Comparing Private Payer and Medicare Payment Rates for Select Inpatient Hospital Services

Issue Brief
  1. Hospitalizations reported from March 1, 2020 to June 13, 2020 according to CDC data, https://gis.cdc.gov/grasp/COVIDNet/COVID19_5.html (accessed June 29, 2020).

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  2. Eric Lopez, Tricia Neuman, Gretchen Jacobson, and Larry Levitt, How Much More Than Medicare Do Private Insurers Pay? A Review of the Literature (Washington, D.C: Kaiser Family Foundation, April 2020), https://www.kff.org/medicare/issue-brief/how-much-more-than-medicare-do-private-insurers-pay-a-review-of-the-literature/

     

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  3. “ICD-10 MS-DRGs Version 37.1 R1 Effective April 1, 2020,” Centers for Medicare & Medicaid Services, 2020, https://edit.cms.gov/files/document/icd-10-ms-drgs-version-371-r1-effective-april-1-2020-updated-march-23-2020.pdf

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  4. “CARES Act Provider Relief Fund: General Information,” Department of Health & Human Services, accessed May 15, 2020, https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/general-information/index.html#targeted

     

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  5. See the Methods section for the formal definitions used by the Centers for Medicare and Medicaid Services for each of these diagnosis-related group (DRG) codes.

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  6. Peterson, Eric D et al,  “Contemporary mortality risk prediction for percutaneous coronary intervention: results from 588,398 procedures in the National Cardiovascular Data Registry,” Journal of the American College of Cardiology 55 (May 4, 2010): 1923-32. doi:10.1016/j.jacc.2010.02.005

     

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  7. “Non-Emergent, Elective Medical Services, and Treatment Recommendations,” Centers for Medicare & Medicaid Services, 2020, https://www.cms.gov/files/document/cms-non-emergent-elective-medical-recommendations.pdf; “Hospital volumes hit unprecedented lows $1.4B daily revenue losses mean long recovery ahead,” Crowe, May 1, 2020, https://www.crowe.com/news/hospital-data-analysis-examines-the-financial-impact-of-covid-19.

     

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  8. “Opening Up America Again: Centers for Medicare & Medicaid Services (CMS) Recommendations, Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase 1,” Centers for Medicare & Medicaid Services, 2020, https://www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services.pdf

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  9. Examining the Impact of Health Care Consolidation: Statement before the Committee on Energy and Commerce Oversight and Investigations Subcommittee, 115th Cong. (2018), https://docs.house.gov/meetings/IF/IF02/20180214/106855/HHRG-115-IF02-Wstate-GaynorM-20180214.pdf

     

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  10. The annual averages of the Consumer Price Index for all Urban Consumers (CPI-U) were 236.736 and 245.120 in 2014 and 2017, respectively.

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  11. The value of the relative weight for MS-DRG 177, respiratory infections and inflammation with major comorbidities or complications, decreased from 1.9934 in FY 2014 to 1.8672 in FY 2017—a 6.3 percent change decrease.

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  12. Rabah Kamal, Daniel McDermott, and Cynthia Cox, How has U.S. spending on healthcare changed over time?(Washington, DC: Kaiser Family Foundation, December 2019), https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/#item-start

     

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  13. The value of the relative weight for MS-DRG 470, knee and hip replacement, decreased from 2.1463 in FY 2014 to 2.0671 in FY 2017—a 4 percent change decrease.

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  14. Eric Lopez, Tricia Neuman, Gretchen Jacobson, and Larry Levitt. How Much More Than Medicare Do Private Insurers Pay? A Review of the Literature (Washington, DC: Kaiser Family Foundation, April 2020), https://www.kff.org/medicare/issue-brief/how-much-more-than-medicare-do-private-insurers-pay-a-review-of-the-literature/

     

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  15. Zack Cooper, Stuart V Craig, Martin Gaynor, John Van Reenen, “The Price Ain’t Right? Hospital Prices and Health Spending on the Privately Insured,” The Quarterly Journal of Economics 134, no. 1 (Feb.  2019): 51–107, https://doi.org/10.1093/qje/qjy020

     

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