2010 Healthcare Business Market Handbook

The 2010 Healthcare Business Market Research Handbook
Richard K. Miller & Associates
since 1972
THE 2010 HEALTHCARE BUSINESS MARKET RESEARCH HANDBOOK
By: Richard K. Miller and Kelli Washington
Published by: Richard K. Miller & Associates 4132 Atlanta Highway, Suite 110 Loganville, GA 30052 (770) 466-9709 www.rkma.com
Richard K. Miller & Associates
since 1972

Copyright 2010 by Richard K. Miller & Associates
All rights reserved. Printed in the United States of Am erica. Use of the electronic edition of this publication is lim ited to internal use within the purchasing organization. The electronic edition m ay be stored on com puters, Intranets, servers, and networks by organizations which have purchased this publication, and those for which an em ployee has m ade such purchase. Copies, including m ultiple copies, m ay be printed from the electronic edition for use within the purchasing organization. Libraries m ay store the electronic edition on an archival database or proxy server for access by library users. Governm ental agencies purchasing this publication m ay share the content within the agency or departm ent. Universities and colleges m ay share the inform ation within their cam pus, but not with other universities. Mem bership associations m ay use the inform ation within their internal organization, but m ay not distribute to their m em bership. This publication m ay not be stored on Internet websites, nor m ay it be file-shared through the Internet. This publication m ay not be resold or distributed without prior written agreem ent with the publisher. W hile every attem pt is m ade to provide accurate inform ation, the author and publisher cannot be held accountable for any errors or om issions.
ISBN Number: 1-57783-157-8
Richard K. Miller & Associates 4132 Atlanta Highway, Suite 110 Loganville, GA 30052 (770) 466-9709 www.rkma.com
CONTENTS
PART I: 1 2 3 4 5 6 7 PART II: 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 AMERICAS HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 ARRA FUNDING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 DEMOGRAPHICS OF HEALTHCARE SPENDING . . . . . . . . . . . . . . . . . . 13 GEOGRAPHIC VARIATIONS IN HEALTHCARE SPENDING . . . . . . . . . . 17 NATIONAL HEALTH EXPENDITURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 OBESITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 SMOKING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 STATE HEALTH RANKINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 HOSPITALS & HEALTHCARE PROVIDERS . . . . . . . . . . . . . . . . . . . . . . CHILDRENS HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . COMPARATIVE EFFECTIVENESS RESEARCH . . . . . . . . . . . . . . . . . . . . COMPLEMENTARY & ALTERNATIVE MEDICINE . . . . . . . . . . . . . . . . . . . CONVENIENT-CARE CLINICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DEBT COLLECTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DESIGN & CONSTRUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ECONOMIC CONTRIBUTION OF HOSPITALS . . . . . . . . . . . . . . . . . . . . . ELECTRONIC MEDICAL RECORDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . EMERGENCY DEPARTMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FINANCIAL ISSUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GREEN HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GROUP PURCHASING ORGANIZATIONS . . . . . . . . . . . . . . . . . . . . . . . . HOME CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOSPICE & PALLIATIVE CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOSPITAL PATIENT DIAGNOSES, PROCEDURES & SPENDING . . . . . HOSPITAL-ACQUIRED INFECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOSPITALS IN PURSUIT OF EXCELLENCE . . . . . . . . . . . . . . . . . . . . . . IMPACT OF THE ECONOMIC CRISIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . INFECTION PREVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . INFORMATION TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LARGEST HEALTHCARE SYSTEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LARGEST HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LONG-TERM CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MARKETING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MEDICAL LIABILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MEDICAL TOURISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MEDICARE & MEDICAID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NEW HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OUTSOURCING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PATIENT SATISFACTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PATIENT SATISFACTION MEASUREMENT . . . . . . . . . . . . . . . . . . . . . . . PATIENTS FROM OVERSEAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PAY-FOR-PERFORMANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PREVENTABLE MEDICAL ERRORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 28 30 33 35 37 39 41 43 44 48 50 51 53 55 57 59 61 62 63 65 66 68 69 71 73 75 78 79 80 82 84 85 87 89
42 43 44 45 46 47 48 49 50
PRIMARY CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 PROFILE OF U.S. HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 QUALITY & PATIENT SAFETY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 READMISSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 RURAL HEALTHCARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 SPECIALTY HOSPITALS & CENTERS . . . . . . . . . . . . . . . . . . . . . . . . . . 104 STATE SPENDING FOR HOSPITAL CARE . . . . . . . . . . . . . . . . . . . . . . . 107 TOP ISSUES CONFRONTING HOSPITALS . . . . . . . . . . . . . . . . . . . . . . 108 UNCOMPENSATED HOSPITAL CARE . . . . . . . . . . . . . . . . . . . . . . . . . . 109 110 111 112 115 124 125 128 131 132 133 134 135 138 141 143 146 153 154 156 158 161 163 164 166 169 171 173 174 175 178 180 182 184 186 187 189
PART III: AWARD-WINNING HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 CIRCLE OF LIFE AWARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 COMMUNITY VALUE INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 CONSUMER CHOICE AWARDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 DESIGN AWARDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 MOST HIGHLY INTEGRATED HEALTHCARE NETWORKS . . . . . . . . . . 56 MOST WIRED HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 NATIONAL QUALITY HEALTHCARE AWARD . . . . . . . . . . . . . . . . . . . . . 58 NOVA AWARDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 QUEST FOR QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 SPIRIT OF EXCELLENCE AWARDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 TOP 100 HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 TOP CARDIOVASCULAR HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . . . 63 TOP HEALTHCARE SYSTEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 TOP-RANKED CHILDRENS HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . 65 TOP-RANKED HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PART IV: HEALTH INSURANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 BENEFICIARY SATISFACTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 COST-CONTROL INITIATIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 EMPLOYER-SPONSORED HEALTH INSURANCE PREMIUMS . . . . . . . 69 INDIVIDUAL INSURANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 LARGEST HEALTH INSURERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 MEDICAL SPENDING FOR PPO-COVERED FAMILIES . . . . . . . . . . . . . 72 MEDICARE & MEDICAID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 STATE CHILDRENS HEALTH INSURANCE PROGRAM . . . . . . . . . . . . 74 TOP-RANKED HEALTH INSURANCE PLANS . . . . . . . . . . . . . . . . . . . . . PART V: PHARMACEUTICALS & MEDICAL DEVICES . . . . . . . . . . . . . . . . . . . . 75 DISTRIBUTION CHANNELS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 DRUG CLASSIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 LARGEST PHARMACEUTICAL COMPANIES . . . . . . . . . . . . . . . . . . . . . 78 MARKET FORECAST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 MEDICAL DEVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 PERSONALIZED MEDICINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 PRESCRIPTION DRUG USE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 PROMOTIONAL SPENDING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 STEM CELL RESEARCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
84 TOP-SELLING PHARMACEUTICAL PRODUCTS . . . . . . . . . . . . . . . . . . 191 85 TOP-SELLING THERAPEUTIC DRUG CLASSES . . . . . . . . . . . . . . . . . . 192 PART VI: DISEASES & TREATMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 ALCOHOL ADDICTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 ALLERGIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 ALZHEIMERS DISEASE & DEMENTIA . . . . . . . . . . . . . . . . . . . . . . . . . . 89 ARTHRITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 ASTHMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 BARIATRIC SURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 BEHAVIORAL & MENTAL HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 CARDIOVASCULAR DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 CHRONIC CONDITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 CHRONIC OBSTRUCTIVE PULMONARY DISEASE . . . . . . . . . . . . . . . . 97 COLDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 COSMETIC & RECONSTRUCTIVE SURGERY . . . . . . . . . . . . . . . . . . . . 99 DIABETES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 END-OF-LIFE CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 HEADACHES & MIGRAINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 HIV & AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 INFECTIOUS DISEASES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 INFLUENZA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 KIDNEY DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 OPHTHALMOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 ORGAN TRANSPLANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 ORTHOPEDICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 OSTEOPOROSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 PAIN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 ROBOTIC SURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 SLEEP DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 SUBSTANCE ABUSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 SURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PART VII: HEALTHCARE PROFESSIONALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 HEALTHCARE WORKFORCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 HOSPITAL EXECUTIVE COMPENSATION . . . . . . . . . . . . . . . . . . . . . . 117 MEDICAL SCHOOLS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 NURSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 NURSING SCHOOLS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 PHYSICIAN COMPENSATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 PHYSICIANS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 195 197 200 203 205 208 210 213 217 220 222 224 225 227 230 233 235 238 241 243 245 248 252 256 258 260 262 265 268 270 271 272 273 275 279 281 283
PART I: AMERICAS HEALTH
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1 ARRA FUNDING
Of the $787 billion in funds for the American Recovery and Reinvestment Act (ARRA) of 2009 (P.L. 111-5), signed into law by Pres. Barack Obama in February 2009 and commonly known as the stimulus package, $151 billion is designated to fund healthcare projects. This funding is summarized in this chapter.
and healthcare providers to facilitate greater use of broadband services to enhance healthcare delivery. Grantees m a y b e n o n-prof it f oundat i on s , corporations, institutions, or associations. Other eligible grantees may be identified by the Commerce Department by rule at a later time.
BIOMEDICAL RESEARCH
$8.2 billion for expanding biomedical research Agency: National Institutes of Health (NIH) Description: To expand jobs in biomedical research to study diseases: $7.4 million will be distributed to specific NIH institutes and centers and to the common fund for biomedical research grants; $800 million will be used by the Office of the Director for purposes that can be completed within two years, including short-term grants focused on specific scientific challenges, new research that expands the scope of ongoing projects, research on public and international health priorities, and to enhance central research support activities.
COBRA CONTINUATION COVERAGE

$24.7 billion for Consolidated Omnibus Budget Reconciliation Act (COBRA) Continuation Coverage Agency: U.S. Department of Labor, Group Health Plan Description: To provide individuals and their families with a premium subsidy of 65% of the COBRA continuation premiums for a maximum of nine months of coverage only with respect to involuntary terminations that occurred on or after September 1, 2008, and before January 1, 2010.
COMMUNITY HEALTH CENTER INFRASTRUCTURE GRANTS

$1.5 billion for Community Health Centers Agency: U.S. Department of Health and Human Services Description: To renovate clinics and make health information technology improvements. These funds will be distributed through a competitive grants process and are to be used for construction, renovation, and equipment, and for the acquisition of health
BROADBAND TECHNOLOGY OPPORTUNITIES ACT

$4.35 billion for grants and other initiatives Agency: National Telecommunications and Information Administration Description: Grants for education on broadband technology, awareness, training, access, equipment, and support to medical
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information technology systems for community health centers, including health center-controlled networks receiving operating grants under section 330 of the Public Health Service Act.
NIH, and $400 million will be allocated at the discretion of the Secretary of HHS.
FACILITIES CONSTRUCTION
$415 million included for facilities construction, to be distributed as follows: $227 million for two new facilities on the Indian Priority Facilities List, $100 million for maintenance and improvements, $68 million for construction, repair and maintenance of sanitation facilities, and $20 million for purchase of medical equipment Agency: U.S. Department of Labor Description: The objectives of the Indian Health Service health facilities management, healthcare facilities construction, sanitation facilities construction, and environmental health services programs are: 1. To provide optimum availability of functional, well-maintained IHS and tribally operated healthcare facilities and adequate staff housing at healthcare delivery locations where no suitable housing alternative is available 2. To reduce the incidence of environmentally related illness and injury by: a. Determining and addressing factors contributing to injuries b. Working with the tribes to improve environmental conditions c. Constructing sanitation facilities and ensuring the availability of safe water supply and adequate waste disposal facilities in American Indian and Alaska Native homes and communities. Funding will be used for facilities construction projects, deferred maintenance and improvement projects, the backlog of sanitation projects, and the purchase of equipment.
COMMUNITY HEALTH CENTER SERVICES GRANTS $500 million for Community Health
Centers Agency: U.S. Department of Health and Human Services Description: To increase the number of uninsured Americans who receive quality healthcare. These funds will be dispersed through a competitive grants process and are to be used to support new sites and service areas, to increase services at existing sites, and to provide supplemental payments for spikes in uninsured populations.
COMPARATIVE EFFECTIVENESS RESEARCH

$1.1 billion to compare the effectiveness of different medical treatments Agencies: Agency on Healthcare Research and Quality (AHRQ) and National Institutes of Health (NIH) Description: This funding, to be dispersed through a competitive grants process, will be used to conduct or support research to evaluate and compare clinical outcomes, effectiveness, risk, and benefits of two or more medical treatments and services that address a particular medical condition. This research will not be used to mandate coverage decisions or impose "one sizefits-all" medicine on patients. It will be designed to enable medical professionals and patients to improve treatment. Of total funding, $300 million will be administered by AHRQ, $400 million will be transferred to
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10
HEALTH INFORMATION TECHNOLOGY GRANTS

$2.0 billion for discretionary grants to promote the adoption and use of interoperable health information technology Agencies: Office of the National Coordinator of Health Information Technology, Agency for Healthcare Research and Quality, CDC, and Indian Health Service/states or state-designated entities Description: To promote the use and exchange of electronic health information in a manner consistent with the Office of the National Coordinator of Health Information Technologys strategic plan. To award planning and implementation grants to states or qualified state-designated entities to facilitate and expand electronic health information exchange. To award grants to states or Indian tribes to establish loan programs for healthcare providers to purchase certified electronic health record technology, train personnel in the use of such technology, and improve the secure electronic exchange of health information. To provide financial assistance to universities to establish or expand medical informatics programs.
Health Records (EHR). Provides eligible professionals who show meaningful use of an EHR in 2011 or 2012 with incentive payments of $18,000 in the first year. Payment adjustments for eligible professionals not demonstrating meaningful use of an EHR would begin in 2015. Provides eligible hospitals with incentive payments starting in Fiscal Year 2011 and payments adjustments for hospitals not demonstrating meaningful use of an EHR in FY2015.
HEALTHCARE WORKFORCE
$200 million for programs under Title VII and Title VIII of the Public Health Service Act Agency: Bureau of Health Professions, Health Resources and Services Administration Description: To provide for training of health professions. These competitive grants, scholarships, and loan repayment programs will be used for all the disciplines trained through the primary care medicine and dentistry program, the public health and preventive medicine program, and the scholarship and loan repayment programs for nurses and health professions.
HEALTH INFORMATION TECHNOLOGY IMPROVEMENTS

$17.0 billion to improve investments and incentives through Medicare and Medicaid to ensure widespread adoption and use of interoperable health information technology (HIT) Agency: Centers for Medicare and Medicaid Services (CMS) Description: Provides incentives for the early adoption and use of interoperable HIT to Medicare and Medicaid providers and penalties in future years for providers not demonstrating meaningful use of Electronic
MEDICAID FEDERAL MATCHING ASSISTANCE PERCENTAGE

$87.0 billion for increases in the Medicaid program Agency: Centers for Medicare and Medicaid Services Description: Provides each state with an increase in federal matching funds for state Medicaid expenditures in order to assist states with budget shortfalls to avoid cutting back Medicaid assistance. States are required to maintain at least current eligibility for the Medicaid program in order to receive this funding.
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11
NATIONAL HEALTH SERVICE CORPS

$300 million for the National Health Service Corps Agency: Health Resources and Services Administration Description: To address shortages of primary healthcare providers in specific health professional shortage areas. These competitive grants, scholarships, and loan repayment programs will be used for training primary healthcare providers including doctors, dentists, and nurses as well as helping to pay medical school expenses for students who agree to practice in underserved communities through the National Health Service Corps.
healthcare facilities in rural areas Agency: U.S. Department of Agriculture Description: Provides loans and grants for non-profit corporations in rural areas (fewer than 20,000 people) providing essential community services for construction, enlargement or improvement of essential community facilities, including healthcare facilities. Funds to acquire land, pay professional fees, and purchase equipment.
TRAINING AND EMPLOYMENT SERVICES

$250 million for grants Agency: Department of Labor, Employment and Training Administration Description: Grants for worker training and placement in high growth and emerging industry sectors, including healthcare.
PREVENTION AND WELLNESS PROGRAM

$1 billion for evidence-based clinical and community prevention and wellness programs Agency: U.S. Department of Health and Human Services, Center for Disease Control and Prevention Description: To support state and local efforts to fight preventable chronic diseases and infectious diseases. Funds will be dispersed through a competitive grants process to carry out evidence-based clinical and community-based prevention and wellness strategies and public health workforce development activities, including immunization programs and state efforts to reduce healthcare-related infections.
UNIVERSITY RESEARCH FACILITIES

$1.3 billion to renovate and equip university research facilities Agency: National Institutes of Health, National Center for Research Resources Description: These funds will be distributed using the competitive grants process and will be used for the construction and renovation of extramural research facilities and for the acquisition of shared instrumentation and other capital research equipment.
RURAL COMMUNITY FACILITIES PROGRAM ACCOUNT

$130 million for loans and grants for construction, enlargement or improvement of essential community facilities, including
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DEMOGRAPHICS OF HEALTHCARE SPENDING
This chapter presents an analysis of consumer out-of-pocket healthcare spending. The assessment is based on the Consumer Spending Survey of the Bureau of Labor Statistics and is part of the 5th edition of Whos Buying Health Care, published by New Strategist. The assessment focuses on health insurance (including Medicare), medical services (including physician, hospital, and dental services), and pharmaceuticals (including prescription and nonprescription). The total annual consumer out-of-pocket spending in these three areas is as follows: Health insurance: $174.1 billion Medical services: $ 79.7 billion Pharmaceuticals: $ 61.0 billion Further assessment is made of each of the three healthcare areas for the following demographics: Age of householder Household income Type of household Race and ethnicity Region Education
45-to-54: 55-to-64: 65-to-74: 75 and older: Average household:
$1,310 $1,676 $2,718 $2,510 $1,465
By age of householder, average annual consumer out-of-pocket spending for medical services is as follows: Under age 25: $193 25-to-34: $469 35-to-44: $634 45-to-54: $798 55-to-64: $978 65-to-74: $636 75 and older: $692 Average household: $670 By age of householder, average annual consumer out-of-pocket spending for pharmaceuticals is as follows: Under age 25: $ 97 25-to-34: $243 35-to-44: $345 45-to-54: $499 55-to-64: $759 65-to-74: $859 75 and older: $916 Average household: $514
HEALTHCARE SPENDING BY AGE

By age of householder, average annual consumer out-of-pocket spending for health insurance is as follows: Under age 25: $ 367 25-to-34: $ 883 35-to-44: $1,214
HEALTHCARE SPENDING BY HOUSEHOLD INCOME

By household income, average annual consumer out-of-pocket spending for health insurance is as follows:
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Under $20,000: $20,000 to $39,999: $40,000 to $49,999: $50,000 to $69,999: $70,000 to $79,999: $80,000 to $99,999: $100,000 to $119,999: $120,000 to $149,999: $150,000 and above: Average household:
$ 872 $1,341 $1,465 $1,628 $1,727 $1,669 $1,983 $2,005 $2,282 $1,465
Married couples, no children: Married couples, oldest child under 6: Married couples, oldest child 6-to-17: Married couples, oldest child 18 or older: Single parent with child under 18: Single person: Average household:
$2,416 $1,449 $1,570 $1,839 $ 644 $ 949 $1,465
By household income, average annual consumer out-of-pocket spending for medical services is as follows: Under $20,000: $ 303 $20,000 to $39,999: $ 516 $40,000 to $49,999: $ 580 $50,000 to $69,999: $ 676 $70,000 to $79,999: $ 879 $80,000 to $99,999: $ 947 $100,000 to $119,999: $ 946 $120,000 to $149,999: $ 971 $150,000 and above: $1,654 Average household: $ 670 By household income, average annual consumer out-of-pocket spending for pharmaceuticals is as follows: Under $20,000: $337 $20,000 to $39,999: $505 $40,000 to $49,999: $461 $50,000 to $69,999: $588 $70,000 to $79,999: $499 $80,000 to $99,999: $588 $100,000 to $119,999: $603 $120,000 to $149,999: $699 $150,000 and above: $748 Average household: $514
By household type, average annual consumer out-of-pocket spending for medical services is as follows: Married couples, no children: $1,000 Married couples, oldest child under 6: $ 855 Married couples, oldest child 6-to-17: $ 864 Married couples, oldest child 18 or older: $ 894 Single parent with child under 18: $ 383 Single person: $ 424 Average household: $ 670 By household type, average annual consumer out-of-pocket spending for pharmaceuticals is as follows: Married couples, no children: $839 Married couples, oldest child under 6: $336 Married couples, oldest child 6-to-17: $448 Married couples, oldest child 18 or older: $679 Single parent with child under 18: $209 Single person: $348 Average household: $514
HEALTHCARE SPENDING BY HOUSEHOLD TYPE

By household type, average annual consumer out-of-pocket spending for health insurance is as follows:
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HEALTHCARE SPENDING BY RACE AND ETHNICITY

By race and ethnicity, average annual consumer out-of-pocket spending for health insurance is as follows: Asian: Black: Hispanic: Non-Hispanic white and other: Average household: $1,363 $ 927 $ 780 $1,651 $1,465
Northeast: Midwest: South: West: Average household:
$596 $697 $614 $798 $670
By race and ethnicity, average annual consumer out-of-pocket spending for medical services is as follows: Asian: $523 Black: $248 Hispanic: $504 Non-Hispanic white and other: $761 Average household: $670 By race and ethnicity, average annual consumer out-of-pocket spending for pharmaceuticals is as follows: Asian: $286 Black: $272 Hispanic: $305 Non-Hispanic white and other: $582 Average household: $514
By region, average annual consumer out-ofpocket spending for pharmaceuticals is as follows: Northeast: $412 Midwest: $500 South: $594 West: $489 Average household: $514
HEALTHCARE SPENDING BY EDUCATION

By education, average annual consumer outof-pocket spending for health insurance is as follows: Less than high school graduate: $1,123 High school graduate: $1,446 Some college: $1,323 Associate degree: $1,473 Bachelor degree: $1,690 Masters, doctoral degree: $1,912 Average household: $1,465 By education, average annual consumer outof-pocket spending for medical services is as follows: Less than high school graduate: $ 368 High school graduate: $ 531 Some college: $ 627 Associate degree: $ 690 Bachelor degree: $ 937 Masters, doctoral degree: $1,018 Average household: $ 670 By education, average annual consumer outof-pocket spending for pharmaceuticals is as follows: Less than high school graduate: $435 High school graduate: $504 Some college: $442 Associate degree: $599
HEALTHCARE SPENDING BY REGION

By region, average annual consumer out-ofpocket spending for health insurance is as follows: Northeast: $1,462 Midwest: $1,505 South: $1,459 West: $1,437 Average household: $1,465 By region, average annual consumer out-ofpocket spending for medical services is as follows:
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Bachelor degree: Masters, doctoral degree: Average household:
$577 $604 $514
REFERENCES AND RESOURCES

New Strategist Publications, P.O. Box 242, Ithaca, NY 14851. (800) 848-0842. (www.newstrategist.com) U.S. Bureau of Labor Statistics, 2 Massachusetts Avenue NE, Washington, DC 20212. (202) 691-5200. (www.bls.gov) Whos Buying Health Care, 5th edition, New Strategist Publications, December 2008.
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GEOGRAPHIC VARIATIONS IN HEALTHCARE SPENDING
Researchers have long documented variations in healthcare spending. Variations occur across geographic areas and among providers, and even populations within a geographic area. Some researchers suggest that reducing spending in high-spending areas of the U.S. to the rates observed in the lowest spending regions could yield significant savings for the healthcare system without harming quality of care. Figure 3.1 shows variations in Medicare spending per beneficiary.
DARTMOUTH ATLAS OF HEALTHCARE

For more than 20 years, the Dartmouth Atlas Project has documented glaring variations in how medical resources are distributed and used in the United States. The project uses Medicare data to provide comprehensive information and analysis about national, regional, and local markets, as well as individual hospitals and their affiliated physicians.
# # # # # #
< $7,000 $7,000 $7,500 $7,500 $8,000 $8,000 $9,000 > $9,000 Not populated
Figure 3.1. Medicare spending per beneficiary (sources: American Hospital Association based ion The 2009 Dartmouth Atlas of Healthcare)
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For its assessment, the Dartmouth Atlas Project uses the hospital care intensity index, or HCI, which reflects both the amount of time spent in a hospital and the intensity of physician services delivered in the hospital. Chronically ill patients living in states and regions or using hospitals with a high HCI are likely to spend more days in the hospital and see more physicians during hospitalizations.
STATES RANKED BY HCI SCORE

Based on the HCI, New Jersey is the most aggressive in providing healthcare services; Utah is the most conservative. States are ranked as follows: 1. New Jersey 2. New York 3. Louisiana 4. Hawaii 5. Nevada 6. Florida 7. California 8. Mississippi 9. Pennsylvania 10. Delaware 11. Texas 12. Illinois 13. Arkansas 14. Tennessee 15. Kentucky 16. West Virginia 17. South Carolina 18. Maryland 19. Alabama 20. Michigan 21. Oklahoma 22. Massachusetts 23. Missouri 24. Virginia 25. Rhode Island 26. Ohio 27. Connecticut 28. Georgia 29. Kansas 30. North Carolina 31. Indiana
32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50.
Arizona Nebraska South Dakota Iowa Alaska Wisconsin Colorado Maine New Hampshire Minnesota New Mexico Vermont North Dakota Wyoming Montana Washington Idaho Oregon Utah

Dartmouth Atlas of Health Care, The Dartmouth Institute for Health Policy and Clinical Practice, 35 Centerra Parkway, Suite 202, Lebanon, NH 03766. (603) 653-0800. (www.dartmouthatlas.org) Geographic Variation in Health Care Spending: A Closer Look, Trend Watch, American Hospital Association, November 2009. (www.aha.org/aha/trendwatch/2009/ twnov09geovariation.pdf)
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NATIONAL HEALTH EXPENDITURES
The Centers for Medicare & Medicaid Services (CMS) assesses and forecasts national health expenditures by type of service delivered (hospital care, physician services, nursing home care, etc.) and source of funding for those services (private health insurance, Medicare, Medicaid, out-of-pocket spending, etc.) annually.
SOURCES OF FUNDS
The $2.51 trillion in health expenditures in 2009 were distributed by source of funds as follows (change from 2008 in parenthesis): Private health insurance: $854.4 billion (4.5%) Federal: $873.2 billion (7.7%) State and local: $317.3 billion (6.5%) Out-of-pocket payments: $282.7 billion (1.4%) Other private funds: $181.8 billion (4.6%)
SPENDING
Spending (growth) % of GNP
2000: 2001: 2002: 2003: 2004: 2005: 2006: 2007: 2008: 2009: 2010: 2011: 2012: 2013: 2014: 2015: 2016: 2017: 2018:
$1.35 trillion (7.0%) $1.47 trillion (8.6%) $1.60 trillion (9.1%) $1.73 trillion (8.0%) $1.85 trillion (6.9%) $1.98 trillion (6.8%) $2.11 trillion (6.7%) $2.24 trillion (6.1%) $2.38 trillion (6.1%) $2.51 trillion (5.5%) $2.62 trillion (4.6%) $2.77 trillion (5.6%) $2.93 trillion (5.8%) $3.11 trillion (6.2%) $3.31 trillion (6.5%) $3.54 trillion (6.9%) $3.79 trillion (7.0%) $4.06 trillion (7.2%) $4.35 trillion (7.2%)
13.8% 14.5% 15.3% 15.8% 15.9% 15.9% 16.0% 16.2% 16.6% 17.6% 17.7% 17.9% 18.0% 18.2% 18.5% 18.9% 19.3% 19.9% 20.3%
DISTRIBUTION OF EXPENDITURES
The $2.51 trillion in health expenditures in 2009 were distributed by type of expenditure as shown in Table 4.1

National Health Expenditures, Centers for Medicare & Medicaid Services, 2009.
(www.cm s.hhs.gov/NationalHealthExpendData/)
Note: Projections made prior to passage of healthcare reform legislation.
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TABLE 4.1 Distribution of 2009 health expenditures by type of expenditure (change from 2008 in parenthesis) Hospital care: Physician and clinical services: Prescription drugs (retail outlet sales): Government administration and net cost of private health insurance: Nursing home care: Structures and equipment: Dental services: Other personal healthcare: Government public health activities: Home healthcare: Other professional services: Research: Non-durable medical products (retail outlet sales): Durable medical equipment (retail outlet sales): $785.8 billion (5.7%) $539.1 billion (6.0%) $244.8 billion (4.0%) $178.8 billion (8.0%) $143.9 billion (4.8%) $114.9 billion (5.9%) $101.9 billion (2.0%) $ 76.1 billion (7.9%) $ 72.3 billion (5.8%) $ 69.7 billion (8.1%) $ 68.7 billion (4.4%) $ 44.5 billion (2.3%) $ 40.2 billion (3.0%) $ 25.2 billion (0.1%)
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OBESITY
National and State Estimates of the Impact of Obesity on Direct Health Care Expenses, a November 2009 report by the American Public Health Association and United Health Foundation, estimated the prevalence of adult obesity at 31.3%. This estimate is higher than the 27% estimate by the Centers for Disease Control and Prevention (CDC), which is based on selfreported weight estimates from telephone surveys. Kenneth E. Thorpe, Ph.D., at Emory University, has found individuals have a tendency to under-report their weight on telephone surveys by about 9.5%. The prevalence of adult obesity in the U.S. has increased over the last 20 years, from 12% in 1989 to 27% in 2008, according to the CDC.
PERCENTAGE OF ADULTS WHO ARE OBESE, STATE-BY-STATE

Alabama: Alaska: Arizona: Arkansas: California: Colorado: Connecticut: Delaware: District of Columbia: Florida: Georgia: Hawaii: Idaho: Illinois: Indiana: Iowa: Kansas: Kentucky: Louisiana: Maine: Maryland: Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: 36.3% 31.4% 30.4% 34.3% 28.8% 23.8% 26.1% 32.7% 26.4% 29.4% 32.0% 28.0% 30.1% 31.5% 31.7% 31.1% 32.8% 34.8% 33.9% 30.3% 31.2% 26.0% 34.4% 29.8% 37.7% 33.5% 29.3% 32.0% 30.9% 29.1% 28.1% 30.6% 29.4% 34.2% 32.4% 33.9% 35.2%
If current trends continue, 103 million American adults will be considered obese by 2018. The U.S. would spend an estimated $344 billion on healthcare costs attributable to obesity in 2018, or 21% of direct healthcare spending, if rates continue to increase at their current levels. If obesity levels were held at their current rates, the U.S. could save an estimated $820 per adult in healthcare costs by 2018 a savings of almost $200 billion dollars.
United Health Foundation, 11/09
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Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:
29.2% 32.6% 26.5% 35.6% 32.7% 35.3% 34.0% 27.9% 27.8% 30.2% 30.4% 36.7% 30.7% 30.3%

American Public Health Association, 800 I Street NW, Washington, DC 20001. (202) 777-2742. (www.apha.org) Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333. (404) 639-3311. (www.cdc.gov) National and State Estimates of the Impact of Obesity on Direct Health Care Expenses, United Health Foundation, November 2009. (www.americashealthrankings.org/2009/ report/Cost%20Obesity%20Report-final.pdf) United Health Foundation, 9900 Bren Road East, Minnetonka, MN 55343. (www.unitedhealthfoundation.org)
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6 SMOKING
According to the Centers for Disease Control and Prevention (CDC), 20.6% of U.S. adults smoke. A June 2009 survey by Gallup reported the same percentage, 20%. Among smokers, 41% smoke at least one pack per week.
(source: Gallup): Less than $12,000: $12,000 to $35,999: $36,000 to $59,999: $60,000 to $89,999: $90,000 and higher:
34% 28% 22% 16% 15%
HEALTH IMPACT
According to the CDC, smoking-related diseases kill 440,000 Americans a year, including more than 35,000 exposed only to secondhand smoke. The American Cancer Society estimates that smoking accounts for 30% of all cancer deaths. Smoking accounts for about 8% of all personal healthcare-related spending. Each pack of cigarettes sold in the United States costs an average of $7.18 in health-related losses, according to the CDC. Even these numbers are low, because the CDC does not include the impact of cigars, pipes, and smokeless tobacco. Nor does it include lost productivity from smoking-related disability, absenteeism, and smoke breaks. The CDC reports that the economic toll from smoking is $157 billion a year increasing despite a decline in the number of people who smoke.
The CDC has advocated further increasing the price of cigarettes to help reduce smoking. The 2009 increase in cigarette tax reflected this philosophy.
The 62 increase in federal cigarette taxes going into effect is nearly three times as likely to affect low-income Americans as it is to affect highincome Americans.
Gallup, 4/1/09
PERCENTAGE OF ADULTS WHO SMOKE, STATE-BY-STATE

Alabama: Alaska: Arizona: Arkansas: California: Colorado: Connecticut: Delaware: District of Columbia: Florida: Georgia: Hawaii: Idaho: 22.5% 22.2% 19.8% 22.4% 14.3% 18.7% 15.4% 18.9% 17.2% 19.3% 19.4% 17.0% 19.1%
CORRELATION WITH PERSONAL INCOME

Adult smoking in the U.S. correlates to household income, with smoking habits dropping as income rises. By annual income, the percentage who smoke is as follows
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Illinois: Indiana: Iowa: Kansas: Kentucky: Louisiana: Maine: Maryland: Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:
20.1% 24.1% 19.8% 17.9% 28.2% 22.6% 20.2% 17.1% 16.4% 21.1% 16.5% 23.9% 24.5% 19.5% 19.9% 21.5% 19.3% 17.1% 20.8% 18.9% 22.9% 20.9% 23.1% 25.8% 16.9% 21.0% 17.0% 21.9% 19.8% 24.3% 19.2% 11.7% 17.6% 18.5% 16.8% 26.9% 19.6% 22.1%
Gallup Inc., 901 F Street NW, Washington, DC 20004. (202) 715-3030. (www.gallup.com)

Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333. (404) 639-3311. (www.cdc.gov)
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7 STATE HEALTH RANKINGS
Since 1989, UnitedHealth Foundation has developed an annual healthcare index for each state. The annual assessment uses a composite of seventeen criteria measuring demographic and lifestyle factors, access to healthcare, occupational safety, and disease/ mortality rates. Ranking score is based on the weighted number of standard deviations a state is above or below the national norm. The following presents a summary of the 2009 assessment.
2009 RANKINGS
Ranking Score
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 21. 23. 24.
Vermont: Utah: Massachusetts: Hawaii: New Hampshire: Minnesota: Connecticut: Colorado: Maine: Rhode Island: Washington: Wisconsin: Oregon: Idaho: Iowa: Nebraska: North Dakota: New Jersey: Wyoming: South Dakota: Maryland: Virginia: California: Kansas:
1.064 1.006 0.905 0.892 0.886 0.828 0.779 0.606 0.569 0.557 0.538 0.534 0.530 0.524 0.503 0.475 0.421 0.414 0.343 0.286 0.281 0.281 0.278 0.245
25. New York: 26. Montana: 27. Arizona: 28. Pennsylvania: 29. Illinois: 30. Michigan: 31. New Mexico: 32. Delaware: 33. Ohio: 34. Alaska: 35. Indiana: 36. Florida: 37. North Carolina: 38. Missouri: 39. Texas: 40. Arkansas: 41. Kentucky: 42. West Virginia: 43. Georgia: 44. Tennessee: 45. Nevada: 46. South Carolina: 47. Louisiana: 48. Alabama: 49. Oklahoma: 50. Mississippi: (The District of Columbia is the assessment)
0.203 0.192 0.082 -0.031 -0.056 -0.063 -0.067 -0.082 -0.084 -0.091 -0.188 -0.200 -0.206 -0.238 -0.320 -0.416 -0.434 -0.446 -0.469 -0.480 -0.482 -0.492 -0.530 -0.546 -0.566 -0.789 not included in
HEALTH SCORE IMPROVEMENTS

The following states had the greatest increase in ranking score from 1990 to 2009: New York: 37.5 Vermont: 36.5 Hawaii: 35.0 New Hampshire: 34.8 New Jersey: 32.5 Minnesota: 32.5
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The following states had the improvement in ranking score: Oklahoma: -2.7 West Virginia: 3.9 Mississippi: 6.2 Kentucky: 6.7
least

Americas Health Rankings: A Call To Action For Individuals & Their Communities, United Health Foundation, 2009. (www.americashealthrankings.org) United Health Foundation, 9900 Bren Road East, Minnetonka, MN 55343. (www.unitedhealthfoundation.org)
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PART II: HOSPITALS & HEALTHCARE PROVIDERS
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CHILDRENS HOSPITALS
According to the National Association of Childrens Hospitals and Related Institutions (NACHRI), there are approximately 200 childrens hospitals in the United States. These free-standing childrens hospitals serve about 12% of all hospitalized children, are responsible for 20% of the cost of treating children, and train about 25% of all pediatricians in the United States. More than 8.3 million outpatient visits are provided by childrens hospitals. Academic medical centers with childrens hospitals admit 18% of all inpatient children and garner 29% of the revenue in that area. There are 60 independent childrens teaching hospitals.
According to the NACHRI, nearly two-thirds of the care at childrens hospitals is for kids 5 and younger, with 25% for newborns. Compared with the 9% of general hospital beds allotted to intensive care, childrens hospitals devote 26% of their beds to the ICU. The largest childrens hospitals, as identified by the NACHRI Annual Survey on Utilization and Financial Indicators of Childrens Hospitals, Fiscal 2009, are presented in Table 8.1.
TABLE 8.1 Largest Childrens Hospitals

Staffed Beds Admissions
Childrens Hospital of Atlanta: Texas Childrens Hospital (Houston): Cincinnati Childrens Hospital Medical Center: Childrens Hospital of Philadelphia: Riley Hospital for Children (Indianapolis): Childrens Hospital Boston: Cleveland Clinic Childrens Hospital: Childrens Medical Center Dallas: Nationwide Childrens Hospital (Columbus): Phoenix Childrens Hospital: Childrens Hospitals and Clinics of Minnesota: Arkansas Childrens Hospital (Little Rock): Childrens Hospital Central California (Madera): Morgan Stanley Childrens Hospital of New York Presbyterian:
502 458 449 421 393 383 372 366 344 344 332 316 315 300
22,925 22,080 15,938 25,699 9,866 23,747 6,663 18,276 16,247 12,248 14,166 13,891 12,680 12,489
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TABLE 8.1 (Cont)

Staffed Beds Admissions
Childrens Mercy Hospitals and Clinics (Kansas City): Childrens Hospital Los Angeles: Childrens Hospital (Aurora, Colorado): Childrens Hospital of Alabama (Birmingham): Cook Childrens Medical Center (Ft. Worth): Miami Childrens Hospital: Lucile Packard Childrens Hospital at Stanford (Calif.): Loma Linda University Childrens Hospital: Childrens Hospital Medical Center of Akron: Kosair Childrens Hospital (Louisville): Childrens Hospital of Pittsburgh of UPMC: Rady Childrens Hospital (San Diego):
295 286 284 282 281 272 271 270 264 261 260 260
15,325 10,784 11,649 14,283 11,999 12,066 8,229 9,704 8,647 9,220 14,367 13,569

National Association of Childrens Hospitals and Related Institutions, 401 Wythe Street, Alexandria, VA 22314. (703) 684-1355. (www.childrenshospitals.net)
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COMPARATIVE EFFECTIVENESS RESEARCH
ARRA FUNDING FOR RESEARCH

The American Recovery and Reinvestment Act (ARRA) of 2009 (P.L. 111-5), appropriated $1.1 billion for comparative effectiveness research (CER) to help identify which healthcare services work best. This allocation reflects legislators belief that better decisions about the use of healthcare resources could improve the publics health and reduce the costs of care. CER is the direct comparison of healthcare interventions to determine which work best for which patients and which pose the greatest benefits and harms, and under what circumstances. Today, when a patient and physician, perhaps with other clinicians and family caregivers, are discussing the best course of treatment for the patients medical condition, they often do not have the scientific evidence they need to make a determination. Although there may be studies that indicate that a treatment is efficacious relative to a placebo, there frequently are no studies that directly compare the different available alternatives or that have examined their impacts in populations of the same age, sex, and ethnicity or with the same comorbidities as the patient.
Institute of Medicine, 6/09
The ARRA also appropriated $400 million to the National Institutes of Health (NIH), $300 million to the Agency for Healthcare Research and Quality (AHRQ), and the remaining $400 million to the Secretary of Health and Human Services (HHS). The ARRA also directed the Institute of Medicine (IOM) to recommend national priorities for spending the $400 million designated for the HHS Secretary.
PRIORITIES FOR CER

In June 2009, the IOM published a list of 100 recommendations as a starting point for a sustained effort to conduct comparative effectiveness research in the United States. T h e li st is available o nl in e a t www.iom.edu/cerpriorities.
OUTLOOK
CER will expand medical research beyond strictly controlled, randomized clinical trials to also include studies involving real patients in real settings. It will examine the difference in effectiveness between drugs, devices, and/or interventions for the same condition.
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This shift will correct a long-standing limitation of traditional medical research. Healthcare is probably the only industry that doesnt formally learn from its daily work. We find out what works and what doesnt in healthcare in clinical studies. The problem is the studies are so strict about who can enroll that their findings dont always pan out when applied in other healthcare settings, where the patient population is more diverse. What we need to also do is say, How can I be sure that this therapy is also going to work when I try it in a community hospital or outside of the study? The way you do that is by doing an effectiveness study. You loosen up the inclusion criteria and say, Lets just see if I try to do this therapy, what do I get in the real world?
Prof. Peter J. Pronovost, M.D. Johns Hopkins University H&HN, 11/09
It cant just be a comparison of this drug versus that drug. This misses important aspects of practice and ends up exempting high-cost procedures from scrutiny. Researchers should focus on comparisons that include lifestyle modifications, such as diet and exercise, as well as alternative therapies that patients often implement on their own. In addition, research is needed on the most effective ways of delivering care. For instance, some studies show better chronic disease outcomes with nurse case managers compared with physicians working alone.
Prof. Randall Stafford, M.D. Stanford School of Medicine Stanford Health Policy, 6/16/09
The Obama Administration sees comparative effectiveness research as a key strategy for reforming the nations healthcare system. CER would help identify the treatment options that are most effective for a given condition. Many healthcare providers, consumer groups, and professional organizations have also expressed enthusiasm at the prospect of identifying new knowledge about how the effectiveness of one treatment compares with others.
Despite its far-reaching potential, some view CER with skepticism. For instance, the Partnership to Improve Patient Care, a coalition of 36 industry, patient-advocacy, and clinician organizations, raised concerns that CER will not take adequate account of individual patient differences and may impede the development and adoption of improvements in medical care and stymie progress in personalized medicine. Further, the drug and medical device industries have expressed concerns that research on comparing medical treatments could be a first step to government rationing of healthcare.

Alexander, G. Caleb and Randall S. Stafford, Does Comparative Effectiveness Have A Comparative Edge? Journal of the American Medical Association, June 17, 2009.
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Aston, Geri, Comparative Effectiveness, Hospitals & Health Networks, November 2009, pp 22-24. Garber, Alan M. and Sean R. Tunis, Does Comparative-Effectiveness Research Threaten Personalized Medicine? The New England Journal of Medicine, May 7, 2009. Initial National Priorities For Comparative Effectiveness Research, Institute of Medicine, June 2009. Mundy, Alicia, Drug Makers Fight Stimulus Provision, The Wall Street Journal, February 10, 2009. Rhea, Shawn, Decisive Moment, Modern Healthcare, July 6, 2009, pp 8-9.
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10
COMPLEMENTARY & ALTERNATIVE MEDICINE
CAM USE IN AMERICA

According to a December 2008 report by the National Center for Complementary and Alternative Medicine, 38% of adults in the United States aged 18 years and over and 12% of children aged 17 years and under use some form of complementary and alternative medicine (CAM). The most commonly used CAM therapies among U.S. adults are as follows: Non-vitamin, non-mineral, and natural products (most common of which are fish oil, omega 3/DHA, glucosamine, echinacea, flaxseed oil/pills, and ginseng): 18% Deep breathing exercises: 13% Meditation: 9% Chiropractic or osteopathic manipulation: 9% Massage: 8% Yoga: 6% Adults use CAM most often to treat pain, including back pain or problems, neck pain or problems, joint pain or stiffness/other joint condition, arthritis, and other musculoskeletal conditions. CAM use is highest among the following demographic categories: Women (43%, compared to men 34%) Those aged 30-to-69 (30-to-39 years: 39%, 40-to-49 years: 40%, 50-to-59 years: 44%, 60-to-69 years: 41%) Those with higher levels of education
(masters, doctorate or professional: 55%) Those living in the West (45%) Those who have quit smoking (48%) Overall, CAM use among children is nearly 12%, or about 1 in 9 children. Children are five times more likely to be treated by CAM if a parent or other relative uses CAM. Among children, CAM therapies are most often for back or neck pain, head or chest colds, anxiety or stress, other musculoskeletal problems, and attention deficit/ hyperactivity disorder (AD/HD). The most commonly used CAM therapies among children are as follows: Non-vitamin, non-mineral, and natural products: 4% Chiropractic or osteopathic manipulation: 3% Deep breathing exercises: 2% Yoga: 2%
SPENDING
According to a July 2009 report by the National Center for Complementary and Alternative Medicine, adults spent $33.9 billion out of pocket on visits to CAM practitioners and purchases of CAM products, classes, and materials in 2007. Nearly two-thirds of the total out-of-pocket costs that adults spent on CAM were for selfcare purchases of CAM products, classes, and materials. Despite this emphasis on selfcare therapies, 38.1 million adults made an estimated 354.2 million visits to practitioners
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of CAM. Distribution of CAM spending in 2007 was as follows: Non-vitamin, non-mineral, and natural products: $14.8 billion Office visits: Classes (yoga, tai chi, etc.): $ 4.1 billion Homeopathic medicine: $ 2.9 billion Relaxation techniques: $ 0.2 billion
Possible cost savings: Employee requests: Insurance coverage: Other:
14% 11% 4% 9%
Eighty-one percent (81%) of CAM users paid for CAM services out-of-pocket.

Barnes Patricia M., Barbara Bloom and Richard L. Nahin, Complementary and Alternative Medicine Use Among Adults and Children: United States, National Center for Health, December 2008. Nahin, Richard L., Patricia M. Barnes, Barbara J. Stussman, and Barbara Bloom, Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007, National Center for Health Statistics, July 2009. National Center for Complementary and Alternative Medicine, 9000 Rockville Pike, Bethesda, MD 20892. (888) 644-6226. (www.nccam.nih.gov)
HOSPITAL CAM PROGRAMS

According to the American Hospital Association, 21% of hospitals offer some type of CAM, an increase from 17% in 2002 and 8% in 1998 that had such programs. A survey by Health Forum, a subsidiary of the American Hospital Association, found that among hospitals that offered CAM, the top therapies offered were as follows: Inpatient CAM Services Massage therapy: 37% Music/art therapy: 26% Therapeutic touch: 25% Guided imagery: 22% Relaxation training: 20% Acupuncture: 12% Outpatient CAM Services Massage therapy: Tai Chi, yoga, or qi gong: Relaxation training: Acupuncture: Guided imagery: Therapeutic touch:
71% 47% 43% 39% 32% 30%
The following were the key reasons for offering CAM services: Patient demand: 87% Reflecting organizational mission: 62% Clinical effectiveness: 61% Attracting new patients: 38% Physicians requests: 37% Differentiation from competitors: 28%
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11
CONVENIENT-CARE CLINICS
RETAIL-BASED HEALTHCARE
A rising number of pharmacy and retail chains are opening in-store health clinics. Consumers are receptive to innovations such as retail clinics. Sixteen percent of consumers have used a walk-in clinic located in a pharmacy, shopping center store or other retail setting, and 34% say they might do so in the future. Forty-four percent of consumers say they would be comfortable with the accuracy, safety and quality of care offered in a retail clinic that is staffed by a nurse practitioner.
American Hospital Association 2009 AHA Environmental Scan
There were over 14,000 retail-based clinics in the U.S. at year-end 2009, according to the Convenient Care Association
PATIENT SERVICES
An assessment by Rand Corporation and the University of Pittsburgh School of Medicine analyzing data from more than 1.3 million visits to retail clinics found the following: Patients ages 18-to-44 accounted for 43% of the people visiting retail clinics, compared to 23% for primary care physician offices. Just 39% of the patients at retail clinics say they had a primary care physician; 80% of people surveyed nationally say they have a personal doctor. When the concept of retail clinics first launched, most patients paid out-of-pocket. Now most use insurance for reimbursement. The percentage of retail office visits paid for out-of-pocket dropped from 100% in 2000 to 16% in 2007. About 90% of the visits to retail clinics were for preventive care and 10 simple acute conditions: upper respiratory infections, sinusitis, bronchitis, sore throat, immunizations, inner ear infections, swimmers ear, conjunctivitis, urinary tract infections, and either a screening test or a blood test. The same conditions accounted for 18% of visits to primary care physician offices and 12% of emergency department visits. A recent survey by Harris Interactive found that 7% of households had a family member who visited a retail-based clinic during the prior 12 months. Among those patients, 16%
These retail health clinics are creating a new model: one with more limited services at lower prices and almost always staffed by nurses or physician assistants. For many consumers the clinics are attractive because of the low cost; most charge less than $65 per visit. CVS, Duane Reed, Osco Drug, Rite Aid, and Walgreens are among the drug store chains offering in-store clinics. In other retail segments, Costco, Target, and Walmart also operate clinics at some locations. With 500 MinuteClinics operating in its stores in 25 states, CVS is the marketshare leader.
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were uninsured, an increase from 22% in 2007. Visits were for the following reasons: Vaccination: 40% Treatment for a common medical condition like an ear infection, cold, strep throat, skin rash, or sinus infection: 39% Preventive screening tests for conditions like high blood pressure, high cholesterol, diabetes, or allergies: 24% Physical exam for sports, school, camp, etc.: 10% Received a referral from family physician or hospital emergency department: 8% Other: 16%
in San Francisco, among others, also operate convenient-care clinics.

Convenient Care Association, 260 South Broad Street, Suite 1800, Philadelphia, PA 19102. (215) 731-7140. (www.ccaclinics.org) Mehrotra, A., M.C. Wang, J.R. Lave, J.L. Adams and E.A. McGlynn, Retail Clinics, Primary Care Physicians, and Emergency Departments: A Comparison of Patients Visits, Health Affairs, September/October 2008, pp 1272-1282. New WSJ.com/Harris Interactive Study Finds Satisfaction with Retail-Based Health Clinics Remains High, Harris Interactive, May 1, 2008. Vesely, Rebecca, Where Are The Retail Clinics? Modern Healthcare, June 1, 2009, p. 16.
PATIENT SATISFACTION
Harris Interactive found that almost all clinic patients are very/somewhat satisfied with the quality of the care (90%), cost (86%), and staff qualifications (88%). The biggest driver of satisfaction appears to be convenience, with 93% satisfied with the convenience of these clinics. Although an increasing number say they are satisfied with staff qualifications, 65% have concerns that serious medical problems might not be accurately diagnosed. CVS in-store MinuteClinics report a 95% customer satisfaction rating from the more than five million patient visits the clinics have generated.
HOSPITAL-OPERATED CLINICS
Several healthcare systems have entered the retail market. Pennsylvania-based Geisinger Health System operates five clinics in Weis Market locations. Mayo Clinic opened a Mayo Express Clinic in a Minneapolis mall. Alegent Health operates nine clinics at HyVee grocery stores in Nebraska. Houstonbased Memorial Hermann and Sutter Health,
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12
DEBT COLLECTION
OUT-OF-POCKET PAYMENTS
According to the Centers for Medicare and Medicaid Services, patients paid $24.5 billion out-of-pocket for hospital services in 2008. This amount includes payment of deductibles and co-payments by those with health insurance as well as payments by uninsured consumers. Hospitals generally find reimbursement from individuals more challenging than from health insurance companies. Insurance may provide patients little protection from catastrophic medical bills. Health insurers are very creative in how they can erode the actual value of a policy. Medical bills can escalate rapidly when patients need more than routine care and run into clauses that limit benefits or exclude certain spending from applying to deductibles.
Prof. Karen Pollitz, Ph.D. Health Policy Institute Georgetown University Modern Healthcare, 8/17/09
BAD DEBT
Bad debt typically amounts to 3% to 4% of hospitals gross revenue, one of the highest rates among all industry sectors. Bad debt among California hospitals alone amounted to $8.0 billion in 2008, according to Kurt Salmon Associates. Denial of claims by health insurance companies for treatments that fall outside of coverage is a contributor to unpaid patient debt.
FAIR BILLING FOR UNINSURED PATIENTS

Following clarification of a federal policy by the U.S. Department of Health & Human Services (HHS) in 2004 stating there are no federal rules preventing hospitals from offering discounts to uninsured patients, many large for-profit hospital chains announced discount policies. Most hospitals subsequently revised pricing policies for the uninsured. Now most groups charge uninsured patients no more than the highest managed-care rate. Recent legislation in California requires hospitals to offer discounts to uninsured patients who earn up to 350% of the federal poverty level, or a household income of about $72,000.
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Some hospitals have taken the lead in fair billing for uninsured patients. University Medical Center in Tucson, for example, never charges uninsured patients, regardless of their income, more than the rates Medicare pays.
U.S. Census Bureau figures for average per capita income and home value by neighborhood Prior hospital visits and payment history Insured or uninsured?
COLLECTION STRATEGIES
Hospitals are implementing various measures to reduce bad debt, such as capturing patient information at the time of service, requiring early verification of insurance, instituting processes to reduce claims denials, and offering a greater say in managed-care contract negotiations. With less fanfare, some hospitals are adopting steps such as collecting insurance and credit card information before elective procedures, c o un s el in g p a t i e n t s o n f i na n ci al responsibilities, collecting co-payments more consistently at the time of service, and billing patients even receiving reimbursement from insurance.
Emergency services or elective care? Did the patient pay part of the bill before leaving the hospital?
UPFRONT PAYMENTS
An increasing number of hospitals have instituted upfront payment policies.
Healthcare executives say patients are more likely to pay before or during a hospital visit rather then after.
Modern Healthcare, 8/17/09
Increasingly [hospitals] now know exactly which patients will be able to pay for visits. More hospitals and systems are using credit scores and financial records in collection strategies and theyre asking patients to pay upfront.
Holy Name Hospital (Teaneck, New Jersey), for example, has targeted easily identifiable copayments in the emergency room and outof-pocket payments for elective and sameday procedures for upfront collection. In 2008, cash payments from emergency room patients contributed $186,900 to the hospitals bottom line, while cash payments from elective admissions were $205,000. These cash payments amounted to 22% of the hospitals operating margin.
Conifer Health Solutions, the revenue-cycle subsidiary of Tenet Healthcare Corporation, instituted a procedure in 2009 that profiles patients into 15 categories based on their estimated ability to pay medical bills. The system uses 44 variables, including the following: Credit score, available credit, mortgage

Evans, Melanie, Cash Is King, Modern Healthcare, August 17, 2009, pp 28-30.
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13 DESIGN & CONSTRUCTION
Modern Healthcare assesses the healthcare construction market annually. This chapter presents a summary of the 2009 assessment.
HOSPITAL CONSTRUCTION
The cost of hospital construction projects completed in 2008 totaled $36.3 billion. This represented 3,728 projects of all types (new facilities, expansions, and renovations) and 38,296 beds. Distribution by type of facility is presented in Table 13.1. Representing 3,651 projects and 83,449 beds, in total, $88.8 billion in hospital projects were designed during 2008.
Bovis Lend Lease (www.bovis.com): $1.8 billion McCarthy Building Cos. (www.mccarthy.com): $1.3 billion Skanska USA (www.skanskausa.com): $1.2 billion Jacobs Engineering Group (www.jacobs.com): $1.2 billion J.E. Dunn Construction (www.jedunn.com): $1.0 billion Whiting-Turner Contracting Co. (www.whiting-turner.com): $1.0 billion William A. Berry & Son (www.berry.com): $ 889 million Parsons Corp. (www.parsons.com): $ 767 million General Contractors Robins & Morton Group (www.robinsmorton.com): $759 million Brasfield & Gorrie (www.brasfieldgorrie.com): $737 million Hunt Construction Group (www.huntconstructiongroup.com): $656 million DPR Construction (www.dprinc.com): $487 million Clark Construction Group (www.clarkconstruction.com): $450 million BE&K Building Group (www.bekbuildinggroup.com): $431 million Rodgers Builders (www.rodgersbuilders.com): $294 million
LARGEST HEALTHCARE DESIGN AND CONSTRUCTION FIRMS

Design Firms HDR Architecture (www.hdrinc.com): $5.9 billion HKS (www.hksinc.com): $4.4 billion Perkins & Will (www.perkinswill.com): $1.9 billion NBBJ (www.nbbj.com): $1.4 billion Granary Associates (www.granaryassoc.com): $1.3 billion Karlsberger (www.karlsberger.com): $1.2 billion Hellmuth, Obata + Kassabaum (www.hok.com): $1.1 billion Construction Management Firms Turner Construction Co (www.turnerconstruction.com): $2.6 billion
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TABLE 13.1 Distribution Of Completed Healthcare Construction Projects in 2008 Acute-care hospitals: - Entire acute-care hospitals: - Hospital expansions: - Hospital renovations: Free-standing outpatient facilities: Specialty hospitals: Research facilities: Medical office buildings: Parking garages: Rehabilitation facilities: Assisted-living facilities: Nursing homes: $21.9 billion (2,015 projects) $11.1 billion (197 projects, 12,884 beds) $ 6.7 billion (392 projects, 8,130 beds) $ 4.2 billion (1,426 projects, 6,800 beds) $ 3.8 billion (629 projects) $ 3.4 billion (179 projects) $ 3.0 billion (127 projects) $ 2.1 billion (530 projects) $ 723 million (76 projects) $ 700 million (76 projects) $ 486 million (66 projects) $ 118 million (30 projects)

Robeznicks, Andis, The Pressure Builds, Modern Healthcare, March 16, 2009, pp 24-30.
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14 ECONOMIC CONTRIBUTION OF HOSPITALS
The American Hospital Association published The Economic Contribution of Hospitals in January 2009. This chapter sources data from this report.
HOSPITAL CARE AND THE U.S. ECONOMY

Hospital care is the largest component of the healthcare sector. This sector represents 16.2% of GDP, or approximately $2.2 trillion. Hospital revenue accounts for $697 billion of that total. Hospitals employ nearly 5.3 million people and are the second largest source of private sector jobs. Hospitals pay $299 billion in wages and salaries annually. Hospitals spend about $304 billion annually on goods and services. Combining salaries/wages and spending for goods and services, the direct annual contribution to the U.S. economy by hospitals is $603 billion.
STATE-BY-STATE HOSPITAL EXPENDITURES*

Alabama: Alaska: Arizona: Arkansas: $ 7.99 billion $ 1.51 billion $10.06 billion $ 4.73 billion
California: Colorado: Connecticut: Delaware: District of Columbia: Florida: Georgia: Hawaii: Idaho: Illinois: Indiana: Iowa: Kansas: Kentucky: Louisiana: Maine: Maryland: Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota:
$59.59 billion $ 8.61 billion $ 7.35 billion $ 2.08 billion $ 3.26 billion $33.10 billion $15.24 billion $ 2.11 billion $ 2.42 billion $27.54 billion $13.58 billion $ 6.27 billion $ 4.78 billion $ 8.89 billion $ 8.17 billion $ 3.36 billion $10.88 billion $20.14 billion $22.48 billion $12.05 billion $ 5.53 billion $14.78 billion $ 2.02 billion $ 4.37 billion $ 3.67 billion $ 3.32 billion $16.11 billion $ 2.90 billion $49.65 billion $17.49 billion $ 1.74 billion $28.05 billion $ 6.08 billion $ 6.84 billion $30.84 billion $ 2.52 billion $ 8.46 billion $ 1.97 billion
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Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:
$13.95 billion $37.77 billion $ 4.14 billion $ 1.48 billion $13.42 billion $11.83 billion $ 4.19 billion $12.72 billion $ 908 million
* Expenditures = wages/salaries + purchased goods and services

The Economic Contribution Of Hospitals, American Hospital Association, January 2009. (www.aha.org/aha/content/2009/pdf/ 011209-econmic-contrib-hosp.pdf)
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15
ELECTRONIC MEDICAL RECORDS
The adoption of electronic medical records (EMRs), also called electronic health records (EHRs), is seen as an import effort in making the healthcare system more efficient. The federal government has set 2014 as the target for making interoperable EHRs available for all Americans. By some estimates, it could cost more than $300 billion over a decade to create a national system of electronic health records about the same amount that studies show is currently wasted on unnecessary or ineffective medical treatments. The Annual Leadership Survey, conducted by the Healthcare Information and Management Systems Society (HIMSS), documents progress by hospitals in the adoption of electronic health records (see Table 15.1).
EMR VENDORS
According to the HIMSS Analytics Database, the top vendors of acute-care EMR systems, ranked by total installations as of January 2009, are as follows: Meditech (www.meditech.com): 1,185 McKesson Provider Technologies (www.mckesson.com/): 630 Cerner Corp. (www.cerner.com): 560 Siemens Medical Solutions (http://medical.siemens.com): 425 CPSI (www.cpsinet.com): 353 Epic Systems Corp. (www.epicsys.com): 265 Eclipsys Corp. (www.eclipsys.com): 243 Healthcare Management Systems Inc. (www.hmstn.com): 237 Healthland (www.healthland.com): 198
TABLE 15.1 EMR Implementation in Hospitals (source: HIMSS)

2006 2007 2008
Fully operational system: Installation begun: Signed contract: Developed plan to implement: No plans yet:
24% 37% 4% 24% 12%
32% 37% 6% 16% 8%
44% 27% 4% 14% 10%

Healthcare Information and Management Systems Society, 230 East Ohio Street, Suite 500, Chicago, IL 60611. (312) 664-4467. (www.himss.org)
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EMERGENCY DEPARTMENTS
PROFILE OF EMERGENCY MEDICINE

According to Hospital Statistics 2009, by the American Hospital Association (AHA), the number of emergency department (ED) visits and total number of EDs have been as follows:
Total ED Visits # EDs
PROFILE OF ED PATIENTS
According to the Agency for Healthcare Research and Quality (AHRQ), the following are the major reasons for hospitalizations through EDs: Circulatory disorders: 26% Respiratory disorders: 15% Injuries: 11% Mental health and substance abuse: 6% Endocrine disorders: 5% Genitourinary disorders: 5% All other disorders: 18% The immediacy of care needed for ED visits is as follows: Urgent: 35% Emergent: 15% Semi-urgent: 20% Non-urgent: 13% No triage/unknown: 17% Contrary to popular perception, individuals who are uninsured and who do not have a usual source of care are actually less likely to visit an emergency department than those who are insured and have a regular healthcare provider. According to the National Hospital Ambulatory Medical Care Survey (NHAMCS), by the National Center for Health Statistics, only 17% of ED patients are uninsured. ACEP found that among frequent visitors (four or more visits a year) to EDs, 84% are insured; 81% have a primary source of care. Similar findings were reported by Ellen J. Weber, M.D., professor of clinical medicine in
2001: 2002: 2003: 2004: 2005: 2006: 2007:
106.0 million 110.0 million 111.0 million 112.6 million 114.8 million 118.4 million 120.8 million
4,621 4,620 4,570 4,595 4,611 4,587 4,565
The emergency department has become the hospitals front door. Not only are more people using EDs, but more than half of all hospital inpatients are admitted through the ED.
Hospital Pulse Report 2009 Press Ganey Associates
The American College of Emergency Physicians (ACEP) provides the following profile of emergency medicine in the United States: Emergency physicians in clinical practice: 31,797 Emergency nurses: 89,300 EMS providers (EMT basics, EMT intermediates paramedics, and first responders): 815,000 Ambulance services: 17,000
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the division of emergency medicine at the University of California, San Francisco, whose research concluded that the biggest factor driving people to seek emergency care is poor physical and mental health. The University of California study, based on a sample of nearly 50,000 adults, found 83% of emergency department visits were made by people who reported having a usual source of healthcare other than an emergency department. Moreover, 85% reported having medical insurance and 79% reported having incomes exceeding the poverty threshold. Individuals without health insurance were no more likely to have had an emergency visit than those with private health insurance. Individuals without a usual source of care were 25% less likely to have had an emergency visit than those with a private physician. The study found 48% of emergency department visits were by adults who said they had poor physical health.
poor or near-failing grades. Eleven states received an overall grade of D. The ACEP assessment concludes that the countrys emergency system suffers from a variety of problems, such as overcrowding in emergency rooms, unreimbursed costs related to caring for the uninsured, and a shortage of medical specialists.
OVERCROWDING AND DIVERSIONS

According to the AHA, the percentages of hospital EDs at or over capacity are as follows:
At Over
All hospitals: Urban hospitals: Rural hospitals: Teaching hospitals:
25% 29% 21% 28%
25% 39% 10% 47%
THE STATE OF EMERGENCY CARE

In its 2009 National Report Card on the State of Emergency Medicine, ACEP gives the national emergency medical care system an overall grade of C-, which represents the average of grades for all 50 states and the District of Columbia. An ACEP task force uses a range of available data to develop 50 measures for grading each state on a scale of A through F for its support in four areas: access to emergency care, quality and patient safety, public health and injury prevention, and medical liability environment. While no state received an overall A grade, California ranked highest in the nation, followed by Massachusetts, Connecticut, and the District of Columbia, all earning overall B grades. The assessment reported that half of states are providing below-average support for their emergency medical systems, earning
When EDs exceed capacity, incoming patients are generally diverted to other EDs where they can be given more immediate care. According to the NHAMCS, 16.2 million patients annually arrive at emergency departments by ambulance; about 501,000 are diverted. According to Sg2, hospital EDs spend 3% of their time in diversion status. An estimated 40% to 60% of hospitals report ED diversion at least once a year. According to a survey of California hospitals by researchers from the University of California, Los Angeles, the following are the primary reasons for ambulance diversion: Lack of staffed critical-care beds: 40% Overcrowded ED: 19% Lack of general acute-care beds: 17% Staff shortages: 10% Lack of specialty physician coverage: 4%
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WAIT TIME
According to the NHAMCS, waits for emergency care have increased to an average of 56 minutes from 38 minutes a decade ago. The median wait is 31 minutes. A study by Harvard Medical School and researchers at Cambridge Health Alliance, published in 2008 in an online edition of Health Affairs, reported a similar finding. The study, which analyzed the time between patients arrivals in the ED and when they were first seen by a doctor, reported a 36% increase in wait time over the past seven years. For those whom a triage nurse classified as needing immediate attention, waits increased from 10 to 14 minutes, up 40%. Waits increased 150% for emergency patients suffering heart attacks, to 20 minutes. Some hospital EDs use check-in kiosks to streamline the admissions process. Besides offering patients more privacy, the kiosks can help nurses identify the most urgent cases.
Patient satisfaction was lowest during the evening shift, 3:00 p.m.-11:00 pm, and highest during the daytime, 7:00 a.m.-3:00 p.m. The more patients an ED sees, the longer each patient spends in the ED. The average time spent in the ED increases by 30 minutes for every additional 10,000 patients seen annually. Patient satisfaction drops significantly based on amount of time spent in the ED. Although overall patient satisfaction declines for patients who have spent more than two hours in the ED, hospitals that cannot eliminate long waits can give satisfaction a considerable boost by keeping patients informed about delays.
2009 Emergency Department Pulse Report Press Gamey Associates
REFERENCES AND RESOURCES ED PATIENT SATISFACTION

The 2009 Emergency Department Pulse Report, by Press Ganey Associates, reports patient satisfaction with care in the ED has increased since 2003. Still, patients admitted through the ED report lower satisfaction scores than those otherwise admitted to hospitals. The following are further findings of the report: There is a notable variation in overall patient satisfaction among metropolitan areas. Ranking highest in patient satisfaction are EDs at hospitals in Miami, Detroit, Philadelphia, Pittsburgh, Boston, Chicago, Baltimore, Houston, Dallas, and New York City. The average ED patient experience lasts four hours and three minutes, a 2% decrease from a year prior. 2009 Emergency Department Pulse Report: Patient Perspectives on American Health Care, Press Ganey Associates, June 2009. 2009 National Report Card on the State of Emergency Medicine (www.emreportcard.org), American College of Emergency Physicians, 2009. Agency for Healthcare Research and Quality, 2101 East Jefferson Street, Suite 501, Rockville, MD 20852. (301) 594-1364. (www.ahrq.gov) American College of Emergency Physicians, 1125 Executive Circle, Irving, TX 75038. (800) 798-1822. (www.acep.org)
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American Hospital Association, One North Franklin, Chicago, IL 60606. (312) 422-3000. (www.aha.org) Andrews, Michelle, A Wait At The ER Measured In Minutes, Not Hours, U.S. News & World Report, September 29, 2009, pp 79-80. Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139. (617) 665-2300. (www.challiance.org) Emergency Medicine Network, c/o EMNet Coordinating Center, Department of Emergency Medicine, Massachusetts General Hospital, 326 Cambridge Street, Suite 410, Boston, MA 02114. (www.emnet-usa.org) National Hospital Ambulatory Medical Care Survey, National Center for Health Statistics, June 2009. Sg2, 5250 Old Orchard Road, Skokie, IL 60077. (847) 779-5300. (www.sg2.com)
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FINANCIAL ISSUES
Based on discussions with health system chief financial officers (CFOs), Ernst & Young identified the following as critical issues likely to reshape the hospital industry in years to come: Healthcare Affordability Hospital finances are being eroded by the growing numbers of uninsured and underinsured. Aging populations, highprice drugs and technology, and rising labor costs have combined to create a perfect storm for the industry. Stepping up workforce productivity is seen as the only last chance to improve margins. Access to capital Many hospitals have construction projects on hold because financing is not available. Lower credit ratings and tighter credit markets have both played a role. With few options, CFOs are seeking greater consolida t ion o f resources and organizations. The merging of hospitals can bring savings, greater access to technology, more leverage with suppliers, and the power to negotiate with large insurance companies. Physician relationships CFOs are seeking to develop more mutually beneficial relationships with physicians. Workforce issues With supply of nurses and other hospital workers falling far short of demand, the cost of labor is skyrocketing. While the number of qualified applicants to nursing schools is on the rise, the dwindling number of faculty
means many applicants are turned away. Quality and pay-for-performance (P4P) While P4P proponents have argued that initiatives will drive dramatic reform in the delivery system, CFOs see goals falling short with incremental improvements at best. CFOs have invested significant sums on quality measures, yet there are few measures to gauge long-term outcomes. The need is great, CFOs say, to involve doctors in the fabric of hospital leadership and to collectively take ownership for quality. The race for new technologies CFOs observe that pressure on providers to invest in new clinical and information technologies is unprecedented. Yet CFOs say new technologies, often enormously expensive, do not always produce improved outcomes or a return on investment. In response, CFOs see scale as one answer. As hospitals consolidate, duplication will be avoided, and expenses and technology purchases can be better leveraged. Transparency and community benefit The demand for transparency is great in areas of patient safety, quality of care, and costs and charges. Not-for-profit hospitals are required to disclose even greater detail on bad debts and collection policies, charitable care, and community benefit. CFOs point to a very full and growing compliance agenda that must be managed and integrated into business operations.
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Reform or Transformation? A CFO Perspective, Ernst & Young, June 2008.
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18
GREEN HOSPITALS
ENVIRONMENTALLY FRIENDLY CONSTRUCTION

According to the American Society for Healthcare Engineering (ASHE), 81% of hospitals specify green or environmentally friendly construction materials in projects, an increase from 55% that did so in 2006.
SUSTAINABLE DESIGN FEATURES

The percentage of environmentally friendly and sustainable features being incorporated into facilities design is as follows: High-efficiency HVAC: 59% High-efficiency building controls: 57% Low-flow water fixtures: 49% Sustainable wall coverings, and paints and finishes with low VOCs: 47% Low-emission glass for windows: 40% Increased day-lighting: 34% Chemical waste reclamation: 16%
GREEN CONSTRUCTION PRACTICES

The 2009 Construction Survey by ASHE reports the percentage of green construction practices hospitals are employing in building projects as follows: Use of physical/mechanical design and building materials to improve indoor air quality: 49% Optimize layout and orientation of building to optimize energy performance: 32% Reuse/recycle demolition materials: 31% Segregate construction and demolition waste: 31% Minimize site development footprint: 22% Add language to contract specifications that constructors will follow LEED requirements: 21% Maintain and restore site biodiversity: 12% Specify cogeneration, fuel cells, renewable energy systems, and other alternative energy sources: 11%

The American Society for Healthcare Engineering of the American Hospital Association, One North Franklin, 28th Floor, Chicago, IL 60606. (312) 422-3800. (www.ashe.org)
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19
GROUP PURCHASING ORGANIZATIONS
After personnel costs, the supply chain is the single largest expense center for U.S. hospitals. Supply chain costs represent as much as 10% to 30% of net patient revenues. According to the Health Industry Group Purchasing Association (HIGPA), hospitals purchase over $275 billion in supplies annually, including over $30 billion in pharmaceuticals and $50 billion in medical and surgical equipment. Virtually all U.S. hospitals buy through group purchasing organ izations (GPOs), cooperatives that marshal the collective buying power of their healthcare provider members to broker deep-discounted deals with suppliers and distributors. According to HIGPA, hospitals and nursing homes purchase as much as 80% of their supplies under GPOs and integrated delivery network contracts. Most hospitals join GPOs because of the contract negotiations and pricing services. Providers also rely on GPOs for product standardization, revenue cycle management, labor staffing, and support for safety and quality initiatives. According to an April 2009 study directed by Prof. Eugene S. Schneller, Ph.D., at Arizona State University, GPOs help hospitals save over $36 billion in annual healthcare and related costs. Savings are as follows: $8.5 billion for medical/surgical purchases $6.8 billion for hospital pharmaceuticals $1.9 billion in the cardiology implant marketplace $1.8 billion in reduced administrative
costs $840 million in the orthopedic implant marketplace
LARGEST GPOs
In its 2009 Group Purchasing Survey, Modern Healthcare identified the following as the largest GPO organizations, ranked by 2008 estimated volume: Novation: $35.9 billion HealthTrust Purchasing Group: $17.0 billion AmeriNet: $ 7.0 billion Resource Optimization & Innovation: $ 0.7 billion FirstChoice Cooperative: $ 0.6 billion
REGIONAL GPOs
When regional GPOs consolidated into a handful of national groups in the 1980s and 90s, the moves were based on a belief that healthcare providers leverage better pricing when large organizations band together to contract with suppliers. Regional GPOs are reemerging largely because national supply chain organizations are acknowledging they have limited influence on their members use of negotiated contracts and that it is impossible for centralized organizations to address the idiosyncratic needs of their members.
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Health Industry Group Purchasing Association, 2025 M Street, Suite 800, Washington, DC 20036. (202) 367-1162. (www.higpa.org) Rhea, Shawn, Above And Beyond, Modern Healthcare, August 31, 2009, pp S1-S5. Schneller, Eugene S., The Value of Group Purchasing 2009: Meeting the Needs for Strategic Savings, Health Care Sector Advances Inc., April 2009.
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HOME CARE
Home care is a cost-effective service, not only for individuals recuperating from a hospital stay, but also for those who, because of a functional or cognitive disability, are unable to care for themselves. At any given time, 1.4 million Americans are receiving some form of healthcare at home for a period of one to three months. The following are characteristics of this market (sources: National Center for Health Statistics): Receive skilled nursing services: 75% Over age 65: 70% Rely on Medicare as primary payment source: 52% Heart disease: 11% Diabetes: 8% Congestive heart failure: 4% Osteoarthritis: 4% Fractures: 4% Hypertension: 3%
Home health industry expenditures are distributed as follows (sources: Deutsche Bank and Forbes): Home nursing, excluding Medicare (including commercial, Medicaid and other): 38% Equipment and other: 27% Medicare home nursing: 25% Hospice: 10% Under some reimbursement systems, insurers pay hospitals based on illness, giving hospitals an added incentive to get patients out of their beds as quickly as possible. Home care can assist in meeting this need, providing follow-up for patients who continue to need care but do not need to remain in the hospital. Studies indicate that home care reduces hospital inpatient days. Providing regular care in the home for certain conditions also reduces ED visits. Also it frees resources for acute-care patients and more profitable procedures.
COST ANALYSIS
According to The 2009 Market Survey of Long-Term Care Costs, by the MetLife Mature Market Institute, the average hourly rate for home health aides provided by a home care agency is $21 per hour. Costs range from an average of $30 per hour in Rochester, Minnesota, to $13 per hour in Shreveport, Louisiana. According to the Centers for Medicare and Medicaid Services, national expenditures for home healthcare in 2009 were $69.7 billion, an 8% increase over the prior year.
HOSPITALS IN THE HOME CARE MARKET

According to Hospital Statistics 2009, by the American Hospital Association, 66% of community hospitals are direct providers of some aspect of home care service (nursing, physical therapy, occupational therapy, respiratory care, equipment, etc.). Of Medicare-certified agencies, free-standing proprietary agencies comprise 40%; hospital-
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based agencies make up 30%. This differs markedly from the industry composition in the early 1980s, when public health agencies dominated the ranks of certified agencies and proprietary and hospital-based agencies combined accounted for only one-fourth of the total. The number of hospital-based and free-standing proprietary agencies has been growing faster than any other type of Medicare-certified agency, according to the National Association of Home Care and Hospice.
American Hospital Association, One North Franklin, Chicago, IL 60606. (312) 422-3000. (www.aha.org) National Association for Home Care & Hospice, 228 Seventh Street SE, Washington, DC 20003. (202) 547-7424. (www.nahc.org)
HOME CARE FOR SENIORS

Some three million people over age 65 can only leave their homes with extreme difficulty, according to Joanne Schwartzberg, M.D., the American Medical Associations director of aging and community health. Many suffer from a complex mix of chronic conditions that require constant attention. One solution is home care for this population. A recent study directed by Prof. Bruce Leff, M.D., at Johns Hopkins University School of Medicine found that providing acute, hospitallevel care to elderly patients in their homes results in better treatment outcomes, higher patient satisfaction, and lower costs than traditional hospitalization for some serious illnesses. According to Retooling for an Aging America, 90% of those receiving care at home get help from family and friends; 80% rely solely on them.

2009 Market Survey of Long-Term Care Costs, MetLife Mature Market Institute, October 2009. (www.maturemarketinstitute.com)
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21
HOSPICE & PALLIATIVE CARE
Hospice and palliative services provide patient end-of-life care. The big difference between hospice care and hospital-based palliative care is that hospice care seeks to move end-of-life patients out of the hospital to a home environment.
MARKET ASSESSMENT
Annual hospice and palliative care expenditures in the U.S. are estimated at $3 billion to $4 billion. Spending is distributed by payer as follows (source: Modern Healthcare): Medicare: 79% Private insurance: 13% Medicaid: 5% Private sources: 2% Self-pay: 1%
Characteristics of patients served by hospice An estimated 1.45 million patients were served by hospice programs in 2008. The median time spent receiving hospice care is 21.3 days. 57% of hospice patients are female; 43% are male 67% are 75 years of age or older Primary diagnosis of hospice patients: cancer (38%), heart disease (12%), and dementia (11%); 15% have unspecified debilities In 2008, 963,000 patients died under hospice care. Volunteer commitment Approximately 550,000 hospice volunteers contributed 125 million hours to hospices in 2008. The following are the largest providers of hospice care: Beverly Enterprises (www.beverlycares.com) Manor Care (www.manorcare.com) Odyssey Healthcare (www.odysseyhealthcare.com) VistaCare (www.vistacare.com) Vitas (www.vitas.com)
HOSPICE CARE
Hospice Care in America - 2009 Edition, published by The National Hospice and Palliative Care Organization, provides the following data on hospice care in the United States: Characteristics of U.S. hospice programs 4,850 estimated operational hospice programs 50% of hospices are not-for-profit, 46% are for-profit, and 4% are run by government agencies 77% of hospices had fewer than 500 total admissions in 2008
HOSPITAL PALLIATIVE CARE

According to the Center to Advance Palliative Care and the American Hospital Association, 31% of hospitals offer palliative care programs. Among hospitals with more than 50 beds, 47% have palliative care programs; 77% of hospitals with more than 250 beds
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have such programs. Wherever a palliative care program has been implemented, treating a patient, attending to quality of life, and cost-effective service are not mutually exclusive. Palliative care systems have been shown to enhance compliance with pain and quality accreditation standards and improved support for staff who deal with complex diagnoses and around-theclock needs. Pain, nausea, fatigue, and weakness; depression or other psychological issues; family needs; and provider-patient communication all of these interventions improve when a hospital puts a palliative care system in place. In conjunction with the Center to Advance Palliative Care, The Robert Wood Johnson Foundation has funded Palliative Care Leadership Centers model programs that offer hands-on technical assistance, training, and a year of mentoring to hospitals hoping to launch a palliative care program at the following hospitals: Fairview Health Services (Minneapolis, Minnesota) Massey Cancer Center of Virginia Commonwealth University Health System (Richmond, Virginia) Medical College of Wisconsin (Milwaukee, Wisconsin) Mount Carmel Health System (Columbus, Ohio) Palliative Care Center of the Bluegrass (Lexington, Kentucky) The University of California (San Francisco, California)
National Association for Home Care & Hospice, 228 Seventh Street SE, Washington, DC 20003. (202) 547-7424. (www.nahc.org) National Hospice and Palliative Care Organization, 1731 King Street, Suite 100, Alexandria, VA 22314. (703) 837-1500. (www.nhpco.org)

Center to Advance Palliative Care, 1255 Fifth Avenue, Suite C-2, New York, NY 10029. (212) 201-2670. (www.capc.org)
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22 HOSPITAL PATIENT DIAGNOSES, PROCEDURES & SPENDING
The 2009 Healthcare Cost and Utilization Project, from the Agency for Healthcare Research and Quality (AHRQ), provides statistics for principal diagnoses, procedures, and spending for stays at community hospitals. Data for the most frequent diagnoses and procedures are presented in this chapter.
REFERENCES AND RESOURCES Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, 2009. (www.hcup-us.ahrq.gov)
TABLE 22.1 Most Frequent Primary Diagnoses Pregnancy, childbirth, and newborn infants: Pneumonia: Coronary atherosclerosis (coronary artery disease): Congestive heart failure: Non-specific chest pain: Cardiac dysrhythmias (irregular heart beat): Osteoarthritis (degenerative joint disease): Mood disorders (depression and bipolar disorders): Acute myocardial infarction (heart attack): Disorders of intervertebral discs and bones in spinal column (back problems): Complication of device, implant or graft: Septicemia (blood infection): Chronic obstructive lung disease: Skin and subcutaneous tissue infections: Acute cerebrovascular disease (stroke): 9.25 million 1.22 million 1.20 million 1.10 million 857,000 749,000 735,000 729,000 675,000 636,000 634,000 611,000 598,000 597,000 537,000
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TABLE 22.2 Most Frequent Hospital Procedures Blood transfusion: Diagnostic cardiac catheterization, coronary arteriography (diagnostic procedure to explore the functioning of the heart): Repair of obstetric laceration: Cesarean section (C-section): Respiratory intubation and mechanical ventilation: Circumcision: Upper gastrointestinal endoscopy (procedure to view and biopsy the esophagus, stomach, and first portion of intestine through a lighted tube): Artificial rupture of membranes to assist delivery: Fetal monitoring: Prophylactic vaccinations and inoculations: Episiotomy (surgical incision into the perineum and vagina to prevent traumatic tearing during delivery): 2.38 million 1.67 million 1.37 million 1.35 million 1.30 million 1.22 million
1.21 million 1.01 million 958,000 945,000 393,000
TABLE 22.3 Spending For The Most Frequent Hospital Procedures Coronary atherosclerosis (coronary artery disease): Acute myocardial infarction (heart attack): Congestive heart failure: Liveborn (newborn infant): Osteoarthritis (degenerative joint disease): Septicemia (blood infection): Pneumonia: Complication of medical device, implant, or graft: Adult respiratory failure, insufficiency, or arrest: Disorders of intervertebral discs and bones in spinal column (back problems): Cardiac dysrhythmias (irregular heart beat): Acute cerebrovascular disease (stroke): Complications of surgical procedures or medical care: Rehabilitation care, fitting of prostheses, and adjustment of devices: Diabetes mellitus with complications: Biliary tract disease (gall bladder disease): Chronic obstructive lung disease: Fracture of neck of femur (hip fracture): $17.5 billion $11.8 billion $11.2 billion $10.8 billion $10.3 billion $10.2 billion $ 9.9 billion $ 9.4 billion $ 8.1 billion $ $ $ $ $ $ $ $ $ 7.6 billion 6.8 billion 6.7 billion 5.1 billion 5.0 billion 4.5 billion 4.4 billion 4.2 billion 4.1 billion
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23
HOSPITAL-ACQUIRED INFECTIONS
INCIDENCE & MORTALITY According to the Centers for Disease Control and Prevention (CDC), approximately two million patients contract infections while being treated in a hospital for a non-susceptible illness or injury each year, and almost 88,000 die because of their infections. Many victims are old, with chronic conditions that weaken their immune systems. Trauma patients, like victims of car crashes or bad burns, are also especially vulnerable, as are cancer patients in for radiation or chemotherapy, and newborns. An additional 340,000 infections occur in home healthcare and another 100,000 in long-term care centers, according to the CDC. Four categories account for 78% of healthcare-related infections each year. They are as follows:
Infections Deaths
and better record-keeping, according to Dr. Martin.
ANTIBIOTIC-RESISTANT INFECTIONS Bacteria like staphylococcus aureus roam hospitals freely, spreading by contact with the hands, a stethoscope, or a bed railing. The more resistant to commonly used antibiotics the bacteria become, the greater the threat. In 1974, only 2% of staphylococcus aureus infections were MRSA (methicillin-resistant). That figure has now soared to over 70%, according to the CDC. Most troubling are superbugs like Clostridium difficile, or C. diff, that are resistant to a wide range of antibiotics.
Urinary tract: Surgical site: Ventilator-associated pneumonia: Central-line associated pneumonia:
561,667 290,485 250,205 248,678
8,205 13,088 35,967 30,665
INFECTION-CONTROL PROGRAMS Hospitals must bear much of the responsibility for the failure to prevent hospital-borne infections. The 2009 Hospital Quality and Safety Survey, conducted by The Leapfrog Group, found 65% of hospitals do not have all of the recommended policies in place to prevent the most common hospitalacquired infections, and 75% do not fully meet the standards for 13 evidence-based safety practices, ranging from hand washing to competency of the nursing staff. Specific measures being taken by hospitals, as reported by the 2009 Infection Prevention & Hospital Cleaning Survey, are assessed in Chapter 26 of this handbook. Most hospitals
According to Greg Martin, M.D., of the Emory University School of Medicine, the continued prevalence of hospital-acquired infections may be due to several factors: increased resistance to antibiotics; more invasive procedures, transplants, and use of immunosuppressive drugs and chemotherapy; and more patients with illnesses that compromise immune systems, like AIDS. The numbers may also reflect greater awareness and diagnosis of sepsis
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now have infection-control programs. Some hospitals have implemented programs to aggressively screen for patients who may have problematic infections, isolating those carrying MRSA strains to prevent spreading. And hospitals are also increasingly using diagnostic tests and automated surveillance systems to control infections. Along with compromising patient safety, infections are costly to hospitals.
Antibiotic-resistant infections increase direct costs by 30% to 100%, according to various studies. MRSAspecific studies suggest that the additional cost of treating an antibiotic-resistant staph infection versus an antibiotic-sensitive infection range from a minimum of $3,000 to more than $35,000 per case. This suggests that such infections cost the healthcare system an extra $830 million to $9.7 billion, even without taking into account indirect costs related to patient pain, illness and time spent in the hospital.
Hospitals & Health Networks
REFERENCES AND RESOURCES Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333. (404) 639-3311. (www.cdc.gov) The Leapfrog Group, 1801 K Street NW, Suite 701-L, Washington, DC 20006. (202) 292-6713. (www.leapfroggroup.org)
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24 HOSPITALS IN PURSUIT OF EXCELLENCE
In March 2009, the AHA Quality Center of the American Hospital Association (AHA) released a guide to support the ongoing efforts to improve the patient experience and outcomes in hospitals. Titled Hospitals in Pursuit of Excellence, the guide shows how hospitals can reduce waste and inefficiency, optimize the use of resources, and enhance their ability to deliver safe, high-quality, affordable patient care. Hospitals in Pursuit of Excellence focuses on four areas identified as common opportunities for improvement: healthcare-associated infections, patient flow, medication management, and patient safety (such as falls and pressure ulcers).
Manage organizational viability Achieve consistency in structure and function of staff and units, where possible. Remove waste Removing waste, including unnecessary steps, has a direct, positive impact on the bottom line. Eliminate defects Finding and resolving problem points will result in greater efficiency and better health outcomes. Reduce process variation Using quality tools and frameworks can increase consistency in processes of care and administration, thus reducing the risk of errors.
CORE PRINCIPALS
Hospitals in Pursuit of Excellence recommends the following six core principles: Focus on the patients experience of care Care must be respectful of, and responsive to, individual preferences, needs, and values. Create a culture of reliability Culture defines the values and behaviors of organizations. Highly reliable cultures are known to be the safest organizations in the world.
REFERENCES
American Hospital Association, One North Franklin, Chicago, IL 60606. (312) 422-3000. (www.aha.org) Hospitals in Pursuit of Excellence, American Hospital Association (www.apoe.org)
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IMPACT OF THE ECONOMIC CRISIS
Based on a survey of hospital CEOs, the American Hospital Association published The Economic Crisis: Ongoing Monitoring of Impact on Hospitals in April 2009. The following are findings of the survey.
behavioral health, post acute care, clinic, patient education, and other services that require subsidies.
FINANCIAL HEALTH IMPACTS REPORTED BY THE MAJORITY OF HOSPITALS

The proportion of emergency department patients without insurance is increasing. A higher proportion of patients are unable to pay for care and many hospitals are seeing more patients covered by Medicaid and other public programs. Fewer patients are seeking inpatient and elective services, raising concerns that individuals are putting off needed care. Community need for subsidized services such as clinics, screenings, and outreach is increasing even as charitable contributions are down for many hospitals.
Despite the actions taken, seven of 10

hospitals report a decline in overall financial health, which will impact their ability to care for their communities. Forty-three percent (43%) of hospitals reported financial losses in the first quarter of 2009, up from 26% for the same period in 2008. Nearly all hospitals report that the capital situation has not improved or is still deteriorating since December 2008. Since the beginning of 2008, eight of 10 hospitals have cut capital spending for facility upgrades, clinical technology, and/or information technology. Eight in 10 hospitals report an increase in the degree to which physicians are seeking the financial support of hospitals, including oncall pay and/or employment.
ACTIONS TAKEN
Nine in 10 hospitals have made cutbacks to address economic concerns. Nearly half have reduced staff. Eight in 10 have cut administrative expenses. One in five have reduced services communities depend on, including

The Economic Crisis: The Toll on the Patients and Communities Hospitals Serve, American Hospital Association, April 27, 2009. (www.aha.org/aha/content/2009/pdf/ 090427econcrisisreport.pdf)
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26 INFECTION PREVENTION
The 2009 Infection Prevention & Hospital Cleaning Survey was conducted by the American Society for Healthcare Environmental Services, the Association for Professionals in Infection Control and Epidemiology, Health Facilities Management, and Materials Management in Health Care. Infection preventionists from 686 hospitals participated in the survey.
Microfiber mops: Change cubical curtains after discharge of patients placed under contact precautions: Microfiber cloths: Pour bottles to dispense disinfectant: Copper and copper-alloy fixtures: Hydrogen peroxide vapor decontamination system:
68%
57% 46% 42% 4% 2%
The important link between environmental cleanliness and infection prevention has long been appreciated, but how best to achieve these objectives remains a source of ever-changing science and application. So how are hospitals faring today in this all-important area and how are they responding to the rapid changes in cleaning technologies and processes, and verifying proper cleaning procedures are followed?
Materials Management in Health Care, 5/09
CLEANING VERIFICATION
Hospitals using chemicals (e.g., fluorescing markers) to verify cleaning of the following high-risk objects are as follows: Bed rail: 16% Tray table: 16% Nurse call device: 16% Bedside table: 15% Bathroom doorknobs: 15% Toilet seat: 15% Patient telephone: 15% Sinks: 14% Toilet handle: 14% Patient room doorknobs and cabinet pulls: 14% Bathroom light switch: 14% Restroom grab bars: 13%
CLEANING PRACTICES
Cleaning practices and technologies hospitals routinely employ to disinfect patient rooms are as follows: Quaternary ammonium disinfectant: 85% Disinfectant-impregnated wipes: 77% Sodium hypochlorite, household bleach: 68%
STAFF PERFORMANCE OPTIMIZATION

Hospitals have taken the following steps to optimize environmental services staff performance: Hands-on training in cleaning protocols: 84%
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Education on transmission of healthcare-associated pathogens and resultant infection: Ongoing performance feedback: Predefined performance targets for patient area cleaning: Patient interviews by supervisory staff: Well-defined quality management program for patient area cleaning: Use of visually observable feedback tool (e.g., black-light marker): Quality control assessments tied to compensation:
81% 62% 31% 27% 24% 20% 10%
High turnover rates among environmental services technicians: Inadequate financial resources to invest in cleaning technologies and equipment: Lack of objective microbiologic standards for hospital cleaning: Lack of knowledge of the role specific high-risk objects play in transmitting healthcare-associated pathogens:
26%
26% 20%
20%

2009 Infection Prevention & Hospital Cleaning Survey, Health Facilities Management, December 2009, p. 17. (www.hfmmagazine.com/hfmmagazine/ima ges/pdf/2009PDFs/12HFM_InfectionControl _16.pdf) 2009 Infection Prevention & Hospital Cleaning Survey, Materials Management in Health Care, May 2009, pp 18-22. (www.matmanmag.com/matmanmag_app/j sp/articledisplay.jsp?dcrpath=MATMANMA G/Article/data/05MAY2009/0905MMH_Cove rstory&domain=MATMANMAG) American Society for Healthcare Environmental Services of the American Hospital Association, One North Franklin, Suite 2800, Chicago, IL 60606. (312) 422-3860. (www.ashes.org) Association for Professionals in Infection Control and Epidemiology, 1275 K Street NW, Suite 1000, Washington, DC, 20005. (202) 789-1890. (www.apic.org)
MEASURING COMPLIANCE
Hospitals measure compliance with cleaning standards in patient core areas as follows: Observation-based audit: 87% Patient satisfaction scores on cleanliness of room: 78% Monitor compliance with performance targets: 34% Risk-based audit: 15% Environmental culture results: 14% Measuring cleaning rates of high-risk objects in patient area: 14%
TOP CHALLENGES
The following are the top challenges to cleaning and disinfecting the patient environment: Pressure to expedite room turns for incoming patients: 42% Assigned responsibility for cleaning mobile objects: 41% High hospital occupancy: 35% Inadequate time to properly clean patient rooms and care areas: 32% Reluctance to clean electronic equipment with saturated cloths: 32% Inadequate staffing levels: 31% Too busy/insufficient time allowed to consistently follow protocols: 28%
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INFORMATION TECHNOLOGY
The Healthcare Information and Management Systems Society (HIMSS) has conducted an annual leadership survey since 1989. This chapter summarizes results of the 20th Annual Leadership Survey, published in February 2009.
MOST IMPORTANT APPLICATIONS

Clinical information systems: Computer-based practitioner order entry (CPOE): Electronic medical record (EMR): Enterprise-wide clinical information sharing: Closed-loop medication management: Clinical data repository: Point-of-care data collection: Clinical portal: 45% 42% 31% 30% 30% 29% 21% 21%
TOP ISSUES FACING HEALTHCARE

Improving quality of care: Patient satisfaction: Medicare cutbacks: Increased need for healthcare services: Adoption of new technology: Demand for capital: Government regulation/compliance issues: 69% 55% 52% 45% 38% 31% 20%
BARRIERS TO ADOPTION
Lack of financial support: Lack of staffing resources: Vendors inability to effectively deliver product: Lack of time from clinicians: Lack of strategic IT plan: Providing quantifiable benefits/ROI: Difficulty achieving end-user acceptance: Lack of clinical leadership: 26% 13% 12% 9% 8% 5% 5% 5%
TOP IT PRIORITIES
Reduce medical errors/promote patient safety: Inpatient clinical information systems: Implement an EMR: Business continuity and disaster recovery: Integrate systems in a multi-vendor environment: Connect hospital with remote environments: Upgrade network infrastructure: Implementing ambulatory care systems: 54% 48% 48% 35% 34% 33% 25% 23%

Healthcare Information and Management Systems Society, 230 East Ohio Street, Suite 500, Chicago, IL 60611. (312) 664-4467. (www.himss.org)
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LARGEST HEALTHCARE SYSTEMS
The 2009 Hospital Systems Survey is the 33rd annual such survey conducted by Modern Healthcare. Rankings of the largest healthcare systems from this survey are presented in this chapter.
LARGEST FOR-PROFIT HEALTHCARE SYSTEMS RANKED BY STAFFED ACUTE-CARE BEDS

HCA: Community Health Systems: Tenet Healthcare Corporation: Health Management Associates: Universal Health Services: LifePoint Hospitals: Vanguard Health Systems: Iasis Healthcare Corp.: Prime Healthcare Services: Capella Healthcare: 40,742 17,245 14,532 8,019 6,101 5,686 4,181 2,502 2,311 1,556
LARGEST HEALTHCARE SYSTEMS RANKED BY REVENUE

Department of Veterans Affairs: HCA: Ascension Health: Tenet Healthcare Corp.: New York-Presbyterian Healthcare System: Catholic Health Initiatives: Community Health Systems: Catholic Healthcare West: Sutter Health: Mayo Clinic: $40.7 billion $28.4 billion $12.7 billion $10.8 billion $ $ $ $ $ $ 8.5 billion 8.3 billion 7.8 billion 7.6 billion 6.9 billion 6.1 billion
LARGEST PUBLIC HEALTHCARE SYSTEMS RANKED BY STAFFED ACUTE-CARE BEDS

Department of Veterans Affairs: University of California: Carolinas HealthCare System: Jackson Health System: Memorial Healthcare System: Lee Memorial Health System: Broward Health: WellStar Health System: 17,296 2,881 2,817 1,858 1,797 1,462 1,362 1,122
LARGEST HEALTHCARE SYSTEMS RANKED BY HOSPITAL COUNT

HCA: Department of Veterans Affairs: Community Health Systems: Catholic Health Initiatives: Ascension Health: Health Management Associates: Tenet Healthcare Corporation: LifePoint Hospitals: Catholic Healthcare West: Adventist Health System: 166 153 118 77 67 56 53 48 41 37
LARGEST SECULAR NOT-FORPROFIT HEALTHCARE SYSTEMS RANKED BY STAFFED ACUTE-CARE BEDS

New York-Presbyterian Healthcare System: 8,090
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Sutter Health: North Shore-Long Island Jewish Health System: Banner Health System: University of Pittsburgh Medical Center: BJC HealthCare: MedStar Health: Mayo Clinic: Partners HealthCare: Intermountain Healthcare:
5,208 5,066 3,856 3,448 3,259 2,799 2,717 2,538 2,306

Carlson, Joe and Vince Galloro, Into the Red, Modern Helathcare, June 8, 2009, pp 26-30.
LARGEST CATHOLIC HEALTHCARE SYSTEMS RANKED BY STAFFED ACUTE-CARE BEDS

Ascension Health: Catholic Health Initiatives: Catholic Healthcare West: Catholic Health East: Christus Health: Trinity Health: Providence Health & Services: Catholic Healthcare Partners: Sisters of Mercy Health System: SSM Health Care: 15,296 8,267 7,249 6,371 5,463 5,401 4,938 3,963 3,363 2,999
LARGEST NON-CATHOLIC RELIGIOUS HEALTHCARE SYSTEMS RANKED BY STAFFED ACUTE-CARE BEDS

Adventist Health System: Advocate Health Care: Texas Health Resources: Baylor Health Care System: Baptist Memorial Health Care: Iowa Health System: OhioHealth: Fairview Health Services: Methodist Hospital System: Methodist Healthcare: 5,596 2,827 2,712 2,467 2,347 2,092 1,802 1,627 1,464 1,336
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LARGEST HOSPITALS
According to the American Hospital Association Guide, 2009 Edition, there are 20 hospitals in the U.S. with 1,000 or more staffed beds. These hospitals are listed in Table 29.1.

American Hospital Association, One North Franklin, Chicago, IL 60606. (312) 422-3000. (www.aha.org)
TABLE 29.1 Largest U.S. Hospitals New York Presbyterian Hospital* (New York, New York): Florida Hospital* (Orlando, Florida): Jackson Health System* (Miami, Florida): Central Texas Veterans Healthcare* (Temple, Texas): Patton State Hospital (Patton, California): UPMC Presbyterian* (Pittsburgh, Pennsylvania): Lee Memorial Hospital* (Fort Myers, Florida): Sonoma Development Center (Eldridge, California): Methodist Hospital* (San Antonio, Texas): Orlando Regional Medical Center* (Orlando, Florida): Clarian Health* (Indianapolis, Indiana): Methodist Healthcare - Fayette Hospital (Somerville, Tennessee): Methodist University Hospital* (Memphis, Tennessee): Napa State Hospital (Napa, California): Atascadero State Hospital (Atascadero, California): Kaleida Health* (Buffalo, New York): Montefiore Medical Hospital* (New York, New York): Barnes Jewish Hospital (St. Louis, Missouri): Veterans Affairs Greater Los Angeles Healthcare System: Central Virginia Training Center (Madison Heights, Virginia):
* includes multiple campuses
2,207 staffed beds 1,906 staffed beds 1,833 staffed beds 1,532 staffed beds 1,510 staffed beds 1,471 staffed beds 1,462 staffed beds 1,413 staffed beds 1,405 staffed beds 1,387 staffed beds 1,380 staffed beds 1,316 staffed beds 1,315 staffed beds 1,196 staffed beds 1,127 staffed beds 1,161 staffed beds 1,094 staffed beds 1,087 staffed beds 1,087 staffed beds 1,008 staffed beds
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LONG-TERM CARE
NURSING HOMES
According to the American Health Care Association, there were 15,702 certified skilled nursing facilities in the U.S. as of June 2009. Combined, they had 1.67 million certified beds and 1.41 million patients. According to the Centers for Medicare and Medicaid Services, national expenditures for nursing home care in 2009 were $143.9 billion.
COST ANALYSIS
According to the 2009 Market Survey of Long-Term Care Costs, by the MetLife Mature Market Institute, the average daily rate for a private room in a nursing home in 2009 was $219, or $79,935 annually, a 3.3% increase from 2009. For semi-private rooms, the average daily cost was $198. Costs range from $594 per day in Alaska (statewide) to $132 per day in Baton Rouge and Shreveport, Louisiana. The average monthly base price in 2008 for assisted living communities was $3,131, or $37,572 annually. The highest cost was reported in Wilmington, Delaware, at $5,219 per month. The lowest was in Nor\th Dakota, at $2,041. According to MetLife, 59% of assisted living facilities offer dementia care; the additional costs for these services average $1,110 per month.
ASSISTED LIVING FACILITIES

Assisted living is defined as a housing option for older adults that promotes independence and autonomy while also providing services to assist individuals with daily living. Facilities can range in size from a small house to a large apartment-style complex; most have between 25 and 125 units. According to the 2009 Overview of Assisted Living, more than 900,000 Americans live in approximately 39,500 assisted living residences. The average age of an assisted living resident is 86.9 years old; the average length of stay in assisted living is approximately 28.3 months. The senior assisted care business is an $18 billion to $20 billion annual industry, according to the Assisted Living Federation of America (ALFA).
FOR-PROFIT CHAINS
Approximately 75% of nursing homes are owed by for-profit chains. By comparison, only 15% of hospitals are owned by for-profit chains. The largest chains are listed in Table 30.1.
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TABLE 30.1 Largest Skilled-Nursing Companies

Facilities Beds
RehabCare Group (www.rehabcare.com):

Golden Living (www.goldenliving.com): HCR Manor Care (www.hcr-manorcare.com): Kindred Healthcare (www.kindredhealthcare.com): Genesis HealthCare (www.genesishcc.com): Sun Healthcare Group (www.sunh.com): Extendicare Health Services (www.extendicare.com): Signature HealthCare (www.signaturehealthcarellc.com): Advocate (www.irinfo.com/avc): Covenant Care (www.covenantcare.com): Revera Health Systems (www.reverahealthsystems.com): Alden Network (www.thealdennetwork.com):
1,068 324 279 228 208 184 171 65 50 43 30 28
n/a 33,356 n/a 28,527 25,277 23,345 17,615 7,737 5,773 4,869 3,732 4,356
source: Modern Healthcare (November 23, 2009)

2009 Market Survey of Long-Term Care Costs, MetLife, October 2009. 2009 Overview of Assisted Living, copublished by the American Association of Homes and Services for the Aging, American Seniors Housing Association, Assisted Living Federation of America, National Center for Assisted Living, and National Investment Center for the Seniors Housing & Care Industry, June 2009. American Association of Homes and Services for the Aging, 2519 Connecticut Avenue NW, Washington, DC 20008. (202) 783-2242. (www.aahsa.org) American Health Care Association, 1201 L Street NW, Washington, DC 20005. (202) 842-4444. (www.ahcancal.org) American Seniors Housing Association, 5100 Wisconsin Avenue NW, Suite 307,
Washington, DC 20016. (202) 237-0900. (www.seniorshousing.org) Assisted Living Federation of America, 1650 King Street, Suite 602, Alexandria, VA 22314. (703) 894-1805. (www.alfa.org) Largest Skilled-Nursing Companies, Modern Healthcare, November 23, 2009, p. 34. MetLife Mature Market Institute, 57 Greens Farms Road, Westport, CT 06880. (203) 221-6580. (www.maturemarketinstitute.com) National Center for Assisted Living, 1201 L Street NW, Washington, DC 20005. (202) 842-4444. (www.ahcancal.org) National Investment Center for the Seniors Housing & Care Industry, 1997 Annapolis Exchange Parkway, Suite 110, Annapolis, MD 21401. (410) 267-0504. (www.nic.org)
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MARKETING
MARKETING BUDGETS
Health systems and hospitals spend approximately 0.5% to 2% of their operating budgets on marketing. Marketing expenditures are roughly evenly split between advertising and community relations/ educational/PR activities. According to a recent survey by the 3,600member Society for Healthcare Strategy and Market Development, marketing budgets by healthcare organizations are distributed as follows: Advertising: 48% Publications: 17% Collateral materials: 10% Community events/giveaways: 9% Marketing research: 6% Website management: 5% Call center: 2% Other: 9%
Print ads: Forming alliances or partnerships: Direct mail: Billboard ads: Television ads:
97% 77% 74% 40% 34%
Betsy Gelb, Ph.D., professor of marketing and director of the Institute for Health Care Marketing at the University of Houston, explains that marketers approach their work as a decision-making process like any other in business. Prof. Gelb enthusiastically supports service enhancing, informational marketing. Though marketing encompasses contract negotiation, patient satisfaction, market research and more, half of hospital marketing budgets go to advertising. According the Direct Marketing Association, healthcare provider companies spend $2.4 billion annually on direct marketing, approximately 90% of which targets consumers. Most spending goes toward offline channels, particularly telephone marketing and direct mail. Hospitals are large distributors of promotional items, for example, giving away such items as bee sting kits, first aid kits, and health education materials. Hospitals also focus on educational programs and health promotions to gain name recognition. Hospitalsponsored wellness and fitness programs within the workplace and in communities nationwide have become popular. Even shopping centers have become a place hospitals use to promote themselves to the public.
ADVERTISING AND PROMOTIONS

Hospitals have engaged in advertising since 1979, after the American Medical Association (AMA) was forced by a Supreme Court decision to drop its policy that discouraged most forms of ads. Though some ads are little more than public services messages, most are direct-to-patient marketing efforts aimed at creating demand. According to a survey of hospital executives by Modern Healthcare, the following methods were being used by hospitals to increase marketshare:
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WORD-OF-MOUTH
According to a survey by The Henry J. Kaiser Family Foundation, when trying to find information on healthcare quality, 70% of consumers ask friends, family members, or co-workers; 65% ask a doctor, nurse, or other healthcare professional. Exceptional service helps to attracts new patients; retain patients, physicians, and employees; recruit employees and physicians; and foster a reputation that brings business to the hospital.

American Medical Association, 515 State Street, Chicago, IL 60610. (800) 621-8335. (www.ama-assn.org) Direct Marketing Association, 1120 Avenue of the Americas, New York, NY 10036. (212) 768-7277. (www.the-dma.org) Healthcare Online, Richard K. Miller & Associates (www.rkma.com), February 2010. Institute for Health Care Marketing, C.T. Bauer College of Business, University of Houston, 334 Melcher Hall, Houston, TX 77204. (713) 743-4600. (www.bauer.uh.edu/centers/ihcm) Society for Healthcare Strategy and Market Development, One North Franklin, Chicago, IL 60606. (312) 422-3888. (www.shsmd.org) The Henry J. Kaiser Family Foundation, 2400 Sand Hill Road, Menlo Park, CA 94025. (650) 854-9400. (www.kff.org)
Patients perceptions of the care they receive at a facility has a positive correlation with that of employees of the facility. Organizations with patients who are likely to recommend it for care have employees who are likely to make the same recommendation. And it is important to note that employees are proud to work at a place that provides the excellent care that patients want to receive.
American Hospital Association Hospitals & Health Networks
COMMUNITY OUTREACH PROGRAMS

According to the AMA, the following percentages of hospitals offer selected community outreach programs: Health screenings: 80% Health fairs: 78% Support groups: 67% Patient education center: 60% Health information: 49% Enrollment assistance services: 45%
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MEDICAL LIABILITY
Costs related to malpractice lawsuits are blamed for contributing to the high spending on healthcare in the United States. But the impact is difficult to estimate. Malpractice premiums makeup less than 1% of U.S. healthcare spending. Defensive medicine is estimated by some analysts to increase total spending by about 2% studies show that up to 60% of medical tests are unnecessary, done in large part because doctors fear being sued. Data, however, is not clear. Texas, for example, has not seen healthcare spending drop since instituting award caps in 2003. A number of states have instituted tort reform, limiting the size of damage awards by juries in medical malpractice cases.
Journal. An exact figure is very difficult to determine, however, since settlements are often kept confidential. The contingent fees charged by plaintiffs lawyers vary widely and are often limited by law, but a common rate is 33% of any payment. Ninety-seven percent (97%) of cases are settled out of court. The average malpractice award in 2008 was $326,931, according to the Kaiser Family Foundation.
APOLOGIZING FOR ERRORS

In a recent survey by the American College of Physician Executives, almost 80% of doctors said physicians and hospitals that make mistakes should apologize for errors. In a survey of patients, 57% said they would be less likely to sue if the provider issued an apology after an error; only 25% indicated that they would be more likely to sue. Since 2001, prominent institutions from the Dana-Farber Cancer Institute to Johns Hopkins Hospital have made it a policy to urge their doctors to own up to mistakes and apologize, according to The Wall Street Journal. Consultants are increasingly in demand for seminars on how best to deliver lawsuit-deflecting apologies. At some medical schools, including Vanderbilt University School of Medicine, courses in communicating errors and apologizing are now mandatory for medical students and residents. Even some insurers are beginning to urge their clients to acknowledge errors and to apologize.
LIABILITY INSURANCE
Liability insurance costs fluctuate significantly. According to Medical Liability Monitor, in 2008, premiums for obstetricians in Miami were approximately $200,000, about $80,000 in Los Angeles, but only $20,000 in Minneapolis. According to the Handbook of Health Economics, 40 of every dollar spent on malpractice insurance premiums goes toward awards; insurers spend much of the rest on legal fees.
MALPRACTICE AWARDS
More than $4 billion is estimated to be paid out annually to settle malpractice claims against doctors, according to The Wall Street
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Since launching a program in which doctors admit errors and offer payments out of court, the University of Michigan Health System has cut claims in half.
Medical Liability Monitor, 1100 Lake Street, P.O. Box 680, Oak Park, IL 60303. (312) 944-7900. (www.medicalliabilitymonitor.com) Pickert, Kate, Malpractice Reform, Time, September 28, 2009.
COUNTERSUING UNWARRANTED MALPRACTICE LAWSUITS

Medical Justice Corp., launched in 2002 during the peak of the malpractice insurance crisis, assists doctors in minimizing get rich quick lawsuits by countersuing when lawsuits are considered unwarranted. The approach appears to be effective. Of the 1,400 physicians subscribing to the service, only 2% have been sued, compared with 8% to 12% of all U.S. doctors.

2009 Hospital Professional Liability and Physician Liability Benchmark Analysis, Aon Consulting (www.aon.com), 2009. American Society for Healthcare Risk Management, One North Franklin, 28th Floor, Chicago, IL 60606. (312) 422-4580. (www.ashrm.org) Culyer, Anthony J. and Joseph P. Newhouse, Handbook of Health Economics, Elsevier, 2000. Medical Justice Corp., P.O. Box 49669, Greensboro, NC 27419. (877) 633-5878. (www.medicaljustice.com)
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MEDICAL TOURISM
TRAVELING ABROAD FOR MEDICAL PROCEDURES

A May 2008 study by McKinsey & Co. estimated 60,000 to 85,000 patients from the U.S. travel abroad annually for treatment at foreign hospitals. Taking into account travel for cosmetic and dental procedures, the number of U.S. patients traveling abroad is much higher than the McKinsey & Co. estimate. Josef Woodman, author of Patients Beyond Borders (2007, Healthy Travel Media), estimated that more than 150,000 Americans travel abroad annually for healthcare. The Deloitte Center for Health Solutions put the number as high as 750,000. Because medical tourism is primarily for the uninsured making independent decisions, it is tough to judge the industry, and very difficult to estimate the number of people going overseas.
Michael Chee Communications Director Healthplace America Modern Healthcare, 6/15/09
employers, and the U.S. government begin encouraging treatment abroad. Cost is the primary driver attracting U.S. patients to other countries. Compared to $50,000 or more for a heart bypass performed in the U.S., the procedure costs $8,000 to $15,000 in Thailand or India, for example. In addition to excellent medical care, services in Asia typically include limo pick-up and convalescence time in a hotel.
HEALTH PLANS ENCOURAGE MEDICAL TOURISM

Some healthcare insurers have launched initiatives to eventually allow coverage for overseas medical care for policyholders. Medical tourism is not something patients by themselves will seek to do. It will be a product of what happens with the insurance companies. More and more, the expense of care is falling on patients, and there will be mounting pressure for patients to leave their homes and go overseas for less-expensive care.
Richard Wade, Senior V.P. American Hospital Association Modern Healthcare, 5/7/08
Paul Mango, director of the healthcare practice at McKinsey & Co., projects the potential market for Americans seeking lowercost care abroad at 710,000 procedures a year. These 710,000 procedures, currently bringing $35 billion of revenue to U.S. hospitals, could be done overseas at a savings of about $15,000 per procedure. The extent that the overseas healthcare market develops will depend upon whether insurers,
Blue Cross & Blue Shield of South Carolina, one of the first to launch such a program, has alliances through its Companion Global Healthcare subsidiary with Bumrungrad
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International Hospital (Bangkok), Parkway Group Healthcare (owner of three hospitals in Singapore), and hospitals in Turkey, Ireland, and Costa Rica. According to Ruben Toral, president of the International Medical Travel Association, three areas of concern limit employers and insurers in adopting medical tourism as a solution to lower healthcare costs: quality, liability, and continuity of care. Payers typically ask three basic questions: How do I know these hospitals offer the same quality services as U.S. hospitals? What happens if something goes wrong? Who is responsible for delivering aftercare when these patients return from overseas?
Italy: Japan: Jordan: Korea: Malaysia: Mexico: Pakistan: Philippines: Portugal: Qatar: Saudi Arabia: Singapore: Spain: Switzerland: Taiwan: Thailand: Turkey: United Arab Emirates: Vietnam:
17 1 5 2 6 8 1 3 2 5 30 15 17 1 7 9 35 31 1
CERTIFIED FOREIGN HOSPITALS DOMESTIC COMPETITION

More than 290 foreign hospitals and healthcare providers are certified by Joint Commission International, a not-for-profit subsidiary of the Joint Commission, which accredits U.S. hospitals. As of January 2010, the number of certified organizations by country are as follows: Austria: 4 Bangladesh: 1 Barbados: 1 Bermuda: 1 Brazil: 20 Chile: 2 China: 5 Columbia: 1 Costa Rica: 3 Cyprus: 1 Czech Republic: 4 Denmark: 6 Egypt: 2 Ethiopia: 1 Germany: 5 India: 14 Indonesia: 1 Ireland: 20 Israel: 3 Some hospitals see the threat of patients considering overseas options as a market opportunity. At a time when patients are looking for more affordable quality healthcare options in the midst of a dismal economy, heart procedures and hip replacements costing thousands of dollars less in places such as Costa Rica, India, or Malaysia can look very attractive. Some hospitals in the U.S., however, seeking to bulk up their patient base and fill beds during lower-volume periods, have decided they can compete with these institutions by offering discounted surgeries.
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One such hospital is Calichia Heart Hospital (Wichita, Kansas), which structured its pricing for self-pay patients to compete with those offered overseas. For surgeries performed during periods when patient load is low, for instance, Calichia cut its price for a coronary bypass to $10,000 down $40,000 to $50,000 from what the typical major medical center would charge and a hip replacement for $12,000, about one-third of the going U.S. rate. This is all cash; patients are uninsured but with means, and they pay upfront. Consumers want high quality, discounted services, and if they can get that in the U.S., theyll pay for it.
Toral, Ruben, Quality, Liability, Aftercare, Modern Healthcare, May 25, 2009, p. 20.

International Medical Travel Association, P.O. Box 9, Prasarnmitr Post Office, Bangkok, Thailand 10114. (www.intlmta.org) Joint Commission International, 1515 West 22nd Street, Suite 1300W, Oak Brook, IL 60523. (630) 268-4800. (www.jointcommisisioninternational.org) Lubell, Jennifer, New Tourist Attractions, Modern Healthcare, June 15, 2009, p. 28. Medical Tourism Association, 10130 Northlake Boulevard, Suite 214, West Palm Beach, FL 33412. (561) 791-2000. Rhea, Shawn, Medical Migration, Modern Healthcare, May 7, 2008, pp 6-10. Rhea, Shawn, Still Packing Their Bags, Modern Healthcare, July 27, 2009, pp 2830.
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MEDICARE & MEDICAID
Payment rates for Medicare and Medicaid, with the exception of managed care plans, are set by law rather than through a negotiation process as with private insurers. Each year, the American Hospital Association (AHA) collects aggregate information on the payments and costs associated with care delivered to beneficiaries of Medicare and Medicaid. The AHA finds that since 2000, payment rates have been set below the costs of providing care, essentially resulting in underpayment. Moreover, the amount of underpayment is on the rise. Data for 2000 through 2008 is presented in Table 34.1. Underpayment data in the table is defined as the difference between the costs incurred and the reimbursement received for delivering care to patients.
Hospital participation in Medicare and Medicaid is voluntary. However, as a condition for receiving federal tax exemption for providing healthcare to communities, notfor-profit hospitals are required to care for Medicare and Medicaid beneficiaries. Moreover, Medicare and Medicaid patients account for 55% of all care provided by hospitals. Consequently, very few hospitals can elect not to participate in Medicare and Medicaid.

Underpayment By Medicare and Medicaid Fact Sheet, American Hospital Association, November 2009. (www.aha.org/aha/
content/2009/pdf/09medicunderpayment.pdf)
TABLE 34.1 National Underpayment For Medicare and Medicaid

Medicare Medicaid Total
2000: 2001: 2002: 2003: 2004: 2005: 2006: 2007: 2008:
$ 1.3 billion $ 2.3 billion $ 3.3 billion $ 8.1 billion $15.0 billion $15.5 billion $18.6 billion $21.5 billion $22.0 billion
$ 2.5 billion $ 2.0 billion $ 2.3 billion $ 4.9 billion $ 7.1 billion $ 9.8 billion $11.3 billion $10.4 billion $10.4 billion
$ 3.8 billion $ 4.3 billion $ 5.5 billion $13.0 billion $22.1 billion $25.3 billion $29.9 billion $31.9 billion $32.4 billion
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NEW HOSPITALS
HOSPITALS IN PLANNING PHASE

Engineering News-Record identified the hospital construction projects listed in Table 35.1 as the largest in the planning stage as of November 2009.

Dicker, Lisa Steakley, Owners Start To Resume Work On Projects That Were On Hold, Engineering News-Record, November 9, 2009, pp 30-32.
TABLE 35.1 Largest Healthcare Construction Projects in Planning Phase Parkland Hospital (Dallas, Texas): MCLNO LSU Medical Center (New Orleans, Louisiana): UNMH North Campus Hospital (Albuquerque, New Mexico): Rush University Medical Center (Chicago, Illinois): Saint Vincent Catholic Medical Centers (New York, New York): San Francisco General Hospital Acute Care Hospital (San Francisco, California): Exempla St Joseph Hospital - Phase 1 (Denver, Colorado): Kaiser San Leandro Hospital (San Leandro, California): Stanford University Medical Center Hospital (Palo Alto, California): Kaiser Hospital (Anaheim, California): CPMC Cathedral Hill Hospital (San Francisco, California): UMHHC C.S. Mott Childrens & Womens Hospital (Ann Arbor, Michigan): Owensboro Hospital - Regional Campus (Owensboro, Kentucky): Veterans Admin. Medical Center (Omaha, Nebraska): Methodist Medical Center (Peoria, Illinois): Albert Einstein Healthcare Network (Norristown, Pennsylvania): Albany Medical Center Expansion (Albany, New York): Scripps Cardiovascular Institute (La Jolla, California): Southwestern Medical Center (Dallas, Texas): University Hospital - Cancer/Critical Care (Columbus, Ohio): Scripps Memorial Hospital (Encinitas, California): Alta Bates Summit Acute Care Tower, Oakland, California): Fort Riley Hospital (Fort Riley, Kansas): Fort Benning Martin Hospital (Fort Benning, Georgia): $1.27 billion $1.20 billion $1.00 billion $925 million $835 million $717 million $650 million $600 million $500 million $500 million $450 million $423 million $400 million $400 million $375 million $369 million $360 million $360 million $360 million $356 million $350 million $350 million $334 million $333 million
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OUTSOURCING
Modern Healthcare estimates that at least three-quarters of hospitals outsource at least one hospital function.
LARGEST OUTSOURCING FIRMS

Clinical/Diagnostic Equipment Maintenance GE Healthcare TriMedx HSS Crest Services Crothall Services Corp. Emergency Department EmCare TeamHealth Schumacher Group Emergency Medicine Physicians EXL Service Foodservice Morrison Management Specialists Healthcare Services Group HHA Services Housekeeping Healthcare Services Group Crothall Services Group HHA Services Rite Way Service ISS TMC Services Information Systems Perot Systems Corp. CSC PHNS ACS McKesson Technology Solutions
OUTSOURCED SERVICES
According to Modern Healthcares 31st Annual Outsourcing Survey (September 28, 2009), the top hospital department management contracts, ranked by number of healthcare facilities outsourcing various functions, are as follows: Laundry: 7,986 Clinical/diagnostic equipment maintenance: 2,959 Housekeeping: 2,932 Foreign-language services: 1,512 Emergency departments: 1,091 Foodservice: 1,196 Hospital call centers: 862 Pharmacy: 499 Information systems: 460 Accounts receivable: 440 Medical records: 331 Facility operations/equipment maintenance: 307 Security: 267 Rehabilitation: 179 Nursing staff: 162 Parking garages: 149 Reimbursement: 137 Anesthesia: 92 Radiology: 93 Other: 931
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Laundry Angelica Corp. Healthcare Services Group Crothall Services Group Unitex HHA Services Pharmacy Comprehensive Pharmacy Services Pharmacy Systems EXL Service CompleteRx TeamHealth

Carlson, Joe, Finding A Niche, Modern Healthcare, September 28, 2009, pp 24-30.
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PATIENT SATISFACTION
According to Hospital Pulse Report 2009, by Press Ganey Associates, overall patient satisfaction has steadily increased since 2003. The Press Ganey assessment is based on survey responses from 2.95 million patients who had inpatient stays at 2,021 U.S. hospitals. Patient satisfaction is measured as the average response to 38 standard questions related to admission, rooms, meals, nurses, tests and treatments, visitation, physicians, discharge, personal issues, and overall satisfaction. Responses are reported on a 100-point scale (very good = 100; good = 75; fair = 50; poor = 25; very poor = 0). The overall Patient Satisfaction Score reported in the Hospital Pulse Report 2009 was 85.0, an improvement from 83.3 in 2003.
Nurses play a critical role in communications patients expect them to stay in touch and keep them informed about what is happening and what to expect, and to respond promptly to their immediate needs.
SATISFACTION SCORES
Satisfaction scores by various parameters are as follows: Number of Beds 50 or fewer beds: 51-to-149 beds: 150-to-299 beds: 300-to-449 beds: 450-to-599 beds: 600 or more beds:
HIGHEST PRIORITIES
Patients surveyed by Press Ganey ranked their highest priorities with respect to overall satisfaction as follows: 1. Response to concerns/complaints made during your stay 2. Degree to which hospital staff addressed your emotional needs 3. Staff effort to include you in decisions about your treatment 4. How well nurses kept you informed 5. Promptness in responding to the call button
87.8 85.6 84.4 83.9 83.8 83.7
A continual challenge for large healthcare providers is to personalize the inpatient experience.
Patient Age Under 18: 18-to-34: 35-to-49: 50-to-64: 65-to-79: 80 and older:
85.2 84.8 83.7 84.6 85.5 83.0
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Specialists Obstetrics/gynecology: Intensive care unit: Cardiology/coronary: Pediatrics: Orthopedics: Rehabilitation: Urology/renal: Oncology: Neurology: Pulmonary/respiratory: Type of Admission Direct admission: Emergency department:
86.7 85.6 85.5 85.0 85.0 84.8 84.8 84.2 83.3 82.6
Top 10 States Maine: South Carolina: New Hampshire: Wisconsin: Montana: Iowa: Oklahoma: Vermont: Indiana: Mississippi:
87.3 86.9 86.6 86.6 86.2 86.2 86.2 86.0 85.9 85.9
85.6 82.6

Hospital Pulse Report, Press Ganey Associates, 2009 Press Ganey Associates, 404 Columbia Plaza, South Bend, IN 46601. (800) 232-8032. (www.pressganey.com)
Patients who are hospitalized through direct admission are more satisfied with their care. This may be due, in part, to the unexpected nature and gravity of a situation requiring a trip to the ED followed by a hospital stay. Patients who have more time to plan for an admission are more likely to educate themselves on their condition, know what to expect during and after their stay, and even have the choice of which hospital to use.
Top 10 Metropolitan Areas Columbia, South Carolina: Greenville, South Carolina: Indianapolis, Indiana: Oklahoma City, Oklahoma: Madison, Wisconsin: Toledo, Ohio: Tulsa, Oklahoma: Miami-Ft. Lauderdale, Florida: New Orleans, Louisiana: Columbus, Ohio:
87.6 87.4 87.4 87.0 86.7 86.5 86.4 86.2 86.2 85.8
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PATIENT SATISFACTION MEASUREMENT
Modern Healthcare conducts an annual survey of companies that provide patient satisfaction measurement services. The 2009 Patient Satisfaction Measurement Firm Survey ranked companies based on total number of engagements as presented in Table 38.1.

Largest Patient-Satisfaction Measurement Firms, Modern Healthcare, December 7, 2009, p. 34.
TABLE 38.1 Largest Patient-Satisfaction Measurement Firms

Engagements
Press Ganey Associates (www.pressganey.com): Avatar International (www.avatar-intl.com): Strategic Healthcare Programs (www.shpdata.com): OCS HomeCare (www.ocshomecare.com): HealthStream Research (www.healthstreamresearch.com): Professional Research Consultants (www.prconline.com): PatientImpact (www.patientimpact.com): Synovate (www.synovate.com): Gallup (www.healthcare.gallup.com): DSS Research (www.dssresearch.com): National Business Research Institute (www.nbri.com): DataStat (www.datastat.com): Clinical Pharmacology Services (www.cpshealth.com): Fazzi Associates (www.fazzi.com): J.L. Morgan & Associates (www.jlmorganassociates.com): Arbor Associates (www.arbor-associates.com): Jackson Group (www.jacksongroup.com):
n/a 6,660 3,250 3,065 2,447 2,285 2,151 1,550 1,109 987 727 675 432 350 254 173 153
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PATIENTS FROM OVERSEAS
U.S. hospitals provide some of the best medical care in the world and have always attracted wealthy foreigners.
MARKET ASSESSMENT
Most hospitals do not disclose their international patient volumes, but analysts estimate the number of foreign patients admitted to U.S. hospitals in the tens of thousands each year. The U.S. Department of Commerce has not tracked this market since 1998, when the U.S. international trade in medical services was reported at $915 million. The market in 2009 is estimated at $1.6 billion. Shannon OKelley, executive director of international and corporate care at New YorkPresbyterian Hospital, estimates that about 3% of U.S. inpatient admissions at academic medical centers and other specialized facilities come from abroad. Since patients typically bring family with them, each dollar that foreign patients spend on inpatient care is estimated to generate another $3 of spending elsewhere in the U.S. economy, including spending for lodging, hospitality, and shopping. Until relatively recently, only a handful of high profile U.S. medical centers were active outside the U.S. market. Now several hospitals across the country attract foreign patients.
Once the domain of cutting-edge research institutions like the Cleveland and Mayo Clinics and Johns Hopkins, the international clientele are finding a wider array of options.
Hospitals & Health Networks, 6/08
Baptist Health South Florida, a seven-hospital system, for example, serves about 12,000 patients from Latin America annually. Its Gamma Knife Center, in Coral Gables, draws a large number of patients with inoperable brain tumors.
MARKETING OVERSEAS
Nine hospitals in the Philadelphia area joined to establish Philadelphia International Medicine, a group that focuses on attracting foreign patients. The groups international services center helps patients and their families with interpreters and travel arrangements to the U.S. The top medical centers continue to expand their reach overseas. The Cleveland Clinic, for example, has a Global Patient Services program that focuses on the markets in India and Japan. And Johns Hopkins Hospital has developed consulting and referral relationships with providers in India, Japan, and Singapore.
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U.S. HOSPITALS OPERATING ABROAD

Several U.S. hospital systems have partnered with local governments overseas to operate hospitals and clinics abroad. The following are some examples: Cleveland Clinic broke ground in 2008 for a 360-bed hospital slated to open in 2011 in Abu Dhabi. It also manages Sheikh Khalifa Medical City, a network of healthcare facilities, also in Abu Dhabi. Harvard Medical School, through Partners Harvard Medical International, partnered with Dubais Healthcare City to build University Hospital. Johns Hopkins Medicine has a 10-year deal with the United Arab Emirates to manage Tawam Hospital in Abu Dhabi. The University of Miami Hospital Miller School of Medicine is negotiating to open clinics in both Colombia and in the Caribbean. The hospital also hopes for expansions in Egypt, Saudi Arabia, and Haiti.

Partners Harvard Medical International, 131 Dartmouth Street, 5th Floor, Boston, MA 02116. (617) 535-6400. (www.phmi.partners.org) Philadelphia International Medicine, 1835 Market Street, 10th Floor, Philadelphia, PA 19103. (215) 563-4733. (www.philadelphiamedicine.com) Rotenberk, Lori, As The World Flattens, U.S. Hospitals Expand Their Global Reach, Hospitals & Health Networks, June 2008, p. 14. Volz, David, Reverse Medical Tourism, Hospitals & Health Networks, June 2008, pp 13-14.
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PAY-FOR-PERFORMANCE
Pay-for-performance (P4P) programs pay bonuses to providers based on quality and patient safety data. According to Med Vantage, there were approximately 160 active P4P programs in the U.S. in 2009.
OUTLOOK
With the success of pilot P4P programs, the question now is what the future model or models for pay-for-performance will look like and how will they affect hospitals. Researchers from the Harvard School of Public Health found that performance measures used to evaluate and reward physicians and hospitals have shifted from a focus on processes of care to emphasis on patient outcomes, cost efficiency, and use of information technology. They found, for example, a sharp increase in use of outcome measures to reward physician and hospital behavior, with less focus on processes such as keeping rates of mammography screening high. Pay-for-performance adopters are now basing rewards on such things as whether diabetic patients have actually achieved healthy cholesterol levels and blood pressure rates, not just whether or not a doctor has prescribed pills. Among P4P programs, there is little to no consistency. A study by PricewaterhouseCoopers found great variation exists among commercial health plans P4P programs. Among nearly 60 indicators of physician performance being used by plans surveyed, no one indicator was used by all plans being studied. Also, among the plans surveyed, no two reward providers for performance in the same way. And all plans were administered in widely different ways.
BACKGROUND
Several initiatives launched in the early 2000s have brought P4P incentives into the mainstream. The following are the major pioneering efforts in the P4P field: The Bridges to Excellence initiative launched in 2002 as a plan to pay bonuses to physicians who provide optimum care for diabetes patients. The program now serves as a model for other groups entering the pay-for-performance arena. Some Blue Cross and Blue Shield groups have licensed the Bridges to Excellence model, and UnitedHealth and Cigna have adopted it as well. The Integrated Healthcare Association (IHA) includes six California HMOs covering approximately 45,000 doctors and eight million patients. Insurers allied with IHA pay $50 million annually in bonuses to physicians. In 2003, Centers for Medicare & Medicaid Services and hospital alliance Premier launched the Hospital Quality Incentive Demonstration project, with 274 hospitals participating. Under the project, hospitals in the top 10% in five clinical areas coronary artery bypass graft, heart attack, heart failure, hip and knee replacement, and pneumonia received a 2% bonus Medicare payment based on outcomes. The project was extended through 2010.
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Bridges to Excellence, 13 Sugar Street, Newtown, CT 06470. (www.bridgestoexcellence.org) Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244. (410) 786-3000. (www.cms.gov) Integrated Healthcare Association, 300 Lakeside Drive, Suite 1975, Oakland, CA 94612. (510) 208-1740. (www.iha.org) Premier Inc., 2320 Cascade Pointe Road, Suite 100, Charlotte, NC 28208. (704) 357-0022. (www.premierinc.com) PricewaterhouseCoopers, Health Research Institute, 2001 Ross Avenue, Suite 1800, Dallas, TX 75201. (214) 999-1400. (www.pwc.com)
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41 PREVENTABLE MEDICAL ERRORS
NEVER EVENTS
The National Quality Forum (NQF) has published a list of 28 so-called never events errors that should never occur in a hospital. Payers have embraced the list and some now withhold payment if a never event happens. The NQF never events are as follows: Surgical Events Surgery performed on the wrong body part Surgery performed on the wrong patient Wrong surgical procedure on a patient Retention of a foreign object in a patient after surgery or other procedure Intraoperative or immediately postoperative death in a normal-health patient Product or Device Events Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility Care Management Events Patient death or serious disability associated with a medication error Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible
blood or blood products Maternal death or serious disability associated with labor or delivery on a lowrisk pregnancy while being cared for in a healthcare facility Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility Death or serious disability associated with failure to identify and treat hyperbilirubinemia in neonates Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility Patient death or serious disability due to spinal manipulative therapy Artificial insemination from the wrong donor Patient Protection Events Infant discharged to the wrong person Patient death or serious disability associated with patient elopement (disappearance) for more than four hours Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility Environmental Events Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances Patient death or serious disability associated with a burn incurred from any source while being cared for in a
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healthcare facility Patient death associated with a fall while being cared for in a healthcare facility Patient death or serious disability associated with the use of restraints or bed rails while being cared for in a healthcare facility Criminal Events Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider Abduction of a patient of any age Sexual assault on a patient within or on the grounds of a healthcare facility Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility
passed a resolution in favor of no longer paying for the CMS list of eight conditions as well as three other preventable mistakes. Massachusetts officials announced the state would no longer pay for care related to 28 serious reportable events as defined by the National Quality Forum. The New York State Medicaid program has stopped paying for the eight hospitalacquired conditions identified by Medicare. Maine and Pennsylvania passed laws that preclude hospitals from billing patients if an error occurs. The Tennessee Hospital Association approved a policy for hospitals not to seek payment from patients or their insurance companies for care related to serious preventable adverse events.
REFERENCES AND RESOURCES NON-REIMBURSEMENT

The Centers for Medicare and Medicaid Services has taken action to reduce medical errors, no longer paying hospitals for treating eight particular preventable medical errors. The following complicating conditions have been deemed non-reimbursable: Stage III and IV pressure ulcers Falls or trauma resulting in fractures, burns, or other serious injuries Foreign object accidentally left behind after surgery Air embolism Blood incompatibility Vascular catheter-associated infections Catheter-associated urinary tract infections Mediastinitis after coronary artery bypass graft, a surgical site infection Reimbursement policies in several state Medicaid programs followed Medicare in not reimbursing for certain never events. Such state policies include the following: The California Association of Health Plans Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244. (410) 786-3000. (www.cms.gov) National Quality Forum, 601 13th Street NW, Suite 500 North, Washington DC 20005. (202) 873-1300. (www.qualityforum.org)
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PRIMARY CARE
PHYSICIAN VISITS
According to the National Center for Health Statistics, consumers make 465 million visits to doctors offices each year. Including visits to hospitals and clinics, the total number of medical visits is 1.1 billion. The number of doctor visits has increased 26% over the past decade, a rise attributed in large part to an aging population. Eighty percent (80%) of people surveyed nationally in 2008 by Rand Corporation and the University of Pittsburgh School of Medicine said they have a personal doctor. A recent survey by Gallup found that 71% of American adults had been to a doctor, nurse practitioner, or physicians assistant at least once in the previous six months. The following are percentages among individuals with specific health-related attributes: Define their health status as excellent or good: 76% Define health as fair or poor: 87% Aged 50 and older: 81% Very/somewhat overweight: 78% Smoke every day: 71% According to IMS Health, the following are the leading diagnoses by total number of patient visits for primary care: Essential hypertension: 86 million Diabetes mellitus without complications: 42 million Hyperlipidemia: 32 million Acute respiratory infection: 27 million Otitis media: 22 million Depressive disorder: 20 million Chronic sinusitis: 17 million
Asthma: Esophagitis: Allergic rhinitis:
17 million 17 million 16 million
STRENGTHENING PRIMARY CARE

Access to primary care physicians is critical to the healthcare system. A 2008 white paper from the American College of Physicians concluded that the proportion of primary care doctors in a community is relative to health outcomes and system costs. According to a study by researchers from the Johns Hopkins University School of Medicine published in the February 2009 issue to the American Journal of Medicine, a 15% increase in the number of primary care physicians in a metropolitan area would yield the following benefits: Reduced emergency department visits by 10.9% Reduced number of surgeries by 7.2% Reduced inpatient admissions by 5.5% Reduced outpatient visits by 5.0% In a metropolitan area with a population of 775,000, increasing the proportion of primary care physicians from 35% to 40% would yield the following: Reduced emergency department utilization by 15,000 visits a year Reduced surgery by about 2,500 cases a year Reduced hospital admissions by 2,500 a year, saving an estimated $23 million
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According to Merritt Hawkins & Associates, a physician search firm, primary care physicians are in greater demand today than any other type of doctor. For the year ending March 31, 2009, the company fielded 23% more requests for primary care doctors (defined as family physicians, internists, and pediatricians) than the previous 12-month period.
In the 2008 Healthcare Leaders Opinion Survey, conducted by Commonwealth Fund and Modern Healthcare, 84% of respondents supported providing supplemental payments to primary-care physicians on top of feefor-service payments for delivering comprehensive, coordinated, and accessible care. The concept is supported by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Assn. The AARP and employers including IBM, Dow Chemical, and General Motors advocate medical homes.
Virtually every hospital or large medical group in the United States would be happy to add a family physician or general internist. There simply are not enough primary care doctors to go around.
Mark Smith, President Merritt Hawkins & Associates Hospitals & Health Networks, 7/09
CONCIERGE PHYSICIAN PRACTICES

Physician practices that provide exclusive medical services to affluent clientele are springing up around the country. They have been called boutique practices, white-glove service, and concierge physician practices. Frustrated with long hours and hassles with managed care, physicians who start or join such ventures say they spare themselves the traditional payment hassles, and they dont have to rush through their patients. Virtually unknown 10 years ago, there are now about 5,000 such practices, according to the Society for Innovative Medical Practice Design, a professional society of concierge physicians. At least two chains have emerged in this niche: Seattle-based MD2 (www.md2.com) and MDVIP (www.mdvip.com) in Boca Raton, Florida.
MEDICAL HOMES
The medical home concept is a model in which a physician receives compensation for coordinating patient care that enhances patient access to physicians and engages patients in their own care management. The following are some pilot programs testing the medical homes concept: Nationwide, 27 of 39 Blue Cross Blue Shield insurers are testing some type of medical home pilot. Bridges to Excellence is testing the approach with an incentive plan that pays annual rewards of up to $125 per patient per year to physicians who demonstrate medical homes for patients connected to proven positive outcomes. Six Pennsylvania insurers, including Independence Blue Cross and Aetna, are spending $13 million over three years to help doctors in 32 primary care practices set up medical homes.
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American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS 66211. (800) 274-2237. (www.aafp.org) American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, IL 60007. (847) 434-4000. (www.aap.org) American College of Physicians, 190 North Independence Mall West, Philadelphia, PA 19106. (800) 523-1546. (www.acponline.org) American Medical Association, 515 State Street, Chicago, IL 60610. (800) 621-8335. (www.ama-assn.org) Bridges to Excellence, 13 Sugar Street, Newtown, CT 06470. (www.bridgestoexcellence.org) Gallup Inc., 901 F Street NW, Washington, DC 20004. (202) 715-3030. (www.gallup.com) IMS Health, 901 Main Avenue, Suite 612, Norwalk, CT 06851. (203) 845-5200. (www.imshealth.com) Kravet S.J., A.D. Shore, R. Miller, G.B. Green, K. Kolodner and S.M. Wright, Health Care Utilization and the Proportion of Primary Care Physicians, American Journal of Medicine, February 2009. Medical Group Management Association, 104 Inverness Terrace East, Englewood, CO 80112. (303) 799-1111. (www.mgma.com) Merritt, Hawkins & Associates, 5001 Statesman Drive, Irving, TX 75063. (800) 876-0500. (www.merritthawkins.com)
Meyer, Harris, The Disappearing Primary Care Physician, Hospitals & Health Networks, November 2008, pp 29-32. National Center for Health Statistics, 3311 Toledo Road, Hyattsville, MD 20782. (800) 232-4636. (www.cdc.gov/nchs) Rand Corporation, 1776 Main Street, Santa Monica, CA 90401. (310) 393-0411. (www.rand.org) Physician Search Firm Finds Higher Demand For Primary Care, Hospitals & Health Networks, July 2009, p. 79. Physicians Foundation, 77 Summer Street, 8th Floor, Boston, MA 02110. (617) 399-0417. (www.physiciansfoundations.org) Society for Innovative Medical Practice Design, P.O. Box 448, Richmond, VA 23219. (877) 448-6009. (www.simpd.org) The Commonwealth Fund, 1 East 75th Street, New York, NY 10021. (212) 606-3800. (www.commonwealthfund.org)
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43
PROFILE OF U.S. HOSPITALS
DATA SUMMARY
Hospital Statistics 2009 by the American Hospital Association provides current data on U.S. hospitals. Table 43.1 provides a summary of data about U.S. hospitals.
Dental services: Bariatric/weight control: Complementary medicine services: Alzheimers center: Free-standing emergency center:
23% 22% 21% 4% 4%
UTILIZATION
Inpatient, emergency department, and outpatient utilization in community hospitals is presented in Table 43.2.
The following percentages of U.S. community hospitals provide services beyond traditional inpatient and outpatient care: Health fair: 78% Home health service: 66% Hospice: 65% Skilled nursing facility: 55% Assisted living: 18% Other long-term care: 16% Meals on wheels: 13%
FINANCIAL PERFORMANCE
Total Revenue Profit Margin

American Hospital Association, One North Franklin, Chicago, IL 60606. (312) 422-3000. (www.aha.org) Chartbook: Trends Affecting Hospitals and Health Systems, American Hospital Association, 2009. (www.aha.org/aha/ research-and-trends/chartbook/index.html)
2002: 2003: 2004: 2005: 2006: 2007:
$435.8 billion $472.7 billion $507.5 billion $544.7 billion $587.1 billion $626.0 billion
4.4% 4.8% 5.2% 5.3% 6.0% 6.7%
HOSPITAL SERVICES
The following percentages of U.S. community hospitals offer specialized healthcare services: Birthing, labor, and delivery: 65% Chemotherapy: 57% Sleep center: 49% Sports medicine: 40% Hospice: 25% Ambulatory surgery center: 24%
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TABLE 43.1 Profile Of U.S. Hospitals Total number of all U.S. registered hospitals: - U.S. community hospitals*: - Non-government not-for-profit community hospitals: - State and local government community hospitals: - Investor-owned (for-profit) community hospitals: - Non-federal psychiatric hospitals: - Federal government hospitals: - Non-federal long-term care hospitals: - Hospital units of institutions (prison hospitals, college infirmaries, etc.): Total staffed beds in all U.S. registered hospitals: - Staffed beds in community hospitals: Total admissions in all U.S. registered hospitals: - Admissions in community hospitals: Number of urban community hospitals: Number of rural community hospitals: Number of community hospitals in a system**: Number of community hospitals in a network***: 5,708 4,897 2,913 1,111 873 444 213 136 18 945,199 800,892 37,120,387 35,345,986 2,900 1,997 2,730 1,472
* Community hospitals are defined as all non-federal, short-term general, and other special hospitals. Other special hospitals include obstetrics and gynecology; eye, ear, nose, and throat; rehabilitation; orthopedic; and other individually described specialty services. Community hospitals include academic medical centers or other teaching hospitals if they are non-federal short-term hospitals. Excluded are hospitals not accessible by the general public, such as prison hospitals or college infirmaries. ** System is defined by AHA as either a multi-hospital or a diversified single hospital system. A multi-hospital system is two or more hospitals owned, leased, sponsored, or contract managed by a central organization. Single, freestanding hospitals may be categorized as a system by bringing into membership three or more, and at least 25%, of their owned or leased non-hospital pre-acute or post-acute healthcare organizations. System affiliation does not preclude network participation. *** Network is a group of hospitals, physicians, other providers, insurers and/or community agencies that work together to coordinate and deliver a broad spectrum of services to their community. Network participation does not preclude system affiliation.
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TABLE 43.2 Inpatient, Emergency Department, and Outpatient Utilization Total inpatient admissions: Inpatient admissions per 1,000: Total inpatient days: Inpatient days per 1,000: Inpatient surgeries: Average length of stay: Emergency department (ED) visits: ED visits per 1,000: Outpatient visits: Outpatient visits per 1,000: Outpatient surgeries: 35,345,986 117.2 194,549,348 645.0 10,189,630 5.5 120,800,000 401 603,300,374 2,000.2 17,146,334
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44
QUALITY & PATIENT SAFETY
HEALTHCARE QUALITY INITIATIVES

There have been concerted efforts by U.S. hospitals to improve quality and patient safety. The quality movement was sparked, to a large extent, by the report To Err is Human: Building a Better Healthcare System, published in 1999 by the Institute of Medicine, which estimated that between 44,000 to 98,000 people die each year from medical errors at a total national cost of up to $29 billion. Efforts to improve quality in healthcare have been spearheaded nationally by several organizations and initiatives. The Leapfrog Group, a coalition of more than 100 member companies, works with its employer members to encourage healthcare safety, quality, transparency and easy access to healthcare information. Leapfrogs consortium of companies, most of whom are in the Fortune 500, spend more than $56 billion annually for health benefits to their 33 million employees. Another organization, The Institute for Healthcare Improvement (IHI), launched the 100,000 Lives Campaign, an effort to avoid 100,000 patient deaths through the implementation of improvements in basic patient care. IHI also implemented the 5 Million Lives campaign, which focuses on incidents of harm. Over 3,000 hospitals have participated in the initiatives. There are several other quality initiatives and model quality guidelines. So many, in fact, that the need for the quality movement to coalesce around a strategy has become
apparent. The IOM has called for the creation of a national quality-coordination board to oversee existing initiatives and to develop clinical performance measures.
QUALITY REPORTING
In 2005, the U.S. Department of Health & Human Services, along with the nations major hospital groups, launched Hospital Compare (www.hospitalcompare.hhs.gov), an online database that reports quality measures from more than 4,200 acute-care hospitals nationwide. Hospitals must provide data for the Hospital Compare assessment to receive full Medicare and Medicaid reimbursement from HHS. The granddaddy of quality reporting sites, Hospital Compare scores hospitals in 26 clinical quality and 10 patient satisfaction areas. Patients can get granular level data, such as the percentage of heart attack patients who are given aspirin on arrival or the percentage of pneumonia patients whose blood culture was performed in the emergency department prior to the first dose of antibiotics. The site also discloses how much Medicare pays for the reported services.
Hospitals & Health Networks
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There are also quality reporting systems by non-governmental organizations. HealthGrades (www.healthgrades.com), for example, examines mortality and complication rates for 28 procedures and diagnoses. In addition, hundreds of hospitals post their own quality data for consumers.

Agency for Healthcare Research and Quality, 2101 East Jefferson Street, Suite 501, Rockville, MD 20852. (301) 594-1364. (www.ahrq.gov) Association For Professionals In Infection Control and Epidemiology, 1275 K Street NW, Suite 1000, Washington, DC 20005. (202) 789-1890. (www.apic.org) Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138. (617) 301-4800. (www.ihi.org) Institute for Safe Medication Practices, 200 Lakeside Drive, Suite 200, Horsham, PA 19044. (215) 947-7797. (www.ismp.org) National Quality Forum, 601 13th Street NW, Suite 500 North, Washington DC 20005. (202) 873-1300. (www.qualityforum.org) The Henry J. Kaiser Family Foundation, 2400 Sand Hill Road, Menlo Park, CA 94025. (650) 854-9400. (www.kff.org) The Leapfrog Group, 1801 K Street NW, Suite 701-L, Washington, DC 20006. (202) 292-6713. (www.leapfroggroup.org)
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45
READMISSIONS
THE COST OF READMISSIONS

The Medicare Payment Advisory Commission (MedPAC) reported that 17.6% of Medicare patients discharged from a hospital are readmitted within 30 days, costing Medicare alone more than $15 billion annually. Medicare spent an average of $7,200 for each of those potentially avoidable readmissions. Experts estimate that 76% of those readmissions are for reasons that may have been preventable. A similar finding was reported by researchers from the Centers for Medicare and Medicaid Services (CMS), published in the April 2, 2009 issue of The New England Journal of Medicine. The CMS reported cumulative rehospitalizations as follows: Within 30 days: 19.5% Within 90 days: 34.0% Within 365 days: 56.1%
The researchers found wide variation in rehospitalization rates among states. The five states with the highest re-hospitalization rates (Maryland, New Jersey, Louisiana, Illinois, and Mississippi) had rates 45% higher than the five states with the lowest rates (Idaho, Utah, Oregon, Colorado, and New Mexico). Millions of patients each year leave the hospital only to return within weeks or months for lack of proper follow-up care. It is one of the biggest avoidable costs on the nations medical bill.
The New York Times, 5/9/09
According to MedPAC, seven conditions account for 30% of Medicare spending on readmissions (Table 45.1).
TABLE 45.1 Leading Causes Of Readmissions

Admissions Readmission Rate Avg. Medicare Payment Total Spending
Heart failure: COPD: Pneumonia: AMI: CABG: PTCA: Other vascular:
90,273 52,327 74,419 20,866 18,554 44,239 18,029
12.5% 10.7% 9.5% 13.4% 13.5% 10.0% 11.7%
$ 6,531 $ 6,587 $ 7,165 $ 6,535 $ 8,136 $ 8,109 $10,091
$590 million $345 million $533 million $136 million $151 million $359 million $182 million
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REDUCING READMISSIONS
Some health systems have been successful in reducing readmissions. Fuqua Heart Center at Piedmont Hospital, in Atlanta, for example, reported a dramatic 75% reduction of 30-day readmission rates for heart failure through use of a telehealth program that monitored patient health status. And Intermountain Health Care, in Salt Lake City, recorded a 40% decrease in heart failure readmissions after implementing Joint Commission quality measures across the system. A July 2009 assessment found Baylor University Medical Center had the lowest readmission rate for heart failure among all U.S. hospitals, 15.9%. Nationally, about onequarter of heart failure patients need to be readmitted within 30 days of discharge. The hospitals success is attributed, in large part, to follow-up care. One of the most important elements of Baylors program has been to jettison the notion that patients are discharged from the hospital. Instead, hospital workers have begun to think of discharge as a transition from the hospital to care in the community.
USA Today, 7/9/09
provide the follow-up care. Park Nicollet earned a bonus of $247,000 from Medicare in 2008, but that payment equaled only about a third of the cost of running the program. Catholic Healthcare Partners, in Cincinnati, has dropped a similar follow-up program because it could not afford the additional expense. With the help of a federal grant, provided from 2002 to 2006, the hospital system had hired six nurses to oversee the care of its high-risk heart failure patients. Return visits dropped sharply. But when that grant ended, Catholic Healthcare could not persuade insurers to pay for the program.
Even when hospitals find ways to greatly reduce the return trips, saving money for Medicare and other insurers, their efforts go unrewarded. In fact, because insurers typically pay hospitals to treat patients not to keep them away by keeping them healthy hospitals can actually lose money by providing better care.
FEDERAL INITIATIVES
The focus by the federal government on readmission rates is increasing. President Barack Obamas 2010 budget blueprint cited reducing hospital readmission rates as an $8.4 billion cost-saver over 10 years. MedPAC has recommended that hospitals with relatively high readmission rates be penalized with lower Medicare reimbursement as part of a larger plan to improve hospital efficiency.
Such gains, however, do not come easily. Park Nicollet Health Services, in Minnesota, spends as much as $750,000 annually on staffing more nurses and on sophisticated software to track heart failure patients after they leave the hospital. Readmissions for such patients were reduced to only 1 in 25 from nearly 1 in 6, however, the gain has been a losing proposition financially. Although the effort saves Medicare roughly $5 million a year, Park Nicollet is not paid to
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In order for hospitals to continue doing business with Medicare, its very likely that some sort of financial model will be established on readmissions in the future.
Margaret Namie, V.P. of Quality Mercy Health Partners Modern Healthcare, 4/20/09
Medicare Payment Advisory Commission, 601 New Jersey Avenue NW, Suite 9000, Washington, DC 20001. (202) 220-3700. (www.medpac.gov) Sternberg, Steve and Jack Gillum, Baylor Leads The Way To Lower Readmissions, USA Today, July 9, 2009, p. 6D.
In April 2009, the CMS launched a pilot project to eliminate unnecessary hospital readmissions in 14 communities across the country.

Abelson, Reed, Hospitals Pay For Cutting Costly Readmissions, The New York Times, May 9, 2009. Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244. (410) 786-3000. (www.cms.gov) DerGurahian, Jean, Reading Into Readmissions, Modern Healthcare, July 20, 2009, p. 16. Favole, Jared A., Readmitted Patients Cost Billions, The Wall Street Journal, April 2, 2009. Jencks, S. F., M. V. Williams, and E. A. Coleman, Rehospitalizations Among Patients in the Medicare Fee-for-Service Program, New England Journal of Medicine, April 2, 2009, pp 1418-1428. Lubell, Jennifer, Red Flags Raised, Modern Healthcare, April 20, 2009, pp 8-9.
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46
RURAL HEALTHCARE
According to Hospital Statistics 2009, by the American Hospital Association, there are 1,997 rural hospitals in the U.S., representing 41% of all hospital locations. This number has declined by 10% over the past decade.
According to a study by Howard Rabinowitz, M.D., director of the Physician Shortage Area Program at Jefferson Medical College, only 3% of the roughly 17,100 medical students who graduate each year, or about 513 graduates a year, plan to practice in a rural or small-town setting.
STAFFING CHALLENGES
The rural population of the U.S. is about 20%, or 61 million people. However, less than 9% of physicians practice in non-metropolitan counties. In recent years, shortages of nonphysician providers, including pharmacists, nurses, dentists, radiology and laboratory technicians, and mental health professionals, have also become more apparent. Rural doctors can be difficult to recruit. The primary reason is that rural doctors generally earn less than those in metro areas. Further, social and cultural isolation deters many physicians from locating in rural areas.
MEDICARE REFORM PROVISIONS FOR RURAL HEALTHCARE

The Medicare Modernization Act of 2003 (MMA) authorized more than $25 billion over 10 years for the purpose of ensuring the longterm fiscal health of rural hospitals as well as addressing the physician shortage in small and outlying communities. The Medicare reform law boosts payments to rural hospitals and provides incentives aimed at enticing physicians to practice in underserved areas, such as 5% reimbursement bonuses to physicians and 15% bonuses to doctors performing outpatient services at criticalaccess hospitals. Medicare has programs through which rural hospitals and medical centers can earn higher levels of reimbursement. These programs and the number of participating hospitals in FY2009 were as follows: Critical-Access Hospitals: 25 or fewer beds and certain criteria to be met, including providing emergency services and nursing services 24 hours-a-day: 1,313 Sole Community Hospitals: located more than 35 miles from other like hospitals: 460
Problems with the distribution of physicians and other health professionals, as well as recruitment and retention issues in general, are an ongoing problem for rural areas that compete with urban areas to maintain an adequate workforce.
National Rural Health Assn., 1/9/10
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Medicare-dependent Hospitals: at least 60% of inpatient days attributable to patients covered by Medicare:

169 American Hospital Association, One North Franklin, Chicago, IL 60606. (312) 422-3000. (www.aha.org) Medicare Payment Advisory Commission, 601 New Jersey Avenue NW, Suite 9000, Washington, DC 20001. (202) 220-3700. (www.medpac.gov) National Rural Health Association, 1108 K Street NW, 2nd Floor, Washington, DC 20005. (202) 639-0550. (www.nrharural.org) Rural Health and the American Recovery and Reinvestment Act Of 2009, National Rural Health Association, May 13, 2009.
Cost-based, efficiency-indifferent payments to critical-access hospitals totaled about $5 billion in FY2009, about $1.3 billion more than the prospective payment system (PPS) schedule, according to the Medicare Payment Advisory Commission. Inpatient payments to critical-access hospitals that filed cost reports totaled $1 billion, about 1.1% of all Medicare payments for inpatient care.
AMERICAN RECOVERY AND INVESTMENT ACT OF 2009

Along with the funding of various healthcare initiatives of benefit to all Americans, the American Recovery and Reinvestment Act of 2009 (ARRA) contains provisions specifically aimed at rural healthcare, as follows: The Rural Community Facilities Program Account provides $130 million for essential community facilities in rural areas. Critical-Access Hospitals can fully depreciate costs of electronic health record systems in one year beginning in FY2011. The American Recovery and Reinvestment Act of 2009 was, dollarfor-dollar, the largest investment in rural health in our countrys history.
Beth Landon, President National Rural Health Assn., 5/12/09
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47 SPECIALTY HOSPITALS & CENTERS
The landscape of the U.S. healthcare system has been transformed in recent years with the emergence of specialty facilities. These include ambulatory surgery centers, specialty hospitals focusing on cardiac and orthopedic procedures, and diagnostic imaging centers. Hospitals generally view specialty facilities as competitors. Administrators of community hospitals say that losing profitable patients to specialty competitors threatens their ability to provide unprofitable services like emergency care, which it subsidizes in part with profits from procedures like cardiac surgery. Hospitals in states with certificate-of-need laws are somewhat insulated from direct competition from niche providers, who are required to show a basis for qualification to get facilities built.
A backlash against specialty hospitals, led by the American Hospital Association (AHA), began in 2003, culminating with provisions that were incorporated in The Medicare Improvement Act of 2003, which effectively halted development or significant expansions of specialty hospitals. The moratorium on specialty hospitals expired in 2006, but controversies remain. The Obama Administration has made addressing the financial conflicts of interest in physician-owned specialty hospitals a budget priority for 2010. Proponents say specialty hospitals and facilities are more efficient and provide equal or better care to patients. But detractors, including mainstream hospital groups, accuse the specialty hospitals of isolating those procedures that bring the most profitable returns under federal Medicare and privateinsurance schedules, leaving nonprofit competitors with the sickest patients and most costly businesses. An April 2009 study by the Center for Studying Health System Change concluded that specialty hospitals have not done serious harm to their general hospital competitors. Among the many serious financial challenges faced by general hospitals, competition from specialty hospitals does not rank high on the list.
SPECIALTY HOSPITALS
According to Modern Healthcare, 127 specialty hospitals opened in 2008 (most recent data available), bringing the total in the U.S. to about 350. According to the Medicare Payment Advisory Commission (MedPAC), the following are the share of specialty hospitals owned by physicians: All specialty hospitals: 60% Heart hospitals: 35% Orthopedic hospitals: 67% Surgical hospitals: 73%
AMBULATORY SURGERY CENTERS

Ambulatory Surgery Centers (ASCs), which compete with hospital outpatient departments for procedures that dont require overnight
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stays, like colonoscopies and some joint surgeries, are hollowing out hospitals as well. Four in five ASCs are at least partly owned by physicians, many in partnership with hospitals seeking to minimize losses. From the early 1980s to present, the share of outpatient surgeries performed in hospitals has declined from more than 90% to 45% as the result of ASCs. There was rapid growth in ambulatory surgery centers from 1996 through 2005; more recent growth has been moderate. According to Hospital Statistics 2009, by the American Hospital Association, there are 5,876 freestanding ambulatory care surgery centers in the U.S. The following companies are the largest ASC operators: AmSurg (www.amsurg.com) NovaMed (www.novamed.com) Surgical Care Affiliates (www.scasurgery.com) United Surgical Partners International (www.unitedsurgical.com) In 2007, the Centers for Medicare & Medicaid Services (CMS) issued a series of rules that set a new compensation rate of 65% of that which hospital outpatient departments get paid under Medicare. Previously, ASCs were reimbursed at 83% of the hospital rate. The new payment schedule is being phased in over a period of four years, through 2011. The CMS also expanded the list of procedures ASCs could get paid for under Medicare. The CMS paid approximately $3 billion to ASCs in 2008. Ambulatory surgery is further assessed in Chapter 114 of this handbook.
IMAGING CENTERS
According to SDI Health, there are about 6,200 free-standing imaging centers in the U.S., a number that has increased 80% from 3,300 in 2000. Total annual spending on scans performed at imaging centers, including hospital departments, is estimated at more than $100 billion. Medicares annual imaging spending is more than $15 billion, an amount that has been increasing 16% a year.
More than 95 million high-tech scans are done each year, and medical imaging, including CT, MRI, and PET scans, has ballooned into a $100billion-a-year industry in the United States.

American Hospital Association, One North Franklin, Chicago, IL 60606. (312) 422-3000. (www.aha.org) Carlson, Joe, Specialty Hospitals OK: Study, Modern Healthcare, April 27, 2009, p. 8. Center for Studying Health System Change, 600 Maryland Avenue SW, Suite 550, Washington, DC 20024. (202) 484-5261. (www.hschange.com) Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244. (410) 786-3000. (www.cms.gov)
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Kolata, Gina, Good Or Useless, Medical Scans Cost The Same, The New York Times, March 2, 2009. Medicare Payment Advisory Commission, 601 New Jersey Avenue NW, Suite 9000, Washington, DC 20001. (202) 220-3700. (www.medpac.gov) SDI Health, 220 West Germantown Pike, Plymouth Meeting, PA 19462. (610) 834-0800. (www.sdihealth.com) Tynan, Ann, Elizabeth A. November, Johanna Lauer, Hoangmai H. Pham, and Peter Cram, General Hospitals, Specialty Hospitals and Financially Vulnerable Patients, Center For Studying Health System Change, Research Brief No. 11, April 2009.
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48 STATE SPENDING FOR HOSPITAL CARE
According to Health Expenditures by State, published in 2007 (most recent data available as of January 2010) by the Centers for Medicare & Medicaid Services (CMS), spending for hospital care accounts for 36.5% of total U.S. healthcare spending.
PERCENTAGE OF TOTAL HEALTHCARE SPENDING FOR HOSPITAL CARE

Alabama: Alaska: Arizona: Arkansas: California: Colorado: Connecticut: Delaware: District of Columbia: Florida: Georgia: Hawaii: Idaho: Illinois: Indiana: Iowa: Kansas: Kentucky: Louisiana: Maine: Maryland: Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: 34.2% 40.2% 36.0% 38.1% 34.8% 35.1% 31.7% 36.7% 49.2% 33.1% 35.6% 37.1% 37.1% 38.3% 38.7% 38.9% 35.0% 36.6% 30.4% 35.3% 37.2% 39.2% 39.6% 33.9% 41.9% 41.5% 41.3% 40.3%
Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:
32.5% 35.7% 33.8% 39.0% 36.1% 36.8% 41.5% 37.8% 38.4% 34.2% 36.4% 36.5% 38.8% 42.7% 33.4% 37.6% 36.1% 38.4% 37.1% 33.9% 41.1% 37.3% 41.1%

Health Expenditures by State of Residence, Centers for Medicare & Medicaid Services, 2009.
(www.cm s.hhs.gov/NationalHealthExpendData/)
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49
TOP ISSUES CONFRONTING HOSPITALS
A 2009 survey conducted by the American College of Healthcare Executives (ACHE) found the following top issues confronting hospitals (based on the percentage of survey respondents indicating that an issue is one of the top three concerns presently confronting their hospital): Financial challenges: 77% Patient safety and quality: 43% Care for the uninsured: 41% Physician/hospital relations: 32% Personnel shortages: 30% Governmental mandates: 26% Patient satisfaction: 22% Capacity: 16% Technology: 9% Issues about not-for-profit status: 2% Malpractice insurance: 2% Disaster preparedness: 1% For the three top issues, specific concerns are ranked as follows:
PATIENT SAFETY & QUALITY

Redesigning care processes: Redesigning work environment to reduce errors: Compliance with accrediting organizations: Medication errors: Nosocomial infections: Nonpayment for never events: Pay for performance: Leapfrog demands: Public reporting of outcomes data: Surgical mistakes: 66% 66% 60% 57% 47% 43% 41% 40% 40% 24%
CARE FOR THE UNINSURED

Medicaid: Advocacy for funding: Underwriting costs: Reaching out to all community members: Other: Response to other hospital closings: 87% 75% 61% 27% 20% 10%
FINANCIAL CHALLENGES
Medicaid reimbursement: Bad debt: Increasing costs for staff, supplies, etc.: Medicare reimbursement: Inadequate funding for capital improvements: Managed care payments: Other commercial insurance reimbursement: Revenue cycle management: Emergency Department: Competition from specialty hospitals: Other: 83% 78% 75% 73% 63% 46% 40% 40% 36% 20% 9%

American College of Healthcare Executives, One North Franklin, Chicago, IL 60606. (312) 424-2800. (www.ache.org)
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50 UNCOMPENSATED HOSPITAL CARE
Each year, the American Hospital Association publishes aggregate information on the level of uncompensated care care provided for which no payment is received delivered in U.S. hospitals. Data for 2000 through 2008 is presented in Table 50.1.

Uncompensated Hospital Care Cost Fact Sheet, November 2009, American Hospital Association, November 2009. (www.aha.org/aha/content/2009/pdf/ 09uncompensatedcare.pdf)
TABLE 50.1 National Uncompensated Care Costs

Hospitals Cost % of Total Expenses
2000 2001 2002 2003 2004 2005 2006 2007 2008
4915 4908 4927 4895 4919 4936 4927 4897 5010
$21.6 billion $21.5 billion $22.3 billion $24.9 billion $26.9 billion $28.8 billion $31.2 billion $34.0 billion $36.4 billion
6.0% 5.6% 5.4% 5.5% 5.6% 5.6% 5.7% 5.8% 5.8%
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PART III: AWARD-WINNING HOSPITALS
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51
CIRCLE OF LIFE AWARD
The Circle of Life Award honors innovation in palliative and end-of-life care. The award is sponsored by the American Academy of Hospice and Palliative Medicine, the American Association of Homes and Services for the Aging, the American Hospital Association, the Archstone Foundation, the California Healthcare Foundation, the Catholic Health Association, the Hospice and Palliative Nurses Association, the National Hospice and Palliative Care Organization, and the National Hospice Foundation.
Avenue, Glenview, IL 60025. (847) 375-4712. (www.aahpm.org) American Association of Homes and Services for the Aging, 2519 Connecticut Avenue NW, Washington, DC 20008. (202) 783-2242. (www.aahsa.org) American Hospital Association, One North Franklin, Chicago, IL 60606. (312) 422-3000. (www.aha.org) Archstone Foundation, 401 E. Ocean Boulevard, Suite 1000, Long Beach, CA 90802. (562) 590-8655. (www.archstone.org) California Healthcare Foundation, 1438 Webster Street, Suite 400, Oakland, CA 94612. (510) 238-1040. (www.chcf.org) Catholic Health Association, 1875 I Street NW, Suite 1000, Washington, DC 20006. (202) 296-3993. (www.chausa.org) Hospice and Palliative Nurses Association, One Penn Center West, Suite 229, Pittsburgh, PA 15276. (412) 787-9301. (www.hpna.org) National Hospice & Palliative Care Organization and National Hospice Foundation, 1731 King Street, Suite 100, Alexandria, VA 22314. (703) 837-1500. (www.nhpco.org) A list of past award winners is presented at www.aha.org/aha/news-center/awards/circle -of-life/awardees.html.
2009 WINNERS
Four Seasons (Flat Rock, North Carolina) Oregon Health and Science University Palliative Medicine & Comfort Care Program (Portland, Oregon) Wishard Health Services Palliative Care Program (Indianapolis, Indiana)
2009 CITATIONS OF HONOR

Palliative Care Service, St. Johns Regional Medical Center (Oxnard, California) and St. Johns Pleasant Valley Hospital (Camarillo, California) Gilchrist Hospice Care (Towson, Maryland) and Greater Baltimore Medical Center (Baltimore, Maryland)

American Academy of Hospice and Palliative Medicine, 4700 West Lake
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52
COMMUNITY VALUE INDEX
Since 2004, Cleverly + Associates has evaluated hospitals using the Community Value Index (CVI) as a tool for assessment. The CVI contains four core areas of evaluation, as follows: Financial viability and plant reinvestment Cost structure Charge structure Quality performance Each area contains metrics that compare a hospitals performance to an appropriate peer group. The combined performance in each area is the CVI score. Measurement in these areas suggest that hospitals operating with a high degree of community value are those that are low cost, low charge, use a strong financial position to reinvest back into the provision of care at the facility, and provide high quality care to patients.
The 2009 Community Value Index
2009 TOP 100 CVI HOSPITALS Adair County Health Center (Stilwell,
Oklahoma) Adena Regional Medical Center (Chillicothe, Ohio) American Fork Hospital (American Fork, Utah) American Legion Hospital (Crowley, Louisiana) Anna Jaques Hospital (Newburyport,
Massachusetts) Augusta Health Care (Fishersville, Virginia) Aultman Hospital (Canton, Ohio) Baptist Hospital East (Louisville, Kentucky) Baptist Medical Center (Little Rock, Arkansas) Bay Medical Center (Bay City, Michigan) Baystate Medical Center (Springfield, Massachusetts) Beverly Hospital (Beverly, Massachusetts) Brockton Hospital (Brockton, Massachusetts) Bronx-Lebanon Hospital Center (Bronx, New York) Buffalo General Hospital (Buffalo, New York) Butler Memorial Hospital (Butler, Pennsylvania) Calvert Memorial Hospital (Prince Frederick, Maryland) Carney Hospital (Boston, Massachusetts) Carolinas Medical Center - Behavioral Health (Charlotte, North Carolina) Cascade Valley Hospital (Arlington, Washington) Central Washington Hospital (Wenatchee, Washington) Cookeville Regional Medical Center (Cookeville, Tennessee) Craig General Hospital (Vinita, Oklahoma) Dixie Regional Medical Center (St. George, Utah) EMH Regional Medical Center (Elyria, Ohio) Franklin Square Hospital Center (Baltimore, Maryland) Froedtert Memorial Lutheran Hospital (Milwaukee, Wisconsin)
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Good Samaritan Medical Center (Brockton, Massachusetts) Griffin Hospital (Derby, Connecticut) Hardin Memorial Hospital (Elizabethtown, Kentucky) Hartford Hospital (Hartford, Connecticut) Heritage Hospital (Taylor, Michigan) Heywood Hospital (Gardner, Massachusetts) Hospital Metropolitano San German (San German, Puerto Rico) Immanuel-St. Josephs-Mayo Health System (Mankato, Minnesota) Inova Alexandria Hospital (Alexandria, Virginia) Jamaica Hospital Medical Center (Jamaica, New York) John Dempsey Hospital (Farmington, Connecticut) Kootenai Medical Center (Coeur Dalene, Idaho) Lahey Clinic Hospital (Burlington, Massachusetts) Lakeview Medical Center (Rice Lake, Wisconsin) Lawrence General Hospital (Lawrence, Massachusetts) Long Beach Memorial Medical Center (Long Beach, California) Lowell General Hospital (Lowell, Massachusetts) LSU Health Sciences Center - Shreveport (Shreveport, Louisiana) Lutheran Medical Center (Brooklyn, New York) Maine Medical Center (Portland, Maine) Mary Hitchcock Memorial Hospital (Lebanon, New Hampshire) Mercy Hospital (Springfield, Massachusetts) Mercy Medical Center (Canton, Ohio) Meriter Hospital (Madison, Wisconsin) Metrohealth Medical Center (Cleveland, Ohio) Morton Hospital and Medical Center (Taunton, Massachusetts) Mount Auburn Hospital (Cambridge,
Massachusetts) Mount St. Marys Hospital (Lewiston, New York) New York Presbyterian Hospital (New York, New York) Northeast Medical Center (Concord, North Carolina) Owatonna Hospital (Owatonna, Minnesota) Parkland Health and Hospital System (Dallas, Texas) Providence St. Vincent Medical Center (Portland, Oregon) Regional Medical Center (Madisonville, Kentucky) Robert Packer Hospital (Sayre, Pennsylvania) Rutherford Hospital (Rutherfordton, North Carolina) Saint Marys Hospital (Rochester, Minnesota) Sisters of Charity Hospital (Buffalo, New York) Southcoast Hospitals Group (Fall River, Massachusetts) Southern Maryland Hospital (Clinton, Maryland) Spectrum Health - Butterworth Campus (Grand Rapids, Michigan) St John North Shores Hospital (Harrison Township, Michigan) St Vincent Healthcare (Billings, Montana) St Vincents Hospital Staten Island (Staten Island, New York) St. Agnes Hospital (Baltimore, Maryland) St. Bernard Hospital (Chicago, Illinois) St. Bernards Regional Medical Center (Jonesboro, Arkansas) St. Elizabeth Hospital (Appleton, Wisconsin) St. Francis Hospital (Roslyn, New York) St. James Mercy Hospital (Hornell, New York) St. John Medical Center (Longview, Washington) St. Joseph Medical Center (Towson, Maryland) St. Josephs Medical Center (Yonkers,
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New York) St. Mary Hospital (Livonia, Michigan) St. Marys Hospital (Waterbury, Connecticut) St. Marys Medical Center (Racine, Wisconsin) St. Vincents Medical Center (Bridgeport, Connecticut) Staten Island University Hospital (Staten Island, New York) Sturgis Hospital (Sturgis, Michigan) The Chambersburg Hospital (Chambersburg, Pennsylvania) The Gettysburg Hospital (Gettysburg, Pennsylvania) The Moses H. Cone Memorial Hospital (Greensboro, North Carolina) The Mount Sinai Hospital (New York, New York) The NY Hospital Medical Center of Queens (Flushing, New York) The Union Memorial Hospital (Baltimore, Maryland) Thorek Hospital and Medical Center (Chicago, Illinois) Uniontown Hospital (Uniontown, Pennsylvania) Unity Hospital (Rochester, New York) University of North Carolina Hospital (Chapel Hill, North Carolina) University of VA Medical Center (Charlottesville, Virginia) UPMC Bedford (Everett, Pennsylvania) Wayne General Hospital (Waynesboro, Mississippi) Yale-New Haven Hospital (New Haven, Connecticut)
REFERENCES AND RESOURCES The 2009 Community Value Index, Cleverly + Associates, 438 East Wilson Bridge Road, Suite 200, Worthington, OH 43085.
(888) 779-5663. (www.cleverleyassociates. com/Information/CommunityValueIndex.aspx)
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53 CONSUMER CHOICE AWARDS
Since 1998, National Research Corporation has presented Consumer Choice Awards for the most-preferred hospitals in over 300 U.S. markets annually. Winners, named in Modern Healthcare each October, are selected based on responses in surveys of over 250,000 households.
Asheville, North Carolina Mission Health and Hospitals Atlanta, Georgia Emory University Hospital Northside Hospital Atlantic City, New Jersey AtlantiCare Regional Medical CenterAtlantic City Campus Augusta, Georgia University Health Care System Austin, Texas Seton Medical Center Austin Bakersfield, California Mercy Southwest Hospital Baltimore, Maryland Johns Hopkins Hospital Bangor, Maine Eastern Maine Medical Center Baton Rouge, Louisiana Our Lady of the Lake Regional Medical Center Beaumont-Port Arthur, Texas CHRISTUS Hospital-St. Elizabeth Bergen-Passaic, New Jersey Hackensack University Medical Center Bethesda, Maryland Johns Hopkins Hospital Shady Grove Adventist Hospital
2009 AWARD WINNERS

Akron, Ohio Akron General Medical Center Cleveland Clinic Foundation Albany, New York Albany Medical Center Albuquerque, New Mexico Presbyterian Hospital Alexandria, Louisiana CHRISTUS Hospital-St. Frances Cabrini Allentown, Pennsylvania Lehigh Valley Hospital & Health Network Altoona, Pennsylvania Altoona Regional Health Amarillo, Texas Baptist St. Anthonys Health System Ann Arbor, Michigan University of Michigan Health System Appleton, Wisconsin ThedaCare
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Biloxi, Mississippi Memorial Hospital at Gulfport Binghamton, New York Our Lady of Lourdes Memorial Hospital Birmingham, Alabama UAB Hospital Blacksburg, Virginia Carilion New River Valley Medical Center Bloomington, Indiana Bloomington Hospital Bloomington, Illinois Bromenn Regional Medical Center Boise, Idaho St. Lukes Regional Medical Center Boston, Massachusetts Massachusetts General Hospital Boulder, Colorado Boulder Community Hospital Longmont United Hospital Bowling Green, Kentucky The Medical Center Bremerton, Washington Harrison Medical Center Buffalo, New York Buffalo General Hospital Millard Fillmore Suburban Hospital Camden, New Jersey Cooper University Hospital Virtua Canton, Ohio Aultman Hospital Champaign-Urbana, Illinois Carle Foundation Hospital
Charleston, South Carolina Medical University of South Carolina Medical Center Charleston, West Virginia Charleston Area Medical Center Charlotte, North Carolina Carolinas Medical Center Charlottesville, Virginia University of Virginia Medical Center Chattanooga, Tennessee Memorial Hospital Chicago, Illinois Northwestern Memorial Hospital Chico, California Enloe Medical Center Cincinnati, Ohio The Christ Hospital Clarksville, Tennessee Vanderbilt University Medical Center Cleveland, Ohio Cleveland Clinic College Station-Bryan, Texas St. Joseph Regional Health Center Columbia, Missouri Boone Hospital Center Columbia, South Carolina Lexington Medical Center Columbus, Georgia Columbus Regional Medical Center St. Francis Hospital Columbus, Ohio Riverside Methodist Hospital
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Corpus Christi, Texas CHRISTUS Spohn Hospital-Shoreline Dallas, Texas Baylor University Medical Center at Dallas Daphne-Fairhope, Alabama Thomas Hospital Davenport, Iowa Genesis Davenport East Dayton, Ohio Miami Valley Hospital Daytona Beach, Florida Halifax Health Denver, Colorado Swedish Medical Center Des Moines, Iowa Mercy Medical Center - Des Moines Detroit, Michigan Henry Ford Hospital Beaumont Hospital, Royal Oak Duluth, Minnesota St. Lukes St. Marys Medical Center Durham, North Carolina Duke University Medical Center Eau Claire, Wisconsin Luther Midelfort Edison, New Jersey Robert Wood Johnson University Hospital-New Brunswick El Paso, Texas Sierra Providence Health Network Elizabethtown, Kentucky Hardin Memorial Hospital
Elkhart-Goshen, Indiana Elkhart General Hospital Elmira, New York Arnot-Ogden Medical Center Erie, Pennsylvania Hamot Medical Center Eugene-Springfield, Oregon Sacred Heart Medical Center Evansville, Indiana Deaconess Hospital Fargo, North Dakota Meritcare Medical Center Fayetteville, North Carolina Cape Fear Valley Medical Center Fayetteville-Springdale, Arkansas Washington Regional Medical Center Flint, Michigan Genesys Regional Medical Center Florence, South Carolina McLeod Regional Medical Center Fort Collins, Colorado Poudre Valley Hospital Fort Myers, Florida Lee Memorial Hospital Fort Smith, Arkansas St. Edward Mercy Medical Center Fort Wayne, Indiana Lutheran Hospital Parkview Hospital Fort Worth, Texas Texas Health Harris Methodist Hospital
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Fresno, California Saint Agnes Medical Center Gainesville, Florida Shands at the University of Florida Gary, Indiana The Community Hospital Grand Junction, Colorado St. Marys Hospital Grand Rapids, Michigan Spectrum Health Green Bay, Wisconsin Bellin Memorial Hospital Greensboro, North Carolina Moses H. Cone Memorial Hospital Greenville, South Carolina Greenville Memorial Hospital Hagerstown, Maryland Johns Hopkins Hospital Washington County Hospital Harrisburg, Pennsylvania Penn State Milton S. Hershey Medical Center Hartford, Connecticut Hartford Hospital Hickory-Morganton, North Carolina Frye Regional Medical Center Holland-Grand Haven, Michigan Spectrum Health Houston, Texas University of Texas, Maryland Anderson Huntington-Ashland, West VirginiaKentucky-Ohio Kings Daughters Medical Center
St. Marys Medical Center Huntsville, Alabama Huntsville Hospital Indianapolis, Indiana St. Vincent Hospitals and Health Services Iowa City, Iowa University of Iowa Hospitals and Clinics Jackson, Mississippi Baptist Medical Center University of Mississippi Medical Center Jacksonville, Florida Baptist Medical Center Johnson City-Kingsport-Bristol, Tennessee Johnson City Medical Center Wellmont Holston Medical Center Johnstown, Pennsylvania Conemaugh Memorial Medical Center Joplin, Missouri Freeman Hospital Kalamazoo, Michigan Bronson Methodist Hospital Kennewick, Washington Kadlec Regional Medical Center Knoxville, Tennessee University of Tennessee Medical Center Lafayette, Indiana St. Elizabeth Central Lafayette, Louisiana Lafayette General Medical Center Lake Charles, Louisiana CHRISTUS St. Patrick Hospital
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Lake County, Illinois & Kenosha County, Wisconsin Lake Forest Hospital Lakeland, Florida Lakeland Regional Medical Center Lancaster, Pennsylvania Lancaster General Hospital Lansing, Michigan Sparrow Health System Las Cruces, New Mexico Memorial Medical Center-Las Cruces Mountain View Regional Medical Center Las Vegas, Nevada Summerline Hospital and Medical Center Sunrise Hospital and Medical Center Lawton, Oklahoma Comanche County Memorial Hospital Lexington, Kentucky Central Baptist Hospital Little Rock, Arkansas Baptist Health Medical Center-Little Rock Longview, Texas Good Shepherd Medical Center Los Angeles, California Cedars-Sinai Medical Center Louisville, Kentucky Baptist Hospital East Lubbock, Texas Covenant Medical Center-Lubbock University Medical Center-Lubbock Lynchburg, Virginia Centra Lynchburg General Hospital
Macon, Georgia The Medical Center of Central Georgia Madison, Wisconsin University of Wisconsin Hospital and Clinics Manchester-Nashua, New Hampshire Elliot Hospital Medford, Oregon Rogue Valley Medical Center Melbourne, Florida Holmes Regional Medical Center Memphis, Tennessee Baptist Memorial Hospital - Memphis Miami, Florida Baptist Hospital of Miami Milwaukee, Wisconsin Froedtert Hospital Minneapolis-St. Paul, Minnesota Mayo Clinic Mobile, Alabama Providence Hospital Modesto, California Memorial Medical Center Montgomery, Alabama Baptist Medical Center Morgantown, West Virginia Ruby Memorial Hospital Myrtle Beach, South Carolina Grand Strand Regional Medical Center Naples, Florida NCH Healthcare System
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Nashville, Tennessee Vanderbilt University Medical Center Nassau-Suffolk, New York North Shore University Hospital Stony Brook University Medical Center Neenah, Wisconsin Theda Clark Medical Center New Haven, Connecticut Yale-New Haven Hospital New Orleans, Louisiana Ochsner Medical Center New York - Bronx County Montefiore Medical Center New York - Kings County Maimonides Medical Center New York Methodist Hospital New York - Queens County Long Island Jewish Medical Center New York - Richmond County Staten Island University Hospital New York - Westchester County Westchester Medical Center White Plains Hospital Center Newark, New Jersey Morristown Memorial Hospital Saint Barnabas Medical Center Niles-Benton Harbor, Michigan Lakeland HealthCare Norfolk-Virginia Beach, Virginia Sentara Norfolk General Hospital Norwich-New London, Connecticut Lawrence & Memorial Hospital
Oakland, California John Muir Medical Center-Walnut Creek Ocala, Florida Munroe Regional Medical Center Ogden, Utah McKay-Dee Hospital Center Oklahoma City, Oklahoma INTEGRIS Health Mercy Health Center Olympia, Washington Providence St. Peter Hospital Omaha, NE The Nebraska Medical Center Orange County, California Hoag Memorial Hospital Presbyterian Orlando, Florida Florida Hospital - Orlando Panama City-Lynn Haven, Florida Bay Medical Center-Panama Parkersburg-Marrietta, West VirginiaOhio Camden-Clark Memorial Hospital Pascagoula, Mississippi Ocean Springs Hospital Pensacola, Florida Sacred Heart Health System Peoria, Illinois OSF Saint Francis Medical Center Philadelphia, Pennsylvania Hospital of the University of Pennsylvania Phoenix, Arizona Mayo Clinic
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Pittsburgh, Pennsylvania UPMC-Presbyterian Port St. Lucie, Florida Martin Memorial Medical Center Portland, Maine Maine Medical Center Portland, Oregon OHSU Healthcare Providence St. Vincent Medical Center Poughkeepsie, New York Vassar Brothers Medical Center Prescott, Arizona Yavapai Regional Medical Center Providence, Rhode Island Rhode Island Hospital Provo-Orem, Utah Utah Valley Regional Medical Center Pueblo, Colorado Parkview Medical Center Raleigh, North Carolina Rex Healthcare Reading, Pennsylvania The Reading Hospital and Medical Center Redding, California Mercy Medical Center-Redding Reno, Nevada Renown Health Riverside-San Bernardino, California Loma Linda University Medical Center Roanoke, Virginia Carilion Medical Center Lewis-Gale Medical Center
Rochester, Minnesota Mayo Clinic Rochester, New York Strong Memorial Hospital Rockford, Illinois SwedishAmerican Hospital Rockingham-Strafford, New Hampshire Massachusetts General Hospital Wentworth-Douglass Hospital Rocky Mount, North Carolina Pitt County Memorial Hospital Sacramento, California UC Davis Medical Center Saginaw-Saginaw Township, Michigan Covenant Medical Center Saint Louis, Missouri Barnes-Jewish Hospital Salem, Oregon Salem Hospital Salinas, California Community Hospital of the Monterey Peninsula Salt Lake City, Utah University of Utah Hospital San Antonio, Texas Methodist Hospital San Diego, California Kaiser Foundation Hospital-San Diego Scripps Memorial Hospital-La Jolla San Francisco, California UCSF Medical Center San Jose, California Stanford Hospital & Clinics
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San Luis Obispo-Paso Robles, California French Hospital Medical Center Santa Barbara, California Santa Barbara Cottage Hospital Santa Cruz, California Dominican Hospital Santa Rosa, California Santa Rosa Memorial Hospital Sarasota, Florida Sarasota Memorial Health Care System Savannah, Georgia St. Joseph/Candler Seattle, Washington Swedish Medical Center Sherman-Denison, Texas Texoma Medical Center Wilson N. Jones Medical Center Shreveport, Louisiana Willis-Knighton Health System Sioux City, Iowa St. Lukes Regional Medical Center Sioux Falls, South Dakota Sanford USD Medical Center South Bend, Indiana Memorial Hospital of South Bend Spartanburg, South Carolina Spartanburg Regional Medical Center Spokane, Washington Sacred Heart Medical Center & Childrens Hospital Springfield, Illinois Memorial Medical Center
Springfield, Massachusetts Baystate Medical Center Springfield, Minnesota St. Cloud Hospital Springfield, Missouri St. Johns Health System State College, Pennsylvania Geisinger Medical Center Stockton, California St. Josephs Medical Center-Stockton Syracuse, New York St. Josephs Hospital Health Center Tacoma, Washington St. Joseph Medical Center Tacoma General Hospital Tallahassee, Florida Tallahassee Memorial Healthcare Tampa, Florida Tampa General Hospital Temple, Texas Scott and White Memorial Hospital Terre Haute, Indiana Union Hospital Toledo, Ohio The Toledo Hospital Topeka, Kansas St. Francis Health Center Stormont Vail Healthcare Trenton, New Jersey Robert Wood Johnson University Hospital-Hamilton Tucson, Arizona Tucson Medical Center University Medical Center - Tucson
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Tulsa, Oklahoma Saint Francis Hospital Tuscaloosa, Alabama DCH Regional Medical Center Tyler, Texas Trinity Mother Frances Utica, New York Faxton - St. Lukes Healthcare St. Elizabeth Medical Center Ventura, California Community Memorial Hospital of San Buenaventura Los Robles Hospital & Medical Center Visalia, California Kaweah Delta Health Care District Waco, Texas Providence Health Center Washington, D.C. Inova Fairfax Hospital Waterloo-Cedar Falls, Iowa Covenant Medical Center Allen Memorial Hospital Wheeling, West Virginia Wheeling Hospital Wichita, Kansas Via Christi Regional Med Center-St. Francis Campus Wesley Medical Center Wilmington, Delaware Christiana Care Health System Christiana Hospital Wilmington, North Carolina New Hanover Regional Medical Center
Winston-Salem, North Carolina Wake Forest University Baptist Medical Center Worcester, Massachusetts UMass Memorial Medical Center University Campus Yakima, Washington Yakima Valley Memorial Hospital York, Pennsylvania York Hospital Youngstown, Ohio St. Elizabeth Health Center

Consumer Choice Awards, National Research Corporation, 1245 Q Street, Lincoln, NB 68508. (402) 475-2525. (http://hcmg.nationalresearch.com/Default.a spx?DN=7,1,Documents)
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54 DESIGN AWARDS
Since 1985, Modern Healthcares annual Design Awards program has recognized excellence in the design and planning of new and remodeled healthcare facilities.
2009 AWARDS
Award of Excellence Grand Itasca Clinic & Hospital (Grand Rapids, Minnesota) Honorable Mentions Childrens Medical Center at Legacy (Plano, Texas) Kennedy Krieger Institute, Harry and Jeanette Weinberg Building, Outpatient Center (Baltimore, Maryland) Stanford Medicine Outpatient Center (Redwood City, California) Citations Cleveland Clinic Abu Dhabi (United Arab Emirates) Miller Family Pavilion and Glickman Tower (Cleveland, Ohio) SSM St. Clare Health Center (St. Louis County, Missouri)
In recent years, judges in the Modern Healthcare annual Design Awards contest noted how award-winning projects made exceptional use of natural light, and how the new facilities fit into and matched their environments. This year the 24th annual design competition judges noted these features again. But they also chose the projects that took a regional approach to the use of materials; made extraordinary efforts to accommodate family members and personal caregivers; incorporated way-finding elements as well as patient-safety and energy-efficiency concepts into their designs; attempted to ergonomically engineer a workplace that made life easier for hospital staff; and added amenities that could help recruit and retain top personnel.

24th Design Awards, Modern Healthcare, September 7, 2009, pp 16-32
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55
MOST HIGHLY INTEGRATED HEALTHCARE NETWORKS
Since 1997, SDI has ranked the 100 most highly integrated healthcare networks (IHNs). The assessment evaluates each of the 570 non-specialty, local, and regional networks in the U.S. based on their ability to operate as a unified organization. IHNs are ranked based on scores in eight categories: integration, integrated technology, contractual capabilities, outpatient utilization, financial stability, services and access, hospital utilization, and physicians. The following is the most recent ranking.
2009 RANKING
St. Johns Health System (Springfield, Missouri) ProMedica Health System (Toledo, Ohio) Intermountain Healthcare (Salt Lake City, Utah) Sentara Healthcare (Norfolk, Virginia) Sutter Health (Sacramento, California) MultiCare Health System (Tacoma, Washington) Providence Health & Services (Portland, Oregon) Franciscan Health System (Tacoma, Washington) Community Health Network (Indianapolis, Indiana) University Hospitals (Cleveland, Ohio) WellStar Health System (Marietta, Georgia)
Novant Health (Winston-Salem, North Carolina) Sharp HealthCare (San Diego, California) Fairview Health Services (Minneapolis, Minnesota) Bon Secours Richmond Health System (Richmond, Virginia) McLaren Health Care Corporation (Flint, Michigan) Alegent Health (Omaha, Nebraska) Carilion Clinic (Roanoke, Virginia) Henry Ford Health System (Detroit, Michigan) North Shore - Long Island Jewish Health System (Great Neck, New York) Advocate Health Care (Oak Brook, Illinois) Banner Health (Phoenix, Arizona) Gundersen Lutheran Health Care Network (La Crosse, Wisconsin) University of Wisconsin Hospital & Clinics (Madison, Wisconsin) OSF HealthCare (Peoria, Illinois) Roper St. Francis Healthcare (Charleston, South Carolina) Wheaton Franciscan Healthcare (Glendale, Wisconsin) St. Johns Mercy Health Care (St. Louis, Missouri) Affinity Health System (Menasha, Wisconsin) OhioHealth (Columbus, Ohio) Baystate Health (Springfield, Massachusetts) Scripps Health (San Diego, California) Health First (Rockledge, Florida) Emory Healthcare (Atlanta, Georgia)
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UPMC (Pittsburgh, Pennsylvania) Aurora Health Care (Milwaukee, Wisconsin) Mercy Health System (Janesville, Wisconsin) Presbyterian Healthcare Services (Albuquerque, New Mexico) Baptist Memorial Health Care Corporation (Memphis, Tennessee) Norton Healthcare (Louisville, Kentucky) Baylor Health Care System (Dallas, Texas) Beaumont Hospitals (Royal Oak, Michigan) Covenant Health (Knoxville, Tennessee) Group Health Cooperative (Seattle, Washington) Inova Health System (Falls Church, Virginia) Monroe Clinic (Monroe, Wisconsin) Spectrum Health (Grand Rapids, Michigan) North Mississippi Health Services (Tupelo, Mississippi) CoxHealth (Springfield, Missouri) TriHealth (Cincinnati, Ohio) Methodist Healthcare (Memphis, Tennessee) UC Davis Health System (Sacramento, California) Riverside Health System (Newport News, Virginia) Sanford Health (Sioux Falls, South Dakota) Archbold Medical Center (Thomasville, Georgia) JPS Health Network (Fort Worth, Texas) Legacy Health System (Portland, Oregon) Lehigh Valley Hospital and Health Network (Allentown, Pennsylvania) MaineHealth (Portland, Maine) Broward Health (Fort Lauderdale, Florida) Geisinger Health System (Danville, Pennsylvania) Saint Lukes Health System (Kansas
City, Missouri) Cook Childrens Health Care System (Fort Worth, Texas) Catholic Health System (Buffalo, New York) Lahey Clinic (Burlington, Massachusetts) MemorialCare (Huntington Beach, California) Carolinas HealthCare System (Charlotte, North Carolina) Memorial Hermann Healthcare System (Houston, Texas) Bon Secours St. Francis Health System (Greenville, South Carolina) Genesys Health System (Grand Blanc, Michigan) Spartanburg Regional Healthcare System (Spartanburg, South Carolina) Swedish American Health System (Rockford, Illinois) St. Francis Health System (Tulsa, Oklahoma) Fletcher Allen Health Care (Burlington, Vermont) WellSpan Health (York, Pennsylvania) Rochester General Health System (Rochester, New York) Kaleida Health (Buffalo, New York) Trinity Mother Frances Hospitals and Clinics (Tyler, Texas) ProHealth Care (Waukesha, Wisconsin) Oakwood Healthcare (Dearborn, Michigan) University Health Systems of Eastern Carolina (Greenville, North Carolina) NorthShore University HealthSystem (Evanston, Illinois) Western Maryland Health System (Cumberland, Maryland) Mountain States Health Alliance (Johnson City, Tennessee) Crozer-Keystone Health System (Springfield, Pennsylvania) Renown Health (Reno, Nevada) Ochsner Health System (New Orleans, Louisiana)
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Stormont-Vail HealthCare (Topeka, Kansas) Memorial Health System (Springfield, Illinois) Greenville Hospital System (Greenville, South Carolina) St. Josephs/Candler (Savannah, Georgia) Orlando Health (Orlando, Florida) Genesis Health System (Davenport, Iowa) Lifespan (Providence, Rhode Island) Akron General Health System (Akron, Ohio) University of Chicago Medical Center (Chicago, Illinois) Altru Health System (Grand Forks, North Dakota) Sparrow Health System (Lansing, Michigan) Appalachian Regional Healthcare (Lexington, Kentucky) Yale New Haven Health System (New Haven, Connecticut)

SDI, 220 West Germantown Pike, Plymouth Meeting, PA 19462. (610) 834-0800. (www.sdihealth.com)
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MOST WIRED HOSPITALS
Hospitals & Health Networks, published by the American Hospital Association, identifies the 100 Most Wired Hospitals annually based on their use of IT in the following five areas: Safety and Quality: Reducing errors in prescribing medications, monitoring changes in patient conditions and sending alerts to staff in real time, providing hospital clinicians with patients health records in electronic form, and more. Customer Service: Helping patients research illnesses and pre-registering them for hospital admissions. Business: Using software to streamline purchasing operations and to coordinate and track transactions with insurance companies, and similar upgrades. Workforce: Training physicians, nurses, and other clinicians, measuring staff performance, and related matters. Public Health: Safeguarding patient privacy with security measures, participating in cooperative health efforts with other institutions, and improving specific clinical practices.
2009 LIST OF MOST WIRED HOSPITALS AND HEALTHCARE SYSTEMS

Advocate Health Care (Oak Brook, Illinois) Akron General Medical Center (Akron, Ohio) AtlantiCare (Egg Harbor Township, New Jersey) Aurora Health Care (Milwaukee, Wisconsin)
Avera Health (Sioux Falls, South Dakota) Baptist Health South Florida (Coral Gables, Florida) Battle Creek Health System (Battle Creek, Michigan) Beaufort Memorial Hospital (Beaufort, South Carolina) Beth Israel Deaconess Medical Center (Boston, Massachusetts) Billings Clinic (Billings, Montana) Blanchfield Army Community Hospital (Fort Campbell, Kentucky) Carilion Clinic (Roanoke, Virginia) Carolinas HealthCare System (Charlotte, North Carolina) Centra (Lynchburg, Virginia) Central DuPage Health (Winfield, Illinois) Childrens Hospital & Medical Center (Omaha, Nebraska) Childrens Hospital Boston (Boston, Massachusetts) Childrens Medical Center of Dallas (Dallas, Texas) Citizens Memorial Hospital (Bolivar, Missouri) Clarian Health (Indianapolis, Indiana) Community Health Network (Indianapolis, Indiana) Concord Hospital (Concord, New Hampshire) Continuum Health Partners (New York, New York) Covenant Health (Knoxville, Tennessee) Crittenton Hospital Medical Center (Rochester, Michigan) Crozer-Keystone Health System (Springfield, Pennsylvania) Denver Health and Hospital Authority (Denver, Colorado) Detroit Medical Center (Detroit, Michigan)
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Dublin Methodist Hospital (Dublin, Ohio) Duke University Health System (Durham, North Carolina) Eastern Maine Medical Center (Bangor, Maine) Fairview Health Services (Minneapolis, Minnesota) Geisinger Health System (Danville, Pennsylvania) Genesis Health System (Davenport, Iowa) Greenville Hospital System University Medical Center (Greenville, South Carolina) Greenwich Hospital (Greenwich, Connecticut) H. Lee Moffitt Cancer Center & Research Institute (Tampa, Florida) Hartford Hospital (Hartford, Connecticut) Health First (Rockledge, Florida) Henry County Health Center (Mount Pleasant, Iowa) Hunterdon Healthcare System (Flemington, New Jersey) Inland Northwest Health Services Washington and Idaho Region (Spokane, Washington) Inova Health System (Falls Church, Virginia) Intermountain Healthcare (Salt Lake City, Utah) Kootenai Medical Center (Coeur dAlene, Idaho) Lehigh Valley Health Network (Allentown, Pennsylvania) Loyola University Medical Center (Maywood, Illinois) Madigan Army Medical Center (Tacoma, Washington) Maimonides Medical Center (Brooklyn, New York) MedCentral - Mansfield Hospital (Mansfield, Ohio) MedCentral - Shelby Hospital (Shelby, Ohio) MedStar Health (Columbia, Maryland) Memorial Healthcare (Owosso, Michigan) Memorial Hermann Healthcare System (Houston, Texas)
Memorial Sloan-Kettering Cancer Center (New York, New York) Memorial University Medical Center (Savannah, Georgia) Mercy Health Partners of Southwest Ohio (Cincinnati, Ohio) Meridian Health (Neptune, New Jersey) MeritCare Health System (Fargo, North Dakota) Methodist Hospital System (Houston, Texas) Mission Hospitals (Asheville, North Carolina) Montefiore Health System (Bronx, New York) MultiCare Health System (Tacoma, Washington) Naval Hospital Lemoore (Lemoore, California) North Mississippi Medical Center (Tupelo, Mississippi) NorthShore University HealthSystem (Evanston, Illinois) Northwestern Memorial Hospital (Chicago, Illinois) Ochsner Health System (New Orleans, Louisiana) Park Nicollet Health Services (St. Louis Park, Minnesota) Partners HealthCare (Boston, Massachusetts) Piedmont Fayette Hospital (Fayetteville, Georgia) Piedmont Hospital (Atlanta, Georgia) Poudre Valley Health System (Fort Collins, Colorado) ProMedica Health System (Toledo, Ohio) Providence Sacred Heart Medical Center & Childrens Hospital (Spokane, Washington) Richard L. Roudebush Veterans Affairs Medical Center (Indianapolis, Indiana) Riverside Health System (Newport News, Virginia) Rush University Medical Center (Chicago, Illinois) Saint Clares Hospital (Weston, Wisconsin)
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Saint Lukes Health System (Kansas City, Missouri) Sentara Leigh Hospital (Norfolk, Virginia) Sharp HealthCare (San Diego, California) Spartanburg Regional Healthcare System (Spartanburg, South Carolina) Susquehanna Health (Williamsport, Pennsylvania) Texas Health Resources (Arlington, Texas) ThedaCare (Appleton, Wisconsin) TriHealth (Cincinnati, Ohio) UAMS Medical Center (Little Rock, Arkansas) University of California San Diego Medical Center (San Diego, California) University of Illinois Medical Center at Chicago (Chicago, Illinois) University of Kansas Hospital (Kansas City, Kansas) University of New Mexico Hospitals (Albuquerque, New Mexico) University of Pittsburgh Medical Center (Pittsburgh, Pennsylvania) University of Tennessee Medical Center (Knoxville, Tennessee) VA Central California Health Care System (Fresno, California) VA Medical Center (Washington, DC) VA Northeast Region 4 (Brooklyn, New York) Valley Health System (Ridgewood, New Jersey) Vanderbilt University Medical Center (Nashville, Tennessee) Yale-New Haven Hospital (New Haven, Connecticut)

Hospitals & Health Networks Most Wired, Health Forum Inc., 155 North Wacker Drive, 4th Floor, Chicago, IL 60606. (www.hhnmostwired.com)
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NATIONAL QUALITY HEALTHCARE AWARD
The National Quality Healthcare Award was created in 1993 to recognize outstanding quality-driven healthcare organizations. For 16 years, first through the National Committee for Quality Health Care and now through the National Quality Forum, the award has provided encouragement for improvements in quality through public recognition of organizations accomplishments.
(Dallas) 2009: Memorial Hermann Healthcare System (Houston)

National Quality Forum, 601 13th Street NW, Suite 500 North, Washington, DC 20005. (202) 783-1300. (www.qualityforum.org)
AWARD WINNERS
1994: Henry Ford Health System (Detroit) 1995: Evanston (Illinois) Hospital Corp. 1996: Intermountain Health Care (Salt Lake City) 1997: St. Lukes Health System (Kansas City) 1998: University of Pennsylvania Health System (Philadelphia) 1999: BJC Health System (St. Louis) 2000: Munson Medical Center (Traverse City, Michigan) 2001: Catholic Health Initiatives (Denver) 2002: Carilion Health System (Roanoke) 2003: Lehigh Valley Hospital and Health Network (Allentown, Pennsylvania) 2004: Trinity Health (Novi, Michigan) 2005: Northwestern Memorial Hospital (Chicago) 2006: Brigham and Womens Hospital (Boston) 2007: Health Partners (Bloomfield, Minnesota) 2008: Baylor Health Care System
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NOVA AWARDS
Presented annually by the American Hospital Association, NOVA Awards honor hospitals and health systems that improve community health through healthcare, economic, or social initiatives and do so collaboratively, working with other organizations.

American Hospital Association, One North Franklin, Chicago, IL 60606. (312) 422-3000. (www.aha.org)
2009 WINNERS
Brigham and Womens Hospital (Boston) Duke Raleigh Hospital (Raleigh, North Carolina) Holy Cross Hospital (Taos, New Mexico) Jacobi Medical Center and North Central Bronx Hospital (New York City) Mission Health System (Asheville, North Carolina)
2009 FINALISTS
Baylor Health Care System (Dallas) Bellevue Hospital Center (New York City) Bucyrus Community Hospital (Bucyrus, Ohio) Chilton Memorial Hospital (Pompton Plains, New Jersey) Intermountain Healthcare (Salt Lake City, Utah) McLeod Medical Center (Dillon, South Carolina) Oakwood Healthcare System (Dearborn, Michigan) Owensboro Medical Health System (Owensboro, Kentucky)
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QUEST FOR QUALITY
The American Hospital Association (AHA) McKesson Quest for Quality Prize, given annually since 2002, aims to raise awareness of the need for a hospital-wide commitment to highly reliable, exceptional quality, patientcentered care; reward successful efforts to develop and promote a systems-based approach toward improvements in quality of care; inspire hospitals to systematically integrate and align their quality improvement efforts throughout the organization; and communicate successful programs and strategies to the hospital field. The prize honors hospitals that have committed in a systematic manner to achieving the Institute of Medicines six quality aims safety, patient-centeredness, effectiveness, efficiency, timeliness, and equity.
Center (Erie, Pennsylvania)
2007 AWARDS
Winner: Columbus Regional Hospital (Columbus, Indiana) Finalist: Cedars-Sinai Medical Center (Los Angeles) Finalist: INTEGRIS Baptist Medical Center (Oklahoma City) Citations of Merit: Amarillo VA Health Care System (Amarillo, Texas) Citations of Merit: McLeod Regional Medical Center (Florence, South Carolina)
2006 AWARDS
Winner: Cincinnati Childrens Hospital Medical Center Citation of Merit: Bronson Methodist Hospital (Kalamazoo, Michigan) Citation of Merit: Baptist Memorial Hospital for Women (Memphis, Tennessee)
2009 AWARDS
Winner: Bronson Methodist Hospital (Kalamazoo, Michigan) Finalist: Beth Israel Deaconess Medical Center (Boston) Citation of Merit: Duke University Hospital (Durham, North Carolina)
REFERENCES AND RESOURCES 2008 AWARDS

Winner: Munson Medical Center (Traverse City, Michigan) Finalist: University of Michigan Hospitals and Health Centers (Ann Arbor) Citation of Merit: Avera McKennan Hospital & University Health Center (Sioux Falls, South Dakota) Citation of Merit: Saint Vincent Health American Hospital Association, One North Franklin, Chicago, IL 60606. (312) 422-3000. (www.aha.org/questforquality)
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60 SPIRIT OF EXCELLENCE AWARDS
Modern Healthcare and Sodexo Health Care Services have sponsored the Spirit of Excellence Awards since 1992, honoring organizations and individuals that go beyond whats expected in serving their patients and communities. Five awards are given as part of the program: Service Spirit Award, which recognizes excellence in service and in patient and resident satisfaction Quality Spirit Award, which recognizes quality, safety, and performance improvement Community Spirit Award, which recognizes community education, support, and outreach Team Spirit Award, which recognizes employee recruitment and retention CARES Spirit Award, which recognizes a team or group of individuals whose collective actions, attitudes, and behaviors personify compassion, accountability, respect, enthusiasm, and service
(Mechanicsville, Virginia) Community Spirit Award Winner: Family Health Center of San Diego Honorable Mention: Kaiser Permanente Team Spirit Award Winner: Starlight Community Services (Oakland, California) Honorable Mention: Avera McKennan Hospital & University Health Center (Sioux Falls, South Dakota) CARES Spirit Award Winner: Sts. Mary & Elizabeth Hospital (Louisville, Kentucky) Honorable Mention: Sinai Urban Health Institute (Chicago, Illinois)

Getting Into The Spirit, Modern Healthcare, December 14, 2009, pp 27-32.
2009 AWARDS
Service Spirit Award Winner: Tanner Medical Center (Carrollton, Georgia) Honorable Mention: Good Shepherd Rehabilitation Network (Allentown, Pennsylvania) Quality Spirit Award Winner: Primary Stroke Center at Mary Washington Hospital (Fredericksburg, Virginia) Honorable Mention: Bon Secours Memorial Regional Medical Center Sodexo Health Care Services, 9801 Washington Boulevard, Gaithersburg, MD 20878. (800) 763-3946. (www.sodexousa.com)
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TOP 100 HOSPITALS
Since 1992, Thomson Reuters Healthcare has developed an annual list of the 100 Top Hospitals based on a comparison of Medicare data for eight measures utilizing the Agency for Healthcare Research and Qualitys publicsafety indicators. The assessment compares hospitals actual patient-safety performance with expected performance.
(Charlottesville, Virginia) Vanderbilt University Medical Center (Nashville, Tennessee)
Teaching Hospitals
Avera McKennan Hospital & University Health Center (Sioux Falls, South Dakota) Bryn Mawr Hospital (Bryn Mawr, Pennsylvania) Cleveland Clinic Florida (Weston, Florida) Good Samaritan Hospital (Cincinnati, Ohio) Gundersen Lutheran Health System (La Crosse, Wisconsin) Hamot Medical Center (Erie, Pennsylvania) Hillcrest Hospital (Mayfield Heights, Ohio) Lancaster General Hospital (Lancaster, Pennsylvania) Mercy Medical Center-North Iowa (Mason City, Iowa) Metro Health Hospital (Wyoming, Michigan) MidMichigan Medical Center-Midland (Midland, Michigan) Munson Medical Center (Traverse City, Michigan) North Mississippi Medical Center (Tupelo, Mississippi) Providence St. Vincent Medical Center (Portland, Oregon) Riverside Methodist Hospital (Columbus, Ohio) Robert Packer Hospital (Sayre, Pennsylvania) Rose Medical Center (Denver, Colorado) St. Cloud Hospital (St. Cloud, Minnesota) St. Elizabeth Medical Center (Edgewood, Kentucky)
2009 BENCHMARK LIST Major Teaching Hospitals

Advocate Lutheran General Hospital (Park Ridge, Illinois) Beth Israel Deaconess Medical Center (Boston, Massachusetts) Duke University Hospital (Durham, North Carolina) Mayo Clinic - Saint Marys Hospital (Rochester, Minnesota) NorthShore University HealthSystem (Evanston, Illinois) Northwestern Memorial Hospital (Chicago, Illinois) Providence Hospital and Medical Center (Southfield, Michigan) Scott and White Memorial Hospital (Temple, Texas) St. Josephs Hospital and Medical Center (Phoenix, Arizona) The Western Pennsylvania Hospital (Pittsburgh, Pennsylvania) University Hospitals Case Medical Center (Cleveland, Ohio) University Medical Center (Tucson, Arizona) University of Michigan Hospitals & Health Centers (Ann Arbor, Michigan) University of Virginia Medical Center
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St. Lukes Boise Medical Center (Boise, Idaho) St. Vincent Indianapolis Hospital (Indianapolis, Indiana) Saint Joseph Regional Medical CenterSouth Bend (South Bend, Indiana) Union Memorial Hospital (Baltimore, Maryland) Waukesha Memorial Hospital (Waukesha, Wisconsin) Wheaton Franciscan Healthcare-St. Joseph (Milwaukee, Wisconsin)
St. Johns Regional Medical Center (Joplin, Missouri) St. Mary Mercy Livonia Hospital (Livonia, Michigan)
Medium Community Hospitals

Aurora Sheboygan Memorial Medical Center (Sheboygan, Wisconsin) Aurora West Allis Medical Center (West Allis, Wisconsin) Columbus Regional Hospital (Columbus, Indiana) Gratiot Medical Center (Alma, Michigan) Holland Hospital (Holland, Michigan) Licking Memorial Hospital (Newark, Ohio) Marion General Hospital (Marion, Indiana) Memorial Hospital and Health Care Center (Jasper, Indiana) Memorial Regional Medical Center (Mechanicsville, Virginia) Mercy Hospital Clermont (Batavia, Ohio) Middlesex Hospital (Middletown, Connecticut) Riverside Medical Center (Kankakee, Illinois) Rutherford Hospital (Rutherfordton, North Carolina) St. Francis Hospital-Indianapolis (Indianapolis, Indiana) Saint Joseph East (Lexington, Kentucky) Sycamore Medical Center (Miamisburg, Ohio) The Monroe Clinic (Monroe, Wisconsin) Union Hospital (Dover, Ohio) West Anaheim Medical Center (Anaheim, California) Wooster Community Hospital (Wooster, Ohio)
Large Community Hospitals

Advocate Good Samaritan Hospital (Downers Grove, Illinois) Alegent Health Bergan Mercy Medical Center (Omaha, Nebraska) Baptist Hospital East (Louisville, Kentucky) Centennial Medical Center (Nashville, Tennessee) Central DuPage Hospital (Winfield, Illinois) Citizens Medical Center (Victoria, Texas) Doctors Hospital at Renaissance (Edinburg, Texas) Kings Daughters Medical Center (Ashland, Kentucky) Memorial Health Care System (Chattanooga, Tennessee) Memorial Hospital West (Pembroke Pines, Florida) Mercy Medical Center-Dubuque (Dubuque, Iowa) Missouri Baptist Medical Center (St. Louis, Missouri) Providence Regional Medical Center Everett (Everett, Washington) Saint Elizabeth Regional Medical Center (Lincoln, Nebraska) Saint Thomas Hospital (Nashville, Tennessee) San Antonio Community Hospital (Upland, California) Silver Cross Hospital (Joliet, Illinois) Southwest General Health Center (Middleburg Heights, Ohio)
Small Community Hospitals

Castleview Hospital (Price, Utah) Central Michigan Community Hospital (Mount Pleasant, Michigan) Chambers Memorial Hospital (Danville, Arkansas) Desert Valley Hospital (Victorville, California)
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Douglas County Hospital (Alexandria, Minnesota) Duncan Regional Hospital (Duncan, Oklahoma) Jamestown Hospital (Jamestown, North Dakota) Lake Whitney Medical Center (Whitney, Texas) Lakeview Hospital (Stillwater, Minnesota) Major Hospital (Shelbyville, Indiana) Meadows Regional Medical Center (Vidalia, Georgia) Mercy Hospital Cadillac (Cadillac, Michigan) Parkland Health Center-Farmington (Farmington, Missouri) St. Elizabeth Community Hospital (Red Bluff, California) St. Marys Jefferson Memorial Hospital (Jefferson City, Tennessee) St. Marys Medical Center of Campbell County (LaFollette, Tennessee) Sacred Heart Hospital on the Emerald Coast (Miramar Beach, Florida) Saint Joseph-London (London, Kentucky) Saint Joseph Mercy Saline Hospital (Saline, Michigan) The Kings Daughters Hospital & Health Services (Madison, Indiana)

Center for Healthcare Improvement, Thomson Reuters Healthcare, 777 East Eisenhower Parkway, Ann Arbor, MI 48108. (734) 913-3000. (www.top100hospitals.com)
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TOP CARDIOVASCULAR HOSPITALS
Since 1998, The Center for Healthcare Improvement at Thomson Reuters has conducted an annual study identifying the 100 U.S. hospitals that set the nations benchmarks for inpatient cardiovascular services. The assessment examines the performance of 971 hospitals by analyzing outcomes for patients with heart failure and heart attacks and for those who received coronary bypass surgery or percutaneous cardiovascular interventions (PCI) such as angioplasties. Compared with peer hospitals, performance of the 100 Top Cardiovascular Hospitals is as follows: 27% lower mortality for bypass surgery patients 22% lower mortality following PCI 17% lower mortality rates for heart attack patients 12% lower cost per case 10% lower mortality rates for heart failure patients Close to 12% shorter average hospital stay Fewer post-operative complications - 99% of patients were complication-free The top performing hospitals perform over 50% more cardiac surgeries than peer hospitals.
2009 LIST OF TOP CARDIOVASCULAR HOSPITALS

Teaching Hospitals with Cardiovascular Residency Programs
Advocate Christ Medical Center (Oak Lawn, Illinois) Advocate Lutheran General Hospital (Park Ridge, Illinois) Albany Medical Center (Albany, New York) Aurora St. Lukes Medical Center (Milwaukee, Wisconsin) Baystate Medical Center (Springfield, Massachusetts) Beth Israel Deaconess Medical Center (Boston, Massachusetts) Caritas St. Elizabeths Medical Center (Boston, Massachusetts) Cleveland Clinic Florida (Weston, Florida) Dartmouth-Hitchcock Medical Center (Lebanon, New Hampshire) Fletcher Allen Health Care (Burlington, Vermont) Geisinger Medical Center (Danville, Pennsylvania) Good Samaritan Hospital (Cincinnati, Ohio) Grandview Medical Center (Dayton, Ohio) Hackensack University Medical Center (Hackensack, New Jersey) Kettering Medical Center (Kettering, Ohio) Lahey Clinic Medical Center (Burlington, Massachusetts) Loyola University Medical Center (Maywood, Illinois) Maine Medical Center (Portland, Maine) Mercy Medical Center-North Iowa (Mason City, Iowa) Providence Hospital and Medical Center (Southfield, Michigan) Scott and White Memorial Hospital (Temple, Texas) St. Vincent Indianapolis Hospital (Indianapolis, Indiana)
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2St. Josephs Hospital and Medical Center (Phoenix, Arizona) Staten Island University Hospital (Staten Island, New York) The Ohio State University Medical Center (Columbus, Ohio) UMass Memorial Medical Center (Worcester, Massachusetts) University of Virginia Medical Center (Charlottesville, Virginia) University of Wisconsin Hospital and Clinics (Madison, Wisconsin) UPMC Passavant (Pittsburgh, Pennsylvania) Vanderbilt University Medical Center (Nashville, Tennessee) Teaching Hospitals Without Cardiovascular Residency Programs Altru Hospital (Grand Forks, North Dakota) Aspirus Wausau Hospital (Wausau, Wisconsin) Ball Memorial Hospital (Muncie, Indiana) Bethesda North Hospital (Cincinnati, Ohio) Billings Clinic (Billings, Montana) Carolinas Medical Center-NorthEast (Concord, North Carolina) Centra Health (Lynchburg, Virginia) Firelands Regional Medical Center (Sandusky, Ohio) Gundersen Lutheran Health System (La Crosse, Wisconsin) Hamot Medical Center (Erie, Pennsylvania) Henry Ford Macomb Hospitals (Clinton Township, Michigan) Marquette General Hospital (Marquette, Michigan) Memorial Hospital of Carbondale (Carbondale, Illinois) Mercy Medical Center Redding (Redding, California) Mercy Medical Center (Canton, Ohio) Mercy Medical Center-Des Moines (Des Moines, Iowa)
MeritCare Hospital (Fargo, North Dakota) Morton Plant Hospital (Clearwater, Florida) Mount Carmel (Columbus, Ohio) Munson Medical Center (Traverse City, Michigan) North Shore Medical Center (Salem, Massachusetts) Park Nicollet Methodist Hospital (St. Louis Park, Minnesota) PinnacleHealth (Harrisburg, Pennsylvania) Providence St. Vincent Medical Center (Portland, Oregon) Rapides Regional Medical Center (Alexandria, Louisiana) Riverside Methodist Hospital (Columbus, Ohio) Robert Packer Hospital (Sayre, Pennsylvania) Rochester General Hospital (Rochester, New York) Saint Josephs Hospital (Marshfield, Wisconsin) Spectrum Health Hospitals (Grand Rapids, Michigan) St. John West Shore Hospital (Westlake, Ohio) St. Lukes Boise Medical Center (Boise, Idaho) St. Joseph Mercy Oakland (Pontiac, Michigan) St. Johns Hospital (Springfield, Illinois) St. Joseph Mercy Hospital (Ann Arbor, Michigan) St. John Macomb-Oakland Hospital (Warren, Michigan) St. Marys Hospital (Richmond, Virginia) St. Marys Hospital and Regional Medical Center (Grand Junction, Colorado) St. Peters Hospital (Albany, New York) William Beaumont Hospital-Troy (Troy, Michigan) Community Hospitals Arizona Heart Hospital (Phoenix, Arizona) Arrowhead Hospital (Glendale, Arizona) Aurora BayCare Medical Center (Green
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Bay, Wisconsin) Avera Heart Hospital of South Dakota (Sioux Falls, South Dakota) Dixie Regional Medical Center- St. George, Utah) DuBois Regional Medical Center (DuBois, Pennsylvania) EMH Regional Medical Center (Elyria, Ohio) Fairview Southdale Hospital (Edina, Minnesota) French Hospital Medical Center (San Luis Obispo, California) Harlingen Medical Center (Harlingen, Texas) Heart Hospital of Austin (Austin, Texas) Hoag Memorial Hospital Presbyterian (Newport Beach, California) JFK Medical Center (Atlantis, Florida) Medcenter One (Bismarck, North Dakota) Mercy Hospital (Coon Rapids, Minnesota) Munroe Regional Medical Center (Ocala, Florida) Northwest Community Hospital (Arlington Heights, Illinois) Oklahoma Heart Hospital (Oklahoma City, Oklahoma) Parma Community General Hospital (Parma, Ohio) Providence Regional Medical Center Everett (Everett, Washington) Saint Joseph-London (London, Kentucky) Southwest General Health Center (Middleburg Heights, Ohio) St. Vincent Heart Center of Indiana (Indianapolis, Indiana) St. Joseph Medical Center (Towson, Maryland) The Indiana Heart Hospital (Indianapolis, Indiana) Thomas Hospital (Fairhope, Alabama) Trinity Regional Medical Center (Fort Dodge, Iowa) Tucson Heart Hospital (Tucson, Arizona) Venice Regional Medical Center (Venice, Florida) Western Baptist Hospital (Paducah, Kentucky)

Center for Healthcare Improvement, Thomson Reuters Healthcare, 777 East Eisenhower Parkway, Ann Arbor, MI 48108. (734) 913-3000. (www.top100hospitals.com)
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63 TOP HEALTHCARE SYSTEMS
Thomson Reuters Healthcare evaluated 252 healthcare systems on measures of clinical quality and efficiency. The list of top-rated healthcare systems, which was published in the August 11, 2009 issue of Modern Healthcare, is as follows:
10 BEST-PERFORMING HEALTHCARE SYSTEMS Advocate Health Care (Oak Brook, Illinois) Catholic Healthcare Partners (Cincinnati, Ohio) Health Alliance of Greater Cincinnati (Cincinnati, Ohio) HealthEast Care System (St. Paul, Minnesota) Henry Ford Health System (Detroit, Michigan) Kettering Health Network (Dayton, Ohio) OhioHealth (Columbus, Ohio) Prime Healthcare Services (Victorville, California) Trinity Health (Novi, Michigan) University Hospitals (Cleveland, Ohio)
50 BEST-PERFORMING HEALTHCARE SYSTEMS In addition to the 10 healthcare systems listed above, the following were ranked among the top 50 in clinical quality and efficiency: Affinity Health System (Menasha, Wisconsin) Alexian Bros. Health System (Arlington
Heights, Illinois) Allina Health System (Minneapolis, Minnesota) Ascension Health (St. Louis, Missouri) Aurora Health Care (Milwaukee, Wisconsin) Avera Health (Sioux City, South Dakota) Baptist Health System of East Tennessee (Knoxville, Tennessee) BayCare Health System (Clearwater, Florida) Beaumont Hospitals (Royal Oak, Michigan) Cascade Healthcare Community (Bend, Oregon) Catholic Health Initiative (Denver, Colorado) Centegra Health System (Crystal Lake, Illinois) Clarian Health (Indianapolis, Indiana) Cleveland Clinic (Cleveland, Ohio) Community Health Network (Indianapolis, Indiana) Community Healthcare System (Hammond, Indiana) Detroit Medical Center (Detroit, Michigan) East Regional Hospitals of the Cleveland Clinic Health System (Independence, Ohio) Exempla Healthcare (Denver, Colorado) Fairview Health Services (Minneapolis, Minnesota) Genesis Health System (Davenport, Iowa) Gutherie Healthcare System (Sayre, Pennsylvania) Iowa Health System (Des Moines, Iowa) Maury Regional Healthcare System (Columbia, Tennessee) Mayo Foundation (Rochester, Minneapolis)
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McLaren Health Care Corp. (Flint, Michigan) MedStar Health (Columbia, Maryland) Memorial Health Services (Long Beach, California) MidMichigan Health (Midland, Michigan) Oakwood Healthcare (Dearborn, Michigan) PeaceHealth (Bellevue, Washington) Premier Health Partners (Dayton, Ohio) Provena Health (Mokena, Illinois) Resurrection Health Care (Chicago, Illinois) Spectrum Health (Grand Rapids, Michigan) SSM Health Care (St. Louis, Missouri) SMDC Health System (Duluth, Minnesota) University of Pittsburgh Medical Center (Pittsburgh, Pennsylvania) Via Christi Health System (Wichita, Kansas) Wheaton Franciscan Healthcare of Southeast Wisconsin (Glendale, Wisconsin)

Center for Healthcare Improvement, Thomson Reuters Healthcare, 777 East Eisenhower Parkway, Ann Arbor, MI 48108. (734) 913-3000. (www.top100hospitals.com) Wilson, Linda, A Systematic Approach, Modern Healthcare, April 11, 2009.
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TOP-RANKED CHILDRENS HOSPITALS
U.S. News & World Reports has annually ranks the best U.S. childrens hospitals by specialty. The 2009 assessment analyzed data on 160 childrens medical centers in 10 specialty fields. The annual assessment considers reputation, outcomes, and carerelated indicators. By category, this chapter presents the topranked childrens hospitals in 2009.
6.
UCSF Childrens Hospital (San Francisco) 7. New York-Presbyterian Morgan Stanley-Komansky Childrens Hospital 8. Childrens Hospital of Pittsburgh of UPMC 9. Texas Childrens Hospital (Houston) 10. Childrens Hospital (Denver)
DIGESTIVE DISORDERS CANCER

1. 2. 3. Childrens Hospital of Philadelphia Childrens Hospital Boston St. Jude Childrens Research Hospital (Memphis) 4. Texas Childrens Hospital (Houston) 5. Cincinnati Childrens Hospital Medical Center 6. Seattle Childrens Hospital 7. Memorial Sloan-Kettering Cancer Center (New York City) 8. Childrens Hospital Los Angeles 9. Johns Hopkins Childrens Center (Baltimore) 10. Childrens Hospital (Denver) 1. Cincinnati Childrens Hospital Medical Center 2. Childrens Hospital of Philadelphia 3. Childrens Hospital Boston 4. Texas Childrens Hospital (Houston) 5. Childrens Hospital, Denver 6. Childrens Hospital of Pittsburgh of UPMC 7. Nationwide Childrens Hospital (Columbus, Ohio) 8. Mattel Childrens Hospital UCLA (Los Angeles) 9. Childrens Hospital of Wisconsin (Milwaukee) 10. Johns Hopkins Childrens Center (Baltimore)
DIABETES & ENDOCRINE DISORDERS

1. 2. 3. 4. 5. Childrens Hospital of Philadelphia Childrens Hospital Boston Johns Hopkins Childrens Center (Baltimore) Cincinnati Childrens Hospital Medical Center Childrens Hospital Los Angeles
HEART & HEART SURGERY

1. 2. 3. 4. 5. Childrens Hospital Boston Childrens Hospital of Philadelphia Texas Childrens Hospital (Houston) University of Michigan C.S. Mott Childrens Hospital (Ann Arbor) Lucile Packard Childrens Hospital at Stanford (Palo Alto, California)
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6.
New York-Presbyterian Morgan Stanley-Komansky Childrens Hospital 7. Childrens Healthcare of Atlanta 8. Childrens Hospital of Wisconsin (Milwaukee) 9. Cincinnati Childrens Hospital Medical Center 10. Childrens Hospital Los Angeles
NEUROLOGY & NEUROSURGERY

1. 2. 3. Childrens Hospital Boston Childrens Hospital of Philadelphia Johns Hopkins Childrens Center (Baltimore) 4. Childrens Hospital Cleveland Clinic 5. Texas Childrens Hospital (Houston) 6. St. Louis Childrens HospitalWashington University 7. New York-Presbyterian Morgan Stanley-Komansky Childrens Hospital 8. Cincinnati Childrens Hospital Medical Center 9. Seattle Childrens Hospital 10. Mayo Eugenio Litta Childrens Hospital (Rochester, Minnesota)
KIDNEY DISORDERS
1. 2. 3. Texas Childrens Hospital (Houston) Childrens Hospital of Philadelphia Mattel Childrens Hospital UCLA (Los Angeles) 4. Seattle Childrens Hospital 5. Childrens Hospital Boston 6. Massachusetts General Hospital for Children (Boston) 7. Johns Hopkins Childrens Center (Baltimore) 8. UCSF Childrens Hospital (San Francisco) 9. Childrens Hospital Los Angeles 10. Holtz Childrens Hospital at UMJackson Memorial Hospital (Miami)
ORTHOPEDICS
1. 2. Childrens Hospital Boston Childrens Medical Center-Texas Scottish Rite Hospital for Children (Dallas) 3. Childrens Hospital of Philadelphia 4. Rady Childrens Hospital (San Diego, California) 5. Childrens Healthcare of Atlanta 6. Cincinnati Childrens Hospital Medical Center 7. Childrens Hospital Los Angeles 8. Childrens Hospital, Denver 9. St. Louis Childrens HospitalWashington University 10. Johns Hopkins Childrens Center (Baltimore)
NEONATAL CARE
1. 2. Childrens Hospital of Philadelphia Rainbow Babies and Childrens Hospital (Cleveland) 3. Childrens Hospital Boston 4. Cincinnati Childrens Hospital Medical Center 5. Lucile Packard Childrens Hospital at Stanford (Palo Alto, California) 6. New York-Presbyterian Morgan Stanley-Komansky Childrens Hospital 7. Texas Childrens Hospital (Houston) 8. Childrens Hospital, Denver 9. Johns Hopkins Childrens Center (Baltimore) 10. Childrens National Medical Center (Washington, DC)
RESPIRATORY DISORDERS
1. 2. 3. 4. 5. Childrens Hospital of Philadelphia Texas Childrens Hospital (Houston) Cincinnati Childrens Hospital Medical Center Childrens Hospital Boston Childrens Hospital, Denver
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6.
Johns Hopkins Childrens Center (Baltimore) 7. Childrens Hospital of Pittsburgh of UPMC 8. St. Louis Childrens HospitalWashington University 9. Seattle Childrens Hospital 10. Rainbow Babies and Childrens Hospital (Cleveland)
UROLOGY
1. 2. 3. Childrens Hospital of Philadelphia Childrens Hospital Boston Riley Hospital for Children Clarion Health Partners (Indianapolis) 4. Johns Hopkins Childrens Center (Baltimore) 5. Cincinnati Childrens Hospital Medical Center 6. Monroe Carell Jr. Childrens Hospital at Vanderbilt (Nashville) 7. Childrens Memorial Hospital (Chicago) 8. Seattle Childrens Hospital 9. Texas Childrens Hospital (Houston) 10. Childrens Medical Center (Dallas)

Comarow, Avery, Americas Best Childrens Hospitals, U.S. News & World Report, August 2009, pp 84-112. (http://health.usnews.com/health/best-hospi tals/childrens-hospitals)
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TOP-RANKED HOSPITALS
Since 1989, U.S. News & World Reports has ranked the best U.S. hospitals by specialty annually, from cancer and heart disease to respiratory disorders and urology. The 2009 assessment analyzed data on 4,861 medical centers in 16 specialty fields. The assessment considered affiliation with a medical school, availability of key technologies such as robotic surgery, and performance of a minimum number of specified procedures on Medicare inpatients, reputation, death rate, and care-related factors such as nursing and patient services. By category, this chapter presents the topranked specialty hospitals in 2009.
13. Vanderbilt University Medical Center (Nashville) 14. Hospital of the University of Pennsylvania (Philadelphia) 15. Brigham and Womens Hospital (Boston) 16. H. Lee Moffitt Cancer Center (Tampa) 17. University of Chicago Medical Center 18. Ohio State University James Cancer Hospital (Columbus) 19. University of Michigan Hospitals and Health Centers (Ann Arbor) 20. Fox Chase Cancer Center (Philadelphia)
CANCER
1. University of Texas M.D. Anderson Cancer Center (Houston) 2. Memorial Sloan-Kettering Cancer Center (New York) 3. Johns Hopkins Hospital (Baltimore) 4. Mayo Clinic (Rochester (Minnesota) 5. Dana-Farber Cancer Institute (Boston) 6. University of Washington Medical Center (Seattle) 7. Massachusetts General Hospital (Boston) 8. University of California, San Francisco Medical Center 9. Duke University Medical Center (Durham (North Carolina) 10. Stanford Hospital and Clinics (Stanford (California) 11. Ronald Reagan UCLA Medical Center (Los Angeles) 12. Cleveland Clinic
DIABETES & ENDOCRINE DISORDERS

1. 2. Mayo Clinic (Rochester, Minnesota) Massachusetts General Hospital (Boston) 3. Johns Hopkins Hospital (Baltimore) 4. University of California, San Francisco Medical Center 5. New York-Presbyterian University Hospital of Columbia and Cornell 6. Cleveland Clinic 7. Brigham and Womens Hospital (Boston) 8. Ronald Reagan UCLA Medical Center (Los Angeles) 9. Yale-New Haven Hospital (New Haven, Connecticut) 10. Hospital of the University of Pennsylvania (Philadelphia) 11. Barnes-Jewish Hospital/Washington University (St. Louis) 12. University of Virginia Medical Center (Charlottesville)
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13. Joslin Clinic and Beth Israel Deaconess Medical Center (Boston) 14. University of Chicago Medical Center 15. Vanderbilt University Medical Center (Nashville) 16. Washington Hospital Center (Washington, DC) 17. University of Michigan Hospitals and Health Centers (Ann Arbor) 18. Beaumont Hospital (Royal Oak, Michigan) 19. Cedars-Sinai Medical Center (Los Angeles) 20. University of Washington Medical Center (Seattle)
Center 19. Beth Israel Deaconess Medical Center (Boston) 20. Medical University of South Carolina (Charleston)
EAR, NOSE & THROAT

1. 2. 3. 4. 5. Johns Hopkins Hospital (Baltimore) University of Texas M.D. Anderson Cancer Center (Houston) University of Iowa Hospitals and Clinics (Iowa City) UPMC-University of Pittsburgh Medical Center Massachusetts Eye and Ear Infirmary (Boston) Hospital of the University of Pennsylvania (Philadelphia) Mayo Clinic (Rochester, Minnesota) Ronald Reagan UCLA Medical Center (Los Angeles) Cleveland Clinic Barnes-Jewish Hospital/Washington University (St. Louis) University of Michigan Hospitals and Health Centers (Ann Arbor) University of Washington Medical Center (Seattle) Memorial Sloan-Kettering Cancer Center (New York City) Stanford Hospital and Clinics (Stanford, California) University of California, San Francisco Medical Center Vanderbilt University Medical Center (Nashville) Mount Sinai Medical Center (New York City) Ohio State University Hospital (Columbus) New York-Presbyterian University Hospital of Columbia and Cornell University of Miami (Jackson Memorial Hospital)
DIGESTIVE DISORDERS
6. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Mayo Clinic (Rochester, Minnesota) Cleveland Clinic Johns Hopkins Hospital (Baltimore) Massachusetts General Hospital (Boston) Ronald Reagan UCLA Medical Center (Los Angeles) University of Chicago Medical Center Mount Sinai Medical Center (New York City) Hospital of the University of Pennsylvania (Philadelphia) University of California, San Francisco Medical Center Cedars-Sinai Medical Center (Los Angeles) Brigham and Womens Hospital (Boston) New York-Presbyterian University Hospital of Columbia and Cornell Clarion Health (Indianapolis) University of Michigan Hospitals and Health Centers (Ann Arbor) Barnes-Jewish Hospital/Washington University (St. Louis) Methodist Hospital (Houston) Duke University Medical Center (Durham, North Carolina) UPMC-University of Pittsburgh Medical 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
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GERIATRIC CARE
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Ronald Reagan UCLA Medical Center (Los Angeles) Johns Hopkins Hospital (Baltimore) Mount Sinai Medical Center (New York City) Massachusetts General Hospital (Boston) Duke University Medical Center (Durham, North Carolina) Mayo Clinic (Rochester, Minnesota) Yale-New Haven Hospital (New Haven, Connecticut) UPMC-University of Pittsburgh Medical Center University of California, San Francisco Medical Center Cleveland Clinic Johns Hopkins Bayview Medical Center (Baltimore) New York-Presbyterian University Hospital of Columbia and Cornell Emory University Hospital (Atlanta) University of Washington Medical Center (Seattle) University of Michigan Hospitals and Health Centers (Ann Arbor) University of Alabama Hospital at Birmingham Beth Israel Deaconess Medical Center (Boston) NYU Langone Medical Center (New York City) Northwestern Memorial Hospital (Chicago) Hospital of the University of Pennsylvania (Philadelphia)
5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
University of California, San Francisco Medical Center Cleveland Clinic Magee-Womens Hospital of UPMC (Pittsburgh) New York-Presbyterian University Hospital of Columbia and Cornell Massachusetts General Hospital (Boston) Ronald Reagan UCLA Medical Center (Los Angeles) Parkland Memorial Hospital (Dallas) University of Texas M.D. Anderson Cancer Center (Houston) Memorial Sloan-Kettering Cancer Center (New York City) Stanford Hospital and Clinics (Stanford, California) University of Washington Medical Center (Seattle) Vanderbilt University Medical Center (Nashville) Hospital of the University of Pennsylvania (Philadelphia) Northwestern Memorial Hospital (Chicago) Yale-New Haven Hospital (New Haven, Connecticut) Ohio State University Hospital (Columbus)
HEART & HEART SURGERY

1. 2. 3. 4. 5. Cleveland Clinic Mayo Clinic (Rochester, Minnesota) Johns Hopkins Hospital (Baltimore) Massachusetts General Hospital (Boston) Texas Heart Institute at St. Lukes Episcopal Hospital (Houston) Brigham and Womens Hospital (Boston) New York-Presbyterian University Hospital of Columbia and Cornell Duke University Medical Center (Durham, North Carolina) Hospital of the University of
GYNECOLOGY
1. 2. 3. 4. Brigham and Womens Hospital (Boston) Johns Hopkins Hospital (Baltimore) Mayo Clinic (Rochester, Minnesota) Duke University Medical Center (Durham, North Carolina)
6. 7. 8. 9.
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Pennsylvania (Philadelphia) 10. Ronald Reagan UCLA Medical Center (Los Angeles) 11. NYU Langone Medical Center (New York City) 12. Barnes-Jewish Hospital/Washington University (St. Louis) 13. Emory University Hospital (Atlanta) 14. Stanford Hospital and Clinics (Stanford, California) 15. Cedars-Sinai Medical Center (Los Angeles) 16. University of Michigan Hospitals and Health Centers (Ann Arbor) 17. Vanderbilt University Medical Center (Nashville) 18. Mount Sinai Medical Center (New York City) 19. Methodist Hospital (Houston) 20. Washington Hospital Center (Washington, DC)
14. Hospital of the University of Pennsylvania (Philadelphia) 15. University of Colorado Hospital (Aurora) 16. University of Washington Medical Center (Seattle) 17. University of Chicago Medical Center 18. University of Michigan Hospitals and Health Centers (Ann Arbor) 19. Yale-New Haven Hospital (New Haven, Connecticut) 20. Cedars-Sinai Medical Center (Los Angeles)
NEUROLOGY & NEUROSURGERY

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Mayo Clinic (Rochester, Minnesota) Johns Hopkins Hospital (Baltimore) University of California, San Francisco Medical Center Massachusetts General Hospital (Boston) New York-Presbyterian University Hospital of Columbia and Cornell Cleveland Clinic Ronald Reagan UCLA Medical Center (Los Angeles) Barnes-Jewish Hospital/Washington University (St. Louis) St. Josephs Hospital and Medical Center (Phoenix) NYU Langone Medical Center (New York City) Northwestern Memorial Hospital (Chicago) Rush University Medical Center (Chicago) Methodist Hospital (Houston) Emory University Hospital (Atlanta) Cedars-Sinai Medical Center (Los Angeles) Mount Sinai Medical Center (New York City) UPMC-University of Pittsburgh Medical Center
KIDNEY DISORDERS
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Brigham and Womens Hospital (Boston) New York-Presbyterian University Hospital of Columbia and Cornell Mayo Clinic (Rochester, Minnesota) Massachusetts General Hospital (Boston) Cleveland Clinic Johns Hopkins Hospital (Baltimore) Ronald Reagan UCLA Medical Center (Los Angeles) Barnes-Jewish Hospital/Washington University (St. Louis) Vanderbilt University Medical Center (Nashville) University of California, San Francisco Medical Center Duke University Medical Center (Durham, North Carolina) UPMC-University of Pittsburgh Medical Center University of Alabama Hospital at Birmingham
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18. Duke University Medical Center (Durham, North Carolina) 19. University of Chicago Medical Center 20. University of Texas Southwestern Medical Center (Dallas)
4. 5. 6. 7. 8.
OPHTHALMOLOGY
1. 2. 3. 4. Bascom Palmer Eye Institute at the University of Miami Wilmer Eye Institute - Johns Hopkins Hospital (Baltimore) Wills Eye Hospital (Philadelphia) Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital (Boston) Jules Stein Eye Institute, UCLA Medical Center (Los Angeles) University of Iowa Hospitals and Clinics (Iowa City) Duke University Medical Center (Durham, North Carolina) Doheny Eye Institute (USC University Hospital (Los Angeles) Emory University Hospital (Atlanta) University of California, San Francisco Medical Center Cleveland Clinic Mayo Clinic (Rochester, Minnesota) Cullen Eye Institute (Methodist Hospital (Houston) Barnes-Jewish Hospital/Washington University (St. Louis) New York Eye and Ear Infirmary W.K. Kellogg Eye Center - University of Michigan (Ann Arbor) University of Illinois Medical Center at Chicago
9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
Cleveland Clinic Johns Hopkins Hospital (Baltimore) Duke University Medical Center (Durham, North Carolina) New York-Presbyterian University Hospital of Columbia and Cornell University of Iowa Hospitals and Clinics (Iowa City) NYU Hospital for Joint Diseases UPMC-University of Pittsburgh Medical Center Barnes-Jewish Hospital/Washington University (St. Louis) Rush University Medical Center (Chicago) Ronald Reagan UCLA Medical Center (Los Angeles) Brigham and Womens Hospital (Boston) University of Washington Medical Center (Seattle) Stanford Hospital and Clinics (Stanford, California) Thomas Jefferson University Hospital (Philadelphia) Harborview Medical Center (Seattle) University of California, San Francisco Medical Center University Hospitals Case Medical Center (Cleveland)
PSYCHIATRY
1. 2. 3. 4. Massachusetts General Hospital (Boston) Johns Hopkins Hospital (Baltimore) McLean Hospital (Belmont, Massachusetts) New York-Presbyterian University Hospital of Columbia and Cornell UCLAs Neuropsychiatric Hospital (Los Angeles) Sheppard and Enoch Pratt Hospital (Baltimore) Mayo Clinic (Rochester, Minnesota) UPMC-University of Pittsburgh Medical Center
ORTHOPEDICS
1. 2. 3. Mayo Clinic (Rochester, Minnesota) Hospital for Special Surgery (New York City) Massachusetts General Hospital (Boston)
5. 6. 7. 8.
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9. Menninger Clinic (Houston) 10. Emory University Hospital (Atlanta) 11. Yale-New Haven Hospital (New Haven, Connecticut) 12. Austen Riggs Center (Stockbridge, Massachusetts) 13. Duke University Medical Center (Durham, North Carolina) 14. Barnes-Jewish Hospital/Washington University (St. Louis) 15. Stanford Hospital and Clinics (Stanford, California) 16. Hospital of the University of Pennsylvania (Philadelphia) 17. University of California, San Francisco Medical Center 18. NYU Langone Medical Center (New York City) 19. Hartford Hospitals Institute of Living (Hartford, Connecticut) 20. University of California, San Diego Medical Center)
Center 15. MossRehab (Elkins Park, Pennsylvania) 16. Johns Hopkins Hospital (Baltimore) 17. University of Colorado Hospital (Aurora) 18. Rancho Los Amigos National Rehabilitation Center (Downey, California 19. Mount Sinai Medical Center (New York City) 20. Virginia Commonwealth University Health System (Richmond)
RESPIRATORY DISORDERS
1. 2. 3. 4. 5. 6. National Jewish Health (Denver) Mayo Clinic (Rochester, Minnesota) Johns Hopkins Hospital (Baltimore) Cleveland Clinic Massachusetts General Hospital (Boston) Duke University Medical Center (Durham, North Carolina) UPMC-University of Pittsburgh Medical Center Hospital of the University of Pennsylvania (Philadelphia) Barnes-Jewish Hospital/Washington University (St. Louis) University of California, San Francisco Medical Center New York-Presbyterian University Hospital of Columbia and Cornell University of Colorado Hospital (Aurora) Brigham and Womens Hospital (Boston) University of California, San Diego Medical Center University of Michigan Hospitals and Health Centers (Ann Arbor) University of Washington Medical Center (Seattle) Ronald Reagan UCLA Medical Center (Los Angeles) Vanderbilt University Medical Center
REHABILITATION
7. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Rehabilitation Institute of Chicago Kessler Institute for Rehabilitation (West Orange, New Jersey) University of Washington Medical Center (Seattle) TIRR Memorial Hermann (Houston) Mayo Clinic (Rochester, Minnesota) Spaulding Rehabilitation Hospital (Boston) Craig Hospital (Englewood, Colorado) NYU Rusk Institute of Rehabilitation Medicine Shepherd Center (Atlanta) Ohio State University Hospital (Columbus) Thomas Jefferson University Hospital (Philadelphia) National Rehabilitation Hospital (Washington, DC) Baylor Institute for Rehabilitation (Dallas) UPMC-University of Pittsburgh Medical 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
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(Nashville) 19. Yale-New Haven Hospital (New Haven, Connecticut) 20. Wake Forest Univ. Baptist Medical Center (Winston-Salem, North Carolina)
UROLOGY
1. 2. 3. 4. 5. Johns Hopkins Hospital (Baltimore) Cleveland Clinic Mayo Clinic (Rochester, Minnesota) Ronald Reagan UCLA Medical Center (Los Angeles) University of California, San Francisco Medical Center Duke University Medical Center (Durham, North Carolina) New York-Presbyterian University Hospital of Columbia and Cornell Memorial Sloan-Kettering Cancer Center (New York City) University of Texas M.D. Anderson Cancer Center (Houston) Vanderbilt University Medical Center (Nashville) Massachusetts General Hospital (Boston) Hospital of the University of Pennsylvania (Philadelphia) Methodist Hospital (Houston) University of Michigan Hospitals and Health Centers (Ann Arbor) University of Texas Southwestern Medical Center (Dallas) Clarion Health (Indianapolis) Stanford Hospital and Clinics (Stanford, California) University of California (Irvine Medical Center (Orange) Brigham and Womens Hospital (Boston) NYU Langone Medical Center (New York City)
RHEUMATOLOGY
6. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Johns Hopkins Hospital (Baltimore) Cleveland Clinic Hospital for Special Surgery (New York City) Mayo Clinic (Rochester, Minnesota) Ronald Reagan UCLA Medical Center (Los Angeles) Massachusetts General Hospital (Boston) Brigham and Womens Hospital (Boston) University of Alabama Hospital at Birmingham) University of California, San Francisco Medical Center UPMC-University of Pittsburgh Medical Center NYU Hospital for Joint Diseases Northwestern Memorial Hospital (Chicago) University of Michigan Hospitals and Health Centers (Ann Arbor) Stanford Hospital and Clinics (Stanford, California) Hospital of the University of Pennsylvania (Philadelphia) Medical University of South Carolina (Charleston) Duke University Medical Center (Durham, North Carolina) Barnes-Jewish Hospital/Washington University (St. Louis) University of Colorado Hospital (Aurora) New York-Presbyterian University Hospital of Columbia and Cornell 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

Comarow, Avery, Americas Best Hospitals, U.S. News & World Report, August 2009, pp 84-112. http://health. usnews.com/health/best-hospitals
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PART IV: HEALTH INSURANCE
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66
BENEFICIARY SATISFACTION
A study by researchers at Commonwealth Fund, published in Health Affairs in May 2009, found that elderly Medicare beneficiaries are more satisfied with their healthcare, and experience fewer problems accessing and paying for their healthcare, than Americans with employer-sponsored insurance (ESI). The assessment is summarized in this chapter.
problems due to cost, such as not filling a prescription or not visiting a doctor for a medical problem. Choice of Physicians Ten percent (10%) of elderly Medicare beneficiaries said their physician didnt take their insurance, compared to 17% of those with ESI and 24% of those with individual coverage. Financial Pressure Medicare beneficiaries reported fewer problems with medical bills, such as an inability to pay or being contacted by collection agencies. Fifteen percent (15%) of them reported at least one of these problems, compared to 26% of those in the employer-coverage group. Additionally, elderly Medicare beneficiaries were no more likely than those with ESI to be devoting 5% to 10% of their income or more to healthcare. Quality of Care Sixty-one percent (61%) of elderly Medicare beneficiaries said that they had received excellent or very good care, compared to just half of those with ESI. Moreover, 57% of elderly Medicare beneficiaries were confident that they could get high-quality, safe care in the future, versus 46% of those in the employer group.
OVERALL SATISFACTION: MEDICARE VS. ESI

Medicare Beneficiaries Employer Plan Members
Excellent: Very Good: Good: Fair/poor:
37% 30% 24% 8%
20% 33% 27% 18%
The favorable ratings given Medicare by beneficiaries suggest that they are fundamentally more satisfied with their coverage relative to those with employer-sponsored insurance.
Karen Davis, President Commonwealth Fund, 5/12/09
SURVEY FINDINGS
Access to Care In spite of having poorer health and lower incomes than those with ESI, elderly Medicare beneficiaries were less likely (20% versus 37%) to report access
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Commonwealth Fund, 1 East 75th Street, New York, NY 10021. (212) 606-3800 (www.commonwealthfund.org) Davis, Karen, Stuart Guterman, Michelle M. Doty, Ph.D., and Kristof M. Stremikis, Meeting Enrollees Needs: How Do Medicare and Employer Coverage Stack Up? Health Affairs, May 12, 2009.
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67
COST-CONTROL INITIATIVES
Milliman Inc. has assessed that increases in average annual family healthcare spending dropped from 9.6% in 2006 to 7.4% in 2009. Cost-control initiatives are, in large part, responsible for stemming the growth.
2009 nationwide rollout of Medicare Recovery Audit Contractor (RAC) programs with a focus on recovering payments for admissions not meeting medical necessity Focus on reducing admissions equated with poor quality, including readmissions, ambulatory-care-sensitive admissions, and preference-sensitive admissions Mandatory reporting of hospital-acquired infections in some states Adoption of Medicare payment policy by commercial payers to not pay for never events (hospital-preventable errors) Growing use of hospitalists to improve inpatient throughput
Heightened federal, state, commercial payer, and business community initiatives are focusing on inpatient efficiency and quality. More pervasive adaption of prevention, wellness, and disease management programs intended to improve the health of individuals is apparent. This has been coupled with more aggressive utilization management of outpatient services and use of patient decision-support programs aimed at reducing the supply of medically unnecessary services. Enhanced pharmacy-management techniques are becoming the norm. Last, there is a resurgence of provider organization risk contracting and a movement to establish non-risk-bearing accountable care organizations.
2009 Milliman Medical Index
OUTPATIENT COST-CONTROL INITIATIVES

Medical home model primary-care delivery intended to coordinate care, reduce unnecessary specialist care, and reduce duplication of diagnostics and treatments Wellness programs that provide financial incentive for behavior changes and clinical outcomes Increased adoption of radiological benefit management Increased focus on conducting and utilizing comparative effectiveness
INPATIENT COST-CONTROL INITIATIVES

Renewed focus on inpatient utilization review by commercial payers to identify medically unnecessary hospital stays and days spent in hospitals
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research to evaluate treatment options Patient decision-support education programs to foster shared patient/ physician treatment decision making
PHARMACEUTICAL COSTCONTROL INITIATIVES

More aggressive pharmacy benefit management, including programs that employ step edits, therapeutic substitution, dose optimization, prior authorization, day supply limits, refill-toosoon supply limits, and promotion of generics Medicare Part D requirement to provide medication management therapy program Targeted value-based insurance designs (VBID) that reduce copays for compliant patients, not across-the-board copay reductions

2009 Milliman Medical Index, Milliman Inc., May 2009. (www.milliman.com/expertise/ healthcare/publications/mmi/pdfs/millimanmedical-index-2009.pdf) Milliman Inc., 1301 Fifth Avenue, Suite 3800, Seattle, WA 98101. (206) 624-7940. (www.milliman.com)
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68
EMPLOYER-SPONSORED HEALTH INSURANCE PREMIUMS
In 2008, approximately 161 million Americans were covered by employer-sponsored health insurance.
OUT-OF-POCKET SPENDING BY EMPLOYEES WITH EMPLOYERSPONSORED HEALTH PLANS

According to a June 2009 report by The Commonwealth Fund, adults with employer coverage face an average of $729 annually in out-of-pocket costs for medical services, including deductibles and other forms of cost sharing such as copayments and coinsurance.
PREMIUMS FOR FAMILIES AND INDIVIDUALS

According to an August 2009 report by The Commonwealth Fund, premiums for employer-sponsored health insurance averaged $12,298 for families and $4,386 for individuals. Nationally, family premiums for employersponsored health insurance increased 119% between 1999 and 2008. Between 2003 and 2008, the increase was 33% for families and 26% for individuals. Employer-based premiums for family coverage ranged from a high of 45% in Indiana and North Carolina to a low of 25% in Michigan, Texas, and Ohio. In 2008, average family premium costs were highest in Indiana, Massachusetts, Minnesota, and New Hampshire, at more than $13,500. Idaho, Iowa, and Hawaii had the lowest average family premiums, around $11,000. By state, premiums and five-year increases (2003-to-2008) are presented in Table 68.1.

Schoen, Cathy, Jennifer L. Nicholson, and Sheila D. Rustgi, Paying the Price: How Health Insurance Premiums Are Eating Up Middle-Class Incomes, The Commonwealth Fund, August 2009. Gabel, Jon R., Roland McDevitt, Ryan Lore, Jeremy Pickreign, Heidi Whitmore and Tina Ding, Trends In Underinsurance And The Affordability Of Employer Coverage, Health Affairs, June 2, 2009. The Commonwealth Fund, 1 East 75th Street, New York, NY 10021. (212) 6063800 (www.commonwealthfund.org)
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TABLE 68.1 Single and Family Average Health Insurance Premium, by State, in 2008 and Five-Year Increases
Premium Single Family Increase Single Family
Alabama: Alaska: Arizona: Arkansas: California: Colorado: Connecticut: Delaware: District of Columbia: Florida: Georgia: Hawaii: Idaho: Illinois: Indiana: Iowa: Kansas: Kentucky: Louisiana: Maine: Maryland: Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania:
$4,139 $5,293 $4,214 $3,923 $4,280 $4,303 $4,740 $4,733 $4,890 $4,517 $4,160 $3,831 $4,104 $4,643 $4,495 $4,146 $4,197 $4,009 $4,055 $4,910 $4,360 $4,836 $4,388 $4,432 $4,124 $4,124 $4,355 $4,392 $3,927 $5,247 $4,798 $4,074 $4,638 $4,460 $3,830 $4,089 $4,072 $4,384 $4,499
$11,119 $13,383 $12,292 $11,220 $12,254 $11,952 $13,436 $13,386 $13,427 $12,697 $11,659 $11,044 $10,837 $12,603 $13,504 $10,947 $11,662 $11,506 $11,207 $13,102 $12,541 $13,788 $11,321 $13,639 $11,363 $11,557 $11,438 $11,648 $11,487 $13,592 $12,789 $12,071 $12,824 $12,308 $11,178 $11,425 $11,053 $12,585 $12,339
31% 32% 31% 25% 30% 18% 29% 23% 31% 26% 15% 27% 23% 26% 29% 27% 23% 17% 22% 27% 27% 38% 20% 20% 25% 25% 24% 25% 10% 47% 26% 21% 29% 31% 28% 20% 24% 30% 30%
38% 27% 37% 41% 35% 26% 33% 27% 25% 36% 35% 40% 27% 30% 45% 30% 31% 26% 28% 27% 36% 40% 20% 35% 41% 29% 34% 27% 30% 39% 26% 30% 36% 45% 42% 25% 26% 42% 35%
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TABLE 68.1 (cont)
Premium Single Family
Increase Single Family
Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:
$4,930 $4,477 $4,233 $4,276 $4,205 $4,197 $4,900 $4,202 $4,404 $4,892 $4,777 $4,622
$13,363 $12,068 $11,382 $12,302 $11,967 $11,783 $13,091 $11,935 $13,036 $12,887 $12,956 $12,734
32% 33% 26% 19% 24% 25% 36% 26% 25% 28% 27% 25%
41% 35% 34% 33% 25% 41% 38% 30% 42% 41% 35% 32%
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INDIVIDUAL INSURANCE
According to The Henry J. Kaiser Family Foundation, 18 million people are covered through private individual heath insurance; they make up about 5% of the total health benefits market nationwide.
ADULTS WITH INDIVIDUAL INSURANCE

Among adults with individual insurance coverage, employment status is as follows: Unemployed: 36% Working for firms with >20 employees: 28% Self-employed: 22% Working for firms with <20 employees: 13%
Source: The Commonwealth Fund
amount their insurance will pay for healthcare (49%); doctors charging more than insurance will pay and being forced to pay the difference (39%); and expensive bills that their insurance will not cover (36%). In addition, 41% of individually insured adults reported forgoing needed healthcare because of costs, an increase from 24% who did so in 2001. Over one-third of those with individual coverage (36%) also reported medical bill or debt problems.
OUT-OF-POCKET SPENDING
A recent study by the California HealthCare Foundation found that a consumer with individual coverage pays almost three times more in out-of-pocket expenses than a consumer with small-group coverage. Among patients with chronic conditions, the following is a cost comparison of average outof-pocket expenses for small group vs. individual coverage:
Group Individual
COVERAGE CHALLENGES
According to a July 2009 study by The Commonwealth Fund, 73% of adults who tried to buy insurance on their own in the last three years did not purchase a policy, primarily because premiums were too high. More than half (57%) said it was very difficult or impossible to find coverage they could afford, 47% said it was very difficult or impossible to find a plan with the coverage they needed, and 36% were denied coverage or charged more because of a pre-existing condition, or had the condition excluded from their coverage. Those who are able to purchase individual health insurance are more likely to see limited coverage, including going without prescription drug coverage (20%); limits on the total dollar
Asthma: Cancer: Chronic obstructive pulmonary disease: Diabetes: Hypertension:
$ 886 $1,010 $ 859 $1,100 $ 933
$2,607 $2,951 $2,528 $3,275 $2,759
MARKET OPPORTUNITIES
Recent declines in the proportion of people with employer-sponsored insurance and a sizeable population of younger, healthier people who are forgoing insurance have prompted insurers to recognize the growth
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potential of the individual market.
The Henry J. Kaiser Family Foundation, 2400 Sand Hill Road, Menlo Park, CA 94025. (650) 854-9400. (www.kff.org)
Insurers are pursuing strategies to tap the growth potential of the individual health insurance market, including entering less-regulated markets and developing lower-cost, less-comprehensive products targeting younger, healthy consumers.
Center For Studying Health System Change, 11/5/09

California HealthCare Foundation, 1438 Webster Street, Suite 400, Oakland, CA 94612. (510) 238-1040. (www.chcf.org) Center for Studying Health System Change, 600 Maryland Avenue SW, Suite 550, Washington, DC 20024. (202) 484-5261. (www.hschange.com) Commonwealth Fund, 1 East 75th Street, New York, NY 10021. (212) 606-3800 (www.commonwealthfund.org) M. M. Doty, S. R. Collins, J. L. Nicholson, and S. D. Rustgi, Failure to Protect: Why the Individual Insurance Market Is Not a Viable Option for Most U.S. Families, Commonwealth Fund, July 2009. November, Elizabeth A., Genna R. Cohen, Paul B. Ginsburg, and Brian C. Quinn, Individual Insurance: Health Insurers Try to Tap Potential Market Growth, Center For Studying Health System Change, November 2009.
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70 LARGEST HEALTH INSURERS
According to TheStreet.com Ratings and Modern Healthcare, the 25 largest health insurance groups, listed in Table 70.1, had $363.6 billion in combined revenue in 2008, garnering 66% share of the U.S. health insurance market.

Largest Health Insurers, Modern Healthcare, June 1, 2009, p. 32. TheStreet.com Ratings, 15430 Endeavour Drive, Jupiter, FL 33478. (800) 289-9222. (www.thestreetratings.com)
TABLE 70.1 Largest Health Insurance Groups UnitedHealth Group (www.unitedhealthgroup.com): WellPoint (www.wellpoint.com): Kaiser Foundation (www.kaiserpermanente.org): Aetna (www.aetna.com): Humana (www.humana.com): Health Care Service Corp. (www.hcsc.com): American Family Corp. (www.aflac.com): Health Net (www.healthnet.com): Highmark (www.highmark.com): Cigna Group (www.cigna.com): Coventry Health Care (www.cvty.com): Independence Blue Cross (www.ibx.com): Blue Cross and Blue Shield of Michigan (www.bcbsm.com): Blue Shield of California (www.blueshieldca.com): Blue Cross and Blue Shield of Florida (www.bcbsfl.com): Horizon Healthcare Services (www.horison-healthcare.com): CareFirst Blue Cross and Blue Shield (www.carefirst.com): Regence Group (www.regence.com): Blue Cross and Blue Shield of Massachusetts (www.bcbsma.com): American International Group (www.aigcorporate.com): MetLife (www.metlife.com): HIP Health Plan (www.hipusa.com): Lifetime Healthcare Cos. (www.lifethc.com): Blue Cross and Blue Shield of North Carolina (www.bcbsnc.com): Universal American Corp. (www.universalamerican.com): $69.56 billion $56.79 billion $46.90 billion $25.45 billion $24.60 billion $16.62 billion $13.39 billion $13.37 billion $11.09 billion $10.35 billion $10.28 billion $10.02 billion $ 9.04 billion $ 8.80 billion $ 7.76 billion $ 7.59 billion $ 6.82 billion $ 6.71 billion $ 6.67 billion $ 6.41 billion $ 5.74 billion $ 5.58 billion $ 5.12 billion $ 4.71 billion $ 4.25 billion
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71 MEDICAL SPENDING FOR PPO-COVERED FAMILIES
Since 2005, Milliman Inc. has measured average annual medical spending for a typical American family of four covered by an employer-sponsored preferred provider organization (PPO) program. The Milliman assessment, which refers to annual spending as the Milliman Medical Index (MMI), looks at various components of spending, including cost changes for employers and employees. Medical spending figures for 14 metropolitan areas show that medical costs vary widely by region.
AVERAGE ANNUAL MEDICAL SPENDING

Average medical spending for a family of four has been as follows (increase from the previous year in parenthesis): 2005: $12,214 (9.1%) 2006: $13,382 (9.6%) 2007: $14,500 (8.4%) 2008: $15,609 (7.6%) 2009: $16,771 (7.4%)
The current economic environment has significant implications for healthcare costs. The consequences of employers lost business, consumer insecurity, and provider revenue pressures affect healthcare utilization, charges for healthcare services, and who pays for the healthcare. The unprecedented uncertainty has accelerated cost increases in some ways and at the same time has reduced certain categories of utilization (e.g., elective procedures).
2009 Milliman Medical Index
COMPONENTS OF SPENDING
The distribution of the $16,771 medical costs paid by and on behalf of the typical American family in 2009 was as follows: Physician: $5,760 Inpatient: $5,088 Outpatient: $2,772 Pharmacy: $2,484 Other: $ 667
GEOGRAPHIC VARIATIONS
The 2009 MMIs for 14 metropolitan areas were as follows: Miami: $20,282 New York City: $19,684 Chicago: $19,008 Boston: $18,119 Memphis: $17,734 Washington, DC: $17,453 Minneapolis: $17,374
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Philadelphia: Los Angeles: Dallas: Denver: Atlanta: Seattle: Phoenix:
$17,292 $16,965 $16,849 $16,517 $15,979 $15,564 $15,857
EMPLOYEE SHARE OF SPENDING

The distribution of employer and employee spending for healthcare in 2009 was as follows: Employer contribution: $9,947 Employee contribution: $4,004 Employee out-of-pocket: $2,820

2009 Milliman Medical Index, Milliman Inc., May 2009. (www.milliman.com/expertise/ healthcare/publications/mmi/pdfs/millimanmedical-index-2009.pdf) Milliman Inc., 1301 Fifth Avenue, Suite 3800, Seattle, WA 98101. (206) 624-7940. (www.milliman.com)
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MEDICARE & MEDICAID
MEDICARE OVERVIEW
Created in 1955, Medicare provides health insurance coverage to people who are aged 65 and over and to those who meet other special criteria. Medicare is funded entirely at the federal level. In general, individuals are eligible for Medicare if (1) they are a U.S. citizens or have been a permanent legal residents for 5 continuous years and are 65 years or older, (2) they are under 65, disabled, and have been receiving either Social Security benefits or the Railroad Retirement Board disability benefits for at least 24 months from date of entitlement (first disability payment), (3) they get continuing dialysis for end stage renal disease or need a kidney transplant, or (4) they are eligible for Social Security Disability Insurance and have amyotrophic lateral sclerosis (ALS-Lou Gehrigs disease). All Medicare benefits are subject to medical necessity. The Medicare program has four parts, which are as follows: Part A covers hospital stays (including stays in a skilled-nursing facility) if certain criteria are met. Part B helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred. Part B coverage includes physician and nursing services, xrays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs f or organ transplant recipients,
chemotherapy, hormonal treatments such as lupron, and other outpatient medical treatments administered in a doctors office. In 1997, Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans, instead of through the original Medicare plan (Parts A and B). These programs are known as Medicare+Choice or Part C plans. Medicare Part D, prescription drug coverage, went into effect in January 2006 following passage of the Medicare Prescription Drug, Improvement, and Modernization Act. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). Unlike Parts A and B, Part D coverage is not standardized. Providers choose which drugs or classes of drugs they wish to cover and at what level they wish to provide coverage.
STATE-BY-STATE MEDICARE SPENDING The 2009 Dartmouth Atlas of Health Care reported Medicare reimbursements per enrollee as follows:
Part A Part B
Alabama: Alaska: Arizona: Arkansas: California:
$4356.83 $4511.94 $4273.44 $4166.92 $4898.02
$3476.79 $3202.47 $3566.84 $3304.12 $4000.86
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Colorado: Connecticut: Delaware: Florida: Georgia: Hawaii: Idaho: Illinois: Indiana: Iowa: Kansas: Kentucky: Louisiana: Maine: Maryland: Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia:
$4016.09 $5081.77 $4105.62 $4401.57 $3996.33 $2732.17 $3362.87 $4816.96 $4295.92 $3545.48 $4070.27 $4721.78 $5142.93 $3763.34 $5120.97 $5451.40 $4728.67 $3711.57 $4442.31 $4332.63 $3358.03 $3663.53 $4784.25 $4380.93 $5328.46 $3630.68 $5380.05 $4138.12 $3105.45 $4692.48 $4868.77 $3294.91 $4619.61 $4939.91 $4185.99 $3275.65 $4541.01 $4875.75 $3648.03 $4046.71 $3603.60 $3834.55 $4548.11
$3479.15 $3885.55 $3539.22 $4978.33 $3454.22 $2574.64 $3045.60 $3637.81 $3402.40 $3026.89 $3350.07 $3543.54 $4257.73 $3188.06 $3862.90 $3920.09 $4056.99 $2889.31 $3413.05 $3377.21 $2980.35 $3259.81 $3930.33 $3434.42 $4220.23 $3168.85 $4180.67 $3354.44 $3006.30 $3555.90 $3777.40 $2826.46 $3591.88 $3603.57 $3422.17 $2977.43 $3610.02 $4480.19 $3209.48 $3238.61 $3252.77 $3275.06 $3288.83
MEDICAID OVERVIEW
Created in 1965, Medicaid is the health program for individuals and families with low income and resources, based on eligibility. Jointly funded by states and the federal government, it is managed by the states. Among the groups of people served by Medicaid are low-income people with dependents, seniors, and people with disabilities. Being poor, or even very poor, does not necessarily qualify an individual for Medicaid. It is estimated that approximately 60% of Americans classified as poor are not covered by Medicaid. Medicaid is the largest source of funding for medical and healthrelated services for people with limited income in the United States. With the aging population, the fastest growing aspect of Medicaid is nursing home coverage.
STATE-BY-STATE MEDICAID SPENDING Health Care State Rankings 2009, based on data from the National Association of State Budget Officers, estimates reimbursements per Medicaid enrollee as follows: Alabama: $ 928 Alaska: $1,766 Arizona: $1,044 Arkansas: $1,251 California: $ 997 Colorado: $ 556 Connecticut: $1,229 Delaware: $1,213 Florida: $ 814 Georgia: $ 799 Hawaii: $ 901 Idaho: $ 793 Illinois: $1,082 Indiana: $ 824 Iowa: $ 910 Kansas: $ 849 Kentucky: $1,133 Louisiana: $1,362
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Maine: Maryland: Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming: National average:
$1,824 $ 986 $1,269 $1,014 $1,239 $1,075 $1,291 $ 813 $ 964 $ 449 $ 950 $1,025 $1,497 $1,593 $1,192 $ 868 $1,227 $1,020 $ 889 $1,454 $1,732 $1,099 $ 892 $1,225 $ 912 $ 586 $1,532 $ 688 $ 914 $1,306 $ 874 $ 946 $1,059
Morgan, Kathleen OLeary and Scott Morgan, Health Care State Rankings 2009, CQ Press, 2009. National Association of State Budget Officers, 444 North Capital Street NW, Suite 642, Washington, DC 20001. (202) 624-5382. (www.nasbo.org)

Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244. (410) 786-3000. (www.cms.gov) The 2009 Dartmouth Atlas of Health Care, The Dartmouth Institute for Health Policy and Clinical Practice. (www.dartmouthatlas.org)
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73 STATE CHILDRENS HEALTH INSURANCE PROGRAM
Created in 1997, the State Childrens Health Insurance Program (SCHIP) provides matching funds to states for health insurance to families with children. The program is intended to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid. States are given flexibility in designing their SCHIP eligibility requirements and policies within broad federal guidelines. In spite of SCHIP, the number of children with no health insurance has continued to rise, particularly among families that cannot qualify for SCHIP. In February 2009, President Barack Obama signed legislation expanding the program to an additional four million children and pregnant women. Approximately 7.2 million children 9.7% of children ages 17 and younger are enrolled in SCHIP. Annual spending is $6 billion.
STATE-BY-STATE
SCHIP ENROLLMENT & SPENDING Health Care State Rankings 2009, based on data from the Centers for Medicare and Medicaid Services, provides the SCHIP enrollment and spending statistics presented in Table 73.1.

Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244. (410) 786-3000. (www.cms.gov) Morgan, Kathleen OLeary and Scott Morgan, Health Care State Rankings 2009, CQ Press, 2009.
TABLE 73.1 SCHIP Enrollment and Spending

Enrollment % of Children Spending
Alabama: Alaska: Arizona: Arkansas: California: Colorado:
107,000 18,000 104,000 90,000 1.54 million 85,000
9.5% 9.6% 6.2% 12.8% 16.4% 7.1%
$ 95.2 million $ 16.2 million $117.7 million $ 68.8 million $980.7 million $ 65.9 million
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TABLE 73.1 (cont)

Enrollment % of Children Spending
Connecticut: Delaware: Florida: Georgia: Hawaii: Idaho: Illinois: Indiana: Iowa: Kansas: Kentucky: Louisiana: Maine: Maryland: Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:
24,000 11,000 324,000 356,000 24,000 33,000 346,000 130,000 50,000 50,000 69,000 154,000 31,000 133,000 184,000 114,000 5,000 82,000 82,000 20,000 46,000 42,000 12,000 150,000 17,000 652,000 240,000 5,000 232,000 117,000 63,000 227,000 26,000 60,000 15,000 41,000 711,000 45,000 6,000 144,000 15,000 39,000 63,000 9,000
2.9% 5.4% 8.0% 14.1% 8.4% 8.1% 10.8% 8.2% 7.1% 7.1% 6.6% 14.2% 11.1% 9.8% 12.9% 4.7% 0.4% 10.6% 5.7% 9.2% 10.4% 6.3% 4.1% 7.3% 3.3% 14.8% 10.8% 3.8% 8.4% 13.0% 7.3% 8.2% 11.2% 5.7% 7.6% 2.8% 10.7% 5.5% 4.7% 7.9% 1.0% 10.0% 4.7% 6.8%
$ 30.1 million $ 8.6 million $261.7 million $318.7 million $ 28.1 million $ 27.4 million $448.5 million $ 92.1 million $ 51.3 million $ 45.1 million $ 81.2 million $119.9 million $ 31.2 million $138.4 million $211.5 million $171.6 million $ 64.4 million $107.5 million $ 79.4 million $ 18.2 million $ 33.2 million $ 30.3 million $ 11.1 million $280.0 million $ 49.9 million $324.4 million $166.6 million $ 10.5 million $186.9 million $ 96.4 million $ 66.6 million $190.0 million $ 47.7 million $ 31.4 million $ 9.8 million $ 4.1 million $385.7 million $ 38.9 million $ 5.9 million $110.7 million $ 36.8 million $ 35.4 million $ 84.5 million $ 7.8 million
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TOP-RANKED HEALTH INSURANCE PLANS
Annually, U.S. News & World Report ranks health insurance plans based on member satisfaction, prevention and treatment, and accreditation by the National Committee for Quality Assurance. This chapter presents the top-ranked health insurance plans in 2009.
COMMERCIAL PLANS
1. 2. 3. Harvard Pilgrim Health Care (HMO/POS/Maine and Massachusetts) Harvard Pilgrim Health Care of New England (HMO/POS; New Hampshire) Tufts Associated Health Maintenance Organization (HMO/POS; Massachusetts, New Hampshire, and Rhode Island) Grand Valley Health Plan (HMO; Michigan) Capital Health Plan (HMO; Florida) Geisinger Health Plan (HMO/POS; Pennsylvania) Fallon Community Health Plan (HMO/POS; Massachusetts) Health New England (HMO/POS; Connecticut and Massachusetts) CIGNA HealthCare of New Hampshire (HMO/POS) Group Health Cooperative of South Central Wisconsin (HMO) Health Net of Connecticut (HMO/POS) Blue Cross and Blue Shield of Massachusetts (HMO/POS; Massachusetts) Kaiser Foundation Health Plan of Colorado (HMO)
14. CDPHP Universal Benefits (POS; New York) 15. Capital District Physicians Health Plan (HMO/POS; New York) 16. Anthem Blue Cross and Blue Shield (HMO/POS; Maine) 17. HealthAmerica Pennsylvania (HMO/POS; Pennsylvania) 18. Health Alliance Medical Plans (HMO/POS; Illinois, Iowa) 19. Anthem Blue Cross and Blue Shield Connecticut (HMO/POS) 20. Anthem Blue Cross and Blue Shield (HMO/POS; New Hampshire)
MEDICARE PLANS
1. 2. 3. 4. 5. 6. 7. Kaiser Foundation Health Plan of Colorado (HMO) Fallon Community Health Plan (HMO; Massachusetts) Geisinger Health Plan (HMO, Pennsylvania) Tufts Associated Health Maintenance Organization (HMO; Massachusetts) Capital Health Plan (HMO; Florida) MVP Health Care - Rochester Area (HMO; New York) Kaiser Foundation Health Plan of the Northwest (HMO; Oregon and Washington) Kaiser Foundation Health Plan of Southern California (HMO) Kaiser Foundation Health Plan of the Northwest (HMO; Oregon and Washington)
4. 5. 6. 7. 8. 9. 10. 11. 12.
8. 9.
13.
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10. Capital District Physicians Health Plan (HMO; New York)
MEDICAID PLANS
1. Kaiser Foundation Health Plan of Hawaii (HMO) 2. Boston Medical Center HealthNet Plan (HMO) 3. Fallon Community Health Plan (HMO; Massachusetts) 4. Neighborhood Health Plan (HMO; Massachusetts) 5. Blue Cross and Blue Shield of Rhode Island (POS; Rhode Island) 6. Capital District Physicians Health Plan (HMO; New York) 7. Neighborhood Health Plan of Rhode Island (HMO) 8. HIP Health Plan of New York (HMO; New York) 9. Excellus BlueCross BlueShield (HMO; New York) 10. Health Plan of Michigan (HMO; Michigan)

Comarow, Avery, Americas Best Health Insurance Plans, U.S. News & World Report, December 2009, pp 91-94. (http://health.usnews.com/health/best-hospi tals/childrens-hospitals) National Committee for Quality Assurance, 1100 13th Street NW, Suite 1000, Washington, DC 20005. (202) 955-3500. (www.ncqa.org)
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PART V: PHARMACEUTICALS & MEDICAL DEVICES
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75
DISTRIBUTION CHANNELS
According to the National Association of Chain Drug Stores (NACDS), there are approximately 55,600 pharmacies in the United States, distributed as follows: Traditional chain drug stores: 22,000 Independent pharmacies: 16,900 Supermarkets: 9,300 Mass merchants: 7,400 Prescription drug sales in 2008 were $253.6 billion; 3.53 billion prescriptions were filled.

National Association of Chain Drug Stores, 413 North Lee Street, Alexandria, VA 22314. (703) 549-3001. (www.nacds.org)
DISTRIBUTION BY PRESCRIPTION SALES Traditional chain

drug stores: Mail order: Independent drug stores: Supermarket: Mass merchants: $104.4 billion $ 55.1 billion $ 43.8 billion $ 25.8 billion $ 24.8 billion
DISTRIBUTION BY PRESCRIPTIONS FILLED

Traditional chain drug stores: Independent drug stores: Supermarket: Mass merchants: Mail order: 1.68 billion 732 million 481 million 400 million 238 million
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DRUG CLASSIFICATION
Pharmaceutical drugs are classified by the Anatomical Therapeutic Chemical (ATC) Classification System, which is controlled by the World Health Organization Collaborating Centre for Drug Statistics Methodology (WHOCC). The classification system divides drugs into different groups according to the organ or system on which they act and/or their therapeutic and chemical characteristics.
Laxatives Stomach acid (Antacids, H2 antagonists, Proton pump inhibitors) Vitamins
B - Blood and Blood Forming Organs

Antithrombotics (Antiplatelets, Anticoagulants, Thrombolytics/fibrinolytics) Antihemorrhagics (Platelets, Coagulants, Antifibrinolytics)
Drugs are classified by five-level codes, as follows: The first level of the code indicates the anatomical main group and consists of one letter. There are 14 main groups. The second level of the code indicates the therapeutic main group and consists of two digits. The third level of the code indicates the therapeutic/pharmacological subgroup and consists of one letter. The fourth level of the code indicates the chemical/therapeutic/pharmacological subgroup and consists of one letter. The fifth level of the code indicates the chemical substance and consists of two digits. There are 14 primary drug groups, as follows:
C - Cardiovascular System
Antihyperlipidemics (Statins, Fibrates, Bile acid sequestrants) Antihypertensives Beta blockers Calcium channel blockers Cardiac therapy/antianginals (Cardiac glycosides, Antiarrhythmics, Cardiac stimulants) Diuretics Renin-angiotensin system (ACE inhibitors, Angiotensin II receptor antagonists, Renin inhibitors) Vasodilators
A - Gastrointestinal tract/metabolism
Anti-diabetics Anti-obesity drugs Antidiarrhoeals/Antipropulsives Antiemetics Dietary minerals
D - Dermatologicals
Antipruritics Antipsoriatics Cicatrizants Emollients Medicated dressings
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M - Musculo-Skeletal System G - Genito-Urinary System and Sex Hormones

Hormonal contraception Fertility agents SERMs Sex hormones Anabolic steroids Anti-inflammatories (NSAIDs) Antirheumatics Bisphosphonates Corticosteroids Muscle relaxants
H - Systemic Hormonal Preparations (excluding sex hormones) and Insulins

Corticosteroids (Glucocorticoids, Mineralocorticoids) Hypothalamic-pituitary hormones Sex hormones Thyroid hormones/Antithyroid agents
N - Brain and Nervous System

Analgesics Anesthetics (general, local) Anticonvulsants/Mood stabilizers (Lithium pharmacology) Antimigraines Anti-Parkinson drugs Psycholeptics (Anxiolytics, Antipsychotics, Hypnotics/Sedatives) Psychoanaleptics (Antidepressants, Stimulants)
J and P - Infections and Infestations

Antibiotics (Antimycobacterials) Antifungals Antivirals Antiparasitics (Antiprotozoals, Anthelmintics) Ectoparasiticides Intravenous immunoglobulin Vaccines
R - Respiratory System
Bronchodilators Cough medicines Decongestants H1 antagonists
S - Sensory Organs L - Antineoplastic and Immunomodulating Agents

L01-L02 - Malignant Disease Anticancer agents (Antimetabolites, Alkylating, Spindle poisons, Antineoplastic, Topoisomerase inhibitors) L03-L04 - Immune Disease Immunomodulators (Immunostimulants, Immunosuppressants) Ophthalmologicals Otologicals
V - Other
Antidotes Contrast media Dressings Radiopharmaceuticals
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World Health Organization (WHO) Collaborating Centre for Drug Statistics Methodology, Norwegian Institute of Public Health, P.O.Box 4404 Nydalen, 0403 Oslo, Norway. Tel: + 47 21 07 81 60. (www.whocc.no)
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77
LARGEST PHARMACEUTICAL COMPANIES
RANKED BY U.S. SALES

IMS Health provides the assessment presented in Table 77.1 of the largest pharmaceutical companies, ranked by U.S. prescription drug sales for the 12-month period ending September 2009.
Merck & Co.: Abbott Laboratories: Eli Lilly: Amgen Corp.: Wyeth Corp.: Teva Pharmaceuticals: Bayer: Takeda:
$26.2 billion $19.7 billion $19.1 billion $15.8 billion $15.7 billion $15.3 billion $15.7 billion $13.8 billion
RANKED BY 2008 GLOBAL SALES

Pfizer: GlaxoSmithKline: Novartis: Sanofi Aventis: AstraZeneca: Roche: Johnson & Johnson: $43.4 billion $36.5 billion $36.2 billion $35.6 billion $32.5 billion $30.3 billion $29.4 billion

IMS Health, 901 Main Avenue, Suite 612, Norwalk, CT 06851. (203) 845-5200. (www.imshealth.com) Top 20 Pharmaceutical Companies, Modern Healthcare, January 4, 2010.
TABLE 77.1 Top 20 Pharmaceutical Companies Pfizer (www.pfizer.com): AstraZeneca (www.astrazeneca.com): GlaxoSmithKline (www.gsk.com): Merck & Co. (www.merck.com): Hoffman-LaRoche (www.rocheusa.com): Johnson & Johnson (www.jnj.com): Novartis (www.novartis.com): Eli Lilly and Company (www.lilly.com): Amgen Corp. (www.amgen.com): Teva Pharmaceuticals (www.tevapharm.com): Sanofi Aventis (http://en.sanofi-aventis.com): Abbott Laboratories (www.abbott.com): $20.1 billion $17.6 billion $16.5 billion $14.8 billion $13.7 billion $13.4 billion $12.9 billion $12.9 billion $12.4 billion $12.1 billion $11.2 billion $ 9.5 billion
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TABLE 77.1 (cont)
Bristol-Myers Squibb Co. (www.bms.com): Takeda Pharmaceuticals (www.tpna.com): Wyeth Corp. (www.wyeth.com): Boehringer Ingelheim (www.boehringer-ingelheim.com): Schering Plough Corp. (www.sch-plough.com): Forest Laboratories (www.frx.com): Eisai (www.eisai.com): Mylan (www.mylan.com):
$8.7 billion $8.2 billion $7.7 billion $7.2 billion $4.8 billion $4.3 billion $4.3 billion $3.9 billion
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78
MARKET FORECAST
According to IMS Health, global pharmaceutical sales have been as follows (increase from previous year in parenthesis): 2001: $393 billion (11.8%) 2002: $429 billion (9.2%) 2003: $499 billion (10.2%) 2004: $560 billion (7.9%) 2005: $605 billion (7.2%) 2006: $648 billion (6.8%) 2007: $715 billion (6.6%) 2008: $773 billion (4.8%) 2009: $786 billion (1.8%) IMS Health forecasts the value of the global pharmaceutical market in 2010 to increase 4% to 6% on a constant-dollar basis, exceeding $825 billion, driven by stronger near-term growth in the U.S. market. Global pharmaceutical market value is expected to expand at a 4% to 7% compound annual growth rate through 2013, reaching $975 billion in 2013.
Overall, market growth is expected to remain at historically low levels, but stronger-than-expected demand in the U.S. is lifting both short- and longerterm forecasts. The economic climate will continue to be a dampening influence in most mature markets, particularly in those countries with rising budget deficits and publicly funded healthcare systems. In the U.S., pricing flexibility and inventory management actions are contributing to higher growth.
Murray Aitken, Sr. V.P. IMS Health, 10/7/09
IMS identifies five key market dynamics, as described in the following sections.
GROWTH PROSPECTS IN THE U.S. MARKET IMPROVE

Near-term growth prospects in the U.S. have strengthened in recent months, reflecting both sustained levels of price increases and changing inventory stocking patterns. Pharmacy chains are more tightly managing their inventory levels based on expectations of patient demand, which has led to greater purchasing volatility than in previous years. This played a role in unusually high sales growth in the first quarter of 2009 relative to forecast expectations. U.S. market growth in 2009 is estimated at 4.5% to 5.5%, and 3% to 5% in 2010. While payers seek to limit price increases and boost the use of lowercost generics, pharmaceutical manufacturers are expected to maintain their pricing practices, competing on the basis of clinical evidence and value.
ECONOMIC DOWNTURN AFFECTS MARKETS TO VARYING DEGREES

Growth has slowed in countries where there is high out-of-pocket spending on pharmaceuticals and steep declines in macroeconomic activity, especially in Russia, Mexico, and South Korea. At the same time, growth has been less affected to date in countries where drugs are largely
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funded publicly, such as in Germany, Japan and Spain. However, new costcontainment measures expected to be introduced during the forecast period likely will impact the pace of growth in these markets. In the U.S., pharmaceutical manufacturers efforts to expand access to and awareness of patient assistance programs, as well as co-pay subsidies for patients in need, are limiting the impact of the economic downturn to some extent.
expected in aggregate to grow by 12% to 14% in 2010, and 13% to 16% over the next five years. Chinas pharmaceutical market is expected to continue to grow at a 20% pace annually, and to contribute 21% of overall global growth through 2013. Russia and Turkey may be impacted significantly by new measures intended to reduce the level of healthcare spending in those two markets.
IMPACT OF THE INNOVATION/ PATENT LOSS IMBALANCE DAMPENS GROWTH PROSPECTS

Consistent with trends of the past several years, the next five years are expected to reflect a significant imbalance between new product introductions and patent losses. This is the primary factor limiting global pharmaceutical market growth to the midsingle digits through 2013. During the next five years, products that currently generate an unprecedented $137 billion in sales are expected to face generic competition, including Lipitor, Plavix, and Seretide. At the same time, new products that will enable innovative approaches for treating patients suffering from diseases such as osteoporosis, respiratory ailments, thrombosis, multiple sclerosis, and cancer are not expected to generate the same magnitude of sales as products losing patent protection.
HEALTHCARE ACCESS AND FUNDING UNDER INTENSIFYING PRESSURE

The economic climate has heightened concerns by payers about healthcare funding, and intensified their efforts to limit access to non-generic drugs. During the next five years, markets will be impacted by numerous payer actions, including the imposition of price cuts on existing drugs, the raising of standards required to achieve reimbursement of innovative therapies, and the use of economic incentives for prescribers and pharmacists to drive a shift to generic alternatives. Evidence of the value that medicines bring to healthcare systems will be required to achieve access and funding in both developed and emerging markets.

IMS Health, 901 Main Avenue, Suite 612, Norwalk, CT 06851. (203) 845-5200. (www.imshealth.com)
PHARMERGING MARKETS IN AGGREGATE SUSTAIN STRONG GROWTH

Despite economic conditions significantly affecting some markets notably Russia, Turkey, South Korea, and Mexico the seven pharmerging countries are
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79
MEDICAL DEVICES
MARKET ASSESSMENT
Medical technology products include the following categories, as defined by the NAIC Code Grouping of the U.S. Department of Commerce: 325413 - Diagnostic Reagents 334510 - Electromedical Devices and Equipment 334517 - Irradiation Apparatus 339112 - Surgical & Medical Instruments 339113 - Surgical Appliances and Supplies 339114 - Dental Equipment and Supplies 339115 - Ophthalmic Goods According to the Advanced Medical Technology Association, U.S. spending for medical technology products was $131.6 billion in 2006 (most recent data available as of January 2010), an 8.5% increase over the prior year. Extrapolating this data suggests a market of approximately $168 billion in 2009. This represents approximately 6.2% of total national health expenditures. According to a 2009 estimate by McKinsey Global Institute, annual U.S. spending for the six highest-cost implanted devices is $13 billion.
Corneal Laboratories, and Inamed) American Medical Systems Holdings Bausch & Lomb Biomet Incorporated Boston Scientific (EndoTex Interventional Systems, Guidant) Cochlear Limited Coloplast A/S Cook Group C.R. Bard Incorporated (Davol) Cyberonics Incorporated Edwards Lifesciences Johnson & Johnson (ALZA, Codman & Shurtleff, Conor, Cordis, DePuy, Ethicon, Hand Innovations) Medtronic Incorporated Mentor Corporation Optobionics Corporation Smith & Nephew (OsteoBiologics) St. Jude Medical (Advanced Neuromodulation Systems, Savacor) Stryker Corporation Synthes Incorporated Theragenics Corporation W.L. Gore & Associates Zimmer Holdings
Source: The Freedonia Group
LARGEST SUPPLIERS
Implantable Medical Devices Abbott Laboratories ABIOMED Incorporated Advanced Medical Optics Akzo Nobel (Organon International) Allergan Incorporated (EndoArd, Groupe
In Vitro Diagnostics Abbott Laboratories Bayer AG Beckman Coulter (Lumigen) Becton, Dickinson and Company (BD GeneOhm, Cytopeia, TriPath) Bio-Rad Laboratories bioMerieux SA Celera Corporation Danaher Corporation (Leica Biosystems) Gen-Probe Incorporated Hologic Incorporated (Cytyc, Third Wave)
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Inverness Medical Innovations (Biosite, Cholestech, First Check, Redwood Toxicology, Swiss Precision) Johnson & Johnson (LifeScan, OrthoClinical Diagnostics, Veridex) Life Technologies (Applied Biosystems, Invitrogen) Meridian Bioscience Olympus Corporation QIAGEN NV (Digene) Quidel Corporation Roche Holding (454 Life Sciences, BioVeris, NimbleGen, Ventana) Siemens AG (Dade Behring, Oncogene Science) Sysmex Corporation Thermo Fisher Scientific Trinity Biotech
Source: The Freedonia Group

Advanced Medical Technology Association, 701 Pennsylvania Avenue NW, Suite 800, Washington, DC 20004. (202) 783-8700. (www.advamed.org) Implantable Medical Devices To 2013, The Freedonia Group, August 2009. In Vitro Diagnostics To 2013, The Freedonia Group, March 2009. Meier, Barry, Costs Surge For Medical Devices, But Benefits Are Opaque, The New York Times, November 5, 2009. Orthopedic Implants To 2012, The Freedonia Group, July 2008. The Freedonia Group, 767 Beta Drive, Cleveland, OH 44143. (440) 684-9600. (www.freedoniagroup.com)
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80 PERSONALIZED MEDICINE
Personalized medicine uses new methods of molecular analysis to better manage a patients disease or predisposition toward a disease. It aims to achieve optimal medical outcomes by helping physicians and patients choose the disease management approaches likely to work best in the context of a patients genetic and environmental profile. Such approaches may include genetic screening programs that more precisely diagnose diseases and their sub-types, or help physicians select the type and dose of medication best suited to a certain group of patients. People vary from one another in many ways what they eat, the types and amount of stress they experience, exposure to environmental factors, and their DNA. Many of these variations play a role in health and disease. For example, the natural variations found in a persons genes could influence their risk of developing a certain disease, as well as how their bodies respond to that disease. The combination of these variations across several genes can affect each individuals risk of developing a disease or reacting to something in the environment, and can be one of the reasons why a drug works for one patient and not another. Personalized medicine hopes to use these variations both in the patient and in the molecular underpinnings of the disease itself to develop new treatments and to identify the sub-groups of patients for whom they will work best. It can also help determine which groups of patients are more prone to developing some diseases and, ideally, help with the selection of lifestyle changes and/or
treatments that can delay onset of a disease or reduce its impact.
FUTURE POTENTIAL
Personalized medicine is poised to transform healthcare over the next several decades. New diagnostic and prognostic tools will increase our ability to predict the likely outcomes of drug therapy, while the expanded use of biomarkers biological molecules that indicate a particular disease state could result in more focused and targeted drug development. Personalized medicine also offers the possibility of improved health outcomes and has the potential to make healthcare more costeffective. The potential of genetic testing for guiding patient care is vast. Experts say that most drugs, whatever the disease, work for only about half the people who take them. The result is wasted spending and use of countless patients to unnecessary side effects. Genetic testing has the potential of screening patients for the applicability of medications. Personalized medicine promises many medical innovations and has the potential to change the way treatments are discovered and used. The implications for current systems, such as healthcare payer and physician incentives, medical records privacy, and clinical trial ethics, must be explored by all stakeholders, who will need to reach agreement on what modifications should be made.
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In 15 or 20 years, personalized medicine ... will just be the way medicine is practiced.
Edward Abrahams, Ph.D. Executive Director Personalized Medicine Coalition U.S. News & World Report, 8/09
Guidance on Pharmacogenomics Tests and Genetic Tests for Heritable Markers, Food and Drug Administration. (www.fda.gov/OHRMS/DOCKETS/98fr/06d0012-gdl0001.pdf) Hobson, Katherine, Era Of Personalized Medicine, U.S. News & World Report, August 2009, p. 35. Personalized Medicine Coalition, 1225 New York Avenue NW, Suite 450, Washington, DC 20005. (202) 589-1770. (www.personalizedmedicinecoalition.org) Pharmacogenetics Research Network and Knowledge Base, National Institutes of Health. (www.nigms.nih.gov/Initiatives/PGRN)
CURRENT STATUS
Though sometimes described as a phenomenon of the future, personalized medicine is already having an impact on how patients are treated. Molecular testing is being used to identify those breast cancer and colon cancer patients likely to benefit from new treatments, and newly diagnosed patients with early stage invasive breast cancer can now be tested for the likelihood of recurrence. In another example, a genetic test for patients with an inherited cardiac condition can help their physicians determine which course of hypertension treatment to prescribe in order to avoid serious side effects. According to the Personalized Medicine Coalition, there were 37 products on the market in 2009 that facilitate personalized therapy. Most of those were in oncology. An increasing percentage are in other areas, such as products in cardiology and central nervous system disorders, in diseases such as autism, and in diabetes.

Evaluation of Genomic Applications in Practice and Prevention, Centers for Disease Control and Prevention, (www.cdc.gov/genomics/gtesting/index.htm)
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PRESCRIPTION DRUG USE
Consumers are increasing their use of prescription drugs at a rapid pace. In 2008, 51% of American adults and children were taking one or more prescription drugs for a chronic condition, according to Medco Health Solutions.
INCREASED USE
Express Scripps found that the increase from 2000 to 2006 in usage of prescription medications for cholesterol, depression, diabetes, high blood pressure, and stomach problems drove up drug spending by 50%, or $12 billion. Researchers observe that while the higher usage may prevent heart attacks, strokes, and other problems, more preventive efforts could reduce the need for drugs.
Express Scripps found significant variations in drug use among states. Some differences appear to be linked to health factors in each state, such as varying rates of smoking, diet, and exercise. States with high rates of obesity, for instance, such as Mississippi and West Virginia, had high usage of drugs for cholesterol, diabetes, and high blood pressure, conditions that can be associated with obesity. The following are some other distinctions: Diabetes drug use in Mississippi is nearly double that in Minnesota. Michigan has the highest rate of cholesterol drug use at 13.7%; Oregon has the lowest at 9.4%. About 18% of Utah residents were prescribed anti-depressants, twice that of the lowest prescribed state, New York, at about 9%.
TABLE 81.1 Percentage of Insured Adults Taking Prescription Drugs

2000 2006
High blood pressure: Cholesterol: Diabetes:
8.0% 6.1% 3.1%
14.1% 13.2% 5.5%

Express Scripts, 1 Express Way, St. Louis, MO 63121. (314) 996-0900. (www.express-scripts.com) Medco Health Solutions, 100 Parsons Pond Drive, Franklin Lakes, NJ 07417. (201) 269-3400. (www.medcohealth.com)
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PROMOTIONAL SPENDING
TYPES OF PROMOTIONS
Marketing by pharmaceutical companies primarily consists of professional promotion, direct-to-consumer (DTC) advertising, and advertising in professional journals. Professional Promotion Promotional spending includes the practice of pharmaceutical companies sending representatives to doctors offices, referred to as detailing, and direct gifts to doctors. Direct-to-Consumer Direct-to-consumer promotion represents the expenditures for direct-to-consumer pharmaceutical advertising for prescription products on television, radio, magazines and newspapers, as well as outdoor advertising. Journal Advertising Journal advertising reflects advertising expenditures for prescription products appearing in medical journals. IMS Health assesses promotional spending in these three categories as follows:
DTC ADVERTISING
2004: 2005: 2006: 2007: 2008: $4.03 billion $4.25 billion $4.90 billion $4.90 billion $4.43 billion
JOURNAL ADVERTISING
2004: 2005: 2006: 2007: 2008: $544 million $476 million $527 million $470 million $387 million
TOTAL PROMOTIONAL SPENDING

TRENDS
Pharmaceutical marketing increased dramatically during the first half of the past decade, peaking in the mid-2000s. The industry employs an estimated 90,000 detailers a ratio of one representative for every 4.7 office-based physicians. Drug company spending for one-on-one marketing to doctors increased 78% between
DETAILING
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1999 and 2003, peaked in 2004, then declined 15% from 2005 to 2008. Drug companies spend about $7 billion (not including drug samples) annually marketing to doctors. This works out to about $8,400 to $15,400 per doctor per year. Studies show that such marketing works: interaction with drug company representatives are associated with changes in doctors prescribing patterns. The practice of detailing has become controversial because gifts to doctors can undermine the doctor-patient relationship by creating the appearance of impropriety. Direct-to-consumer advertising of prescription drugs surged after 1997, when the Food and Drug Administration relaxed restrictions on the advertising of drugs to consumers. Critics say DTC ads, which are permitted in few other countries, inflate healthcare costs by prompting patients to request brand-name medicines, rather than cheaper generic alternatives. The pharmaceutical industry, however, cites a statement from the Federal Trade Commission that argues that the ads educate consumers about drug options and have not been shown to lead to higher prices. DTC advertising peaked in 2006, then declined 10% from 2007 to 2008.

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STEM CELL RESEARCH
Stem cell therapy has the potential to dramatically change the treatment of human disease. Several adult stem cell therapies already exist. One example is bone marrow transplants that are used to treat leukemia. Medical researchers anticipate that in the future stem cell therapy will treat a wide variety of diseases including cancer, congestive heart failure, multiple sclerosis, Parkinsons disease, and spinal cord injuries, among other diseases and impairments. A primer on stem cells from the National Institutes of Health is available online at http://stemcells.nih.gov/info/basics.
projects a r e pr ovid ed online at http://clinicaltrials.gov/search/term=stem+ce lls?term=stem+cells.
CALIFORNIA INSTITUTE FOR REGENERATIVE MEDICINE

The California Institute for Regenertive Medicine (CIRM) was established in November 2004 with the passage of Proposition 71, the California Stem Cell Research and Cures Act. The statewide ballot measure provided $3 billion in funding for stem cell research at California universities and research institutions. As of year-end 2009, CIRM had approved 328 grants totaling more than $1 billion, making CIRM the largest source of funding for human embryonic stem cell research in the world. An overview of CIRM research is presented in Table 83.1.
FEDERAL POLICY
In August 2001, former President George W. Bush announced federal policy that restricted funds for certain types of stem cell research. This policy was reversed in March 2009 when President Barack Obama issued Executive Order 13505, Removing Barriers to Responsible Scientific Research Involving Human Stem Cells (http://edocket.access. gpo.gov/2009/pdf/E9-5441.pdf).

American Society for Cell Biology, 8120 Woodmont Avenue, Suite 750, Bethesda, MD, 20814. (301) 347-9300. (www.ascb.org) California Institute for Regerative Medicine, 210 King Street, San Francisco, CA 94107. (415) 396-9100. (www.cirm.ca.gov) Genetics Policy Institute, 11924 Forest Hill Boulevard, Suite 22, Wellington, FL 33414. (888) 238-1423. (www.genpol.org)
NATIONAL INSTITUTES OF HEALTH

The National Institutes of Health is the Federal governments leading biomedical research organization and primary supporter of stem cell research. The objectives and findings of over 2,800 current and completed NIH-funded research
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National Institutes of Health, Stem Cell Unit, 9000 Rockville Pike, Bethesda, MD 20892. (301) 496-5787. (http://stemcells.nih.gov/ research/nihresearch/)
Figure 83.1.
Overview of research projects funded by the California Institute for Regenerative Medicine.
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TOP-SELLING PHARMACEUTICAL PRODUCTS
IMS Health provides the following rankings of top-selling pharmaceutical products in 2008:
RANKED BY U.S. SALES

Lipitor (Pfizer): Nexium (AstraZeneca): Plavix (Bristol-Myers Squibb): Advair Diskus (GlaxoSmithKline): Seroquel (AstraZeneca): Singulair (Merck): Enbrel (Immunex): Neulasta (Amgen): Actos (Takeda Pharmaceuticals): Epogen (Amgen): Prevacid (TAP): Abilify (Bristol-Myers Squibb): Remicade (Centocor): Effexor XR (Wyeth Ayerst): Lexapro (Forest Laboratories): $7.8 billion $5.9 billion $4.9 billion $4.4 billion $3.9 billion $3.5 billion $3.4 billion $3.1 billion $3.1 billion $3.1 billion $3.1 billion $3.1 billion $3.1 billion $3.0 billion $2.7 billion
Furosemide: Metformin Hcl: Alprazolam: Atenolol: Metoprolol Succinate: Omeprazole:
43 million 42 million 42 million 41 million 40 million 35 million
RANKED BY GLOBAL SALES

Lipitor (Pfizer): Plavix (Bristol-Myers Squibb): Nexium (AstraZeneca): Seretide (GlaxoSmithKline): Enbrel (Immunex): Seroquel (AstraZeneca): Zyprexa (Eli Lilly): Remicade (Centocor): Singulair (Merck): Lovenox (Sanofi-Aventis): Mabthera (Hoffman LaRoche): Takepron (Takeda): Effexor (Wyeth Ayerst): Humira (Abbott): Avastin (Genentech): $13.7 billion $ $ $ $ $ $ $ $ $ $ $ $ $ $ 8.6 billion 7.8 billion 7.7 billion 5.7 billion 5.4 billion 5.0 billion 4.9 billion 4.7 billion 4.4 billion 4.3 billion 4.3 billion 4.2 billion 4.1 billion 4.0 billion
RANKED BY NUMBER OF U.S. DISPENSED PRESCRIPTIONS

HYCD/APAP: Lisinopril: Simvastatin: Levothryroxine sodium: Lipitor: Azithromycin: Amoxicillin: Hydrochlorothiazid: Amlodipine Besylate: 124 million 76 million 67 million 61 million 58 million 51 million 50 million 48 million 44 million

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TOP-SELLING THERAPEUTIC DRUG CLASSES
IMS Health assessed the 2008 U.S. market for prescription drugs at $291.5 billion, an increase of 1.3%. Dispensed prescription volume in the U.S. grew at a 0.9% pace. Factors influencing the markets slower growth in 2008 included higher demand for less-expensive generic drugs, lower new product sales, and reduced consumer demand due to the economic downturn.
TOP DRUG CLASSES (U.S.) RANKED BY DISPENSED PRESCRIPTIONS

Lipid regulators: Codeine and combinations: Anti-depressants: ACE Inhibitors: Beta Blockers: Proton pump inhibitors: Seizure disorders: Thyroid hormone, synth.: Calcium blockers: Benzodiazepines: Angiotensin II antagonists: Oral contraceptives: Anti-arthritics, plain: Macrolides and related antibiotics: Penicillins: 202 million 194 million 164 million 160 million 131 million 113 million 109 million 105 million 89 million 85 million 84 million 82 million 76 million 66 million 61 million
TOP DRUG CLASSES (U.S.) RANKED BY SALES

The top therapeutic drug classes, ranked by 2008 U.S. sales, were as follows: Antipsychotics: $14.6 billion Lipid regulators: $14.5 billion Proton pump inhibitors: $13.9 billion Seizure disorders: $11.3 billion Anti-depressants: $ 9.6 billion Angiotensin II antagonists: $ 7.5 billion Antineo monoclonal antibodies: $ 7.5 billion Erythropoietins: $ 7.2 billion Anti-arthritics, biological response modifiers: $ 6.0 billion Anti-platelets, oral: $ 5.3 billion Analogs of human insulin: $ 5.1 billion Steroid, inhaled bronchial: $ 4.8 billion Analeptics: $ 4.8 billion GI anti-inflammatory: $ 4.4 billion Codeine and combinations: $ 4.3 billion
TOP DRUG CLASSES (GLOBAL) RANKED BY SALES

Oncologics: Lipid regulators: Respiratory agents: Antidiabetics: Acid pump inhibitors: Angiotensin II antagonists: Antipsychotics: Antidepressants: Anti-epileptics: Autoimmune agents: $48.2 billion $33.8 billion $31.3 billion $27.3 billion $26.5 billion $22.9 billion $22.9 billion $20.4 billion $16.9 billion $15.9 billion
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Platelet aggr. inhibitors: HIV antivirals: Erythropoietins: Non-narcotic analgesics: Narcotic analgesics:
$13.6 billion $12.2 billion $11.5 billion $11.2 billion $10.6 billion

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PART VI: DISEASES & TREATMENTS
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86
ALCOHOL ADDICTION
PREVALENCE
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) estimates that almost 18 million people in the U.S. abuse or are addicted to alcohol. More than 30% of Americans engage in risky drinking at some point in their lives, according to the NIAAA. Estimates of the number of people with alcohol addiction vary.
encourages behavioral changes and faith in a higher power in treatment. Up to a million alcoholics connect with AA programs annually. According to SAMHSA, 41% of patients seeking admission to state-licensed or certified substance abuse treatment facilities do so because of alcohol abuse. Approximately 500,000 alcohol abusers each year seek treatment at centers such as the Betty Ford Center, Ridgeview Institute, the Hazelden Foundation, Par Village, Delancey Street in San Francisco, and a host of other inpatient and outpatient treatment centers. Until recently, physicians werent sought for or involved in alcoholism treatment counselors, recovering drinkers, and clergy were most commonly sought out for help. The NIAAA recently published Helping Patients Who Drink Too Much: A Clinicians Guide, which simplifies alcohol screening and offers step-by-step guidance for conducting brief interventions and managing patient care. The guide is available at no cost on the NIAAA website. Despite the fact that up to 18 million Americans are alcoholics, the U.S. market for related drug treatments is less than $60 million annually. Only about 140,000 alcoholics in the U.S. receive medication for their disease, with treatment ranging from such drugs as Antabuse or Naltrexone to anti-depressants to anti-seizure drugs. A clearer understanding of the biological underpinnings of alcoholism is opening the
Researchers have made up dozens of screening tests over the years. But theres no consensus on exactly what an alcoholic is. Even Alcoholics Anonymous relies on alcoholics to diagnose themselves.
The Wall Street Journal
Alcohol use has seen slight increases, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), with 51% of people in 2008 reporting they drank alcohol during the previous 30 days. States with the highest increase in drinking are Alabama, Arizona, Kansas, Minnesota, Tennessee, Texas, and Wisconsin.
MEDICAL TREATMENT
Since 1935, when Alcoholics Anonymous (AA) was founded, the vast majority of treatments for alcoholism in the U.S. have been based on AAs 12-step program, which
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way to better drugs. Scientists, for example, have identified a number of genes that confer a predisposition to alcohol addiction. They have also found that the brain goes through profound changes when a person starts drinking to excess. Cognitive therapy is being used to aid addicts in forming new, healthier habits by helping them recognize what situations or patterns of thinking trigger an urge to abuse alcohol. It has been found that treatments combining medication and such psychotherapy work better than either strategy does by itself.

National Institute on Alcohol Abuse and Alcoholism (NIAAA), 5635 Fishers Lane, MSC 9304, Bethesda, MD 20892. (301) 443-3860 (www.niaaa.nih.gov) Substance Abuse and Mental Health Services Administration, P.O. Box 2345, Rockville, MD 20847. (www.samhsa.gov)
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ALLERGIES
PREVALENCE AND ECONOMIC IMPACT

According to the Asthma and Allergy Foundation of America (AAFA), more than 50 million people in America (about one of every five adults and children) have allergies. Annual direct costs for treating allergies are $6 billion ($5.7 billion in medications and $300 million in office visits). Among adults, allergies are the fifth leading chronic disease and a major cause of work absenteeism, resulting in nearly four million missed or lost workdays each year, and accounting for more than $700 million in total lost productivity. An estimated two million school days are lost each year due to allergies. The AAFA provides the following additional facts about the impact of allergies: Allergies have a genetic component. If one parent has allergies, chances are one in three that each child will have an allergy. If both parents have allergies, it is even more likely (7 in 10) that their children will have allergies. Allergies are the most frequently reported chronic condition in children, limiting activities for more than 40% of them. Each year, allergies account for more than 17 million outpatient office visits, primarily in the spring and fall; seasonal allergies account for more than half of all allergy visits.
There are no cures for allergies, however, allergies can be managed through prevention and treatment.
TYPES OF ALLERGIES
AAFA classifies allergies as follows: Indoor and Outdoor Allergies Indoor and outdoor allergies include allergic rhinitis, hay fever, nasal allergies, and seasonal/perennial allergies. The most common indoor/outdoor allergy triggers are tree, grass and weed pollen; mold spores; dust mite and cockroach allergen; and cat, dog, and rodent dander. Approximately 75% of all allergy sufferers have indoor/outdoor allergies as their primary allergy. Approximately 10 million people are allergic to cat dander, the most common pet allergy. Skin Allergies Skin allergies include atopic dermatitis, contact allergies, eczema, hives, and urticaria. Approximately 7% of allergy sufferers have skin allergies as their primary allergy. Plants such as poison ivy, oak, and sumac are the most common skin allergy triggers. However, skin contact with cockroach and dust mite allergen, certain foods, or latex may also trigger symptoms of skin allergy.
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mite allergen) as their primary allergy. Skin allergies alone account for more than 7 million outpatient visits each year. Food and Drug Allergies Approximately 6% of allergy sufferers have food/drug allergies as their primary allergy. Food allergy is more common among children than adults. Ninety percent (90%) of all food allergy reactions are cause by eight foods: milk, soy, eggs, wheat, peanuts, tree nuts, fish, and shellfish. Food allergies account for 30,000 visits to the emergency room each year. More than 200 deaths occur each year due to food allergies. For drug allergies, penicillin is the most common allergy trigger. Nearly 400 Americans die each year due to allergic reactions from penicillin. Latex Allergy Approximately 4% of allergy sufferers have latex allergy as their primary allergy. An estimated 10% of healthcare works suffer from latex allergy. Exposure to latex allergen alone is responsible for over 200 cases of anaphylaxis (severe allergic reactions) each year. An average of 10 deaths each year are attributed to severe reactions to latex allergy. Insect Allergies Approximately 4% of allergy sufferers have insect allergies (bee/wasp stings and venomous ant bites, cockroach and dust Each year nearly 100 Americans die due to insect allergies. Eye Allergies Eye allergies include allergic conjunctivitis and ocular allergies. Approximately 4% of allergy sufferers have eye allergies as their primary allergy, often caused by many of the same triggers as indoor/outdoor allergies.
ALLERGY CAPITALS
The Asthma and Allergy Foundation of America publishes an annual list of the top 100 American cities dubbed Allergy Capitals (www.allergycapitals.com), where allergies are most severe for sufferers. The rankings are based on analysis of three factors, as follows: Pollen scores (airborne grass/tree/weed pollen and mold spores) Number of allergy medications used per patient Number of allergy specialists per patient The lists are part of the organizations nationwide Allergy Action Plan, created to help consumers recognize, prevent, and safely relieve allergy symptoms. The following were the Spring Allergy Capitals in 2009: Louisville, Kentucky Knoxville, Tennessee Charlotte, North Carolina Madison, Wisconsin Wichita, Kansas McAllen, Texas Greensboro, North Carolina Dayton, Ohio Little Rock, Arkansas Augusta, Georgia
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The following were the Fall Allergy Capitals in 2009: McAllen, Texas Wichita, Kansas Louisville, Kentucky Oklahoma City, Oklahoma Jackson, Mississippi Dayton, Ohio Augusta, Georgia Tulsa, Oklahoma Knoxville, Tennessee Little Rock, Arkansas

Asthma and Allergy Foundation of America, 1233 20th Street NW, Suite 402, Washington, DC 20036. (800) 727-8462. (www.aafa.org)
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88
ALZHEIMERS DISEASE & DEMENTIA
PREVALENCE
According to the Alzheimers Association, an estimated 5.3 million Americans of all ages have Alzheimers disease. This figure includes 5.1 million people age 65 and over and 200,000 individuals under age 65 who have younger-onset Alzheimers. Another 300,000 Americans under age 65 have a dementia other than Alzheimers disease. Alzheimers disease is the most frequent cause of dementia, accounting for 70% of all cases of dementia in Americans ages 71 and over. Vascular dementia accounts for 17% of cases of dementia. Other diseases and conditions, including Parkinsons disease, Lewy body disease, frontotemporal dementia, and normal pressure hydro-cephalus, account for the remaining 13%. The following are other facts about Alzheimers disease and dementia provided by the Alzheimers Association in 2009 Alzheimers Disease Facts and Figures: Each year over 420,000 people are diagnosed with Alzheimers. The longer a person lives, the more likely he/she is to contract Alzheimers. Because women live longer, on average, than men, they are more likely to have Alzheimers disease and dementia. Fourteen percent (14%) of all people age 71 and over have dementia, including 16% of women and 11% of men in that age group. People with more years of education are less likely to develop Alzheimers disease and dementia. One study found that people with less than 12 years of education have a
35% greater risk of developing dementia than people with more than 15 years of education. The number of Americans surviving into their 80s and 90s is expected to grow because of advances in medicine, medical technology, and social and environmental conditions. Since the incidence and prevalence of Alzheimers disease and dementia increase with age, the number of people with these conditions is likely to also grow. The Alzheimers Association forecasts cases to increase to 615,000 new cases a year in 2030 and 959,000 new cases a year in 2050. The number of people age 65 and over with Alzheimers disease is estimated to reach 7.7 million in 2030, a greater than 50% increase from the five million ages 65 and over who are currently affected. Alzheimers disease is among the top 10 leading causes of death for people of all ages and ranks fifth for those ages 65 and older. In 2005 (most recent data available), about 72,000 death certificates reported people to have died of the disease; this number is likely to be low because many studies say that death certificates substantially underreport the occurrence of deaths due to Alzheimers. No treatment has proven successful in reversing the course of Alzheimers disease.
COSTS AND ECONOMIC IMPACT

According to 2009 Alzheimers Disease Facts and Figures, the direct and indirect costs associated with care of persons with
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Alzheimers and other dementias amount to more than $148 billion annually. This cost is assessed and projected to increase as follows: Medicare costs for care of beneficiaries with Alzheimers and other dementias were $91 billion in 2005; this figure is projected to increase to $160 billion by 2010 and $189 billion by 2015. State and federal Medicaid costs for nursing home care for people with Alzheimers and other dementias in 2005 were $21 billion; this figure is projected to increase to $24 billion in 2010 and $27 billion in 2015. Indirect costs to businesses for employees who are caregivers of people with Alzheimers and other dementias are estimated at $36.5 billion.
Alzheimers Association. Most people with Alzheimers and dementia have one or more other serious medical conditions. Among those diagnosed with dementia, the following percentages have coexisting medical conditions: Hypertension: 60% Coronary heart disease: 26% Stroke late effects: 25% Diabetes: 23% Osteoporosis: 18% Congestive heart failure: 16% COPD: 15% Cancer: 13% Parkinsons disease: 8% Further, people with Alzheimers disease and other dementias have more than three times as many hospital stays as other older people. Their total Medicare costs for hospital care are more than three times higher than other Medicare beneficiaries. Treatment of these patients poses a challenge for hospitals. Hospitalized patients with Alzheimers or another dementia are at greater risk of a number of serious complications, including falls, infections, bed sores, worsening of their dementia or onset of delirium. These patients often arent able to effectively communicate when theyre feeling feverish or in pain. They dont understand or cant remember that a nurse asked them to stay in bed or to call if they wanted to get up. Patients with dementia also are at risk of poor nutrition and dehydration.
Hospitals & Health Networks, 11/09
The $148 billion estimate does not include the costs of care for people with Alzheimers and other dementias that are paid by the U.S. Department of Veterans Affairs, private healthcare and long-term care insurance, and other public and private payers. It also does not include out-of-pocket expenditures, longterm care, and end-of-life care services that are not covered by Medicare, Medicaid, and other public and private payers.
PATIENT CARE
Nearly 70% of those afflicted with dementia Alzheimers disease live at home and are cared for by family and friends. In the last stages of the disease, it is often necessary for those afflicted to be cared for in a nursing home. Nearly 50% of all nursing home patients in the United States suffer from Alzheimers disease. In 2009, ten million family members and other (unpaid) caregivers of people with Alzheimers and other dementias provided 8.5 billion hours of care, according to the
People with dementia are high users of home and community services such as personal
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care and adult day center services. At any one time, about 30% of people with dementia are living in such long-term care settings.
to manifest itself. If these findings are confirmed, researchers could develop a blood test that would identify at-risk people who have the abnormal gene. The long-range hope is that genetic screening and pharmaceutical remedies combined could eventually lead to prevention of dementia.
RESEARCH FOR TREATMENTS

The category of Alzheimers medications is a $1.4 billion business, according to SDI Health, despite the fact that treatment only acts on the symptoms, not the underlying disease. According to Todd Golde, M.D., professor of neuroscience at the Mayo Clinic, the large expenditures reflect the desperation of patients and their families to treat the disease. This suggests the huge market potential should an effective treatment be developed. More than 60 dementia drugs are now in human testing trials. The New York Times reported that one pharmaceutical company alone has spent $450 million on research efforts.
INFLUENCE OF MENTAL ACTIVITY

Medical research studies have produced sometimes conflicting conclusions, but experts increasingly say lifestyle factors such as physical activity, challenging hobbies, and lots of friends or social engagements might help keep the brain more nimble and fit as it ages. In a recent editorial in the Journal of the American Medical Association, Sally Shumaker, M.D., a professor of public health sciences and associate dean for research at Wake Forest University, said that she foresees programs that include exercise, cognition, and things like meditation being combined with drug programs to treat dementia.
Virtually every major pharmaceutical and biotech company is trying to develop a drug that can reverse or delay Alzheimers, the biggest unmet medical need out there.
BusinessWeek

Researchers are also achieving a better understanding of genetic links to Alzheimers disease. Researchers from the University of Southern California published findings in the Archives of General Psychiatry suggesting that 58% to 79% of the risk of developing late-onset Alzheimers is genetic. Also, researchers from the Duke University Medical Center presented findings at the 2009 International Conference on Alzheimers Disease that the gene TOMM40 may help pinpoint the age at which the disease begins Alzheimers Association, 225 North Michigan Avenue, 17th Floor, Chicago, IL 60601. (800) 272-3900. (www.alz.org) Aston, Geri, Alzheimers Disease: A Growing Patient Imperative, Hospitals & Health Networks, November 2009, pp 2629. SDI Health, 220 West Germantown Pike, Plymouth Meeting, PA 19462. (610) 834-0800. (www.sdihealth.com)
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89
ARTHRITIS
PREVALENCE
Arthritis is the number one cause of disability in America, affecting an estimated 46 million people, according to an April 2009 report by the Centers for Disease Control and Prevention (CDC). As a cause of disability, it affects more people than back pain, heart or lung conditions, diabetes, or cancer. Arthritis can affect any age. Seventy-nine percent (79%) of arthritis sufferers are over age 45. However, approximately 285,000 children and 8.4 million Americans age 17-to44 are affected by arthritis. Almost all juvenile arthritis is rheumatoid arthritis, a systemic immune problem. Especially with children, early diagnosis and treatment are very effective. As the U.S. population ages, the prevalence of arthritis will significantly increase. The numbers of individuals with arthritis who have a disability and are prevented from living their lives to the fullest are already staggering, and they are projected to worsen considerably. With the aging of baby boomers, the prevalence of arthritis is expected to rise by 40% that is up to 67 million people by the year 2030. These findings suggest a critical need to expand the reach of effective strategies aimed at disability prevention and management.
John H. Klippel, M.D., President Arthritis Foundation, 4/30/09
The 2009 CDC study found that females had a higher prevalence of the disease. Women are more likely to cite arthritis as the cause of their disability than men (6.4 million women vs. 2.2 million men). More African-Americans than whites say it limits their activities. It is less prevalent among Hispanics.
ECONOMIC IMPACT
Arthritis costs the U.S. economy $128 billion per year in medical care and lost wages. It is responsible for 427 million days of restricted activity, 156 million days in bed, and 45 million days lost from work each year, according to the Arthritis Foundation. The CDC reports a correlation between arthritis and diabetes. The inactivity caused by arthritis hinders the successful management of both diseases, and people with diagnosed diabetes are nearly twice as likely to have arthritis. According to Chad Helmick, M.D., an epidemiologist at CDC, people with arthritis face barriers to physical activity. Many have concerns about aggravating their arthritis pain, possibly causing further joint damage, and are uncertain about which types and amounts of activity are safe for their joints. The disability caused by arthritis often robs people of the ability to live independently. People with arthritis commonly report needing help getting around inside their home, getting out of bed or a chair, bathing, dressing, eating, and other important activities of daily living.
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TYPES OF ARTHRITIS
There are more than 100 types of arthritis, with osteoarthritis affecting approximately 50% of the sufferers, most of them over the age of 45. Other serious and common forms of arthritis include gout, lupus, scleroderma, and fibromyalgia. Nearly 21 million Americans have osteoarthritis, arthritis that causes a progressive degeneration of the cartilage, and their ranks are expected to explode as people get older. The joint disease often hits people 65 years and older, but it can appear decades younger. By 2030, when 70 million people will be 65 and older and at risk for the disease, the number of people with osteoarthritis is projected by the CDC to be at 41.1 million. Genetic defects are estimated to cause approximately 25% of osteoarthritis cases. According to Dr. Roland Moskowitz of Case Western Reserve University, who was the first to discover an osteoarthritis gene, identifying the genes in arthritis gives researchers a handle in treating and preventing the disease. Rheumatoid arthritis, an autoimmune disease, affects approximately 2.5 million people in the United States. Patients own immune systems go awry and attack joints, causing inflammation and stiffness as rogue immune cells eat away cartilage and eventually erode bone. The disease strikes mainly women, usually between ages 25 and 50. Within 10 years of incurring the disease, approximately 50% of patients are too disabled to work. No cures are available, only treatments to relieve symptoms. Many factors influence this breakdown of cartilage, including genetic defects; sports injuries, especially in young people; the stresses associated with being overweight, which strain the weight-bearing joints; and some metabolic conditions.
Unlike arthritis, in which joint pain is aggravated by movement, the muscle symptoms of fibromyalgia are always present, even at rest. In addition to pain, individuals with fibromyalgia suffer from constant fatigue. They tend to wake repeatedly during the night, and awaken in the morning still tired. They are also apt to be depressed, and many suffer from a nervous stomach. Other symptoms include sore throat; diarrhea or constipation; sensitivity to changes in temperature, bright light, odors and loud sounds; and mottled skin. Fibromyalgia is estimated to affect approximately six million Americans, or 2% of the population. The most effective treatment for fibromyalgia is regular exercise. Some medications relieve the symptoms.
TREATMENT
According to a 2009 estimate by the CDC, there are approximately 44 million arthritisrelated outpatient visits and 992,000 hospitalizations annually. Health experts believe that a combination of proper diet, weight control, exercise, and regular medical treatment are effective in controlling both the prevalence and severity of arthritis. The annual arthritis drug market is $6.6 billion, according to Newsweek. The current drugs used to treat arthritis are aimed only at symptomatic relief. There are more than 40 approaches to treatment nearing or already in clinical trials.

Arthritis Foundation, 1330 West Peachtree Street NW, Atlanta, GA 30309. (800) 283-7800. (www.arthritis.org)
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90 ASTHMA
PREVALENCE AND MORTALITY

According to the Centers for Disease Control and Prevention, approximately 15 million adults suffer from asthma. An additional 4.8 million children have the disease. Approximately 1.8 million emergency room visits per year are for asthma. Asthma results in approxim at ely 500, 000 hospitalizations each year. The female hospitalization rate from asthma is 38% higher than the male rate. For adults, asthma is the fourth leading cause of work loss, resulting in nine million lost workdays each year. Asthma attacks also result in uncommonly high rates of missed school days. Approximately 5,000 people die from asthma each year. There are 3.5 average annual deaths from asthma per million among five to 34 year olds. Blacks are twice as likely to die from the disease as whites. The death rate from asthma has increased 6% each year since the late 1970s. Asthma rates have more than doubled in the U.S. since 1980, hitting particularly hard the inner-city poor. One theory for the increase suggests that germ-conscious Americans are shielding infants so much that immune system development is stunted, causing immune cells to overreact to normally harmless substances, like dust. The Pew Environmental Health Commission predicts 29 million Americans will suffer from asthma by 2020.
COST
Asthma accounts for approximately $12.7 billion in healthcare costs annually, according to the CDC.
ASTHMA CAPITALS
While no place is free from asthma triggers, some cities are more challenging places to live for those with the disease than others. The Asthma and Allergy Foundation of America conducts an annual assessment of major U.S. cities, ranking the 100 most challenging places to live with asthma as Asthma Capitals. Factors that contribute to such designation include higher than average annual pollen levels, high air pollution, and lack of 100%-smoke-free laws. The following were the top 10 Asthma Capitals for 2009: St. Louis, Missouri Milwaukee, Wisconsin Birmingham, Alabama Chattanooga, Tennessee Charlotte, North Carolina Memphis, Tennessee Knoxville, Tennessee McAllen, Texas Atlanta, Georgia Little Rock, Arkansas The state with the highest rate of people currently suffering from asthma is Maine, with almost 9%. Louisiana has the lowest, at 5%.
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ASTHMA IN CHILDREN
The CDC estimates that 6.2% of children in America have asthma, a figure that has doubled since 1980. Experts can provide no specific explanation for the dramatic rise. The estimated cost of treating people under the age of 18 with asthma is $3.2 billion a year. Fall is the most severe season for asthma attacks in children. Researchers speculate that the increase in asthma attacks has to do with kids getting together in small indoor spaces, as they do in school and classrooms, and passing around viruses. Getting a respiratory virus such as the flu or a cold can trigger an asthma attack. Increased exposure to pollutants from mold growing on classroom ceiling tiles to diesel-powered school bus exhaust fumes is also a factor. For millions of children with asthma, the start of the school year can bring a rise in severe attacks and trips to the emergency room. More than six times as many asthmatic children of elementary school age are admitted to the hospital in early fall, compared with the hot, smoggy days of summer. According to a five-year federally financed study conducted at eight medical centers in seven cities, as experts had long suspected, children are at high risk of asthma attacks if they are allergic to cockroaches and their homes show high levels of the insects body parts and droppings. Dr. David Rosenstreich, an allergy specialist at Albert Einstein College of Medicine in the Bronx and the senior investigator of the study, estimated that cockroaches cause about 25% of all asthma in inner city areas.
Health. More than half of adults with serious asthma believe they only have asthma when they experience symptoms, and many forego using medications when they feel symptomfree, according to researchers at Mount Sinai School of Medicine. Patients who have this no symptoms, no asthma belief are onethird less likely to take their asthma medication daily. Male patients, those over 65 years old, and patients with no consistent place of care are most likely to have the no symptoms, no asthma belief. The study also found that 20% of the patients felt they will not always have asthma, and 15% expect their doctor to cure them of the disease. Americans spend approximately $5 billion annually on inhaled steroids and other daily inflammatory asthma drugs. The top selling respiratory drug is Singulair (Merck), with U.S. sales of $3.5 billion in 2008, according to IMS Health.

American Academy of Allergy, Asthma and Immunology, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202. (414) 2726071. (www.aaaai.org) American Association for Respiratory Care, 9425 North MacArthur Boulevard, Suite 100, Irving, TX 75063. (972) 243-2272. (www.aarc.org) American Lung Association, 61 Broadway, 6th Floor, New York, NY 10006. (212) 315-8700. (www.lungusa.org) Asthma and Allergy Foundation of America, 1125 15th Street, NW, Suite 502, Washington, DC 20005. (800) 727-8462. (www.aafa.org)
TREATMENT
There are more than 17 million physician visits for asthma each year, according to IMS
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IMS Health, 901 Main Avenue, Suite 612, Norwalk, CT 06851. (203) 845-5200. (www.imshealth.com) Pew Environmental Health Commission, 901 E Street NW, Washington, DC 20004. (202) 552-2000. (www.pewtrusts.com)
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BARIATRIC SURGERY
According to the National Center for Health Statistics, approximately 33% of adults in the U.S. are obese. The National Institutes of Health (NIH) has endorsed bariatric surgery as the only proven procedure for weight loss in severely obese patients. As with any surgery, there are associated risks, which may be compounded by the health problems of the morbidly obese patient. When a person becomes morbidly obese, however, the risk of doing nothing may exceed the risk of surgery, making surgery a reasonable option. According to The American Society for Metabolic & Bariatric Surgery (ASBS), the number of bariatric procedures have been as follows: 2002: 62,000 2003: 105,000 2004: 144,000 2005: 171,000 2006: 178,000 2007: 205,000 2008: 220,000 People considered medically eligible for bariatric surgery are those overweight with a body mass index (BMI) of over 40, or a BMI of 35 to 40 with an obesity-related disease such as Type 2 diabetes, heart disease or sleep apnea; criteria established by the NIH. Among the 22 million people in the U.S. meeting this criteria, only 0.4% actually get the surgery. Clinical studies show that most bariatric surgery patients lose weight quickly and continue to lose weight 18-to-24 months after the procedure. Patients may lose 30% to
50% of their excess weight in the first six months and 77% of excess weight as early as 12 months after surgery. Studies have also shown that patients can maintain a 50% to 60% loss of excess weight 10 to 14 years after weight loss surgery. Bariatric surgery typically costs $17,000 to $25,000.
IMPACT ON OBESITY-RELATED DISEASES

A recent study published in the Journal of the American Medical Association reported bariatric surgery patients showed improvements in the following obesity-related conditions: Type II diabetes eliminated in 77% of patients, eliminated or improved in 86% Hypertension eliminated in 62% patients and resolved or improved in 78% Obstructive sleep apnea or sleepdisordered breathing eliminated in 86% of patients High cholesterol levels or hyperlipidemia decreased in more than 70% of patients Most noteworthy about bariatric surgery is that in some cases it appears to cure diabetes, a disease otherwise considered incurable. Studies have shown that patients who had bariatric surgery are five times more likely to see their diabetes symptoms disappear over the following two years than are patients who have standard diabetes care. According to Prof. David Cummings, M.D., at the University of Washington, practitioners and patients are increasingly
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seeing bariatric surgery not as a last resort but as a really good option as well as a way to learn more about the mechanisms behind the diabetes.
RISKS The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium, a National Institutes of Health (NIH)-funded consortium of six clinical centers, reported on the safety of bariatric surgery in the July 30, 2009 issue of the New England Journal of Medicine. Findings were as follows: Risks of bariatric surgery have dropped dramatically and now are no greater than gallbladder or hip replacement surgery. Risks are lower than the longer-term risk of dying from heart disease, diabetes, and other consequences of carrying more weight than a persons organs can tolerate. At 30 days post-surgery, researchers found the mortality rate among patients who underwent a Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding to be 0.3%, and a total of 4.3% of patients had at least one major adverse outcome.
The findings of this research very strongly reaffirm the safety of bariatric surgery and should help to inspire greater confidence from the general public and policymakers, thus making it more difficult to deny or delay coverage of these life-saving and life-extending procedures. The safety and effectiveness of bariatric surgery on morbid obesity and expensive obesity-related conditions is emerging as an even more powerful force in this new era of healthcare reform.
American Society for Metabolic & Bariatric Surgery, 7/30/09

American Society for Metabolic & Bariatric Surgery, 100 SW 75th Street, Suite 201, Gainesville, FL 32607. (352) 331-4900. (www.asbs.org) Perioperative Safety in the Longitudinal Assessment of Bariatric Surgery by the Longitudinal Assessment of Bariatric Surgery (LABS) Consortium, New England Journal of Medicine, July 30, 2009, pp 445454.
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BEHAVIORAL & MENTAL HEALTH
PREVALENCE & COST

Estimates suggest that in the U.S., 10.3 million people have serious mental illness. Of these, approximately 60% are treated in hospitals or public health facilities, 90% as outpatients. According to the World Health Organization, mental illness tops all other diseases as a cause of disability in the United States, Canada, and Western Europe, accounting for 25% of all disability. According to the National Alliance on Mental Illness (NAMI), the economic cost of untreated mental illness in the United States is more than $100 billion annually. The consequences of untreated mental illness for the individual and society are staggering: unnecessary disability, substance abuse, unemployment, homelessness, incarceration, and suicide, not to mention wasted lives.
MENTAL HEALTH EXPENDITURES

Of the more than $100 billion spent on mental healthcare annually in the U.S., government healthcare programs pay about 60% of the total. According the Healthcare Cost and Utilization Project, from the Agency for Healthcare Research and Quality (AHRQ), the following are the top five behavioral health-related hospitalizations (primary diagnosis) and total charges:
Discharges Charges
Mood disorders: 713,377 Schizophrenia and other psychotic disorders: 372,749 Substance-related disorders: 229,269 Screening: 71,507 Delirium, dementia, amnestic, and other cognitive disorders: 133,004
$8.9 billion
$6.9 billion $2.5 billion $2.4 billion
$2.3 billion
Mental-health and substance-abuse conditions account for more disability than any other condition in America. Approximately 217 million days of work are lost annually because of productivity decline related to mentalillness and substance-abuse disorders, costing U.S. employers $17 billion each year.
David Shern, CEO Mental Health America Modern Healthcare, 1/12/09
In 2008, sales in the U.S. of anti-psychotic and anti-depressant medications were $14.6 billion and $9.6 billion, respectively, according to IMS Health.
REIMBURSEMENT PARITY
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, part of the federal bailout package signed into law in October 2008, requires group health plans of 50 or more employees that provide medical-surgical coverage and mental health and substance-abuse benefits
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to ensure that financial requirements and treatment limitations for mental health coverage are on par with those for medicalsurgical services. According to NAMI, 42 states had some form of parity legislation prior to the federal law. However, selfinsured plans, which cover some 82 million people, didnt fall under the jurisdiction of state parity laws. The federal parity law took effect in 2010. The Medicare Improvements for Patients and Providers Act of 2008 calls for the reduction of co-insurance for outpatient mental health services from 50% to 20% which is the same level as non-psychiatric services by 2014.
THE STATE OF MENTAL HEALTH AND TREATMENT

In 2009, NAMI conducted its second comprehensive state-by-state analysis of mental health services. Each state was scored on 39 specific criteria resulting in an overall grade and four sub-category grades. The national average grade was D. No state received an A. Fourteen states improved their grades from the previous assessment, conducted in 2006; grades for 12 states declined. The assessment graded each state as follows: Alabama: D Alaska: D Arizona: C Arkansas: F California: C Colorado: C Connecticut: B Delaware: D District of Columbia: C Florida: D Georgia: D Hawaii: C Idaho: D Illinois: D
Indiana: Iowa: Kansas: Kentucky: Louisiana: Maine: Maryland: Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:
D D D F D B B B D C F C D D D C C C B D D C B C C C D F D D D C C C F C F
COMMUNITY HOSPITAL SERVICES

Many community hospitals are not adequately prepared to provide services for patients with behavioral health problems. According to the American Hospital Association, only 1,349 of 4,919 community general hospitals, or 27%,
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have an organized inpatient psychiatric unit.

Agency for Healthcare Research and Quality, 2101 East Jefferson Street, Suite 501, Rockville, MD 20852. (301) 594-1364. (www.ahrq.gov) Grading The States, National Alliance on Mental Illness, March 2009. Huff, Charlotte, Something New For Mental Health Services, Hospitals & Health Networks, February 2009, pp 32-33. IMS Health, 901 Main Avenue, Suite 612, Norwalk, CT 06851. (203) 845-5200. (www.imshealth.com) National Alliance on Mental Illness, 2107 Wilson Boulevard, Suite 300, Arlington, VA 22201. (703) 524-7600. (www.nami.org) National Association of Psychiatric Health Systems, 701 13th Street NW, Suite 950, Washington, DC 20005. (202) 393-6700. (www.naphs.org) Shern, David, Parity Pays Dividends, Modern Healthcare, January 12, 2009, p. 24. The 2008 NAPHS Annual Survey, National Association of Psychiatric Health Systems, March 2009.
According to the AHRQ, approximately 25% of all hospitalizations involve depressive, bipolar, schizophrenia, substance abuse, or other behavioral health disorders as a primary or secondary diagnosis. Emergency departments have become the safety net for many patients with severe behavioral health disorders who often seek care in general hospitals that are designed for short-stay medical-surgical patients. General hospitals that lack adequate psychiatric services generally attempt to move behavioral health patients to other facilities with such capabilities.
BEHAVIORAL HEALTH HOSPITALS

According the National Association of Psychiatric Health Systems (NAPHS), occupancy rates at behavioral health hospitals have been at record highs. In The 2008 NAPHS Annual Survey, published in March 2009, inpatient behavioral hospital admissions were found to have increased 3.5% (to an average of 2,688). Hospital lengths of stay increased 1% to 9.7 days. Residential treatment admissions remained steady at average of 175. Behavioral health facilities scaled back beds for decades because of low occupancy rates. In Illinois, for example, there were as many as 55,000 behavioral health beds during the 1950s; now there are only 1,400. The numbers are now increasing in some areas.
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93
CANCER
PREVALENCE
Cancer is the second-leading cause of death in the United States, exceeded only by heart disease. According to Cancer Facts and Figures 2009, by the American Cancer Society, an estimated 1.48 million people in the U.S. were diagnosed with cancer in 2009, and an estimated 562,300 died of the disease. As Americas population ages, incidences of cancer are likely to increase, since cancer is much more common in the elderly than in the young. As diagnostic technology improves and more treatment options become available, however, survival rates are improving. The 5-year survival rate for all cancers combined is 66%, according to the American Cancer Society.
The American Cancer Society estimates that 292,540 men died from cancer in 2009. The following are the leading sites: Lung and bronchus: 88,900 Prostate: 27,360 Colon and rectum: 25,240 Pancreas: 18,030 Leukemia: 12,590 Liver: 12,090 Esophagus: 11,490 Urinary bladder: 10,180 Non-Hodgkin lymphoma: 9,830 Kidney and renal pelvis: 8,160
CANCER IN WOMEN
The American Cancer Society estimates 713,220 new cancer cases among women in 2009. The following are the leading sites: Breast: 192,370 Lung and bronchus: 103,350 Colon and rectum: 71,380 Uterine corpus: 42,160 Non-Hodgkin lymphoma: 29,990 Melanoma: 29,640 Thyroid: 27,200 Kidney and renal pelvis: 22,330 Ovary: 21,550 Pancreas: 21,420 The American Cancer Society estimated that 269,800 women died from cancer in 2009. The following are the leading sites: Lung and bronchus: 70,490 Breast: 40,170 Colon and rectum: 24,680 Pancreas: 17,210 Ovary: 14,600 Non-Hodgkin lymphoma: 9,670
CANCER IN MEN
According to the American Cancer Society, 766,130 new cancer cases were estimated among men in 2009. The following are the leading sites: Prostate: 192,280 Lung and bronchus: 116,090 Colon and rectum: 75,590 Urinary bladder: 52,810 Non-Hodgkin lymphoma: 35,990 Melanoma: 39,080 Kidney and renal pelvis: 35,430 Leukemia: 25,630 Oral cavity and pharynx: 24,240 Pancreas: 21,050
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Leukemia: Uterine corpus: Liver: Brain:
9,280 7,780 6,070 5,590
CANCER IN CHILDREN
According to the American Cancer Society, childhood cancers are rare. An estimated 10,730 new cancer cases occurred among children under age 14 in 2009. An estimated 1,380 deaths are estimated to have occurred among children in 2009, about one-third from leukemia.
to adopt more favorable health behaviors (such as quitting smoking) and higher use of screening (such as colonoscopy), as well as optimal treatment outcomes for colorectal cancer (such as mor e ef f ective chemotherapy), there could be an overall colorectal cancer mortality reduction of 50% by 2020. Other highlights from the report show that in men, incidence rates have declined for cancers of the prostate, lung, oral cavity, stomach, brain, colon and rectum, but continue to rise for kidney/renal, liver, and esophageal cancer, as well as for leukemia, myeloma, and melanoma. In women, incidence rates decreased for breast, colorectal, uterine, ovarian, cervical, and oral cavity cancers, but increased for lung, thyroid, pancreatic, bladder, and kidney cancers, as well as for non-Hodgkin lymphoma, melanoma and leukemia.
TRENDS IN INCIDENCE AND MORTALITY

The Annual Report to the Nation on the Status of Cancer, published in December 2009, reported decreases of 1.0% and 1.6%, respectively, in incidence and death rates for all cancers combined. The drops are driven largely by declines in rates of new cases and rates of death for the three most common cancers in men (lung, prostate, and colorectal cancers) and for two of the three leading cancers in women (breast and colorectal cancer). Overall cancer rates continue to be higher for men than for women, but men experienced the greatest declines in incidence (new cases) and mortality (death) rates. For colorectal cancer, the third most frequently diagnosed cancer in both men and women, and the second leading cause of cancer deaths in the United States, overall rates are declining but increasing incidence in men and women under 50 years of age is of concern. The 2009 Annual Report used modeling projections to estimate that with accelerated cancer control efforts to get more Americans
The continued decline in overall cancer rates documents the success we have had with our aggressive efforts to reduce risk in large populations, to provide for early detection, and to develop new therapies that have been successfully applied in this past decade. Yet we cannot be content with this steady reduction in incidence and mortality. We must, in fact, accelerate our efforts to get individualized diagnoses and treatments to all Americans and our belief is that our research efforts and our vision are moving us rapidly in that direction.
John E. Niederhuber, M.D., Director National Cancer Institute, 12/7/09
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Among racial/ethnic groups, cancer death rates were highest in black men and women and lowest in Asian/Pacific Islander men and women. Although trends in death rates by race/ethnicity were similar for most cancer sites, death rates from pancreatic cancer, the fourth most common cause of cancer death in the United States, increased among white men and women but decreased among black men and women. First issued in 1998, the annual report is a collaboration among the National Cancer Institute, the Centers for Disease Control and Prevention, the American Cancer Society, and the North American Association of Central Cancer Registries. The report can be accessed online at http://seer.cancer.gov/report_to_nation/.
Driven by increasing demand, for-profit chains continue to add facilities. Changes in reimbursement and advances in drug therapy, which has made it easier for oncologists to administer care in their offices, has prompted hospitals to push cancer care into the outpatient setting, according to Lee Mortenson of the Association of Community Cancer Centers. The shift to outpatient settings began increasing in the mid- and late-1990s. With 90 outpatient centers nationwide, U.S. Oncology (www.usoncology.com) is the largest for-profit company in outpatient cancer services. Another key player is Aptium Oncology (www.aptiumoncology.com), which partners with hospitals. Hospitals maintain their own brand in centers co-developed and operated by Aptium.
THE MEDICAL TREATMENT MARKETPLACE

The U.S. spends about $200 billion annually on cancer care. According to the National Center for Health Statistics and the National Institutes of Health, cancer care in the U.S. is distributed as follows: Inpatient care Number of discharges: 1.2 million Length of stay: 6.6 days Ambulatory care Number of visits to officebased physicians: Number of hospital outpatient visits:
PREVENTION
According to the American Cancer Society, the cancer burden from tobacco smoking (approximately 30% of all cancer deaths) and the combination of poor nutrition, lack of physical activity, and obesity (35%) can largely be avoided. Heredity factors, which account for 20% to 25% of cancer deaths, present a greater challenge for prevention, but can be minimized through screening. The American Cancer Society estimates that in 2008 more than 168,000 cancer deaths were caused by tobacco use alone, all of which could have been prevented. Half of all those who continue to smoke will die from smoking-related diseases.
Cancer Facts & Figures 2009
27.7 million 2.5 million
Approximately 85% of cancer care is delivered in community-based centers or physicians offices. According to one estimate, there are over 1,000 outpatient ambulatory-care cancer centers in the U.S.
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In the U.S., obesity contributes to 14% to 20% of all cancer-related mortality.
Annual Report to the Nation on the Status of Cancer, National Cancer Institute, December 2009. Association of Community Cancer Centers, 11600 Nebel Street, Suite 201, Rockville, MD 20852. (301) 984-9496. (www.accc-cancer.org) Cancer Facts & Figures 2009, American Cancer Society, January 2009. National Cancer Institute, 6116 Executive Boulevard, Bethesda, MD 20892. (800) 442-6237. (www.cancer.gov) North American Association of Central Cancer Registries, 2121 West White Oaks Drive. Suite B, Springfield, IL 62704. (217) 698-0800. (www.naaccr.org)
For the majority of Americans who do not use tobacco, dietary choices and physical activity are the most important modifiable determinants of cancer risk.
Cancer Facts & Figures 2009
Certain cancers are related to infectious exposures (e.g., hepatitis B virus [HBV], human papillomavirus [HPV], human immunodeficiency virus [HIV], helicobacter, and others) and could be prevented through behavioral changes, vaccines, or antibiotics. In addition, many of the occurrences of skin cancer could have been prevented with proper sun protection, according to the American Cancer Society. Screenings and examinations by a healthcare professional can lead to detection of cancers of the breast, colon, rectum, cervix, prostate, oral cavity, and skin at earlier stages, when treatment is more likely to be successful. A heightened awareness of breast changes or skin changes may also result in detection of tumors at earlier stages. Cancers that can be detected earlier by screening account for about half of all new cancer cases. The fiveyear relative survival rate for these cancers is about 84%. If all of these cancers were diagnosed at a localized stage through regular cancer screenings, five-year survival would increase to about 95%.

American Cancer Society, 2200 Lake Boulevard, Atlanta, GA 30319. (404) 816-7800. (www.cancer.org)
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94
CARDIOVASCULAR DISEASE
PREVALENCE
According to 2009 Heart Disease and Stroke Statistics, by the American Heart Association, 80.0 million Americans have one or more type of cardiovascular disease (CVD). Of them, 48% are male and 52% are female; 38% are ages 65 and older. Approximately six million U.S. patients show up in emergency rooms or doctors offices each year complaining of chest pain. Only 10% to 15% are actually having a heart attack. An additional 30% to 40% have some other cardiac ailment. Approximately 50% of patients with chest pain likely have no heart problems. Heartburn, joint inflammation, pleurisy, a little-understood condition called chest-all pain, and a blood clot in the lung are among problems whose symptoms mimic a heart attack. There are approximately 60 million physician office visits and six million outpatient department visits with a primary diagnosis of CVD.
The following is a breakdown of the 864,480 annual deaths in the U.S. attributed to CVD: Coronary heart disease: 52% Stroke: 17% Congestive heart failure: 7% High blood pressure: 7% Other: 18%
COST
According to 2009 Heart Disease and Stroke Statistics, direct costs of cardiovascular diseases and stroke in 2008 were $313.8 billion, distributed as follows: Hospitals: $150.1 billion Drugs and other medical durables: $ 52.3 billion Nursing homes: $ 48.2 billion Physicians/other professionals: $ 46.4 billion Home healthcare: $ 16.8 billion Indirect costs (i.e., lost productivity from morbidity and mortality) were estimated at $161.5 billion.
TABLE 94.1 Incidences Of Specific Cardiovascular Diseases High blood pressure: Coronary heart disease, total: - Angina pectoris: - Myocardial infarction: Stroke: Congestive heart failure: Congenital cardiovascular defects: 73.6 million 16.8 million 9.8 million 7.9 million 6.5 million 5.7 million 1.3 million to 650,000
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TABLE 94.2 Distribution of Direct Costs of Cardiovascular Disease Heart disease (includes coronary heart disease, congestive heart failure, part of hypertensive disease, cardiac dysrhythmias, rheumatic heart disease, cardiomyopathy, pulmonary heart disease, and other heart diseases): Coronary heart disease (included in the above total): Hypertensive disease: Stroke: Congestive heart failure:
$183.0 billion $ 92.8 billion $ 52.4 billion $ 45.9 billion $ 33.7 billion
Regardless of its size or scope of services, cardiovascular services can account for up to 40% of the net revenue of an acute care hospital, according to the Healthcare Financial Management Association. Successful cardiovascular programs can help make up for revenue declines in a hospitals other service areas.
new strategy to stem diabetes and obesity is found, a new wave of cardiovascular disease deaths can be anticipated.
PREVENTION
Recent studies have confirmed that four risk factors high blood pressure, bad cholesterol numbers, diabetes, and smoking explain at least 80% to 90% of all heart disease. While these root causes of cardiovascular and other health conditions are well known by both the medical community and general public a high percentage of the population in these risk categories continues to ignore their necessary lifestyle changes and/or medical treatments. Several studies have presented accounts of how well statins work in helping patients avoid heart attacks after undergoing angioplasty procedures that clear out diseased coronary arteries. These findings add to the host of previous studies suggesting that patients benefit from statins regardless of how high their cholesterol is. Positive findings like these have made statins the largest therapeutic class in the U.S., with annual sales of $15 billion.
TRENDS IN CARDIOVASCULAR DISEASE

The Centers for Disease Control and Prevention had set as a goal a 25% reduction in the heart disease mortality rate for the 2000-2009 decade. The goal was reached five years early, as heart disease rates dropped 25.8% between 1999 and 2005, from 195 to 144 deaths for every 100,000 people. Stroke deaths dropped 24.4% during the same period, from 61 to 47 deaths per 100,000. Extrapolating this data suggests that as many as 260,000 lives were saved in 2009. The biggest hurdle to continued progress in the nations heart health is the growing prevalence of obesity and diabetes. According to Daniel Jones, M.D., president of the American Heart Association, unless a
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CARDIAC SURGERY
According to 2009 Heart Disease and Stroke Statistics, the following number of inpatient cardiovascular operations and procedures were performed in the U.S. in 2006 (most recent data available): Diagnostic cardiac catheterizations: 1,271,000 Angioplasty: 1,265,000 - Stenting (in conjunction with angioplasty): 620,000 Open-heart surgery: 699,000 Cardiovascular revascularization (bypass): 469,000* Pacemakers: 180,000 Valve procedures: 106,000 Endarterectomy: 103,000 Implantable defibrillators: 91,000
*number of procedures, including multiple procedures on patients; the total number of patients was 261,000
angioplasty procedures performed each year has declined by 10% to 15% since 2006.

2009 Heart Disease and Stroke Statistics, American Heart Association, March 2009. American College of Cardiology, 240 N Street NW, Washington, DC 20037. (202) 375-6000. (www.acc.org) American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231. (800) 242-8721. (www.americanheart.org) Edelson, Ed, Angioplasty No Better Than Drug Treatment In Long Run, U.S. News & World Report, August 13, 2008. Healthcare Financial Management Association, Two Westbrook Corporate Center, Suite 700, Westchester, IL 60154. (800) 252-4362. (www.hfma.org) IMS Health, 901 Main Avenue, Suite 612, Norwalk, CT 06851. (203) 845-5200. (www.imshealth.com) Landro, Laura, Guidelines For Heart Care Show Promise, The Wall Street Journal, April 15, 2009. Qforma, 20 Nassau Street, Suite 119, Princeton, NJ 08542. (609) 391-8071. (www.qforma.com)
ANGIOPLASTIES
In the past decade, angioplasty has displaced bypass surgery as the primary treatment for blocked coronary arteries. One reason is that angioplasty is a minimally invasive procedure, requiring a mere slit in the groin and one night in the hospital. More than one million angioplasties are performed in the U.S. annually. Virtually all of these are performed in hospitals with cardiovascular surgical capabilities. Recent studies, however, indicate that using the procedure to open blocked arteries to treat chest pain, or angina, may be riskier and no more beneficial than medication. The research suggests angioplasty is used too often, and in many cases, the modest benefits dont justify the procedures cost, which ranges from $10,000 to $12,000. According to an analysis by Qforma using data from IMS Health, the number of
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95 CHRONIC CONDITIONS
PREVALENCE
According to a 2008 report by the Agency for Healthcare Research and Quality, 60% of Americans have at lease one chronic condition. By age, the percentages with chronic disease are as follows:
None One Two +
According to the American Hospital Association, chronic conditions account for approximately 75% of total healthcare spending. People with chronic conditions spend six times more per year on healthcare than do healthy people, while those who have function limitation in addition to a chronic condition spend 16 times more on healthcare.
All adults: 18-to-34: 35-to-54: 55-to-64: 65 and older:
40.0% 63.6% 41.8% 22.7% 8.5%
21.6% 22.0% 24.8% 20.3% 14.9%
38.2% 14.4% 33.4% 57.0% 76.6%
FINANCIAL BURDEN
According to an April 2009 study by the Center for Studying Health System Change, among the 39% of the working-age population, or 72 million people, that have at least one chronic health condition, 28% are within families with problems paying medical bills, an increase from 21% in 2003. While problems paying medical bills are especially acute and still rising for uninsured people with chronic conditions (62%), medical-bill problems also are significant and growing among people with private insurance and higher incomes.
HEALTHCARE SPENDING
People with chronic conditions account for a disproportionately high percentage of healthcare spending. According to a recent study by the Agency for Healthcare Research and Quality, about 5% of the U.S. population accounts for nearly one-half of all medical expenditures. For comparison, the half of the population with the lowest medical expenditures represents 3% of overall national medical expenses. The following is a distribution of healthcare expenditures by age:
Top 5% of spenders Bottom 50% of spenders

Agency for Healthcare Research and Quality, 2101 East Jefferson Street, Suite 501, Rockville, MD 20852. (301) 594-1364. (www.ahrq.gov) Center for Studying Health System Change, 600 Maryland Avenue SW, Suite 550, Washington, DC 20024. (202) 484-5261. (www.hschange.com)
Birth-to-18: 19-to-34: 35-to-44: 45-to-54: 55-to-64: 65-to-79: 80 and above:
5% 9% 10% 15% 18% 29% 14%
37% 27% 16% 11% 5% 3% 1%
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Tu, H.T. and Genna R. Cohen, Financial and Health Burdens of Chronic Conditions Grow, Center for Studying Health System Change, April 2009.
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CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Chronic obstructive pulmonary disease (COPD) encompasses a group of lung disorders including chronic bronchitis, emphysema, and asthmatic bronchitis. Each of these conditions is characterized by a narrowing of the airways (bronchi) and loss of the lungs elasticity. This airway narrowing, most often caused by smoking, develops slowly; however, early detection of COPD can help slow the progress of the disease and allow those diagnosed to maintain active lives.
COST
According to the American Lung Association, the cost to the nation for COPD is approximately $37.2 billion, including direct healthcare expenditures of $20.9 billion, $7.4 billion in indirect morbidity costs, and $8.9 billion in indirect mortality costs. According to the Agency for Healthcare Research and Quality, $10.3 billion is spent on treatment of chronic COPD biannually, distributed as follows: Medicare: $6.6 billion Medicaid: $2.0 billion Commercial: $1.3 billion Other: $0.4 billion
PREVALENCE
According to the American Lung Association, COPD is the fourth leading cause of death in America, claiming the lives of 120,000 Americans annually. In 2008, more than 12 million people were diagnosed with COPD. The disease is associated with over 650,000 hospital discharges annually. The American Association for Respiratory Care estimates that there are as many as 15 million people in the United States with undiagnosed COPD. The majority of these people will have lost 20% to 40% of their lung function before they show any signs of the illness. Approximately 80% to 90% of COPD deaths are caused by smoking. Smokers are about 12 times more likely to die from COPD than those who have never smoked.
TREATMENT
Medications are used to treat COPD, as follows: Bronchodilators relax the muscles around the airways Anti-inflammatory medicines, also called corticosteroids or steroids, help by reducing the swelling and mucus production inside the airways Combination medicines combine inhaled bronchodilators and inhaled corticosteroids Antibiotics treat flare-ups that may be caused by bacterial or viral infections With severe COPD, lung function is reduced to the extent that supplemental oxygen, also called oxygen therapy, is needed to continue normal bodily functions.
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Pulmonary rehabilitation teaches patients to manage COPD through exercise, allowing them to become more active with less shortness of breath. Medicare began reimbursing for pulmonary rehabilitation in 2010.
PREVENTION
Quitting smoking is the single most important thing a person can do to prevent COPD along with a host of other diseases. It is also important to avoid exposure to secondhand smoke, chemicals, dust and fumes, and polluted air. Smoking is assessed in Chapter 6 of this handbook.

American Association for Respiratory Care, 9425 North MacArthur Boulevard, Suite 100, Irving, TX 75063. (972) 243-2272. (www.aarc.org) American Lung Association, 61 Broadway, 6th Floor, New York, NY 10006. (212) 315-8700. (www.lungusa.org)
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COLDS
PREVALENCE
The common cold is caused by not one common virus but five different viral families encompassing a couple of hundred unique viral strains among them. The strains are sufficiently different from one another that even after catching one, people can later be infected by all the others. An adult catches an average of two to four colds each year. Children are the primary targets of cold viruses, suffering from six or more colds each year. It total, it has been estimated that Americans get 1.4 billion colds each year.
for colds. An additional $5 billion is spent annually on over-the-counter cold remedies. There are approximately 800 different overthe-counter cold remedies, most with the same basic ingredients.
DIAGNOSIS & TREATMENT

Distinguishing between colds and flu can be tough, even for doctors. A recent study by researchers from Vanderbilt University found only 28% of children hospitalized and 17% of those treated in clinics who had lab-confirmed flu had been accurately diagnosed by their doctors. Its not that doctors cant make an accurate diagnosis, rather its not easy to get a rapid diagnosis that is specific and accurate. Rapid tests are available but not widely used, according to the researchers. Even still, they are only 75% to 80% accurate. Clearly, patients need to be better informed about colds. A recent survey by Bostons Childrens Hospital of parents with children under age six found that nearly all of the families knew that viruses cause colds, but more than half thought antibiotics are needed to treat them. Nearly two-thirds of parents said they would take their child to the doctor if the child had a cold, while nearly a quarter said theyd take their child to the emergency room. A cure for colds does not appear to be on the horizon.
COSTS
In a recent study by the Consortium for Health Outcomes, Innovation, Cost Effectiveness Studies (CHOICES) at the University of Michigan in Ann Arbor, published in the Archives of Internal Medicine, researchers estimate that coldrelated costs topped $39.5 billion a year in the United States. The study excluded viral respiratory tract infections related to the flu. Over 55% of the cost of colds, or $22.5 billion, is a result of missed workdays. Much of the rest of the cost stems from ineffective medical care, mainly doctors visits and antibiotic prescriptions. The University of Michigan researchers estimated that colds lead to 110 million doctor visits and six million emergency room visits annually. Prof. Mark Fendrick, M.D., at the School of Public Health at the University of Michigan, estimates that more than $1.1 billion is spent annually on 41 million antibiotic prescriptions
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COSMETIC & RECONSTRUCTIVE SURGERY
MARKET ASSESSMENT
According to the American Society of Plastic Surgeons (ASPS), 12.1 million cosmetic procedures were performed in 2008, a 3% increase from 2007. Total spending was $10.3 billion, a 9% decline from 2007.
Cosmetic procedures were performed by type of provider facility as follows: Office: 7.8 million Hospital: 1.8 million Ambulatory surgical center: 2.4 million The cosmetic surgery market is being driven, to a large extent, by Baby Boomers desiring to maintain a youthful appearance.
TABLE 98.1 Top Cosmetic Surgical Procedures Among Women

Number Avg. Cost
Surgical Breast augmentation: Liposuction: Nose reshaping: Eyelid surgery: Tummy tuck: Minimally Invasive Botox injection: Hyaluronic acid: Chemical peel: Laser hair removal: Microdermabrasion:
307,000 218,000 204,000 190,000 117,000
$3,348 $2,881 $4,197 $2,963 $5,167
4.7 million 1.1 million 962,000 717,000 668,000
$391 $578 $815 $456 $200
source: American Society of Plastic Surgeons
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TABLE 98.2 Top Cosmetic Surgical Procedures Among Men

Number Avg. Cost
Surgical Nose reshaping: Eyelid surgery: Liposuction: Breast reduction: Hair transplantation: Minimally Invasive Botox injection: Microdermabrasion: Laser hair removal: Chemical peel: Laser skin resurfacing:
75,000 31,000 27,000 18,000 13,000
$4,197 $2,963 $2,881 $3,282 $4,451
314,000 174,000 174,000 86,000 49,000
$ 391 $ 200 $ 456 $ 815 $1,359
source: American Society of Plastic Surgeons
MARKET TRENDS
Among the more popular cosmetic surgical procedures, the following experienced the highest growth between 2000 and 2008: Botox: 537% Soft tissue fillers: 144% Laser skin resurfacing: 134% Tummy tuck: 94% Dermabrasion: 87% Breast lift: 75% Thigh lift: 71% Breast augmentation: 45% Laser hair removal: 21% The following procedures declined between 2000 and 2008: Collagen fillers: -70% Forehead lift: -65% Hair transplantation: -61% Sclerotherapy: -57% Breast implant removals: -49% Chin augmentation: -48% Eyelid surgery: -32%
Liposuction: Facelift: Chemical peel: Laser treatment of leg veins:
-31% -26% - 9% -10%

American Society of Plastic Surgeons, 444 E. Algonquin Road, Arlington Heights, IL 60005. (847) 288-9900. (www.plasticsurgery.org)
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99
DIABETES
PREVALENCE AND MORTALITY

The Centers for Disease Control and Prevention estimated in 2009 there were 24.0 million Americans, or 8% of the population, with diabetes. Of those, 6.5 million people (or nearly one-third) are unaware they have the disease. This represents a 15% increase from the 20.8 million who had the disease three years prior. The CDC has classified diabetes as reaching epidemic levels in the United States. An additional 10 million Americans are at risk of diabetes because of obesity or a family history of the disease. Diabetes has increased in recent years in all demographics male and female, old and young, white and black, rich and poor. A 2008 report from the Robert Wood Johnson Foundation reported a dramatic increase in diabetes among children, a condition brought about almost entirely by the increasing rate of youth obesity.
reports that 26% of adults have impaired fasting glucose, a form of pre-diabetes, putting them at risk of developing diabetes. Combined, those with either diabetes or prediabetes number more than 77 million. Diabetes, for which there is no cure, is the sixth-leading cause of death in the United States. Approximately 800,000 new cases of diabetes develop each year. By 2030, the total number of Americans with diabetes could reach 50 million, with at least 300 million cases worldwide. Almost 200,000 people die from diabetes and related complications each year. The Yale Schools of Public Health and Medicine predict that the number of annual deaths due to diabetes in the U.S. could triple by 2025, to 622,000.
TYPE I AND TYPE II DIABETES

Type I diabetes, formerly called juvenile diabetes, is the most common chronic childhood disease, less common than Type II and imminently life-threatening. It mainly strikes children and young adults. It affects an estimated 700,000 to one million Americans. With these diabetics, the bodys immune system destroys the insulinproducing beta cells in the pancreas. Type I diabetics require daily insulin, either by injection or a pump, to keep blood sugar from increasing to dangerous levels. The medical cost to raise a child with diabetes through adulthood is $600,000. Type I diabetes typically reduces life expectancy by 15 years.
Nearly 200,000 individuals under the age of 20 have Type II diabetes and two million adolescents ages 12-to-19 have pre-diabetes symptoms. These are illnesses that formerly were seen only in adults.
Robert Wood Johnson Foundation
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
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Type II diabetes, formerly called adult-onset diabetes, is the most common form of diabetes. It affects 15 million Americans. Experts estimate only half of all cases have actually been diagnosed. Type II is caused by a combination of insulin resistance and the improper secretion of insulin. Approximately 80% of people with Type II diabetes are overweight; there are other causative factors. Type II usually can be controlled with diet, exercise, and oral drugs in the early stages. Typically, 40% of Type II diabetics eventually require insulin injections. Prenatal factors, such as gestational (pregnancy-induced) diabetes, which increases the risk of Type II diabetes in mother and child, can also play a role. Recent research shows that 20% of Type II diabetes has a genetic cause. The gene, identified in a study of Icelands comprehensive genetic records, is carried by 38% of the Northern European populations studied, and it is also common among African-Americans. People think its their fault, but thats not true. Roughly 20% of the people with Type II diabetes are thin and 75% of obese people never get it. People with a lot of genetic loading can get it at a younger age and a lower body weight.
Robin Goland, M.D., Co-Director Naomi Berrie Diabetes Center Columbia University The Wall Street Journal, 5/19/09
ECONOMIC IMPACT
According to the American Diabetes Association (ADA), annual direct medical expenditures related to diabetes treatment are $92 billion; approximately 44% of those costs are attributed to inpatient hospital stays. The American Association of Clinical Endocrinologists estimates $23 billion is spent annually on treating complications, primarily cardiovascular disease. Including lost productivity and other indirect costs, the annual cost of diabetes is estimated at $132 billion. According to the National Changing Diabetes Program, diabetes accounts for 12% of federal healthcare spending. Treatment for people with diabetes costs nearly $80 billion more than treatment for those without it.
TREATMENT
What was thought to be the optimal treatment for diabetes was called into question in 2008 when the National Heart, Lung, and Blood Institute called a halt to part of its ACCORD (Action to Control Cardiovascular Risk in Diabetes) study, saying it posed a risk to patients. Conventional wisdom suggested that diabetes patients who kept blood sugar close to normal levels were better off. The ACCORD study was designed to better understand how controlling blood sugar levels could reduce the risk of heart disease in Type II diabetics. The ACCORD test had two groups of patients: an intensive-management group with the goal of driving blood sugars down to less than 6% on the A1C test and a usual-care group, who were supposed to get sugars to the standard range of 7% to 7.9%. (The A1C is a measure of how much sugar is in the blood; people without diabetes have an A1C of 4% to 6%.) The hope was that the ACCORD study would show that near-normal blood sugars could also protect diabetics from heart disease and stroke. Four years
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into the study, 257 people in the intensivemanagement group had died, compared with 203 people getting the standard treatment. The Veterans Affairs Diabetes Trial (VADT), developed to address the effect of intensive glucose therapy in Type II diabetes, also reported in 2008 a possible link between intensively lowering blood sugar and possible increases in cardiovascular complications and heart-related deaths. Analysis of the ACCORD and VADT data, presented in June 2009 at the American Diabetes Associations 69 th Scientific Sessions, suggested that intensively lowering blood sugar in the early years of diabetes may reduce the chance of heart problems and premature death, but the same aggressive treatment does not appear to yield similar benefits in longtime Type II diabetics. Prof. Matthew Riddle, M.D., at Oregon Health Science University and a member of the Glycemia Manage Group of ACCORD, reported that the Type II patients in the study who quickly lowered A1C levels during the first year of treatment appeared to have a lower risk of death. William Duckworth, M.D., director of diabetes research at the Carl T. Hayden VA Medial Center in Phoenix, reported that the VADT data reveals an age factor. In general, the data show intensive treatment within the first 15 years of diagnosis has an increased chance of yielding improved health, while intensive treatment after 20 years of having diabetes has an increased chance of doing harm.

American Diabetes Association, 1701 North Beauregard Street, Alexandria, VA 22311. (800) 342-2383. (www.diabetes.org) Beck, Melinda, Hidden Risk: Millions Of People Dont Know They Are Diabetic, The Wall Street Journal, May 19, 2009. Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333. (404) 639-3311. (www.cdc.gov) Marcus, Mary Brophy, Age May Be Key To Diabetes Risk, USA Today, June 10, 2009. National Changing Diabetes Program, 100 College Road West, Princeton, NJ 08540. (www.ncdp.com) National Heart, Lung, and Blood Institute, P.O. Box 30105, Bethesda, MD 20824. (301) 592-8573. (www.nhlbi.nih.gov) National Institute of Diabetes and Digestive and Kidney Diseases, 31 Center Drive, MSC 2560, Bethesda, MD 20892. (301) 496-3583. (www.niddk.nih.gov) Robert Wood Johnson Foundation, P.O. Box 2316, College Road East and Route 1, Princeton, NJ 08543. (888) 631-9989. (www.rwjf.org)
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100 END-OF-LIFE CARE
Approximately 70% of Americans say that if they were terminally ill they would prefer to die at home; only about 25% do so. Research has suggested that, given a choice, the majority of people facing a terminal illness, debilitating disease, or simply old age would prefer less intervention to more.
Physicians are often willing to provide dialysis care to patients with greatly diminished quality of life. Yet research suggests that dialysis provides little benefit to the oldest, sickest patients. Its main effect: increasing the chance that patients will die in a hospital instead of at home or in a hospice. Many physicians are not well-trained in endof-life care.
Prof. Felix Knauf, M.D. Yale School of Medicine, 10/09 JASN, 10/09
Approximately one-quarter of Medicare is spent on patients in the last year of life, and about one-third goes for care of patients in their last two years. Of concern is that much of this spending is without benefit to patients and, in some cases is counterproductive. A study by researchers from Yale University, published in October 2009 in the Journal of the American Society of Nephrology (JASN), reported that the fastest growing group of patients starting dialysis is those age 75 and older. Yet, among those beginning dialysis in their 80s and 90s, nearly one-half are suffering from congestive heart failure and one-third from diabetes or cardiovascular disease. And a survey of nephrologists (kidney specialists) found that nearly 50% would be willing to continue dialysis in a patient who develops severe dementia.
SPENDING DISPARITIES
Research at Dartmouth Medical School found that Medicare spends twice as much on endof-life care among patients in some parts of the country as in others. The average cost of a Medicare patient in Miami is $16,351; the average in Honolulu is $5,311. In the Bronx, New York, its $12,543, while in Fargo, North Dakota, its $5,738. The average Medicare patient undergoing end-of-life treatment spends 21.9 days in a Manhattan hospital. In Mason City, Iowa, he or she spends only 6.1 days. While spending is frequently higher in big cities than in small towns, there are significant disparities in towns that are otherwise very similar. In Boulder, Colorado, the average cost of Medicare treatment is $9,103, while an hour away in Fort Collins, Colorado, the cost is $6,448. The disparity is explained by the fact that in some places doctors are more likely to order more tests
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and procedures, and more specialists are involved. The Dartmouth researchers found that extra tests and treatment do not necessarily buy better care. In fact, they found worse outcomes in many states and cities where there is more healthcare. Its not about rationing care the real problem is unnecessary and unwanted care.
Prof. Elliott Fisher, M.D. Dartmouth Medical School Newsweek, 9/21/09
The last year of life has been top-ofinterest given the cost. More access to palliative and hospice care will be tremendously important in reducing healthcare costs.
Donald Schumacher, President NHPCO Modern Healthcare, 7/20/09
PSYCHOLOGICAL SUPPORT
Some hospitals have found that providing psychological support through added nursing attention or counseling improves care while reducing costs.
HOSPICE AND PALLIATIVE CARE

Hospice and palliative care, which is further assessed in Chapter 21, is on the rise, in large part because of the benefits they provide with their focus on pain management and emotional support. In a recent survey by researchers from Brown University, reported in the Journal of the American Medical Association, some 70% of family members rated the care in hospice as excellent, while more than one-third reported receiving insufficient emotional support or inadequate treatment in a hospital or nursing home. Hospice and palliative care are also more cost-effective. A recent study of 40,000 Medicare beneficiaries by researchers from Duke University, published in Social Science & Medicine, found that hospice use reduced Medicare program spending by an average of $2,309 per beneficiary.
A program at Massachusetts General Hospital, for example, assigns nurses to the hospitals 2,600 sickest and costliest Medicare patients. Along with providing basic care, such as making sure the patients take their medications, they also act as gatekeepers, deciding if a visit to the doctor is really necessary. The program cut costs by 5% while providing patients with what they want and need most: caring human contact. Counseling initiatives about end-of-life issues provide patients with important support. An assessment published in the Archives of Internal Medicine reported that such conversations between doctors and patients can decrease costs by about 35% while improving the quality of life at the end.
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National Hospice and Palliative Care Organization, 1731 King Street, Suite 100, Alexandria, VA 22314. (703) 837-1500. (www.nhpco.org) Rubin, Rita, Kidney Doctors Question Dialysis Guidelines, USA Today, September 14, 2009. Thomas, Evan, Rethinking End-of-Life Care, Newsweek, September 21, 2008, pp 34-40. Vesely, Rebecca, How Will It End? Modern Healthcare, July 20, 2009, pp 3031.
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101
HEADACHES & MIGRAINES
PREVALENCE & COST

As many as 50 million Americans suffer from headaches. The following are several types of chronic headaches (source: National Headache Foundation): Tension headache is the most common, accounting for more than 75% of all headaches. Migraine is the second most common form of primary headache, affecting an estimated 30 million Americans; 18% of all women and 6% of all men. Cluster headaches are a variant of a migraine. They are not as common and occur almost exclusively in men who smoke or drink heavily. They are called cluster headaches because after the first one starts, headaches usually keep coming back for the next few weeks, or even months. Each attack lasts no more than a couple of hours and is associated with severe pain in one eye. Rebound headaches occur when a person experiences one of the above mentioned headaches and becomes dependent on pain killers. When the last dose begins to wear off, the headache comes back. Seventy-three percent (73%) of headache sufferers report experiencing more than one type of headache. For this majority, it is essential to determine headache type in order to develop a specific treatment regimen. Headaches and migraines are one of the leading health-related causes of work absenteeism.
Headaches and their aftermaths cost the U.S. economy $17 billion a year in lost work, disability payments, and healthcare expenses.
Prof. David W. Dodick, M.D. Mayo Clinic Scientific American, 8/08
TREATMENT
With recent developments, physicians now have at their disposal a growing arsenal of headache drugs medications that can stop an accelerating migraine in its tracks, reduce the risk of recurrence, or, in some cases, keep one from happening in the first place. Scientists are starting to uncover subtle d e f e c t s i n b r a i n c h em i s t r y a nd electrophysiology that lead not just to migraines but to all kinds of headaches. Indeed, many neurologists now believe that the most severely disabling headaches are actually migraines in disguise and so are more likely to respond to migraine medications than to standard analgesics such as aspirin, ibuprofen, or acetaminophen. Migraine sufferers have long been told to treat their headaches at the onset. Now, many doctors are prescribing daily drugs to prevent migraines from ever starting at all. Prevention therapy typically provides significant relief only for about half of the people who try it. While it may reduce the frequency of migraines, it rarely eliminates them entirely. And some doctors question whether the benefit is always worth the
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potentially high cost and the range of side effects that can be caused by some daily drugs. Patients with one or two attacks a month are likely better off with one-dose treatments, rather than preventive therapy.
HEADACHE CLINICS
There are over 80 headache clinics across the U.S., many of which are affiliated with hospitals. While themselves a specialty, a few specialize further by patient demographic. The Headache Clinic at the Childrens Hospital of Pittsburgh, for example, focuses on the treatment of juvenile headaches. The Womens Headache Center at Somerville (Massachusetts) Hospital, the first just for women, opened in 2006. A directory of headache specialists and clinics available from the National Migraine Association is available online at http://www.migraines.org/help/helpclin.htm.

Dodick, David W. and J. Jay Gargus, Why Migraines Strike, Scientific American, August 2008, pp 56-61. National Headache Foundation, 820 North Orleans, Suite 217, Chicago, Illinois 60610. (312) 274-2650. (www.headaches.org)
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102 HIV & AIDS
PREVALENCE & MORTALITY

The HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States and Dependent Areas, is published
annually by the Centers for Disease Control and Prevention. A summary of prevalence and mortality data from the 2009 report is presented in Table 102.1.
TABLE 102.1 HIV/AIDS Prevalence and Mortality in the United States Total reported cases; persons living with HIV (not AIDS): Total reported cases; persons living with AIDS: Race/ethnicity of persons living with HIV/AIDS - African-American: 48% - Hispanic: 17% - Caucasian: 33% - Other: 2% Gender - Male: 73% - Female: 27% New diagnosis,HIV or AIDS (annual): New AIDS diagnosis (annual): Deaths of persons with AIDS (annual): 256,400 455,600
56,300 36,000 14,600
An estimated 21% of adults with HIV infection are undiagnosed. This puts the total number of persons living with HIV or AIDS, diagnosed or undiagnosed, at approximately 1.1 million.
governments spend $14 billion domestically on HIV/AIDS annually, distributed as follows: Care and assistance: 75% Research: 18% Prevention: 7% An additional $4 billion is spent by the U.S. government for funding in developing nations, particularly in sub-Saharan Africa. This aid provides life-extending drugs to 1.3 million people and palliative care for another three million.
COST
The estimated annual cost of HIV infections in the U.S. is approximately $30 billion, roughly evenly split between direct and indirect costs. According to the Henry J. Kaiser Family Foundation, federal, state, and local
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THE CURRENT AIDS EPIDEMIC

Americas AIDS epidemic has changed dramatically since the late 1990s. Two decades ago the U.S. epidemic looked simple and homogenous AIDS was a problem for gay men some felt. Today, about one-third of new infections are transmitted through heterosexual intercourse, up from 3% in 1985. According to the CDC, 53% of new infections have occurred in gay and bisexual men. Black/African-American men and women are also strongly affected, and are estimated to have an incidence rate 7 times as high as the incidence rate among Caucasians. Women now account for 26% of newly diagnosed AIDS cases nearly four times the proportion they made up in 1986 and girls account for the majority of new HIV infections among teens. The number of people over 50 with HIV/AIDS is growing significantly due to an aging population, despite the fact that new HIV/AIDS diagnoses are not increasing in that age group. Of 100,000 New Yorkers living with HIV/AIDS, 31% are over 50. Research shows that this group is likely to have high rates of depression, and many have numerous age-related medical conditions that are complicated by their already compromised health. In 1990, as many as 2,000 babies were born in the U.S. infected with HIV. As of 2009, that number had been reduced to less than 800. The Elizabeth Glaser Pediatric AIDS Foundation, founded in 1988, has been credited with nearly wiping out pediatric AIDS in the United States.
globally. The top 10 products, which hold a combined marketshare of 86%, are as follows: Combivir (GlaxoSmithKline) Crixivan (Merck & Co.) Epivir (GlaxoSmithKline) Kaletra (Abbott) Serit (Bristol-Myers Squibb) Sustiva (Bristol-Myers Squibb) Trizivir (GlaxoSmithKline) Viracept (Pfizer) Viramune (Boehringer Ingelheim) Ziagen (GlaxoSmithKline) The FDA approved in 2003 the first fusion inhibitor that works against AIDS, Fuzeon, which is produced by Roche. At roughly $20,000 a year, Fuzeon costs three times as much as most AIDS medicines. In 2006, FDA approved Atripla, the first HIV treatment that packs a triple-drug cocktail into a one-a-day pill. The pill includes doses of Bristol-Myers Squibbs Sustiva and Gilead Pharmaceuticals Truvada, a combo of Viread and Emtriva. The single dose pill vastly simplifies AIDS care, which a few years ago was a regimen of 20 or 30 tablets. Since 1987, AIDS Drug Assistance Programs (ADAPs), which are federally and statefunded, but administered by each state, have made treatments available to patients without insurance or the resources to purchase drugs. These programs are often a last resort for people who are HIV-positive and dont qualify for Medicaid. To be eligible for Medicaid, patients usually have to be among the low income and already have developed full-blown AIDS. Today, ADAPs buy 20% of the HIV drugs prescribed in the U.S., enough for 92,000 people; the remaining 80% are paid for by insurance or are covered by federal programs.
TREATMENT
According to IMS Health, annual HIV antiviral (J5C) sales are approximately $7 billion
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PREVENTION STRATEGIES
Prevention strategies such as intensive counseling, needle exchanges, and treatment for drug addiction cost $5,000 to $40,000 per infection averted. This is very cost effective compared to the costs of AIDS therapies, especially since addiction treatment also pays off in decreased crime and higher employment among the afflicted population, according to Dr. James G. Kahn, University of California at San Francisco. Early detection, which helps prevent the spread of AIDS, is being enhanced by the availability of rapid point-of-care test product. The OraQuick Advance Rapid HIV-1/2 Antibody Test, which provides 99% accuracy detection of HIV using an oral swab, was recently approved by FDA. In April 2009, the CDC launched a $45 million, five-year public awareness campaign including radio ads, transit signs, airport dioramas, online banner ads, and online video in English and Spanish. It is the first such media barrage on the HIV/AIDS epidemic aimed at the public since 1987.

Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333. (404) 639-3311. (www.cdc.gov) Elizabeth Glaser Pediatric AIDS Foundation, 1140 Connecticut Avenue NW, Suite 200, Washington, DC 20036. (202) 296-9165. (www.pedaids.org) HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States and Dependent Areas, Centers for Disease Control and Prevention, December 2009. Sternberg, Steve, Putting AIDS Back On The Nations Radar, USA Today, April 8, 2009. The Henry J. Kaiser Family Foundation, 2400 Sand Hill Road, Menlo Park, CA 94025. (650) 854-9400. (www.kff.org)
The CDC campaign will confront complacency and put HIV/AIDS back on the nations radar screen.
Kevin Fenton, Director HIV/AIDS Prevention Programs CDC, 4/8/09
Prof. David R. Holtgrave, Ph.D., chairman of the Bloomberg School of Public Health at Johns Hopkins, has calculated annual spending of $800 million to $1.3 billion for prevention measures would be required to cut the number of new HIV infections in half.
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103
INFECTIOUS DISEASES
Various infectious diseases are assessed in this handbook as follows: Colds: Chapter 97 HIV/AIDS: Chapter 102 Influenza: Chapter 104 Other infectious diseases are assessed in this chapter.
HEPATITIS C
More than 170 million people worldwide are infected with hepatitis C. Most of the estimated four million Americans with hepatitis C are not aware they have the disease. Most often there are no symptoms, but when they do occur they include fatigue, abdominal pain, loss of appetite, nausea, and vomiting. As many as 10,000 of those infected die each year. People most at risk are intravenous drug users, but healthcare workers, hemodialysis patients, and sexually active individuals are also at risk. According to the CDC, hepatitis C, or HCV, is the most common chronic blood-borne infection in the United States. Doctors call it the Baby Boomer Disease because many victims contracted it as teens in the 1960s and 1970s while injecting or inhaling drugs. The damage it does to the liver, typically for 10-to-20 years before symptoms develop, is the biggest reason for undergoing liver transplants. Over the next 10 years, annual deaths linked to hepatitis C are expected to at least double, perhaps triple. And cases of liver failure and cancer, the two most serious complications of hepatitis C, are rising and will probably climb faster.
PREVALENCE
The number of cases and incidence rates (per 100,000 population) in 2008 for common infectious diseases were as follows: Salmoneliosis: 46,151/15.2 Chickenpox (Varicella): 26,924/8.8 Lyme Disease: 26,739/8.8 Hepatitis A and B: 5,853/1.9 E.Coli: 5,164/1.7 Rabies (animal): 4,911/1.6 Legionellosis: 2,815/0.9 Rocky Mountain spotted fever: 2,276/0.7 Malaria: 1,075/0.4 Meningococcal infections: 1,057/0.3
MORTALITY
The following are the most fatal infectious diseases in the United States, according to Deaths: Final Data for 2006, published by the National Center for Health Statistics in April 2009: Influenza and pneumonia: 63,001 Viral hepatitis: 5,529 Tuberculosis: 648
Were on the edge of a liver-disease epidemic.

Ian Williams, M.D. Chief of Epidemiology Div. of Viral Hepatitis, CDC
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NORWALK VIRUS
Norwalk virus, formally known as norovirus (better known to the public as stomach flu) is the most common cause of gastrointestinal illness in North America, affecting an estimated 23 million Americans each year. No treatment exists. Those infected generally recover on their own within two to three days. Though often associated with cruise ships because it thrives in closed environments and because cruise lines are required by law to report all gastrointestinal illnesses, the virus can be found many places. Cruise ships calling at North American ports reported gastrointestinal outbreaks to the CDC as follows:
# Reports Total Sick
three million cases of infectious pneumonia occur annually, resulting in approximately 61,000 deaths. More than 100 different organisms can cause pneumonia, an acute or chronic inflammation of the lungs. Depending on the kind of pneumonia, symptoms range from a chronic cough (due to mycoplasma pneumonia, or walking pneumonia) to a fever, cough, and shortness of breath (associated with bacterial pneumonia). Pneumonia is not a single disease. It can have over 30 different causes, the most common of which are bacteria, viruses, and mycoplasma. Viral and mycoplasma pneumonia are not as serious as bacterial pneumonia, which can be lifethreatening. Pneumococcal, among the deadliest bacteria in the U.S., kills approximately 40,000 people annually. The microbe causes 500,000 cases of pneumonia yearly as well as an estimated seven million to 10 million middle-ear infections in children and thousands of cases of brain (meningitis) and bloodstream (bacteremia) infections. Pneumococcal pneumonia kills about one out of 20 people who get it. Bacteremia kills about one person in five and meningitis about three people in 10.
2007: 2008: 2009:
41 35 27
4,570 3,551 3,627
According to the CDC, norovirus outbreaks are common in healthcare settings. When hospitals face an outbreak of the highly contagious Norwalk virus, standard infectioncontrol procedures are not adequate, researchers say. Moreover, an outbreak places hospital staffs at extreme risk and the costs involved are significant. A report on a three-month Norwalk outbreak at The Johns Hopkins Hospital found that total hospital costs including extra cleaning supplies, staff sick leave, diagnostic tests, replacement staff, salaries, and lost revenue from closed beds exceeded $650,000.
SEXUALLY TRANSMITTED DISEASES

According to the CDC, 15 million Americans become infected every year with a STD, 50% of which are incurable viral infections such as herpes or human papilloma virus (HPV), the cause of genital warts and cervical cancer. Such incurable STDs affect a total of 65 million Americans. Some STDs, such as syphilis, have been brought to all-time lows. Others, however, such as genital herpes, gonorrhea, and chlamydia, continue to surge and spread through the population. Genital herpes alone affects a total of 20 million
PNEUMONIA & PNEUMOCOCCAL DISEASE

Because of antibiotics, pneumonia is no longer the leading cause of death in the United States. However, death rates have increased dramatically in recent years. Up to
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Americans. The number of cases and incidence rates (per 100,000 population) in 2008 (most recent data available) for STDs were as follows:
Cases Rate
through 2009, with recent cases and deaths as follows: 2006: 4,269 2007: 3,630 2008: 1,356 2009: 663 The number of reported cases has been declining over the past few years because of natural cycles in weather and the mosquito population.
Chlamydia: Gonorrhea: Syphilis:
1,210,523 336,742 13,500
401.3 111.6 4.5
TUBERCULOSIS
According to the CDC, there were 12,898 tuberculosis (TB) cases reported in the U.S. in 2008, a 3.8% decline from 2007 to 4.2 cases per 100,000 population. There has been a decline of more than 50% from the peak of TB resurgence in 1992. TB among foreign-born persons accounted for the majority (55%) of cases in the United States. In 2008, the TB rate in foreign-born persons in the United States was 10 times higher than in U.S.-born persons. The U.S.-Mexico Binational TB Referral and Case Management Project, initiated in 2003 by the American Lung Association of Texas, is credited with helping improve treatment completion by TB patients who cross the border between the two nations.

WEST NILE VIRUS

The effects of West Nile virus, which is spread through bites of infected mosquitos, range from flu-like symptoms to more serious cases that result in encephalitis and meningitis. About 10% of the more serious cases are fatal, according to the CDC. The spread of the West Nile virus was a prominent public health story in 2002 and 2003. Some 4,156 cases of infection by the virus were reported nationwide in 2002, with 284 confirmed deaths. The number of cases and deaths was on the decline in 2004
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104
INFLUENZA
Influenza, commonly called the flu, is a contagious lung disease caused by a virus. The hospital industry anticipates, monitors, and analyzes the flu season regularly. Hospitals factor into their planning when the flu season will arrive, how long outbreaks will last, and how severe they will be. Clinicians say only the most fragile patients the very young and the very old are typically hospitalized for flu.
As of November 2009, about 32% of all adults had been inoculated against the seasonal flu, and an additional 17% planned to have vaccinations. The number of persons receiving flu shots was about seven percentage points higher than a year prior. Among unvaccinated adults who did not intend to be vaccinated against the seasonal flu in 2009, about 20% said they thought they did not need the vaccine, another 20% said they do not believe in flu vaccines, and slightly less than 20% said they were concerned about getting sick or experiencing side effects.
PREVALENCE AND COST

Approximately 40 million Americans catch the flu each year, resulting in 15 million lost work days, 200,000 hospitalizations, and about 36,000 deaths. Influenza health costs are between $3 billion and $5 billion each year. According to the Centers for Disease Control and Prevention (CDC) the Winter 2008-2009 flu season was one of the mildest in several years. One reason is that the flu vaccine was well-matched to the circulating flu viruses. Flu vaccines are often 70% to 90% effective. In the 2007-2008 season, which was considered severe, the vaccine was only 44% effective.
THREAT OF A FLU PANDEMIC

Influenza pandemics, which occur when a new strain of the influenza virus is transmitted to humans from another animal species, are one of the most serious public health threats. In contrast to regular seasonal epidemics of influenza, pandemics occur irregularly. The 1918 Spanish flu epidemic, which originated among birds and then mutated and spread to humans, was the root cause of 50 million deaths and is the most severe pandemic in recent history. More recent epidemics were the Asian Flu in 1957 and the Hong Kong Flu in 1968.
FLU VACCINATION
Flu shots are considered most essential for school-age children and the elderly. According to the CDC, 70% to 75% of adults aged 65 and older typically received flu shots each year. That 1918 experience is in our minds.
Ann Schuchat, M.D., Interim Deputy Director for Science and Public Health CDC, 5/27/09
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H1N1
There was concern throughout Fall and Winter 2009 that the spread of a new strain of H1N1 influenza, first detected in April 2009, might develop into a pandemic. According to the CDC, there were approximately 50 million cases of H1N1 as of December 2009. There were more than 200,000 hospitalizations and about 10,000 deaths from the strain. Unlike most strains, H1N1 had the greatest impact among children and young adults. Among those who died from H1N1, at least 7,500 were adults aged 18-to-64 and 1,000 were children under age 18. In a typical flu season, roughly 80 children die. Although the spread of H1N1 waned in December 2009, the virus remained highly infectious and the threat of a resurgence remained.

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105
KIDNEY DISEASE
PREVALENCE AND EXPENDITURES

According to the National Kidney Foundation (NKF), at year-end 2009 approximately 26 million Americans or 1 in 10 adults suffered from chronic kidney disease (CKD). Another 20 million are susceptible due to risk factors such as diabetes, high blood pressure, cardiovascular disease, family history of kidney disease, and racial or ethnic heritage. African-Americans and NativeAmericans have a significantly higher risk of developing CKD; rates are also elevated among Hispanics, Asians, and Pacific Islanders. Most of those at risk are not even aware of it. According to the 2008 Annual Data Report, by the U.S. Renal Data System, part of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), more than 485,000 patients suffer from end-stage renal disease (ESRD) and receive dialysis; about 17,500 die of kidney disease each year.
increase from 9% in the early 1990s.
RENAL DIALYSIS SERVICES

While awaiting a kidney transplant, patients undergo dialysis to cleanse their blood. This typically involves a three-hour sitting, three times per week. At year-end 2009, 341,000 people in the U.S. were relying on dialysis to keep them alive, according to the NKF. The annual cost per patient is approximately $64,000. There are 3,600 dialysis facilities in the U.S., 260 of which are hospital-based. The largest providers of renal dialysis services are Fresenius Medical Care and DaVita, reporting revenues of $10.6 billion and $5.7 billion, respectively, in 2008.
MEDICARE SPENDING
For dialysis patients, Medicare pays a composite rate that covers dialysis treatment costs and certain routinely furnished ESRDrelated drugs, laboratory tests, and supplies. The composite rate is adjusted by a drug add-on payment and by basic case-mix adjustment factors including age and body size. A special adjustment is applied for services to pediatric patients. In addition, the composite rate is adjusted for geographic differences in costs using a wage index. For 2009, the unadjusted composite rate was $133.81 and the drug add-on payment was $20.33. In 2007, Medicare paid approximately $9.2 billion for dialysis and related services, of
KIDNEY TRANSPLANTS
In 2008, 17,354 kidney transplants were performed in the U.S. As of January 2010, 90,598 people were on the wait list for a kidney transplant. Organ transplants are discussed in Chapter 107 of this handbook. More and more people with failing kidneys are skipping dialysis and going directly to transplant. Pre-emptive kidney transplants represented 15% of all transplants in 2009, according to the U.S. Renal Data System, an
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which $5.7 billion, or about 62%, was paid under the composite rate. In comparison, $3.5 billion, or about 38%, paid for separately billable ESRD-related items and services, including injectable drugs, non-routine laboratory tests, supplies and services for home dialysis patients who dealt directly with a durable medical equipment supplier, and ESRD-related drugs paid under Part D.

2008 Annual Data Report, U.S. Renal Data System, March 2009. A Clean Break: Kidney Machines Go Mobile, The Economist, October 3, 2009, p. 99. National Institute of Diabetes and Digestive and Kidney Diseases, 31 Center Drive, MSC 2560, Bethesda, MD 20892. (301) 496-3583. (www.niddk.nih.gov) National Kidney Foundation, 30 East 33rd Street, New York, NY 10016. (800) 622-9010. (www.kidney.org) U.S. Renal Data System, 914 South 8th Street, Suite S-206, Minneapolis, MN 55404. (612) 347-7776. (www.usrds.org)
DAILY AT-HOME DIALYSIS

New technology including the first hemodialysis machine the size of a suitcase instead of a refrigerator makes daily athome dialysis possible for a growing number of patients. The FDA has approved two machines for daily home use: Aksys Ltd.s PHD System and NxStage Medicals portable System One. Home dialysis gives patients the ability to have treatment more frequently, even perhaps daily and for shorter periods rather than three hours per session. The hope is that more frequent home dialysis could offer an improvement over current treatment. Kaiser Permanente statistics indicate that home dialysis users require less hospitalization, potentially saving $10,000 to $20,000 in annual healthcare costs per patient. Medicare reimburses the same amount for athome or dialysis center care.
WEARABLE ARTIFICIAL KIDNEY

At the University of California, Los Angeles, Victor Gura, M.D. has invented a wearable artificial kidney. Weighing 5 kg, the device uses disposable cartridges that capture toxins from cleansing water so that it can be recycled.
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106 OPHTHALMOLOGY
COST
The American Academy of Ophthalmology (AAO) estimates that eye disease costs the U.S. about $51.4 billion each year. Costs to Medicare for indirect expenses related to eye disease, including nursing care and assistedliving facilities, are about $2 billion. To increase public awareness of eye diseases, the AAO has launched EyeSmart, a campaign focusing on five major eye diseases: age-related macular degeneration, cataracts, diabetic retinopathy, dry eye, and glaucoma.
EYE DISEASE
The NEI identified age-related macular degeneration (AMD), glaucoma, cataracts, and diabetic retinopathy as the most common eye diseases in Americans ages 40 and over. The leading cause of blindness among white Americans is AMD, accounting for 54% of all blindness. Among African-Americans, the leading causes of blindness are cataract and glaucoma. Among Hispanics, glaucoma is the most common cause of blindness. Age-Related Macular Degeneration Approximately nine million Americans suffer from AMD, the leading cause of blindness in people over 50. By 2020, three million Americans will have advanced cases, an increase from almost two million in 2009. Eight out of 10 people with AMD have the milder, dry form of the disease, but that can develop into the more serious, wet form of AMD that accounts for 90% of the afflicted populations vision loss. AMD can distort and block central vision within days of its onset, or slowly take its toll over years. Sufferers can still see well from the periphery and may be affected in only one eye. The NEI estimates that every year 260,000 people will develop the disease, and the rate will increase as the population ages. Until recently, the only AMD treatment on the market was Visudyne, a laser-activated drug from QLT Inc. and Novartis that stops blood vessels from leaking. Approved in 2000 by the FDA, Visudyne treats only a particular type of macular degeneration, one that afflicts 25% of all wet-AMD patients. Though it generates $350 million
PREVALENCE
Blindness or low vision affects 3.3 million Americans ages 40 and over, or one in 28, according to the National Eye Institute (NEI). This figure is projected to reach 5.5 million by 2020. Further, low vision and blindness increase significantly with age, particularly among people over age 65. People 80 years of age and older currently make up 8% of the population, for example, but account for 69% of blindness. Of the 3.3 million vision-impaired Americans, 937,000 are blind (0.8% of the population) and 2.4 million have low vision. An additional 30.4 million people have myopia (nearsightedness) and 11.7 million have hyperopia (farsightedness).
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in annual sales, Visudyne hasnt lived up to original expectations, with most patients continuing to lose their vision. A breakthrough drug from Genentech (www.genentech.com) offers hope for patients with the wet form of AMD. Lucentis, approved in June 2006, is essentially a fragment of the monoclonal antibody that was used to make the companys colon cancer drug Avastin. Lucentis halts blood-vessel growth when injected into the side of the eye. In two large-scale trials it stopped vision loss in 95% of patients and improved vision in onethird. The downside of Lucentis is its cost: $1,950 per monthly dose. At least 18 companies are now pursuing treatments for macular degeneration, including stem-cell treatments, antiinflammatory medicines, and implants that slowly release protective proteins to stave off cell damage. Cataracts A cataract is a clouding of the lens in the eye that results in blurred vision. Cataracts are formed when proteins that comprise the lens clump together and start to cloud a small area of the lens. Over time, the cataract can enlarge, cloud more of the lens, and impair vision. Approximately 1.3 million cataract surgeries are performed annually in the U.S. Medicare pays about $3.4 billion a year to treat cataracts. Researchers at the Harvard School of Public Health recently found that people with high lead concentrations in their bodies have a much higher risk of developing cataracts and estimated that lead may contribute to 42% of cataract cases. Diabetic Retinopathy Diabetic retinopathy (DR) is a complication of diabetes that results from damage to retina blood vessels. At first, DR may cause no symptoms or only mild vision problems. Eventually, however, DR can
result in blindness. The NEI estimates that 4.1 million adults have diabetic retinopathy, a figure that is projected to increase to 7.2 million by 2020. Up to 45% of adults diagnosed with diabetes in the United States have some degree of diabetic retinopathy, according to the NEI. Glaucoma Glaucoma, the leading cause of preventable blindness, is an eye disease that causes vision loss by damaging the optic nerve. Prevent Blindness America estimates that more than 3 million people in the U.S. have glaucoma. Less than half know it. The only known treatment for glaucoma is a method of lowering eye pressure, usually with prescription eye drops. The number of Americans affected by the disease is expected to increase by about 600,000 by 2020.
MYOPIA AND HYPEROPIA

An estimated 95 million wear prescription eyeglasses and 35 million to 40 million use contact lenses to correct for myopia and hyperopia. Other medical options are as follows: Refractive Surgery Over 10 million Americans have had successful LASIK (laser assisted in situ keratomileusis) surgery for correcting myopia, hyperopia, and astigmatism; about one million are treated annually. Photorefractive keratectomy (PRK), an alternative laser surgery, is used for patients where LASIK is not feasible, such as for those with a thin cornea. Most patients prefer LASIK because of the initial irritation and long healing time associated with PRK. LASIK accounts for 87% of laser procedures, according to Market Scope.
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Corneal Refractive Therapy Corneal refractive therapy (CRT), or corneal reshaping, was approved in 2002 by the FDA. No surgery is involved. Doctors use computers to map the surface of the eye, then make lenses that patients wear while they sleep that work to correct the problem. The lenses reshape the epithelium, the surface of the cornea, redistributing cells from the center to the periphery to compensate for refractive errors and astigmatism. Vision is improved after only a week although patients need to wear the lenses at least every other night or the effect subsides, according to Paragon Vision Sciences (www.paragoncrt.com), maker of CRT lenses. Fitting the lenses and treating both eyes costs $1,000 to $1,500, with an additional $300 to $500 in later years for replacement lenses. CRT is marketed as an alternative to LASIK. Studies show that 93% of CRT patients achieve 20/32 vision or better; 67% improve to 20/20 vision. Intraocular Lenses Intraocular lenses are emerging to become a preferred solution for nearsightedness. In 2004, the FDA approved the Verisyse lens, the U.S. markets first intraocular lens. Although more than 150,000 lenses have been implanted worldwide over the past 17 years, the popularity of laser surgery in the U.S. had for many years discouraged the developer from the arduous testing needed to obtain FDA approval. The approval was the culmination of seven years of U.S. tests. Unlike LASIK, the intraocular lenses are completely reversible. And implantable contact lenses tend to provide better quality of vision than LASIK. Also, the lenses can be designed to provide optimal vision, whereas with laser treatment vision adjusts by the way the person heals.
Right now theyre more invasive than LASIK, so theyre not really appropriate for people with lower levels of nearsightedness. But over time as the implantable lenses get better, I think theyll gradually replace LASIK. My personal belief is that 15to-20 years from now, we wont be doing LASIK any more. Future generations of implantable lenses will completely replace it.
Robert Maloney, M.D. Maloney Vision Institute (L.A.)

American Academy of Ophthalmology, P.O. Box 7424, San Francisco, CA 94120. (415) 561-8500. (www.aao.org) Market Scope, 9859 Big Bend Boulevard, Suite 202, St. Louis, MO 63122. (314) 835-0600. (www.mktsc.com) National Eye Institute, 2020 Vision Place, Bethesda, MD 20892. (301) 496-5248. (www.nei.nih.gov) Prevent Blindness America, 211 West Wacker Drive, Suite 1700, Chicago, IL 60606. (www.preventblindness.org) The Vision Council, 1700 Diagonal Road, Suite 500, Alexandria, VA 22314. (703) 548-4560. (www.thevisioncouncil.org)
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107
ORGAN TRANSPLANTS
The Health Resources and Services Administration, Division of Transplantation, administers and oversees two contracts to facilitate the nations allocation system for organ transplantation. They are as follows: The Organ Procurement and Transplantation Network (OPTN), contracted by the United Network for Organ Sharing (UNOS), is responsible for operating the national network for organ procurement and allocation and works to promote organ donation. Under federal law, all U.S. transplant centers and organ procurement organizations must be members of OPTN to receive funds through Medicare. The Scientific Registry of Transplant Recipients (SRTR), contracted by the Arbor Research Collaborative for Health, provides analytical support for the ongoing evaluation of scientific and clinical status of solid organ transplantation.
Kidney: Liver: Heart: Lung: Kidney/pancreas: Pancreas: Intestine: Heart/lung:
16,517 6,318 2,163 1,478 837 436 185 27
Rates of organ donation in the United States have increased in recent years. But this growth lags far behind the increasing need; approximately 40,000 individuals are added to the U.S. transplant waiting list each year. According to OPTN, the number of transplants in recent years have been as follows: 2003: 25,452 2004: 27,037 2005: 28,113 2006: 28,938 2007: 28,361 2008: 27,961 Of transplants in 2008, 21,744 were through deceased donors; 6,217 from living donors.
ORGAN TRANSPLANT CENTERS

There are approximately 320,000 organ transplant centers in the United States. The number of organ-specific transplant programs, of which some centers may have several, is approximately 1,000. The SRTR website provides statistics and outcomes data for each program.
WAIT LIST
There were 113,758 candidates waiting on organs as of January 2010. The wait list by organ was as follows (source: OPTN): Kidney: 88,334 Liver: 16,454 Heart: 3,029 Kidney/pancreas: 2,264 Lung: 1,852 Pancreas: 1,515
TRANSPLANTS AND DONORS

The number of transplants in 2008, by organ, are as follows:
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Intestine: Heart/lung:
233 77
ORGAN PROCUREMENT
A single individual can help as many as 50 patients by donating tissue and organs. It is possible to transplant 25 different parts of the body, including the corneas, the heart, heart valves, the liver, kidneys, bone and cartilage, marrow, skin, and the pancreas. Medical studies estimate that organs could be obtained from 10,500 to 26,000 brain-dead victims each year if more people consented to the donations. In spite of numerous campaigns aimed at educating healthy Americans about donating their organs after they die, a donor shortage persists. A recent survey from Donate Life America found that 90% of Americans support organ and tissue donation, and roughly one-half say they are registered as an organ donor, but only about 30% have actually signed up as a donor. One recent survey found 66% of people were not clear on how to sign up to become a donor. Laws that govern donation vary from state to state. The coalition offers state-specific guidelines at www.donatelife.net. Americans who want to become organ donors opt in, that is they indicate on a drivers license, for example, that when they die their organs should be made available. Many European and Asian countries take the opposite approach. In Singapore, for example, all residents receive a letter when they come of age informing them that their organs may be harvested unless they explicitly object. In Belgium, which adopted a similar presumed-consent system 12 years ago, less than 2% of the population has decided to opt out.
Complicating the situation in the U.S. is the fact that whatever decision one makes can be overruled by family. The final say is left to surviving relatives, who must decide about allowing donation in the critical hours after brain death has been declared. In nearly half of donation cases, relatives step in and veto the wishes of the deceased. Organ procurement organizations (OPOs), of which there are 58 across the U.S., often facilitate donation from brain-dead patients by counseling families. An OPO representative, known as a family-care coordinator, is there to comfort the families of the victim in their time of grief, to offer whatever assistance they might request, and, when it appears appropriate, to seek permission for donation. This ... makes it unnecessary for the doctor to mention donation, which is usually regarded as an unpleasant task or possibly a conflict of interest.
Thomas Mone, CEO OneLegacy Modern Healthcare, 4/20/09
According to the Department of Health and Human Services, the nations organ transplantation system needs to be reformed to ensure allocation of scarce organs will be based on common medical criteria, not geography. Under the current system, organs are first offered to the region in which they become available. Federal regulations dictate that organs go to the sickest patients first, ranking patients based on the severity of their disease. For example, when a liver suitable for transplant is identified, local Status One patients those who are near death are considered first. If no Status One patients are in the local area or if the organ is not a biological match, the search for a recipient then expands to the organ
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transplant region, which can include several states. If no Status One patient in the region is a match, the transplant surgeons in the city where the liver was recovered can give the organ to the patient ranked highest by the disease severity score, known as the Model for End-stage Liver Disease. If no match is found, the organ is then offered nationwide. The emphasis on treating local transplant patients means less-ill patients may receive a transplant while patients with more urgent medical needs continue to wait. Revised criteria could provide for wider sharing to ensure organs are made available to patients with greatest medical need. A number of state legislatures are passing laws to bar donated hearts, lungs, kidneys, livers, and pancreases from being shipped beyond their state to people elsewhere in the country. Wisconsin was the first. Four other states (Louisiana, Oklahoma, South Carolina, and Florida) adopted laws similar to that of Wisconsin.
expected to pass a law clarifying that such arrangements are legal, codifying a recent Justice Department ruling. The following are some organ donation incentive ideas under consideration or already underway: There have been several proposals to offer the families of brain-dead donors a death benefit of $5,000 to $10,000 for the use of healthy organs. Organs would go into the donor system, not be sold to individuals. A Pennsylvania plan to offer a $300 funeral benefit several years ago was blocked by the federal ban. LifeSharers, a non-profit network of organ donors, is working to increase the organ supply by putting incentives to work now. LifeSharers members direct that their organs first be offered to other members. Non-members can have a members organs if no member can use them when they become available. As LifeSharers grows (people can join at no charge at www.lifesharers.com), so does the incentive to become a registered donor. This should make the system more fair because chances of receiving an organ will be greater for those who have agreed to be a donor. So far none of the 9,000-member group has received an organ from another member. Since 2004, MatchingDonors.com, a nonprofit website, has aided patients who need a liver or kidney in finding living donors. Patients seeking to bypass the normal wait for an organ can join MatchingDonors for fees starting at $295. There some 2,000 donors offer organs for nothing more than goodwill. There are ethical concerns about the process of online-assisted organ procurement, however. UNOS has come out against the website, saying it takes advantage of vulnerable transplant candidates and donors and subverts the equal allocation of organs.
INCENTIVES FOR ORGAN DONATION

The American Medical Association and the American Society of Transplant Surgeons have called for Congress to authorize tests of financial incentives to see whether such incentives would increase organ donations. So, too, has the United Network for Organ Sharing, which operates the national organ distribution system. While federal law clearly bans the sale of organs, kidney swaps are becoming an accepted practice. Such exchanges are an option in cases where there are willing but mismatched donors (because of blood type). Since the first kidney swap at Rhode Island Hospital in 2000, there have been about 230 such exchanges. Johns Hopkins Hospital had done more than 40 swaps. Congress is
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Arkansas, Georgia, Iowa, Minnesota, New Mexico, North Dakota, Utah, and Wisconsin allow tax deductions of up to $10,000 to compensate living donors for travel, expenses, or lost income. This is legal because the money comes from the state. Still, it is controversial. Financial incentives for organ donation have been effective in other countries. In Iran, for example, because the government pays $2,000 to anyone willing to donate a kidney; there is no wait list there. Other countries dont subsidize donation but tacitly permit payment for organs. U.S. federal law, like that of most other countries, absolutely forbids paying for or receiving payment for organs.
Scientific Registry of Transplant Recipients, 315 West Huron Street, Suite 360, Ann Arbor, MI 48103. (800) 830-9664. (www.ustransplant.org) United Network for Organ Sharing, P.O. Box 2484, Richmond, VA 23218. (804) 782-4800. (www.unos.org)

American Society of Transplant Surgeons, 2461 South Clark Street, Suite 640, Arlington, VA 22202. (703) 414-7870. (www.asts.org) Arbor Research Collaborative for Health, 315 West Huron Street, Suite 360, Ann Arbor, MI 48103. (734) 665-4108. (www.arborresearch.org) Donate Life America, 700 North Fourth Street, Richmond, VA 23219. (804) 782-4920. (www.shareyourlife.org) Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation, 5600 Fishers Lane, Rockville, MD 20857. (www.hrsa.gov/hsb) OrganDonor.org, the U.S. government website for organ and tissue donation and transplantation
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108 ORTHOPEDICS
ORTHOPEDIC SURGERY
The American Association of Orthopedic Surgeons lists the following as the primary orthopedic subspecialties: Hand surgery Shoulder and elbow surgery Total joint reconstruction (arthroplasty) Pediatric orthopedics Foot and ankle surgery Spine surgery (also performed by neurosurgeons) Musculoskeletal oncology Surgical sports medicine Orthopedic trauma According to applications for board certification, the most common procedures (in order) performed by orthopedic surgeons are as follows: Knee arthroscopy and meniscectomy Shoulder arthroscopy and decompression Carpal tunnel release Knee arthroscopy and chondroplasty Removal of support implant Knee arthroscopy and anterior cruciate ligament reconstruction Knee replacement Repair of femoral neck fracture Repair of trochanteric fracture Debridement of skin/muscle/bone/fracture Knee arthroscopy repair of both menisci Hip replacement Shoulder arthroscopy/distal clavicle excision Repair of rotator cuff tendon Repair fracture of radius (bone)/ulna Laminectomy Repair of ankle fracture (bimalleolar type) Shoulder arthroscopy and debridement
Lumbar spinal fusion Repair fracture of the distal part of radius Low back intervertebral disc surgery Incise finger tendon sheath Repair of ankle fracture (fibula) Repair of femoral shaft fracture Repair of trochanteric fracture
BACK PAIN AND SPINAL SURGERY

Nationwide, people visit doctors offices for back pain 14 million times a year, making it the second most common reason people see a doctor. Those who receive medical attention represent less than half of the over 30 million Americans who suffer from back pain. The World Health Organization has declared lower back pain an official epidemic. According to data compiled by researchers from the University of Washington School of Medicine, annual spending on spine problems is approximately $85 billion. Studies suggest that much of the spending for x-rays, CT scans, injections, and surgeries is unnecessary. Most acute back problems resolve themselves on their own. Although it might seem counterintuitive for a degenerative disease, the middle-aged are more likely to have back operations than the elderly. The median age for spine surgery is 42. Many of the cases are work-related back conditions, the leading cause of disability in adults. Workers compensation pays for a higher proportion of spine surgeries than for any other condition.
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The number of incidences of back surgery actually declines after age 60. This is not because back pain stops in the elderly, according to Dr. Scott Blumenthal of the Texas Back Institute, but because the body takes so much stress from lifes woes compared to the knees and hips that back pain just appears earlier in life than other arthritic types of pain. For sufferers of back pain who need surgery, the most accepted procedures are discectomy (removal of part of the disc) and spinal fusion combined with discography, in which a surgeon watches on a screen as he pricks each disc to pinpoint the source of pain. Once the culprit is found, a small section of the back is cut open and part or all of the damaged disc is removed. The surrounding vertebrae are fused with screws, rods, or cages. Almost 200,000 people a year undergo fusions, with an 80% rate of improvement. A large-scale randomized trial comparing having surgery vs. delaying surgery as a remedy for sciatica, directed by James N. Weinstein, M.D., chairman of orthopedics at Dartmouth Medical School, found that people with ruptured disks in their lower backs usually recover whether or not they have surgery. Patients who had surgery often reported immediate relief. But by three to six months, patients in both groups reported marked improvement. After two years, about 70% of both the patients who underwent surgery and those that did not said they had a major improvement in their symptoms. None of the patients who waited for treatment had serious consequences, and none who had surgery had a disastrous result. For some back problems, however, surgery is recognized as the best solution. Researchers at Dartmouth Medical School reported that surgery for spinal stenosis and degenerative spondylolisthesis, two common spinal problems, results in significantly reduced
back pain and better physical function than treatment with drugs and physical therapy.
FOOT AND ANKLE PROBLEMS

According to the American Academy of Orthopaedic Surgeons, one in six people in the U.S., or 43 million, has foot problems. Of those, 36% regard theirs as serious enough for medical attention. More than three million Americans each year seek treatment for inflammation of the plantar fascia, a gristle-like connector that runs between the heel and toes and helps support the arch; an estimated seven million more deal with the discomfort on their own. Foot specialists say they are seeing a surge in cases as Baby Boomers jog into middle age. Runners and women in their 40s and 50s are especially vulnerable. Anyone who spends a lot of time on his or her feet, walks or runs on hard surfaces, is overweight, or has tight Achilles tendons is susceptible. The worst chronic cases have traditionally been treated with surgery to snip part of the fascia to loosen it. According to Glenn Pfeffer, M.D., president of the American Orthopaedic Foot & Ankle Society (AOFAS), about 5% of recalcitrant cases require surgery. For moderate sufferers, simple, inexpensive home remedies, such as stretching exercises to loosen the Achilles tendon, can be sufficient to provide relief. According to the AOFAS, the national expenditures for surgery to correct foot problems from tight-fitting shoes is $2 billion a year. If time off from work for the surgery and recovery is included, the annual cost is $3.5 billion. Women have approximately 90% of the almost 530,000 surgeries annually.
HIP SURGERY
Surgeons in the U.S. performed approximately 270,000 artificial hip implants
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in 2009, according to Millennium Research Group (MRG), making it the second most common replaced joint surgery, following knees and ahead of shoulders. The procedure typically costs between $30,000 and $50,000. Based on patients achieving relatively pain-free mobility after a recovery period of a few months, the success rate is higher than 90%. In traditional hip replacements, doctors replace the top of the femur with a metal ball after removing portions of the damaged hip socket. Approximately 5% of artificial hip implants are ceramic. Hip resurfacing, which involves the replacement of hip socket but retains the femoral ball, became widely available in the U.S. in 2006. About 13,000 of the procedures were performed in 2009, according to MRG. Though seemingly a lessdrastic operation, a hip resurfacing is typically more difficult for a surgeon to perform than replacing the total joint. To be sure, hip surgery of any type is often difficult. Patients can generally expect to be hospitalized and then be on crutches for at least a few weeks. Physical therapy might go on for a couple of months.
The Wall Street Journal, 6/4/09
the tibia (the lower leg bone), patella (kneecap), and femur (thigh bone), which are replaced with metal and plastic components. A National Institutes of Health study reported that 90% of people with knee replacements report fast pain relief, increased mobility, and a better quality of life. Arthroscopic knee surgery has been a popular treatment for people whose knees are racked by osteoarthritis. Minimally invasive, it flushes out debris in the joint and smooths bone surfaces. But a surprising study, published in the New England Journal of Medicine, showed that the operation is no more effective than a placebo. One in three patients reported improvement, whether having had real surgery or a simulated procedure with all the same pre- and post-op procedures but no actual treatment. Even if the placebo benefit is ignored, the study still casts doubt on surgery that succeeds only one-third of the time. Patients may be generally better off doing strengthening exercises and taking off a few pounds to ease the burden on their aching knees, or consider total knee replacement if warranted. Prior to the study, more than 200,000 Americans had arthroscopic knee surgery annually, with a typical cost of $5,000.

American Association of Orthopedic Surgeons, 6300 North River Road, Rosemont, IL 60018. (847) 823-7186. (www.aaos.org) American Orthopaedic Foot & Ankle Society, 6300 North River Road, Suite 510, Rosemont, IL 60018. (800) 235-4855. (www.aofas.org) Millennium Research Group, 175 Bloor Street East, South Tower Suite 701, Toronto, Ontario Canada M4W 3R8. (416) 364-7776. (www.mrg.net)
KNEE SURGERY
Surgeons in the U.S. perform 455,000 knee replacements annually, according to the American Association of Orthopedic Surgeons. In knee replacements, the most common joint-replacement procedure, doctors cut into the joint and remove the damaged portions of
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Tergesen, Anne, Doubts Raised Over New Type Of Hip Surgery, The Wall Street Journal, June 4, 2009.
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109
OSTEOPOROSIS
PREVALENCE
According to the National Osteoporosis Foundation (NOF), an estimated 10 million individuals in the U.S. have osteoporosis, and almost 34 million more have low bone mass, which places them at increased risk for osteoporosis. Eighty percent (80%) of those affected by osteoporosis are women. Osteoporosis-related f ractur es are responsible for an estimated 1.5 million bone fractures and $19 billion in medical costs each year. According to the Office of the Surgeon General, unless more older Americans start getting the calcium, vitamin D, and physical activity needed, an osteoporosis epidemic is inevitable.
receptor modulator, which reduces bone loss, and the injectable drug Forteo (Eli Lilly), one of a new class of drugs to stimulate boneforming cells known as osteoblasts. Fosamax, which garnered 55% of the $7 billion market in 2007, became generic in 2008. For those who have suffered an osteoporosis-related fracture, a follow-up osteoporosis program is important to reduce the possibility of recurring fractures. According to Adrianne Feldstein, M.D., a researcher at the Kaiser Permanente Centre for Health Research, such programs targeted to patients with a previous fracture lead to improvements from 13% to 44% of patients being evaluated and/or tested for the disease.
TREATMENT
The cause of osteoporosis is unknown; however for women the bodys rapid drop in estrogen that occurs during menopause is a risk factor. Other risk factors include a thin body build, low bone mass, smoking, Caucasian or Asian descent, and a family history of the disease. Although there is no cure for osteoporosis, there are several medications available to help stop further bone loss, increase bone density, and reduce risk of fracture. Osteoporosis patients typically take Fosamax (Merck) or Actonel (Sanofi-Aventis) drugs in the bisphosphonate family once a week to reduce the risk of fractures. Other options include Evista (Eli Lilly), a selective estrogen
PREVENTION
Osteoporosis is largely preventable for most people. Prevention of this disease is very important because while there are treatments for osteoporosis there is currently no cure. There are four steps to prevent osteoporosis. They are as follows (source: National Osteoporosis Foundation): A balanced diet rich in calcium and vitamin D Weight-bearing exercise A healthy lifestyle with no smoking or excessive alcohol use Bone density testing and medications when appropriate
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No one step alone is enough to prevent osteoporosis but all four may. Bone health is a family issue, particularly as genetics and heredity are among the key factors that influence a persons risk of developing osteoporosis. There are many lifestyle choices that families can make to help build strong bones and prevent osteoporosis later in life.
Robert Recker, M.D., President NOF, 5/1/09
BONE HEALTH PROMOTION AND RESEARCH ACT

In 2009, the Bone Health Promotion and Research Act was proposed by members of Congress to enhance the activities of the Centers for Disease Control and Prevention and augment educational activities on bone health at the national and state levels; to establish an Osteoporosis and Related Bone Disease Advisory Committee to advise the CDC and the National Institutes of Health; to expand and intensify research activities of the NIH on osteoporosis and related bone diseases; and to authorize grants and cooperative agreements to facilitate the collection, analysis, and reporting of data regarding osteoporosis.
The bill would provide for greater comprehensive osteoporosis and related bone disease control and prevention programs along with national educational outreach activities. This act would create a National Bone Health Program to augment education and outreach initiatives through the Centers for Disease Control and Prevention and provide state grants for comprehensive osteoporosis and related bone disease surveillance, control, and prevention programs and activities. This bill would also expand and intensify research activities of the National Institutes of Health on osteoporosis and related bone diseases.
NOF, 11/10/09

National Osteoporosis Foundation, 1232 22nd Street NW, Washington, DC 20037. (202) 223-2226. (www.nof.org)
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110 PAIN MANAGEMENT
PREVALENCE
Chronic pain commonly defined as pain persisting longer than six months affects an estimated 70 million Americans and is a tragically overlooked public health problem, according to the American Pain Foundation. The American Pain Society (APS) estimates that 45% of the population seeks medical help for persistent pain at some point. An estimated 9% of adults suffer moderate to severe chronic pain caused by back injuries, arthritis, and other non-cancer conditions. According to the American Chronic Pain Association, 85% of all patients who seek care from physicians and dentists do so for pain-related complaints. Pain accounts for 25% of all sick days taken in the United States. About 17% of adult Americans, or 34 million people, experience mild to moderate chronic pain to the degree that they seek relief from a physician.
PAIN MANAGEMENT IN HOSPITALS

Pain is the number one reason people seek medical attention, and it is the leading complaint that goes unresolved. Hospitals are looking for ways to assess, record, and treat pain more aggressively. Unrelieved pain causes waste and excessive costs in the healthcare system. Significant costs are borne by patients, health plans, and healthcare institutions. A Michigan Chronic Pain Study found, for example, that one in five adults had significant chronic pain, with 29% using emergency departments for treatment. A study by the University of Pittsburgh Medical Center found that implementing a post-operative clinical pathway for outpatient orthopedic surgery significantly decreased the number of unscheduled post-op admissions for refractory pain, nausea, and vomiting. The pathway reduced the unscheduled admissions from more than 10% of orthopedic outpatients to less than 2%. Beginning in 2001, 20,000 hospitals, healthcare networks, long-term and assistedliving facilities, behavioral health centers, and other health services certified by the Joint Commission were mandated to make pain assessment a priority. Joint Commission standards require organizations to recognize and address patients rights to appropriate pain assessment and management. Assessments that same year found 93% of hospitals in compliance.
ECONOMIC IMPACT
Medical economists estimate pain costs the U.S. over $100 billion each year, including 515 million lost workdays and 40 million doctor visits. Chronic pain is the leading cause of disability in America, costing employers more than $60 billion in lost time and productivity annually. It is estimated that treating soldiers returning from Iraq and Afghanistan for chronic pain will cost $340 billion in coming years.
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PAIN MANAGEMENT IN CHILDRENS HOSPITALS

There are an estimated 10 million Americans age 18 and younger with chronic or recurrent pain. They suffer from a variety of conditions: migraines, cancer, cystic fibrosis, sickle-cell anemia, and nerve injuries from accidents or fractures. Doctors estimate that of the 72 million Americans under age 18, 5% suffer from back pain, 5% endure facial pain, 10% suffer from migraines and severe headaches, and 12% experience significant abdominal pain. New methods of measuring pain and discomfort in children are now being utilized. Doctors are also rethinking the treatment of acute pain for children who go to emergency rooms for more common injuries like broken limbs or cuts that need stitches. Still, too few hospitals offer comprehensive pain programs for children, and pediatric pain units are expensive to run.
medications for ethical reasons.

American Chronic Pain Association, P.O. Box 850, Rocklin, CA 95677. (800) 533-3231. (www.theacpa.org) American Pain Foundation, 201 North Charles Street, Suite 710, Baltimore, MD 21201. (888) 615-7246. (www.painfoundation.org) American Pain Society, 4700 West Lake Avenue, Glenview, IL 60025. (847) 375-4715. (www.ampainsoc.org) Mayday Fund, Special Committee on Pain and the Practice of Medicine, 127 West 26th Street, Suite 800. New York, NY 10011. (www.maydayfund.org) The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181. (630) 792-5000. (www.jointcommission.org)
PAIN MEDICATIONS
Over $20 billion worth of pain relief medications are sold annually in the U.S., not surprising when over 30 million Americans take a nonsteroidal anti-inflammatory drug, or NSAID, every day. Living with chronic pain, millions of Americans currently face a dilemma regarding how to manage symptoms with narcotic drugs and other therapies. Confusion related to pain relievers has abounded since Vioxx was withdrawn from the market in 2004. Already fearful about the widespread abuse of prescription narcotics, some doctors are worrying more about legal risks in prescribing many pain medications while some pharmacists are balking at dispensing pain
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111 ROBOTIC SURGERY
Using robots to perform surgery once seemed a futuristic fantasy, but no more. An estimated 125,000 robotic procedures were performed in 2008 from heart-bypass surgeries to kidney transplants to hysterectomies more than double the 36,600 performed two years prior. Since FDA approval in 2000 of the da Vinci surgical system by Intuitive Surgical still the only general-purpose surgical robot to receive approval over 1,000 units have been purchased, at a cost of $1.4 million per unit.
Acceptance of robotic-assisted procedures has been positive by both physicians and patients. Because different specialists use the same robotic system to assist in various types of procedures, many hospitals end up with several robots. Hackensack University Medical Center, for example, has six. In addition to medical benefits, offering robotic surgery sends a signal that a hospital is cutting edge, which can be attractive for patients. Research shows that the first hospital in a market to incorporate robotic surgery systems generally sees a favorable return on investment. Northwestern Memorial Hospital (Chicago) reported the number of hospital days among oncology patients was down 60% to 65% following the introduction of robotic procedures.
BENEFITS OF ROBOTIC SURGERY

Surgeons who use the system have found that patients have less blood loss and pain, lower risk of complications, shorter hospital stays, and quicker recovery times than those who have open surgery, and in many cases, laparoscopic procedures. The robotic system has already transformed the field of prostate surgery, for which it was approved in May 2001.
Patients experience less bleeding, less pain, and are back to work faster after procedures done robotically, which saves costs for hospitals.
Julian Schink, M.D. Chief of Gynecologic Oncology Northwestern Memorial Hospital Modern Healthcare, 7/6/09
A surgery using a robotic arm can cost $12,000 to $15,000 less than a typical surgery, with fewer complications and a shorter length of stay.
Douglas Murphy, M.D. Chief of Cardiothioracic Surgery St. Josephs Hospital (Atlanta) Modern Healthcare, 7/6/09
TRAINING
Physicians require special training to use surgical robots. Training centers serve this need.
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Despite claims by many doctors that the robot makes minimally invasive surgeries easier to perform, providers arent clamoring to use them. Part of the reluctance is on the part of surgeons who arent sure about learning to use a machine when they can perform the procedures well using their own hands.
ROBOTIC TELESURGERY
Perhaps the most intriguing aspect of robotic surgery is the potential for telesurgery, operations from remote locations. Robotic telesurgery dates to 2001 when surgeons at Mount Sinai Hospital performed a gallbladder operation on a patient in France by remote control. Research advances continue at Johns Hopkins Hospital, the University of Cincinnati Medical School, the University of Washington School of Medicine, and elsewhere for the da Vinci surgical system. The acceptance of telesurgery still faces a lot of obstacles. Any signal delay exceeding 200 milliseconds poses a potential risk to the patient. There are also issues about the ethics of a surgeon operating on a patient who is in another city, or country, with no way to physically intervene if something goes wrong.
There are 21 training centers for robotic surgery in the U.S., as follows: Boston Childrens Hospital Clarian North (Carmel, Indiana) East Carolina University Hospital (Greenville, North Carolina) Ethicon Endosurgery Institute (Cincinnati) Florida Hospital, Celebration (Orlando) Good Samaritan Hospital (Cincinnati) Hackensack University Medical Center University of Pennsylvania Hospital (Philadelphia) Intuitive Surgical Headquarters (Sunnyvale, California) Johns Hopkins University Hospital (Baltimore) Memorial Hermann Medical Center (Houston) Methodist Hospital (Houston) Newark Beth Israel Medical Center Ochsner Hospital (New Orleans) Ohio State University Hospital (Columbus) Oklahoma University (Tulsa) St. Josephs Hospital (Atlanta) Uniformed Services University of the Health Sciences (Bethesda, Maryland) University of California, Irvine University of California, San Diego University of Illinois, Chicago

DerGurahian, Jean, Robo-School, Modern Healthcare, July 6, 2009, pp 26-28. Intuitive Surgical, 950 Kifer Road, Sunnyvale, CA 94086. (408) 523-2100. (www.intuitivesurgical.com)
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112 SLEEP DISORDERS
PREVALENCE
According to the National Commission on Sleep Disorders Research (NCSDR), approximately 70 million people in the United States are affected by a sleep problem. About 40 million Americans suffer from chronic sleep disorders, and an additional 2030 million are affected by intermittent sleeprelated problems. An overwhelming majority of sleep disorders remain undiagnosed and untreated. 2009 Sleep in America, by the National Sleep Foundation, found that the number of Americans who sleep less than six hours a night increased to 20% in 2009 from 13% in 2001, and those who reported sleeping eight hours or more dropped from 38% to 28%. Only 49% say that they get a good nights sleep almost every night. According to the National Sleep Foundation, the following percentages of adults believe that they have symptoms of sleep disorders: Insomnia: 58% Snoring: 37% Restless leg syndrome: 16% Pauses in breathing: 9% Twenty million Americans suffer sleep apnea, according to a study by the NCSDR. According to a recent University of Michigan study, 5% to 10% of all men ages 30-to-60 could unknowingly be in need of apnea treatment. Estimates indicate that untreated sleep apnea may cause $3.4 billion in additional medical costs.
Approximately 10% of the population, or 20 million adults, have chronic insomnia, which is inadequate or poor quality sleep nightly for one month or more. Studies indicate untreated insomnia may put people at higher risk for major depression and may cause elderly people to be placed in nursing homes sooner than if the condition had been treated. Fewer than 15% of people who suffer from chronic insomnia receive treatment, according to surveys. According to a study by researchers at Stanford and Johns Hopkins Universities, as much as 15% of the U.S. population could be affected by restless-legs syndrome (RLS), a sleep and movement disorder characterized by unpleasant (tingling, crawling, creeping, and/or pulling) feelings in the legs, which cause an urge to move in order to relieve the symptoms. Narcolepsy, another sleep disorder, is a chronic neurological disorder that involves the bodys nervous system. People with narcolepsy experience sudden sleep attacks that can occur at any time. Narcolepsy is believed to affect approximately 300,000 people in the U.S., according to the Narcolepsy Network. People with narcolepsy are overcome by uncontrollable urges to sleep, often at inconvenient times, such as when driving. Studies show narcoleptics spend less time in the deeper states of sleep and do not get enough undisturbed sleep and often nod off from sheer fatigue during the day. Approximately 50 million Americans snore. According to the NSF, 55% of all adult
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Americans report being told they snore, with more men (68%) than women (48%) snoring. Only 43% admit to it. There are more than 3,000 patented devices to keep people from snoring, but doctors agree few are effective.
Getting enough sleep everyday is as important to your health as eating healthy and being physically active.
Woodie Kessel, M.D. Assistant Surgeon General, 3/2/09
ECONOMIC IMPACT
Sleep deprivation costs Americans more than $100 billion annually in lost productivity, medical expenses, sick leave, and property and environmental damage, according to the NSF. The National Highway Traffic Safety Administration estimates that 100,000 policereported motor vehicle crashes are caused each year by drowsy drivers. 2009 Sleep in America reports that 54% of adults some 110 million licensed drivers have driven when drowsy at least once in the past year; 28% say that they have nodded off or fallen asleep while driving a vehicle. Short attention spans, fuzzy thinking, and frayed tempers caused by sleep deprivation cost American businesses $15 billion a year in reduced productivity, according to the National Commission on Sleep Disorders Research.
2009 Sleep in America provides data showing that inadequate sleep is associated with unhealthy lifestyles and negatively impacts health and safety. Those in good health are two times more likely than those in poor health to work efficiently, exercise, and eat healthy, because they are getting enough sleep. About 40% of Americans agree that sleep is as important as diet and exercise to overall health and well-being; yet, only 32% of Americans who report sleep problems discuss them with their doctor. Surveys by the National Sleep Foundation have found a direct correlation between the number of diagnosed medical conditions reported by Americas older adults and the quality of their sleep the more medical conditions reported, the more sleep problems are likely to occur. Eighty percent (80%) of those with four or more medical conditions report a sleep problem, compared to 53% of those with no reported medical conditions. Sleep problems are reported by the following: 82% of those diagnosed with depression 81% who have suffered a stroke 76% being treated for heart disease 75% diagnosed with lung disease 72% being treated for diabetes or arthritis 71% of those diagnosed with hypertension Poor sleep is also associated with body pain, excess weight, and ambulatory limitations, according to the NSF. A study published in the December 23, 2008 issue of the Journal of the American Medical Association reported that just one extra hour of sleep a day appears to lower the risk of developing calcium deposits in the arteries, a
SLEEP AND OVERALL HEALTH

There is convincing evidence that untreated sleep disorders can increase the risk of high blood pressure, coronary-artery disease, heart failure, and stroke. According to Dr. Carl E. Hunt, director of the NCSDR, researchers also think lack of sleep can increase the odds of developing obesity and diabetes.
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precursor to heart disease. According to the study, people ages 35-to-47 who on average slept longer were at reduced risk of developing new coronary artery calcifications over five years. Among subjects who had slept less than five hours a night, 27% had developed artery calcification. That dropped to 11% among those who slept five to seven hours, and to 6% among those who slept more than seven hours a night. Researchers at Yale University School of Medicine found those with sleep apnea were twice as likely to have a stroke as those who did not have the condition.
According to the National Center for Complimentary and Alternative Medicine, 4.5% of Americans use some type of alternative medicine to treat their sleep problems. Most common among these treatments are herbal therapies or relaxation techniques.

2009 Sleep in America, National Sleep Foundation, March 2009. American Academy of Sleep Medicine, One Westbrook Corporate Center, Suite 920, Westchester, IL 60154. (708) 492-0930. (www.aasmnet.org) IMS Health, 901 Main Avenue, Suite 612, Norwalk, CT 06851. (203) 845-5200. (www.imshealth.com) National Commission on Sleep Disorders Research, Building 31, Room 5A52, 31 Center Drive, MSC 2486, Bethesda, MD 20892. (301) 592-8573. (www.nhlbi.nih.gov/about/ncsdr/) National Sleep Foundation, 1522 K Street NW, Suite 500, Washington, DC 20005. (202) 347-3471. (www.sleepfoundation.org) U.S. Sleep Market, Marketdata Enterprises, October 2008.
TREATMENT
Sleep disorders are diagnosed and treated by many different healthcare professionals, including general practitioners and specialists in neurology, pulmonary medicine, psychiatry, psychology, pediatrics, and other fields. According to the American Academy of Sleep Medicine, there are approximately 1,400 sleep clinics or medical centers in the U.S. The Academy accredits facilities that have sleep laboratories that adhere to quality standards as well as appropriate medical expertise. A directory is available at www.aasmnet.org/listing. According to IMS Health, over 50 million prescriptions for sleep medications are filled annually, at an approximate cost of $3 billion. Ambien (Sanofi-Aventis) dominates the sector with a marketshare of about 75%. Lunesta (Sepracor) and Rozerem (Takeda Pharmaceutical), introduced in 2005, are designed for longer-term use than drugs previously on the market. The use of some of these medications has come under attack because of dangerous (although rare) side effects, such as occurrences of sleepwalking and even driving under the drugs influence.
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113
SUBSTANCE ABUSE
PREVALENCE AND COST

The National Institute on Drug Abuse reports that approximately 22 million people in the U.S. are suffering from drug abuse and addiction. Of those who abuse drugs, some 3.2 million Americans are addicted to hard drugs such as heroin, cocaine, and speed, according to a recent report by the United Nations. According to a May 2009 report from the National Center on Addiction and Substance Abuse at Columbia University (CASA), federal, state, and local governments spend $467.7 billion a year related to substance abuse. Of that amount, 96% is used to deal with consequences, including 58% for healthcare and 13% for prosecuting and jailing offenders. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), illicit drug use is declining slightly in the U.S. About 8% of people use illicit drugs in any given month. Illicit drug use is highest in Alaska, Colorado, Connecticut, Maine, Massachusetts, Montana, New York, Oregon, Rhode Island, Vermont, and Washington, D.C.
so because of the substances: Opiates: Marijuana: Cocaine: Stimulants and other:
following 30% 27% 24% 19%
primary
The American Medical Association recognized addiction as a disease back in 1956. But only now are treatments that target the underlying biochemistry of that disease beginning to be developed. According to a survey by researchers at Brown University, which appeared in Archives of Internal Medicine, approximately one-third of primary care doctors reported they do not routinely ask new patients if they use illicit drugs, and 15% do not routinely offer any intervention to drug-abusing patients. Of those doctors who do offer intervention, 61% recommend 12-step programs, which research has suggested may be less successful than formal addiction therapy, according to Dr. Peter Friedmann, an assistant professor of Medicine and Community Health at Brown University. Only 55% of providers surveyed reported routinely recommending formal addiction therapy, such as methadone treatment or residential treatment centers. Researchers are developing a range of vaccines against such highly addictive substances as cocaine, nicotine, heroin, and methamphetamine. Unlike medications now used to treat addiction, the vaccines under development are designed to prevent addictive drugs from entering the brain.
MEDICAL TREATMENT
Approximately $12 billion is spent annually in the United States to treat drug addiction. According to the Center for Substance Abuse Research at the University of Maryland, patients who seek admission to substance abuse facilities because of drug addictions do
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NicVax, from Nabi Biopharmaceuticals, currently in a phase-two clinical trial, is the furthest advanced of the vaccines.
PREVENTION
According to a May 2009 report by CASA, only 2% of the $467.7 billion spent by federal, state, and local governments on substance abuse, or about $9.4 billion, is used for prevention programs.
We are spending 96 of every dollar we spend on substance abuse and addiction to shovel up the human wreckage. Were making this really tiny investment in prevention and treatment when we have enough experience to know that prevention and treatment can reduce the shoveling-up burden. These governments have it backwards. Theyre wasting billions of dollars of taxpayers money and not making some relatively simple investments that could sharply reduce the consequences of drug and alcohol addiction. The main reason that federal and state governments arent ready to change priorities is because there is a stigma attached to alcohol and drug addiction. To reduce the amount spent on substance abuse, the government needs to mount major prevention programs, with a focus on kids.
Joseph Califano, Jr., Chairman CASA, 5/28/09
Abuse Prevention and Treatment (SAPT) Block Grant. Those grants, administered by SAMHSAs Center for Substance Abuse Treatment (CSAT), support almost 40% of all substance abuse treatment provided through state agencies. Using these federal resources, states are able to provide treatment to over 340,000 people annually. Recognizing the importance of prevention, the block grant program also provides that states use a minimum of 20% of their funds to deliver substance abuse prevention services in community and school settings. These services are targeted to populations with the greatest need, including high-risk youth, youth involved with the criminal justice system, pregnant and postpartum women, and people with HIV infection. Research shows that for every $1 spent on drug abuse prevention, communities can save $4 to $5 in costs for drug abuse treatment and counseling.

Center for Substance Abuse Research, University of Maryland, 4321 Hartwick Road, Suite 501, College Park, MD 20740. (301) 405-9770. (www.cesar.umd.edu) National Center on Addiction and Substance Abuse at Columbia University, 633 Third Avenue, 19th Floor, New York, NY 10017. (212) 841-5200. (www.casacolumbia.org) National Institute on Drug Abuse, c/o National Institutes of Health, 6001 Executive Boulevard, Room 5213, Bethesda, MD 20892. (301) 443-1124. (www.nida.nih.gov)
The Substance Abuse and Mental Health Services Administration provides funds directly to states through the Substance
Shoveling Up II: The Impact of Substance Abuse on Federal, State and Local Budgets, National Center on Addiction and
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Substance Abuse at Columbia University, May 2009. Substance Abuse and Mental Health Services Administration, P.O. Box 2345, Rockville, MD 20847. (www.samhsa.gov)
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114 SURGERY
Including surgeries performed at hospitals, ambulatory surgery centers, and in physicians offices, over 75 million surgical procedures are performed annually.
INPATIENT PROCEDURES
The top inpatient procedures are presented in Table 114.1.
TABLE 114.1 Top Five Inpatient Hospital Procedures (source: Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality)
Procedures Total Charges
Cesarean section: Upper gastrointestinal endoscopy to diagnose ulcers, stomach cancer, and other problems: Catheterization to diagnose heart problems: Respiratory intubation and mechanical ventilation: Angioplasty to widen narrowed arteries:
800,000 712,000 707,000 617,000 676,000
$14.6 billion $14.5 billion $17.3 billion $35.4 billion $26.5 billion
AMBULATORY PROCEDURES
According to data released in August 2009 by the National Center for Health Statistics, hospitals perform more ambulatory surgeries than did free-standing surgery centers. The numbers of ambulatory procedures in 2006 (most recent data available) were as follows: Hospital-based: 30.76 million Ambulatory centers: 22.57 million
QUALITY STANDARDS
The American Hospital Association teamed with the Centers for Medicare and Medicaid Services, the Agency for Healthcare
Research and Quality, the American College of Surgeons, and the Institute for Healthcare Improvement, among others, to launch in 2005 the Surgical Care Improvement Project (SCIP). SCIP is an effort to use evidencebased practices to target four of the most common surgical complications: blood clots, heart attacks, surgical site infections, and ventilator-associated pneumonia. The goal is to reduce the incidences of these complications nationally by 25% by 2010. Guidelines for deep vein thrombosis (DVT), for example, which occurs in about 25% of major surgeries without prophylaxis, helps clinicians determine the appropriate prophylactic treatment. And, guidelines for the reduction of cardiac events, which occur in 2% to 5% of patients undergoing non-cardiac surgery,
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outline the appropriate use of beta blockers and how to identify patients who are at risk. The Leapfrog Group established evidencebased quality standards for five surgical procedures pancreatic surgery, esophageal surgery, open heart surgery, percutaneous coronary interventions (such as angioplasty), and abdominal aortic aneurysm repair that hospitals must meet to be on the groups preferred list. If all hospitals met the quality standards for the five high-risk surgeries set by the Leapfrog Group, 7,818 lives each year would be saved, according to a recent study by researchers at the University of Michigan Health System. Open heart surgery alone would see about 4,089 fewer deaths, and procedures such as angioplasty would see another 3,016 fewer deaths if all patients were treated at hospitals who meet and maintain these standards.

Agency for Healthcare Research and Quality, 2101 East Jefferson Street, Suite 501, Rockville, MD 20852. (301) 594-1364. (www.ahrq.gov) American College of Surgeons, 633 North St. Clair Street, Chicago, IL 60611. (312) 202-5000. (www.facs.org) National Center for Health Statistics, 3311 Toledo Road, Hyattsville, MD 20782. (800) 232-4636. (www.cdc.gov/nchs) The Leapfrog Group, 1801 K Street NW, Suite 701-L, Washington, DC 20006. (202) 292-6713. (www.leapfroggroup.org)
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PART VII: HEALTHCARE PROFESSIONALS
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115 HEALTHCARE WORKFORCE
HEALTHCARE OCCUPATIONS
The U.S. Bureau of Labor Statistics assesses growth in healthcare occupations as shown in Table 115.1. Employment by healthcare setting is as follows: Hospitals: 4.73 million
Nursing and residential care facilities: Physician offices: Home healthcare services: Outpatient facilities:
3.06 million 2.33 million 1.02 million 539,700
Despite the recession, overall healthcare employment increased by nearly 20,000 workers monthly during the first half of 2009.
TABLE 115.1 Healthcare Occupation Employment and Projected Growth

2008 2018 Growth
Registered nurses: Nursing aids, orderlies, and attendants: Home aide: Physicians and surgeons: Medical assistants:
2,618,700 1,469,800 921,700 661,400 483,600
3,200,200 1,745,800 1,382,600 805,500 647,500
22% 34% 19% 22% 34%
LARGEST EMPLOYERS
According to the American Hospital Association, the following health systems have the largest number of full-time employees: HCA: 128,896 Ascension Health: 74,601 Community Health Systems: 67,084 Tenet Healthcare Corp.: 51,726 Kaiser Foundation Hospitals: 47,961 Catholic Health Initiatives: 45,363 Quorum Health Resources: 43,791 Catholic Healthcare West: 38,943 Trinity Health: 37,284
Adventist Health System: Catholic Health East: New York City Health and Hospitals Corp.:
33,293 31,930 29,916

U.S. Bureau of Labor Statistics, Office of Occupational Statistics and Employment Projections, Suite 2135, 2 Massachusetts Avenue NE, Washington, DC 20212. (202) 691-5700. (www.bls.gov/emp)
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116 HOSPITAL EXECUTIVE COMPENSATION
Modern Healthcare has conducted its Executive Compensation Survey since 1980. The 29th annual survey was conducted in 2009 based on data compiled by Sullivan, Cotter and Associates. This chapter presents a summary of that survey. Many healthcare execs are seeing smaller raises, flat salaries, or even decreases in compensation, according to our annual survey.
HOSPITAL TOP-EXECUTIVE MEDIAN TOTAL COMPENSATION

Chief Medical Officer: Quality Management (M.D.): Legal services: Chief Financial Officer: Chief Operating Officer: Chief Information Officer: Ambulatory services: Patient-care services: Planning: Nursing services: Human resources: Professional services: Fund development: Facilities and engineering: Managed care: Quality Mgt. (non-M.D.): Public affairs: Marketing: $329,500 $309,000 $255,800 $244,200 $242,600 $217,700 $215,100 $210,500 $209,800 $206,000 $197,400 $189,600 $177,100 $169,500 $167,000 $157,500 $156,500 $136,700
CEO MEDIAN TOTAL COMPENSATION

Free-Standing Hospitals All hospitals: Hospitals with net revenue < $250 million: Hospitals with net revenue > $250 million: System Hospitals All hospitals: Hospitals with net revenue < $250 million: Hospitals with net revenue > $250 million: Systems Hospitals with net revenue < $1 billion: Hospitals with net revenue > $1 billion: $560,100 $415,800 $703,800

Carlson, Joe, A Cut In Pay, Modern Healthcare, August 3, 2009, pp 26-30. Sullivan, Cotter and Associates, 3011 W. Grand Boulevard, Suite 2800, Detroit, MI 48202. (313) 872-1760. (www.sullivancotter.com)
$400,800 $364,300 $499,700
$ 615,000 $1.14 million
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117
MEDICAL SCHOOLS
ENROLLMENT AND GRADUATES

The Association of American Medical Colleges (AAMC) represents the 125 accredited U.S. medical schools. For the 2009-2010 entering class, medical schools received 562,694 applications from 42,269 applicants, an average of 13 per applicant. There were 31,063 first-time applicants. Among applicants, 18,390 were accepted for enrollment in 2009, a 2% increase over the prior year. Enrollment for the 2009-2010 school year was 77,722. The class of 2009 had 16,468 medical school graduates. To meet projected demand for physicians in the United States, the AAMC has called for a 15% increase in medical student enrollments, or about 2,500 per year, by 2015.
Medical School: University of Texas Medical School at Houston: University of Texas Medical Branch at Galveston: University of Texas Health Science Center School of Medicine: Ohio State University College of Medicine: University of Washington School of Medicine: Albert Einstein College of Medicine of Yeshiva University: Medical College of Wisconsin: University of Minnesota Medical School: Harvard Medical School:
976 939 929 897 895 871 857 850 841 839
TEACHING HOSPITALS
The U.S. healthcare system relies on teaching hospitals and their clinics, emergency rooms, free-standing ambulatory care centers, chronic care facilities, hospices, and individual and group practices for the clinical education of medical students and residents. Some 400 in number, they are the training ground for more than 100,000 new physicians, nurses, and other health professionals each year. A listing of teaching hospitals is provided at www.aamc.org/teachinghospitals.htm.
LARGEST MEDICAL SCHOOLS RANKED BY 2009 ENROLLMENT

University of Illinois College of Medicine: Wayne State University School of Medicine: Indiana University School of Medicine: Drexel University College of Medicine: Jefferson Medical College of Thomas Jefferson University: University of Texas Southwestern 1,426 1,234 1,211 1,099 1,079
NEW MEDICAL SCHOOLS

Seven allopathic medical schools and five osteopathic schools were accredited in 2007-
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2009, as follows: Allopathic Medical Schools Commonwealth Medical College (Scranton, Pennsylvania) Florida International University College of Medicine (Miami) Hofstra University School of Medicine (Hempstead, New York) Oakland University Beaumont Medical School (Rochester, Michigan) Paul L. Foster School of Medicine at Texas Tech Health Sciences Center (El Paso) Touro University College of Medicine (Hackensack, New Jersey) University of Central Florida College of Medicine (Orlando) Osteopathic Medical Schools A.T. Still University of Health Sciences College of Osteopathic Medicine-Mesa (Mesa, Arizona) Lincoln Memorial University-DeBusk College of Osteopathic Medicine (Harrogate, Tennessee) Pacific Northwest University of Health Sciences, College of Osteopathic Medicine (Yakima, Washington) Rocky Vista University College of Osteopathic Medicine (Parker, Colorado) Touro College of Osteopathic Medicine (New York City)

Association of American Medical Colleges, 2450 N Street NW, Washington, DC 20037. (202) 828-0400. (www.aamc.org)
Officials who accredit medical schools are busier than usual these days. The creation of new campuses and the expansion of existing ones has accreditation agencies hopping as state officials and medical educators seek more physicians to prevent a shortage.
American Medical News American Medical Association
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118
NURSES
LICENSED REGISTERED NURSES

According to the National Sample Survey of Registered Nurses, conducted by the Health Resources and Services Administration, nursing is the largest healthcare profession, with more than 2.9 million Registered Nurses (RNs) nationwide. Of all licensed RNs, 2.42 million, or 83.2%, are employed as nurses. With more than four times as many RNs in the United States as physicians, nursing delivers an extended array of healthcare services, including primary and preventive care by advanced nurse practitioners in such areas as pediatrics, family health, womens health, and gerontological care.
Nursings scope also includes services by certified nurse-midwives and nurse anesthetists, as well as care in cardiac, oncology, neonatal, neurological, and obstetric/gynecological nursing and other advanced clinical specialties. Nearly 57% of RNs work in general medical and surgical hospitals, where RN salaries average $60,970 per year. Nurses comprise the largest single component of hospital staff, are the primary providers of hospital patient care, and deliver most of the nations longterm care. Registered Nurse distribution by state is presented in Table 118.1.
TABLE 118.1 Total number of nurses by state, rate of nurses per 100,000 population, and rank by state (source: Health Care State Rankings 2009, based on data from the Bureau of Labor Statistics):
Number Rate Rank
Alabama: Alaska: Arizona: Arkansas: California: Colorado: Connecticut: Delaware: District of Columbia: Florida: Georgia: Hawaii:
42,180 5,150 34,580 21,920 233,200 36,850 34,690 8,420 8,110 148,180 62,230 9,620
912 756 544 774 641 761 994 977 1,380 814 653 753
17 38 50 35 46 37 10 12 n/a 30 44 39
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TABLE 118.1 (cont)

Number Rate Rank
Idaho: Illinois: Indiana: Iowa: Kansas: Kentucky: Louisiana: Maine: Maryland: Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin:
9,600 104,130 54,770 29,550 24,070 39,120 39,090 13,850 48,840 78,280 84,480 52,690 25,350 56,290 7,160 17,870 14,670 12,730 78,510 11,400 166,990 80,090 7,000 114,920 25,700 29,700 126,370 10,600 35,040 9,670 54,960 157,870 16,670 5,660 57,740 49,910 16,970 50,690
642 812 864 999 867 923 894 1,053 869 1,210 841 1,017 868 958 748 1,010 574 970 907 580 859 886 1,097 1,001 712 795 1,017 1,007 795 1,215 894 662 625 912 750 774 938 905
45 31 27 11 26 16 21 4 24 2 29 5 25 14 41 7 49 13 19 48 28 23 3 9 42 33 5 8 33 1 21 43 47 17 40 35 15 20
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NURSES AND HEALTHCARE QUALITY

In many ways, nurses are the key to safety in hospitals and nursing homes. A landmark 2002 study found that for every additional patient a hospital nurse has to handle, complications increase and mortality rises 7%. Similarly, a recent study by Prof. Susan Horn, Ph.D., at the University of Utah, found that when nurses spend less than 15 minutes a day with each nursing home resident, as is typical, patients suffer more pressure sores, falls, infections, and hospitalizations. At 30to-40 minutes of daily nursing time, according to Prof. Horn, outcomes are so much better that it is actually cheaper to hire more nurses. Researchers from Baystate Medical Center (Springfield, Massachusetts) found that while fewer patients per hospital nurse is costeffective, lower nurse-to-patient ratios are still costly at a cost of anywhere from $24,000 to $136,000. In July 2009, the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation (RWJF) launched The Initiative On The Future Of Nursing, a study to address critical issues in nursing, including the following: What role should nurses play in the context of the entire healthcare workforce? Where can nurses innovate in care delivery? How can the various care settings attract the right nurses, including acute, ambulatory, primary and long-term care, and community and public health?
The Initiative ... is intended as a critical examination that could shatter existing conceptions of the field and lay out a blueprint for 21st century nursing.
The IOM/RWJF study will publish its findings in Fall 2010.
NURSE STAFFING REQUIREMENTS

Since 2005, California hospitals have been required to have one nurse on duty for every five patients at all times. While California remains the only state with nurse-ratio requirements, seven states Illinois, Maine, New Jersey, Oregon, Rhode Island, Texas, Vermont have some type of legislation affecting staffing.
NURSE SHORTAGES
The need for new nurses has never been more acute. An aging population will increase the demand over the coming decades. At the same time, with more and more nurses approaching retirement, the supply will further decline. An increasing demand for nurses outside of hospitals makes shortages at hospitals even more acute. As recently as 2007, almost 70% of hospitals reported a nursing shortage, according to the American College of Healthcare Executives. The current downturn in the U.S. economy has eased the nursing shortage to some extent. According to Dr. Peter Buerhaus, Director of the Center for Interdisciplinary
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Health Workforce Studies at Vanderbilt University, the economy is bringing many retired nurses back into the workforce. Also, some nurses who had planned to retire are holding on to their positions, and others who were working part-time have taken full-time positions. While some hospitals reported an end to the shortage, a significant nursing shortage still looms. Dr. Buerhaus projects the shortfall in the number of nurses needed is expected to grow to 260,000 by 2025.

American Association of Colleges of Nursing, One Dupont Circle NW, Suite 530, Washington, DC 20036. (202) 463-6930. (www.aacn.nche.edu) American Nurses Association, 8515 Georgia Avenue, Suite 400, Silver Spring, MD 20910. (301) 628-5000. (www.nursingworld.org) Carlson, Joe, Rethinking Nursing, Modern Healthcare, July 20, 2009, pp 6-7. Health Resources and Services Administration, 5600 Fishers Lane, Rockville, MD 20857. (www.hsra.gov) National League for Nursing, 61 Broadway, 33rd Floor, New York, NY 10006. (212) 363-5555. (www.nln.org)
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119
NURSING SCHOOLS
ENROLLMENT AND GRADUATES

According to the 2009 State of the Schools, by the American Association of Colleges of Nursing (AACN), there are 762 nursing schools in the U.S. with baccalaureate and graduate programs. Combined enrollment is as follows: Baccalaureate: 201,407 Masters degree: 69,565 Doctoral (research-focused): 3,976 Doctoral (practice-focused): 3,416 Graduations were as follows: Baccalaureate: Masters degree: Doctoral (research-focused): Doctoral (practice-focused):
STATE REQUIREMENTS
Requirements for educating new nurses are regulated under different standards in the 50 states. Many within the profession believe that educational requirements for nurses should be standardized across the U.S. It makes no sense that so many levels of education are available to nurses, including two-year associate degrees, three-year nursing diplomas, and four-year baccalaureate programs. We favor a single educational standard based on the available scientific evidence.
Rebecca Patton, President American Nurses Association Modern Healthcare, 10/15/08
62,141 17,247 555 362
For the 2008-2009 school year, 49,948 qualified applications were not accepted due primarily to a shortage of faculty and resource constraints. Nursing schools experienced declining enrollment from 1995 through 2000, then increased for seven consecutive years, peaking with 16.6% growth in 2003. Enrollment more recently has begun to plateau. This years minimal 2.2% growth in the baccalaureate student population may signal that schools have reached enrollment capacity.
Fay Raines, President AACN 2009 State of the Schools
LARGEST NURSING SCHOOLS

Ranked by enrollment, the following are the largest U.S. nursing schools (source: National League of Nursing): Excelsior College School of Nursing: 15,080 University of Phoenix College of Health and Human Services: 6,650 Kent State University College of Nursing: 2,690 Northwestern State University College of Nursing: 1,928 Southeastern Louisiana University College of Nursing: 1,815 Trinitas School of Nursing: 1,740
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University of Louisiana Lafayette College of Nursing: Maricopa Community Colleges District Nursing Program: University of Wisconsin Milwaukee College of Nursing: Hawaii Pacific University School of Nursing:
1,575 1,510 1,505 1,446
Carlson, Joe, Rethinking Nursing, Modern Healthcare, July 20, 2009, pp 6-7. Council for the Advancement of Comprehensive Care AT Columbia University, 630 West 168th Street, Box 6, New York, NY 10032. (212) 305-3254. (www.caccnet.org)
DOCTORATE IN NURSING
More than 200 nursing schools have established or plan to launch doctorate of nursing practice (DNP) programs to equip graduates with skills the schools say are equivalent to those of primary-care physicians. The two-year programs, including a one-year residency, create a hybrid practitioner with more skills, knowledge, and training than a nurse practitioner with a masters degree. According to Mary Mundinger, R.N., Ph.D., dean of the Columbia University School of Nursing, DNPs are being trained to have more focus than doctors on coordinating care among many specialists and healthcare settings. The Council for the Advancement of Comprehensive Care, in conjunction with the National Board of Medical Examiners is in the process of establishing a national standard for doctors of nursing practice. By 2015, the American Association of Colleges of Nursing aims to make the doctoral degree the standard for all new advanced practice nurses, including nurse practitioners.

American Association of Colleges of Nursing, One Dupont Circle NW, Suite 530, Washington, DC 20036. (202) 463-6930. (www.aacn.nche.edu)
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120 PHYSICIAN COMPENSATION
COMPENSATION FOR PHYSICIAN SPECIALITIES

In 2009, Modern Healthcare published its 14th annual Report on Physician Income. Table 120.1 presents a summary of the findings of that report.
Physicians are seeing smaller pay gains, with many failing to keep up with inflation. With cash in short supply, hospitals and physician practices are forced to get creative. This creativity has manifested itself with growing use of guaranteed income, signing bonuses, training stipends, education debt forgiveness, and even housing.
TABLE 120.1 Compensation Ranges For Physician Specialities Orthopedic surgery: Urology: Radiation oncology: Cardiology (invasive): Radiology: Gastroenterology: Plastic surgery: Cardiology (noninvasive): Anesthesiology: Oncology (including hemotology): Dermatology: General surgery: Pathology: Emergency medicine: Obstetrics/gynecology: Intensivist: Neurology: Neonatology: Psychiatry: Hospitalist: Internal medicine: Pediatrics: Family practice: $363,600 $328,800 $377,800 $387,600 $391,000 $358,300 $327,000 $346,800 $327,600 $301,800 $297,000 $287,500 $233,700 $224,200 $240,700 $255,900 $211,500 $230,900 $184,900 $183,200 $179,900 $150,000 $166,800 to to to to to to to to to to to to to to to to to to to to to to to $615,600 $502,300 $501,300 $496,100 $483,000 $478,000 $445,600 $432,500 $413,800 $408,000 $401,600 $369,900 $334,200 $327,400 $321,700 $299,000 $295,300 $290,000 $232,100 $226,900 $222,400 $217,000 $212,000
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SALARY SURVEYS
The following groups conduct healthcare salary surveys: American Medical Group Association, 1422 Duke Street, Alexandria, VA 22314. (703) 838-0033. (www.amga.org) Cejka Search, 4 CityPlace Drive, Suite 300, St. Louis, MO 63141. (800) 678-7858. (www.cejkasearch.com) Daniel Stern Associates, 10 Duff Road, Suite 215, Pittsburgh, PA 15235. (800) 438-2476. (www.danielstern.com) Delta Physician Placement, Four Hickory Centre, 1755 Wittington Place, Suite 175, Dallas, TX 75234. (800) 521-5060. (www.tdcpeople.com) Hay Group, The Wanamaker Building, 100 Penn Square East, Philadelphia, PA 19107. (215) 861-2000. (www.haygroup.com) Hospital & Healthcare Compensation Service, P.O. Box 376, Oakland, NJ 07436. (201) 405-0075. (www.hhcsinc.com) Jackson & Coker, 3000 Old Alabama Road, Suite 119-608, Alpharetta, GA 30022. (800) 272-2707. (www.jacksoncoker.com) Martin Fletcher, 909 Lake Carolyn Parkway, Suite 1300, Irving, TX 75039. (800) 377-0730. (www.martinfletcher.com) MD Network, 9901 E. Valley Ranch Parkway, Suite 1040, Irving, TX 75063. (800) 705-7055. (www.md-network.com) Medical Group Management Association, 104 Inverness Terrace East, Englewood, CO 80112. (303) 799-1111. (www.mgma.com) Medicus Partners, 14114 North Dallas Parkway, Suite 380, Dallas, TX 75240. (972) 759-0331. (www.medicuspartners.com) Merritt, Hawkins & Associates, 5001 Statesman Drive, Irving, TX 75063. (800) 876-0500. (www.merritthawkins.com)
Pacific Communications, 675 Anton Boulevard, Suite 900, Costa Mesa, CA 92626. (714) 427-1900. (www.pacificcom.com) Pinnacle Health Group, 5887 Glenridge Drive, Suite 200, Atlanta, GA 30328. (800) 492-7771. (www.phg.com) Sullivan, Cotter and Associates, 3011 W. Grand Boulevard, Suite 2800, Detroit, MI 48202. (313) 872-1760. (www.sullivancotter.com) Warren Surveys, 3218 Fawnridge Drive, Rockford, IL 61114. (815) 877-8794. (www.demarcowarren.com)

Robeznieks, Andis, Feeling The Pain, Modern Healthcare, July 13, 2009, pp 2028.
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121 PHYSICIANS
PHYSICIAN SUPPLY
According to Physician Characteristics and Distribution in the U.S. 2009, by the American Medical Association (AMA), there are 941,000 practicing physicians in the United States. Physician distribution by state is presented in Table 121.1.
DEMOGRAPHICS
Seventy-two percent (72%) of U.S. physicians are male; 28% are female. Distribution by age is as follows: Under 35: 16% 35-to-44: 26% 45-to-54: 27% 55-to-64: 18% 65 and older: 12%
TABLE 121.1 Total number of physicians by state, rate of physicians per 100,000 population, and rank by state (source: Health Care State Rankings 2009, based on data from the American Medical Association):
Number Rate Rank
Alabama: Alaska: Arizona: Arkansas: California: Colorado: Connecticut: Delaware: District of Columbia: Florida: Georgia: Hawaii: Idaho: Illinois: Indiana: Iowa: Kansas: Kentucky: Louisiana: Maine: Maryland:
11,239 1,717 15,710 6,548 112,776 14,515 14,753 2,456 5,152 55,037 23,239 4,665 2,993 39,986 15,478 6,536 7,180 11,024 12,741 4,305 26,402
243 252 247 231 310 300 423 285 876 302 244 365 200 312 244 219 259 260 291 327 470
41 37 38 44 17 19 5 25 n/a 18 39 7 50 16 39 46 35 34 23 11 2
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TABLE 121.1 (cont)

Number Rate Rank
Massachusetts: Michigan: Minnesota: Mississippi: Missouri: Montana: Nebraska: Nevada: New Hampshire: New Jersey: New Mexico: New York: North Carolina: North Dakota: Ohio: Oklahoma: Oregon: Pennsylvania: Rhode Island: South Carolina: South Dakota: Tennessee: Texas: Utah: Vermont: Virginia: Washington: West Virginia: Wisconsin: Wyoming:
33,313 28,356 17,178 5,961 15,968 2,580 4,942 5,591 4,232 30,595 5,533 85,304 26,046 1,769 34,472 7,245 12,048 43,257 4,430 11,514 2,012 18,137 56,531 6,269 2,735 24,162 20,353 4,760 16,485 1,165
515 282 331 204 272 270 279 219 322 354 282 439 288 277 300 201 323 348 421 261 253 295 237 235 441 314 316 263 294 223
1 26 10 48 30 31 28 46 13 8 26 4 24 29 19 49 12 9 6 33 36 21 42 43 3 15 14 32 22 45
SPECIALISTS
According to the AMA Physician Medical File, 764,783 physicians practice specialities. Distribution is as follows: Allergy & Immunology: 4,220 Anatomic/Clinical Pathology: 15,562 Anesthesiology: 38,691 Cardiovascular Disease: 21,497 Child & Adolescent Psychiatry: 7,310 Dermatology: 10,385 Emergency Medicine: 30,718
Endocrinology, Diabetes & Metabolism: Family Medicine/General Practice: Gastroenterology: General Surgery: Geriatric Medicine: Hematology & Oncology: Infectious Disease: Internal Medicine: Internal Medicine/Pediatrics: Neonatal-Perinatal Medicine: Nephrology:
5,441 103,182 12,083 26,751 3,767 11,789 6,415 104,699 3,182 4,053 7,543
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Neurological Surgery: Neurology: Obstetrics & Gynecology: Ophthalmology: Orthopedic Surgery: Otolaryngology: Pediatrics: Physical Medicine & Rehabilitation: Plastic Surgery: Preventive Medicine: Psychiatry: Pulmonary Disease & Critical Care Medicine: Radiation Oncology: Radiology & Diagnostic Radiology: Rheumatology: Thoracic Surgery: Urology: Vascular Surgery:
4,918 12,612 39,665 17,841 20,028 9,218 54,016 8,068 6,670 7,080 39,355 11,558 4,208 27,550 4,559 4,820 9,915 2,609
More than 250,000 active physicians are over age 55. Whether the United States will have enough doctors in the future is subject for debate.
American Hospital Association, 8/09
The shortage is most acute for primary care physicians, and many specialists fields are also experiencing shortages. The number of practicing general surgeons per 100,000 population has dropped 26% over the past two decades, for example, creating shortages in that field. A shortage of 124,000 physicians in 2025 Is projected by the Association of American Medical Colleges.
GROUP PRACTICES PHYSICIAN SHORTAGES

A physician shortage is developing in the United States, a situation which will likely intensify in coming years. Increasing demand for medical services is expected as the population ages the number of Americans older than 65 is projected to double by 2030. In addition, over 200,000 physicians are projected to be retiring in the next 15 years. According to the Medical Group Management Association, a total of 226,231 doctors work in 19,747 physician groups in the U.S., distributed by group size as presented in Table 121.2. Approximately 70% of group practices are single-specialty.
TABLE 121.2 Physician Group Distribution By Group Size 3 or 4 physicians: 5-to-9 physicians: 10-to-25 physicians: 26-to-75 physicians: 76-to-99 physicians: 100 or more physicians: 8,478 groups; 29,081 physicians 7,096 groups; 45,027 physicians 2,989 groups; 43,781 physicians 862 groups; 34,675 physicians 81 groups; 6,883 physicians 241 groups; 66,784 physicians
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HOSPITALISTS
Hospitalists, physicians who exclusively manage the care of inpatients, represent a new and rapidly growing specialty. The Society of Hospital Medicine (SHM) estimates approximately 23,000 hospitalists are currently working in U.S. hospitals, an increase from only about 2,000 a decade ago. The SHM estimates 40% of U.S. hospitals employ hospitalists. For those with 200 to 499 beds, the figure is estimated at 55%; and 45% for those with 100 to 199 beds. About 75% of practicing hospitalists are trained in general internal medicine, with another 5% in an internal medicine subspecialty, such as pulmonary or critical care medicine. About 3% are trained in family practice; the remaining 11% are mostly pediatric hospitalists trained as general pediatricians. There are now several early residency tracks and fellowship programs to train future hospitalists.
31 or more years: 21-to-31 years: 11-to-20 years: 6-to-10 years: 4-to-5 years: 2-to-3 years: 1 year or less:
33% 19% 17% 9% 7% 8% 6%

AMA Physician Medical File, American Medical Association, January 2009. American Hospital Association, One North Franklin, Chicago, IL 60606. (312) 422-3000. (www.aha.org) American Medical Association, 515 State Street, Chicago, IL 60610. (800) 621-8335. (www.ama-assn.org) CompHealth, 6440 South Millrock Drive, Suite 175, Salt Lake City, UT 84121. (800) 453-3030. (www.comphealth.com) Medical Group Management Association, 104 Inverness Terrace East, Englewood, CO 80112. (303) 799-1111. (www.mgma.com) Society For Hospital Medicine, 1500 Spring Garden, Suite 501, Philadelphia, PA 19130. (800) 843-3360. (www.hospitalmedicine.org)
LOCUM TENENS
Temporary physician staffing, or locum tenens, firms continue to grow market share in a niche industry that is estimated at $2 billion. Hospitals and health systems continue to be the largest users of locum tenens physicians, accounting for 60% to 70% of all physician placements, or about 26,000 doctors per year. According to Profile of a Locum Tenens Physician, by CompHealth, locum tenens physicians have the following number of years in practice:
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Richard K. Miller & Associates

THE 2010 HEALTHCARE BUSINESS MARKET RESEARCH HANDBOOK

By: Richard K. Miller and Kelli Washington

Richard K. Miller & Associates

THE 2010 HEALTHCARE BUSINESS MARKET RESEARCH HANDBOOK

ISBN Number: 1-57783-157-8

PART I: AMERICAS HEALTH

COBRA CONTINUATION COVERAGE

COMMUNITY HEALTH CENTER INFRASTRUCTURE GRANTS

BROADBAND TECHNOLOGY OPPORTUNITIES ACT

COMPARATIVE EFFECTIVENESS RESEARCH

HEALTH INFORMATION TECHNOLOGY GRANTS

HEALTH INFORMATION TECHNOLOGY IMPROVEMENTS

MEDICAID FEDERAL MATCHING ASSISTANCE PERCENTAGE

NATIONAL HEALTH SERVICE CORPS

TRAINING AND EMPLOYMENT SERVICES

PREVENTION AND WELLNESS PROGRAM

UNIVERSITY RESEARCH FACILITIES

RURAL COMMUNITY FACILITIES PROGRAM ACCOUNT

DEMOGRAPHICS OF HEALTHCARE SPENDING

45-to-54: 55-to-64: 65-to-74: 75 and older: Average household:

$1,310 $1,676 $2,718 $2,510 $1,465

HEALTHCARE SPENDING BY AGE

HEALTHCARE SPENDING BY HOUSEHOLD INCOME

$2,416 $1,449 $1,570 $1,839 $ 644 $ 949 $1,465

HEALTHCARE SPENDING BY HOUSEHOLD TYPE

HEALTHCARE SPENDING BY RACE AND ETHNICITY

Northeast: Midwest: South: West: Average household:

$596 $697 $614 $798 $670

HEALTHCARE SPENDING BY EDUCATION

HEALTHCARE SPENDING BY REGION

Bachelor degree: Masters, doctoral degree: Average household:

$577 $604 $514

REFERENCES AND RESOURCES

GEOGRAPHIC VARIATIONS IN HEALTHCARE SPENDING

DARTMOUTH ATLAS OF HEALTHCARE

STATES RANKED BY HCI SCORE

REFERENCES AND RESOURCES

NATIONAL HEALTH EXPENDITURES

REFERENCES AND RESOURCES

Note: Projections made prior to passage of healthcare reform legislation.

PERCENTAGE OF ADULTS WHO ARE OBESE, STATE-BY-STATE

REFERENCES AND RESOURCES

34% 28% 22% 16% 15%

PERCENTAGE OF ADULTS WHO SMOKE, STATE-BY-STATE

CORRELATION WITH PERSONAL INCOME

REFERENCES AND RESOURCES

7 STATE HEALTH RANKINGS

HEALTH SCORE IMPROVEMENTS

REFERENCES AND RESOURCES

PART II: HOSPITALS & HEALTHCARE PROVIDERS

TABLE 8.1 Largest Childrens Hospitals

TABLE 8.1 (Cont)

REFERENCES AND RESOURCES

COMPARATIVE EFFECTIVENESS RESEARCH

ARRA FUNDING FOR RESEARCH

PRIORITIES FOR CER

REFERENCES AND RESOURCES

COMPLEMENTARY & ALTERNATIVE MEDICINE

CAM USE IN AMERICA

Possible cost savings: Employee requests: Insurance coverage: Other:

REFERENCES AND RESOURCES