The first step was to define sub-categories for Cardiology and Cardiovascular/Thoracic Surgery (CVT surgery) service lines for a clearer picture of where declines are occurring.

Total Medicare Cardiac Services inpatient cases declined, -8.6% from 2009 to 2011.  Cardiology inpatient cases declined, -7.6% from 2009 to 2011.  Cardiovascular/Thoracic Surgery inpatient cases also declined but at a much larger rate, -11.2% from 2009 to 2011.

Looking inside Cardiology, we can see that the largest decline in Electrophysiology (EP)/Devices (pacemaker replacements and revisions).  This decline was followed by Cardiac Catheterizations, Other Cardiology and Acute Myocardial Infarctions (Acute MI).  Acute MIs declined the least, -6.5% from 2009-2011.

Although Cardiovascular/Thoracic Surgery declined more than Cardiology, some subservice lines actually increased in volume. Heart and lung transplant MS-DRGs increased 32% from 2009 to 2011.  Valve surgeries increased 3.9% from 2009 to 2011.  Major chest trauma increased 6.4% from 2009-2011.  The largest declines in the CVT Surgery service line were Cardiac defibrillator implants with cardiac catheterization, declining 23% from 2009 to 2011.  This decline was followed by EP/Devices declining 18%.  Cardiac bypass surgery is down 13% and Cardiac interventions are also down 13%.

Looking even further inside the Transplants sub-service line (MS-DRGs 001, 002, and 007).  MS-DRG 001, Heart transplant or implant of heart assist system with major complications or comorbidities increased 51.7% from 2009 to 2011.  The proliferation of heart assist systems has propelled this tremendous growth, not necessarily heart transplants.

State Data Comparisons

In California and Florida we analyzed the same time period, 2009 to 2011 for trends.

In California, the Cardiology trends are the same as for Medicare, declining 5.8%.  The highest decline was in EP/Devices (-17%), and the lowest decline in Acute MI (-1.5%).  In CVT Surgery, again the same trends, total volume down 6.2% with increases in transplants (21.9%), trauma (11.6%) and valve surgery (9.5%) while EP/Devices with Cath (-13.2%) and EP/Devices (-11.8%) declined the most.

In Florida, Cardiology declined 5.4% while CVT surgery declined 8.5%.  In Cardiology, Cardiac Caths (-8.2%) edged out EP/Devices (-7.2%) for the highest declines in Cardiology.  Other Cardiology (-4.2%) declined less than Acute M.I (-6.2%).  In CVT Surgery, the same trends appeared, transplants (21.6%), trauma (13.5%) and valve surgery (13.5%) increased while the EP/Devices with Cath (-23%) led the decliners followed by EP/Devices (-14.8%).

In Texas, we analyzed 2010 and 2011 data.  All of the Cardiology sub service lines declined  for a total 2.7% decline, and EP/Devices (-9.3%) led the way.  CVT surgery declined 3.5%, but the trends within CVT surgery shifted slightly, transplants were down (-17.8%), but Other CVT surgeries increased 4% from 2010 to 2011, trauma (8.6%) and valve surgery (4.1%) also increased.  The decliners were led by EP/Devices with Cath (-27.1%) and EP/Devices (-10.2%).

If you would like a cardiac services analysis for your market, give us a call. Phone: 615-500-3497, Fax: 615-208-9657, Email: tod@stratasan.com, www.stratasan.com

Sources:  Center for Medicare & Medicaid Services, Medicare Provider Analysis and Review (MedPar) hospital discharge data, 2009-2011. State of California Office of Statewide Health Planning and Growth, 2009-2011 hospital inpatient discharge data.  State of Florida Agency for Health Care Administration 2009-2011 hospital inpatient discharge data.  Texas Department of State Health Services, Texas Health Care Information Collection 2010-2011 hospital inpatient discharge data.

Case Study – Memorial Hospital, Anytown, USA. 

In the last blog post, we covered how to define a service area.  In this post, we will cover a case study demonstrating the pros and cons of different service area definitions focusing on competitor identification.  Below is a case study based on a real hospital and real service areas blinded to protect the innocent.

Anytown is a city of 33,000 located in Mine County population 159,000, 20 miles north of a metropolitan city with population of 752,000.  Below is a table of market share by hospital by the different service area definitions discussed in-depth in the previous blog post.  Eighteen ZIP Codes represent 90 percent patient origin, 7 ZIP Codes represent 75 percent patient origin (all contiguous ZIP Codes meeting Stark service area definition) and 2 ZIP Codes represent 50 percent patient origin.   The 7 ZIP Code area is essentially the primary service area (PSA) and secondary service area (SSA) defined by PSA being 50 percent patient origin (the 2 ZIP Code area referenced above) and the SSA the next 25 percent of patient origin combined.

The table above demonstrates how the competitors change based on the definition of service area.  Using the two larger service area definitions, the primary competitor is Neighbor Hospital.  However, when only looking at the two ZIP Codes that make up 50 percent of patient origin, Large Medical Center becomes the primary competitor.  If market share by service line is available, look at outmigration by service line to Large Medical Center.  The only services out-migrating may be tertiary services Memorial Hospital doesn’t provide.  In that case, our focus would shift to Nearby Town Medical Center as our primary competition if they are seeing patients in service lines where we offer the services.  In the 7 ZIP service area, Neighbor Hospital is our primary competitor, followed by Nearby Town Hospital.

Also, notice the how the market share percentages change as the service area changes.  Using the 18 ZIP Code definition, our hospital has a market share of 13.1%.  When using the 7 ZIP Code service area our market share is 27.7%.  Using the 2 ZIP Code definition, our market share is 56.9%.  I am arguing the primary service area of our hospital is the 2 ZIP Code definition.  Those are the people we primarily serve.

This exercise demonstrates the importance of a thoughtful, deliberate service area definition.  A well-defined service area assists with targeted marketing and physician business development.  It also assists in understanding who your true competitors are by service line.  The service area definition is both science and art involving the use of analytics and judgment.

Footnotes

1. http://www.mwe.com/info/news/hlu0404.pdf

The first step in any planning or marketing project for a hospital/provider is to define a service area.  Before demographics or market share can be run, an appropriate service area must be applied.  Defining a service area is both art and science.

There are several ways to define a service area.  Which one is best?  The answer is: it depends.

Regional Strategy Approach

With the regional strategy approach the facility defines a service area as large as possible.  A facility may define its primary service area as 75 percent of its inpatients (and/or outpatients) and its secondary service area as the next 15 percent for a total of 90 percent patient origin.  This is the “no ZIP Code left behind” definition.  This service area definition will most likely incorporate a very large area and ZIP Codes where the hospital has very low market share.

Service Area defined by 75% and 90% of patient origin results in an over-expanded view

Two of the key areas where an overly large service areas cause issues are marketing and physician recruitment. Marketing departments with limited budget and staff struggle to make a meaningful impact over such a large geography.  The large area also causes a lack of focus by your physician liaison potentially leading to missed opportunities with great partner physicians close to your facility. However, if a facility is looking at a regional outreach strategy or growing a specialty service line, a larger service area may be appropriate.

Stark-Influenced Definition

The 2004 Stark regulations relative to physician recruitment define a hospital’s geographic service area as the lowest number of contiguous ZIP Codes from which the hospital draws 75 percent of its inpatients.  Some hospitals prefer to define their service area in this manner, essentially killing two birds with one stone – the service area for marketing/planning etc. matches the physician recruitment service area.  However, what is ideal for physician recruiting may not be ideal for service line marketing and development.  If 50 percent of Cardiology patients come from 2 ZIP Codes, but 10 ZIP Codes make up 75 percent of patients in contiguous ZIP codes, cardiology development loses geographic focus.

The Stark defined service area for a hospital is an easy solution, as you should already have these defined. Be careful when using tools out of convenience over selecting the right tool for the job.

Stratasan’s ZIP Code Recommendation

When using ZIP Codes, we prefer a more focused primary service area representing 50 percent patient origin with a secondary service area for the next 25 percent of patients.  If a tertiary service area is warranted, then the next 15 percent of patients is sufficient.  Sounds simple, right?  As football analyst Lee Corso says, “not so fast my friend.”  The percentages are science, now for the art.

Reducing your definition to 50% and 75% tightens your ability to know your patient base

When selecting ZIP Codes for a Primary Service Area (PSA) and Secondary Service Area (SSA) as defined above, gather five pieces of information: patient origin by ZIP Code, market share of top 75 percent of patient origin ZIP Codes (if available), population by ZIP Code, and the physical location of the ZIP Code on a map.

Select ZIP Codes for the PSA representing approximately 50% of patient origin (blue area), where the facility has high market share, and that make sense geographically.  Select ZIP Codes for the SSA that represent approximately the next 25 percent of patient origin, where the facility has decent market share, and that make sense geographically.

What does “make sense geographically” mean?  It means eliminating ZIP Codes on an “island” away from the rest of service area or adding “bullet holes” back in to fill in gaps inside the newly defined service area.

Removing the ZIP (37210) in the northeast on an “island” allows for even further tightening of your Service Area

An example of this is the removal of ZIP 37210 in the map above. The floating ZIP Code is usually a highly populated ZIP Code in a nearby larger city where your facility receives some patients placing the ZIP code in the top 75% of patient origin.  However, your market share of that ZIP Code may be very low, 2% for example.  You may want to omit this ZIP Code in favor of ZIP Codes closer to the facility where the facility has higher market share.  An example is 65432 above.  It is a very large ZIP Code in a metropolitan area south of our facility.  There are facilities that designate dream ZIP Codes in their service, meaning those they dream of serving.  This is fine as long as you don’t actually include these in your real service area, defined as those people you currently serve.

Moving Away from ZIP Codes

But that is not the end of the story. When patient data is available, a custom polygon shape file built from your patient address level geo-coded data can serve as the best solution for all parties involved.

Building a custom Market Service Area based on your patient data tells the most accurate story

The service area above is based on an algorithm between the hospital location and the actual addresses of their current patients. ZIP Codes are built to deliver mail. They have no real influence on where a patient decides to receive healthcare services (when they have a choice).

Large populations are included in your service area by using standard geographic boundaries like ZIP Codes

Overlaying this new approach with the tighter ZIP Code approach helps you visualize the difference.

Tighter Area + Market Share + Population

Using a tighter service area is a great first step into improving your service area definitions. But many times this is not the end of your journey. Adding a quick study of market share and population by ZIP Code keeps a facility from “majoring in the minors.” What we mean by this is focusing too many efforts on the wrong ZIP Codes.

For example, our fictitious Brentwood Medical Center facility gets a mere 3.8% market share of ZIP Code 67891.  The other ZIP Codes in the primary service area warrant more attention because we already have better traction but have opportunity to grow.  One could even argue that if a facility only gets 4% of a market, then it’s NOT your service area.  You may WANT it to be your service area, but it isn’t.  In ZIP 87654, our facility gets 27% market share.  However, there are only 2,400 people in the ZIP Code.  I would recommend focusing on another ZIP Code with more population first.  In fact, I am arguing for focusing on two ZIP Codes highlighted in yellow first, then the remaining list in the PSA, other than 67891.

Arriving at Your Destination Definition

Based on all five pieces information, selecting your primary and secondary service areas (whether ZIP Code-based or Market Service Area) is much more precise.

Select ZIP Codes for the PSA that represent approximately 50% of patient origin, where the facility has high market share, and that make sense geographically.  Select ZIP Codes for the SSA that represent approximately the next 25 percent of patient origin, where the facility has decent market share, and that make sense geographically.

What does “make sense geographically” mean?  It means eliminating ZIP Codes on an “island” away from the rest of service area or adding “bullet holes” back in to fill in gaps inside the newly defined service area.

A floating ZIP Code is usually a highly populated ZIP Code in a nearby larger city where your facility receives some patients placing the ZIP code in the top 75% of patient origin.  However, your market share of that ZIP Code may be very low, 2% for example.  You may want to omit this ZIP Code in favor of ZIP Codes closer to the facility where the facility has higher market share.  An example is 65432 above.  It is a very large ZIP Code in a metropolitan area south of our facility.  There are facilities that designate dream ZIP Codes in their service, meaning those they dream of serving.  This is fine as long as you don’t actually include these in your real service area, defined as those people you currently serve.

The benefits of a well-defined service area are: better use of constrained resources, more focused resources in marketing and physician liaison budgets and personnel, focused development of service lines, and better defined competitors.

The damage from the storm surge and high powered sustained winds has been broadcasted to the world throughout the day, and we noticed that we could not find a list of affected New York City area hospitals and their current statuses anywhere.

Below we have made a map of the area hospitals that have been effected.  Hospitals have either been classified as Closed or Trauma only.  Hospitals in the area have not necessarily closed their Emergency Departments, but it is strongly recommended that you seek treatment at a non-affected hospital if at all possible.

Here are the addresses and statuses of those hospitals displayed in the map above.

If you have any information or news to report regarding hospitals opening or closing in response to Sandy, please email us at info@stratasan.com

UPDATE 10/31/12 2:00 EST: Bellevue Hospital has evacuated its 500 remaining patients

This area of the country is the most populated area of the United States and cities are preparing for the worst.  The storm’s projected path contains more than 68,000,000 people and 30,000,000 homes.  A little under 17 million are children under 18 years of age.  In total, the area represents 228,393 square miles in our study analysis according to the Census and ESRI.

A small bit of good news is there are 982 hospitals and an estimated 250,000 physicians in the affected areas.  Hospitals, Physicians, and Emergency Responders have all been put on alert and are ready to respond.  Based on our experiences with Hurricane Katrina and Irene, tetanus shots will be needed for responders and people living in affected areas.

Healthcare Services Prepared for Hurricane Sandy

If you are living in a low lying area or near the coast, plan an evacuation route as water rises.  Many areas will be without water and electricity as Hurricane Sandy makes landfall.

“Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs.” 

We have worked with many hospitals on their Community Health Needs Assessment, and the most feared section of the Form 990 is question #7 in Section V (above).  Hospital executive staffs are frequently classic overachievers.  They want to provide 100% customer satisfaction, 100% clinical quality, the best financial results, have the most satisfied employees, and meet 100% of community health needs.  However, the Internal Revenue Service (IRS) is allowing hospitals to say, “we can’t address every need identified.”

Honest Dialogue – Issues Hospitals Can Most Effectively Address

Hospital leadership teams need to sit down and have an honest dialogue about what issues they can most effectively address and what issues are better left to another community organization.  Just because an issue is better addressed by another organization doesn’t mean the hospital is left out. They can still help. The hospital is the catalyst for the entire community health needs assessment process.  The hospital can receive reports on progress on all issues and assist at any time.  The hospital can get the community together annually to discuss progress.

Feel free to be brutally honest on question 7 and list the initiatives for which the hospital will take responsibility and the ones the hospital will encourage another community group to take responsibility.  As long as the top priority needs are being addressed by someone, isn’t that what matters?  The IRS says it’s OK.  Don’t be scared.

Let us know how we can help.

Other Resources:

http://www.naccho.org/topics/infrastructure/CHAIP/chachip-online-resource-center.cfm

http://www.assesstoolkit.org/

http://www.chausa.org/

Photo Credit: Sam Bradley, Low-light phone photographer extraordinaire

Stratasan was honored on September 27th with the NEXT Award for Healthcare Startup Company of the Year. We are extremely honored with this recognition, especially in a city where healthcare plays such a major role in the overall economy. A huge thanks to all of those behind the scenes from the Entrepreneur Center and Nashville Chamber of Commerce who put on a fantastic event (yes, I am now biased!).

As I sat there with the Stratasan team (and a few Emma folks, too), there was an overwhelming sense of family as we continue to push and pull every day together.

This thought line continued as we watched as our friends, vendors, customers, and neighbors (many falling into multiple buckets) nominated and selected as the recipients of award after award.

Right off the top of my head: Michael Brody-Waite and the InQuicker team, Kate O’Neal and metamarketer, Evan Owens and centresource, Evan Austill/David Frederickson and PatientCredit, Christopher Redhage/Michael Rosen and ProviderTrust, Jerry Baker and Conexess, Brian Prentice and Ingenuity Associates, and the list could go on and on.

So what’s the point?  Well, I have two.

First, I am very grateful and humbled by this honor in THIS city. Second, the bigger reward for me that night was to be there with the Stratasan team (and my wife!) alongside the other incredible people in Nashville celebrating entrepreneurship together.

Our company has come a long way since that fate-filled conversation with Tod Fetherling many moons ago. I’m more excited now than ever about the impact Stratasan can have on healthcare and how it serves the many communities throughout our country.

Here’s to what’s NEXT!

Apple’s 3D Mapping working incorrectly (you can see some other great examples of this here)

The exciting part about this is a large number of people have been talking about maps! With the transition from Google Maps to Apple Maps many failed to realize a good thing until it was gone. This whole thing made me think about just how bad maps can be.

Through my work at Stratasan and having the responsibility of improving our map products I am exposed to maps from many places. And as you can imagine, much of what is out there is pretty bad. We will assume these maps were not intended to be bad; but similar to any creative output some people do not know better. This is especially true in many work places where a business “needs” a map and someone without the appropriate skills is tasked and performs to the level they are capable.

Apple will likely improve their map app over time, but there will never be shortage of good examples in bad mapping.

Bad symbology and poor legend design

Let me start with the map directly above. First of all, the number units in the legend are not identified. I assume it’s in millions, but I really have no idea. The second and (excuse the pun) bigger issue is the size of graduated circles. There is no reason to have symbols get that large. They cover the map and are opaque so no one can see what is underneath. The city name labels are too small and the label weight (think bold vs regular) are set low enough where the city names fill in on top of the circles. There is also no neatline to show the borders of the map page and no source for the data used in the map.  This map would accomplish its goal more effectively by leaving the capitol cities on and shading the states in a thematic map using the data for their capitol city’s population. This is a great example of someone finding a great base map and a good projection for the US and not adjusting the data enough to present it properly.

Good concept trumped by poor execution

This map showing the generic names for soft drinks is a great concept; the problem is the execution. The text in the legend and over the Gulf of Mexico is too small. I have 20/20 vision in my mid-20′s and can barely read it.

The second issue revolves around color and Legend choices. “No Data” is tacked onto the green “Other” category. These values are unrelated. To add, this purple bleeds into the blue “Pop” areas in the northern half of the county. I use either white or black for “No Data” so the person reading the map knows instantly that there is no information available there. Finally, the size and font of the map title are both poor choices.  Never use a small fancy font. Make sure you make big and legible. There are tons of fonts that let you do this, and this is obviously not one of them.

There are better projections and non-autumn themed color palettes that can show how small the population is in the West

This map showing population density by state gets a quick mention for using Mercator projection on the coterminous United States elongates on the horizontal axis and squeezing Alaska in the corner. Map projections are very important! Always investigate other options than the default way data is presented in your mapping software. We will ignore the lack of a neatline; the legend is too small, and the mistakes made in all aspects of the title.

Great data displayed with an outdated and unsightly symbology 

The map above is from Nashville’s Metro’s “Interactive Mapping Site.” The base layer shows gray-scale relief and is a great start. However, the roads as plain lines; the small generic labels for rivers, lakes, and cities; and the tiny road labels make the map look outdated and amateur. The data and layers associated with this site are great! But the presentation of the data is poorly executed. This reduces the map’s creditably and trustworthiness as well as calls the content into question.

Maps are a great tool usually taken for granted! It has been nice to see the latest testament to their importance.  One flaw in a map and the people who use it will discredit it and find a better option. If you’re interested in mapping make sure you learn the ropes before you publish anything. Maps allow us to display data, make strategic, decisions, and help us find our way. Without them you could find yourself in a cathedral instead of your local Burger King.

Stratasan decided that its giveaway not only needed to make a national impact but also needed to showcase Stratasan’s tools and services. Stratasan delivered free on-demand market intelligence to the conference attendees who signed-up. Less than 15 minutes after entering their hospital name, they received a market intelligence package including a patient origin site map, a patient origin by ZIP code report, and market share analysis. 58 hospitals from 25 states took advantage of these free reports.

Stratasan’s SHSMD Footprint

SHSMD was abuzz with Stratasan’s products. At a conference where iPad giveaways and branded pens are customary, Stratasan put intelligence data into the hands of hospitals trying to deliver superior healthcare in their communities. Patient Origin and Market Share barely scratch the surface of Stratasan’s product suite.  Whether you need all payor reports, market intelligence, or diagnosis trends, Stratasan is the solution for your health data needs.

If you missed out this year, don’t fret. We are already working on next year’s offering!

Healthcare 101: Cradle to Grave

When: Friday, October 12, 12 pm Central Time
Duration: 90 minutes
Cost: Free

J. Tod Fetherling presents this 90 minute white board session walking the user through every aspect of the healthcare system from wellness to death. The webcast presentation is packed full of statistics and data analysis. Where possible, the data will be presented in visual manner including many maps.

Webcast topics will include:

• coding
• payers
• providers
• physicians
• referrals
• HIM
• HIEs
• State Data
• Medicare
• Data Sources and more