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ACCOUNTABLE CARE ORGANIZATIONS: It is cost effective to have specialists see patients, up to a point

Some specialist involvement in care processes for patients appears to be necessary for accountable care organizations to lower their costs.”

Health care spending in accountable care organizations (ACOs) was studied based on the percent of patient visits which were provided by specialists.  Data from 620 ACOs for the period April 2012 through September 2017 were analyzed.  It was found that ACOs in which specialists provided 40 to 45 percent of office visits had the lowest expenditures.  ACOs at either extreme – the fewest or the most specialist encounters – had the highest expenditure rates.

Source: Shetty, V.A., Balzer, L.B., Geissler, K.H., and Chin, D.L. (2019, July 10). Association between specialist office visits and health expenditures in accountable care organizations. JAMA Network Open, 2(7).  Click here for free full text:  https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2737841  Posted by AHA Resource Center (312) 422-2050 rc@aha.org

COST OF HEALTH CARE: Specialist visits to hospitalized Medicare patients cost over $1.3 billion in 2014

What is the cost to the nation to bring in specialists to consult on hospitalized Medicare patients?  This question was studied based on analysis of over 700,000 discharges from over 4500 U.S. hospitals in 2014.  Medicare Part B payment for consultative care was found to represent 41.3 percent of all physician visits during the hospital stays.  The total dollar amount was estimated to be $1.3 billion.  These figures are thought to be underestimates because the patients studied excluded surgical patients and because there was no analysis of downstream costs – such as additional diagnostic testing and follow-up visits.  Characteristics of hospitals which were found to be more likely to have higher rates of consultative visits included those in the Northeast, those in urban areas and teaching hospitals.

Source: Ryskina, K.L., Association of Medicare spending with subspecialty consultation for elderly hospitalized adults. JAMA Network Open, 2(4).  Click here for full text:  https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2729802 Posted by AHA Resource Center (312) 422-2050 rc@aha.org

How Well Does Insurance Coverage Protect Consumers from Health Care Costs?

In 2016, over a quarter of insured adults in the U.S. were underinsured — more than double the 2003 rate and and currently an estimated 41 million people. This is the finding from the latest Commonwealth Fund’s biennial health insurance survey that looked at the number of insured adults that had high out-of-pocket expenses and deductibles relative to their incomes.

The underinsured rates were highest [44-47%] for those purchasing individual coverage directly or through a Marketplace exchange and for the disabled under age 65 covered by Medicare.

The share of privately insured adults that had health plans without deductibles has shrunk by nearly half since 2003, while deductible amounts have increased. The number of insured adults with deductibles of $3000 or more has grown from 1% in 2003 to 13% in 2016.

Underinsured adults may defer needed medical care because of the costs and/or face medical debt and long term financial issues.

The survey report also discusses health policy implications of its findings.

Source: Collins SR and others. How well does insurance coverage protect consumers from health care costs? Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016. Commonwealth Fund Issue Brief, Oct. 2017. http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2017/oct/collins_underinsured_biennial_ib.pdf 

Posted by AHA Resource Center (312) 422-2050, rc@aha.org


Average Cost of a Hospital Stay, Emergency Room Visit, Physician or Dental Office Visit, or Home Care Service

In 2014, the mean cost for a hospital stay was $13,450, with an average out-of-pocket expense of $351. That’s according to Medical Expenditures Panel Survey [MEPS] Household Component data available from the Agency for Healthcare Research and Quality.

An emergency room visit averaged $1,048 in 2014, with $95 of that in out-of-pocket expenses.

A hospital outpatient visit expense averaged $927 with a $54 out-of-pocket cost, while an office-based physician visit totaled $222 with $29 out-of-pocket. The mean out-of pocket expense for a dental visit was $132 of the total visit cost of $295.

Finally, home health care expenses averaged $1,454 per month for those who had the expense during the year.

MEPS data on household medical expenditures is also available for earlier years.

Source: Expenditures per event by health care service type. Medical Expenditures Panel Survey, Household Component summary tables, Agency for Healthcare Research and Quality, accessed Feb. 15, 2017 at https://meps.ahrq.gov/mepsweb/data_stats/quick_tables_results.jsp?component=1&subcomponent=0&year=-1&tableSeries=9&searchText=&SearchMethod=1&Action=Search

Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

Health Innovations State Law Database

The Health Innovations State Law Database created by the National Conference on State Legislatures is  a resource for identifying over 800 recently enacted state laws and regulations that address health policy innovations related to access, Medicaid, private and commercial insurance markets, the Accountable Care Act and social determinants of health.. The database supports searching by keyword, state, legislative status, bill number, sponsor, and/or these topics:

  • Exchanges and Health Marketplaces
  • Free Market; Challenges and Alternatives
  • Market-Cost Containment
  • Market-Coverage
  • Market-Delivery Reform [includes accountable care]
  • Market-Health Insurance Reforms
  • Market-Mandates and Essential Health Benefits
  • Market-Network Adequacy
  • Market-Other
  • Market-Payment Reforms
  • Market-Price Transparency
  • Medicaid Expansion and Waivers
  • Medicaid Payment Reform
  • Medicaid-General
  • PPACA – ACA-Health Reforms
  • State-Run Programs
  • Telehealth Programs

However, the full-text of the legislation located is restricted to NCLS members.

Source: Health innovations state law database: tracking state laws for health care transformation, 2015-2016. National Conference of State Legislatures, accessed Jan. 27, 2017. http://www.ncsl.org/research/health/health-innovations-database.aspx

Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

Milliman Medical Index: Average Family Spends $25,000 a Year on Health Care

The new 2016 Milliman Medical Index reports the lowest annual increase rate in health care costs since it started tracking them 15 years ago — it’s now down to 4.7%. That said, health care expenses for a typical American family of four now top $25,000 a year, triple the amount from 15 years earlier in 2001. The fastest growing health care expenditure over the past year was for prescription drugs that account for 17% of all family health care costs.

The $25,826 average annual family medical costs are allocated into these three categories:

  1. Employer subsidy to health plan: $14,793 [57%]
  2. Employee contribution to health plan: $6,717 [26%]
  3. Employee out-of-pocket: $4,316 [17%]

Source: Girod C and others. 2016 Milliman medical index. Milliman, 2016. http://www.milliman.com/uploadedFiles/insight/Periodicals/mmi/2016-milliman-medical-index.pdf

Posted by AHA Resource Center (312) 422-2050, rc@aha.org

CANCER: $158 billion cost of cancer care in 2020

Cancer treatment is expensive.  The National Cancer Institute estimates that cancer care costs will increase from $125 billion in 2010 to $158 billion in 2020.  This is partly due to the aging of the population, to better control of other serious diseases, and to the development of new chemotherapy and other treatment options.  Among the reasons that the trend toward costly chemotherapy is expected to continue to escalate is that oncology drugs are being used in combination.  There is one newly approved combined treatment for advanced melanoma that is expected to cost the patient $250,000 or so in the first year.  Yes, you read it right – a quarter of a million dollars.

The American Society of Clinical Oncology has published a framework that can be used to assess how valuable a cancer treatment might be.  The framework is intended to be used by the patient and the physician together in partnership to help establish the cost-benefit of different options.


Schnipper, L.E., and others. (2015). American Society of Clinical Oncology statement: A conceptual framework to assess the value of cancer treatment options. Journal of Clinical Oncology. Click here : http://jco.ascopubs.org/content/early/2015/06/16/JCO.2015.61.6706.full.pdf

Gittlen, S. (2016, Jan.-Feb.). Cancer: Aligning costs and care. HealthLeaders, 19(1), 47-50. Click here for the magazine http://www.healthleadersmagazine-digital.com/healthleadersmagazine/january_february_2016?pg=1#pg1  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

Health Care Consumerism: Spending on Shoppable Services

A new report from the Health Care Cost Institute suggests that providing consumers with pricing to help them shop for health care may only have a modest impact on reducing overall health expenditures. Less than 7% of health expenditures are paid for by consumers for shoppable services.

Here are some numbers from the HCCI study:

  • About 43% of the $524.2 billion spent in 2011 on health care for the privately insured was considered shoppable.
  • Roughly a quarter of the privately insured population does not have a claim during a given year.
  • Around 15%, or almost $81 billion, was spent out of pocket on health care by privately insured consumers.
  • Of the out-of-pocket spending, $37.7 billion [7%] was spent on shoppable services.
  • Coinsurance and deductibles made up about three quarters of out-of-pocket shoppable spending.
  • Most out-of-pocket shoppable dollars [44%] were for ambulatory doctor services.

While price and quality information is important and should be available to consumers, it may be unrealistic to expect that it will drive major market changes. The HCCI analysis found less price variation for outpatient than for inpatient services, and the more shoppable outpatient services generally are lower-priced to start with. While consumers with serious health conditions or high deductibles could realize significant savings, there may be little value for many consumers to shop when there is minimal price variation.

The report concludes that one should be realistic about the power of consumers to control health care costs. Instead, it recommends efforts be focused directly on providers and payers who are better positioned to put downward pressure on prices.


Spending on shoppable services in health care. Health Care Cost Institute, Issue Brief #11, Mar. 2016. http://www.healthcostinstitute.org/files/Shoppable%20Services%20IB%203.2.16.pdf

Frost A and others. Health care consumerism: can the tail wag the dog? Health Affairs Blog, Mar. 2. 2016. http://healthaffairs.org/blog/2016/03/02/health-care-consumerism-can-the-tail-wag-the-dog-2/

Related sources:

White C; Eguchi M. Reference pricing: a small piece of the health care price and quality puzzle. National Institute for Health Care Reform, Research Brief 18, Oct. 2014. http://www.nihcr.org/Reference-Pricing2

Price transparency efforts accelerate: what hospitals and other stakeholders are doing to support consumers. American Hospital Association, Trendwatch, July 2014. http://www.aha.org/research/reports/tw/14july-tw-transparency.pdf

White C and others. Healthcare price transparency: policy approaches and estimated impacts on spending. West Health Policy Center, Policy Analysis, May 2014. http://www.westhealth.org/wp-content/uploads/2015/05/Price-Transparency-Policy-Analysis-FINAL-5-2-14.pdf

Muir MA and others. Clarifying costs: can increased price transparency reduce healthcare spending? William & Mary Policy Review 4: 319-366, 2013. https://www.wm.edu/as/publicpolicy/wm_policy_review/archives/volume-4/volume-4-issue-2/MuirAlessiKing_s13f.pdf

Posted by AHA Resource Center (312) 422-2050, rc@aha.org

What’s the Average Cost of an ER Visit? December 2015 Update

The average cost for an emergency room visit in the nation for 2013 was $1423, while the median cost was $703. Regionally in the U.S., costs were higher in the South and West and lower in the Northeast and Midwest:

  • Northeast: $1328 mean, $648 median
  • Midwest: $1372 mean, $639 median
  • South: $1487 mean, $752 median
  • West: $1452 mean, $$719 median

Other data from the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey include ER expense data by patient age, gender, race/ethnicity, health insurance status, income status, and perceived health status. Based on the population sample used in the survey, 13.4% of the national population had emergency room expenses in 2013.

Source: Medical expenditure panel survey, household, table 6: emergency room service-median and mean expenses per person with expense and distribution of expenses by source of payment: United States, 2013, facility and SBD expenses. Agency for Healthcare Research and Quality, latest table generated online, Dec. 30, 2015 at http://meps.ahrq.gov/mepsweb/data_stats/tables_compendia_hh_interactive.jsp?_SERVICE=MEPSSocket0&_PROGRAM=MEPSPGM.TC.SAS&File=HCFY2013&Table=HCFY2013%5FPLEXP%5FE&VAR1=AGE&VAR2=SEX&VAR3=RACETH5C&VAR4=INSURCOV&VAR5=POVCAT13&VAR6=REGION&VAR7=HEALTH&VARO1=4+17+44+64&VARO2=1&VARO3=1&VARO4=1&VARO5=1&VARO6=1&VARO7=1&_Debug=

Posted by AHA Resource Center (312) 422-2050 rc@aha.org

Five Most Costly Medical Conditions Among Children and Adults

According to data from the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey [MEPS], the five costliest conditions for children under age 18 are:

  1. Mental disorders
  2. Chronic obstructive pulmonary disease and asthma
  3. Trauma-related disorders
  4. Acute bronchitis and upper respiratory infections
  5. Infectious diseases

For the adult population, these are the five most expensive conditions:

  1. Trauma-related disorders
  2. Cancer
  3. Mental disorders
  4. Heart conditions
  5. Arthritis and other non-traumatic joint disorders


Soni A. Top five most costly conditions among children, ages 1-17, 2012: estimates for the U.S. civilian noninstutionalized population. MEPS Statistical Brief, April 2015. http://meps.ahrq.gov/mepsweb/data_files/publications/st472/stat472.pdf

Soni A. Top five most costly conditions among adults age 18 and older, 2012: estimates for the U.S. civilian noninstutionalized population. MEPS Statistical Brief, April 2015. http://meps.ahrq.gov/mepsweb/data_files/publications/st471/stat471.pdf

Posted by AHA Resource Center (312) 422-2050 rc@aha.org