Academic Health Centers Leading Change in the 21st Century (2004) / Chapter Skim
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Appendix A: Academic Health Centers: All the Same, All Different, or...
Appendix A: Academic Health Centers: All the Same, All Different, or...
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From page 161... ...
Appendix A ACADEMIC HEALTH CENTERS: ALL S , ALL DIFFERENT, THE AME OR ... Report Prepared for The Committee on the Roles of Academic Health Centers in the 21st Century Presented by: Gerard Anderson, Ph.D.
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small teaching hospitals. DEFINITIONS For purposes of this analysis, the following definitions are used: Academic health center (AHC)
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Margins The Medicare Payment Advisory Commission (MedPAC) calculated three types of margins for this analysis that are included in Tables A-1 and A-2: Medicare hospital inpatient margins excluding direct GME payments and costs, overall Medicare margins including direct GME payments and costs, and total hospital margins.
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From page 164... ...
Data Sources The following data sources are used in this analysis: · Medicare Hospital Cost Reports for FY 1990 and 1999 · American Hospital Association Annual Surveys for 1990 and 2000 · NIH data on trends in awards to medical schools 1990 and 2000 · American Association of Health Service Library Surveys, 1990 and 2000 · American Association of Colleges of Nursing Annual Survey, 1994 and 2001, special runs performed for this project · AAMC, special runs performed for this project. · MedPAC, special runs performed for this project DATA ANALYSIS These analyses are based on 120 AHC hospitals and 119 medical schools.
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From page 165... ...
APPENDIX A 165 -- MSA Fewer than 1 million inhabitants More than 1 million inhabitants -- Location Northeast South Midwest West · Characteristics of Medical Schools -- Date founded Before 1960 During or after 1960 -- Type Free standing University based · Top 50 ranking by funding category -- NIH, GME, and DSH -- NIH and GME only -- NIH and DSH only -- GME and DSH only -- NIH only -- GME only -- DSH only -- Not top 50 in any category · Differences among groups calculated using analysis of variance (ANOVA)
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From page 166... ...
Patient Care · Patient care services showing moderate dispersion across AHCs were total emergency room visits, total outpatient visits, Medicare inpatient days, Medicaid inpatient days, and percent Medicaid inpatient days. All the other patient care services had low dispersion.
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From page 167... ...
Market Share · Hospitals were classified into four groups -- AHC hospitals, large teaching, small teaching, and nonteaching hospitals. AHC hospitals generally provide more education, patient care, and DSH share than the other types of hospitals.
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From page 168... ...
· Moderate dispersion was demonstrated in: -- Total emergency room visits -- Total outpatient visits -- Total Medicare inpatient days -- Total Medicaid inpatient days -- Percent Medicaid inpatient days · Low dispersion was demonstrated in -- Average daily census -- Total hospital inpatient beds -- Occupancy rate -- Total inpatient days -- Percent Medicare inpatient days -- Medicare case mix index -- Total FTE personnel -- FTE nurses per 1,000 inpatient days -- Total FTE personnel per 1,000 inpatient days -- Length of stay (overall, Medicare, Medicaid) · There was high dispersion in disproportionate share payments per Medicare discharge.
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From page 169... ...
, fewest FTE nurses per 1,000 inpatient day, fewest FTE personnel per 1,000 inpatient days, lowest percent of Medicaid days, highest occupancy rate, and highest Medicare overall and Medicare inpatient margins. DSH Funds · AHC hospitals located in larger MSAs received higher DSH payments per Medicare discharge.
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From page 170... ...
· AHC hospitals with the highest occupancy rates were in the top 50 for GME only, while hospitals with the lowest occupancy rates were not in the top 50 in any category. Notes on Table A-4 Rate of Change in Activity by Statistical Dispersion Category (1990-2000)
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From page 171... ...
The one major exception was private hospitals, which had greater increases in the number of outpatient visits and total FTE personnel and showed a more rapid decline in overall length of stay. It is also noted that private hospitals had a statistically significant increase in hospital beds as compared with public hospitals, which experienced a decline in that time period.
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From page 172... ...
They had: · Higher daily censuses · More emergency room visits · More outpatient visits · More hospital beds · Higher occupancy rates · More Medicare days · More Medicaid days · More total inpatient days · Higher proportion of Medicaid days · Higher Medicare case mix · Longer overall, Medicare, and Medicaid lengths of stay · Lower percentage of Medicare days. · Given their higher intensity of care, it is somewhat surprising that there were no statistically significant differences in number of FTE nurses per 1,000 inpatient days.
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From page 173... ...
AHCs had the smallest rate of change among the three groups of teaching hospitals. · Between 1990 and 2000, AHC hospitals had: -- Smallest reduction in hospital beds -- Smallest reduction in average daily census -- Smallest reduction in percent of Medicare inpatient days -- Greatest overall decline in percent of Medicaid days -- Largest increase in Medicare case mix index -- Smallest reduction in overall length of stay · There were no statistically significant differences in the rate of change between 1990 and 2000 in DSH payments.
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From page 174... ...
The AHC share of Medicare and Medicaid discharges increased similarly. In general, AHCs and major teaching hospitals increased their market share between 1990 and 1999, while small teaching and nonteaching hospitals lost market share.
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From page 176... ...
176 Percentile 7.8 2.5 3.2 1.1 2.1 1.4 1.3 1.3 1.3 1.7 1.6 1.9 1.8 25th 7 22 10 38 919 $11 410 0.74 219 $86,769 $76,713 $3,581,601 $90,728,000 Percentile 9 20 35 564 $10 278 0.59 159 Percentile/ $56,223 $59,794 $2,714,715 75th Median $42,219,000 7 17 29 364 $10 198 0.44 115 $27,244 $47,077 $1,986,795 75th Percentile $11,649,000 2000 755 9 23 39 717 $10 308 0.59 169 $63,403 $65,200 Activity, $2,861,640 Ratio 25th Mean $62,689,524 by AHCs the 2000 Across Faculty basic Centers, faculty Residents Science MCAT Residents Expenses full-time Residents Dispersion Health Bed per clinical Residents Medicine Care Resident Clinical Science Practice per A-1 and Graduates per Recurring Residents -- Hospital Funding Funding $ Academic Family Internal Pediatric Primary TABLE All Variable NIH Full-Time NIH science Biological Total % % % % Residents GME Nursing Library
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From page 177... ...
per Rate Days Days Days per direct direct Daily Visits Inpatient IP Case Personnel per LOS LOS Inpatient Days IP IP Length Medicare ER Outpatient Hospital IP FTE Hospital Total Nurses Payment MCR MCD Includes Excludes Average Total Total Total Occupancy Medicare Medicaid Total % % Medicare FTE FTE Total Overall Medicare Medicaid Medicare Overall Total DSH *
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From page 178... ...
1 mil. NIH Funding $62,689,524 $40,435,000 $77,216,782 Full-Time Clinical Science Faculty 717 478 879 NIH Funding per full-time basic $63,403 $52,644 $70,525 science and clinical faculty Biological Science MCAT 10.2 9.9 10.5 Total Residents -- Hospital 483 361 564 % of Family Practice Residents 7 9 6 % Internal Medicine Residents 23 20 24 % Pediatric Residents 9 9 10 % Primary Care Residents 39 38 40 Residents per Bed 0.59 0.51 0.64 GME $ per resident $65,200 $63,248 $66,510 Total Clinical Faculty 674 473 807 Nursing Graduates 169 160 177 Library Recurring Expense $2,861,640 $2,472,726 $3,146,843 Average daily census 428 367 469 Total ER visits 57,690 52,591 61,090 Total outpatient visits 419,145 399,889 431,982 Total Hospital Beds 532 482 566 Occupancy Rate 69% 69% 69% Medicare IP Days -- Total Hospital 40,331 40,678 40,098 Medicaid IP Days -- Total Hospital 27,970 23,597 30,906 Total IP Days -- Hospital 135,726 121,570 145,231 % MCR IP Days (Hospital)
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From page 179... ...
APPENDIX A 179 1 AMC 2+ AMCs in MSA in MSA Private Public <500 beds 500+ beds $54,008,947 $77,485,961 $68,806,056 $51,475,881 $35,676,712 $88,373,836 592 939 786 586 497 920 $62,315 $65,301 $61,757 $66,494 $50,404 $75,549 10 10.4 10.1 10.4 267 382 447 745 386 570 8 7 9 6 21 23 21 23 9 10 10 9 38 40 40 38 0.54 0.66 0.56 0.64 0.61 0.56 $60,123 $74,265 $65,889 $63,921 $63,768 $66,759 692 745 560 776 167 172 164 176 159 177 $2,743,769 $3,075,081 $2,796,980 $2,969,405 $2,399,390 $3,257,853 402 473 446 396 270 576 55,955 60,688 54,976 62,732 45,191 69,383 414,047 427,950 405,256 444,937 331,629 501,014 505 580 565 472 358 722 68% 71% 69% 69% 68% 70% 37,602 45,204 47,811 26,466 27,869 53,905 25,214 32,890 25,527 32,498 17,387 39,497 125,565 153,870 143,713 120,920 89,783 185,771 31% 29% 33% 24% 31% 29% 19% 22% 17% 26% 20% 21% 1.79 1.73 1.79 1.72 1.73 1.81 3,489 4,265 3,983 3,386 2,610 4,862 7.0 6.5 6.6 7.2 7.0 6.6 25.0 26.1 24.9 26.2 26.8 24.1 5.8 5.8 5.7 6.0 5.6 6.0 6.4 6.8 6.5 6.6 6.3 6.8 6.1 6.8 6.5 6.1 5.9 6.9 19.8 22.9 20.1 20.8 11.4 10.8 11.3 11.3 3.6 2.2 1.5 4 3 0 2 2 11 24 13 16 33 42 43 30 $1,348 $1,645 $1,188 $1,948 $1,408 $1,505
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From page 180... ...
32% 29% % MCD IP Days (Hospital) 18% 21% Medicare Casemix Index 1.75 1.78 FTE total personnel 3,189 4,039 FTE Nurses per 1,000 IP Days 6.4 7.0 Total FTE per 1,000 IP Days 24.5 25.7 Overall Length of Stay (LOS)
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From page 181... ...
APPENDIX A 181 UniversityFreestanding Based Northeast South Midwest West $48,119,458 $66,981,588 $72,009,621 $53,113,674 $52,777,910 $88,502,882 621 743 1,002 579 599 799 $55,531 $65,413 $62,720 $56,978 $56,521 $94,812 10.1 10.3 10.5 10 10.1 10.6 514 474 604 416 441 528 8 7 4 8 8 9 22 23 27 19 21 24 9 9 9 10 10 10 39 39 40 37 39 43 0.58 0.58 0.66 0.53 0.54 0.70 $60,017 $66,059 $76,985 $63,534 $62,679 $55,195 611 690 797 657 580 678 168 169 150 172 179 168 $2,910,297 $2,848,585 $3,014,322 $2,844,958 $2,501,413 $3,262,530 422 432 556 407 380 353 52,715 58,859 61,182 59,008 48,455 65,242 392,005 428,558 474,213 362,008 399,546 505,465 527 537 578 560 498 456 67% 69% 76% 66% 67% 69% 35,911 41,848 53,355 37,868 42,882 21,080 26,270 28,155 28,135 33,420 19,840 29,066 128,791 138,107 162,502 136,095 122,904 115,667 28% 31% 33% 28% 35% 19% 22% 19% 16% 24% 17% 24% 1.78 1.77 1.84 1.77 1.74 1.70 3,467 3,865 4,445 3,476 3,622 3,658 6.6 6.9 5.9 6.8 7.1 7.9 24.3 25.6 23.4 24.2 26.6 29.5 6.2 5.7 6.5 5.9 5.4 5.3 6.8 6.4 7.3 6.5 6.2 5.9 6.7 6.3 6.4 7.0 5.6 5.9 20.8 19.7 25.4 19.1 15.9 21.4 12 15.3 15.3 10.4 6.3 11.3 0.9 2.1 0.9 2.1 7.2 2.9 2 0 0 3 0 7 11 24 4 12 26 27 33 52 29 43 34 20 $1,741 $1,344 $1,338 $1,670 $954 $2,019
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From page 182... ...
30% 28% 30% % MCD IP Days (Hospital) 25% 13% 19% Medicare Casemix Index 1.76 1.81 1.88 FTE total personnel 6,286 5,355 3,736 FTE Nurses per 1,000 IP Days 7.3 7.4 6.1 Total FTE per 1,000 IP Days 27.0 27.2 22.8 Overall Length of Stay (LOS)
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From page 183... ...
APPENDIX A 183 Top 50, GME and DSH Top 50, NIH Top 50, GME Top 50, DSH None $23,770,455 $113,201,583 $25,971,667 $17,040,333 $17,734,657 590 926 453 356 382 $39,171 $103,314 $53,477 $32,731 $36,754 10.1 10.6 10.1 9.7 9.8 351 591 386 322 353 6 10 4 11 9 23 22 19 21 23 9 10 8 9 10 38 31 41 42 0.59 0.70 0.75 0.43 0.48 $81,584 $47,154 $91,343 $58,327 $58,790 905 832 445 362 378 178 190 185 162 129 $3,159,827 $3,718,533 $2,442,508 $2,249,832 $1,933,196 423 369 305 381 293 60,910 46,276 42,728 57,950 48,715 385,021 443,800 316,424 339,509 298,022 574 429 369 542 372 69% 66% 77% 68% 64% 47,647 27,931 26,354 36,490 27,946 32,032 15,004 20,865 41,660 14,639 144,267 101,960 103,805 131,504 87,575 33% 28% 26% 29% 32% 23% 15% 22% 31% 18% 1.68 1.83 1.70 1.76 1.74 3,919 3,576 2,767 2,985 2,458 6.7 7.5 6.9 6.6 6.5 26.2 27.7 25.6 22.2 25.2 5.9 5.7 5.7 5.7 5.8 6.7 6.0 6.8 6.3 6.5 6.2 6.6 5.1 6.8 5.9 $1,697 $1,141 $1,843 $1,938 $1,257
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- Total Hospital Beds 0% 15% 3% 10% % Chg. - Occupancy Rate 8% 12% 7% 1% % Chg.
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- Total Hospital Beds 0% 3% 0% % Chg. - Occupancy Rate 8% 7% 9% % Chg.
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From page 187... ...
APPENDIX A 187 1 AHC 2+ AHCs in <500 500+ in MSA MSA Private Public beds beds 137% 108% 126% 127% 131% 122% 35% 28% 43% 20% 34% 37% 34% 37% 39% 29% 43% 28% 1% 6% 7% 2% 1% 7% 81% 80% 66% 93% 66% 94% 6% 17% 3% 20% 15% 4% 2% 10% 0% 6% 7% 2% 49% 63% 66% 33% 38% 69% 135% 128% 171% 61% 107% 157% 2% 4% 5% 6% 4% 8% 9% 7% 9% 7% 7% 9% 7% 6% 8% 2% 6% 5% 10% 12% 2% 22% 14% 3% 9% 13% 6% 14% 13% 4% 0% 1% 1% 1% 0% 1% 3% 2% 2% 3% 3% 2% 22% 18% 19% 23% 20% 20% 30% 21% 31% 18% 24% 29% 33% 33% 33% 34% 32% 34% 32% 39% 36% 32% 38% 32% 16% 18% 20% 11% 17% 16% 32% 30% 32% 29% 32% 30% 5% 2% 5% 1% 6% 1% 85% 102% 95% 82% 83% 98%
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From page 188... ...
- Total outpatient visits 125% 138% 142% % Chg. - Total Hospital Beds 1% 0% 1% % Chg.
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APPENDIX A 189 UniversityBased Northeast South Midwest West 126% 92% 137% 143% 128% 36% 42% 25% 42% 19% 38% 45% 32% 39% 19% 1% 7% 3% 1% 1% 73% 83% 80% 91% 73% 2% 56% 2% 9% 3% 2% 4% 7% 6% 4% 53% 75% 51% 44% 46% 132% 183% 87% 162% 110% 1% 0% 3% 3% 3% 8% 6% 9% 8% 10% 7% 13% 3% 9% 0% 11% 17% 8% 5% 36% 9% 8% 14% 6% 10% 0% 2% 2% 2% 1% 3% 4% 0% 0% 10% 19% 28% 35% 18% 30% 27% 35% 28% 31% 42% 31% 36% 34% 33% 43% 27% 18% 17% 13% 24% 14% 31% 37% 27% 32% 29% 6% 19% 12% 13% 0% 87% 119% 104% 73% 47%
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- Total outpatient visits 126% 200% 30% % Chg. - Total Hospital Beds 4% 1% 12% % Chg.
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From page 191... ...
APPENDIX A 191 Top 50, GME and DSH Top 50, NIH Top 50, GME Top 50, DSH None 137% 120% 119% 166% 110% 34% 23% 22% 33% 36% 36% 23% 21% 25% 45% 12% 2% 11% 5% 1% 78% 67% 86% 143% 62% 0% 8% 11% 2% 22% 14% 7% 7% 12% 3% 53% 97% 53% 102% 26% 163% 236% 55% 166% 95% 1% 4% 0% 11% 5% 7% 9% 6% 8% 11% 8% 7% 27% 16% 16% 9% 14% 21% 6% 14% 10% 7% 6% 1% 16% 0% 1% 2% 3% 0% 1% 3% 7% 1% 3% 10% 18% 16% 18% 23% 15% 46% 33% 29% 24% 34% 39% 52% 43% 26% 41% 40% 44% 20% 37% 15% 16% 15% 17% 15% 31% 29% 28% 33% 32% 12% 0% 14% 8% 7% 147% 71% 100% 80% 81%
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30% 37% 43% 52% % MCD IP Days (Hospital) 20% 17% 11% 12% Medicare Casemix Index 1.77 1.53 1.54 1.30 FTE total personnel 3,774 2,566 1,895 812 FTE Nurses per 1,000 IP Days 6.8 6.8 6.1 5.6 Total FTE per 1,000 IP Days 25.4 28.0 22.3 19.9 Overall Length of Stay (LOS)
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From page 193... ...
- Total Hospital Beds 0% 16% 9% 6% % Chg. - Occupancy Rate 8% 9% 6% 7% % Chg.
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From page 194... ...
194 ACADEMIC RESEARCH CENTERS TABLE A-9 Provision of Specialized Serviced by Teaching Status Provision of Specialized Services Who Provides What Services Large Small Variable AHC Teaching Teaching Nonteaching Total Hospital Beds 10% 8% 31% 51% Medicare Inpatient Days -- Hospital 9% 9% 34% 48% Medicaid Inpatient Days -- Hospital 20% 17% 30% 34% Total Inpatient Days -- Hospital 13% 11% 35% 41% Interns and Residents -- Hospital 48% 30% 22% 0% Total Medicare Discharges -- Hospital 8% 8% 34% 50% Total Medicaid Discharges -- Hospital 16% 14% 30% 41% Total Discharges -- Hospital 11% 10% 35% 44% Has HIV AIDS Unit 10% 8% 20% 62% Has Burn Unit 43% 16% 17% 23% Has Geriatrics Unit 6% 6% 16% 72% Has Neonatal Unit 16% 12% 31% 41% Has Pediatric Unit 23% 16% 29% 32% Has >1 PET Scanner 22% 7% 23% 48% Has Single PET Scanner 8% 5% 18% 69% Has Transplant Services 33% 10% 28% 29% Has Trauma Center 9% 6% 18% 67% Has Angioplasty Center 13% 8% 29% 50% Has Open Heart Surgery 15% 9% 32% 43% Percent of Hospitals 3% 4% 9% 84% SOURCES: Hospital Cost Report Information System, 1999; American Hospital Association, 2000.
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From page 196... ...
AHC Teaching Teaching Nonteaching Total Hospital Beds 63,492 46,357 278,088 480,139 Medicare Inpatient Days- Total Hospital 5,391,356 4,320,665 29,998,331 43,837,324 Medicaid Inpatient Days- Total Hospital 4,081,416 2,969,668 8,142,101 8,978,683 Total Inpatient Days -- Hospital 18,126,428 13,220,641 67,855,270 88,833,843 Interns and Residents -- Hospital 29,233 20,017 22,808 - Total MCR Discharges -- Hospital 557,916 430,066 3,289,418 5,602,497 Total MCD Discharges -- Hospital 619,421 475,744 1,376,539 1,804,251 Total Discharges -- Hospital 2,577,235 1,939,022 10,611,524 15,464,833 % of Hospitals 2% 2% 17% 79% % of Totals Total Hospital Beds 7% 5% 32% 55% Medicare Inpatient Days- Total Hospital 6% 5% 36% 52% Medicaid Inpatient Days- Total Hospital 17% 12% 34% 37% Total Inpatient Days -- Hospital 10% 7% 36% 47% Interns and Residents -- Hospital 41% 28% 32% 0% Total MCR Discharges -- Hospital 6% 4% 33% 57% Total MCD Discharges -- Hospital 14% 11% 32% 42% Total Discharges -- Hospital 8% 6% 35% 51%
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From page 197... ...
APPENDIX A 197 TABLE A-10 Continued Hospital Cost Report Information System, 1999 (sums) Total Hospital Beds 63,064 52,395 198,408 321,031 Medicare Inpatient Days -- Hospital 4,763,347 4,669,159 18,009,980 24,925,268 Medicaid Inpatient Days -- Hospital 3,306,950 2,776,128 4,946,093 5,691,269 Total Inpatient Days -- Hospital 16,050,935 13,689,631 43,257,039 50,686,618 Interns and Residents -- Hospital 36,111 22,376 16,270 -Total MCR Discharges -- Hospital 724,861 698,953 2,998,947 4,510,503 Total MCD Discharges -- Hospital 554,365 489,894 1,044,790 1,447,558 Total Discharges -- Hospital 2,776,901 2,535,508 8,941,337 11,158,306 % of Hospitals 3% 4% 18% 75% % of Totals Total Hospital Beds 10% 8% 31% 51% Medicare Inpatient Days -- Hospital 9% 9% 34% 48% Medicaid Inpatient Days -- Hospital 20% 17% 30% 34% Total Inpatient Days -- Hospital 13% 11% 35% 41% Interns and Residents -- Hospital 48% 30% 22% 0% Total MCR Discharges -- Hospital 8% 8% 34% 50% Total MCD Discharges -- Hospital 16% 14% 30% 41% Total Discharges -- Hospital 11% 10% 35% 44%
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