Analyzing MHSA Hospital Treatment: Results from an AHRQ-SAMHSA

Collaboration

Carol Stocks, RN, MHSA Sam Schildhaus, PhD

Katharine LevitPat Santora, PhD

AHRQ September 19, 2011

Overview of Session

HCUP Data Overview Carol Stocks

Emergency Departments– MHSA Visits to Emergency Departments

Carol Stocks– SA Visits to Emergency Departments for the

Uninsured Sam Schildhaus

Inpatient Stays– MHSA Inpatient Stays in Community Hospitals

Katharine Levit

2

HCUP Data OverviewCarol Stocks

3

Healthcare Cost and Utilization Project (HCUP)

What is HCUP?– Hospital-based administrative data– Large collection going back many years– Encounter-level with all “payers” including

the uninsured– Includes inpatient, emergency department

and ambulatory surgery data

4

5

Demographic Data

Diagnoses

Procedures

Charges

The Foundation of HCUP Data is Hospital Billing Data

6

Patient enters hospital

Hospital sends billing data and any

additional data elements to

Data Organizations

States store data in varying formats

Billing record created

AHRQ standardizes data to create uniform HCUP databases

The Making of HCUP Data

What Are Community Hospitals?

AHA definition of community hospitals: Non-Federal, short-term, general, and other specialty hospitals, excluding hospital units of other institutions (e.g., prisons)

Include these hospitals: Multi-specialty general

hospitals OB-GYN

ENT Orthopedic Pediatric Public

Academic medical centers

Exclude these hospitals:Long-term care

Psychiatric

Alcoholism/chemical

dependency

Rehabilitation

DoD / VA / IHS

7

HCUP Databases

Research PublicationsUser Support

Research Products

SASDSEDD

NIS

SID

KID

NEDS

8

HCUP is a Family of Databases, Tools, and Products

Key: Participating

Non-participating

AZ

CA

UT

CT

FL

GA

IA

IL

KS

MA

MD

MO

NJ

NY

OR

PA

SC

TN

CO

WA

WI

VA

ME

MN

MI

NC

TX

KYWV

RI

NE

VT

NV OH

SD

AR

IN

NH

MT

ID

WY

ND

NMOK

LA

MS AL

DE

HI

AKAK

9

HCUP Partners Providing 2010 Inpatient Data

HI

AKAK

Key: Participating

Non-participating

RI

AZ

CA

UT

CT

FL

GA

IA

IL

KS

MA

MD

MO

NJ

NY

OR

PA

SC

TN

CO

WA

WI

VA

ME

MN

MI

NC

TX

KYWV

NE

VT

NV OH

SD

AR

IN

NH

MT

ID

WY

ND

NMOK

LA

MS AL

DE

10

HCUP Partners Providing 2010 Emergency Department Data

HCUP National Databases are Sampled from State Databases

11

State Inpatient Databases

NIS

State Emergency Department Databases

KID NEDS

What is HCUP and What Is It Not?

HCUP is...A collection of electronic discharge records from health care encounters

All payer, including the uninsured

Hospital, ambulatory surgery, emergency department data

All hospital discharges from participating states (currently 44)

Accessible multiple ways: raw data, reports, on-line aggregate statistics

HCUP is NOT...A survey

Specific to a single payer, e.g. Medicare

Office visits, pharmacy, laboratory, radiology

Only a sample

Inaccessible

12

Recap: Use of HCUP Databases

Benefits Large sample size Uniformity of coding

Routine, regular collection

Ease of access All-payer Available at local, state,

regional, national level Supplemental files available

Limitations Differences in coding across

hospitals No data on individuals outside

of hospital system May not show complete

episode of care May not include all hospitals Lack revenue information Limited clinical details ED data do not contain

information on time to triage, time to treatment, time to disposition, etc.

13

Mental Health and Substance Abuse (MHSA)

Emergency Department (ED) Visits, 2007

Carol Stocks

14

Characteristics of MHSA-related Adult ED Visits

• 12.5 percent of all ED visits (12 million visits) were MHSA-related:

• 41 percent of visits resulted in hospital admission – over 2.5 times the rate of admission for other conditions

• 54 percent of MHSA ED visits were for women

• 18-44 year olds comprised the largest share (47 percent) of adult ED visits

• Medicare was the most frequently billed payer (30 percent of visits)

• 64 percent of visits involved MH conditions, 24 percent SA conditions, and 12 percent co-occurring MHSA conditions

15

Most Common Reasons for MHSA-related Adult ED Visits

• Five all-listed MHSA conditions accounted for 96 percent of documented MHSA conditions during ED visits:

• Mood disorders (43 percent of visits)

• Anxiety disorders (26 percent of visits)

• Alcohol disorders (23 percent of visits)

• Drug disorders (18 percent of visits)

• Schizophrenia and other psychoses (10 percent of visits)

16

Percentage of Hospital Admissions for Adult ED Visits with MHSA Conditions, 2007

20.3

42.0

67.9

24.9

43.9

68.8

51.163.2

82.0

79.7

58.0

32.1

75.1

56.1

31.2

48.936.8

18.0

0

20

40

60

80

100

18-44 Yr 45-64 Yr 65+ Yr 18-44 Yr 45-64 Yr 65+ Yr 18-44 Yr 45-64 Yr 65+ Yr

Perc

enta

ge o

f ED

Vis

its

Admitted to the Hospital Treated and ReleasedMental health condition only Substance abuse disorder only Co-occurring MHSA conditions

17

Payers for MHSA Adult Care in Community Hospitals, 2007

58.9

29.1 32.9

15.1

58.0

41.635.0

23.8

70.860.2 58.0

41.3

41.1

70.9 67.1

84.9

42.0

58.465.0

76.2

29.239.8 42.0

58.7

0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge o

f ED

Vis

its

Admitted to the Hospital Treated and ReleasedMental health condition only Substance abuse disorder only Co-occurring MHSA conditions

18

Adult ED Visits with MHSA Conditions by Age Groups, 2007

42.8

47.9

47.4

63.1

41.1

69.0

34.2

31.2

43.6

32.1

37.1

27.6

23.1

20.9

9.0

4.9

21.8

3.4

0 20 40 60 80 100

Mood disorders (5,101,384 visits)

Anxiety disorders (3,124,412 visits)

Alcohol-related conditions (2,738,638 visits)

Drug-related conditions(2,108,081 visits)

Schizophrenia & other psychotic disorders (1,180,445 visits)

Intentionall Self Harm (792,939 Visits)

Percentage of ED Visits

18-44 Years 45-64 Years 65+ Years

19

Expected Payer for ED Visits with MHSA Conditions, 2007

36.6

29.8

17.3

17.3

47.4

16.6

19.6

17.7

19.6

27.2

26.3

23.0

26.3

32.1

24.6

18.9

10.8

26.5

14.2

17.1

33.3

31.9

12.3

29.3

3.3

3.4

5.1

4.7

3.2

4.5

0 20 40 60 80 100

Mood disorders (5,082,409 visits)

Anxiety disorders (3,112,528 visits)

Alcohol-related conditions (2,729,409 visits)

Drug-related conditions(2,099,719 visits)

Schizophrenia & other psychoticdisorders (1,176,676 visits)

Intentionall Self Harm (788,033 Visits)

Percentage of ED Visits

Medicare Medicaid Private Uninsured Other

20

ED Visits and MHSA-related Conditions

• MHSA conditions were documented for 12.5 percent of the 122.3 million total ED visits for all conditions.

• Mental health diagnoses were involved in 8 percent of all ED visits (9.9 million visits).

• Alcohol-related disorders were involved in 2.3 percent of ED visits (2.8 million visits).

• Drug-related disorders were involved in 1.8 percent of visits (2.2 million visits).

21

MHSA Discharge Status from the ED

22

Most Frequent Types of MHSA – related ED Visits

23

Substance Use Disorder (SUD) Emergency Department Visits for the Uninsured, 2009

Sam Schildhaus

24

Emergency Department

Major portal for entry into hospital and institutional care.

Emergency Department (ED) source of admission to hospital of 50% of all non-obstetric admissions in 2006, up from 36% in 1996.

Legal mandate under Emergency Medical Treatment and Labor Act (EMTALA) – those who come to ED must receive medical screening and be stabilized regardless of insurance status or ability to pay

25

Increase in ED Visits

Between 1997 and 2007, ED visits increased by 23% from 95 million to 117 million*

ED is crucial to patients with substance use disorders (SUD), saving the lives of those with drug/alcohol overdoses and treating the consequences of SUD

* National Hospital Ambulatory Medical Care Survey: 1997 Emergency Department Summary, Vital and Health Statistics, Centers for Disease Control and Prevention, National Center for Health Statistics, number 304, May 6, 1999, Table 1, page 4; National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary, Centers for Disease Control and Prevention, National Center for Health Statistics, number 26, August 6, 2010,Table 1, page 7

26

Prior Related Research

Owens and Mutter: HCUP-NEDS (2006) – – Treat-and-Release (routine discharge) 1.4 times

higher among the uninsured than the insured– Admission among insured 2.1 times higher among

insured than uninsured Owens, Mutter, and Stocks: HCUP-NEDS

(2007) – – Uninsured mental health and substance use

related ED visits were two to four times less likely to result in hospitalization than patient visits with insurance coverage

27

Study Purpose

Analyze ED visits with principal or secondary SUD diagnosis (Dx) to examine the following:

– Does payer status differ among types (e.g., alcohol only, drug only, both) of SUD patients?

– When the relationships are statistically controlled, is discharge of SUD patients to hospital or institution associated with patient, payer, and hospital characteristics?

28

Operational Definition: SUD

– Any SUD diagnosis (Dx), both principal and secondary Dx

– ICD-9-CM Alcohol Abuse: 291.0-291.9 303.00-303.92,

305.00-305.02, but excluding remission code of 303.03.

Drug Abuse: 292.0-292.9, 304.00-304.92, 305.20-305.92,648.30-648.34, 965.00-965.02, but excluding medication error and remission codes 292.81,304.03, 304.13, 304.23, 304.33, 304.43, 304.63, 304.73, 304.83, 305.43, 305.53, 305.63, 305.73

29

Findings

Approximately 19 million of 77 million (25%) emergency department visits were by the uninsured ages 18-64 years

Approximately 1.4 million of the 19 million (7%) had a diagnosed substance use disorder

30

Findings

Payer status of ED visits by those 18-64 – Uninsured: 25%– Private insurance: 39% – Medicaid: 20% – Medicare: 9%– Other payers: 6%

SUD discharges more likely than non-SUD discharges to be uninsured (35% vs. 25%)

31

Multivariate Analysis

Would the substantial difference in discharge disposition between the SUD and non-SUD patients be associated with many patient and facility characteristics?

To test the relationship among the characteristics, we used a multivariate model that statistically controls for patients’ socio-demographic characteristics, chronic conditions, self harm, insurance, and hospital characteristics

32

Likelihood of discharge to hospital/institution after ED visit

Older patients (45-64) 9% less likely than younger (18-44) patients

Women 21% less likely than men Patients residing in poorest zip codes 17%

less likely than patients residing in wealthier zip codes

Patients with Medicare 15% more likely than uninsured

Patients with private insurance 41% more likely than uninsured

33

Likelihood of discharge to hospital/institution after ED visit

Patients with other insurance 57% more likely than uninsured

Patients with higher number of Dx 42% more likely than with lower number of Dx

Visits by patients with higher number of chronic conditions 31% more likely than with lower number of chronic conditions

Visits by patients who intended to hurt self 3.9 times more likely than others

Visits at teaching hospital 31% more likely than visits at nonteaching hospital

34

Issues

Over one third (35%) of MHSA visits treated in community hospital EDs are uninsured

Lack of insurance is associated with decreased post-ED care in community hospitals even after demographic, diagnostic, and hospital characteristics are statistically controlled

Important to monitor this relationship under expanded insurance coverage through the Affordable Care Act

35

Mental Health and Substance Abuse (MHSA) Community Hospital Inpatient Visits, 2008

Katharine Levit

36

MHSA Conditions Accounted for 5% of Hospital Stays

39.9 million inpatient stays in 2008, 1.8 million (about 5%) for MHSA

6 MHSA stays per 1,000 population MHSA stays averaged 7.1 days compared to

4.6 days for all stays– MH stays: 10.8 days per stay– SA stays: 4.7 days per stay

MHSA stays cost $5,500 per stay compared to $9,100 for all stays

37

Mood Disorders were the Single Largest Reason for an MHSA Stays

38

Bipolar Disorders20%

Depression24%

Schizophrenia/Other Psychotic Disorders

19%

Alcohol-related Disorders

14%

Drug-related Disorders

12%

Adjustment Disorders2%

Anxiety Disorders2%

All Other†5%

Distribution of MHSA Discharges by Major Reason* for Hospital Stay, 2008

* Based on principal CCS conditions.† Includes attention-deficit, conduct, and disruptive behavior disorders; impulse control disorders; personality disorders; autismand other childhood disorders; developmental disorders; and pregnancy-related and other miscellaneous MH disorders.Note: Pie slices do not add to 100% because of rounding.Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide InpatientSample, 2008.

1.8 Million MHSA Stays

Substance Abuse

Disorders26%

Mood Disorders

44%

ALOS 2.5 Days Longer for MHSA Stays than for All Diagnoses

39

1,602 1,700 1,770 1,820 1,837

7.97.3 7.1 7.2 7.1

0

1

2

3

4

5

6

7

8

9

10

1,400

1,500

1,600

1,700

1,800

1,900

1997 2005 2006 2007 2008

Ave

rage

Len

gth

of S

tay

in D

ays

Num

ber

of D

isch

arge

s in

Tho

usan

ds

Number of Inpatient Hospital Stays and Average Length of Stay for Discharges with a Principal MHSA Diagnosis, 1997-2008

MHSA Discharges in Thousands

MHSA Average Length of Stay in Days

Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 1997, 2005, 2006, 2007 and 2008.

ALOS Varied Considerably by MHSA Diagnosis

40

3.6

4.4

4.5

4.8

5.2

5.4

6.5

6.7

7.8

10.1

10.7

11.1

11.3

0 2 4 6 8 10 12

Adjustment disorders

Anxiety disorders

Alcohol-related disorders

Drug-related disorders

Pregnancy-related/other misc. MH disorders

Developmental disorders

Depression

Personality disorders

Bipolar disorders

Autism/other childhood disorders

Impulse control disorders

Schizophrenia/other psychotic disorders

Attention-deficit/conduct/disruptive behavior disorders

Average Length of Stay in Days

Average Length of Stay by Principal Reason for MHSA Stay, 2008

Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008.

All MHSA Stays 7.1 Days

MHSA Stays Accounted for 21% of All Discharges Leaving the Hospital Against

Medical Advice (AMA)

41

All Other Diagnoses292,300

79%

MH 25,000

7%

SA52,700

14%

* Based on principal CCS diagnosis.Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008.

370,000 DischargesAgainst Medical Advice

MHSA* Inpatient Hospital Discharges Against Medical Advice (AMA) as a Share of All Discharges AMA, 2008

MHSA Diagnoses had a Higher Rate of Discharges AMA than All

Other Diagnoses

42

19

107

8

0

20

40

60

80

100

120

MH SA All Other Diagnoses

Dis

char

ges A

MA

per

1,0

00 D

isch

arge

s

Discharge Rate Against Medical Advice (AMA) for MHSA* and All Other Diagnoses, 2008

* Based on principal CCS diagnosis.Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008.

Non-elderly Adults had a Disproportionate Share of All MHSA Stays Relative to their

Share of the Total Population and All Hospital Stays

43

12%

23%

7%

4%

37%

50%25%

26% 33%

24%

11% 8%

27%

8%

0

10

20

30

40

50

60

70

80

90

100

U.S. Population MHSA Stays All Stays

Perc

ent D

istr

ibuti

onDistribution of U.S. Population, MHSA Stays, and All Stays by Age, 2008

85+

65-84

45-64

18-44

1-17

<1

304 Million Residents

1.8 Million Discharges

39.9 Million Discharges

Note: Excludes a small number of MHSA discharges (2,500 or 0.1 percent) and of all discharges (50,000 or 0.1 percent) with missing age.Note: Bar segments representing 2 percent or less have not been labeled. Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008.

There were 60 MHSA Hospital Stays per 10,000 Population

44

20

84

63

54

59

59

19

81

79

43

41

60

0 20 40 60 80 100

1-17

18-44

45-64

65-84

85+

All Ages

Number of Discharges per 10,000 Population

Age

Gro

up

MHSA Discharges per 10,000 Population by Age, 1997 and 2008

2008

1997

Note: Excludes a small number of discharges (4,000 or 0.2 percent) less than 1 year of age or with missing age.Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 1997 and 2008.

Most Frequent Principal MHSA Diagnoses by Age

• Mood disorders was the most frequent principal MHSA diagnosis across all age groups in 1997 and 2008

• Alcohol-related disorders accounted for 12 percent of MHSA stays among 18-44 year olds, 21 percent of MHSA stays among 45-64 year olds, and 12 percent of MHSA stays for 65-84 year olds

• The number of hospital stays for drug-related conditions rose rapidly for all age groups over 45 years old (87-117-percent increase from 1997-2008), while remaining relatively stable (11-percent decline) among 18-44 year olds

• The underlying causes of this increase were rapid growth in drug-induced delirium and in poisonings by opiate-based pain medications

45

Rise in Drug-induced Delirium and Poisonings by Opiate-based Pain Medications Fueled

Increase in Drug-related Hospitalizations for Patients 85 and Older

• Drug-induced delirium and poisonings by opiate-based pain medications accounted for 78 percent of the drug-related stays and 89 percent of the increase in drug-related stays for patients 85 and older

• Drug-induced delirium can result from side-effects of medications and occurs often in elderly hospitalized patients

• Drug-induced delirium and poisonings by opiate-based pain medications were also responsible for a large number of drug-related discharges in 45-64 year olds (19 percent) and 65-84 year olds (60 percent)

46

NUMBER OF DRUG- RELATED DISCHARGES IN

2008

CUMULATIVE GROWTH IN DRUG-RELATED

DISCHARGES 1997-2008

PERCENT CONTRIBUTION TO GROWTH IN DRUG-RELATED DISCHARGES

1997-20008

PRINCIPAL ICD-9-CM DIAGNOSIS 45-64 Years

65-84 Years

85+ Years

45-64 Years

65-84 Years

85+ Years

45-64 Years

65-84 Years

85+ Years

All drug-related discharges 65,400 16, 000 3,200 117% 96% 87% 100.0% 100.0% 100.0%

Drug withdrawal (ICD-9-CM 292.0) 20,300 2,000 100 270 107 71 41.9 13.5 3.9

Drug-induced delirium (ICD-9-CM 292.81)

4,200 6,400 2,100 143 56 98 7.0 29.0 69.8

Poisonings by codeine (methylmorphine), meperdine (pethidine), morphine (ICD-9-CM 965.09)

8,300 3,300 400 693 381 245 20.6 32.9 19.1

All other drug related conditions* 32,600 4,300 600 49 80 24 30.6 24.6 7.3

Adults 18-44 Accounted for Large Shares of Stays for the Most Frequent MHSA Conditions

47

9% 12% 13% 13%

48%54%

49%42%

61% 40%

63%

32%28%

38% 50%

29%

30%

19%10%

6% 10% 7% 7%14%

4%

0

20

40

60

80

100

Depression448,000

Discharges

Bipolar Disorders377,000

Discharges

Schizophrenia/ Other Psychotic

Disorders356,000

Discharges

Alcohol-related Disorders261,000

Discharges

Drug-related Disorders230,000

Discharges

Anxiety Disorders

40,000 Discharges

Adjustment Disorders

37,000 Discharges

Perc

ent D

istr

ibuti

on

Distribution of the Most Frequent MHSA Conditions* by Age, 2008

85+

65-84

45-64

18-44

1-17

* Based on principal CCS diagnosis.Note: Excludes a small number of MHSA discharges (2,500 or 0.1 percent ) and of all discharges (50,000 or 0.1 percent) with missing age.Note: Bar segments representing 3 percent or less have not been labeled. Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008.

The Gender Split for MHSA Stays Varied by Diagnosis

48

12%

37%

39%

43%

44%

50%

53%

56%

59%

69%

70%

72%

76%

0 20 40 60 80

Pregnancy-related/other misc. MH disorders

Anxiety disorders

Personality disorders

Depression

Bipolar disorders

Adjustment disorders

Developmental disorders

Schizophrenia/other psychotic disorders

Drug-related disorders

Attention-deficit/conduct/disruptive behavior disorders

Impulse control disorders

Alcohol-related disorders

Autism/other childhood disorders

Male Percent of StaysSource: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008.

Percent of MHSA Stays for Males by Principal MHSA Diagnosis, 2008

14% of All Discharges had a Secondary MH Diagnosis

49

105,800

111,000

111,200

113,200

121,800

133,300

145,700

174,700

196,200

207,100

115,400

134,600

161,300

224,000

277,600

0 50,000 100,000 150,000 200,000 250,000 300,000

Fluid and electrolyte disorders

Coronary atherosclerosis

Cardiac dysrhythmias

Urinary tract infections

Spondylosis, intervertebral discdisorders, and other back problems

Congestive heart failure

Osteoarthritis

Non-specific chest pain

Chronic obstructive pulmonary disease and bronchiectasis

Pneumonia

Drug-related disorders

Alcohol-related disorders

Schizophrenia/other psychotic disorders

Bipolar disorders

Depression

Number of Discharges

Most Common Principal Diagnoses with a Secondary MH Condition,* 2008

*All conditions are defined using CCS. Once a secondary MH diagnosis is detected, the discharge is counted according to its principal CCS diagnosis. Suicide/intentional self-inflicted injury is included as a secondary MH diagnosis .Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008.

Oth

er M

edic

al C

ondi

tions

MH

SA C

ondi

tions

5% of All Discharges had a Secondary SA Diagnosis

50

38,400

38,400

38,700

38,900

44,600

45,700

47,400

49,700

62,800

85,300

106,400

162,900

166,500

189,800

193,600

0 50,000 100,000 150,000 200,000

Chronic obstructive pulmonary disease and bronchiectasis

Diabetes mellitus with complications

Congestive heart failure

Gastrointestinal hemorrhage

Pneumonia

Skin and subcutaneous tissue infections

Poisoning by psychotropic agents

Non-specific chest pain

Poisoning by other medications and drugs

Pancreatic disorders (not diabetes)

Schizophrenia/other psychotic disorders

Bipolar disorders

Drug-related disorders

Depression

Alcohol-related disorders

Number of Discharges

Most Common Principal Diagnoses with a Secondary SA Condition,* 2008

Oth

er

Me

dic

al

Co

nd

itio

ns

MH

SA C

on

diti

on

s

MHSA Stays were More Commonly Uninsured or Insured

by Medicaid than All Stays

51

37%29%

16% 19%

18% 28%

21%31%

35% 30%

33%

26%

5% 9%

23%19%

3% 4% 7% 5%

0

20

40

60

80

100

All Diagnoses

Mental Health

Disorders

Alcohol-related

Disorders

Drug-related

Disorders

Perc

ent D

istr

ibuti

on

Other**

Uninsured***

Private Insurance

Medicaid

Medicare

*Based on principal CCS diagnosis.**Includes other payers such as Workers' Compensation, TRICARE, CHAMPUS, CHAMPVA, Title V, and other government programs.***Includes discharges classified as self-pay or no charge.Note: Excludes a small number of discharges (68,000 or 0.2 percent) with missing payer.Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008.

Distribution of Discharges by Primary Payer and MHSA Diagnosis,* 2008Distribution of Discharges by Primary Payer and MHSA Diagnosis,* 2008

The Uninsured and Medicaid Covered a Disproportionate

Share of Costs for MHSA Stays

52

46%36%

19% 24%

14% 30%

24%

33%

32% 24%

28%

24%

4% 6%

21%14%

3% 4% 8% 5%

0

20

40

60

80

100

All Diagnoses

Mental Health

Disorders

Alcohol-related

Disorders

Drug-related

Disorders

Perc

ent D

istr

ibuti

on

Other**

Uninsured***

Private Insurance

Medicaid

Medicare

*Based on principal CCS diagnosis.**Includes other payers such as Workers' Compensation, TRICARE, CHAMPUS, CHAMPVA, Title V, and other government programs.***Includes discharges classified as self-pay or no charge.Note: Excludes a small number of discharges (68,000 or 0.2 percent) with missing payer that have a small sum of missing costs ($642 million or 0.2 percent).Note: Costs reflect all costs associated with stay, not solely those associated with the principal diagnosis.Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008.

Distribution of Aggregate Costs by Primary Payer and MHSA Diagnosis,* 2008

Schizophrenia was the Most Costly MHSA Diagnosis

53

24

37

18

40

230

261

377

448

356

$100

$100

$100

$200

$1,100

$1,300

$2,100

$2,100

$2,700

-5,000-4,000-3,000-2,000-1,000 0 1,000 2,000 3,000 4,000

Pregnancy-related MH disorders

Adjustment disorders

Attention-deficit/conduct/disruptive behavior disorders

Anxiety disorders

Drug-related disorders

Alcohol-related disorders

Bipolar disorders

Depression

Schizophrenia/other psychotic disorders

Discharges (Thousands) Aggregate Costs (Millions)

Note: Costs reflect all costs associated with stay, not solely those associated with the principal diagnosis.Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008.

500 400 300 200 100

Number of Discharges and Aggregate Costs for the Most Frequent Principal MHSA Diagnoses, 2008

The Average MHSA Hospital Stay Cost $1,200 Less than Stays

without a Major OR Procedure

54

$2,800

$3,500

$4,500

$4,700

$4,900

$5,000

$5,600

$7,200

$7,500

0 2,000 4,000 6,000 8,000 10,000

Adjustment disorders

Pregnancy-related MH disorders

Anxiety disorders

Depression

Drug-related disorders

Alcohol-related disorders

Bipolar disorders

Attention-deficit/conduct/disruptive behavior disorders

Schizophrenia/other psychotic disorders

Average CostNote: Costs reflect all costs associated with stay, not solely those associated with the principal diagnosis.Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008.

Average Cost of All Hospital Stays with

No Major Operating Room Procedure

Performed $6,700

Average Cost of a Hospital Stay for the Most Frequent Principal MHSA Diagnoses, 2008

MH Hospitalization Rates were Higher in Poorest Communities than in All Other Communities

55

8

14

12

37

50

71

129

111

1,147

1,399

949

11

13

18

54

94

111

147

153

1,521

1,704

1,854

0 500 1,000 1,500 2,000

Developmental disorders

Autism/other childhood disorders

Personality disorders

Impulse control disorders

Attention-deficit/conduct/disruptive behavior disorders

Pregnancy-related MH disorders

Anxiety disorders

Adjustment disorders

Bipolar disorders

Depression

Schizophrenia/other psychotic disorders

Number of Discharges per 1,000,000 Population

MH Discharges per 1,000,000 Population in the Poorest Communities,* 2008

Poorest Communities

All Other Communities

* The poorest communities are defined by ZIP code and have median household income of less than $39,000. Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008.

SA Hospitalization Rates in Poorest Communities were

Similar to All Other Communities

56

53

283

489

24

204

330

66

338

496

35

330

410

0 100 200 300 400 500 600

Non-dependent abuse of alcohol

Alcohol dependence syndrome

Alcohol induced mental disorders

Non-dependent abuse of illicit/legal drugs

Drug dependence

Drug induced mental disorders

Number of Discharges per 1,000,000 Population

SA Discharges per 1,000,000 Population in the Poorest Communities,* 2008

Poorest Communities

All Other Communities

* The poorest communities are defined by ZIP code and have median household income of less than $39,000. Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sam ple, 2008.

Dru

g-re

late

dD

isor

ders

Alco

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elat

edD

isor

ders

Summary

26% of treatment spending for MHSA conditions went for hospital care in 2005, making stays key parts of treatment 5% of inpatient stays are for MHSA conditions MHSA stays are longer on average but less costly MHSA conditions vary by age and gender and are often

secondary conditions for a stay MHSA stays were 2 to 5 times more likely to be

uninsured, depending on the condition Hospitalized patients with schizophrenia, depression, or

bipolar disorder were more likely to reside in the poorest communities

On the Web at http://www.hcup-us.ahrq.gov/reports/factsandfigures/2008/TOC_2008.jsp57

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Questions and Discussion

For Further Information

HCUP Facts and Figures:http://www.hcupus.ahrq.gov/reports/factsandfigures/2008/TOC_2008.jsp HCUP Topical Reports:http://www.hcup-us.ahrq.gov/reports/mhsa.jsp HCUP Statistical Briefs:http://www.hcup-us.ahrq.gov/reports/statbriefs/sbtopic.jsp

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