PRIVATE HEALTH INSURANCE. Geographic Variation in Spending for Certain High-Cost Procedures Driven by Inpatient Prices

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1 United Sttes Government Aountility Offie Report to the Rnking Memer, Committee on Energy nd Commere, House of Representtives Deemer 2014 PRIVATE HEALTH INSURANCE Geogrphi Vrition in Spending for Certin High-Cost Proedures Driven y Inptient Pries GAO

2 Deemer 2014 PRIVATE HEALTH INSURANCE Geogrphi Vrition in Spending for Certin High- Cost Proedures Driven y Inptient Pries Highlights of GAO , report to the Rnking Memer, Committee on Energy nd Commere, House of Representtives Why GAO Did This Study Reserh shows tht spending on helth re vries y geogrphi re nd tht higher spending in n re is not lwys ssoited with etter qulity of re. While sustntil ody of reserh exists on geogrphi vrition in spending in Medire, less reserh hs een done on vrition in privte setor helth re spending, lthough this spending ounts for out third of overll helth re spending. As U.S. helth expenditures ontinue to rise, poliymkers nd others hve expressed interest in etter understnding spending vrition nd how helth re systems n operte effiiently tht is, providing equivlent or higher qulity re while mintining or lowering urrent spending levels. GAO ws sked to exmine geogrphi vrition in privte setor helth re spending. GAO exmined (1) how spending per episode of re for ertin high-ost proedures vries ross geogrphi res for privte pyers, nd (2) how the mix of servie types, nd the volume, intensity, nd prie of servies ontriute to vrition in episode spending ross geogrphi res for privte pyers. Using lrge privte setor lims dtse for 2009 nd 2010, GAO exmined spending y MSA for episodes of re for three ommonly performed inptient proedures nd exmined spending y hospitl inptient, hospitl outptient, postdishrge, professionl, nd nillry servie tegories. For inptient nd professionl servies, GAO exmined the volume, intensity, nd prie of servies. GAO's findings my not e generlizle to ll privte insurers due to dt limittions. View GAO For more informtion, ontt Jmes Cosgrove t (202) or Wht GAO Found Spending for n episode of re in the privte setor vried ross metropolitn sttistil res (MSA) for oronry stent plement, lprosopi ppendetomy, nd totl hip replement, even fter GAO djusted for geogrphi differenes in the ost of doing usiness nd differenes in enrollee demogrphis nd helth sttus. MSAs in the highest-spending quintile hd verge djusted episode spending tht ws 74 to 94 perent higher thn MSAs in the lowest-spending quintile, depending on the proedure. MSAs with higher spending on one proedure generlly hd higher spending on the other two proedures. High- or low-spending MSAs were not onentrted in prtiulr regions of the ntion. The prie of the initil hospitl inptient dmission ounted for 91 perent or more of the differene in episode spending etween MSAs in the lowest- nd highest-spending quintiles. The prie of the initil dmission ws the lrgest ontriutor to the differene for two resons. First, it represented the lrgest perentge of djusted episode spending. For exmple, for totl hip replement, the verge prie of the initil dmission ws $17,134, representing 76 perent of the $22,463 in totl episode spending for MSAs in the lowest-spending quintile nd $30,332, representing 82 perent of the $36,969 in totl episode spending for MSAs in the highest-spending quintile. Seond, the prie of the initil dmission vried onsiderly ross MSAs. For MSAs in the highest-spending quintile, the verge prie of the initil dmission for totl hip replement ws 77 perent higher thn for MSAs in the lowest-spending quintile. Professionl servies offie visits nd other servies provided y physiin or other helth professionl were the seond lrgest ontriutor to geogrphi differenes in episode spending, ut ounted for 7 perent or less of the differene in episode spending etween MSAs in the lowest- nd highest-spending quintiles. (See tle.) MSAs in the highest-spending quintile hd higher verge pries nd intensity ( mesure of the resoures needed to provide servie) ut fewer servies (volume) thn MSAs in the lowest-spending quintile for ll three proedures. Contriutions of Eh Servie Ctegory to Differenes in Averge Episode Spending etween MSAs in Lowest- nd Highest-Spending Quintiles Servie tegory Coronry stent plement Lprosopi ppendetomy Totl hip replement Hospitl inptient Prie of initil dmission 92% 96% 91% Hospitl inptient Redmissions 1% 0% 0% Hospitl outptient 1% 1% 1% Postdishrge 0% 0% 0% Professionl 5% 3% 7% Anillry nd unlssified 1% 0% 1% Totl 100% 100% 100% Soure: GAO nlysis of 2009 nd 2010 lims dt from Truven Helth Anlytis. GAO The Deprtment of Helth nd Humn Servies provided tehnil omments on drft of this report, whih were inorported s pproprite. United Sttes Government Aountility Offie

3 Contents Letter 1 Bkground 6 Episode Spending Ws 74 to 94 Perent Higher in Highest- Compred with Lowest-Spending Ares, with High-Spending Ares Generlly High for All Three Proedures 9 Prie per Initil Inptient Admission Ws Lrgest Contriutor to Geogrphi Differenes in Episode Spending 15 Ageny Comments 21 Appendix I Dt nd Methods 23 Appendix II Episode Spending, y Proedure, within Metropolitn Sttistil Ares GAO Anlyzed 29 Appendix III Distriution of Episode Spending 44 Appendix IV Episode Spending, y Proedure, for Metropolitn Sttistil Ares in Lowest- nd Highest-Spending Quintiles 45 Appendix V Hospitl Inptient Spending nd Other Informtion, y Metropolitn Sttistil Are nd Proedure 47 Appendix VI Professionl Servies Spending nd Other Informtion, y Metropolitn Sttistil Are nd Proedure 56 Appendix VII GAO Contt nd Stff Aknowledgments 65 Pge i GAO Geogrphi Vrition in Spending

4 Tles Tle 1: Contriutions of Eh Servie Ctegory to Differenes in Averge Episode Spending etween Metropolitn Sttistil Ares (MSA) in the Lowest- nd Highest- Spending Quintiles 16 Tle 2: Professionl Servies: Differene in Averge Spending, Volume, Intensity, nd Prie 21 Tle 3: Rnking of Metropolitn Sttistil Ares (MSA) y Adjusted Episode Spending for Coronry Stent Plement Episodes 29 Tle 4: Rnking of Metropolitn Sttistil Ares (MSA) y Adjusted Episode Spending for Lprosopi Appendetomy Episodes 34 Tle 5: Rnking of Metropolitn Sttistil Ares (MSA) y Adjusted Episode Spending for Totl Hip Replement Episodes 39 Tle 6: Averge Adjusted Episode Spending for Coronry Stent Plement, Metropolitn Sttistil Ares (MSA) in Lowest- nd Highest-Spending Quintiles 45 Tle 7: Averge Adjusted Episode Spending for Lprosopi Appendetomy, Metropolitn Sttistil Ares (MSA) in Lowest- nd Highest-Spending Quintiles 45 Tle 8: Averge Adjusted Episode Spending for Totl Hip Replement, Metropolitn Sttistil Ares (MSA) in Lowest- nd Highest-Spending Quintiles 46 Tle 9: Hospitl Inptient Spending, Initil Admission Prie, nd Numer of Dys, y Metropolitn Sttistil Are (MSA), for Coronry Stent Plement Episodes 47 Tle 10: Hospitl Inptient Spending, Initil Admission Prie, nd Numer of Dys, y Metropolitn Sttistil Are (MSA), for Lprosopi Appendetomy Episodes 50 Tle 11: Hospitl Inptient Spending, Initil Admission Prie, nd Numer of Dys, y Metropolitn Sttistil Are (MSA), for Totl Hip Replement Episodes 53 Tle 12: Professionl Servies Spending, Numer of Servies, Intensity, nd Prie, y Metropolitn Sttistil Are (MSA), for Coronry Stent Plement Episodes 56 Tle 13: Professionl Servies Spending, Numer of Servies, Intensity, nd Prie, y Metropolitn Sttistil Are (MSA), for Lprosopi Appendetomy Episodes 59 Pge ii GAO Geogrphi Vrition in Spending

5 Tle 14: Professionl Servies Spending, Numer of Servies, Intensity, nd Prie, y Metropolitn Sttistil Are (MSA), for Totl Hip Replement Episodes 62 Figures Figure 1: Distriution of Averge Episode Spending Aross Metropolitn Sttistil Ares (MSA) 11 Figure 2: Correltion of Averge Episode Spending etween Proedures 13 Figure 3: Averge Pries of Initil Hospitl Inptient Admissions for Metropolitn Sttistil Ares (MSA) in the Lowestnd Highest-Spending Quintiles 18 Figure 4: Averge Spending on Professionl Servies in Metropolitn Sttistil Ares (MSA) in the Lowest- nd Highest-Spending Quintiles 20 Arevitions GDP IOM MedPAC MSA RVU gross domesti produt Institute of Mediine Medire Pyment Advisory Commission metropolitn sttistil re reltive vlue unit This is work of the U.S. government nd is not sujet to opyright protetion in the United Sttes. The pulished produt my e reprodued nd distriuted in its entirety without further permission from GAO. However, euse this work my ontin opyrighted imges or other mteril, permission from the opyright holder my e neessry if you wish to reprodue this mteril seprtely. Pge iii GAO Geogrphi Vrition in Spending

6 441 G St. N.W. Wshington, DC Deemer 29, 2014 The Honorle Henry A. Wxmn Rnking Memer Committee on Energy nd Commere House of Representtives Der Mr. Wxmn: Ntionl helth expenditures re projeted to grow from $2.8 trillion in 2012 to over $5 trillion in 2023, outping gross domesti produt (GDP) growth over this period, nd ounting for lmost 20 perent of GDP y The United Sttes spends signifintly more on helth re thn ny other ntion, yet helth outomes in the United Sttes re not neessrily etter thn those of other ntions with lower spending. Further, reserh on U.S. helth re spending hs shown tht spending n vry y geogrphi re nd tht this vrition remins even fter ounting for importnt differenes ross res, suh s differing helth sttus of popultions nd differing osts of doing usiness. Studies hve lso shown tht higher spending is not lwys ssoited with etter qulity of re. 2 As U.S. helth expenditures ontinue to rise, there is widespred interest mong poliymkers nd others in improving their understnding of drivers of spending nd in lerning more out where nd how helth re systems operte effiiently tht is, provide equivlent or higher qulity re while mintining or lowering urrent spending levels. While reserhers hve developed sustntil ody of work on 3 geogrphi vrition in Medire spending, less reserh hs een done 1 See Centers for Medire & Mediid Servies, Tle 1: Ntionl Helth Expenditures nd Seleted Eonomi Inditors, Levels nd Annul Perent Chnge: Clendr Yers , essed Otoer 28, 2014, nd-systems/sttistis-trends-nd- Reports/NtionlHelthExpendDt/Downlods/Proj2013tles.zip. 2 See, for exmple, E. Fisher et l., The Implitions of Regionl Vritions in Medire Spending. Prt 1: The Content, Qulity, nd Aessiility of Cre, Annls of Internl Mediine, vol. 138, no.4 (2003). 3 Medire is the federlly finned helth insurne progrm for persons ged 65 nd over, ertin individuls with disilities, nd individuls with end-stge renl disese. Pge 1 GAO Geogrphi Vrition in Spending

7 on geogrphi vrition in privte setor helth re spending. Reserhers hve primrily foused on Medire spending euse of the vilility of Medire spending dt. However, privte setor spending on helth re ounts for out one-third of U.S. helth expenditures nd more omprehensive privte setor dt hs eome ville in reent yers. 4 Additionl reserh on privte setor spending will provide importnt ontriutions to n overll understnding of geogrphi vrition in helth re spending. A useful frmework for exploring geogrphi vrition nd resons ehind geogrphi spending differenes is exmining spending within n episode of re defined s the re nd servies provided for speifi medil prolem, ondition, or illness during speifi time period. Using the episode, we n exmine the ontriution of omponents tht drive spending vrition. These omponents inlude the mix of servies provided hospitl inptient, hospitl outptient, physiin nd other professionl servies, postdishrge, nd nillry servies nd the 5 volume, intensity, nd prie of those servies. A greter understnding of the resons for higher or lower spending in ertin res my provide insights into the poliy options tht re most likely to e effetive t promoting effiienies nd ost svings. You sked us to exmine geogrphi vrition in privte setor helth re spending. We exmined how spending per episode of re for ertin high-ost proedures vries ross geogrphi res for privte pyers nd how the mix of servie types, nd the volume, intensity, nd prie of servies ontriute to vrition in episode spending ross geogrphi res for privte pyers. To exmine how spending per episode of re for ertin high-ost proedures vries ross geogrphi res, we lulted verge 4 In 2012, privte setor spending ounted for $917 illion of the $2.8 trillion in overll ntionl helth expenditures. 5 Volume is the numer of servies used, nd intensity is the resoures needed to provide servie for exmple, 30-minute offie visit hs greter intensity thn 15-minute offie visit. Pge 2 GAO Geogrphi Vrition in Spending

8 episode spending y metropolitn sttistil res (MSA). 6 We reted episodes sed on n inptient dmission for eh of the following proedures: oronry stent plement, lprosopi ppendetomy, nd totl hip replement. 7 For the yers we nlyzed in the privte setor dtse 2009 nd 2010 these proedures were ommonly performed nd ssoited with high levels of ntionl spending. 8 These proedures lso represent different medil speilties. In ddition, we seleted hospitl-sed proedures euse the United Sttes spends more ntionlly on hospitl servies thn ny other type of helth re servie. 9 To rete the episodes, whih inluded ll servies from the dy of dmission to 30 dys fter dishrge nd ertin servies in the 3 dys 6 The Offie of Mngement nd Budget defines MSAs s hving t lest one urnized re with popultion of 50,000 or more, plus djent territory tht hs high degree of soil nd eonomi integrtion with the ore. Offie of Mngement nd Budget, Exeutive Offie of the President, OMB Bulletin No , Revised Delinetions of Metropolitn Sttistil Ares, Miropolitn Sttistil Ares, nd Comined Sttistil Ares, nd Guidne on Uses of the Delinetions of These Ares (Wshington, D.C.: Fe. 28, 2013). 7 Coronry stent plement, lso known s perutneous trnsluminl oronry ngioplsty, is surgil rdiology proedure to open loked oronry rtery nd insert stent (n expndle metl oil) into the newly opened rtery to help prevent renrrowing or relosure. Lprosopi ppendetomy is generl surgil proedure to remove n infeted ppendix using instruments pled into smll dominl inisions. Totl hip replement, lso known s totl hip rthroplsty, is surgil orthopedi proedure where rtilge nd one from the hip joint re repled with prostheti omponents. 8 These proedures lso hve high levels of volume mong ll ptients in the United Sttes. For exmple, ording to the Helthre Cost nd Utiliztion Projet, whih inludes dt for ll privtely insured, Medire, Mediid, uninsured, nd ll other ptients, these 3 proedures were mong the 20 proedures with the most dishrges in During tht yer, there were pproximtely 614,000 dishrges for oronry stent plement, pproximtely 200,000 dishrges for lprosopi ppendetomy, nd pproximtely 274,000 dishrges for totl hip replement. 9 In 2012, out one-third of ll helth re spending in the United Sttes ws for hospitl servies. Spending for professionl servies represented over one-qurter of spending, nd the reminder of spending inluded servies suh s presription drugs, nursing home re, nd home helth re, s well s dministrtive osts. See Centers for Medire & Mediid Servies, Tle 2: Ntionl Helth Expenditures; Aggregte nd Per Cpit Amounts, Annul Perent Chnge nd Perent Distriution, y Type of Expenditure: Seleted Clendr Yers , essed Otoer 28, 2014, Reports/NtionlHelthExpendDt/Downlods/tles.pdf. Pge 3 GAO Geogrphi Vrition in Spending

9 prior to dmission, 10 we used privte setor helth insurne lims nd enrollment dt from the Truven Helth Anlytis MrketSn Commeril Clims nd Enounters Dtse for 2009 nd This dtse ontins lims for over 50 million enrollees pid y over 100 privte insurers ross 50 sttes nd the Distrit of Columi in 2009 nd We ssigned episodes to MSAs sed on the lotion of the hospitl inptient dmission, keeping only MSAs tht hd suffiient numer of episodes to support our nlyses. 11 We lulted undjusted spending y using the pyment mounts on the lims. We then djusted spending for geogrphi differenes in the ost of doing usiness nd differenes in the demogrphis nd helth sttus of enrollees in eh MSA. 12 Using ll MSAs inluded in our nlyses, we determined the distriution of verge episode spending for eh proedure, nd, using the 78 MSAs with suffiient numer of episodes for ll three proedures, we lulted the extent to whih MSAs with high or low episode spending for one proedure lso hd high or low episode spending for nother proedure. To exmine how the mix of servie types, nd the volume, intensity, nd prie of servies ontriute to vrition in episode spending ross 10 Speifilly, we inluded ny outptient servies reeived y n enrollee in the 3 dys prior to dmission t the sme hospitl where the inptient dmission ourred, euse those servies my e relted to the dmission. 11 We exluded MSAs tht hd fewer thn 24 oronry stent plement episodes, fewer thn 17 lprosopi ppendetomy episodes, or fewer thn 24 totl hip replement episodes. We hd suffiient numer of episodes to support our nlyses of oronry stent plement in 155 MSAs, lprosopi ppendetomy in 139 MSAs, nd totl hip replement in 141 MSAs. For some nlyses where we drew omprisons ross proedures, we reported dt on only those MSAs tht hd suffiient numer of episodes for ll three proedures, nd 78 MSAs fell into this tegory. We took steps to remove nd limit the effet of typil episodes. For exmple, we exluded enrollees who reeived the proedure more thn one time during the episode, enrollees whose overll initil hospitl dmission ws oded s eing for reson unrelted to the proedure nlyzed, enrollees with dignoses of end-stge renl disese, enrollees who were pregnnt, nd enrollees with hospie sty. 12 Enrollee lso refers to ny dependents, unless otherwise speified. To ontrol for geogrphi differenes in the ost of doing usiness, we pplied Medire s pymentdjustment methodology the Geogrphi Prtie Cost Index or the Hospitl Wge Index, s pproprite to the undjusted spending for servies within eh episode. To ontrol for differenes in the demogrphis nd helth sttus of enrollees in eh MSA, we used regression-sed pproh with enrollee-level vriles suh s ge, gender, numer of redmissions, nd ertin omoridities. See pp. I for desription of our pproh. Pge 4 GAO Geogrphi Vrition in Spending

10 geogrphi res, we lulted nd reported on differenes in these omponents for the 78 MSAs with suffiient numer of episodes for ll three proedures, fousing on MSAs in the lowest- nd highest-spending quintile for eh proedure. We nlyzed the mix of servie types y ssigning ll spending within n episode to one of five servie tegories: (1) hospitl inptient, (2) hospitl outptient, (3) postdishrge, (4) professionl, nd (5) nillry. 13 For hospitl inptient nd professionl servies, we lso exmined volume, intensity, nd prie of servies. 14 For hospitl inptient servies, we mesured volume s the numer of dys in the hospitl sty, nd we mesured prie y the mount spent on the initil hospitl inptient dmission (whih exluded spending on ny susequent redmissions), euse hospitls re generlly pid one mount per dmission regrdless of the ptient s length of sty or the servies delivered. For professionl servies, we mesured volume s the numer of servies provided, nd we mesured intensity y using the reltive vlue unit (RVU), whih is n estimte of the resoures needed to provide given servie. 15 We lulted the prie per unit of intensity y dividing verge spending on professionl servies y the totl units of intensity (numer of RVUs) ssoited with those servies. See ppendix I for more detiled desription of our methodology. We ssessed the reliility of the MrketSn dtse y reviewing doumenttion, disussing the dtse with knowledgele offiils, nd performing dt reliility heks, nd we determined the dt were suffiiently relile for our purposes. 13 Exmples of postdishrge servies re servies t skilled nursing fility nd home helth servies. Professionl servies inlude offie visits, hospitl onsulttions, surgeries, nd other servies provided y physiin or other helth professionl, suh s physiin ssistnt. Exmples of nillry servies re l tests nd mulne servies. 14 We lulted volume, intensity, nd prie for hospitl outptient servies ut did not report them euse we found tht hospitl outptient spending onstituted only 1 to 2 perent of episode spending. We ould not lulte onsistent mesures of volume, intensity, nd prie for postdishrge re nd nillry servies euse of the vriility of servies within these tegories nd the sene of mesure of intensity for these servies. 15 Medire ses its pyment rtes for physiin servies on RVUs, whih reflet estimtes of the resoures needed to provide given servie reltive to other servies inluding physiin time nd intensity; other linil lor, equipment, nd supplies; nd premiums pid for mlprtie. Pge 5 GAO Geogrphi Vrition in Spending

11 Our study hd some limittions. We reported results only for those MSAs in whih we hd suffiient numer of episodes to ensure the reliility of our results for eh proedure, ut our results inluded MSAs tht onstituted mjority of the U.S. popultion. Depending on the proedure, 60 to 63 perent of the U.S. popultion lives in the MSAs inluded. 16 In ddition, lthough we hose proedures tht were ommonly performed nd ssoited with high levels of ntionl spending, our results my not e generlizle to other proedures not inluded in our nlysis. Also, while the dt used for our nlyses were from one of the lrgest privte insurne dt soures, the dt did not inlude ll privte pyers nd re not neessrily representtive of the privte helth insurne mrket in the United Sttes. As suh, our findings my not e generlizle to this roder privte helth insurne mrket. For exmple, in 2009 nd 2010, the perentge of enrollees in the dt were disproportiontely from lrge self-insured firms, whih tend to hve more generous enefit pkges ompred with other pyers, nd they were lso disproportiontely from the South. Finlly, 2009 nd 2010 dt do not reflet the impt of more reent poliy or other hnges potentilly ffeting privte setor helth re spending, suh s the implementtion of the Ptient Protetion nd Affordle Cre At. We onduted our work from Jnury 2012 to Deemer 2014 in ordne with ll setions of GAO s Qulity Assurne Frmework tht re relevnt to our ojetives. The frmework requires tht we pln nd perform the enggement to otin suffiient nd pproprite evidene to meet our stted ojetives nd to disuss ny limittions in our work. We elieve tht the informtion nd dt otined, nd the nlysis onduted, provide resonle sis for ny findings nd onlusions in this produt. Bkground Privte setor dt hve eome inresingly ville to reserhers, nd severl studies hve estlished tht signifint geogrphi vrition in spending exists in the privte setor. For exmple, in reent omprehensive ssessment of geogrphi vrition in privte setor spending, the Institute of Mediine (IOM) reported on the presene of sustntil spending vrition, onluding tht lrge mount of the 16 We did not report the nmes of ertin MSAs to protet the onfidentility of entities ontriuting privte dt to the MrketSn dtse. Pge 6 GAO Geogrphi Vrition in Spending

12 vrition remined unexplined fter djusting for enrollee demogrphi nd helth sttus ftors, insurne pln ftors, nd mrket-level ftors, nd suggesting tht ineffiieny is one of the uses of the urrent levels of vrition. 17 Using privte setor lims dt from two ntionwide dtses from 2007 through 2009, IOM found undjusted spending for the re t the 90th perentile ws 36 to 42 perent higher thn the re t the 10th perentile, depending on the dtse used. 18 The spending differenes existed t ll levels of geogrphy IOM studied, inluding MSAs, nd these differenes persisted over time. IOM lso found tht prie is mjor determinnt of geogrphi vrition in the privte setor, nd estimted tht, fter djusting for underlying osts, prie ounted for 70 perent of the geogrphi vrition in privte setor spending. The reserhers ttriuted the lrge impt of prie in explining privte setor geogrphi spending vrition to the reltively strong mrket power of providers in some res. Other studies, inluding one y GAO, hve rehed similr onlusions. The Medire Pyment Advisory Commission (MedPAC) exmined geogrphi vrition in privte setor spending nd estimted tht in 2008, hospitl inptient spending for the MSA t the 90th perentile ws perent higher thn for the MSA t the 10th perentile. MedPAC lso found tht spending for physiin servies vried, ut less so thn hospitl inptient spending. Physiin spending t the 90th perentile ws 50 perent higher thn tht t the 10th perentile. Erly work y GAO nlyzing 2001 privte setor lims in the Federl Employees Helth 17 See Institute of Mediine, Vrition in Helth Cre Spending: Trget Deision Mking, Not Geogrphy (Wshington, D.C.: The Ntionl Ademies Press, July 24, 2013). Helth sttus ws ounted for y IOM using dignosis informtion reorded on lims; insurne pln ftors inluded mesures suh s enefit generosity nd pln type; nd mrket-level ftors inluded mesures suh s hospitl ompetition, pyer mix, nd perentge of popultion uninsured. 18 To do this work, IOM ommissioned originl nlyses of puli nd privte pyer dtses, nd foused on desriing nd ounting for geogrphi vrition in helth re spending, utiliztion, nd qulity for the overll popultion, s well s for popultions with speifi diseses or onditions. IOM ontrtors quntified geogrphi vrition in spending, utiliztion, nd qulity ross vrious popultions, pyers, nd geogrphi units; identified types of helth re servies with disproportiontely high rtes of vrition; nd identified ftors tht drove vrition, suh s enrollee helth sttus nd demogrphi hrteristis, helth pln, nd prie nd mrket ftors, mong other things. 19 Medire Pyment Advisory Commission, Chpter 7, Vrition in privte-setor pyment rtes, in Report to the Congress: Medire nd the Helth Cre Delivery System (June 15, 2011). Pge 7 GAO Geogrphi Vrition in Spending

13 Benefits Progrm lso found sustntil geogrphi vrition in privte setor hospitl inptient pries, physiin pries, nd spending. 20 IOM lso found tht res with reltively high pries tended to hve reltively low utiliztion nd vie vers. In ddition, IOM found tht privte setor utiliztion vried more for some servie types thn others. For exmple, emergeny deprtment use ws 50 to 100 perent higher for the re t the 90th perentile of utiliztion reltive to the 10th perentile, nd hospitl outptient visits were 30 to 46 perent higher. In ddition, onsistent with other reserh, use of disretionry servies vried sustntilly. For exmple, the utiliztion rte for hip replement, onsidered disretionry proedure, for the re t the 90th perentile ws 53 perent higher thn the re t the 10th perentile, nd other disretionry proedures, suh s hysteretomies, lower k surgeries, nd nuler stress tests, hd even lrger differenes. 21 Reserhers from the Ntionl Institute for Helth Cre Reform reently exmined geogrphi vrition in spending for hip nd knee replement episodes of re using 2011 lims dt for utoworkers nd their dependents in nine geogrphi res in six sttes. 22 They defined episodes s those eginning with hospitl dmission nd inluding ll servies up to 30 dys postdishrge. Averge spending per episode ross the nine mrkets rnged from elow $25,000 in Louisville, Kentuky, to ove $30,000 in Bufflo, New York. 23 However, vrition ross the 36 hospitls within these mrkets vried more thn twofold, 20 GAO, Federl Employees Helth Benefits Progrm: Competition nd Other Ftors Linked to Wide Vrition in Helth Cre Pries, GAO (Wshington, D.C.: Aug. 15, 2005). 21 These findings pper in suontrtor report ommissioned y IOM. See Mihel MKellr et l., Geogrphi Vrition in Helth Cre Spending, Utiliztion, nd Qulity mong the Privtely Insured, speil report prepred t the request of The Institute of Mediine Committee on Geogrphi Vrition in Helth Cre Spending nd Promotion of High-Vlue Cre (Boston, Mss.: Hrvrd Medil Shool Deprtment of Helth Cre Poliy, Aug. 29, 2012). 22 Chpin White, Jmes D. Reshovsky, nd Ameli M. Bond, Inptient Hospitl Pries Drive Spending Vrition for Episodes of Cre for Privtely Insured Ptients, Brief No. 14 (Wshington, D.C.: Ntionl Institute for Helth Cre Reform, Ferury 2014). 23 The mrkets in this nlysis inluded Louisville, Kentuky; Clevelnd, Ohio; Lnsing, Mihign; Flint, Mihign; Wrren, Mihign; Detroit, Mihign; Knss City, Missouri; Indinpolis, Indin; nd Bufflo, New York. Pge 8 GAO Geogrphi Vrition in Spending

14 nd ll ut one of the mrkets hd lower-spending hospitl option, defined s hving verge episode spending elow $25,000. To get roder mesure of vrition in episode spending, these reserhers lso exmined ll episode types ross hospitls. The spending vritions oserved for knee nd hip replements held true for other onditions, nd hospitls with high spending for one servie line (rdiology, orthopedis, et.) were lso likely to hve high spending for other servie lines. In ddition, the prie of the initil hospitl sty ounted for more thn 80 perent of the vrition in overll spending. Vrition in the pries nd volume of physiin nd other servies together ounted for less thn one-tenth of the vrition in episode spending. These reserhers noted tht resons for higher-pried hospitls in some res inluded their provision of speilized servie lines tht other nery hospitls did not offer, eing prt of lol hospitl system with greter rgining lout, hving unusully good linil reputtions, nd eing prt of lrge tehing hospitl. Episode Spending Ws 74 to 94 Perent Higher in Highest- Compred with Lowest-Spending Ares, with High- Spending Ares Generlly High for All Three Proedures Episode Spending Ws 74 to 94 Perent Higher in the Highest- Compred with Lowest-Spending Ares, Depending on Proedure We noted vrition in episode spending ross MSAs for ll three proedures, even fter djusting for geogrphi differenes in the ost of doing usiness nd differenes in demogrphis nd helth sttus of enrollees in eh MSA. For exmple, verge djusted episode spending ross ll MSAs in our nlysis for lprosopi ppendetomy ws $12,506; however, MSAs in the highest-spending quintile hd verge djusted episode spending of $17,047, whih ws lmost 94 perent higher thn the verge djusted episode spending of $8,802 for MSAs in the lowest-spending quintile. Averge djusted episode spending for this proedure for individul MSAs rnged from $25,924 in Slins, Cliforni, Pge 9 GAO Geogrphi Vrition in Spending

15 to $6,166 in Joplin, Missouri. We found similr results for the other two proedures we studied, oronry stent plement nd totl hip replement. Averge djusted episode spending for MSAs in the highest-spending quintile ws out 84 perent nd 74 perent higher thn for MSAs in the lowest-spending quintile, respetively. (See fig. 1; lso, see pp. II for omplete rnkings of MSAs y proedure.) We found greter geogrphi vrition in verge episode spending thn the reserh from the Ntionl Institute for Helth Cre Reform, likely euse our study inluded mny more geogrphi res. 24 For ll three proedures, djustments to ontrol for geogrphi differenes in the ost of doing usiness nd for differenes in demogrphis nd helth sttus of enrollees redued the extent of vrition in spending ross MSAs. For exmple, efore djustment, verge episode spending for lprosopi ppendetomy in the highestspending MSA (Slins, Cliforni) ws 511 perent higher thn the lowest-spending MSA (Joplin, Missouri); nd, fter djustment, spending ws 320 perent higher. 24 The Ntionl Institute for Helth Cre Reform study inluded nine res. IOM lso reported less geogrphi vrition in privte setor spending per enrollee ompred to our episode spending. Our study, with its fous on three hospitl-sed, surgil episodes of re, likely hd different omposition of utiliztion of servies (mix, quntity, nd intensity) nd pries, ompred to the IOM s mesure of totl spending sine not ll servies provided in medil prties re ssoited with inptient dmissions or surgil proedures. Pge 10 GAO Geogrphi Vrition in Spending

16 Figure 1: Distriution of Averge Episode Spending Aross Metropolitn Sttistil Ares (MSA) Intertivity instrutions: Roll over on one of the three proedures to see dt. See ppendix III for dditionl detils. Coronry stent plement Lprosopi ppendetomy Totl hip replement Frequeny of MSAs Quintile omprisons Vlue in dollrs 40,000 Highest quintile: $39, , perent higher 35 Averge for ll MSAs: $29,647 20,000 Lowest quintile: $21, ,000 Averge episode spending to 2,500 2,501 to 5,000 5,001 to 7,500 7,501 to 10,000 10,001 to 12,500 12,501 to 15,000 15,001 to 17,500 22,501 to 25,000 25,001 to 27,500 27,501 to 30,000 30,001 to 32,500 17,501 to 20,000 20,001 to 22,500 32,501 to 35,000 35,001 to 37,500 37,501 to 40,000 40,001 to 42,500 42,501 to 45,000 45,001 to 47,500 47,501 to 50,000 50,001 to 52,500 52,501 to 55,000 55,001 to 57,500 57,501 to 60,000 60,001 to 62,500 Averge episode spending per MSA in dollrs Soure: GAO nlysis of 2009 nd 2010 lims dt from Truven Helth Anlytis. GAO Note: Dt were from 155 MSAs for oronry stent plement episodes, 139 MSAs for lprosopi ppendetomy episodes, nd 141 MSAs for totl hip replement episodes. For eh proedure, we inluded ll MSAs for whih we hd suffiient numer of episodes to support our nlyses. Spending ws djusted to ontrol for geogrphi differenes in the ost of doing usiness nd differenes in demogrphis nd helth sttus of enrollees in eh MSA. Pge 11 GAO Geogrphi Vrition in Spending

17 High-Spending Ares Generlly Were High- Spending for All Three Proedures MSAs with higher spending on one proedure generlly hd higher spending on the other two proedures. For exmple, Slins, Cliforni, nd Fort Wyne, Indin, were mong the highest-spending MSAs for ll three proedures, while Hrtford, Connetiut, nd Youngstown, Ohio, were mong the lowest-spending MSAs for ll three proedures. We exmined verge djusted episode spending in the 78 MSAs tht hd suffiient numer of episodes for ll three proedures nd found tht the extent of orreltion for eh pir of proedures for the 78 MSAs rnged from 0.68 to 0.83, 25 onsistent with the reserh from the Ntionl Institute for Helth Cre Reform. 26 (See fig. 2.) 25 The orreltion oeffiient ptures the reltionship etween two vriles of interest nd tkes vlue etween negtive 1 nd 1. A orreltion oeffiient of 0 would indite tht there ws no reltionship etween the vriles. A orreltion oeffiient lose to 1 would indite strong positive reltionship, while orreltion oeffiient lose to negtive 1 would indite strong negtive reltionship. 26 Reserhers t the Ntionl Institute for Helth Cre Reform found orreltion of 0.68 when ompring hospitls spending on knee nd hip replements to spending ross ll types of episodes, nd found orreltion of 0.80 when ompring rdiology episodes to ll episodes. They onluded tht high-spending hospitl for one episode type is lso likely to hve high spending for other episode types. IOM lso studied this issue y onduting n episode-sed nlysis on suset of onditions nd, lthough finding orreltion, the extent of the orreltion depended on onditions exmined. For exmple, the orreltion etween episode spending for dietes nd oronry hert disese ws 0.79, ut the orreltion etween spending on stroke nd prostte ner ws Pge 12 GAO Geogrphi Vrition in Spending

18 Figure 2: Correltion of Averge Episode Spending etween Proedures Note: All orreltions shown re signifint t p< Dt were from 78 MSAs. We inluded ll MSAs with suffiient numer of episodes to support our nlyses for ll three proedures. Spending ws djusted to ontrol for geogrphi differenes in the ost of doing usiness nd differenes in demogrphis nd helth sttus of enrollees in eh MSA. Pge 13 GAO Geogrphi Vrition in Spending

19 Despite the overll pttern tht MSAs tended to e in the sme spending quintiles for ll three proedures, there were some exeptions. Notly, Alny, New York, ws in the highest-spending quintile for oronry stent plement nd totl hip replement ut ws in the lowest-spending quintile for lprosopi ppendetomy; Sn Antonio, Texs, ws in the highest-spending quintile for totl hip replement ut ws in the lowestspending quintile for lprosopi ppendetomy; nd Allentown, Pennsylvni, ws in the highest-spending quintile for oronry stent plement ut ws in the lowest-spending quintile for totl hip replement. We lso exmined whether high- or low-spending MSAs were onentrted in prtiulr regions of the ntion, nd we found tht they were not. 27 For exmple, we found 11 MSAs tht were in the highestspending quintile for t lest two of the three proedures we exmined, nd these MSAs were loted in different regions of the ntion, suh s Alny, New York; Fort Wyne, Indin; Houston, Texs; Mdison, Wisonsin; Milwukee, Wisonsin; Nshville, Tennessee; Slins, Cliforni; nd Sn Diego, Cliforni. In ddition, some sttes hd MSAs in oth the highest- nd lowest-spending quintiles for given proedure. For exmple, in Cliforni, Slins nd Sn Diego were oth in the highest-spending quintile for lprosopi ppendetomy episode spending, wheres Fresno, Oxnrd, Riverside, Sn Jose, nd Snt Ros were ll in the lowest-spending quintile. Similrly, in New York, Alny ws in the highest-spending quintile for totl hip replement, wheres Rohester ws in the lowest-spending quintile. 27 In ddition, we exmined whether the numer of episodes in n MSA hd n effet on verge episode spending for tht MSA, nd did not find evidene of n effet. Pge 14 GAO Geogrphi Vrition in Spending

20 Prie per Initil Inptient Admission Ws Lrgest Contriutor to Geogrphi Differenes in Episode Spending The prie of the initil hospitl inptient dmission ws the lrgest ontriutor to differenes in privte setor episode spending ross MSAs. 28 Differenes in the prie of the initil dmission ounted for 91 perent or more of the differene in verge djusted episode spending etween the lowest- nd highest-spending quintiles. For exmple, for totl hip replement, the differene in verge djusted episode spending in the MSAs in the lowest- nd highest-spending quintiles ws $14,506, nd $13,198 of tht differene or 91 perent ws ttriutle to differenes in the prie of the initil inptient dmission. Similrly, differenes in initil inptient dmission pries ounted for 92 nd 96 perent of the differenes in episode spending etween MSAs in the lowest- nd highest-spending quintiles for oronry stent plement nd lprosopi ppendetomy, respetively (see tle 1). The role of inptient dmission prie s the primry driver of geogrphi differenes in spending in the privte setor hs een reported in the literture, suh s y the Ntionl Institute for Helth Cre Reform. 28 We identified prie s the mount spent on the initil hospitl inptient dmission (whih exluded spending on ny susequent redmissions), euse hospitls re generlly pid one mount per dmission regrdless of the ptient's length of sty or the servies delivered. Pge 15 GAO Geogrphi Vrition in Spending

21 Tle 1: Contriutions of Eh Servie Ctegory to Differenes in Averge Episode Spending etween Metropolitn Sttistil Ares (MSA) in the Lowest- nd Highest- Spending Quintiles Servie tegory Coronry stent plement Hospitl inptient Prie of initil dmission 92% Lprosopi ppendetomy Totl hip replement 96% 91% Hospitl inptient Redmissions 1% 0% 0% Hospitl outptient 1% 1% 1% Postdishrge 0% 0% 0% Professionl 5% 3% 7% Anillry nd unlssified 1% 0% 1% Totl 100% 100% 100% Soure: GAO nlysis of 2009 nd 2010 lims dt from Truven Helth Anlytis. GAO Note: Dt were from 78 MSAs. We inluded ll MSAs with suffiient numer of episodes to support our nlyses for ll three proedures. For eh proedure, the lowest- nd highest-spending quintiles eh onsist of 16 MSAs. Pries nd spending were djusted to ontrol for geogrphi differenes in the ost of doing usiness nd differenes in demogrphis nd helth sttus of enrollees in eh MSA. We identified prie s the mount spent on the initil hospitl inptient dmission (whih exluded spending on ny susequent redmissions), euse hospitls re generlly pid one mount per dmission regrdless of the ptient s length of sty or the servies delivered. In ddition, mesures of intensity for hospitl inptient spending suh s dignosis-relted groups re ssigned sed on the ptient s linil ondition. Insted, we reported pries djusted for differenes in demogrphis nd helth sttus of enrollees in eh MSA. The prie of the initil inptient dmission ontriuted most to geogrphi differenes in verge djusted episode spending for two resons. First, the prie of the initil dmission represented the lrgest perentge of djusted episode spending. For the lowest- nd highest-spending quintiles in eh of the three proedures, t lest two-thirds of episode spending ws for the prie of the hospitl inptient dmission. For exmple, for totl hip replement, the prie of the initil dmission ws $17,134, representing 76 perent of the $22,463 in totl episode spending for MSAs in the lowest-spending quintile nd $30,332, representing 82 perent of the $36,969 in totl episode spending for MSAs in the highest-spending quintile. Seond, the verge prie of the Pge 16 GAO Geogrphi Vrition in Spending

22 initil inptient dmission vried onsiderly ross MSAs. 29 The differene in the prie of the initil inptient dmission in MSAs in the lowest- nd highest-spending quintiles rnged from 77 perent to 121 perent, depending on the proedure. For exmple, for lprosopi ppendetomy, the prie of the initil dmission ws 121 perent higher for MSAs in the highest-spending quintile ompred with MSAs in the lowest-spending quintile (see fig. 3). Speifilly, MSAs in the highestspending quintile hd n verge prie of $13,177 for the initil dmission nd rnged from $11,087 in Colordo Springs, Colordo, to $23,432 in Slins, Cliforni wheres MSAs in the lowest-spending quintile hd n verge prie of $5,971 for the initil dmission nd rnged from $4,528 in Ls Vegs, Nevd, to $7,430 in Sn Antonio, Texs. (See pp. IV for verge djusted episode spending y proedure nd servie tegory, nd pp. V for omplete rnkings of hospitl inptient spending, initil dmission prie, nd numer of dys y MSA nd proedure.) 29 There ws little or no differene ross MSAs in the numer of dys in the initil dmission. The verge numer of dys ws 2.32 in the lowest-spending quintile nd 2.31 in the highest-spending quintile for oronry stent plement, 1.71 nd 1.53 for lprosopi ppendetomy, nd 2.87 nd 2.91 for totl hip replement. Hospitl inptient pries generlly over ll hospitl servies during n inptient dmission regrdless of the length of sty or the servies delivered, so there is no finnil inentive for hospitls to keep ptients for dditionl dys in n inptient setting. Pge 17 GAO Geogrphi Vrition in Spending

23 Figure 3: Averge Pries of Initil Hospitl Inptient Admissions for Metropolitn Sttistil Ares (MSA) in the Lowest- nd Highest-Spending Quintiles Note: Dt were from 78 MSAs. We inluded ll MSAs with suffiient numer of episodes to support our nlyses for ll three proedures. For eh proedure, the lowest- nd highest-spending quintiles eh onsist of 16 MSAs. Pries nd spending were djusted to ontrol for geogrphi differenes in the ost of doing usiness nd differenes in demogrphis nd helth sttus of enrollees in eh MSA. Pries nd spending my not dd to totls euse of rounding. Although professionl servies offie visits, hospitl onsulttions, surgeries, nd other servies provided y physiin or other helth professionl were the seond lrgest ontriutor to geogrphi differenes in verge djusted episode spending, they ontriuted to muh smller extent thn did the prie of the initil inptient dmission. For eh of the three proedures, differenes in spending on professionl servies ounted for only 3 to 7 perent of the differene in overll episode spending etween MSAs in the lowest- nd highest-spending quintiles. First, professionl servies ontriuted smller mount to geogrphi differenes in episode spending euse they represented muh smller perentge of episode spending thn the prie of the initil inptient dmission. For MSAs in the lowest- nd highest-spending Pge 18 GAO Geogrphi Vrition in Spending

24 quintiles in eh of the three proedures, 10 to 29 perent of episode spending ws for professionl servies. For exmple, for totl hip replement, spending on professionl servies ws $4,157, representing 19 perent of the $22,463 in totl episode spending for MSAs in the lowest-spending quintile nd $5,221, representing 14 perent of the $36,969 in totl episode spending for MSAs in the highest-spending quintile. Seond, professionl servies ontriuted smller mount to geogrphi differenes in episode spending euse spending on professionl servies vried less ross MSAs. Spending on professionl servies for MSAs in the highest-spending quintile ws etween 8 perent nd 26 perent higher thn in the lowest-spending quintile, depending on the proedure (see fig. 4). 30 Overll, spending on professionl servies rnged widely for exmple, from $3,110 in Akron, Ohio, to $9,794 in Mdison, Wisonsin, for totl hip replement. (See pp. IV for verge djusted episode spending y proedure nd servie tegory, nd pp. VI for omplete rnkings of professionl servies spending, numer of servies, intensity, nd prie y MSA nd proedure.) 30 MSAs in the lowest- or highest-spending quintiles did not neessrily hve spending on professionl servies tht oinided with these quintiles. For exmple, for eh of the three proedures, Sn Jose, Cliforni, hd level of spending on professionl servies tht ws mong the 10 highest-spending MSAs, even though it ws not in the highestspending quintile for episode spending for ny proedure. In ontrst, Mdison, Wisonsin, hd the highest or seond-highest level of spending on professionl servies for ll three proedures nd ws lso in the highest-spending quintile for episode spending for ll three proedures. Pge 19 GAO Geogrphi Vrition in Spending

25 Figure 4: Averge Spending on Professionl Servies in Metropolitn Sttistil Ares (MSA) in the Lowest- nd Highest-Spending Quintiles Note: Dt were from 78 MSAs. We inluded ll MSAs with suffiient numer of episodes to support our nlyses for ll three proedures. For eh proedure, the lowest- nd highest-spending quintiles eh onsist of 16 MSAs. Spending ws djusted to ontrol for geogrphi differenes in the ost of doing usiness nd differenes in demogrphis nd helth sttus of enrollees in eh MSA. Spending my not dd to totls euse of rounding. When we exmined how volume, intensity, nd pries ontriuted to differenes in spending on professionl servies, we found tht for ll three proedures servies in MSAs in the highest-spending quintile hd higher verge pries nd higher verge intensity thn servies in MSAs in the lowest-spending quintile, with prie hving greter impt thn intensity. However, MSAs in the highest-spending quintile used fewer servies thn MSAs in the lowest-spending quintile, somewht offsetting the impt of pries on spending. For exmple, for oronry stent plement, MSAs in the highest-spending quintile hd $791 more in spending, 11.4 perent lower volume, 4.0 perent higher intensity, nd 39.8 perent higher pries, ompred to MSAs in the lowest-spending quintile (see tle 2). (See lso pp. VI for omplete rnkings of Pge 20 GAO Geogrphi Vrition in Spending

26 professionl servies spending, numer of servies, intensity, nd prie y MSA nd proedure.) These findings re onsistent with our finding on hospitl inptient spending nd with existing reserh on privte setor dt, whih hs generlly found tht vrition in pries drives overll vrition in spending ross geogrphi res. While high-pried res tend to hve lower utiliztion nd vie vers, the vrition in pries hs lrger effet. Tle 2: Professionl Servies: Differene in Averge Spending, Volume, Intensity, nd Prie Comprison of verges for MSAs in highest- nd lowest-spending quintiles Volume Proedure Adjusted spending (numer of servies) Intensity Prie per unit of intensity Coronry stent plement $791 higher 11.4% lower 4.0% higher 39.8% higher Lprosopi ppendetomy $191 higher 12.6% lower 7.3% higher 14.4% higher Totl hip replement $1,064 higher 14.8% lower 12.5% higher 33.4% higher Soure: GAO nlysis of 2009 nd 2010 lims dt from Truven Helth Anlytis. GAO Note: Dt were from 78 MSAs. We inluded ll MSAs with suffiient numer of episodes to support our nlyses for ll three proedures. For eh proedure, the lowest- nd highest-spending quintiles eh onsist of 16 MSAs. Spending, volume, nd intensity were djusted to ontrol for geogrphi differenes in demogrphis nd helth sttus of enrollees in eh MSA; spending ws lso djusted for differenes in the ost of doing usiness. Intensity is mesured y the reltive vlue unit (RVU) ssigned to eh servie. Ageny Comments We provided drft of this produt to the Deprtment of Helth nd Humn Servies, whih did not omment on our findings ut provided tehnil omments. We inorported these tehnil omments s pproprite. As greed with your offie, unless you pulily nnoune the ontents of this report erlier, we pln no further distriution until 30 dys from the report dte. At tht time, we will send opies to the Seretry of Helth nd Humn Servies nd the Administrtor of the Centers for Medire & Mediid Servies. In ddition, the report is ville t no hrge on the GAO wesite t Pge 21 GAO Geogrphi Vrition in Spending

27 If you or your stff hve ny questions out this report, plese ontt me t (202) or Contt points for our Offies of Congressionl Reltions nd Puli Affirs my e found on the lst pge of this report. GAO stff who mde mjor ontriutions to this report re listed in ppendix VII. Sinerely yours, Jmes Cosgrove Diretor, Helth Cre Pge 22 GAO Geogrphi Vrition in Spending

28 Appendix I: Dt nd Appendix I: Dt nd Methods This ppendix desries the dt nd methods we used in our study. Creting Episodes of Cre from Privte Helth Insurne Clims Dt We reted episodes of re sed on inptient dmissions for three proedures oronry stent plement, lprosopi ppendetomy, nd totl hip replement 1 using privte helth insurne lims nd enrollment dt from the Truven Helth Anlytis MrketSn Commeril Clims nd Enounters Dtse for 2009 nd We identified proedures sed on the presene of speifi proedure odes in the hospitl inptient nd professionl servie lims. 3 We seleted these proedures euse they were ommonly performed in the yers we nlyzed nd were ssoited with high levels of ntionl spending in the MrketSn dtse. In ddition, we seleted proedures tht were generlly provided y different medil speilties, 4 nd we seleted 1 Coronry stent plement, lso known s perutneous trnsluminl oronry ngioplsty, is surgil rdiology proedure to open loked oronry rtery nd insert stent (n expndle metl oil) into the newly opened rtery to help prevent renrrowing or relosure. Lprosopi ppendetomy is generl surgil proedure to remove n infeted ppendix using instruments pled into smll dominl inisions. Totl hip replement, lso known s totl hip rthroplsty, is surgil orthopedi proedure where rtilge nd one from the hip joint re repled with prostheti omponents. 2 The MrketSn dtse ontins lims for over 50 million enrollees pid y over 100 privte insurers ross 50 sttes nd the Distrit of Columi in 2009 nd For oronry stent plement, we identified enrollees with lims with prinipl hospitl proedure ode for perutneous trnsluminl oronry ngioplsty or for oronry theretomy nd professionl proedure ode for inserting n introronry stent, nd we exluded enrollees with lims tht indited plement of stent in more thn one rtery. For lprosopi ppendetomy, we identified enrollees with prinipl hospitl proedure ode nd professionl proedure ode for lprosopi ppendetomy, nd we exluded enrollees with lims tht indited extr work or dditionl proedures. For totl hip replement, we identified enrollees with lims with prinipl hospitl proedure ode for totl hip replement nd professionl proedure ode for totl hip rthroplsty, nd we exluded enrollees with lims tht indited ilterl proedures. 4 These proedures lso hve high levels of volume mong ll ptients. For exmple, ording to the Helthre Cost nd Utiliztion Projet, whih inludes dt for ll privtely insured, Medire, Mediid, uninsured, nd ll other ptients, these 3 proedures were mong the 20 proedures with the most dishrges in During tht yer, there were pproximtely 614,000 dishrges for oronry stent plement, pproximtely 200,000 dishrges for lprosopi ppendetomy, nd pproximtely 274,000 dishrges for totl hip replement. Pge 23 GAO Geogrphi Vrition in Spending

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