D. Hospital Services

El Centro Regional Medical Center and Pioneers Memorial Hospital play a major role in ensuring local availability of acute care services which result in positive patient outcomes for Imperial County residents. These facilities are faced with the challenge of responding to a complex, rapidly changing health care environment and must seek appropriate strategies to ensure their future survival. Rural hospitals, which typically have lower patient volume and operating margins, find they are having to redefine their role in the marketplace and determine which services should be delivered locally to maximize patient outcomes while also remaining fiscally solvent.

The information presented in this section is intended to provide an overview of the utilization of hospital services by Imperial County residents, both in Imperial and in surrounding communities. The majority of this information is extracted from data files maintained by the California Office of Statewide Health Planning and Development (OSHPD) regarding hospital discharges.

Hospital Occupancy Ratios: A common statistic when first looking at hospital utilization is the hospital occupancy ratios. This information is presented in Table 6.6. While El Centro Regional Medical Center and Pioneers Memorial Hospital each reported a 47% occupancy ratio, there was variability between the hospitals on the different medical/surgical services. For example, El Centro Regional Medical Center has eight ICU beds that are fully occupied 54% of the time. Pioneers Memorial Hospital has eight ICU beds that are fully occupied 45% of the time.

Hospital Discharges: Table 6.7 shows the number of hospital discharges of Imperial County residents in 1995, both from the hospitals located in Imperial County as well as other California hospitals located out of the county. This reveals that approximately one out of every four residents leaves the county for the purpose of hospitalization.

To answer the question of whether or not this ratio is stable or has changed in recent years, discharge data from the most recent five years of available data were evaluated. Table S6.7.1 shows that the number and percentage of patients leaving Imperial County remains unchanged during this recent five-year time period.

To determine if there were other patterns associated with outflow from Imperial County, we also examined the ethnicity of those patients leaving for a cumulative 3-year period. Nearly two out of every five non-Hispanic residents leave Imperial County when they need to be hospitalized and less than one out of every five Hispanic residents leaves the County for hospitalization; see Table S.6.7.2.

In addition to analyzing discharges from California hospitals outside of Imperial County, the Arizona Department of Health Services, Office of Health Planning, Evaluation and Statistics was contacted to obtain information on Imperial residents who travel to Arizona for hospitalization in Arizona hospitals. This office reported that in 1996, a total of 652 patients from Imperial County were discharged from Arizona hospitals. A ZIP Code analysis of these numbers revealed that 92% of these patients were from ZIP Codes 92283 (Winterhaven) and 92222 (Bard) which are geographically adjacent to the California/Arizona border. This represents approximately 15% of the total number of Imperial County patients discharged from out-of-area hospitals in 1996. Information is not available on the number of patients who cross the border and are hospitalized in hospitals in Mexicali.

Imperial Hospitals Discharge Diagnoses: The top twenty Diagnostic-Related Group codes for patients discharged from Imperial County hospitals in 1995 are listed in Table 6.9, on the following page. The diagnoses associated with births in the hospitals dominate the top twenty list, accounting for 39.3% of all discharges. Given the younger population structure in the county and the higher Hispanic birth rates, this is not unexpected. Throughout California, these same DRG codes account for 29.4% of the discharges. The Imperial hospitals are providing a major service to the community by providing obstetrical services. Studies have shown that when patients have to travel long distances for prenatal care and delivery services, good birth outcomes decline.

Because hospitals do not report the revenue generated by various discharge diagnoses, the best proxy reported to the State is "Total Charges." This will allow 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 than actual reimbursement. 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 the insurance carrier has negotiated for that particular diagnosis. It would appear that the large percentage of obstetrical and newborn services provided does not generate a corresponding percentage of charges. However, the majority of these hospital stays are relatively uncomplicated and brief.

Table S6.9.1, on the following page, provides a comparison of the top twenty In-Market DRGs by ethnicity. Of note is the fact that 15 of the top twenty DRGs are the same for Hispanic and Non-Hispanic residents. The DRGs that are different (cardiac related DRGs for Non-Hispanics; more delivery-related diagnoses for Hispanics) seem to be related to the differing age structures of the two groups.

Table 6.10 provides a comparison of Imperial County and California DRGs as a percentage of the total number of discharges. Again, there is a higher percentage of deliveries and newborns in Imperial when compared to the State. The other differences of note include higher rates of Cesarean section (5.8% of all discharges in Imperial vs. 1.5% for California), bronchitis and asthma, Age 0-17 (3.8% vs. 0.9%), simple pneumonia and pleurisy, Age 0-17 (2.0% vs. 0.6%) and nutritional & miscellaneous metabolic disorders, age 0-17 (1.8% vs. 0.3%).

Out-of-Area Hospital Discharges: The top Imperial County resident discharge DRGs by frequency from California hospitals located outside of Imperial County are listed in Table 6.11. The majority of these DRGs represent specialized treatments or surgical procedures which probably are not available or at least commonly performed in Imperial. When comparing the top twenty DRGs in Imperial with out-of-area DRGs, twelve of the DRGs appear in out-of-area hospitals only. These procedures include psychoses, cardiovascular procedures (bypass), back and neck procedures, chemotherapy, and various circulatory disorders. However, eight of the DRGs which appear on both lists are primarily related to delivery services. Although some of these instances, such as neonates with major problems, may be more appropriately treated in tertiary care facilities, other DRGs represent patients who are leaving Imperial for services that are currently available in the county.

Table S.6.11.1, on the following page, provides a comparison of the two twenty DRGs seen in out-of-area hospitals by Imperial Residents, by ethnicity. Again, there is heavy overlap between the two groups, with fifteen of the DRGS appearing on both lists.

Information received from the State of Arizona revealed similar DRG patterns for Imperial County residents. Because the DRG information was provided to us in a different format, we are unable to develop a similar "top twenty" listing of DRGs from Arizona Hospitals. However, we do have the following breakdown by DRG grouping for 1996 discharges:

Top Destinations for Out-of-Area Hospital Utilization

Table 6.12 provides information on the top five out-of-area California hospitals that discharged the greatest number of Imperial County residents in 1995. This information was taken from California OSHPD data and includes only California hospitals. If Arizona hospitals were included, Yuma Regional Medical Center in Yuma, Arizona would rank second. They reported 652 discharges in 1996.

To identify any different out-of-area referral patterns for Imperial County residents, we ran a comparison of Out-of-Area Hospital Utilization by ethnicity. Differing referral patterns were indeed identified and are shown in Table S.6.11-1. While ethnicity provides the first indication of different referral patterns, the interplay between diagnosis and payer source most likely are the dominant factors in out-of-area hospital choice.

Patient In-Migration

OSHPD hospital discharge data also allows us to track patients from out of the area who are coming into Imperial County for hospitalization. Table 6.13, on the following page, lists the top five geographic areas from which patients came into the County in 1995 for inpatient care. To identify these geographic areas the "Health Facility Planning Area" designations were used. This designation was developed by the State to help identify each local hospital’s usual catchment area. The process involves grouping together the ZIP codes of patients most likely to go to a particular hospital for inpatient care. The assumption regarding "Non-California HFPA" is that the majority of these patients are from Mexico.

Over the past five years, the numbers of patients coming into Imperial County for hospitalization has decreased as shown in Table S6.13.1

Hospital Payer Mix: The payer mix of patients seen by an acute care facility can provide additional understanding of the utilization of these services by community members as well as a sense of the financial reimbursement levels being received for the care. Table 6.14 provides a broad overview of the mix of patients seen in Imperial County hospitals. Please note: The numbers and percentages in all the tables in this section are for discharges by payer source rather than revenue by payer source.

Exhibit 6.1: Imperial Inpatient Payer Mix

Again, to gain a more detailed understanding of payer source trends, we developed more detailed tables, Table S6.14-1; S.6.14-2, and S.6.14-3, on the following pages, which provide information on all Imperial County Residents, Hispanic Residents and Non-Hispanic Residents for a five-year period (1991-1995). In addition, each category is further broken down by all residents in that category and by those who stay in Imperial County for hospitalization and those who leave. Table S.6.14-4 provides a one-year comparison of numbers of patients by ethnicity hospitalized in Imperial County versus those hospitalized out-of-area.

Source: California OSHPD Hospital Discharge Data, 1991-1995

Table S6.14-2: Hospital In-Patient Payer Mix of Imperial Hispanic Residents by Percentage, 1991-1995

All Hispanic Residents 1991 1992 1993 1994 1995 Medicare 16.3% 15.2% 15.7% 16.8% 17.5% MediCal 55.5 58.6 57.5 55.9 48.6 Blue Cross/Private Insurance 19.0 18.1 17.6 10.6 6.8 HMO/PPO 1.1 1.2 1.9 5.7 15.2 Self-Pay/Other 8.1 6.8 7.3 11.0 11.9 Residents Staying in Imperial 1991 1992 1993 1994 1995 Medicare 15.5% 14.0% 14.1% 15.2% 16.5% MediCal 57.1 60.7 60.6 59.2 50.6 Blue Cross/Private Insurance 19.8 18.9 18.5 10.2 6.4 HMO/PPO 0 0.1 0.3 4.9 14.4 Self-Pay/Other 7.6 6.4 6.5 10.2 12.0 Residents Leaving Imperial 1991 1992 1993 1994 1995 Medicare 21.7% 22.5% 24.5% 25.3% 23.0% MediCal 44.5 45.5 40.7 38.2 37.6 Blue Cross/Private Insurance 13.4 14.0 12.8 13.1 8.4 HMO/PPO 8.4 8.1 10.5 10.3 19.6 Self-Pay/Other 12.0 9.9 11.4 13.1 11.3

Source: California OSHPD Hospital Discharge Data, 1991-1995

Table S.6.14-3: Hospital In-Patient Payer Mix of Imperial Non-Hispanic Residents by Percentage, 1991-1995

All Non-Hispanic Residents 1991 1992 1993 1994 1995 Medicare 35.6% 35.6% 35.9% 36.6% 35.5% MediCal 21.3 21.9% 22.2 26.0 19.4 Blue Cross/Private Insurance 28.8 27.5 26.1 15.9 10.4 HMO/PPO 7.9 8.1 9.3 14.8 25.2 Self-Pay/Other 6.4 6.8 6.5 6.7 9.6 Residents Staying in Imperial 1991 1992 1993 1994 1995 Medicare 35.3% 34.1% 35.1% 37.0% 33.8% MediCal 26.9 26.7 27.3 32.0 23.3 Blue Cross/Private Insurance 31.0 32.9 31.6 17.1 9.8 HMO/PPO 0.1 0.2 0.8 8.2 21.9 Self-Pay/Other 6.8 6.0 5.1 5.7 11.3 Residents Leaving Imperial 1991 1992 1993 1994 1995 Medicare 36.2% 37.8% 37.0% 36.1% 38.5% MediCal 12.1 14.7 14.4 16.7 12.3 Blue Cross/Private Insurance 25.2 19.7 17.9 13.9 11.4 HMO/PPO 21.0 19.8 22.2 25.0 31.2 Self-Pay/Other 5.7 7.9 8.7 8.3 6.6

Source: OSHPD Hospital Discharge Data, 1995

Table S6.14-4: Imperial County and Out-of-Area Hospitalizations by Payer Source, by Ethnicity, 1995

Medicare MediCal Com. Insurance (Managed Care) Self-Pay/Other   # % # % # % # % Hispanic Residents All residents 1738 - 4820 - 2183 - 1181 - Staying in Imperial Co. 1375 79% 4227 88% 1741 80% 1003 85% Leaving Imperial County 363 21% 593 12% 442 20% 178 15% Non-Hispanic Residents All Residents 2086 - 1139 - 2092 - 566   Staying in Imperial Co. 1282 61% 882 77% 1200 57% 428 76% Leaving Imperial County 804 39% 257 23% 892 43% 138 24% All Residents All Residents 3824 - 5959 - 4275 - 1747 - Staying in Imperial Co. 2657 69% 5109 86% 2941 69% 1431 82% Leaving Imperial County 1167 31% 850 14% 1334 31% 316 18%

From these different tables, we note the following:

• Medicare: Out-of-area hospitals see a higher percentage of Medicare patients than do local hospitals. In numbers, this translates to roughly one out of every three Medicare patients leaving the county for hospitalization. Approximately 55% of the Medicare population is Non-Hispanic, which is not surprising given the County’s demographics. This group is more likely to leave the county for hospitalization than are Hispanics.
• MediCal: Of all payer sources, patients with MediCal coverage are the most likely to utilize Imperial County hospitals. Again, slightly more MediCal non-Hispanics leave the county than do Hispanic patients. Reasons why MediCal patients remain in Imperial may include having a local provider who accepts MediCal versus difficulty finding such a provider out of the area, transportation problems, poverty, and the fact that 61% of all births in Imperial County are reimbursed by MediCal. We found that in 1995 there was nearly an 8% drop in the percentage of patients covered by MediCal with a slight rise in private insurance and self-pay categories. This could suggest a trend which will be worth monitoring in the future.
• Commercial Insurance: While 80% of Hispanic patients with private insurance choose to stay in Imperial County, only 57% of Non-Hispanic patients do so. Of note in this category is the rapid shift within the commercial payer category between types of private insurance. In 1991, HMO/PPO health plans accounted for only 3.5% of all hospitalized patients compared to 22.5% with Blue Cross/Other Private Insurance. Five years later, these numbers had nearly reversed with 18.9% now enrolled in HMO/PPO plans and only 8.1% with Blue Cross/Other Private Insurance Coverage. This transition has markedly accelerated since 1993 and is expected to continue.
• Self-Pay/Other: This category includes patients who have no health insurance and who pay for care themselves, who are considered indigent, who are covered by governmental programs or whose accounts are considered bad debt. The hospitalization trends for this group almost matches the trends with MediCal coverage in that four out of every five patients stay in Imperial County for inpatient care. Of note is the fact that the percentage of patients categorized as self-pay has increased steadily, from 6.9% of all patients in 1992 to 11.1% in 1995.

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 such services as ambulatory care services, outpatient surgeries, laboratory and pharmaceutical services. Table 6.15 illustrates the number of outpatient encounters at Imperial County hospitals, by payer category for 1995. As the OSHPD hospital discharge data base does not include a patient’s zip code for these services, it is not possible to determine which of these patients reside in Imperial and which come into the County for services. Likewise, it is not possible to identify patients who leave Imperial County for hospital 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 the hospitals.

Exhibit 6.2: Imperial County 1995 In-Market Hospital Outpatient Encounters

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