Teaching Hospitals, FY2017

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Teaching Hospital Characteristics Association of American Medical Colleges

© 2019 AAMC. May not be reproduced without permission. Table of Contents Series 1: AAMC-Member Teaching Hospitals Overview • AAMC-Member Teaching Hospitals by Category • AAMC-Member Teaching Hospitals by Ownership Category • AAMC Membership Geography • Comparison of Hospitals by Bed Size Series 2: AAMC-Member Teaching Hospitals and GME • The Role of AAMC-Member Teaching Hospitals in Graduate Medical Education • Residents Educated at AAMC-Member Teaching and Other Teaching Hospitals • Per Resident Amount • Medicare Coverage of DGME costs Series 3: AAMC-Member Teaching Hospital 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 AAMC-Member Teaching, Other Teaching, and Non-Teaching Hospitals • AAMC-Member Teaching Hospitals Treat Higher Rates of Transfers • Mortality is Lower at Teaching Hospitals Series 4: AAMC-Member Teaching Hospital Financial Information • Proportion of Charity Care Costs Provided at AAMC-Member Teaching and Other Hospitals • Median Amount of Charity and Uncompensated Care Provided at AAMC-Member Teaching and Other Hospitals • Net Patient Revenue Payer Mix at AAMC-Member Teaching and Other Hospitals • Aggregate Patient Care Margins at AAMC-Member and Non-Member Teaching Hospitals • Impact of IPPS Medicare Revenue Cuts Series 5: AAMC-Member Veteran’s Affairs (VA) and Children’s Hospitals • Distribution of Residents at VA Hospitals • Distribution of Residents at Children’s Teaching Hospitals © 2019 AAMC. May not be reproduced without permission. Return to Table of Contents Table 1-1: AAMC-Member Teaching Hospitals by Category, 2019 AAMC-Member Teaching Number of Members Percentage Hospital Category Integrated 115 40.8%

Independent 109 38.7%

Specialty 6 2.1%

Children’s 17 6.0%

Veteran’s Affairs 34 12.1%

Other Federal (NIH) 1 0.4%

Total Hospitals 282 100.0%

Note: Counts exclude corresponding members. Integrated and independent institutions are all short-term, general, nonfederal COTH members.

Source: AAMC membership data, December 2018

Category Number of Members Percent

Church 16 7.1%

For-profit 6 2.7%

Municipal/county/city 24 10.7%

Other not-for-profit 154 68.8%

State government 24 10.7%

Total 224 100.0%

Note: Data reflect short-term, general, nonfederal, integrated and independent COTH members. Short-term, general, nonfederal designation obtained from the FY2017 American Hospital Association file. Excludes all corresponding members as well as specialty, children’s, VA, and other federal hospitals. Source: AAMC membership data, December 2018 Ownership categories obtained from the FY2017 American Hospital Association data.

Count of COTH Members

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 AAMC-member teaching hospitals. Source: AAMC membership data, December 2018

© 2019 AAMC. May not be reproduced without permission. Return to Table of Contents Table 1-4: Comparison of Hospitals by Bed Size, FY2017 Bed Size AAMC-Member Integrated and All Hospitals Independent Hospitals No. of Hospitals Percent of All AAMC No. of Hospitals Percent of All Hospitals

Fewer than 200 beds 5 2.2% 3,114 71.3%

200-299 beds 17 7.6% 497 11.4%

300-399 beds 22 9.8% 304 7.0%

400-499 beds 34 15.2% 170 3.9%

500+ beds 146 65.2% 282 6.5%

All 224 100.0% 4,367 100.0%

Note: Data reflect short-term, general, nonfederal hospitals. AAMC-member hospitals reflect integrated and independent AAMC members, excluding corresponding members, as well as specialty, children’s, VA, and other federal hospitals. Source: AAMC analysis of FY2017 American Hospital Association data

AAMC-Member Teaching Hospitals as a Residents Educated at AAMC-Member and Percent of All Teaching Hospitals Other Teaching Hospitals

26% AAMC Teaching AAMC Teaching 20% 80% Other Teaching Other Teaching 74%

Note: Data reflect short-term, general, non-federal hospitals. Data for AAMC-member teaching hospitals reflect integrated and independent AAMC members. Source: AAMC analysis of FY2017 American Hospital Association data

Bed Size AAMC-Member Teaching Hospitals All Other Teaching Hospitals No. of Percent of All Median No. of No. of Percent of All Other Median No. Hospitals AAMC Residents Hospitals Teaching Hospitals of Residents

Fewer than 200 3 1.6% 79 182 31.5% 11

200-299 14 7.4% 68 141 24.4% 20

300-399 18 9.5% 77 111 19.2% 30

400-499 26 13.7% 242 78 13.5% 47

500+ 129 67.9% 407 66 11.4% 68

All 190 100.0% 274 578 100.0% 24

Note: Data reflect short-term, general, nonfederal hospitals. Teaching hospitals are defined as having intern and resident to bed ratio greater than zero (FY2019 IPPS final rule impact file) and reported number of FTE residents in the FY2017 AHA annual survey. The counts of hospitals reflect such a definition. Source: AAMC analysis of FY2017 American Hospital Association data

© 2019 AAMC. May not be reproduced without permission. Return to Table of Contents Table 2-3: Per Resident Amount, FY2016 There are approximately 109,539 trainees, including 105,808 residents in ACGME and AOA accredited programs. Of trainees in those programs, Medicare only reimburses 85,774 at or below the cap established in 1997. DGME Cost per Trainee Average Cost

Average Cost per trainee $169,280

Average Per Resident Amount (PRA)* $111,526 Average Medicare DGME payment per Resident (based on Medicare’s share of the PRA) $44,205 Total Cost of Training in US Teaching Hospitals $18.5 billion

Total Medicare DGME Payment $3.8 billion Medicare underpayment (based on Medicare share of DGME costs) $3.8 billion *The amount Medicare uses which represents the maximum payment from Medicare per resident assuming 100% of care is borne by Medicare Source: July 2018 Healthcare Cost Report Information System data

$3.79 Billion in Medicare DGME Payments

$14.75 Billion

in DGME Costs Not Paid *DGME Costs Not Paid for by Medicare = $3.83B in Medicare for by Medicare* Costs above the Cap that Medicare does not pay and $10.91B in non- Medicare DGME costs.

Source: AAMC Analysis of the Medicare Cost Reports. FY 2016/FY 2015. Note: This analysis was restricted to hospitals that were included in the FY2019 IPPS impact file released by CMS. Previous years’ data were used for hospitals missing FY 2016 data. About 99% of hospitals reported FY 2016 data, and 1% reported FY 2015. The total training costs include intern and resident salary, fringe, and other costs. © 2019 AAMC. May not be reproduced without permission. Overview of AAMC-Member Hospital Services

AAMC-member teaching hospitals operate:

of all U.S. hospitals are 5% AAMC-member of comprehensive teaching hospitals 98% cancer centers

69% of burn unit beds

However, they provide: of level-one 68% trauma centers 25% 32% of Medicaid of hospital of pediatric ICU hospitalizations charity care 63% beds

Source: AAMC analysis of FY2017 American Hospital Association data, American College of Surgeons Level 1 Trauma Center designations, 2018, and the National Cancer Institute’s Office of Cancer Centers, 2018. Note: Data reflect short-term, general, nonfederal hospitals. © 2019 AAMC. May not be reproduced without permission. Return to Table of Contents Chart 3-2: Poison Control Centers at AMCs, 2015

Total Number of Poison Academic Medical AAMC-Member Control Centers Center Affiliated Teaching Hospitals Centers as Percent of All Centers 57 48 84%

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.

© 2019 AAMC. May not be reproduced without permission. Return to Table of Contents Table 3-3: Outpatient Visits, by Bed Size and Teaching Status, FY2017 Bed Size Median Outpatient Visits AAMC-Member Other Teaching Nonteaching Teaching Hospitals Hospitals Hospitals Fewer than 200 beds 317,568 125,128 49,079

200-299 beds 355,435 195,015 145,374

300-399 beds 240,218 215,785 202,771

400-499 beds 488,443 333,727 277,912

500+ beds 670,907 427,914 313,894

All 552,556 203,287 58,533

Note: Data reflect short-term, general, nonfederal hospitals. Data for AAMC-member teaching hospitals reflect integrated and independent AAMC members. Source: AAMC analysis of FY2017 American Hospital Association data

© 2019 AAMC. May not be reproduced without permission. Return to Table of Contents Table 3-4: Comparison of Length of Stay, Case Complexity and Occupancy Rates Among AAMC-Member Teaching, Other Teaching, and Non-Teaching Hospitals

Median Aggregate Median Occupancy Rate Length of Case Mix** Stay (days)* AAMC-Member Teaching Hospitals 5.7 2.05 76%

Other Teaching Hospitals 4.7 1.75 64%

Nonteaching Hospitals 4.4 1.63 46%

*Length of stay is not adjusted to reflect complexity of patient population (i.e., case mix) **Based on 2016 Medicare claims data

Note: Data reflect short-term, general, nonfederal hospitals. Data for AAMC-member teaching hospitals reflect integrated and independent AAMC members.

Source: AAMC analysis of FY2017 American Hospital Association data

Table 3-5: AAMC-Member Teaching Hospitals Treat Higher Rates of Transfers, 2016

Percent of Medicare Aggregate Case Mix Inpatient Cases that for Transfers are Transfers AAMC-Member Teaching Hospitals 12.7% 2.58

Other Teaching Hospitals 6.3% 2.14

Nonteaching Hospitals 2.8% 2.01

Note: Data reflect short-term, general, nonfederal hospitals. Data for AAMC-member teaching hospitals reflect integrated and independent AAMC members.

Source: Medicare claims data, 2016.

12% p<0.001 for all results 10% 9.2% 9.5% 8.3% 8%

4% 3.3% 3.6% 3.6%

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): 2105-2113.

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.

© 2019 AAMC. May not be reproduced without permission. Return to Table of Contents Chart 4-1: Proportion of Charity Care Costs Provided at AAMC-Member Teaching, Other Teaching, and Non- Teaching Hospitals, FY2017

100%

90% 32% 80%

70%

60% 75%

50% 35%

40%

30%

20% 19% 32% 10%

0% 5% AS A % OF ALL HOSPITALS AS A % OF ALL CHARITY CARE AAMC Other Teaching Non-Teaching

Note: Data reflect short-term, general, nonfederal hospitals. Data for AAMC-member teaching hospitals reflect integrated and independent AAMC members. Charity care is defined as the revenue forgone as a result of care provided without the expectation of payment. As these labels are rounded percentages, the totals for each bar may not add up to 100%.

Source: AAMC analysis of FY2017 American Hospital Association data

© 2019 AAMC. May not be reproduced without permission. Return to Table of Contents Table 4-2: Median Amount of Charity and Uncompensated Care Costs Provided at AAMC-Member, Other Teaching, and Nonteaching Hospitals, FY2017

Median Amount (Millions of $) Number of Hospitals Charity Care Uncompensated Costs Care Costs AAMC-member teaching hospitals 224 $15.3 $26.8

Other teaching hospitals 851 $4.2 $8.4

Nonteaching hospitals 3,292 $0.6 $2.0

Note: Data reflect short-term, general, nonfederal hospitals. Data for AAMC-member teaching hospitals reflect integrated and independent AAMC 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 FY2017 American Hospital Association (AHA) data and AAMC membership data as of December 2018.

90%

80% 40% 41% 70% 48%

60%

50%

40% 38% 31% 39% 30%

20%

10% 18% Payer Percent of Net Patient Revenue Patient Net of Percent Payer 17% 14% 0% AAMC HOSPITALS OTHER TEACHING HOSPITALS NONTEACHING HOSPITALS Medicaid Medicare 3rd Party Self-Pay Other

Note: Data reflect short-term, general, nonfederal hospitals. Data for AAMC-member teaching hospitals reflect integrated and independent AAMC 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 FY2017 American Hospital Association (AHA) data and AAMC membership data as of December 2018.

10% 6.9% 5.4% 5.9% 6.5% 5% 2.0% 0%

-5% -3.5% -10% -9.8% -15% -12.1%

Aggregate Margin Aggregate -20%

-25%

-30% MEDICARE OVERALL ALL PAYER PATIENT ALL PAYER OPERATING ALL PAYER TOTAL MARGINS CARE MARGINS MARGINS MARGINS

AAMC-Member Hospitals Non-AAMC-Member Hospitals

Note: Data reflect short-term, general Medicare hospitals subject to IPPS. Data for AAMC-member teaching hospitals reflect integrated and independent AAMC 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, 2018 update.

Notes: 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 FY2019 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 FY2016, total IPPS payments are as reported on CMS’s HCRIS databases. For FY2017-FY2019, total IPPS payments are estimated using the Medicare IPPS Final Rules. Quality pay-for-performance reductions are estimated from adjustment factors for HVBP, HRRP, and HACRP published in the FY2013 to FY2019 Medicare IPPS Final Rules. AAMC membership is as of September 2018. 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: http://www.ncsl.org/documents/health/ACAMCProv.pdf © 2019 AAMC. May not be reproduced without permission. Return to Table of Contents Table 5-1: Distribution of Residents Among VA AAMC- Member and Other Teaching VA Hospitals, FY2017

VA AAMC-Member All Other Teaching Teaching Hospitals VA Hospitals

Number of Hospitals 31 73

Percent of All VA Teaching Hospitals 29.8% 70.2% Total Number of Resident FTEs 983 1,216

Percent of Resident FTEs* 44.7% 55.3%

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 104 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 FY2017 American Hospitals Association data.

AAMC-Member Other Children’s Children’s Teaching Teaching Hospitals Hospitals

Number of Hospitals 17 38

Percent of Residents Educated at Children’s 80.1% 19.9% Teaching Hospitals Median Number of Residents and Fellows 134 33

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 FY2017 American Hospital Association (AHA) data