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1 Presentation title goes here Subtitle of Presentation Teaching Hospital Characteristics Association of American Medical Colleges

2 Table of Contents Series 1: COTH Overview COTH Hospitals by Category COTH Members by Ownership Category COTH Membership Geography Comparison of Hospitals by Bed Size Series 2: COTH and GME The Role of COTH Hospitals in Graduate Medical Education Residents Educated at COTH and Other Teaching Hospitals Per Resident Amount Series 3: COTH Clinical Services Overview of AAMC-Member Hospital Services Poison Control Centers at AMCs Outpatient Visits, by Bed Size and Teaching Status Comparison of Length of Stay, Case Complexity and Occupancy Rates Among COTH, Other Teaching, and Non-Teaching Hospitals COTH Hospitals Treat Higher Rates of Transfers Mortality is Lower at Teaching Hospitals Series 4: COTH Financial Information Proportion of Charity Care Costs Provided at COTH and Other Hospitals Median Amount of Charity and Uncompensated Care Provided at COTH and Other Hospitals Net Patient Revenue Payer Mix at COTH and Other Hospitals Aggregate Patient Care Margins at COTH and Non-COTH Hospitals Impact of IPPS Medicare Revenue Cuts 2 Series 5: COTH Veteran s Affairs (VA) and Children s Hospitals Distribution of Residents at VA Hospitals Comparison of Children s Teaching Hospitals by Bed Size Distribution of Residents at Children s Teaching Hospitals

3 Table 1-1: COTH Hospitals by Category, 2018 COTH Hospital Category Number of Members Percentage Integrated % Independent % Specialty 7 2.4% Children s % Veteran s Affairs % Other Federal (NIH) 1 0.3% Total Hospitals % Note: Counts exclude corresponding members. Integrated and independent institutions are all short-term, general, nonfederal COTH members. Source: AAMC membership data, November 2017

4 Table 1-2: Integrated and Independent COTH Members by Ownership Category, 2018 Category Number of Members Percent Church % For-profit 7 3.1% Municipal/county/city % Other not-for-profit % State government % Total % Note: Data reflect short-term, general, nonfederal, integrated and independent COTH members. Short-term, general, nonfederal designation obtained from the FY2016 American Hospital Association file. Excludes all corresponding members as well as specialty, children s, VA, and other federal hospitals. Source: AAMC membership data, November 2017 Ownership categories obtained from the FY2016 American Hospital Association data.

5 Chart 1-3: COTH Membership Geography, 2018 Note: Includes independent, integrated, children s, specialty, VA, and other federal hospitals. Counts exclude corresponding members. Integrated and independent institutions are all short-term, general, nonfederal COTH members. Source: AAMC membership data, November 2017

6 Table 1-4: Comparison of Hospitals by Bed Size, FY2016 Bed Size Return to Table of Contents COTH Integrated and Independent Hospitals All Hospitals No. of Hospitals Percent of All COTH No. of Hospitals Percent of All Hospitals Fewer than 200 beds 4 1.8% 3, % beds % % beds % % beds % % 500+ beds % % All % 4, % Note: Data reflect short-term, general, nonfederal hospitals. COTH hospitals reflect integrated and independent COTH members, excluding corresponding members, as well as specialty, children s, VA, and other federal hospitals. Source: AAMC analysis of FY2016 American Hospital Association data

7 Chart 2-1: The Role of COTH Hospitals in Graduate Medical Education, FY2016 COTH Hospitals as a Percent of All Teaching Hospitals Residents Educated at COTH and Other Teaching Hospitals 25% 80% 20% COTH Teaching Other Teaching COTH Teaching Other Teaching 75% Note: Data reflect short-term, general, non-federal hospitals. Data for COTH hospitals reflect integrated and independent COTH members. Source: AAMC analysis of FY2016 American Hospital Association data

8 Table 2-2: Residents Educated at COTH and Other Teaching Hospitals, FY2016 Bed Size COTH Hospitals All Other Teaching Hospitals No. of Hospitals Percent of All COTH Median No. of Residents No. of Hospitals Percent of All Other Teaching Hospitals Median No. of Residents Fewer than % % % % % % % % % % 60 All % % 21 Note: Data reflect short-term, general, nonfederal hospitals. Teaching hospitals are defined as having intern and resident to bed ratio greater than zero (FY2018 IPPS final rule impact file) and reported number of FTE residents in the FY2016 AHA annual survey. The counts of hospitals reflect such a definition. Source: AAMC analysis of FY2016 American Hospital Association data

9 Table 2-3: Per Resident Amount, FY2015 DGME Cost per Trainee Return to Table of Contents There are approximately 107,463 trainees, including 103,197 residents in ACGME and AOA accredited programs. Of trainees in those programs, Medicare only reimburses 84,268 at or below the cap established in Average Cost Average Cost per trainee $165,556 Average Per Resident Amount (PRA)* $110,130 Average Medicare DGME payment per Resident (based on Medicare s share of the PRA) Total Cost of Training in US Teaching Hospitals Total Medicare DGME Payment $43,370 $17.8 billion $3.7 billion Medicare underpayment (based on Medicare share of DGME costs) $3.6 billion *The amount Medicare uses which represents the maximum payment from Medicare per resident assuming 100% of care is borne by Medicare Source: July 2017 Healthcare Cost Report Information System data

10 Overview of AAMC-Member Hospital Services 5% of all U.S. hospitals are AAMC-member teaching hospitals 96% 69% AAMC-member teaching hospitals operate: of comprehensive cancer centers of burn unit beds However, they provide: 25% 31% of Medicaid hospitalizations 2017 AAMC. May not be reproduced without permission. of hospital charity care 71% 61% of level-one trauma centers of pediatric ICU beds Source: AAMC analysis of FY2016 American Hospital Association data, American College of Surgeons Level 1 Trauma Center designations, 2017, and the National Cancer Institute s Office of Cancer Centers, 2017.

11 Chart 3-2: Poison Control Centers at AMCs, 2015 Total Number of Poison Control Centers Academic Medical Center Affiliated Centers COTH Percent of All Centers % Notes: includes US poison control centers only. AMC affiliation is defined as academic school and/or teaching hospital affiliation. Source: AAMC analysis of the American Association of Poison Control Centers, November 2015.

12 Table 3-3: Outpatient Visits, by Bed Size and Teaching Status, FY2016 Bed Size Median Outpatient Visits COTH Hospitals Other Teaching Hospitals Nonteaching Hospitals Fewer than 200 beds 194, ,309 47, beds 331, , , beds 248, , , beds 525, , , beds 695, , ,896 All 549, ,536 57,260 Note: Data reflect short-term, general, nonfederal hospitals. Data for COTH hospitals reflect integrated and independent COTH members. Source: AAMC analysis of FY2016 American Hospital Association data

13 Table 3-4: Comparison of Length of Stay, Case Complexity and Occupancy Rates Among COTH, Other Teaching, and Non-Teaching Hospitals, FY2016 Median Length of Stay (days)* Aggregate Case Mix** Median Occupancy Rate COTH Hospitals % Other Teaching Hospitals % Nonteaching Hospitals % *Length of stay is not adjusted to reflect complexity of patient population (i.e., case mix) **Based on 2015 Medicare claims data Note: Data reflect short-term, general, nonfederal hospitals. Data for COTH hospitals reflect integrated and independent COTH members. Source: AAMC analysis of FY2016 American Hospital Association data

14 Table 3-5: COTH Hospitals Treat Higher Rates of Transfers, 2015 Percent of Medicare Cases that are Transfers Aggregate Case Mix for Transfers COTH Hospitals 11.0% 2.50 Other Teaching Hospitals 5.7% 2.09 Nonteaching Hospitals 2.7% 1.94 Note: Data reflect short-term, general, nonfederal hospitals. Data for COTH hospitals reflect integrated and independent COTH members. Source: Medicare claims data, 2015.

15 Table 3-6: Mortality is Lower at Teaching Hospitals 16% 15.5% 15.0% 13.8% 14% 12% 10% 8% p<0.001 for all results 8.3% 9.2% 9.5% 6% 4% 3.3% 3.6% 3.6% 2% 0% 7 Day Mortality 30 Day Mortality 90 Day Mortality Major Teaching Minor Teaching Non Teaching Burke, Laura G., Austin B. Frakt, Dhruv Khullar, E. John Orav, and Ashish K. Jha. "Association Between Teaching Status and Mortality in US Hospitals." JAMA 317, no. 20 (2017): Model includes state fixed effects and adjusted for correlation of patients at the hospital level. Patient characteristic adjustments include principal discharge Diagnosis Related Group Weight, age, sex, Medicaid eligibility, and Hierarchical Condition Category. Hospital characteristic adjustments include profit status, rural/urban location, and volume of hospitalizations.

16 Chart 4-1: Proportion of Charity Care Costs Provided at COTH, Other Teaching, and Non-Teaching Hospitals, FY % Return to Table of Contents 90% 80% 32% 70% 60% 76% 50% 40% 37% 30% 20% 10% 0% 19% 31% 5% AS A % OF ALL HOSPITALS AS A % OF ALL CHARITY CARE COTH Other Teaching Non-Teaching Note: Data reflect short-term, general, nonfederal hospitals. Data for COTH hospitals reflect integrated and independent COTH members. Charity care is defined as the revenue forgone as a result of care provided without the expectation of payment. Source: AAMC analysis of FY2016 American Hospital Association data

17 Table 4-2: Median Amount of Charity and Uncompensated Care Costs Provided at COTH, Other Teaching, and Nonteaching Hospitals, FY2016 Number of Hospitals Median Amount (Millions of $) Charity Care Costs Uncompensated Care Costs COTH hospitals 224 $15.3 $26.9 Other teaching hospitals 840 $4.3 $8.5 Nonteaching hospitals 3,310 $0.6 $1.9 Note: Data reflect short-term, general, nonfederal hospitals. Data for COTH hospitals reflect integrated and independent COTH members. Charity care is defined as care provided without the expectation of payment. Excludes hospital s bad debt and is measured in terms of costs, not charges. Source: AAMC analysis of a special tabulation using FY2016 American Hospital Association (AHA) data and AAMC COTH membership data as of November 2017.

18 Payer Percent of Net Patient Revenue 100% Return to Table of Contents Chart 4-3: Net Patient Revenue Payer Mix at COTH, Other Teaching, and Nonteaching Hospitals, FY % 80% 70% 60% 50% 48% 41% 42% 40% 30% 31% 37% 39% 20% 10% 0% 17% 17% 14% COTH HOSPITALS OTHER TEACHING HOSPITALS NONTEACHING HOSPITALS Medicaid Medicare 3rd Party Self-Pay Other Note: Data reflect short-term, general, nonfederal hospitals. Data for COTH hospitals reflect integrated and independent COTH members. Gross patient payer mix is defined as net patient revenue from each source divided by total net patient revenue. Source: AAMC analysis of a special tabulation using FY2016 American Hospital Association (AHA) data and AAMC COTH membership data as of November 2017.

19 Aggregate Margin Chart 4-4: Aggregate Margins at COTH and Non-COTH Hospitals, FY % 5% Return to Table of Contents 2.4% 6.2% 4.8% 5.4% 6.5% 0% -5% -2.9% -10% -15% -20% -25% -10.8% -8.3% -30% MEDICARE OVERALL MARGINS ALL PAYER PATIENT CARE MARGINS ALL PAYER OPERATING MARGINS ALL PAYER TOTAL MARGINS COTH Hospitals Non-COTH Hospitals Note: Data reflect short-term, general Medicare hospitals subject to IPPS. Data for COTH hospitals reflect integrated and independent COTH members. Aggregate values by hospital category. General formula for all margin types: (Revenues - Expenses) / Revenues. Each margin type below uses different types of revenues and expenses, described below. Patient Care Margin: both revenues and expenses are defined as those associated with service to patients. Operating Margin: revenues include all sources other than Contributions, Donations, Bequests and Investment Income and expenses include all hospital expenses. Total Margin: revenues include all sources of revenue and expenses include all hospital expenses. Source: Centers for Medicare and Medicaid Services, HCRIS Database, June 30, 2017 update.

20 Chart 4-5: Impact of IPPS Medicare Revenue Cuts to COTH Hospitals, FY2010 FY2018 Notes: Excludes Maryland and Puerto Rico. Includes IPPS payment cuts only, and does not take into account payment cuts to OPPS, IPF, IRF, or other payment systems. Percent cuts for all cuts except sequestration are derived from the FY2010 to FY2018 Medicare IPPS Final Rules. All payment cuts are computed as the difference between what a hospital would be paid without the relevant cut and actual payments. For FY2010 to FY2015, total IPPS payments are as reported on CMS s HCRIS databases. For FY2016, total IPPS payments are estimated using the FY2016 to FY2018 Medicare IPPS Final Rules. Quality pay-for-performance reductions are estimated from adjustment factors for HVBP, HRRP, and HACRP published in the FY2013 to FY2018 Medicare IPPS Final Rules. 1 Source: Appendix B of the Medicare Provisions in the Patient Protection and Affordable Care Act (PPACA): Summary and Timeline. Congressional Research Service. Accessed at:

21 Table 5-1: Distribution of Residents Among VA COTH and Other Teaching VA Hospitals, FY2016 VA COTH Teaching Hospitals All Other Teaching VA Hospitals Number of Hospitals Percent of All VA Teaching Hospitals Total Number of Resident FTEs 37.6% 62.4% 2,780 3,005 Percent of Resident FTEs* 48.1% 51.9% Note: VA hospitals are institutions that are owned, staffed, and operated by the VA for the primary function of providing inpatient services. This chart reflects data submitted by 101 VA teaching hospitals to AHA in their annual survey. *Resident FTEs reflect the total medical and dental full time equivalent (FTE) residents. Source: AAMC analysis of FY2016 American Hospitals Association data.

22 Table 5-2: Comparison of Children s Acute Care Teaching Hospitals by Bed Size, FY2016 Bed Size COTH Children s Hospitals No. of Hospitals Percent of All Children s Teaching Hospitals within Bed Size Category No. of Hospitals All Other Children s Teaching Hospitals Percent of All Children s Teaching Hospitals within Bed Size Category Fewer than % % % % % % % 3 7.9% % 0 0.0% All % % Note: These numbers reflect acute, general, nonfederal children s teaching hospitals. This chart reflects data submitted by 56 Children s Teaching hospitals to AHA. These data exclude non-teaching Children s hospitals. Source: AAMC analysis of FY2016 American Hospitals Association data

23 Table 5-3: Distribution of Residents at Children s Teaching Hospitals, FY2016 COTH Children s Teaching Hospitals Other Children s Teaching Hospitals Number of Hospitals Percent of Residents Educated at Children s Teaching Hospitals 81.9% 18.1% Median Number of Residents and Fellows Note: These numbers reflect acute, general, nonfederal Children s Teaching hospitals. These data exclude Nonteaching Children s hospitals. Not all hospitals that responded to the AHA survey responded to this question, so the number of hospital counts may be lower. Source: AAMC analysis of FY2016 American Hospital Association (AHA) data

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