The changing health care landscape reflected in the notable growth of alternative places of health care service and the continuing rise in medical prices is a subject of interest to health services researchers. Drawing on data from our repository of over 25 billion privately billed health care claim records, FAIR Health has released a white paper that brings new clarity to these topics. The first part, FH Healthcare Indicators™, focuses on recent trends and patterns related to retail clinics, urgent care centers, telehealth and ambulatory surgery centers (ASCs), as compared to more traditional places of services such as emergency rooms (ERs) and offices. The second part, the FH Medical Price Index™, analyzes changes in medical prices in six procedure categories over a recent five-year period. Here are some of our key findings.

Alternative Places of Service

Private insurance claim lines associated with retail clinics, urgent care centers, telehealth and ASCs all increased in recent years. (Claim lines are the individual procedures listed on an insurance claim.) For example, from 2007 to 2016, claim lines for services delivered in urgent care centers increased 1,725 percent—more than seven times the growth of ER claim lines (229 percent) in the same period.

Growth of alternative places of services varied in rural and urban areas. From 2011 to 2016, claim lines for retail clinics had a greater increase in urban (865 percent) than rural (704 percent) areas. But, in the same period, claim lines for telehealth increased more in rural (960 percent) than urban (629 percent) settings. The greater rural growth of telehealth may be due to its particular advantages in connecting patients to care in locations where hospitals and physicians’ offices may be remote.

Utilization of places of service varied according to age. Among patients using urgent care centers in 2016, the age group 31 to 40 years accounted for the greatest percent of claim lines, at 18 percent. But, among those using telehealth, the peak age groups were 41 to 50 and 51 to 60 years, each accounting for 19 percent. Gender was also a factor in utilization. More claim lines were submitted for women than men in every adult age group across all places of service where gender was studied in 2016—retail clinics, urgent care centers, telehealth, ASCs and ERs.

Different places of service were associated with different diagnoses. For example, acute respiratory infections, such as the common cold, were the leading diagnostic category in retail clinics and urgent care centers in 2016, while in telehealth, mental health-related diagnoses were most prominent.

Places of service varied in cost. In 2016, the median charge for a 20-minute new patient office visit was higher in an office ($176) than in an urgent care center ($165) or retail clinic ($99). But, when we compared median allowed amounts—the estimated amounts that insurers negotiate with providers—the results were different. The median allowed amount for a 20-minute new patient office visit was lower in an office ($93) than in an urgent care center ($111), and lower still in a retail clinic ($74).

Price Changes in Six Procedure Categories

We tracked the weighted average growth in median procedure charges and median allowed amounts from May 2012 to May 2017 in six medical procedure categories (which did not include facility fees):

  • Professional evaluation and management (E&M; excluding E&Ms performed in a hospital setting);
  • Hospital E&M (excluding E&Ms performed in a professional setting, such as typical office visits);
  • Medicine (excluding E&Ms);
  • Surgery (procedures for which the physician would bill);
  • Pathology and laboratory (including both technical and professional components, e.g., both equipment and physician services); and
  • Radiology (including both technical and professional components).

All six categories showed growth in that five-year period, but at different rates. Of the six categories, hospital E&Ms had the greatest percent increase in charges (28 percent) and allowed amounts (26 percent). For professional E&Ms, charges increased 22 percent, and allowed amounts 21 percent.

Surgery had the lowest growth in that period. Surgery charges increased only three percent, and allowed amounts two percent. The relatively low growth of surgery prices may be due to several factors, including hospitals acquiring physician practices, new technologies that can lower prices, and hospital surgeons needing to keep their prices competitive with ASCs.

Prices in the other categories grew at rates in the middle between surgery and E&Ms. Radiology charges and allowed amounts both rose seven percent, as did charges and allowed amounts for pathology and laboratory. Medicine charges increased 14 percent, and medicine allowed amounts 17 percent.

We hope these and other findings in our white paper encourage further study. In addition, we can make available customized indicators and indices based on specific data subsets relevant to your research.

Discounts on FAIR Health data are available to AcademyHealth members. Individual members receive a 25% discount and organizational affiliates receive a 30% discount. To learn more and utilize the member discount, email [email protected].

The opinions expressed in this blog post are the author's own and do not necessarily reflect the view of AcademyHealth.

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