Healthcare Payments Data (HPD): Medical Out-of-Pocket Costs and Chronic Conditions, 2022
Californians with one or more chronic conditions had significantly higher out-of-pocket costs than those with no chronic conditions – a consistent finding across counties and payer types. Californians with one or more chronic conditions experienced out-of-pocket costs 7x higher than those with no chronic conditions ($210 vs. $30) across all payers, excluding Medi-Cal.
Introduction
The Medical Out-of-Pocket Costs and Chronic Conditions report allows users to explore various aspects of the financial responsibility for medical care experienced by California consumers with at least one visit in 2022. These visualizations are made possible by data collected as part of HCAI’s Healthcare Payments Data (HPD) program. For more information about the HPD:
The focus of this report is medical out-of-pocket (OOP) costs, which are consumer payments for medical care that is covered but not reimbursed by insurance. These include the deductibles, co-payments, and co-insurance associated with medical services. In addition to the annual median OOP cost per member, the report can be used to visualize the number of members (unique individuals) with at least one medical visit in 2022 and the median number of claims per member. These metrics can be viewed by payer type, across all payer types or across all payer types excluding Medi-Cal. The last option is provided because California has a large Medi-Cal population–since Medi-Cal OOP costs are typically zero, the inclusion of Medi-Cal data skews the median out-of-pocket cost downward. For additional details see the Notes below the visualization and the Technical Note documentation.
The visualizations can answer a range of questions such as:
- What is the median OOP cost for people with diabetes in 2022? How does that compare to people with diabetes plus other chronic conditions, and to people with no chronic conditions?
- How many people with Medi-Cal coverage had a medical encounter in 2022? How does that compare to commercial, Medicare Advantage, and Medicare Fee-for-Service coverage?
- Which counties have the lowest and highest median OOP costs?
Key Findings
- In 2022, out of 26,749,106 Californians who had at least one medical visit, 10,805,417 of them (40%) are Medi-Cal members. The majority of these Medi-Cal visits had an out-of-pocket medical cost of $0.
- In 2022, the annual median out-of-pocket cost per member was highest for Medicare Fee-for-Service ($574), followed by Commercial ($60), Medicare Advantage ($35) and Medi-Cal plans ($0).
- Californians with one or more chronic conditions had a higher number of claims than those with no chronic conditions. For example, in Santa Barbara County, the annual median claim count per member with one or more chronic conditions was 15 compared to 4 for members with no chronic conditions.
- In 2022, the majority of Californians experiencing chronic conditions were grappling with multiple chronic conditions.
- The top 5 most prevalent chronic conditions across all payer types in California are hypertension, hyperlipidemia, diabetes, depression, and anxiety.
- The annual median out-of-pocket cost per member is the highest for members with acute myocardial infarction ($2,268), followed by hip/pelvic fracture ($1,375), and stroke ($1,020) across all payers excluding Medi-Cal. These conditions also had a wider cost range compared to other chronic conditions.
Notes:
- This report focuses on cost-sharing OOP spending associated with medical services; premiums, the cost of prescription drugs and out-of-plan spending are not included in the OOP costs reported. “Out-of-plan” spending refers to costs incurred by individuals outside of their coverage plans and is not captured by HPD.
- The term claims is used in these dashboards to refer to both medical claims and encounters.
- The member counts only include individuals who had at least one medical claim in 2022.
- Data on OOP costs comes from HPD claim and encounter records and represent the payer’s understanding of the individual’s financial responsibility for the service. The data do not identify whether the individual made the OOP payment.
- Medicare beneficiaries who are eligible for both Medicare and Medi-Cal (“dual eligibles”) and covered under a Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) are counted under the Medicare Advantage payer type.
- Individuals may have supplemental coverage for OOP costs that is not included in the analysis. For example, Medicare beneficiaries in the Medicare Fee-for-Service (traditional Medicare) program may purchase supplemental coverage (also called Medigap) that pays for OOP costs such as copayments and coinsurance.
- The utilization and OOP data are based on the location of the residence of the individual receiving services, not the location of the provider.
- Any cell size smaller than 30 is suppressed in the results. Complementary cells may also be suppressed if they allow the unmasking of suppressed data.
Feedback
HCAI will continue to advance the accessibility and usefulness of HPD as the database becomes more comprehensive and complete and as HCAI builds its capacity over time.
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Glossary
Metrics
- Annual Member Count: The number of unique individuals who received at least one medical service in 2022.
- Annual Claim Count Per Member: The number of distinct claims or encounters associated with a member for all members who received at least one medical service in 2022. Each claim or encounter contains information about one or more medical services received by the member, the associated cost-sharing OOP costs, the provider (e.g., a physician or facility) that provided the service or services, and the date or date range on which these were rendered.
- Annual Out-of-pocket (OOP) Cost per Member: Cost data are reported to HCAI using the All-Payer Claims Database Common Data Layout (APCD-CDLTM). The sum of the following data elements was used to calculate the total OOP cost incurred by a member for all members who received at least one medical service in 2022.
| Copay Amount (CDLMC126) | The total co-payment dollar amount across all services on a claim for which the member is responsible. |
| Coinsurance Amount (CDLMC127) | The total coinsurance dollar amount across all services on a claim for which the member is responsible. |
| Deductible Amount (CDLMC128) | The total dollar amount of the deductible across all services on a claim for which the member is responsible. |
Payer Types
Payers are the companies, programs, and organizations that oversee insurance plans and reimburse healthcare providers. Three main types of payers make up the majority of the insurance market.
- Commercial: Insurance products for which the coverage premium is paid by a private party, such as an employer, individual, or other entity.
- Medicare Fee-For-Service: A federal Medicare program managed and administered by the Centers for Medicare & Medicaid Services (CMS) that provides Hospital (Part A) and Medical (Part B) coverage.
- Medicare Advantage: A federal Medicare program administered through commercial insurers; also known as Medicare Part C or Medicare Managed Care. This includes specialized managed care programs such as Special Needs Plans (SNPs).
- Medi-Cal: A public health insurance program that provides free or low-cost medical services and healthcare benefits to low-income individuals, financed from state and federal funds; California’s version of Medicaid. The Medi-Cal data includes Fee-for-Service and Managed Care grouped together.
How HCAI Created This Product
This product was developed using medical claims data submitted to HCAI’s Healthcare Payments Data (HPD) program, California’s All-Payer Claims Database (APCD).
- Only medical claims paid during 2022 were included.
- Only individuals with at least one medical visit during 2022 were included in the analysis; 8,451,351 members with no utilization during 2022 were excluded.
- Claim records were removed from the analyses if no corresponding eligibility record was found to confirm the member had medical coverage from the payer listed on the claim in that month.
- The HPD Program identifies and tracks individuals across different payers over time. The approach is continually refined to ensure an accurate count of unique individuals. As these methods improve, the HPD Program expects to identify more linkages – cases in which two or more records are determined to belong to a single individual. Therefore, the count of unique individuals is likely to decrease over time as linkages are improved.
- To show geographic variation, the data was broken down by county.
- Health conditions were identified based on diagnosis codes and defined using the criteria outlined by the Centers for Medicare & Medicaid Services (CMS) in the Chronic Conditions Data Warehouse. See the Technical Note and the Chronic Conditions Data Warehouse (CCW) Chronic Conditions Algorithms and Change History documentation for more information.
- To protect patient personal information, the California Health and Human Services Agency has adopted a policy of statistically masking or de-identifying sensitive data (CalHHS Data De-identification Guidelines). Data from any group with less than 30 individuals was removed from the analyses and suppressed in the visualizations. Complementary cells may also be suppressed if they allow the unmasking of suppressed data.
- Additional information on how HCAI created this product is available in the report’s Technical Note.
Additional Information
Topic: Cost Transparency
Source Link: Cost Transparency – Healthcare Payments Database
Citation: HCAI – Healthcare Payments Data (HPD): Medical Out-of-Pocket Costs and Chronic Conditions, 2022
Temporal Coverage: 2022
Spatial/Geographic Coverage: County, Statewide
Frequency: Annually