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Interstate Comparison: Medical Claim Costs and Utilization by Provider Type, 2004/2005 Claims with More Than 7 Days of Lost Time, Adjusted for Injury and Industry Mix (12 months' average maturity)

Measure	AR	CA^a	FL	IL^b	IN	LA	MA	MD	MI	NC	PA	TN	TX	WI	14-State Median^c
Physician
Percentage of medical payments	34%	43%	35%	37%	36%	33%	34%	32%	33%	29%	28%	35%	32%	32%	34%
Percentage of all claims	96%	95%	97%	92%	91%	97%	90%	93%	92%	96%	93%	96%	96%	87%	94%
Average medical payment per claim	$2,510	$2,994	$2,952	$4,767	$3,906	$3,286	$1,633	$1,992	$2,220	$2,592	$2,129	$3,822	$3,034	$3,760	$2,973
Index of per claim utilization	98	116	107	111	102	108	69	99	90	101	98	99	119	79	100
Average number of visits per claim	9.1	13.5	10.0	11.6	9.3	9.8	7.0	9.1	9.5	9.6	9.9	9.1	11.9	8.2	9.5
Average number of services per visit^d	2.4	2.6	2.3	2.5	2.2	2.4	1.8	2.2	2.3	2.2	2.3	2.2	2.6	2.0	2.3
Index of average prices	110	86	101	186	150	110	99	80	97	99	94	144	87	205	100
Average payment per visit	$266	$218	$290	$409	$415	$326	$235	$216	$234	$266	$214	$406	$252	$461	$266
Chiropractor
Percentage of medical payments	0%	7%	0%	2%	0%	1%	2%	2%	1%	0%	3%	0%	16%	2%	1%
Percentage of all claims	3%	20%	3%	8%	2%	5%	8%	7%	3%	2%	8%	3%	27%	11%	6%
Average medical payment per claim	$1,003	$2,209	$1,005	$2,526	$842	$1,664	$1,193	$1,466	$1,275	$914	$2,557	$973	$5,116	$1,755	$1,371
Index of per claim utilization	72	170	102	140	55	n/a^e	123	147	92	76	191	68	316	98	102
Average number of visits per claim	9.5	21.7	13.2	20.4	9.3	15.0	20.0	19.2	15.2	11.1	24.0	9.5	27.9	18.0	16.6
Average number of services per visit^d	3.1	3.3	3.7	3.5	2.7	n/a^f	2.8	3.5	2.6	3.4	3.6	3.4	4.3	2.5	3.4
Index of average prices^g	102	97	79	138	100	130	66	77	104	89	99	100	129	125	100
Average payment per visit	$105	$98	$74	$122	$91	$107	$60	$75	$84	$77	$107	$108	$181	$97	$97
PT/OT
Percentage of medical payments	7%	9%	8%	11%	8%	14%	9%	10%	12%	9%	13%	9%	11%	6%	9%
Percentage of all claims	32%	53%	47%	41%	43%	49%	34%	39%	42%	47%	41%	45%	46%	27%	42%
Average medical payment per claim	$1,477	$1,139	$1,294	$3,232	$1,989	$2,736	$1,177	$1,513	$1,778	$1,706	$2,322	$2,034	$2,119	$2,266	$1,883
Index of per claim utilization	80	69	106	123	81	n/a^e	92	120	92	108	135	96	104	70	96
Average number of visits per claim	13.0	13.7	14.4	16.8	12.5	19.2	14.9	16.8	13.8	15.3	18.8	14.2	14.7	12.2	14.5
Average number of services per visit^d	3.9	3.2	3.6	3.8	3.1	n/a^f	3.5	4.0	3.5	3.8	3.7	3.9	3.5	2.8	3.6
Index of average prices^g	98	85	68	139	124	112	66	67	104	84	96	106	102	158	100
Average payment per visit	$112	$82	$89	$186	$150	$140	$79	$87	$126	$110	$122	$140	$144	$183	$124
Hospital outpatient provider^h
Percentage of medical paymentsⁱ	28%	16%	24%	30%	32%	31%	29%	20%	30%	37%	30%	30%	17%	34%	30%
Percentage of all claimsⁱ	74%	49%	61%	72%	71%	72%	80%	57%	67%	67%	81%	68%	56%	72%	69%
Average medical payment per claimⁱ	$2,764	$2,176	$3,285	$5,102	$4,497	$4,074	$1,648	$1,909	$2,805	$4,905	$2,770	$4,498	$2,761	$4,881	$3,045
Index of per claim utilizationⁱ	99	62	78	119	129	96	89	75	103	101	161	107	87	108	100
Average number of visits per claimⁱ	5.6	3.4	4.1	7.6	7.2	4.8	8.1	3.7	7.0	4.9	9.0	5.3	4.1	8.6	5
Average number of services per visitⁱ	3.2	2.5	3.8	2.8	2.9	3.6	2.4	3.2	2.7	3.2	3.6	3.4	3.2	2.6	3
Index of average prices	82	99	101	146	117	123	67	88	84	133	64	119	99	143	100
Average payment per visitⁱ	$486	$660	$768	$677	$628	$845	$202	$513	$408	$973	$310	$840	$658	$576	$643
Other medical provider^j
Percentage of medical payments	6%	11%	9%	5%	9%	6%	5%	9%	9%	5%	7%	10%	8%	10%	8%
Percentage of all claims	37%	51%	51%	36%	45%	44%	33%	38%	48%	39%	44%	47%	54%	45%	45%
Average medical payment per claim	$1,103	$1,386	$1,365	$1,593	$1,973	$1,287	$649	$1,208	$1,155	$1,166	$1,143	$2,025	$1,290	$2,249	$1,289
Index of per claim utilization	78	105	113	98	124	92	67	93	90	102	97	110	114	109	100
Average number of visits per claim	2.6	5.5	5.4	3.9	3.8	3.6	3.0	4.7	3.3	4.1	4.3	3.5	4.5	4.5	4.0
Average number of services per visit	2.5	2.6	2.3	2.4	2.5	2.0	1.9	2.6	2.5	2.4	2.7	2.7	2.3	2.1	2.4
Index of average prices	104	87	81	188	179	100	73	64	109	100	95	172	87	231	100
Average payment per visit	$413	$223	$224	$329	$336	$309	$216	$240	$239	$273	$228	$350	$273	$408	$273
Notes: Claims with 12 months' average maturity. 2004/2005 refers to claims arising in October 2003 through September 2004, evaluated as of March 2005. Illinois' medical costs and utilization may be understated by an unknown amount due to balance billing.
^a For California, the number of services per visit for providers of physical medicine may be somewhat understated and prices somewhat overstated relative to other states because some physical medicine services are billed in 30 minute increments rather than the standard 15 minutes.
^b Average medical payments per claim are understated by an unknown amount because Illinois permits balance billing.
^c The 14-state median is the average of the states ranked 7th and 8th on a given measure; those states change depending on the measure being evaluated.
^d This includes billing for hot and/or cold packs (97010) which are not necessarily reimbursed in all states.
^e Because unique codes are used for billing physical medicine services in Louisiana, we are unable to distinguish between the relative number of services billed and the service mix intensity for physical medicine services and therefore cannot report the utilization index for these services in Louisiana.
^f Because not all services billed by Louisiana physical/occupational therapists and chiropractors are comparable to those in other states and they are defined too broadly to be crosswalked, we are unable to compare the number of services per visit for these services and providers. As noted, the price index relies on services where crosswalks can be accomplished.
^g Physical medicine codes in Louisiana are billed using state-specific PT/OT codes. While many of these codes can be directly mapped to standard physical therapy services, some cannot be. Specifically, those for therapeutic exercises and activities cannot be directly mapped. We only include those codes that can be directly mapped in the price analysis. In Louisiana, this means that the percentage of physical medicine payments that are included in the price analysis is less than the 85 to 98 percent found in other states. In Louisiana, the price analysis of the physical medicine category (and the services provided by physical/occupational therapists and chiropractors) is based on just over 52 percent of the services (mostly modalities as opposed to therapeutic activities and exercises). However, we are able to use all services for the trend analysis since the analysis is within the state over time and does not depend on comparisons to standardized codes.
^h For the most part, hospital outpatient services do not include payments to ambulatory surgical centers which are not consistently defined in the data, but are most often included in the nonhospital physician category. This does not include payments for hospital inpatient services.
ⁱ More claims receive hospital treatment in Massachusetts and Pennsylvania than in other states. This may mean that more claimants are seen in hospital settings or that more hospital billing is done even when the setting is a physician’s office. The result is that there are more services in the hospital provider category in Massachusetts and Pennsylvania. Overall, injuries treated by hospital providers in Massachusetts and Pennsylvania may be less severe than those treated in other states; therefore, costs and utilization may not be comparable to other states.
^j Other nonhospital providers include physicians' assistants, nurses, counselors, medical equipment suppliers, etc.
Measures:
• Percentage of medical payments: The sum of payments to each provider type or for each service group, divided by the sum of total medical payments.
• Percentage of all claims: The proportion of all claims with medical bill data with at least 1 service rendered by the provider type.
• Average medical payment per claim: The sum of medical payments to each provider type, divided by the number of claims involving the provider type.
• Index of per claim utilization: Measures the relative utilization compared to other states. The median state = 100. An index of 120 means that the state's utilization is 20 percent higher compared to the median state and an index of 80 means that the state's utilization is 20 percent lower compared to the median state. The utilization measures the volume of services provided as well as the relative resource intensity of the services provided per claim.
• Average number of visits per claim: The total number of visits to each provider type, divided by the number of claims involving the provider type or service group.
• Average number of services per visit: The total number of services paid to each provider type, divided by the total number of visits involving the provider type or service group.
• Index of average prices: The index measures average unit prices paid relative to the median state. The median state = 100. If a state's index is 80, this means that prices are on average 20 percent lower than the median state; if a state's index is 120 this means that the prices are on average 20 percent higher than the median state.
• Average payment per visit: The sum of payments made for each unique date of service (visit).
Key: n/a: not available; physician: medical doctor or doctor of osteopathy; PT/OT: physical or occupational therapist. Other providers include nurses, physicians' assistants and other specific providers not included in the list above.

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