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A comparison of Medicare physician fees, physician charges, fees of other payors, and model Medicare fee schedule amounts : final report PDF

170 Pages·1991·8.7 MB·English
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Preview A comparison of Medicare physician fees, physician charges, fees of other payors, and model Medicare fee schedule amounts : final report

HealthPolicyResearch Consortium HellerGraduateSchool BrandeisUniversity 415SouthStreet Waltham. Massachusetts * 02254-9110 \^ (617)736-3900 ACOMPARISONOFMEDICARE PHYSICIANFEES, PHYSICIANCHARGES, FEESOFGTTHERFAYCKS, A?JDMODELMEDICAREFEE SCHEDULE AMOUlvITS HnaiRepo rt Submitted by : Gregory C. Pope, M.S. Jerry Cromwell, Ph.D. Stephen M. Davidson, Ph.D. Janet Mitchell, Ph.D. Center for Health Economics Research 300 Fifth Avenue, 6th Floor MA Waltham, 02154 July, 1991 5 'h^ Tills report was prepared with the support ofHCFA Office ofResearch under Cooperative Agreement No. 99-C9^^2e^/l-06 to the Health Policy Research Consortium-Boston University, Center for Health Economics Research and Urban Institute. Adm.inistrative offices are located at tlie Pleller School, Brandeis Urdversit}'-, Waltham, ?vlA 02154. The total funding for this project was $91,995, Incoocerationwith ^j^h IQO Percent of funding from. HCFA. The authors thank Bill Sobaski and BostonUniversity Sherry Terrell for helpful comjuenrs, but responsibility for any errors and Centerfor interpretations remains with the authors. The viev.^s expressed herein are solely Hea;-:EconomicsResearch those of the authors cwA Qo not nccessarily reflect the views of the Heaidi Care urban institute Financing Adm.inL^lration. FEEll/5 PAGE EXECUTIVE SDMAKT 1.0 IHTROTUCTICHI -1- 1.1 Statement of the Problem -1- 1.2 Institutional Factors in Fee-Setting -2- 1.3 Overview of Report -4- 2.0 A MCH>EL OF PHTSICIAN PRICING UNDER ALTERNATIVE INSURANCE COVERAGES -5- PART I: A CCMPARISOff OF 1984 MEDICARE PHYSICIAN FEES TO USUAL PEnrSICIAN CHARGES AND FEES OF OTHER PAYORS -11- 3.0 DATA SOURCE AND LIMITATKMIS -11- 3.1 The Number of Usable Responses -11- 3.2 Data Limitations -18- 4.0 DESCRIPTIVE RESULTS -20- 4.1 Fees for Intermediate Office Visits -20- 4.2 Fees for Intermediate Hospital Visits -22- 4.3 Fees for Selected Specialty Services -22- 4.4 Comparison of Medicare Fees to Other Fees, 1976 and 1984 -27- 4.5 Urban-Rural and Regional Differences in Relative Fees -29- 4.6 Variation in Medicare Payment Differentials -35- 4.7 Correlations Among the Fees of Different Payors ——n -38- 5.0 EXPLAINING MEDICARE FEE DIFFERENTIALS -40- 5.1 Regression Results -44- 5.2 Regression Results for Follow-up Hospital Visit -50- 6.0 SUMMARY AND IMPLICATIONS -52- PART II: A COMPARISCW OF 1988 MEDICARE PHYSICIAN CHARGES, SIMULATED MEDICARE FEE SCHEDULE AMOUNTS, AND COMMERCIAL INSURER PHYSICIAN CHARGES -56- 7.0 INTRODUCTION TO PART II -56- 8.0 DATA -57-. 8.1 Medicare Charges and Fee Schedule Payments -57- 8.2 Commercial Insurer Physician Charges -58- 9.0 METHODS -58- 9.1 Area Definitions -58- 9.2 Choice of Services for Study -59- 9.3 Computation of Medicare Fees -64- 9.4 Computation of Medicare Fee Schedule -65- 9.5 Computation of Commercial Insurer Fees -66- 9.6 Explanation of Fee Comparison Tables -68- I FEEll/5 TART.F. OF COHTEMTS (conti"ys't^) PAGE 10.0 RESUI.TS -72- 10.1 Summary Table for Services -72- 10.2 Summary Tables for Areas -77- 10.3 Results for Individual Services by Area -82- 10.3.1 Surgical Services -83- 10.3.2 Medical Services -106- 11.0 CONCLUSIONS AND IMPLICATIONS -141- REFERENCES FEEll/5 TABLE OF TABLES PAGE TABLE 1 USABLE RESPONSES TO 1984 PPCIS FEE QUESTIONS BY PROCEDURE, SPECIALTY, AND PAYOR •14- TABLE 2 NATIONAL AVERAGE FEES BY PAYOR AND SPECIALTY, FOR INTERMEDIATE OFFICE VISITS (CPT-4 90060), 1984 -21- TABLE 3 NATIONAL AVERAGE FEES BY PAYOR AND SPECIALTY, FOR FOLLOW-UP HOSPITAL VISITS {CPT-4 90260), 1984 -23- TABLE 4 NATIONAL AVERAGE FEES BY PAYOR AND SPECIALTY, FOR SELECTED SERVICES, 1984 -24- TABLE 5 RATIO OF NATIONAL AVERAGE MEDICARE FEES TO THOSE OF OTHER PAYORS, 1976 AND 1984 -28- TABLE 6 MEAN PHYSICIAN OFFICE AND HOSPITAL VISIT FEE BY PAYOR AND URBAN-RURAL LOCATION, ALL SPECIALTIES, 1984 -31- TABLE 7 MEAN PHYSICIAN OFFICE AND HOSPITAL VISIT FEE BY PAYOR AND REGIONAL LOCATION, ALL SPECIALTIES, 1984 -32- TABLE 8 DISTRIBUTION OF MEDICARE-PRIVATE PHYSICIAN PAYMENT DIFFERENTIALS -36- TABLE 9 CORRELATIONS AMONG THE OFFICE AND HOSPITAL VISIT FEES OF DIFFERENT PAYORS, ALL SPECIALTIES, 1984 -39- TABLE 10 MEANS AND DEFINITIONS OF DEPENDENT AND INDEPENDENT VARIABLES FOR REGRESSION ANALYSIS -45- TABLE 11 REGRESSION RESULTS EXPLAINING VARIATIONS IN MEDICARE DISCOUNT RATES: INTERMEDIATE OFFICE VISIT -46- TABLE 12 REGRESSION RESULTS EXPLAINING VARIATIONS IN MEDICARE DISCOUNT RATES: FOLLOW-UP HOSPITAL VISIT -51- TABLE 13 DISTRIBUTION ACROSS AREAS OF NUMBER OF COMMERCIAL INSURER (HIAA PHCS) CHARGES, BY SERVICE -61- TABLE 14 SERVICES CHOSEN FOR DETAILED ANALYSIS -63- TABLE 15 RELATIONSHIP AMONG MEAN MEDICARE AND COMMERCIAL INSURER (HIAA) FEES BY SERVICE: WEIGHTED AREA AVERAGE, 1988 -73- TABLE 16 RELATIONSHIP AMONG MEAN MEDICARE AND COMMERCIAL INSURER (HIAA) FEES BY AREA: WEIGHTED SURGICAL SERVICES AVERAGE, 1988 -76- TABLE 17 RELATIONSHIP AMONG MEAl-I MEDICARE AND COMMERICAL INSURER (HIAA) FEES BY AREA: WEIGHTED MEDICAL SERVICES AVERAGE, 19! -78- TABLE 18 RELATIONSHIP AMONG MEAN MEDICARE AND COMMERICAL INSURER (HIAA) FEES BY AREA: WEIGHTED ALL-SERVICE AVERAGE, 1988 -79- FEEll/5 TART.F. OF TaRT.F.s (continued) PAgE TABLES SI-A THROUGH S24-A MEAN MEDICARE AND COMMERCIAL INSURER (HIAA) PHYSICIAN FEES, BY SERVICE AND AREA, 1988 85-137 TABLES Sl-B THROUGH S24-B RELATIONSHIP AMONG MEAN MEDICARE AND COMMERCIAL INSURER (HIAA) FEES, BY SERVICE AREA, 1988 86-168 FEEll/5 TABLE OF FIGURES PAGE FIGURE 1 A MODEL OF PHYSICIAN RELATIVE FEES -6- FIGURE 2 THE EFFECT OF A PREVAILING FEE CONSTRAINT ON MEDICARE DISCOUNTS -41-

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