tableofcontents

TABLE OF CONTENTS

CHAPTER 1: Trends in the Overall Health Care Market 1 Chart 1.1:Total National Health Expenditures, 1980 – 2011 3

Chart 1.2:Percent Change in Total National Health Expenditures, 3

1991 – 2011

Chart 1.3:Per Capita National Health Expenditures, 1980 – 2011 4

Chart 1.4:National Health Expenditures as a Percentage of 4

Gross Domestic Product, 1991 – 2011

Chart 1.5:National Expenditures for Health Services and 5

Supplies by Category, 1980 and 2011

Chart 1.6:Percent Change in National Expenditures for 6

Health Services and Supplies by Category, 2010 – 2011

Chart 1.7:Percent Change in National Expenditures for Selected 7

Health Services and Supplies, 2001 – 2011

Chart 1.8:National Health Expenditures, 1980 – 2021 7

Chart 1.9:Consumer Out-of-pocket Payments for National Health 8

Expenditures, 1991 – 2011

Chart 1.10:Total Prescription Drug Spending, 1980 – 2011 8

Chart 1.11:Growth in Total Prescription Drug Spending as a 9

Percentage of Total Growth in National Health

Expenditures, 1991 – 2011

Chart 1.12:Consumer Out-of-pocket Spending vs. Private Health 9

Insurance Spending for Prescription Drugs, 1991 – 2011

Chart 1.13:Distribution of National Health Expenditures by Source 10

of Payment, 1980, 2000, and 2011

Chart 1.14:Distribution of Health Insurance Coverage, Percentage of 10

Population Covered by Payer, 1990, 2010, and 2011

Chart 1.15:Number and Percent Uninsured, 1991 – 2011 11

Chart 1.16:Average Percent Uninsured by State, 2009 – 2011 11

Chart 1.17:Medicare Enrollees, 1992 – 2012 12

Chart 1.18:Medicaid Enrollees, 1990, 1995, 2000 – 2012 12

Chart 1.19:National CHIP Enrollment, FY 1999 – FY 2010 13

Chart 1.20:Percent Change in CHIP Enrollment By State, 13

FY 2009 – FY 2010

i

Chart 1.21:Percentage of Employees with Employer-based 14

Coverage Who Can Choose Conventional, PPO, HMO,

POS, and HDHP/SO Plans, 1988 – 2012

Chart 1.22:Distribution of Employer-sponsored Health Insurance 14

Enrollment by Type of Plan, 1988 – 2012

Chart 1.23:Percentage of Medicare Beneficiaries Enrolled in 15

Medicare Managed Care, 1992 – 2012

Chart 1.24:Percent Growth in Medicare Spending per 15

Beneficiary vs. Private Health Insurance Spending per

Enrollee, 1991 – 2011

Chart 1.25:Percentage of Medicaid Beneficiaries Enrolled in 16

Medicaid Managed Care, 1992 – 2011

Chart 1.26:Percentage of Medicaid Beneficiaries Enrolled in 16

Medicaid Managed Care by State, 2011

Chart 1.27:Annual Change in Health Insurance Premiums, 2000 – 2012 17

Chart 1.28:Managed Care Plan Median Operating Margins, 1997 – 2012 17

Chart 1.29:Operating Margins of the Top Insurers, 2010 – 2012 18

CHAPTER 2: Organizational Trends 19 Chart 2.1:Number of Community Hospitals, 1991 – 2011 21

Chart 2.2:Number of Beds and Number of Beds per 1,000 21

Persons, 1991 – 2011

Chart 2.3:Beds per 1,000 Persons by State, 2011 22

Chart 2.4:Number of Hospitals in Health Systems, 2001 – 2011 22

Chart 2.5:Number of Medicare-certified Ambulatory 23

Surgical Centers, 2006 – 2011

Chart 2.6:Percentage of Hospitals with Physician Affiliates by 23

Type of Relationship, 2001 – 2011

Chart 2.7:Percentage of Hospitals with Insurance Products by 24

Type of Insurance, 2001 – 2011

Chart 2.8:Percentage of Hospitals Offering “Non-hospital” 24

Services, 2001 – 2011

Chart 2.9:Announced Hospital Mergers and Acquisitions, 25

1998 – 2012

ii

CHAPTER 3: Utilization and Volume 27 Chart 3.1:Inpatient Admissions in Community Hospitals, 29

1991 – 2011

Chart 3.2:Total Inpatient Days in Community Hospitals, 29

1991 – 2011

Chart 3.3:Inpatient Admissions per 1,000 Persons, 30

1991 – 2011

Chart 3.4:Inpatient Days per 1,000 Persons, 1991 – 2011 30

Chart 3.5:Average Length of Stay in Community Hospitals, 31

1991 – 2011

Chart 3.6:Average Length of Stay in Community Hospitals 31

by State, 2011

Chart 3.7:Emergency Department Visits and Emergency 32

Departments in Community Hospitals, 1991 – 2011

Chart 3.8:Hospital Emergency Department Visits per 1,000 32

Persons, 1991 – 2011

Chart 3.9:Percent of Hospitals Reporting Emergency 33

Department Capacity Issues by Type of Hospital, March 2010

Chart 3.10:Percent of Hospitals Reporting Time on Ambulance 33

Diversion in Last 12 Months, March 2010

Chart 3.11:Conditions Hospitals Reported as Number One Factor 34

Contributing to Ambulance Diversions, March 2010

Chart 3.12:Total Hospital Outpatient Visits in Community Hospitals, 35

1991 – 2011

Chart 3.13:Hospital Outpatient Visits per 1,000 Persons, 35

1991 – 2011

Chart 3.14:Percentage Share of Inpatient vs. Outpatient Surgeries, 36

1991 – 2011

CHAPTER 4: Trends in Hospital Financing 37 Chart 4.1:Percentage of Hospitals with Negative Total and 39

Operating Margins, 1995 – 2011

Chart 4.2:Aggregate Total Hospital Margins, Operating Margins and 39

Patient Margins, 1991 – 2011

Chart 4.3:Distribution of Outpatient vs. Inpatient Revenues, 40

1991 – 2011

iii

Chart 4.4:Annual Change in Hospital Operating Revenue and 40

Expenses per Adjusted Admission, 1991 – 2011

Chart 4.5:Distribution of Hospital Cost by Payer Type, 41

1980, 2000, and 2011

Chart 4.6:Aggregate Hospital Payment-to-cost Ratios for Private 42

Payers, Medicare and Medicaid, 1991 – 2011

Chart 4.7:Hospital Payment Shortfall Relative to Costs for 42

Medicare, Medicaid and Other Government, 1997 – 2011

Chart 4.8:Income from Investments and Other Non-operating 43

Gains as a Percentage of Total Net Revenue,

1991 – 2011

Chart 4.9:Number of Bond Rating Upgrades and Downgrades, 43

Not-for-profit Health Care, 1994 – 2012

Chart 4.10:Median Average Age of Plant, 1991 – 2011 44

Chart 4.11:Percent Change in Employment Cost Index, All Private 44

Service Industries, All Health Services

and Hospitals, 2003 – 2012

CHAPTER 5: Workforce 45 Chart 5.1:Total Number of Active Physicians per 1,000 Persons, 47

1980 – 2010

Chart 5.2:Total Number of Active Physicians per 1,000 Persons 47

by State, 2010

Chart 5.3:Medical and Dental Residents in Training in Community 48

Hospitals, 1991 – 2011

Chart 5.4:Total Full-time Equivalent Employees Working in 48

Hospitals, 1991 – 2011

Chart 5.5:Full-time Equivalent Employees per Adjusted Admission, 49

1991 – 2011

Chart 5.6:Number of RN Full-time Equivalent Employees and RN 49

FTEs per Adjusted Admission, 1991 – 2011

Chart 5.7:RN Full-time Equivalents as a Percentage of Total 50

Hospital Full-time Equivalents, 1991 – 2011

iv

Chart 5.8:Number of Physicians by Age, 1980, 1990, 2000, and 2011 50

Chart 5.9:RN Employment by Type of Provider, 51

1980 – 2008

Chart 5.10:Distribution of RN Workforce by Age Group, 51

1980 – 2008

Chart 5.11:Annual Percentage Change in Entry Level 52

Baccalaureate Nursing Enrollment, 1990 – 2012

Chart 5.12:National Supply and Demand Projections for FTE RNs, 52

2018 – 2025

CHAPTER 6: The Economic Contribution of Hospitals 53 Chart 6.1:National Health Expenditures as a Percentage of Gross Domestic 55

Product and Breakdown of National Health Expenditures, 2011

Chart 6.2:Number of Full-time and Part-time Hospital Employees, 55

1993 – 2011

Chart 6.3:Impact of Community Hospitals on U.S. Economy 56

(in $ billions), 2011

Chart 6.4: Hospital Employment vs. Employment in Other 56

Industries, 2012

Chart 6.5:Average Weekly Earnings of Workers, Hospitals vs. 57

All Service-providing Industries, 1992 – 2012

Chart 6.6:Hospital Employment by Occupation Type, 2012 57

Chart 6.7:Percent Change in Employment, Seasonally-adjusted: 58

Hospital vs. All Industries (Total Non-farm), 2010 – 2012

Chart 6.8:Percent of Total Regional Employment by Hospitals, 58

2011

Chart 6.9:Impact of Community Hospitals on U.S. Jobs 59

(in millions), 2012

Chart 6.10:Percent of Hospital Costs by Type of Expense, 2012 59

Chart 6.11:Hospital Impact on Sectors of the U.S. Economy 60

(in $ billions), 2011

Chart 6.12:Impact of Community Hospitals on U.S. Economy; 61

All States, DC and Total U.S., 2011

CHAPTER 7: Community Health Indicators 63 Chart 7.1:U.S. Population Trends and Projections by Age, 65

1980 – 2060

v

Chart 7.2:U.S. Population Trends and Projections by Race, 65

2015 – 2060

Chart 7.3:Age-adjusted Death Rates, Selected Causes, by Race, 66

2010

Chart 7.4:Percent of People with Chronic Conditions by Number 66

and Sex, 2006

Chart 7.5:Percent of Fee-for-Service Medicare Beneficiaries with 67

Chronic Conditions, 2011

Chart 7.6:Number of Persons with Asthma, 1980 – 2011 67

Chart 7.7:Percent of Adults with Hypertension by Sex, 1988 – 1994 68

and 2007 – 2010

Chart 7.8:Percent of Adults Who Are Overweight and Obese, 68

1960 – 2010

Chart 7.9:Percent of Expenses Used by People with Chronic Conditions 69

by Service Type, 2006

Chart 7.10:Percent of Spending for Individuals with Chronic 69

Conditions by Insurance Status, 2006

Chart 7.11:Percent of Medicare Fee-for Service Beneficiaries vs. Percent 70

of Medicare Spending, by Number of Chronic Conditions, 2011

Chart 7.12:Percent of Medicare Fee-for-Service Spending on Chronic 70

Conditions by Type of Service, 2010

Chart 7.13:Percent Uninsured by Race, 1984 – 2011 71

Chart 7.14:Percent of Adults with No Usual Source of Care by 71

Race, 1993 – 2011

Chart 7.15:Percent of Adults with No Usual Source of Care by 72

Insurance Status, 1993 – 2011

Chart 7.16:Percent of Children with No Usual Source of Care by 72

Race, 1993 – 2011

Chart 7.17:Percent of Children with No Usual Source of Care by 73

Insurance Status, 1993 – 2011

Chart 7.18:Percent of Individuals with No Health Care Visits by Race, 73

Insurance Status, 1997 and 2011

Chart 7.19:Percent of Children with No Health Care Visits by Race, 74

Insurance Status, 1998 and 2011

Chart 7.20:Percent of Children with No Dental Visits by Race, Poverty 74

Status, 1997 and 2011

Chart 7.21:Percent of Children Vaccinated by Race, Poverty Status, 75

2009 and 2011

vi

Chart 7.22:Percent of Women Receiving Mammography by Race, 75

Poverty Status, 1990 and 2010

Chart 7.23:Percent of Adults with Chronic Conditions by Insurance Type 76

2007 – 2008

Chart 7.24:Total Expenditures on Top 10 Most Costly Conditions Among 76

Adults by Sex, 2008

Chart 7.25:30-Day Readmission Rate for Medicare Fee-for Service 77

Beneficiaries by Number of Chronic Conditions, 2011

LIST OF APPENDICES

APPENDIX 1: Supplementary Data Tables, Trends in the Overall Health Care A-3 Market

Table 1.1:Total National Health Expenditures, 1980 – 2011 A-4

Table 1.2:Percent Change in National Expenditures for Selected A-5

Health Services and Supplies, 2001 – 2011

Table 1.3:National Health Expenditures, 1980 – 2021 A-6

Table 1.4:Consumer Out-of-pocket Payments for National Health A-7

Expenditures, 1991 – 2011

Table 1.5:Growth in Total Prescription Drug Spending as a A-8

Percentage of Total Growth in National Health

Expenditures, 1991 – 2011

Table 1.6:Consumer Out-of-pocket Spending vs. Private Health A-9

Insurance Spending for Prescription Drugs, 1991 – 2011

Table 1.7:Number and Percent Uninsured, 1991 – 2011 A-10

Table 1.8:Average Percent Uninsured by State, 2009 – 2011 A-11

Table 1.9:Medicaid Enrollees, 1990, 1995, 2000 – 2012 A-12

Table 1.10:Percent Change in CHIP Enrollment by State, A-13

FY 2009 – FY 2010

Table 1.11:Percentage of Employees with Employer-based A-14

Coverage Who Can Choose Conventional, PPO, HMO,

POS, and HDHP/SO Plans, 1988 – 2012

Table 1.12:Percent Distribution of Employer-sponsored Health A-14

Insurance Enrollment by Type of Plan, 1988 – 2012

Table 1.13:Growth in Medicare Spending per Beneficiary vs. A-15

Private Health Insurance Spending per Enrollee,

1991 – 2011

vii

Table 1.14:Percentage of Medicaid Beneficiaries Enrolled in A-16

Medicaid Managed Care by State, 2010 and 2011

Table 1.15:Operating Margins of the Top Insurers, 2010 – 2012 A-17

APPENDIX 2: Supplementary Data Tables, Organizational Trends A-19 Table 2.1:Number of Community Hospitals, 1991 – 2011 A-20

Table 2.2:Number of Beds and Number of Beds per 1,000 A-21

Persons, 1991 – 2011

Table 2.3:Beds per 1,000 Persons by State, 2010 and 2011 A-22

Table 2.4:Percentage of Hospitals with Physician Affiliates by A-23

Type of Relationship, 2001 – 2011

Table 2.5:Percentage of Hospitals with Insurance Products by A-23

Type of Insurance, 2001 – 2011

Table 2.6:Percentage of Hospitals Offering “Non-hospital” A-24

Services, 2001 – 2011

APPENDIX 3: Supplementary Data Tables, Utilization and Volume A-25 Table 3.1:Trends in Inpatient Utilization in Community A-26

Hospitals, 1991 – 2011

Table 3.2:Average Length of Stay in Community Hospitals A-27

by State, 2010 and 2011

Table 3.3:Emergency Department Visits, Emergency A-28

Department Visits per 1,000 and Number

of Emergency Departments, 1991 – 2011

Table 3.4:Outpatient Utilization in Community Hospitals, A-29

1991 – 2011

APPENDIX 4: Supplementary Data Tables, Trends in Hospital Financing A-31 Table 4.1:Aggregate Total Hospital Margins, Operating Margins A-32

and Patient Margins; Percentage of Hospitals with

Negative Total Margins; and Aggregate Non-operating

Gains as a Percentage of Total Net Revenue,

1991 – 2011

Table 4.2:Distribution of Inpatient vs. Outpatient Revenues, A-33

1991 – 2011

Table 4.3:Annual Change in Hospital Operating Revenue and A-34

Expenses per Adjusted Admission, 1991 – 2011

viii

Table 4.4:Aggregate Hospital Payment-to-cost Ratios for A-35

Private Payers, Medicare, and Medicaid, 1991 – 2011

Table 4.5:Hospital Payment Shortfall Relative to Costs for Medicare, A-36

Medicaid and Other Government, 1997 – 2011

APPENDIX 5: Supplementary Data Tables, Workforce A-37 Table 5.1:Total Number of Active Physicians per 1,000 Persons A-38

by State, 2009 and 2010

Table 5.2:Medical and Dental Residents in Training in Community A-39

Hospitals, 1991 – 2011

Table 5.3:Total Full-time Equivalent Employees Working in A-40

Hospitals and Full-time Equivalents per Adjusted

Admission, 1991 – 2011

Table 5.4:Number of RN Full-time Equivalent Employees, A-41

RN Full-time Equivalent Employees per Adjusted

Admission and RN Full-time Equivalents as a

Percentage of Total FTEs, 1991 – 2011

Table 5.5:Number of Physicians by Age, 1980, 1990, 2000, and 2011 A-42

Table 5.6:RN Employment by Type of Provider, 1980 – 2008 A-42

Table 5.7:Distribution of RN Workforce by Age Group, A-43

1980 – 2008

Table 5.8:National Supply and Demand Projections for FTE RNs, A-44

2018 – 2025

APPENDIX 6: Supplementary Data Tables, The Economic Contribution of A-45 Hospitals

Table 6.1:Number of Full-time and Part-time Hospital A-46

Employees, 1993 – 2011

Table 6.2:Hospital Employment vs. Employment in Other A-47

Industries, 2012

Table 6.3:Average Weekly Earnings of Workers, Hospitals vs. A-48

All Service-providing Industries, 1992 – 2012

APPENDIX 7: Supplementary Data Tables, Community Health Indicators A-49 Table 7.1:U.S. Population Trends and Projections by A-50

Age, 1980 – 2060

Table 7.2:U.S. Population Trends and Projections by A-51

Race, 2015 – 2060

ix

Table 7.3:Age-adjusted Death Rates, Selected Causes, by A-52

Race, 2010

Table 7.4:Number of Persons with Asthma, 1980 – 2011 A-52

Table 7.5:Percent of Adults Who Are Overweight and A-53

Obese, 1960 – 2010

Table 7.6:Percent Uninsured by Race, 1984 – 2011 A-53

Table 7.7:Percent of Persons with No Usual Source of A-54

Care by Race, 1993 – 2011

GLOSSARY A-55 x