Where to Find the Nations Most Affordable Medical Care

WHERE TO FIND THE NATIONS MOST AFFORDABLE MEDICAL-CARE

Contents

Foreword- 3 -Introduction- 4 -Lower quality and cost inefficiency co-exist- 4 -Methods- 4 -Significance- 5 -With Robust Information Such As This- 5 -About the data used in this report- 6 -How to use the cost rankings- 6 -Recommendations- 7 -Nations Lowest Cost Regions COMMERCIAL INSURANCE- 10 -Nations Highest Cost Regions COMMERCIAL INSURANCE- 11 -Cost by Region Alphabetically COMMERCIAL INSURANCE- 12 -Nations Lowest Cost Regions MEDICARE- 19 -Nations Highest Cost Regions MEDICARE- 20 -Cost by Region Alphabetically MEDICARE- 21 -Nations Lowest Cost Regions COMMERCIAL INSURANCE + MEDICARE- 28 -Nations Highest Cost Regions COMMERCIAL INSURANCE + MEDICARE- 29 -Cost by Region Alphabetically COMMERCIAL INSURANCE + MEDICARE- 30 -Cost Ranked by Region Alphabetically 25 Lowest Cost Regions Shaded in Green; 25 Highest Cost Regions Shaded in Yellow- 37 -Appendix 1: How were these data analyzed?- 44 -Appendix 2: Notes- 46 -Appendix 3: Bruce A. Boissonnault Bio and Contact Information- 47 -

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Foreword

NHQC breaks new ground in this report by releasing the cost of medical-care spending in 274 regions across the United States for both commercial health insurance and Medicare. Its a long-awaited step forward because business can use this information to evaluate relocation options more effectively and because quality and cost are linked. Regional cost comparisons are ranked from the lowest cost region (best) to the highest cost region (worst). Memo information also is provided on commercial insurance plus Medicare in each region. This is not a report of commercial health insurance prices in every region. It is what commercial insurance actually pays providers. The commercial insurance claims cost rankings in this report are adjusted to be on an apples-to-apples basis with what Medicare pays providers in each region. Health insurance company administration cost and profit are excluded to avoid distortions arising from differences among health insurance companies. Governments, policy leaders, researchers, media and consumer watchdogs have clamored for this information for many years because they want to compare the cost of medical-care funded by commercial insurance in each region to learn where costs are most affordable. Now they can.

For nearly two decades, the Niagara Health Quality Coalition (NHQC) has been a respected national leader in the science of health care performance measurement and reward systems. NHQCs work on behalf of consumers has led to better, more effective ways to measure medical-care performance, nationally and statewide. NHQC also pioneered many of the nations most important performance reports for consumers, including NHQCs Patient Survey Project (one of the models used to develop the federal patient survey for hospitals), clinical results such as mortality, infections and safety (now adopted as federally endorsed measures for hospitals) and NHQCs kidney disease early identification and treatment project (adopted by the National Kidney Foundation and in other countries). NHQCs unbiased consumer reports help patients find high quality care; and they drive subpar providers to make needed investments in quality. NHQC accepts no funds from the providers we grade and our governance structure ensures that we remain independent of the industry whose performance we assess.

THANK YOUThank you to researchers at the Institute of Medicine (IOM) for allowing the Niagara Health Quality Coalition to access data and documents compiled as part of IOMs work writing Variation in Health Care Spending: Target Decision Making, Not Geography. Special thanks to Joseph P. Newhouse, Harvard University, Adalsteinn Brown, University of Toronto, and Richard L. Fuller, Payment Design Consultant, Schnecksville, Pennsylvania for sharing their time and for providing valuable suggestions and insights during development of this report. Errors, omissions and perspectives are the authors responsibility alone.

Introduction

Heres a partial score: Notre Dame 6. George Carlin (From a comedy skit in which he played a radio sports announcer)

Excluding cost from discussions about medical-care quality, or vice versa, is reminiscent of this George Carlin comedy routine. Its funny as a comedy routine because the announcer sounds authoritative and informative, but hes not telling us anything. We dont know who Notre Dame is playing or what the opponents score is. We dont even know what sport Norte Dame is playing. Thus, we know nothing about who is winning the game. In health care, a partial score is not funny. Knowing a few scraps of information about medical-care results but nothing about cost, or vice versa, leaves patients and payers in the dark. Its a partial score, like Notre Dame 6. This is the first time that a national ranking of commercial insurance claims cost (i.e., for 274 regions) has been publicly available.[footnoteRef:1] By understanding what drives regional variation in commercial insurance claims cost, we can begin looking for ways to improve quality. [1: The Trustees of Dartmouth College. FAQ. The Dartmouth Atlas of Health Care. Dartmouth Institute, n.d. Web. 30 Mar.2015. . Why does the Dartmouth Atlas Project focus on Medicaredata? There is no counterpart to this [Medicare] database for the commercially insured population.]

Lower quality and cost inefficiency co-existPatients see quality in terms of how much they benefited from medical-care treatments and how much pain resulted from paying for those treatments. In fact, it is a fallacy to ignore the cost of medical-care when evaluating quality[footnoteRef:2] because inefficiency is always accompanied by lower quality. In practice, lower quality and inefficiency co-exist because wasteful care is either directly harmful to health or is harmful by displacing more useful care.[footnoteRef:3] [2: The Oxford English Dictionary defines fallacy as, A mistaken belief, especially one based on unsound argument. ] [3: Donabedian, Avedis. The Quality of Care; How Can It Be Assessed? JAMA 260.12 (1988): 174348.]

MethodsThis report analyzes the cost of claims paid to providers by commercial health insurance. Each regions commercial spending is ranked by Hospital Referral Region (HRR) across the United States on an apples-to-apples basis with the cost of Medicare spending. Costs are ranked from lowest to highest, that is, from the best to worst respectively. Hospital Referral Regions (HRRs) are used to analyze regional variation in medical-care claims cost because HRRs correspond to the area served by a regions major tertiary care hospital(s). Moreover, HRR-level is the most widely established unit of analysis in the literature on geographic variation,[footnoteRef:4] and HRR-level is how Medicare regional cost variation is evaluated in the Dartmouth Atlas. [4: Institute of Medicine. Variation in Health Care Spending: Target Decision Making, Not Geography. Ed. Joseph P. Newhouseet al. Washington: National Academies, 2013. Print.]

Commercial health insurance claims cost rankings in this report are not the same as commercial health insurance company prices. Thats because the regional variation in commercial health insurance claims cost ranked in this report does not include health insurance companies administration cost or profit within a region. By excluding health insurance companies administration cost and profit, we can compare claims cost for commercial health insurance and Medicare on an apples-to-apples basis.Significance Regional variation between the 25th lowest vs. 25th highest cost regions for commercial spending varied by 29%. The Institute of Medicine estimates that 70 percent of variation in total commercial spending is attributable to price markups, most likely reflecting the varying market power of providers across HRRs. See footnote 8. Therefore, an estimated 20% of regional variation in total commercial spending is attributable to higher prices charged by providers for similar services. These high levels of regional price variation (for similar care) mean that the intensity of competition for medical-care is too low to keep care affordable in many regions.With Robust Information Such As This Future users can link this cost information to medical-care results measures to assess regional variation in quality. See Recommendation 3 and related footnotes. Leaders can assess the cost competitiveness for medical-care purchased through commercial health insurance in their region. Federal (and state) policymakers can better understand:i. Which HRR regions have the highest/lowest commercial health insurance claims cost.ii. Which competitive factors contribute to making commercial health insurance more affordable in some regions than in others.iii. The negative (or positive) impact that Medicare (and Medicaid) pilot programs may have on commercial insurance cost. For example, if Medicare pilot projects in a region result in lower regional Medicare claims cost but are also associated with a dramatic rise in commercial health insurance claims cost, then Medicare may elect not to expand pilot projects if they plausibly drive up total cost for the region.[footnoteRef:5] [footnoteRef:6] [5: Illustration: Many Medicare pilots tend to emphasize integrating care as a means to reduce Medicare claims cost. Effective provider integration (or care coordination) works well to cut some types of Medicare claims cost because Medicare prices are set nationally and improved cooperation among providers can reduce utilization. However, prices providers charge under commercial health insurance contracts are not set nationally. Thus, more cooperation among Medicare providers when they provide care to their patients with commercial health insurance might be reducing competition and increasing prices.] [6: The IOM report did not find a significant correlation between commercial insurance and Medicare cost. This does not mean that future changes in Medicare will not have an unforeseen impact on the cost of care provided through commercial insurance markets.]

The return on investment for regional economic development efforts can be enhanced, especially in regions where medical-care cost is low and providers reputation and available performance measures are competitive. Economic development agencies can deploy ads and marketing materials that emphasize the savings that are possible (for self-insured employers) relocating or remaining in the lowest cost regions. i. Commercial health insurance coverage often is one of an employers most significant costs of doing business. ii. For employers in industries that offer extensive benefits, the cost of commercial health insurance will often outweigh regional taxes, regulations, quality of life and most other factors. It can even outweigh the total cost of raw materials, as in the case of the automakers. iii. Illustration: Ford Motor Company claims they spend more money to pay for health insurance benefits than they spend on all of the steel that goes into their cars. iv. Often, the best employers to bolster the economy invest the most in strong health insurance coverage benefits for their employees. If economic development entities are able to use this information to attract or retain more of these high-wage, high-benefit companies, the economic development entities might also be attracting companies with the greatest economic impact and the highest economic impact multipliers. Self-insured employers evaluating relocation or expansion options can use this information to weigh the cost/benefit of their relocation options more precisely. About the data used in this report # of claims in each samplei. MarketScan (Harvard) 109 million claimsii. OptumInsight (Lewin) 68 million claims All claims data used in this report are sorted by region, adjusted for partial year enrollment, year, pharmacy benefit, age, sex, age multiplied by sex, and health status. Data are from 20072009. The IOM research suggests 20072009 data remain valid.[footnoteRef:7] [7: Institute of Medicine. Variation in Health Care Spending: Target Decision Making, Not Geography. Ed. Joseph P. Newhouseet al. Washington: National Academies, 2013. Print. Note from Summary (page 6): ...area-level Medicare and commercial spending and utilization are highly correlated from one year to the next between 1992 and 2010, suggesting that geographic variation arises from systemic differences rather than randomness. In short, the relative cost of commercial health insurance claims within an HRR are unlikely to fluctuate randomly from year to year making this look back at 2007-2009 still valuable for evaluating regional variation in medical-care cost today.]

How to use the cost rankings To determine how the cost of medical-care in your region compares to other regions, simply refer to the tables that follow. Commercial insurance cost, Medicare cost, and commercial insurance cost plus Medicare cost all are ranked for 274 regions across the United States.i. Emphasis should be given to the relative cost of providing medical-care through commercial health insurance in each region because this granular regional rank information has never before been publicly available. ii. Where the regional cost of providing medical-care through commercial health insurance is high (i.e., more costly), we can infer that providers in those regions charge more.[footnoteRef:8] [8: Ibid. Note from Summary (page 6): Harvards analysis of commercial MarketScan data disaggregated unit price into its subcomponents and examined variation input prices and markups (defined as the difference between input and transaction output prices). Harvard reports that 70 percent of variation in total commercial spending is attributable to price markups, most likely reflecting the varying market power of providers across HRRs. Although utilization of various services, particularly rates of inpatient admissions and emergency department visits does contribute to regional differences in spending, it has a notably smaller influence than price markups.]

iii. If you live in a high-cost region for commercial spending, ask yourself, is there enough intense competition among providers? For example, if most or all of the hospitals in your region have merged, it is likely that prices will be higher for hospital care than in regions with more competitors and more intense competition. Unlike Medicare, where prices are set nationally, the level and intensity of regional competition among providers must be adequate in order to keep commercial medical-care insurance coverage from becoming unaffordable. Much has been written about the causes of regional variation in Medicare. This report does not duplicate that research.

Recommendations

1. To be patient-centered, recognize that patients care about results, not effort; and recognize that cost and quality are linked. (a) The medical-care industry too often confuses effort with results. Treatment is an effort, not a result. To be patient-centered, medical-care must held accountable for patients results. (b) Some in the medical-care industry see quality and cost as separate topics. In practice, lower quality and inefficiency co-exist because wasteful care is either directly harmful to health or is harmful by displacing more useful care.[footnoteRef:9] [9: Donabedian, Avedis. The Quality of Care; How Can It Be Assessed? JAMA 260.12 (1988): 174348.]

2. Know when its appropriate to measure medical-care quality vs. health care quality. Medical-care is the physician-hospital centered industry that treats patients. It is not health. Health can be impacted by many things that the medical-care industry does not treat and for which providers and health insurers should not be held accountable.[footnoteRef:10] [10: Note: The medical-care industry is but one of many factors that can impact health. Factors such as governments environmental or farm subsidy policies can have a greater impact on health than medical-care. If governments dont regulate polluters to keep the air and water safe, or if government provides greater tax incentives for producing unhealthy foods, the impacts on health can be immense. Poverty too can have a greater impact on health than medical-care, especially where poverty restricts access to adequate nourishment, clothing, warmth, sanitation, or a safe environment. ]

3. Dont get too hung up on data qualityproviders are paid to submit performance data and it wont improve until we use it. Improvement of performance measurement and reward systems in any complex, dynamic system is iterative. Be cognizant of risks associated with poorly designed performance reporting or reward systems; however, accept also that providers quality data wont get better until its used. Scientists have many valid performance measures based on administrative data that are useful right now[footnoteRef:11]; and these data are improving continuously because they are being used.[footnoteRef:12] [11: Pine, Michael, et al. "Enhancement of Claims Data to Improve Risk Adjustment of Hospital Mortality." JAMA 297.1(2007): 71-76.] [12: Hughes, Ronda G., ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville: Agency forHealthcare Research and Quality, 2008. Print. Chapter 45: However even with these limitations, codes, coding systems, and coding practices are improving and are often subject to auditing or monitoring for accuracy. Coders are becoming more aware of the importance of properly coding the data and how they are used in relation to quality improvement, public reporting, P4P and other initiatives.]

4. Evaluate performance measurement metrics separately from the reward systems tied to them. The value of performance measures must be evaluated separately from the reward systems tied to them. Unintended consequences can arise from performance measurement, the reward system tied to such measures, or both.

5. Look at commercial insurance and Medicare cost. Nearly all patients eventually will need information about both.

6. Studying the impact of competition would be good. There may be several factors that help determine whether medical-care in a region is affordable or not. Regional variation in provider competition intensity and health insurance company competition intensity are two factors that should be studied in detail. By understanding what makes medical-care competition work, leaders can make better policy decisions; and they can avoid policies that are likely to screw things up.

7. Learn from regions with low cost. Federal research is especially relevant for regions such as Honolulu, upstate New York, Bronx NY, western PA, etc. that have the lowest cost. Key factors for success in keeping commercial claims cost low should be studied by federal agencies to ensure cost-effectiveness is preserved and for possible replication in other regions.

8. Learn why we dont see evidence of cost shifting between commercial insurance and Medicare cost. While many economists opine that lower Medicare reimbursements will lead to higher commercial insurance cost, there is no evidence of that phenomenon when we compare regions.

9. Lets not let political lobbying get in the way of releasing this data to the public which is a key driver of needed change. While no plans exist at the Institute of Medicine (IOM) to gather or make the claims information used to prepare this report publicly available in the future, the release of this report willwe hopespur federal action to ensure ongoing annual public releases of similar information in the future.

TABLESNATIONAL ANALYSIS OF THE COST OF COMMERCIAL HEALTH INSURANCE CLAIMS RANKED FOR 274 REGIONS

TABLE 1: Nations Lowest Cost Regions COMMERCIAL INSURANCE TABLE 2: Nations Highest Cost Regions COMMERCIAL INSURANCE TABLE 3: Cost by Region Alphabetically COMMERCIAL INSURANCE

TABLE 4: Nations Lowest Cost Regions MEDICARE TABLE 5: Nations Highest Cost Regions MEDICARE TABLE 6: Cost by Region Alphabetically MEDICARE

TABLE 7: Nations Lowest Cost Regions COMMERCIAL INSURANCE + MEDICARE TABLE 8: Nations Highest Cost Regions COMMERCIAL INSURANCE + MEDICARE TABLE 9: Cost by Region Alphabetically COMMERCIAL INSURANCE + MEDICARE

TABLE 10: Cost by Region Alphabetically 25 Lowest Cost Regions Shaded in Green; 25 Highest Cost Regions Shaded in Yellow

NOTE: HRR rankings for Medicare vs. commercial insurance within the State of Maryland may be distorted due to rate cross-subsidization between Medicare and commercial insurance created by the operation of the Maryland waiver administered by the Health Services Cost Review Commission. http://www.hscrc.state.md.us/

NIAGARA HEALTH QUALITY COALITION

RESEARCH REPORT: COST OF COMMERCIAL HEALTH INSURANCE CLAIMS

RANKED BY HOPSITAL REFERRAL REGION (HRR)

Nations Lowest Cost Regions COMMERCIAL INSURANCE

STATE CityNATIONAL RANK*

HI Honolulu1

NY Buffalo2

NY Bronx3

NY Rochester4

MD - Takoma Park5

IA Dubuque6

AZ Tucson7

DC Washington8

MD Baltimore9

MI Dearborn10

OH Canton11

MI - Royal Oak12

MI Detroit13

NY - East Long Island14

NV - Las Vegas15

PA Johnstown16

TX - San Antonio17

PA Altoona18

NY Syracuse19

MA Springfield20

AR - Fort Smith21

FL Gainesville22

PA Erie23

TX - Corpus Christi24

NJ - New Brunswick25

*Source: NHQC Analysis, Institute of Medicine, Medicare-Acumen, MarketScan-Harvard, OptumInsight-Lewin.




Nations Highest Cost Regions COMMERCIAL INSURANCE

STATE CityNATIONAL RANK*

CA - Santa Cruz274

WV Huntington273

WV Charleston272

MS Gulfport271

WI Wausau270

CA - Contra Costa County269

WI - Green Bay268

AK Anchorage267

CA Sacramento266

WI Marshfield265

MO - Cape Girardeau264

CA Salinas263

KY Owensboro262

CA - San Mateo County261

IN Indianapolis260

GA Albany259

IL Urbana258

WI Milwaukee257

ME Bangor256

IN Muncie255

IN - Fort Wayne254

CA - Alameda County253

MN Duluth252

FL Tallahassee251

CA Napa250


NIAGARA HEALTH QUALITY COALITIONRESEARCH REPORT: COST OF COMMERCIAL HEALTH INSURANCE CLAIMSRANKED BY HOPSITAL REFERRAL REGION (HRR)

Cost by Region Alphabetically COMMERCIAL INSURANCE

STATE - CityNATIONAL RANK*

AL - Birmingham98

AL - Dothan52

AL - Huntsville99

AL - Montgomery49

AL - Tuscaloosa69

AK - Anchorage267

AZ - Mesa124

AZ - Phoenix116

AZ - Sun City40

AZ - Tucson7

AR - Fort Smith21

AR - Jonesboro48

AR - Little Rock102

AR - Springdale61

CA - Orange County104

CA - Bakersfield66


CA - Los Angeles82

CA - Modesto241

CA - Napa250


CA - Palm Springs/Rancho Mira42

CA - Redding100

CA - Sacramento266

CA - Salinas263

CA - San Bernardino63

CA - San Diego190

CA - San Francisco243

CA - San Jose203

CA - San Luis Obispo240


CA - Santa Cruz274

CA - Santa Rosa164

CA - Stockton227

CA - Ventura105

CO - Boulder180

CO - Colorado Springs158

CO - Denver204

CO - Fort Collins244

CO - Grand Junction208

CO - Greeley223

CO - Pueblo67

CT - Bridgeport194

CT - Hartford44

CT - New Haven89

DE - Wilmington188

DC - Washington8

FL - Bradenton75

FL - Clearwater154

FL - Fort Lauderdale58

FL - Fort Myers78

FL - Gainesville22

FL - Hudson173

FL - Jacksonville193

FL - Lakeland172

FL - Miami84

FL - Ocala41

FL - Orlando125

FL - Ormond Beach28

FL - Panama City183

FL - Pensacola150

FL - Sarasota113

FL - St. Petersburg81

FL - Tallahassee251

FL - Tampa109

GA - Albany259

GA - Atlanta77

GA - Augusta32

GA - Columbus31

GA - Macon196

GA - Rome234

GA - Savannah165

HI - Honolulu1

ID - Boise220

ID - Idaho Falls186

IL - Aurora217

IL - Blue Island94

IL - Chicago153

IL - Elgin166

IL - Evanston119

IL - Hinsdale139

IL - Joliet200

IL - Melrose Park112

IL - Peoria229

IL - Rockford236

IL - Springfield233

IL - Urbana258

IL - Bloomington209

IN - Evansville237

IN - Fort Wayne254

IN - Gary198

IN - Indianapolis260

IN - Lafayette178

IN - Muncie255

IN - Munster211

IN - South Bend216

IN - Terre Haute242

IA - Cedar Rapids35

IA - Davenport30

IA - Des Moines39

IA - Dubuque6

IA - Iowa City34

IA - Mason City62

IA - Sioux City43

IA - Waterloo64

KS - Wichita135

KY - Covington219

KY - Lexington152

KY - Louisville74

KY - Owensboro262

KY - Paducah225

LA - Alexandria163

LA - Baton Rouge226

LA - Houma170

LA - Lafayette149

LA - Lake Charles248

LA - Metairie210

LA - Monroe230

LA - New Orleans73

LA - Shreveport144

LA - Slidell238

ME - Bangor256

ME - Portland214

MD - Baltimore9

MD - Salisbury27

MD - Takoma Park5

MA - Boston111

MA - Springfield20

MA - Worcester45

MI - Ann Arbor26

MI - Dearborn10

MI - Detroit13

MI - Flint46

MI - Grand Rapids65

MI - Kalamazoo97

MI - Lansing96

MI - Marquette232

MI - Muskegon50

MI - Petoskey51

MI - Pontiac29

MI - Royal Oak12

MI - Saginaw88

MI - St. Joseph212

MI - Traverse City87

MN - Duluth252

MN - Minneapolis205

MN - Rochester224

MN - St. Cloud213

MN - St. Paul192

MS - Gulfport271

MS - Hattiesburg103

MS - Jackson148

MS - Meridian146

MS - Oxford171

MS - Tupelo159


MO - Joplin76

MO - Springfield142

MT - Billings187

MT - Great Falls110

MT - Missoula176

NE - Lincoln207

NE - Omaha202

NV - Las Vegas15

NH - Lebanon138

NH - Manchester239

NJ - Camden85

NJ - Hackensack55

NJ - Morristown101


NJ - Newark36

NJ - Paterson68

NJ - Ridgewood123

NY - Albany83

NY - Binghamton147

NY - Bronx3

NY - Buffalo2

NY - Elmira37


NY - Rochester4

NY - Syracuse19

NY - White Plains90

NC - Asheville107

NC - Charlotte184

NC - Durham114

NC - Greensboro57

NC - Greenville231

NC - Hickory151

NC - Raleigh129

NC - Wilmington136

NC - Winston-Salem133

ND - Bismarck79

ND - Fargo/Moorhead MN70

ND - Grand Forks161

OH - Akron53

OH - Canton11

OH - Cincinnati118

OH - Cleveland126

OH - Columbus179

OH - Dayton182

OH - Elyria132

OH - Kettering106

OH - Toledo108

OH - Youngstown38

OK - Lawton156

OK - Oklahoma City141

OK - Tulsa117

OR - Bend137

OR - Eugene175

OR - Medford246

OR - Portland155

OR - Salem185

PA - Allentown143

PA - Altoona18

PA - Danville177

PA - Erie23

PA - Harrisburg54

PA - Johnstown16

PA - Lancaster140

PA - Philadelphia93

PA - Pittsburgh33

PA - Reading245

PA - Sayre131

PA - Scranton71

PA - Wilkes-Barre122

PA - York72

RI - Providence80

SD - Sioux Falls157

TN - Chattanooga120

TN - Johnson City228

TN - Kingsport199

TN - Knoxville201

TN - Memphis121

TN - Nashville221

TX - Austin59

TX - Beaumont169

TX - Bryan115


TX - Dallas181

TX - Fort Worth191

TX - Houston206

TX - Longview145

TX - San Antonio17

TX - Temple162

TX - Tyler134

TX - Waco127

TX - Wichita Falls218

UT - Ogden47

UT - Provo130

UT - Salt Lake City167

VT - Burlington160

VA - Arlington56

VA - Norfolk128

VA - Richmond174

VA - Roanoke197

VA - Winchester86

WA - Everett168

WA - Olympia91

WA - Seattle92

WA - Spokane60

WA - Tacoma222

WA - Yakima95

WV - Charleston272

WV - Huntington273

WV - Morgantown195

WI - Appleton215

WI - Green Bay268

WI - La Crosse189

WI - Madison249

WI - Marshfield265

WI - Milwaukee257

WI - Neenah235

WI Wausau270

WY Casper247





Nations Lowest Cost Regions MEDICARE


HI - Honolulu1

CA - Stockton2

CA - San Francisco3

CA - Sacramento4

CA - Santa Cruz5

OR - Medford6

CA - Santa Rosa7

OR - Salem8


NY - Rochester10

CA - San Jose11

NY - Bronx12

NY - Buffalo13

OR - Eugene14


WA - Yakima16

WI - La Crosse17

OR - Portland18

CA - Modesto19

NY - Syracuse20

CA - Bakersfield21

IA - Iowa City22

WA - Olympia23

NY - Binghamton24

GA - Albany25





Nations Highest Cost Regions MEDICARE


FL - Miami274

LA - Monroe273

LA - Alexandria272

LA - Lafayette271

LA - Baton Rouge270

LA - Shreveport269

TX - Houston268

LA - Metairie267


TX - Dallas265


LA - Slidell263

MS - Meridian262

TX - Tyler261


MS - Jackson259

FL - Clearwater258

MS - Hattiesburg257

FL - Panama City256


TX - Bryan254

TX - Beaumont253

TX - Fort Worth252

TX - Longview251

MS - Gulfport250



Cost by Region Alphabetically MEDICARE


AL - Birmingham207

AL - Dothan190

AL - Huntsville208

AL - Montgomery192

AL - Tuscaloosa214

AK - Anchorage61

AZ - Mesa187

AZ - Phoenix94

AZ - Sun City148

AZ - Tucson91

AR - Fort Smith156

AR - Jonesboro172

AR - Little Rock168

AR - Springdale89


CA - Bakersfield21


CA - Los Angeles201

CA - Modesto19

CA - Napa54



CA - Redding35

CA - Sacramento4

CA - Salinas60


CA - San Diego75

CA - San Francisco3

CA - San Jose11



CA - Santa Cruz5

CA - Santa Rosa7

CA - Stockton2

CA - Ventura112

CO - Boulder173


CO - Denver118



CO - Greeley142

CO - Pueblo32

CT - Bridgeport129

CT - Hartford93

CT - New Haven115

DE - Wilmington146

DC - Washington139

FL - Bradenton245

FL - Clearwater258


FL - Fort Myers243

FL - Gainesville210

FL - Hudson227


FL - Lakeland226

FL - Miami274

FL - Ocala205

FL - Orlando235

FL - Ormond Beach215

FL - Panama City256

FL - Pensacola217

FL - Sarasota230


FL - Tallahassee111

FL - Tampa233

GA - Albany25

GA - Atlanta104

GA - Augusta76

GA - Columbus66

GA - Macon119

GA - Rome179

GA - Savannah193

HI - Honolulu1

ID - Boise70

ID - Idaho Falls106

IL - Aurora167

IL - Blue Island229

IL - Chicago219

IL - Elgin236

IL - Evanston221

IL - Hinsdale206

IL - Joliet238


IL - Peoria147

IL - Rockford151

IL - Springfield128

IL - Urbana116

IL - Bloomington130

IN - Evansville212

IN - Fort Wayne108

IN - Gary220


IN - Lafayette159

IN - Muncie169

IN - Munster244

IN - South Bend102

IN - Terre Haute232

IA - Cedar Rapids48

IA - Davenport103

IA - Des Moines53

IA - Dubuque33

IA - Iowa City22

IA - Mason City63

IA - Sioux City71

IA - Waterloo109

KS - Wichita199

KY - Covington186

KY - Lexington170

KY - Louisville184

KY - Owensboro165

KY - Paducah163

LA - Alexandria272

LA - Baton Rouge270

LA - Houma241

LA - Lafayette271


LA - Metairie267

LA - Monroe273

LA - New Orleans223

LA - Shreveport269

LA - Slidell263

ME - Bangor110

ME - Portland44

MD - Baltimore240

MD - Salisbury209

MD - Takoma Park174

MA - Boston157

MA - Springfield58

MA - Worcester133

MI - Ann Arbor185

MI - Dearborn222

MI - Detroit228

MI - Flint150

MI - Grand Rapids85

MI - Kalamazoo125

MI - Lansing161

MI - Marquette117

MI - Muskegon64

MI - Petoskey134

MI - Pontiac237

MI - Royal Oak242

MI - Saginaw213

MI - St. Joseph154


MN - Duluth82

MN - Minneapolis69

MN - Rochester28

MN - St. Cloud67

MN - St. Paul83

MS - Gulfport250

MS - Hattiesburg257

MS - Jackson259

MS - Meridian262

MS - Oxford211

MS - Tupelo224


MO - Joplin152

MO - Springfield84

MT - Billings79

MT - Great Falls99

MT - Missoula68

NE - Lincoln188

NE - Omaha171

NV - Las Vegas231

NH - Lebanon92

NH - Manchester90

NJ - Camden166

NJ - Hackensack177

NJ - Morristown140


NJ - Newark120

NJ - Paterson114

NJ - Ridgewood160

NY - Albany55

NY - Binghamton24

NY - Bronx12

NY - Buffalo13

NY - Elmira30


NY - Rochester10

NY - Syracuse20

NY - White Plains122

NC - Asheville132

NC - Charlotte137

NC - Durham78

NC - Greensboro62

NC - Greenville149

NC - Hickory153

NC - Raleigh143

NC - Wilmington216


ND - Bismarck39


ND - Grand Forks121

OH - Akron175

OH - Canton144

OH - Cincinnati182

OH - Cleveland178

OH - Columbus204

OH - Dayton195

OH - Elyria234

OH - Kettering218

OH - Toledo191

OH - Youngstown181

OK - Lawton155


OK - Tulsa239

OR - Bend29

OR - Eugene14

OR - Medford6

OR - Portland18

OR - Salem8

PA - Allentown96

PA - Altoona105

PA - Danville27

PA - Erie73

PA - Harrisburg74

PA - Johnstown107

PA - Lancaster46

PA - Philadelphia158

PA - Pittsburgh180

PA - Reading88

PA - Sayre56

PA - Scranton126


PA - York81

RI - Providence52

SD - Sioux Falls87

TN - Chattanooga176


TN - Kingsport98

TN - Knoxville189

TN - Memphis197

TN - Nashville202

TX - Austin246

TX - Beaumont253

TX - Bryan254


TX - Dallas265

TX - Fort Worth252

TX - Houston268

TX - Longview251

TX - San Antonio225

TX - Temple145

TX - Tyler261

TX - Waco203


UT - Ogden101

UT - Provo164


VT - Burlington36

VA - Arlington77

VA - Norfolk72

VA - Richmond95

VA - Roanoke26

VA - Winchester45

WA - Everett37

WA - Olympia23

WA - Seattle34

WA - Spokane57

WA - Tacoma38

WA - Yakima16

WV - Charleston31

WV - Huntington113

WV - Morgantown65

WI - Appleton43

WI - Green Bay80

WI - La Crosse17

WI - Madison40

WI - Marshfield59

WI - Milwaukee124

WI - Neenah50

WI - Wausau97

WY Casper127





Nations Lowest Cost Regions COMMERCIAL INSURANCE + MEDICARE


HI - Honolulu1

NY Bronx2

NY Buffalo3

NY - Rochester4

IA - Dubuque5

NY - Syracuse6

IA - Iowa City7

AZ Tucson8

MA - Springfield9

NY Elmira10

IA - Cedar Rapids11

CA - Bakersfield12

WA - Yakima13

PA Erie14

DC - Washington15

IA - Des Moines16

MD - Takoma Park17

GA - Columbus18

PA - Johnstown19


OH Canton21

PA - Altoona22

CO Pueblo23

GA Augusta24

WA Olympia25





Nations Highest Cost Regions COMMERCIAL INSURANCE + MEDICARE


FL - Miami274

MS - Gulfport273

LA - Monroe272

WV - Huntington271

CA - Santa Cruz270

LA - Baton Rouge269


LA - Slidell267

LA - Metairie266

TX - Houston265

LA - Alexandria264

LA - Lafayette263

LA - Shreveport262



WV - Charleston259

TX - Dallas258

WI - Wausau257

IN - Terre Haute256


WI - Green Bay254

KY - Owensboro253

FL - Panama City252

TX - Fort Worth251

IN - Munster250



Cost by Region Alphabetically COMMERCIAL INSURANCE + MEDICARE


AL - Birmingham157

AL - Dothan105

AL - Huntsville159

AL - Montgomery96

AL - Tuscaloosa140

AK - Anchorage224

AZ - Mesa161

AZ - Phoenix86

AZ - Sun City64

AZ - Tucson8

AR - Fort Smith49

AR - Jonesboro85

AR - Little Rock133

AR - Springdale56


CA - Bakersfield12


CA - Los Angeles134

CA - Modesto123

CA - Napa177



CA - Redding45

CA - Sacramento143

CA - Salinas210


CA - San Diego125


CA - San Jose52



CA - Santa Cruz270

CA - Santa Rosa27

CA - Stockton51

CA - Ventura102

CO - Boulder182


CO - Denver175



CO - Greeley199

CO - Pueblo23

CT - Bridgeport168

CT - Hartford43

CT - New Haven89

DE - Wilmington176

DC - Washington15

FL - Bradenton188

FL - Clearwater245


FL - Fort Myers187

FL - Gainesville79

FL - Hudson216


FL - Lakeland215

FL - Miami274

FL - Ocala106

FL - Orlando200

FL - Ormond Beach98

FL - Panama City252

FL - Pensacola193

FL - Sarasota189


FL - Tallahassee222

FL - Tampa190

GA - Albany181

GA - Atlanta68

GA - Augusta24

GA - Columbus18

GA - Macon165

GA - Rome228

GA - Savannah183

HI - Honolulu1

ID - Boise146

ID - Idaho Falls144

IL - Aurora212

IL - Blue Island178

IL - Chicago198

IL - Elgin221

IL - Evanston184

IL - Hinsdale179

IL - Joliet243


IL - Peoria209

IL - Rockford217

IL - Springfield205

IL - Urbana238

IL - Bloomington180

IN - Evansville242

IN - Fort Wayne227

IN - Gary226


IN - Lafayette173

IN - Muncie247

IN - Munster250

IN - South Bend172

IN - Terre Haute256

IA - Cedar Rapids11

IA - Davenport37

IA - Des Moines16

IA - Dubuque5

IA - Iowa City7

IA - Mason City34

IA - Sioux City28

IA - Waterloo66

KS - Wichita171

KY - Covington218

KY - Lexington166

KY - Louisville117

KY - Owensboro253

KY - Paducah213

LA - Alexandria264

LA - Baton Rouge269

LA - Houma236

LA - Lafayette263


LA - Metairie266

LA - Monroe272

LA - New Orleans162

LA - Shreveport262

LA - Slidell267

ME - Bangor229

ME - Portland119

MD - Baltimore87

MD - Salisbury90

MD - Takoma Park17

MA - Boston128

MA - Springfield9

MA - Worcester62

MI - Ann Arbor67

MI - Dearborn60

MI - Detroit74

MI - Flint72

MI - Grand Rapids55

MI - Kalamazoo95

MI - Lansing118

MI - Marquette201

MI - Muskegon26

MI - Petoskey65

MI - Pontiac132

MI - Royal Oak94

MI - Saginaw156

MI - St. Joseph192


MN - Duluth204

MN - Minneapolis131

MN - Rochester122

MN - St. Cloud137

MN - St. Paul135

MS - Gulfport273

MS - Hattiesburg232

MS - Jackson246

MS - Meridian249

MS - Oxford195

MS - Tupelo207


MO - Joplin100

MO - Springfield99

MT - Billings126

MT - Great Falls83

MT - Missoula104

NE - Lincoln211

NE - Omaha197

NV - Las Vegas84

NH - Lebanon103

NH - Manchester191

NJ - Camden113

NJ - Hackensack97

NJ - Morristown109


NJ - Newark50

NJ - Paterson71

NJ - Ridgewood136

NY - Albany40

NY - Binghamton57

NY - Bronx2

NY - Buffalo3

NY - Elmira10


NY - Rochester4

NY - Syracuse6

NY - White Plains91

NC - Asheville110

NC - Charlotte167

NC - Durham77

NC - Greensboro33

NC - Greenville214

NC - Hickory153

NC - Raleigh130

NC - Wilmington186


ND - Bismarck31


ND - Grand Forks139

OH - Akron93

OH - Canton21

OH - Cincinnati148

OH - Cleveland147

OH - Columbus196

OH - Dayton194

OH - Elyria203

OH - Kettering174

OH - Toledo145

OH - Youngstown81

OK - Lawton158


OK - Tulsa208

OR - Bend54

OR - Eugene44

OR - Medford101

OR - Portland42

OR - Salem41

PA - Allentown107

PA - Altoona22

PA - Danville70

PA - Erie14

PA - Harrisburg36

PA - Johnstown19

PA - Lancaster63


PA - Pittsburgh76

PA - Reading202

PA - Sayre61

PA - Scranton78


PA - York53

RI - Providence38

SD - Sioux Falls108

TN - Chattanooga142


TN - Kingsport151

TN - Knoxville206

TN - Memphis163

TN - Nashville230

TX - Austin185

TX - Beaumont244

TX - Bryan231


TX - Dallas258

TX - Fort Worth251

TX - Houston265

TX - Longview239

TX - San Antonio88

TX - Temple155

TX - Tyler241

TX - Waco169


UT - Ogden48

UT - Provo141


VT - Burlington69

VA - Arlington46

VA - Norfolk75

VA - Richmond124

VA - Roanoke82

VA - Winchester39

WA - Everett73

WA - Olympia25

WA - Seattle35

WA - Spokane32

WA - Tacoma127

WA - Yakima13

WV - Charleston259

WV - Huntington271

WV - Morgantown115

WI - Appleton121

WI - Green Bay254

WI - La Crosse58

WI - Madison170

WI - Marshfield220

WI - Milwaukee237

WI - Neenah152

WI - Wausau257

WY - Casper223


See Appendix 1 and Appendix 2 for information about the data and the analyses used in this report.


Cost Ranked by Region Alphabetically 25 Lowest Cost Regions Shaded in Green; 25 Highest Cost Regions Shaded in Yellow

Hospital Referral Region (HRR)HRR# 1Marketscan-HarvardAcumen-MedicareComm + MedicareShaded

HRR 1HRR# 1Rank 1Rank 2Rank 325

AL - Birmingham198207157

AL - Dothan252190105

AL - Huntsville599208159

AL - Montgomery74919296

AL - Tuscaloosa969214140

AK - Anchorage1026761224

AZ - Mesa11124187161

AZ - Phoenix121169486

AZ - Sun City144014864

AZ - Tucson157918

AR - Fort Smith162115649

AR - Jonesboro184817285

AR - Little Rock19102168133

AR - Springdale21618956


CA - Bakersfield25662112


CA - Los Angeles5682201134

CA - Modesto5824119123

CA - Napa6225054177



CA - Redding731003545

CA - Sacramento772664143

CA - Salinas7826360210


CA - San Diego8019075125


CA - San Jose822031152



CA - Santa Cruz872745270

CA - Santa Rosa89164727

CA - Stockton91227251

CA - Ventura96105112102

CO - Boulder101180173182


CO - Denver103204118175



CO - Greeley106223142199

CO - Pueblo107673223

CT - Bridgeport109194129168

CT - Hartford110449343

CT - New Haven1118911589

DE - Wilmington112188146176

DC - Washington113813915

FL - Bradenton11575245188

FL - Clearwater116154258245


FL - Fort Myers11978243187

FL - Gainesville1202221079

FL - Hudson122173227216


FL - Lakeland124172226215

FL - Miami12784274274

FL - Ocala12941205106

FL - Orlando130125235200

FL - Ormond Beach1312821598

FL - Panama City133183256252

FL - Pensacola134150217193

FL - Sarasota137113230189


FL - Tallahassee140251111222

FL - Tampa141109233190

GA - Albany14225925181

GA - Atlanta1447710468

GA - Augusta145327624

GA - Columbus146316618

GA - Macon147196119165

GA - Rome148234179228

GA - Savannah149165193183

HI - Honolulu150111

ID - Boise15122070146

ID - Idaho Falls152186106144

IL - Aurora154217167212

IL - Blue Island15594229178

IL - Chicago156153219198

IL - Elgin158166236221

IL - Evanston161119221184

IL - Hinsdale163139206179

IL - Joliet164200238243


IL - Peoria170229147209

IL - Rockford171236151217

IL - Springfield172233128205

IL - Urbana173258116238

IL - Bloomington175209130180

IN - Evansville179237212242

IN - Fort Wayne180254108227

IN - Gary181198220226


IN - Lafayette184178159173

IN - Muncie185255169247

IN - Munster186211244250

IN - South Bend187216102172

IN - Terre Haute188242232256

IA - Cedar Rapids190354811

IA - Davenport1913010337

IA - Des Moines192395316

IA - Dubuque1936335

IA - Iowa City19434227

IA - Mason City195626334

IA - Sioux City196437128

IA - Waterloo1976410966

KS - Wichita201135199171

KY - Covington203219186218

KY - Lexington204152170166

KY - Louisville20574184117

KY - Owensboro207262165253

KY - Paducah208225163213

LA - Alexandria209163272264

LA - Baton Rouge210226270269

LA - Houma212170241236

LA - Lafayette213149271263


LA - Metairie216210267266

LA - Monroe217230273272

LA - New Orleans21873223162

LA - Shreveport219144269262

LA - Slidell220238263267

ME - Bangor221256110229

ME - Portland22221444119

MD - Baltimore223924087

MD - Salisbury2252720990

MD - Takoma Park226517417

MA - Boston227111157128

MA - Springfield23020589

MA - Worcester2314513362

MI - Ann Arbor2322618567

MI - Dearborn2331022260

MI - Detroit2341322874

MI - Flint2354615072

MI - Grand Rapids236658555

MI - Kalamazoo2389712595

MI - Lansing23996161118

MI - Marquette240232117201

MI - Muskegon242506426

MI - Petoskey2435113465

MI - Pontiac24429237132

MI - Royal Oak2451224294

MI - Saginaw24688213156

MI - St. Joseph248212154192


MN - Duluth25025282204

MN - Minneapolis25120569131

MN - Rochester25322428122

MN - St. Cloud25421367137

MN - St. Paul25619283135

MS - Gulfport257271250273

MS - Hattiesburg258103257232

MS - Jackson259148259246

MS - Meridian260146262249

MS - Oxford261171211195

MS - Tupelo262159224207


MO - Joplin26776152100

MO - Springfield2701428499

MT - Billings27418779126

MT - Great Falls2751109983

MT - Missoula27617668104

NE - Lincoln277207188211

NE - Omaha278202171197

NV - Las Vegas2791523184

NH - Lebanon28113892103

NH - Manchester28223990191

NJ - Camden28385166113

NJ - Hackensack2845517797

NJ - Morristown285101140109


NJ - Newark2893612050

NJ - Paterson2916811471

NJ - Ridgewood292123160136

NY - Albany295835540

NY - Binghamton2961472457

NY - Bronx2973122

NY - Buffalo2992133

NY - Elmira300373010


NY - Rochester3044104

NY - Syracuse30719206

NY - White Plains3089012291

NC - Asheville309107132110

NC - Charlotte311184137167

NC - Durham3121147877

NC - Greensboro313576233

NC - Greenville314231149214

NC - Hickory315151153153

NC - Raleigh318129143130

NC - Wilmington319136216186


ND - Bismarck321793931


ND - Grand Forks323161121139

OH - Akron3255317593

OH - Canton3261114421

OH - Cincinnati327118182148

OH - Cleveland328126178147

OH - Columbus329179204196

OH - Dayton330182195194

OH - Elyria331132234203

OH - Kettering332106218174

OH - Toledo334108191145

OH - Youngstown3353818181

OK - Lawton336156155158


OK - Tulsa340117239208

OR - Bend3411372954

OR - Eugene3421751444

OR - Medford3432466101

OR - Portland3441551842

OR - Salem345185841

PA - Allentown34614396107

PA - Altoona3471810522

PA - Danville3501772770

PA - Erie351237314

PA - Harrisburg352547436

PA - Johnstown3541610719

PA - Lancaster3551404663


PA - Pittsburgh3573318076

PA - Reading35824588202

PA - Sayre3591315661

PA - Scranton3607112678


PA - York363728153

RI - Providence364805238

SD - Sioux Falls37115787108

TN - Chattanooga373120176142


TN - Kingsport37619998151

TN - Knoxville377201189206

TN - Memphis379121197163

TN - Nashville380221202230

TX - Austin38559246185

TX - Beaumont386169253244

TX - Bryan388115254231


TX - Dallas391181265258

TX - Fort Worth394191252251

TX - Houston397206268265

TX - Longview399145251239

TX - San Antonio4121722588

TX - Temple413162145155

TX - Tyler416134261241

TX - Waco418127203169


UT - Ogden4214710148

UT - Provo422130164141


VT - Burlington4241603669

VA - Arlington426567746

VA - Norfolk4301287275

VA - Richmond43117495124

VA - Roanoke4321972682

VA - Winchester435864539

WA - Everett4371683773

WA - Olympia438912325

WA - Seattle439923435

WA - Spokane440605732

WA - Tacoma44122238127

WA - Yakima442951613

WV - Charleston44327231259

WV - Huntington444273113271

WV - Morgantown44519565115

WI - Appleton44621543121

WI - Green Bay44726880254

WI - La Crosse4481891758

WI - Madison44924940170

WI - Marshfield45026559220

WI - Milwaukee451257124237

WI - Neenah45223550152

WI - Wausau45627097257

WY - Casper457247127223


See Appendix 1 and Appendix 2 for information about the data and the analyses used in this report.

Appendix 1: How were these data analyzed?

1. NHQC used data underpinning the recent Institute of Medicine (IOM) report entitled, Variation in Health Care Spending: Target Decision Making, Not Geography. These data were used to rank the cost of commercial insurance spending, Medicare and commercial insurance plus Medicare in 274 regions nationally.

2. The key sources of information obtained by NHQC from IOM were from MarketScan and OptumInsight.

3. In its report, the IOM investigated the correlation between the cost of Medicare and the cost of commercial health insurance spending in each region. (Note: The IOM concluded that there is no meaningful correlation between the cost of Medicare and the cost of commercial health insurance spending in HRRs nationally.)

4. In order for IOM researchers to evaluate if there exists a strong correlation between the regional cost of commercial insurance spending vs. Medicare, the IOM researchers analyzed databases composed of nearly 200 million claims. Adjustments were developed and applied to the two different, commercial sector health insurance claims datasets to make them comparable to Medicare.

5. All claims data are sorted by region, adjusted for partial year enrollment, year, pharmacy benefit, age, sex, age multiplied by sex, and health status.

6. NHQC staff began its research by replicating the IOM correlation analysis published in the draft IOM report. This step confirmed IOMs conclusion that you cant learn about the cost effectiveness of commercial health insurance in all HRRs solely by knowing the cost effectiveness of Medicare in the same HRRs. More important for NHQCs research, duplicating the IOM analysis and reaching precisely the same statistical values reached by IOM researchers ensured an appropriate starting point for NHQC research presented this report.

7. NHQC analyzed valid options for comparing and then ranking the cost of commercial insurance spending by HRR nationally using the two available databases (i.e., MarketScan and OptumInsight).

8. NHQC evaluated MarketScan and OptumInsight as well as the options for ranking regional cost by using each or both data sources. For example, we analyzed:

a. The number of records in each of the two data sourcesb. The number of markets for which information was unavailable in each data sourcec. Whether or not it would be possible to average data from both data sources so that an average of the two data sources could be used to rank regions cost for commercial insurance and Medicared. Whether or not it would be possible to use a weighted averagee. Whether or not a cost of living adjustment factor should be incorporatedf. The level of documentation about individual claims in each of the two data sources, and possible statistical implications where documentation is incompleteg. The component types of medical-care encountersh. How much the cost of commercial insurance spending varied between the two data sources

9. After analysis of available options for ranking the cost of commercial insurance spending based on both MarketScan and OptumInsight data sources, NHQC researchers concluded that using only one of the two data source was an appropriate decision. Averaging the regional summaries provided by the two data sources or combining them in other ways was flawed because of potential differences in how the claims information was gathered, weighted and combined, and because of potential duplication of an unknown number of the confidential individual claims used in each database. Combining claims information from two sources where there exists no mechanism to determine which individual claims were duplicates would cause statistical error that could not be measured and whose impact would be unknown. Moreover, such efforts to enlarge the available data are not necessary where the two data sources have a strong correlation to each other without combining them in any way.

10. NHQC used the MarketScan data to rank the regional cost of commercial insurance spending in 274 regions because the MarketScan sample was comprised of a larger number of claims (i.e., 109 million claims).

11. NHQC used the second data source, OptumInsight, as a confirmation of the MarketScan data source, and to standardize the data by eliminating outlier HRRs where the two data sources varied widely for the estimated cost of commercial health insurance within the same HRR.

12. The correlation between commercial health insurance cost using the MarketScan and OptumInsight data sources without standardizing the data was .66 an acceptable correlation. After standardizing the databases to eliminate outlier HRRs based on the variance between the two data sources, the correlation jumped to .74, a robust correlation for this application. This strong correlation (i.e., .74) between the two data sources provides further confirmation of the robustness of the commercial health insurance regional rankings for the 274 regions compared in this report.

13. Outlier HRRs were removed from the MarketScan dataset where the MarketScan and OptumInsight estimates of HRR cost varied widely. Outliers were removed using a statistical technique called standardizing the data. Employing this widely accepted statistical technique eliminated approximately 5% of the HRRs.

14. Rank order was determined for commercial insurance and for Medicare by indexing the cost of claims in each region on a 0100 scale. The rank order for commercial insurance + Medicare was computed by averaging the indexes for commercial and Medicare in each region.

Appendix 2: Notes

1. Note on interpreting the results: Small differences in HRR rank are not likely to be statistically significant. Thus for example, dont focus on regional variance where one region is ranked 55 and another is ranked 56.

2. Note on unintended consequences: Some studies suggest that publication of provider price information may drive increased provider prices under some circumstances.[footnoteRef:13] If this is a one-time report because the government does not mandate ongoing transparency about the cost of commercial claims in the future, corporate relocation decision-makers may never have access to the information again. Under these circumstances, the risk of unintended consequences, including higher costs in the most efficient regions, is greater. [13: Ginsburg, Paul B. "Shopping for Price in Medical Care." Health Affairs 26.2 (2007): w208-w216. Web. 22 May 2015..]

3. Note on the role of competition in keeping medical-care affordable: Even after implementation of the Affordable Care Act, sixty percent of personal bankruptcies in the U.S. stem in total or in part from medical-care costs; and one in three Americans report difficulty in paying medical bills.[footnoteRef:14] Medical-care industry consolidation, insurance market changes and horizontal and vertical integration between hospitals and health insurers are accelerating individuals exposure to greater financial risk. While more intense regional competition can improve affordability somewhat, competition alone is unlikely to be sufficient to make the cost of medical-care in the U.S. competitive with the cost of medical- care in other nations. [14: Himmelstein, David U., et al. "Medical Bankruptcy in the United States, 2007:Results of a National Study." AmericanJournal of Medicine 122.8 (2009): 741-46.]

Appendix 3: Bruce A. Boissonnault Bio and Contact Information

Bruce A. Boissonnault93 Lehn Springs DriveWilliamsville, NY [email protected]

Bruce A. Boissonnault is CEO of the Niagara Health Quality Coalition (NHQC) and President of the Alliance for Quality Health Care. The Niagara Health Quality Coalition has pioneered many consumer reports that have been widely adopted as the national standard of performance measurement. National firsts include: the New York State Hospital Report CardSM, the Niagara Health Quality Coalition Patient Survey Report CardSM, the New York State Preventable Admissions ReportSM, the New York State Appropriate Utilization Hospital ReportSM and others. NHQC has pioneered similar reports in many states including New York, Florida, Texas and Washington State; and NHQC served as an advisor to the federal government assisting with development of the federal hospital measures and the patient satisfaction survey now used by nearly all U.S. hospitals. The Niagara Health Quality Coalitions reports are state-of-the-art. They are indispensable for consumers that want unbiased information to use when searching for high-quality care. Current reports are available at myHealthFinder.com which has no advertising, no tracking cookies, and is free of charge. Additionally, Mr. Boissonnault is a nationally recognized scientist in his field. He has been co-chairman of, and has served on, national steering committees funded by Congress to recommend the best methods for publicly reporting and rewarding hospital performance and nursing home performance, respectively. He has been an advisor to MEDPAC, the National Health Care Quality Report to Congress, the Institute of Medicine, the American Medical Associations Physician Consortium for Performance Improvement in Cardiac Imaging, and the National Health Care Disparities Report to Congress. He also has served as a national science and technical advisor to government, business and media. He was an invited speaker on national health care data strategy for the National Committee on Vital and Health Statistics Quality Workgroup and for the National Uniform Billing Committee. Mr. Boissonnault is a member of the AARP New York Executive Council focusing on health care and interests of its youngest member group, and he is on the faculty at Northwestern Universitys Kellogg School of Management, where his focus is Health Enterprise Management and Using performance measurement to improve quality. The work of the Niagara Health Quality Coalition has been chronicled in media outlets including The New York Times, The Wall Street Journal, the Associated Press, Gannett, Consumer Reports, NPR, The Buffalo News, the New York Daily News, Newsday, the New York Post, the Rochester Democrat and Chronicle, Hearst Media, the Syracuse Post-Standard, the Albany Times Union, ProPublica, Business First, Albany Business Journal, the Managed Care magazine, Disease Management Advisor, Crains New York Business, and many others. In addition, Mr. Boissonnaults research has been recognized in important peer-reviewed publications including Oxford University Press, Health Affairs, and the U.S. Agency for Healthcare Research and Qualitys Research Monthly.Mr. Boissonnault is recipient of many awards including the national Eye on Quality Award, the National Quality Improvement Award, the Chartered Value Exchange designation for pioneering in the field of public reporting (by HHS Secretary Leavitt), the National Kidney Foundation's Gift of Life Award for transformational work using big data to improve kidney disease results, and the New Yorkers for Patient and Family Empowerments Consumer Rights Award.Prior to his current role, Mr. Boissonnault was an executive in the private sector including as general manager at Walt Disney World with responsibilities in Orlando and Los Angeles, with Price Waterhouse as a strategy consultant, and with Mobil Corporation in west coast retail marketing operations. Mr. Boissonnault has two adult sons and lives with his wife Joan of 29 years in Williamsville, New York.

Dedication: This study is dedicated to Richard J. Dahle. Richard was a beloved marketing executive at Mobil Oil Corporation. He was ethical and found ways to negotiate agreements that were valuable to both Mobil and his clients. Richard offered me the following advice 35 years ago. As a valued mentor, Richard explained for me the art of making promises to management that you can always keep. With an engaging smile, he quipped, Tell them what, or tell them when, but never tell them both. If you do that, management can never pin you down. In the medical-care industry today, we may have some information about price or we may have some information about outcome, but rarely do we have both. Thats why policy leaders never can pin the medical-care industry down.- 3 -

Documents

Where to Find the Nations Most Affordable Medical Care