Additional Utilization,
Payer and Case Mix Information
for Florida Acute Care Hospitals
Commission on Healthcare and Hospital Funding
May 26, 2015
1
Hospital Pricing vs. Average Payment
10 Most Common Inpatient DRGs @ FL Acute Care Hospitals
$90,000.00
$80,000.00
$70,000.00
$60,000.00
$50,000.00
$40,000.00
$30,000.00
$20,000.00
$10,000.00
$0.00
NORMAL
NEWBORN
Average Charge Per Stay
National Average Payment
(Ver 30.0)
PSYCHOSE
S
VAGINAL
DELIVERY
W/O
COMPLICA
TING
DIAGNOSE
S
ESOPHAGI
TIS
GASTROE
NT & MISC
DIGEST
DISORDER
S W/O
MCC
MAJOR
JOINT
REPLACEM
ENT OR
REATTACH
MENT OF
LOWER
EXTREMIT
Y W/O
MCC
CESAREAN
SECTION
W/O
CC/MCC
CELLULITIS
W/O MCC
NEONATE
W OTHER
SIGNIFICA
NT
PROBLEM
S
SEPTICEMI
A OR
SEVERE
SEPSIS
W/O MV
96+
HOURS W
MCC
KIDNEY &
URINARY
TRACT
INFECTION
S W/O
MCC
$3,024
$17,048
$13,900
$27,989
$71,572
$24,620
$25,607
$6,288
$71,621
$26,997
$891.64
$5,102.18
$3,078.21
$3,944.71
$11,207.26
$4,592.45
$4,488.68
$9,584.86
$10,057.27
$4,177.38
2
Major Joint Replacement by Payer
Medicare
Commercial Health Insurance
Medicare Managed Care
25%
22%
Medicaid Managed Care
Medicaid
TriCare or Other Federal Government
VA
Other State/Local Government
Self pay
Workers' Compensation
46%
Non-Payment
Other
Commercial Liability Coverage
3
Septicemia (Severe Sepsis) by Payer
Medicare
Medicare Managed Care
17%
Commercial Health Insurance
9%
Medicaid
Self pay
6%
58%
3%
2%
Medicaid Managed Care
TriCare or Other Federal Government
Non-Payment
Other
VA
Other State/Local Government
4
Neonate w/ Complications by Payer
Medicaid
Commercial Health Insurance
Self pay
31%
Medicaid Managed Care
TriCare or Other Federal Government
54%
7%
6%
Other
Non-Payment
Other State/Local Government
2%
VA
5
Hospital Payer Mix
Proportion of visits by type of payer
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
National Average
(All Services)
Other Gov't.
Other
None
Medicare
Medicaid
Commercial
3.8
5.8
39.1
16.1
35.2
Florida Inpatient
Florida ED
Florida ASC
2.8
0.3
8.6
45
21.1
22.3
2.6
0.4
22.9
16.8
33.5
23.8
2.7
0.6
3.1
44
7.4
42.2
6
Regional Cost Differences
Medicare is statutorily required to adjust payments for physician fee schedule
services to account for differences in costs due to geographic location.
There are currently 89 different localities which have not been revised since 1997.
Miami
Ft. Lauderdale
Rest of Florida
2.5
2.49
2
1.715
1.5
1
1.315
1.033
1.03
0.96
0.5
0
GPCI PE
GPCI MP
7
Case Mix Index
• Methodology defined by U.S. Centers for Medicare and
Medicaid Services (CMS)
– National average is 1.37
• Minimum: 0.58
• Maximum: 3.73
• Standard Deviation: 0.31
• Calculated/Assigned by Diagnostic Related Group (DRG)
• Indicates amount of resources required to treat patients in
that group, compared to other groups
8
Hospital Case Mix Index
• Reflects diversity, clinical complexity, and resource
needs of population served
• Can be used to adjust for average cost per patient
(or per day), relative to other hospitals
– Hospital CMI >1 = adjusted cost will be lower
– Hospital CMI <1 = adjusted cost will be higher
9
15 Acute Care Hospitals in Florida
with Lowest Hospital Case Mix
(Highest Adjusted Cost)
FACL CNTY NAME
FACL NAME
CASE MIX
(Excluding
Newborns)
TOTAL DISCHARGES
(Excluding Newborns)
LEVY
REGIONAL GENERAL HOSPITAL WILLISTON
0.77
638
MONROE
DEPOO HOSPITAL
0.79
671
MADISON
MADISON COUNTY MEMORIAL HOSPITAL
0.83
343
FRANKLIN
GEORGE E WEEMS MEMORIAL HOSPITAL
0.85
279
WALTON
HEALTHMARK REGIONAL MEDICAL CENTER
0.91
953
ORANGE
FLORIDA HOSPITAL APOPKA
0.91
2,704
CALHOUN
CALHOUN-LIBERTY HOSPITAL
0.91
509
SANTA ROSA
JAY HOSPITAL
0.92
499
BAKER
ED FRASER MEMORIAL HOSPITAL
0.92
172
UNION
LAKE BUTLER HOSPITAL HAND SURGERY CENTER
0.93
62
HOLMES
DOCTORS MEMORIAL HOSPITAL
0.94
787
SUWANNEE
SHANDS LIVE OAK REGIONAL MEDICAL CENTER
0.94
1,252
JACKSON
CAMPBELLTON-GRACEVILLE HOSPITAL
0.95
145
HARDEE
FLORIDA HOSPITAL WAUCHULA
0.96
276
BRADFORD
SHANDS STARKE REGIONAL MEDICAL CENTER
0.96
1,535
10
15 Acute Care Hospitals in Florida
with Highest Case Mix
(Lowest Adjusted Cost)
FACL CNTY NAME
FACL NAME
CASE MIX
(Excluding
Newborns)
TOTAL DISCHARGES
(Excluding Newborns)
COLLIER
PHYSICIANS REGIONAL MEDICAL CENTER - PIN
1.71
6,151
DUVAL
UF HEALTH JACKSONVILLE
1.71
23,564
ORANGE
FLORIDA HOSPITAL
1.71
57,666
MARION
OCALA REGIONAL MEDICAL CENTER
1.72
11,497
PINELLAS
ALL CHILDREN'S HOSPITAL
1.72
7,933
DUVAL
ST VINCENT'S MEDICAL CENTER RIVERSIDE
1.72
25,503
BROWARD
HOLY CROSS HOSPITAL
1.73
16,499
BROWARD
CLEVELAND CLINIC HOSPITAL
1.74
10,132
HILLSBOROUGH
FLORIDA HOSPITAL CARROLLWOOD
1.79
4,424
ORANGE
ORLANDO REGIONAL MEDICAL CENTER
1.88
27,996
HILLSBOROUGH
TAMPA GENERAL HOSPITAL
1.93
41,323
HILLSBOROUGH
SHRINERS HOSPITALS FOR CHILDREN-TAMPA
1.97
282
ALACHUA
UF HEALTH SHANDS HOSPITAL
1.98
39,128
DUVAL
MAYO CLINIC
2.20
12,965
HILLSBOROUGH
H LEE MOFFITT CANCER CENTER & RESEARCH INSTITUTE
2.35
9,336
11
Case Mix by Payer Type
Florida Acute Care Hospitals, CY2013
1.69
1.80
1.60
1.40
1.20
1.44
1.33
1.30
1.05
1.16
1.64
1.56
1.43
1.27
1.47
1.39
1.31
1.15
1.00
0.80
0.60
0.40
0.20
0.00
12
Case Mix by Region
REGION
AVG CASE MIX
1
2
3
4
5
6
7
8
9
10
11
1.32
1.25
1.34
1.45
1.44
1.40
1.31
1.38
1.30
1.32
1.33
13
Medical Expenditure Panel Survey (MEPS)
MEPS is the only national data source measuring how Americans use and pay for medical care,
health insurance, and out-of-pocket spending. Annual surveys of individuals and families, as
well as their health care providers, provide data on health status, the use of medical services,
charges, insurance coverage, and satisfaction with care – annually since 1996.
The MEPS Household Component (MEPS-HC) - information from families and individuals that provides timely,
comprehensive information on the health status of Americans, health insurance coverage, and access, use, and
cost of health services. Includes information on medical expenditures, conditions, and events; demographics;
health insurance coverage; access to care; health status; and jobs held. Each surveyed household is interviewed
five times over a two-year period.
The MEPS Medical Provider Component (MEPS-MPC) - information from providers of medical care that
supplements the information collected from persons in the MEPS-HC sample in order to provide the most
accurate cost data possible.
The MEPS Insurance Component (MEPS-IC) - information from employers in the private sector and state and
local governments on the health insurance coverage offered to their employees. Includes information on the
number and types of private health insurance plans offered, benefits associated with these plans, annual
premiums and contributions to premiums by employers and employees, copayments and coinsurance, by
various employer characteristics (for example, State, industry and firm size).
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Healthcare Cost and Utilization Project (HCUP)
HCUP is the Nation’s most comprehensive source of hospital data, including information on inpatient care, ambulatory care, and emergency department visits. HCUP enables researchers,
insurers, policymakers and others to study health care delivery and patient outcomes over time,
and at the national, regional, State, and community levels.
National (Nationwide) Inpatient Sample (NIS)
The National (Nationwide) Inpatient Sample (NIS) is the largest publicly available all-payer hospital inpatient care database in the United States.
Kids' Inpatient Database (KID)
The Kids' Inpatient Database (KID) is composed of hospital inpatient stays for children and is specifically designed to allow researchers to study a
broad range of conditions and procedures related to children's health.
Nationwide Emergency Department Sample (NEDS)
The Nationwide Emergency Department Sample (NEDS) captures information on emergency department (ED) visits that do not result in an
admission as well as ED visits that result in an admission to the same hospital.
State Inpatient Databases (SID)
The State Inpatient Databases (SID) are a set of hospital databases containing the universe of the inpatient discharge abstracts from
participating States, translated into a uniform format to facilitate multi-State comparisons and analyses.
State Ambulatory Surgery and Services Database (SASD)
The State Ambulatory Surgery and Services Database (SASD) are a set of databases that capture surgeries performed on the same day in which
patients are admitted and released.
State Emergency Department Databases (SEDD)
The State Emergency Department Databases (SEDD) are a set of databases that capture discharge information on all emergency department
visits that do not result in an admission. The SEDD combined with SID discharges that originate in the emergency department are well suited for
research and policy questions that require complete enumeration of hospital-based emergency departments within market areas or States.
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QUESTIONS?
Thank You.
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