View WCRI Benchmarks

Interstate Comparison: Medical Claim Costs and Utilization by Provider Type, 2010/2011 Claims with More Than 7 Days of Lost Time, Adjusted for Injury and Industry Mix
(12 months' average maturity)

Measure AR CAa FL IA IL IN LA MA MI MN NC NJ PA TX VA WI 16-State Medianb
Physician
Percentage of medical payments 31% 47% 37% 35% 42% 35% 34% 39% 31% 32% 31% 49% 29% 39% 34% 41% 35%
Percentage of all claims 98% 98% 98% 97% 96% 97% 97% 93% 96% 95% 98% 97% 97% 98% 97% 96% 97%
Average medical payment per claim  $3,440 $3,684 $4,062 $4,799 $8,290 $5,856 $4,322 $2,726 $2,637 $3,872 $3,873 $7,332 $3,436 $3,659 $5,585 $7,137 $3,968
Index of per claim utilization 104 112 108 91 125 98 98 81 92 83 106 91 113 102 113 94 100
Average number of visits per claim 10.5 12.9 10.3 9.2 12.8 9.8 9.8 8.1 9.5 9.2 10.5 10.0 11.8 11.3 10.9 9.6 10.1
Average number of services per visitc 2.5 2.7 2.4 2.2 2.9 2.5 2.4 2.1 2.4 2.3 2.5 2.3 2.6 2.5 2.6 2.2 2.5
Index of average prices 94 78 81 136 173 147 103 97 94 117 83 145 87 96 122 212 100
Average payment per visit $327 $286 $396 $519 $648 $598 $441 $335 $278 $421 $368 $731 $292 $325 $512 $741 $408
Chiropractord
Percentage of medical payments n/a 2% 0% 0% 2% 0% 1% 1% 0% 2% 0% 0% 2% 5% 0% 1% 1%
Percentage of all claims n/a 15% 2% 4% 9% 1% 5% 6% 3% 12% 1% 1% 8% 16% 2% 10% 5%
Average medical payment per claim  n/a $1,250 $735 $590 $4,677 $773 $2,270 $1,068 $1,213 $1,682 $821 $1,495 $2,664 $2,685 $1,329 $1,682 $1,329
Index of per claim utilization n/a 92 73 46 207 51 n/ae 111 95 132 83 83 202 172 109 105 100
Average number of visits per claim n/a 11.1 8.3 8.4 21.7 6.3 17.6 16.4 13.7 16.6 10.6 8.9 21.8 13.3 11.9 17.0 13.3
Average number of services per visitc n/a 3.3 3.6 2.1 4.2 2.9 n/af 2.6 2.4 3.3 3.4 3.5 3.8 4.0 3.9 2.6 3.4
Index of average pricesg n/a 86 88 96 146 105 123 76 101 105 80 114 99 114 96 118 101
Average payment per visit n/a $113 $88 $70 $215 $123 $129 $65 $89 $101 $78 $169 $122 $202 $112 $99 $112
PT/OT
Percentage of medical payments 6% 9% 8% 8% 13% 10% 11% 8% 13% 6% 9% 11% 14% 11% 10% 7% 9%
Percentage of all claims 40% 61% 55% 44% 51% 51% 51% 36% 46% 40% 56% 57% 53% 49% 51% 36% 51%
Average medical payment per claim  $1,696 $1,104 $1,626 $2,440 $5,039 $3,118 $2,697 $1,403 $2,309 $1,739 $1,971 $2,747 $3,045 $1,957 $3,232 $3,169 $2,374
Index of per claim utilization 86 62 108 94 151 100 n/ae 100 113 71 123 135 166 89 143 83 100
Average number of visits per claim 14.3 12.4 16.4 15.6 20.6 15.4 18.2 15.7 16.2 12.7 17.9 20.2 21.6 12.4 18.9 14.2 16.0
Average number of services per visitc 3.8 3.4 3.7 3.5 4.2 3.7 n/af 3.5 3.8 3.3 3.9 4.1 4.3 3.7 4.5 3.3 3.7
Index of average pricesg 91 63 72 119 153 138 102 67 99 109 71 96 88 101 105 170 100
Average payment per visit $119 $89 $99 $157 $244 $203 $148 $89 $142 $137 $110 $136 $141 $158 $171 $223 $142
Hospital outpatient providerh
Percentage of medical paymentsi 27% 10% 21% 35% 24% 31% 34% 26% 33% 30% 32% 15% 24% 18% 29% 33% 28%
Percentage of all claimsi 65% 45% 47% 78% 66% 68% 64% 79% 71% 63% 60% 54% 73% 48% 69% 71% 66%
Average medical payment per claimi $4,410 $1,804 $5,038 $6,117 $6,745 $7,224 $6,630 $2,199 $3,798 $5,607 $6,767 $4,058 $3,662 $3,458 $6,840 $7,907 $5,323
Average number of services per claimj 25.7 8.4 14.8 25.9 20.3 23.0 20.0 21.8 25.7 22.1 19.1 21.1 32.6 14.5 19.4 27.6 21
Average number of visits per claimi 6.8 3.3 3.3 9.2 5.8 6.2 5.0 7.8 7.5 6.8 4.5 5.0 7.8 4.5 5.4 9.0 6.0
Average number of services per visiti 3.8 2.6 4.5 2.8 3.5 3.7 4.0 2.8 3.4 3.3 4.2 4.6 4.2 3.2 3.6 3.1 3.5
Average payment per servicej $172 $214 $341 $236 $333 $314 $331 $101 $148 $254 $354 $206 $113 $239 $353 $286 $246
Average payment per visiti $647 $549 $1,529 $663 $1,172 $1,157 $1,330 $281 $505 $830 $1,492 $816 $471 $763 $1,256 $879 $823
Other medical providerk
Percentage of medical payments 9% 10% 11% 5% 5% 6% 9% 8% 8% 5% 8% 6% 7% 11% 6% 5% 7%
Percentage of all claims 80% 61% 73% 67% 61% 68% 73% 54% 67% 64% 77% 59% 67% 80% 68% 61% 67%
Average medical payment per claim  $1,049 $1,197 $1,528 $1,001 $1,510 $1,309 $1,414 $757 $866 $990 $1,315 $1,538 $1,243 $1,187 $1,444 $1,273 $1,258
Index of per claim utilization 105 93 116 86 110 108 107 90 77 93 95 118 102 212 98 86 100
Average number of visits per claim 6.1 6.8 7.4 5.5 6.0 6.4 7.7 5.4 5.4 5.2 7.5 6.3 6.2 6.7 6.9 5.4 6.3
Average number of services per visit 1.7 1.8 2.0 1.6 1.8 1.6 1.7 1.6 1.6 1.6 1.7 1.8 1.7 1.8 1.7 1.7 1.7
Index of average prices 95 68 73 151 137 142 115 72 86 135 98 102 78 80 122 178 100
Average payment per visit $172 $176 $206 $181 $252 $204 $183 $139 $160 $191 $175 $242 $200 $178 $208 $237 $187
Notes: Claims with 12 months' average maturity. 2010/2011 refers to claims arising in October 2009 through September 2010, evaluated as of March 2011. 
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 The 16-state median is the average of the states ranked 8th and 9th on a given measure; those states change depending on the measure being evaluated.
c This includes billing for hot and/or cold packs (97010), which are not necessarily reimbursed in all states.
d The numbers shown for chiropractic treatment in Indiana, Louisiana, North Carolina, New Jersey, and Virginia should be used with caution because of relatively small cell sizes (less than 200) underlying the measures. The cell sizes underlying the data in Arkansas for chiropractic measures at the claim level are too small to support an interstate comparison.
e 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 with codes used in other states, we are unable to compare the utilization index for these providers.
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 for which 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. Specifically, those codes 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 82 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 62 percent of the services (mostly modalities as opposed to therapeutic activities and exercises). 
h For the most part, hospital inpatient or outpatient services do not include payments to stand-alone ambulatory surgical centers, which are not consistently defined in the data but are most often included in the nonhospital physician category.
i More claims receive hospital treatment in Iowa, Massachusetts, and Pennsylvania than in other states. This may mean that more injured workers are seen in hospital settings or that more services are billed by a hospital even when the setting is a physician’s office. The result is that there are more services in the hospital provider category in Iowa, Massachusetts, and Pennsylvania. Overall, injuries treated by hospital providers in Iowa, 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 For hospital outpatient services, because the revenue codes often used in hospital billing are too broadly defined to support a robust marketbasket of services and an estimate of the relative intensity of services, we report average payment per service and number of services per claim.
k 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 one 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.

 

 

955 Massachusetts Avenue    Cambridge, Massachusetts 02139    617-661-WCRI (9274)

about WCRI  |  what's new  |  search our studies  |  order our publications  |  view WCRI benchmarks  |  members only
Join WCRI  | Conferences & Seminars  |  Media Information  |  Contact Us  |  Site Map