Patient Migration Trends Impacting Hospitals, Physicians, - - PowerPoint PPT Presentation

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Aug 27, 2022 268 likes •436 views

Patient Migration Trends Impacting Hospitals, Physicians, Communities, and the State Medical Facilities Plan Christopher G. Ullrich, MD, FACR, OLLP Chairman, North Carolina State Health Coordinating Council March 4, 2020 NCDHHS, Division of

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Patient Migration Trends Impacting Hospitals, Physicians, Communities, and the State Medical Facilities Plan

Christopher G. Ullrich, MD, FACR, OLLP

Chairman, North Carolina State Health Coordinating Council March 4, 2020

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This presentation is a general overview meant to provide members of the SHCC with basic information. Any data errors present are unintentional. Nothing said during this presentation should be construed as either an endorsement or a criticism of the providers mentioned. I want to express my personal appreciation to Amy Craddock and Tom Dickson who supplied data and helped me refine today’s presentation.

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Medical Care is a Highly Constrained “Economic Ecosystem”

Medicare, Medicaid, & TRICARE use annual government

price fixing formulas.

Medicare Physician payments are calculated at 50% of the cost of

service; No operating margin component!

For physician specialists, NC Medicaid is 72-78% of NC Medicare.
Most physician private insurance contracts are indexed to the

Medicare Resource Based Relative Value Scale (RBRVS)

Hospital integration, physician alignment, insurance-related

narrow networks, benefit managers, steerage, out of network issues, episodes of care and bundled payments, ACOs, CINs, provider at-risk contracts, etc. create economic constraints for patients, physicians, and hospitals.

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Hospitals within Health Systems

Sources: American Hospital Association, 2016 Hospitals Statistics Book 57% 59% 65% 62% 77% 66% 65% 86% 77% 40% 60% 80%

US NC SC

2008 2011 2014 2008 2011 2014 2008 2011 2014

Today, many hospitals have joined integrated networks to gain economies of scale, contracting and information technology expertise , and to more effectively leverage network offerings.

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North Carolina Has 100 Counties

15 have 2 full service hospitals / systems. One county

has 3 systems.

66 have 1 full service hospital.
18 have no hospital.
19 critical access hospitals (4 recent insolvencies).
Large integrated hospital and university systems with

employed physicians are very common.

Large private practice or corporate single-specialty and

multi-service line corporations with employed physicians are growing.

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Out-Migration of General Acute Care Inpatient Admissions: 2007, 2008, 2015- 2018

34 26 21 43 26 14 41 26 14 44 22 15 43 24 14 44 23 14 5 10 15 20 25 30 35 40 45 50 > = 50% 30% - 49.99% < 30%

Number of Counties % Out-Migration

2007 (N=81) 2008 (N=83) 2015(N=81) 2016 (N=81) 2017 (N=81) 2018 (N=81)

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Out-Migration of Inpatient Surgical Cases: 2007, 2015-2018

48 23 9 52 13 10 54 11 10 51 14 10 51 13 10 10 20 30 40 50 60 > = 50% 30% - 49.99% < 30%

Number of Counties % Out-Migration

2007 (N=80) 2015 (N=75) 2016 (N=75) 2017 (N=75) 2018 (N=74)

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Out-Migration of Ambulatory Surgical Cases: 2007, 2015-2018

41 23 18 47 19 14 50 15 14 50 16 13 51 14 14 10 20 30 40 50 60 > = 50% 30% - 49.99% < 30%

Number of Counties % Out-Migration

2007 (N=82) 2015 (N=80) 2016 (N=79) 2017 (N=79) 2018 (N=79)

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Out-of-County Migration of Fixed MRI Patients: 2015-2018

18 24 18 23 23 19 23 24 16 31 19 14 5 10 15 20 25 30 35 > = 50% 30% - 49.99% < 30%

Number of Counties % Out-Migration

2015 (N=60) 2016 (N=65) 2017 (N=63) 2018 (N=65)

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Why are patients migrating out of county?

1. Access to specialized care and perceptions
f quality and service
2. Integrated health systems
3. Various restrictive insurance networks
4. Most are not migrating for lower cost care
5. Etc…

There is surprisingly little reliable hard data. Commonly discussed reasons include:

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Total Hospitals in North Carolina, 2018

“Other 91”

Mostly smaller and rural hospitals in North Carolina

“Big 15”

The top 15 hospitals, ranked by ADC, in urban and suburban counties in North Carolina

“Top 5”

Within the top 15, the top 5 are the Academic Medical Center Teaching Hospitals

106

Source: 2019 License Renewal Applications

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Big15 Hospitals in North Carolina, 2018

Big 15 Hospitals 2018 Average Daily Census % Occupancy Carolinas Medical Center

858 84.9

Duke University Medical Center

801 85.3

UNC Medical Center

673 83.1

North Carolina Baptist Hospital

637 79.3

Vidant Medical Center

619 73.0

Novant Health Forsyth

594 68.6

Mission Hospital

530 74.9

New Hanover Regional Medical Center

494 76.3

Cone Health

460 59.2

Cape Fear Valley Medical Center

454 86.5

WakeMed

438 69.9

Novant Health Presbyterian

348 61.3

UNC Rex Hospital

314 71.5

Atrium Health Cabarrus

290 64.8

First Health Moore Regional Hospital

244 72.3

Source: 2019 License Renewal Applica- tions

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Trends Impacting the SMFP

67 NC counties have 1 hospital; 19 Critical Access

Hospitals are currently operational; 18 NC counties do not have an operational hospital now.

Medical care is a highly constrained economic ecosystem

(market).

Integrated hospital systems and physician groups are a

megatrend.

Patients are choosing to receive their care in more

centralized facilities. The “Big 15” are providing more care. Many of the “Other 91” struggle. The “Top 5” are NC’s Academic Medical Centers.

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Trends Impacting the SMFP

SHCC policies need to avoid damaging the “Other 91” if

patient access is to be maintained in many of our NC

counties. Our most specialized hospitals also need

adequate facility capacity to meet patient’s site of care choices and needs.

For many reasons, the 20th century health care delivery

model is no longer sustainable. Patient and physician preferences, as well as changing government and insurance payment levels, models, and policies increasingly require a transition to a 21st century health care delivery paradigm.

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