each appearance of an outpatient in each unit constitutes one visit regardless of the number of diagnostic and/or therapeutic treatments that the patient receives. Total outpatient visits should include all clinic visits, referred visits, observation services, outpatient surgeries, and emergency room visits. Clinic visits should reflect total number of visits to each specialized medical unit that is responsible for the diagnosis and treatment of patients on an outpatient, nonemergency basis (i.e., alcoholism, dental, gynecology, etc.). Visits to the satellite clinics and primary group practices should be included if revenue is received by the hospital. Referred visits should reflect total number of outpatient ancillary visits to each specialty unit of the hospital established for providing technical aid used in the diagnosis and treatment of patients. Examples of such units are diagnostic radiology, EKG, pharmacy, etc. Emergency Room Visit: The number of visits to the emergency unit. Emergency outpatients can be admitted to the inpatient areas of the hospital, but they are still counted as emergency visits and subsequently as inpatient admissions. STATISTICS: Outpatient visits, excluding emergency room visits, increased 17.7% between 1997 and 2006. Emergency room visits steadily increased by 33 percent. Both variables can be found on page 15 the AHA/DSHS annual survey as E1h1 (Total Outpatient Visits) and E1g1 (Emergency Room Visits). E1h1 includes ER visits. To create the graph above subtract E1g1 from E1h1. 8 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of State Health Services, December 2007

Texas Acute Care Hospitals: Inpatient and Outpatient Surgical Operations, 1997-2006 Number of Surgical Operations (in thousands) 1200 Outpatient 1000 800 Inpatient 600 400 200 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Inpatient Surgeries 637.5 693.9 689.7 714.9 716.7 753.3 768.9 766.2 785 801.9 Outpatient Surgeries 924 1001 1039 1055 1047 1106 1117 1100 1137 1124 Figure 9 DEFINITIONS: Inpatient Surgical Operations: The number of patients undergoing surgery who are lodged in the hospital. Outpatient Surgical Operations: Operations performed on patients who do not remain in the hospital overnight. Includes all operations whether performed in the inpatient operating rooms or in procedure rooms located in an outpatient facility. Includes an endoscopy only when used as an operative tool and not when used for diagnosis alone. Each patient undergoing surgery is counted as one surgical operation regardless of the number of surgical procedures. STATISTICS: Inpatient surgical operations in Texas acute care hospitals increased 25.8 percent between 1997 and 2006. Acute care hospitals reported approximately 1,124,276 outpatient surgical operations in 2006, an increase of 22 percent since 1997. Both variables can be found on page 15 the AHA/DSHS annual survey as E1i1 (Inpatient Surgical Operations) and E1j1 (Outpatient Surgical Operations). 9 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of State Health Services, December 2007

Texas Acute Care Hospitals: Utilization Rate by Public Health Region, 2006 900 Inpatient Days per 1,000 Population 800 700 600 500 400 300 200 100 0 R - 1 R - 2 R - 3 R - 4 R - 5 R - 6 R - 7 R - 8 R - 9 R - 10 R - 11 Utilization Rate 766 623 543 715 611 647 434 588 562 529 603 585 = State Average Utilization Rate R = Region Figure 10 DEFINITIONS: Hospital Utilization: Measures the rate at which the hospital s services are employed with respect to time. In this case, inpatient days per 1,000 of the state s population. STATISTICS: Overall, hospital utilization rates rose during the late 1990 s before declining from 2002 to 2006. Between 1997 and 2006 the utilization rate decreased 3.9 percent. The utilization rate for all Texas acute care hospitals was 585 inpatient days per 1,000 population in 2006. Seven of the 11 regions had hospital utilization rates above the state average hospital utilization rate of 585 inpatient days per 1,000 population. Public Health Regions 3, 7, 9 and 10 had hospital utilization rates below the state average. Public Health Region 7, encompassing the central part of the state, including Austin, had the lowest hospital utilization rate at 434 inpatient days per 1,000 population. Region 1, northwest Texas, including Lubbock, had the highest hospital utilization rate at 766 inpatient days per 1,000 population. A map of the Texas Department of State Health Services Public Health Regions can be found on page 26, Map 2. 10 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of State Health Services, December 2007

III. Hospital Financial Trends 11 Prepared by: Center for Health Statistics - HSU, Texas Department of State Health Services, December 2007

Texas Acute Care Hospitals: Total Uncompensated Care Adjusted for Inflation, 1997-2006 14 12 10 Dollars (Billions) 8 6 4 2 Total Uncompensated Care Adjusted Uncompensated Care 0 Total Uncompensated Care 4.06 4.37 4.7 5 5.46 6.45 7.61 9.22 10.2 11.6 Adjusted Uncompensated Care 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 1.73 1.81 1.88 1.92 1.85 2.07 2.52 2.93 3.12 3.41 Figure 11 DEFINITIONS: Uncompensated Care: The services provided for which no payment is received from the patient or from third-party payers. Uncompensated care is the sum of bad debt expense and charity charges. (AHA/DSHS Survey, item I1c + I2c and E5a + E5b) Bad Debt Charges: Consist of uncollectible inpatient and outpatient charges that result from the extension of credit. (AHA/DSHS survey, item I1c and E5a) Charity Charges: The total amount of hospital charges for inpatient and outpatient services attributable to charity care in a cost reporting period. These charges do not include bad debt charges, contractual allowances or discounts (other than for indigent patients not eligible for medical assistance under the approved Medicaid state plan); that is, reductions or discounts in charges given to other third party payers such as, but no limited to, health maintenance organizations, Medicare or Blue Cross. STATISTICS: Total uncompensated care increased 186 percent between 1997 and 2006. However, adjusted for inflation, uncompensated care increased by only 97 percent during the same period. 12 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of State Health Services, December 2007

Comparison of Uncompensated Care Figures for Seven Most Populous States, 2006 Bad Debt* Charity Charges* Total Uncompensated Care* Gross Patient Revenue* Uncompensated Care as a Percentage of Gross Patient Revenue 2006 Population Total Uncompensated Care per Capita California $3,787 $4,528 $8,314 $200,879 4.14% 36,457,549 $228 Texas $4,762 $6,052 $10,814 $119,302 9.06% 23,507,783 $460 New York $2,611 $2,311 $4,922 $109,281 4.50% 19,306,183 $255 Florida $3,933 $4,723 $8,656 $107,330 8.06% 18,089,888 $478 Illinois $1,892 $1,375 $3,267 $66,063 4.94% 12,831,970 $255 Pennsylvania $1,553 $801 $2,354 $98,608 2.39% 12,440,621 $189 Ohio $1,284 $2,102 $3,386 $65,550 5.17% 11,478,006 $295 United States $42,687 $43,174 $85,860 $1,551,823 5.53% 299,398,484 $287 * Dollars in millions Table 2 STATISTICS: In 2006, Texas ranked first among the seven most populous states in total uncompensated care reported by hospitals ($10,814) and in the ratio of uncompensated care to gross patient revenue (9.06 percent). Texas was second in per capita uncompensated care ($460). Of the top seven most populous states, Pennsylvania had the lowest uncompensated care per capita with approximately $189 per person spent on uncompensated care. The average uncompensated care per capita for the United States was $287 per person 13 Prepared Source: by: 2006 Center AHA for Annual Health Survey Statistics of Hospitals - HSU, Texas Department of State Health Services, December 2007

Texas Acute Care Hospitals: Uncompensated Care by Public Hospitals, 2006 Hospital Authority 3.3% State 15.7% County 2.4% City 0.1% City-County 0.3% Hospital District 78.2% Number of Public Hospitals = 131 Uncompensated Care Provided by Public Acute Care Hospitals = $4.21 billion Total Uncompensated Care = $11.58 billion Figure 12 DEFINITIONS (Public acute care hospitals are divided into six categories): State - Controlled by an agency of state government County - Controlled by an agency of county government. City - Controlled by an agency of municipal government. City-County - Controlled jointly by agencies of municipal and county governments. Hospital District or Authority - Controlled by a political subdivision of a state, county, or city created solely for the purpose of establishing and maintaining medical care or health-related care institutions. STATISTICS: Of the six categories for public acute care hospitals, hospital districts provided the highest amount of uncompensated care. These 92 reporting hospital district hospitals were responsible for most (78.2 percent) of the total uncompensated care provided by Texas public acute care hospitals in 2006. Five state-owned acute care hospitals provided 15.7 percent of the uncompensated care provided by all public acute care hospitals. Hospital authorities and hospitals owned by a county, city-county, or city were responsible for the remaining 2.81 percent. 14 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of State Health Services, December 2007

Texas Acute Care Hospitals: Bad Debt and Charity Charges by Ownership, 2006 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 PUBLIC Bad Debt Expense $0.67 $0.67 $0.77 $0.75 $0.78 $0.82 $0.89 $1.12 $1.30 $1.60 % of Total Public 35.4 33.3 36.6 35.8 36.1 33.4 30.7 33.4 33.6 36.1 Charity Charges $1.22 $1.35 $1.34 $1.35 $1.38 $1.63 $2.03 $2.23 $2.58 $2.70 % of Total Public 64.6 66.7 63.4 64.2 63.9 66.5 69.3 66.6 66.4 63.9 NON-PROFIT Bad Debt Charges $0.67 $0.72 $0.87 $1.00 $1.06 $1.24 $1.47 $1.74 $1.78 $2.00 % of Total Non-Profit 47.2 45.4 50.1 52.7 49 49.38 50.8 46.9 43.3 42.7 Charity Charges $0.75 $0.86 $0.87 $0.90 $1.10 $1.25 $1.42 $1.97 $2.33 $2.70 % of Non-Profit 52.8 54.6 49.9 47.3 50.9 50.2 49.2 53.1 56.7 57.3 FOR-PROFIT Bad Debt Expense $0.58 $0.57 $0.65 $0.76 $0.87 $1.04 $1.25 $1.55 $1.47 $1.90 % of Total For-Profit 77.3 78.3 77.8 76.8 76.3 71.2 70 72.1 65.5 69.5 Charity Charges $0.17 $0.16 $0.19 $0.23 $0.27 $0.42 $0.53 $0.60 $0.77 $0.82 % of Total For-Profit 22.7 21.7 22.2 23.2 23.7 28.8 30 27.9 34.5 30.5 REPORTED TOTALS Bad Debt Expense $1.92 $1.97 $2.30 $2.52 $2.71 $3.11 $3.62 $4.40 $4.60 $5.38 % of Total 47.3 45.3 48.9 50.4 49.6 48.4 47.6 47.8 44.5 46.5 Charity Charges $2.14 $2.38 $2.40 $2.48 $2.75 $3.31 $3.97 $4.81 $5.69 $6.19 % of Total 52.7 54.7 51.1 49.6 50.7 51.5 52.4 52.2 55.5 53.5 * Dollars in billions Includes hospitals that provided complete information for bad debt expense and charity charges. Table 3 DEFINITIONS: Financially Indigent Patient: An uninsured or underinsured person who is accepted for care with no obligation or a discounted obligation to pay for the services rendered based on the hospital s eligibility system. Medically Indigent Patient: A person whose medical or hospital bills after payment by third-party payers exceed a specified percentage of the patient s annual gross income, determined in accordance with the hospital s eligibility system, and the person is financially unable to pay the remaining bill. STATISTICS: Charity charges exceeded bad debt expense for public acute care hospitals in Texas since 1997. In 2006, public acute care hospitals reported 63.9 percent of the uncompensated care as charity charges. For-profit acute care hospitals consistently reported bad debt expense exceeding charity charges since 1997. For-profit hospitals nearly quintupled ($0.65 billion increase) the amount of uncompensated charity care charges between 1997 and 2006. 15 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of and State Hospital Health Tracking Services, Database December 2007

Psychiatric Care Hospitals: Bad Debt, Charity, and Total Uncompensated Care by Ownership 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 PUBLIC Bad Debt Expense $3.5 $2.1 $2.2 $2.1 $2.0 $0.5 $1.2 $1.3 $0.7 $6.3 % of Total Public 0.7 1.2 0.7 0.8 1.1 0.3 0.7 0.7 0.5 3.6 Charity Charges $291.2 $310.7 $312.0 $260.2 $183.2 $207.6 $156.6 $179.9 $126.7 $166.7 % of Total Public 98.8 99.3 99.3 99.2 98.9 99.7 99.3 99.3 99.5 96.4 NON-PROFIT Bad Debt Expense $2.4 $4.4 $4.4 $4.2 $3.2 $6.0 $3.6 $3.2 $9.5 $7.3 % of Total Nonprofit 21.4 39.4 55 58.6 56.7 66.3 52 44.9 24.5 56.2 Charity Charges $8.7 $6.7 $3.6 $3.0 $2.5 $3.0 $3.3 $3.9 $29.2 $6.0 % of Total Nonprofit 78.6 60.6 45 41.4 43.3 33.7 48 55.1 75.5 43.8 FOR-PROFIT Bad Debt Expense $22.4 $15.1 $12.2 $10.6 $13.4 $10.3 $14.6 $12.7 $7.5 $9.9 % of Total For-profit 79.2 73.9 91.6 85 73.6 66.1 81.7 72.8 63.6 68.2 Charity Charges $5.9 $5.3 $1.1 $1.9 $4.8 $5.3 $3.2 $4.8 $4.3 $4.6 % of Total For-profit 20.8 26.1 8.4 15 26.4 33.9 18.3 27.2 36.4 31.8 REPORTED TOTALS Bad Debt Expense $28.2 $21.6 $19.0 $16.9 $18.6 $16.8 $19.4 $17.2 $17.6 $23.5 % of Total 8.4 6.3 5.6 6 8 7.2 10.6 8.4 9.9 11.7 Charity Charges $305.8 $322.7 $316.7 $265.0 $190.5 $215.9 $163.2 $188.6 $160.3 $177.0 % of Total 91.6 93.7 94.4 94 91 92.8 89.4 91.6 90.1 88.3 * Dollars in millions Includes hospitals that provided complete information for bad debt expense and charity charges. In 2005 charity charges increased due to a reported change of ownership by Harris County Table 4 Uncompensated Care as a Percentage of Gross Patient Revenue 1997-2006 Percentage of GPR (%) 50 45 40 35 30 25 20 15 10 5 0 Figure 13 45.7 37.5 39.8 40.2 25.3 26.3 20.3 20.2 17.4 17.2 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Table 5 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Total Uncompensated Care (Dollars in millions) $334.0 $345.9 $336.3 $285.7 $209.1 $232.8 $182.6 $205.8 $177.8 $200.5 Gross Patient Revenue (Dollars in millions) $890.9 $869.0 $736.6 $710.2 $825.4 $883.8 $900.0 $1,021 $1,022 $1,163 Uncompensated Care as a Percentage (%) of Gross Patient Revenue 37.5% 39.8% 45.7% 40.2% 25.3% 26.3% 20.3% 20.2% 17.4% 17.2% 16 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of State Health Services, December 2007

IV. Hospital Utilization and Financial Data - Supplemental Information 17 Prepared by: Center for Health Statistics - HSU, Texas Department of State Health Services, December 2007

Texas Acute Care Hospitals: Reported Beds Set Up and Staffed by Service, 2006 Service Beds Percent of Total Beds General Medical-Surgical Care 31,575 51.0% Obstetrics 5,615 9.1% Medical Surgical Intensive Care 4,142 6.7% Acute Long-Term Care 3,665 5.9% Physical Rehabilitation 3,467 5.6% Pediatric Medical-Surgical Care 2,951 4.8% Neonatal Intensive Care 2,067 3.3% Other Special Care 1,966 3.2% Psychiatric Care 1,855 3.0% Cardiac Intensive Care 1,207 1.9% Skilled Nursing Care 1,000 1.6% Neonatal Intermediate Care 739 1.2% Other Care 563 0.9% Other Intensive Care 470 0.8% Pediatric Intensive Care 376 0.6% Alcoholism-Drug Abuse or Dependency Care 114 0.2% Burn Care 87 0.1% Intermediate Nursing Care 45 0.1% Other Long-Term Care 0 0.0% Total 61,904 Table 6 18 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of and State Hospital Health Tracking Services, Database December 2007

Texas Acute Care and Psychiatric Care Hospitals: Utilization by Type of Service, 2006 Reporting Hospitals Beds Set Up and Staffed Admissions Inpatient Days Staffed Occupancy Rate Average Length of Stay General Medical and Surgical 360 53,363 2,435,659 11,737,704 60.3% 4.8 Acute Long-Term Care Hospital 70 4,164 39,143 1,042,604 68.6% 26.6 Psychiatric 43 4,986 88,187 1,420,632 78.1% 16.1 Rehabilitation 31 1,807 29,309 405,804 61.5% 13.8 Orthopedic 6 207 8,844 30,332 40.1% 3.4 Heart 3 169 12,738 34,489 55.9% 2.7 Tuberculosis and Other Respiratory Diseases 1 72 105 14,440 54.9% 137.5 Cancer 1 512 21,221 155,551 83.2% 7.3 Obstetrics and Gynecology 1 248 14,106 69,933 77.3% 5.0 Alcoholism and Other Chemical Dependency 1 9 510 1,024 31.2% 2.0 Other 9 868 27,267 195,496 61.7% 7.2 Total 526 66,405 2,677,089 15,108,009 62.3% 5.6 Table 7 DEFINITIONS: General medical-surgical care: Provides acute care to patients in medical and surgical units on the basis of physicians orders and approved nursing care plans. Physical rehabilitation: Provides care encompassing a comprehensive array of restoration services for the disabled and all support services necessary to help patients attain their maximum functional capacity. Alcoholism-drug abuse: Provides diagnosis and therapeutic services to patients with alcoholism or other drug dependencies. Includes care for inpatient/residential treatment for patients whose course of treatment involves more intensive care than provided in an outpatient setting or where patient requires supervised withdrawal. Psychiatric care: Provides acute or long-term care to emotionally disturbed patients, including patients admitted for diagnosis and those admitted for treatment of psychiatric problems, on the basis of physicians orders and approved nursing care plans. Long-term care may include intensive supervision to the chronically mentally ill, mentally disordered, or other mentally incompetent persons. Acute long term care: Provides specialized acute hospital care to medically complex patients who are critically ill, have multisystem complication and/or failure, and require hospitalization averaging 25 days, in a facility offering specialized treatment programs and therapeutic intervention on a 24 hour/ 7 day a week basis. Orthopedic services: Services provided for the prevention or correction of injuries or disorders of the skeletal system and associated muscles, joints and ligaments. Cancer services: An organized program for the treatment of cancer by the use of drugs or chemicals. 19 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of and State Hospital Health Tracking Services, Database December 2007

Texas Acute Care and Psychiatric Hospitals: Uncompensated Care by Type of Service, 2006 * Dollars in millions Number of Hospitals Bad Debt Expense Table 8 Charity Charges Total Uncompensated Care Gross Patient Revenue Uncompensated Care as a Percentage of Gross Patient Revenue General Medical Surgical 360 $5,199.7 $6,000.5 $11,200.2 $105,125.6 10.7% Long Term Acute Care 70 $16.4 $26.4 $42.8 $3,480.6 1.2% Pyschiatric 43 $26.4 $177.2 $203.6 $1,177.6 17.3% Rehabilitation 31 $11.8 $14.4 $26.1 $886.1 2.9% Orthopedic 6 $3.6 $0.7 $4.3 $489.2 0.9% Heart 3 $13.1 $1.4 $15 $579.5 2.5% Tuberculosis and Other Respiratory Disease 1 $0.0 $3.8 $3.8 $4.0 94.9% Cancer 1 $52.3 $127.4 $179.7 $3,357.5 5.4% Obestritics and Gynecology 1 $4.5 $0.0 $4.5 $551.5 0.8% Alcoholism and Other Chemical Dependency 1 $6.0 $0.3 $0.4 $1.1 3.5% Other 9 $51.2 $17.6 $68.7 $1,494.1 4.6% Total 526 $5,378.9 $6,369.3 $11,748.2 $117,147.6 10.0% STATISTICS: Psychiatric hospitals and Alcoholism and Other Chemical Dependency hospitals had the second highest rates of uncompensated care as a percentage of gross patient revenue. Obstetrics and Gynecology (0.8 percent) and Orthopedic (0.9 percent) hospitals had the lowest rates of uncompensated care as a percentage of gross patient revenue. 20 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of and State Hospital Health Tracking Services, Database December 2007

Texas Acute Care Hospitals: Reporting the Highest Uncompensated Care, 2006 Facility City County Ownership Total Uncompensated Care* Total Gross Patient Revenue* Uncompensated Care as a Percentage of Gross Patient Revenue Ben Taub General Hospital** Houston HARRIS Public $960 $1,475 65.1% Parkland Memorial Hospital Dallas DALLAS Public $636 $1,649 38.6% John Peter Smith Hospital Fort Worth TARRANT Public $630 $1,221 51.6% University of Texas Medical Branch Hospital Galveston GALVESTON Public $409 $1,185 34.6% University Hospital San Antonio BEXAR Public $330 $907 36.4% CHRISTUS Santa Rosa Hospital San Antonio BEXAR Non-Profit $250 $633 39.5% R. E. Thomason General Hospital El Paso EL PASO Public $182 $487 37.3% University of Texas M.D. Anderson Cancer Ctr Houston HARRIS Public $180 $3,357 5.4% The Methodist Hospital Houston HARRIS Non-Profit $179 $3,037 5.9% East Texas Medical Center Tyler SMITH Non-Profit $167 $1,324 12.6% DCHS - Brackenridge Hospital Austin TRAVIS Non-Profit $164 $948 17.3% CHRISTUS Spohn Hospital Corpus Christi Corpus Christi NUECES Non-Profit $159 $1,772 9.0% Baptist Medical Center San Antonio BEXAR For-Profit $154 $635 24.2% Covenant Medical Center Lubbock LUBBOCK Non-Profit $136 $2,081 6.5% Methodist Hospital San Antonio BEXAR For-Profit $133 $2,881 4.6% Memorial Hermann Hospital Houston HARRIS Non-Profit $131 $1,945 6.7% Valley Baptist Medical Center Harlingen CAMERON Non-Profit $128 $955 13.4% Baylor University Medical Center Dallas DALLAS Non-Profit $128 $1,717 7.5% Harris Methodist H.E.B. Bedford TARRANT Non-Profit $125 $524 23.9% University Medical Center Lubbock LUBBOCK Public $123 $842 14.6% Total $5,304 $29,575 17.9% State Totals $10,248 $105,859 9.7% * Dollars in millions ** Financial information for Lyndon B. Johnson General Hospital, Houston (Harris County) is combined with Ben Taub Hospital, Houston (Harris County Table 9 STATISTICS: The above list includes the twenty acute care hospitals reporting the highest uncompensated care (bad debt expenses and charity charges). Of the twenty hospitals, 8 were public, 10 were nonprofit, and 2 were for-profit. All of these hospitals are located in metropolitan areas. These hospitals accounted for 46 percent of the total uncompensated care reported by Texas acute care hospitals. The overall uncompensated care as a percentage of gross patient revenue for these twenty hospitals was 17.9 percent. 21 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of and State Hospital Health Tracking Services, Database December 2007

Texas Acute Care Hospitals: Uncompensated Care by Public Health Region, 2006 Public Health Region Reporting Hospitals Bad Debt Charges* Charity Charges* Total Uncompensated Care* Gross Patient Revenue* Uncompensated Care as a Percentage of Goss Patient Revenue 2006 PHR Population Total Uncompensated Care per Capita 1 37 217 259 476 5,426 8.8% 823,337 578 2 36 120 103 222 2,434 9.1% 559,126 397 3 105 1,390 1,666 3,056 29,593 10.3% 6,381,435 479 4 38 338 355 693 6,853 10.1% 1,078,660 642 5 24 171 167 338 3,985 8.5% 770,794 438 6 90 1,209 1,842 3,051 32,490 9.4% 5,541,279 551 7 51 330 500 830 9,219 9.0% 2,618,812 317 8 49 940 526 1,465 9,935 14.7% 2,356,649 622 9 30 156 57 212 2,159 9.8% 543,472 391 10 14 206 134 340 4,795 7.1% 778,694 437 11 33 309 588 896 10,284 8.7% 2,012,569 445 Totals 507 $5,384 $6,195 $11,579 $117,173 9.9% 23,464,827 $493 * Dollars in millions Table 10 DEFINITIONS: Uncompensated care: Includes bad debt expense and charity charges. STATISTICS: Total uncompensated care was the highest for Public Health Regions 3 and 6. These regions include the Dallas and Houston metropolitan areas. They account for 50.8 percent of the population and 38.5 percent of the hospitals. Three of the eleven Public Health Regions uncompensated care as a percentage of gross patient revenue was equal to or exceeded the state rate of 9.9 percent. Public Health Region 8 had the highest uncompensated care as a percentage of gross patient revenue at 14.7 percent. This region includes Southwest Texas. Region 4 had the highest uncompensated care per capita at $642 per person. Public Health Region 10 in West Texas, El Paso and Brewster counties, had the lowest uncompensated care as a percentage of gross patient revenue at 7.1 percent; however, the region was ranked fourth for total uncompensated care per capita. A map of Texas Department of State Health Services Public Health Regions and a list of regions by county is included in the appendix. 22 Prepared Source: by: 2006 Center DSHS/AHA/THA for Health Statistics Cooperative - HSU, Annual Texas Survey Department of Hospitals of and State Hospital Health Tracking Services, Database December 2007

Texas Acute Care Hospitals by County, November 2007 64 counties in the state are without an acute care hospital. 122 counties have only one acute care hospital. 68 counties have more than one acute care hospital. Harris county has the most number of acute care hospitals (64) followed by Dallas county (36), Tarrant county (30) and Bexar (20). One Acute Care Hospital More than One Acute Care Hospital No Acute Care Hospital Map 1 Counties Without An Acute Care Hospital, 2006 (64) Aransas Archer Armstrong Bandera Blanco Borden Briscoe Brooks Callahan Carson Coke Cottle Crockett Dallam Delta Dickens Donley Duval Edwards Foard Garza Glasscock Goliad Hall Hardin Hudspeth Irion Jeff Davis Jim Hogg Kendall Kenedy Kent King Kinney La Salle Lee Leon Lipscomb Live Oak Loving Marion Mason McMullen Menard Mills Morris Motley Newton Oldham Presidio Rains Real Roberts Robertson San Jacinto San Saba Shackelford Sherman Sterling Terrell Waller Willacy Zapata Zavala 23 Prepared by: Center for Health Statistics - HSU, Texas Department of State Health Services, December 2007

V. Appendix 24 Prepared by: Center for Health Statistics - HSU, Texas Department of State Health Services, December 2007

Hospital Data Planning Staff Roster, 2006 Dwayne Collins Survey Unit dwayne.collins@dshs.state.tx.us JaNell Jenkins Survey Unit janell.jenkins@dshs.state.tx.us Christopher Webb Survey Unit christopher.webb@dshs.state.tx.us Ramona McFarlin Survey Unit ramona.mcfarlin@dshs.state.tx.us Andria Orbach Survey Unit andria.orbach@dshs.state.tx.us Yun-Chien Wang, Ph.D Survey Unit yun-chien.wang@dshs.state.tx.us Bruce Gunn, Ph.D Manager, HPRD bruce.gunn@dshs.state.tx.us Ramdas Menon, Ph.D Director, CHS ramdas.menon@dshs.state.tx.us 25 Prepared by: Center for Health Statistics - HSU, Texas Department of State Health Services, December 2007

Texas Department of State Health Services Public Health Regions Map 1 Lubbock # 2 3 Arlington # 4 # El Paso 10 9 7 # Temple # Tyler 5 8 # San Antonio 6 # Houston 11 Harlingen # Map 2 Regional Offices 1. Lubbock 4/5. Tyler 7. Temple 9/10. El Paso 2/3. Arlington 6/5. Houston 8. San Antonio 11. Harlingen 26 Prepared by: Center for Health Statistics - HSU, Texas Department of State Health Services, December 2007

Texas Department of State Health Services Public Health Regions By County County Region County Region County Region County Region ANDERSON 4 ANDREWS 9 ANGELINA 5 ARANSAS 11 ARCHER 2 ARMSTRONG 1 ATASCOSA 8 AUSTIN 6 BAILEY 1 BANDERA 8 BASTROP 7 BAYLOR 2 BEE 11 BELL 7 BEXAR 8 BLANCO 7 BORDEN 9 BOSQUE 7 BOWIE 4 BRAZORIA 6 BRAZOS 7 BREWSTER 10 BRISCOE 1 BROOKS 11 BROWN 2 BURLESON 7 BURNET 7 CALDWELL 7 CALHOUN 8 CALLAHAN 2 CAMERON 11 CAMP 4 CARSON 1 CASS 4 CASTRO 1 CHAMBERS 6 CHEROKEE 4 CHILDRESS 1 CLAY 2 COCHRAN 1 COKE 9 COLEMAN 2 COLLIN 3 COLLINGSWORTH 1 COLORADO 6 COMAL 8 COMANCHE 2 CONCHO 9 COOKE 3 CORYELL 7 COTTLE 2 CRANE 9 CROCKETT 9 CROSBY 1 CULBERSON 10 DALLAM 1 DALLAS 3 DAWSON 9 DEAF SMITH 1 DELTA 4 DENTON 3 DE WITT 8 DICKENS 1 DIMMIT 8 DONLEY 1 DUVAL 11 EASTLAND 2 ECTOR 9 EDWARDS 8 ELLIS 3 EL PASO 10 ERATH 3 FALLS 7 FANNIN 3 FAYETTE 7 FISHER 2 FLOYD 1 FOARD 2 FORT BEND 6 FRANKLIN 4 FREESTONE 7 FRIO 8 GAINES 9 GALVESTON 6 GARZA 1 GILLESPIE 8 GLASSCOCK 9 GOLIAD 8 GONZALES 8 GRAY 1 GRAYSON 3 GREGG 4 GRIMES 7 GUADALUPE 8 HALE 1 HALL 1 HAMILTON 7 HANSFORD 1 HARDEMAN 2 HARDIN 5 HARRIS 6 HARRISON 4 HARTLEY 1 HASKELL 2 HAYS 7 HEMPHILL 1 HENDERSON 4 HIDALGO 11 HILL 7 HOCKLEY 1 HOOD 3 HOPKINS 4 HOUSTON 5 HOWARD 9 HUDSPETH 10 HUNT 3 HUTCHINSON 1 IRION 9 JACK 2 JACKSON 8 JASPER 5 JEFF DAVIS 10 JEFFERSON 5 JIM HOGG 11 JIM WELLS 11 JOHNSON 3 JONES 2 KARNES 8 KAUFMAN 3 KENDALL 8 KENEDY 11 KENT 2 KERR 8 KIMBLE 9 KING 1 KINNEY 8 KLEBERG 11 KNOX 2 LAMAR 4 LAMB 1 LAMPASAS 7 LA SALLE 8 LAVACA 8 LEE 7 LEON 7 LIBERTY 6 LIMESTONE 7 LIPSCOMB 1 LIVE OAK 11 LLANO 7 LOVING 9 LUBBOCK 1 LYNN 1 MC CULLOCH 9 MC LENNAN 7 MC MULLEN 11 MADISON 7 MARION 4 MARTIN 9 MASON 9 MATAGORDA 6 MAVERICK 8 MEDINA 8 MENARD 9 MIDLAND 9 MILAM 7 MILLS 7 MITCHELL 2 MONTAGUE 2 MONTGOMERY 6 MOORE 1 MORRIS 4 MOTLEY 1 NACOGDOCHES 5 NAVARRO 3 NEWTON 5 NOLAN 2 NUECES 11 OCHILTREE 1 OLDHAM 1 ORANGE 5 PALO PINTO 3 PANOLA 4 PARKER 3 PARMER 1 PECOS 9 POLK 5 POTTER 1 PRESIDIO 10 RAINS 4 RANDALL 1 REAGAN 9 REAL 8 RED RIVER 4 REEVES 9 REFUGIO 11 ROBERTS 1 ROBERTSON 7 ROCKWALL 3 RUNNELS 2 RUSK 4 SABINE 5 SAN AUGUSTINE 5 SAN JACINTO 5 SAN PATRICIO 11 SAN SABA 7 SCHLEICHER 9 SCURRY 2 SHACKELFORD 2 SHELBY 5 SHERMAN 1 SMITH 4 SOMERVILLE 3 STARR 11 STEPHENS 2 STERLING 9 STONEWALL 2 SUTTON 9 SWISHER 1 TARRANT 3 TAYLOR 2 TERRELL 9 TERRY 1 THROCKMORTON 2 TITUS 4 TOM GREEN 9 TRAVIS 7 TRINITY 5 TYLER 5 UPSHUR 4 UPTON 9 UVALDE 8 VAL VERDE 8 VAN ZANDT 4 VICTORIA 8 WALKER 6 WALLER 6 WARD 9 WASHINGTON 7 WEBB 11 WHARTON 6 WHEELER 1 WICHITA 2 WILBARGER 2 WILLACY 11 WILLIAMSON 7 WILSON 8 WINKLER 9 WISE 3 WOOD 4 YOAKUM 1 YOUNG 2 ZAPATA 11 ZAVALA 8 Table 11 27 Prepared by: Center for Health Statistics - HSU, Texas Department of State Health Services, December 2007