D. Hospital Services

The six acute care hospitals in the Humboldt/Del Norte region play a central role in ensuring local availability to acute care hospital services, which undoubtably contribute to positive patient outcomes for the residents of the two county area. The information presented in this next section is intended to provide an overview of the utilization of hospital services by area residents, both in the region and outside it. Subsections are included to address:

• Hospital Occupancy Ratios
• In-Area Hospital Discharges, by DRG
• Out-of-Area Hospital Discharges, by DRG
• Top Destinations for Out-of-Area Hospital Utilization
• Intra-regional hospitalizations
• In-migration of Patients to Region
• Hospital Payer Mix
• Hospital Outpatient Encounters

The majority of this data has been extracted from data files maintained by the California Office of Statewide Health Planning and Development (OSHPD) regarding Hospital Discharges. At the time this information was obtained, the most recent year of data released by OSHPD was for 1995.

Hospital Occupancy Ratios: A common statistic when first looking at hospital utilization is the hospital occupancy ratios. This information is presented in Table 6.7, on the following page. The number of bed days available by service is calculated by using the number of licensed and staffed beds available for that service multiplied by 365 days. A ratio of 1.00 would mean that every bed is utilized by patients every day in the year. This table illustrates the variation in hospital occupancy ratios in the acute care hospitals in the region, from an all services high of .66 at Sutter Coast Hospital to a low of .39 at Mad River Hospital. Within individual services, there is also variation. Overall, in 1995, there were 364 beds available in the acute care hospitals for the equivalent of 132,860 bed days. There were also a total of 66,432 patient days (adult and pediatric) that year for a ratio of patient days to bed days of 0.50. The same information is presented on the inpatient psychiatric hospital, Sempervirens. This hospital has a patient days to bed days ratio of .73. For the remainder of this section, however, data on this facility is not included.

Hospital Discharges: Table 6.8 shows the number of hospital discharges of Humboldt/Del Norte residents in 1995, both from hospitals within the two county region, as well as other California hospitals located out of the region. This reveals that approximately only one out of every ten residents leaves the area for the purpose of hospitalization. This number is very low for rural areas that traditionally have fewer resources available, requiring patients to leave to obtain more specialized services and treatments. In essence, while 10% of patients leave the area, the remaining 90% are staying within the region for care.

A comment is necessary about the definition of "within the service area." For purposes of this report, "in-market" is defined as any hospital within the two county area. Thus, a patient who lives in Crescent City or Garberville and travels to Eureka for hospitalization is still considered "in-market." In fact, many in these smaller communities would take exception to this definition as it is still perceived as a patient lost to their own community hospital. A limited amount of additional information will be presented later in this section to try and gain a sense of this intra-regional movement.

The Oregon Office of Health Policy and Research was contacted to obtain information on the number of residents from Del Norte County who are hospitalized in Oregon hospitals. In 1995, 282 Del Norte County patients were discharged from Oregon hospitals; in 1996, the total was 270. Eighty percent of these patients were from Rogue Valley Medical Center in Medford. Another 8% were discharged from Providence Medford Medical Center with the remaining percentage from a dozen different hospitals.

Humboldt-Del Norte Discharge Diagnoses: Table 6.9 provides a listing of the top twenty Diagnostic-Related Group codes for patients discharged from Humboldt/Del Norte hospitals in 1995. The diagnoses associated with births dominate the top twenty list, accounting for 21% of all discharges. Throughout California, these same DRGs account for 25.8% of all discharges. Given the lower birth rate in Humboldt/Del Norte County, this smaller percentage of DRGs associated with births is expected.

Because hospitals do not report the reimbursement generated by various discharge diagnoses, the best proxy reported to the State is "Total Charges." This will allow for a rough comparison between the percentage of discharges of an individual DRG compared to the percentage of total charges for that DRG. In actuality, however, charges are very different from the actual payment made to the hospital. Actual reimbursement received is dependent on what type of health care coverage a patient has (i.e., commercial insurance, Medicare, MediCal or self pay) and what rate each insurance carrier has negotiated for that particular diagnosis.

The most obvious difference between percentage of discharges and percentage of charges is for obstetrical and newborn services. Clearly, these services do not generate a corresponding amount of charges. However, the majority of these hospital stays are relatively uncomplicated and brief. This pattern is not dissimilar from other hospitals in California. The hospitals in Humboldt and Del Norte Counties are providing a major service to the community by providing obstetrical services. Studies have shown that when patients have to travel distances for prenatal care and delivery services, good birth outcomes decline.

Table 6.10 provides a comparison of Humboldt/Del Norte Counties and California DRGs as a percentage of the total number of discharges. Again the lower percentage of deliveries and newborns is noted. When comparing other individual local DRGs percentages to state DRG percentages, there is very little difference between the two. However, when the obstetrical and newborn DRGs are removed from the top twenty DRGs, the remaining DRGs comprised 25% of the total discharges in Humboldt/Del Norte compared to 20.1% for state discharges. There are many potential factors that could be contributing to this difference, such as the older composition of the area population and/or the supply of physicians and patients coming into the area for specialty services. Without more detailed analysis, no conclusion can be reached.

Out-of-Area Hospital Discharges: Table 6.11 provides a listing of the top-ranking discharge DRGs by frequency from California hospitals located outside of the two counties. During 1995, a total of 1,486 residents were hospitalized in California facilities outside the area. The majority of these DRGs represent highly specialized treatments or surgical procedures which probably are either not available locally or not commonly performed locally. When comparing the top twenty DRGs in Humboldt/Del Norte with out-of-area DRGs, twelve of the DRGs appear in out-of-area hospitals only. These DRGs are dominated by coronary procedures. Seven of these DRGs appear on both in-market and out-of-market lists including Psychoses, Back and Neck Procedures without complications, Vaginal Deliveries without complications, Major Joint and Limb Reattachment Procedures of Lower Extremity, Rehabilitation, Normal Newborn and Specific Cerebrovascular Disorders Except TIA. Because there is some limited variation within a DRG category, those DRGS from out-of-area hospitals may reflect patients requiring referral to tertiary care centers. However, it may also reflect patients who are leaving the region for services currently available locally.

Evaluation of the patients leaving Del Norte County for hospitalization in Oregon reveals a similar pattern of diagnoses. Of the 181 discharges from the Rogue Valley Medical Center in 1995 and 1996, 162 (89.5%) were for DRGs related to cardiovascular procedures.

Top Destinations for Out-of-Area Hospital Utilization: Table 6.12 provides information on the top five out-of-area hospitals that discharged the greatest number of Humboldt/Del Norte County residents in 1995. This information was taken from California OSHPD data and the Oregon Health Plan Policy and Research office data. Not surprisingly, these are the same five hospitals to which the largest number of air transports are referred each year.

Intra-regional Hospitalizations: Because of the large geographic size of the Humboldt/Del Norte area and a heavy concentration of specialists in the Humboldt Bay area, a certain amount of flow into these hospitals is expected from the smaller communities in the region. To measure this, a brief data extraction was run using the geographic "Health Facility Planning Area" (HFPA) designation. This is a designation developed by the State which helps identify the usual catchment area by zip codes for hospitals in a particular geographic location. Patients living within a hospital HFPA are normally expected to utilize the hospitals within that area. Using the HFPAs, it is possible to get a sense of the extent of the flow of residents from a particular community in Humboldt/Del Norte to a different hospital outside their community. Hospitals included in each HFPA are:

HFPA	Community	Hospital
101	Crescent City	Sutter Coast Hospital
105	Eureka	Mad River Hospital, General Hospital, St. Joseph’s Hospital
107	Fortuna	Redwood Memorial Hospital
109	Garberville & So.	Mendocino Co. Southern Humboldt Community Hospital

This table shows that there is a significant draw from the smaller, more rural communities in Humboldt/Del Norte area into the Eureka and Fortuna hospitals. To determine the purposes of these hospitalizations, the top five DRGs for patients leaving their own community to travel to another hospital are listed in Table S.6.12-2.

Of note is the amount of flow between health facility planning areas for women’s health and obstetrical services. Approximately half of all deliveris from southern Humboldt are leaving to deliver elsewhere in the region. There also appears to be a fairly sizable flow between the Eureka and Fortuna area for nomal deliveries. The presence of Sempervirens Psychiatric Inpatient Facility in Eureka is presumably the facility receiving the area’s patients with DRGs of psychoses.

In-Migration Patients: OSHPD hospital discharge data also allows us to track patients from out of the area who are coming into Humboldt/Del Norte Counties for hospitalization. Again, the Health Facility Planning Area is used for the "referral source." Table 6.13, on the following page, breaks out the top five areas from which patients come into the region for care. The area with the highest number of discharges is listed as a "non-California HFPA." The assumption is that the majority of these patients are from Oregon, crossing into the region for care. HFPA 103 is an area where there is no hospital and includes portions of eastern Humboldt County (Hoopa), southeastern Siskiyou County and western Trinity County. Table S6.11-3 shows the top ten DRGS of patients from outside the Region who come into the area for hospitalizations.

Table 6.13: Humboldt/Del Norte Top Five 1995 In-migration Discharge Sources

Referral Sources Discharges Percentage of Total Non-California HFPA or Patient ZIP Code Unknown 943 44.0% 0103 - Hoopa 744 34.7% 0207 - Weaverville 157 7.3% 0209 - Redding 21 1.0% 0112 - Willits 14 0.7% All Others 266 12.4% Total 2,145

Source: 1995 California OSHPD Discharge Data

Note: Shown in the first column is the patient Health Facility Planning Area, i.e. the place wherethe patient is normally expected to go. By coming into the region for care, the patient is leaving a different hospital catchment area.

These DRGs represent a broad cross-section of medical care, and suggest that these residents are seeking a broad spectrum of care in the region, rather than just coming for specific diagnoses an treatments.

Table 6.14: Humbodlt/Del Norte 1995 Hospital Inpatient Payer Mix

Discharges Percentage of Total Medicare 6,355 39.2% Medi-Cal 4,221 26.0% Commercial 3,991 24.6% Private Pay/Other 1,641 10.1% Total 16,208 100.0%
Source: 1995 California OSHPD Discharge Data

Hospital Payer Mix: The payer mix of patients seen by an acute care facility, reported in Tables 6.14 and 6.14a can provide additional understanding of the utilization of these services by community members as well as a sense of the financial reimbursements levels being received for the care. To help put these numbers into context, Table S.6.14-1 shows the distribution of health insurance coverage for the residents in the two county area.

Table S.6.14-1: Distribution of Health Care Insurance Coverage Humboldt/Del Norte Counties

Insurance Coverage Total # % of Population Medicare 17,800 12.5% MediCal 27,400 19.2% Commercial Insurance 69,000 48.2% Private Pay/Self Pay 28,600 20.1% Total 142,700 100.0%

Source: Humboldt Bay Alliance for Economic Development; Health Data Summaries For California Counties, 1996, CA Department of Health Services

Table S.6.14-2: Trends in Commercial Insurance Mix Humboldt/Del Norte Hospitals, 1993-1995

1993 1994 1995 Type of Commercial Insurance # % of all discharges # % of all discharges # % of all discharges Blue Cross/Blue Shield 1,419 7.6 1,563 8.4 1,116 6.0 Private Insurance Company 3,197 17.0 2,896 15.6 1,243 6.7 HMO/Prepaid Health Plan 391 2.1 385 2.1 2,109 11.4 Total 5,007 26.7 4,844 26.1 4,468 24.1

Source: 1993-1995 California OSHPD Hospital Discharge Data

Table 6.14 provides an overview of the number and percentage of 1995 hospital discharges from area hospitals by payer source. Please note: the numbers and percentages in this table are for patients (i.e., discharges) by payer source rather than revenue by payer source. Medicare dominates the payer mix with 39.2% of all discharges which is not surprising given the age structure of the area’s population.

Health Insurance Coverage: Table S.6.14-1 illustrates the distribution of health insurance coverage across the population in Humboldt/Del Norte counties. Commercial insurance represents by far, the largest payer category at just over 48% of the population. The second largest category is private pay/self pay, which is estimated at 20% based on a survey conducted by the Humboldt Bay Alliance for Econcomic Development in 1996. This means that as many as 28,600 residents may have little or no health insurance coverage. In addition to the sources used in this table, the Health Insurance Plan of Califronia (HIPC) also estimates that the percentage of uninsured population in Northern California (which includes Humboldt/Del Norte Counties) is 20%.

The payer mix in the three-year time period of 1993-1995 using these broad categories remained basically unchanged. However, there was some shifting that took place in the "Commercial Insurance" payer group which is presented in Table S.6.14-2.

While there is overlap in the Blue Cross/Blue Shield category and the HMO/PHP category in terms of managed care programs, there is an undeniable decline in the number of discharges reimbursed from private insurance companies with a corresponding jump in health insurance coverage which involves managed care. Unfortunately, there is a time lag in obtaining hospital discharge data from the State of California. At the time this data was extracted in the Fall of 1997, 1995 was the most current year of data available. This would be an important trend to follow. 

Hospital Outpatient Encounters: In addition to revenue generated by inpatient care, local hospitals also generate significant revenue from services classified as outpatient encounters or procedures. This includes services such as: ambulatory care services, outpatient surgeries, laboratory or pharmaceutical services, etc. Table 6.15 and Exhibit 6.1, on the following page, illustrates the number of outpatient encounters at Humboldt/Del Norte hospitals, by payer category for 1995. As the OSHPD public use data does not currently include zip code information for outpatient services, it is not possible to determine which services are provide to Humboldt/Del Norte County residents and the number of patients who travel into the county for care. Likewise, it is not possible to identify patients who leave Humboldt/Del Norte Counties for outpatient encounters. Again, actual charges are provided in the table below to give a sense of the amount billed. These figures however, are higher than actual reimbursement levels. As these figures indicate, hospital outpatient services provide significant additional revenue for hospitals.

Exhibit 6.1: Humboldt/Del Norte 1995 In-market Hospital Outpatient Encounters

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