Reimbursement Variation Report | Green Mountain Care Board

Reimbursement Variation Dashboard

Background

The Reimbursement Variation Report focuses on the amount providers were reimbursed for providing certain medical services. To determine the amount providers were reimbursed for medical services the total allowed amount is used from the All-Payer Claims Database, VHCURES.

The total allowed amount includes payments from the payer (insurer share) and the expected payment from the patient (expected member share). Allowed amounts are the full payment negotiated between providers and payers. For this report, the allowed amount is considered the “price” of the episode or service. Of note, the allowed amount is different than what providers charge. Most hospital facilities make available their charge amounts on what is called the “charge master”.

The amount the patient is responsible for, the expected member share, is determined based on the patient's insurance. Patients with Medicaid coverage generally have a lower amount of cost sharing than those covered by other types of health insurance. The expected member share is submitted to VHCURES with the insurance claim payment; however, the data do not show if the expected member share was paid by the member, by an HRA/HSA fund, etc.

This report is required by 18 V.S.A. § 9411.

Policy Context

The Green Mountain Care Board has provided reports, briefs, and legislative comments on the usability and feasibility of what are commonly known as "price transparency tools". Historically these communications have identified both: (1) the expense of building a price transparency tool from the APCD, and (2) the data limitations which could impact such a tool's usability. Below are some of those such communications.

The Reimbursement Variation Report attempts to share the information available on the variation of insurance payments within groups (i.e., Commercial reimbursement), and across groups (i.e., Medicaid vs. Medicare reimbursements).

There are several related and compelling policy questions which are out of scope of this report:

Comparing reimbursement trends to identify areas of payment inequity for providers (i.e. between doctors working for hospitals versus independent providers)
Determining "fair" market price for services in network versus out of network for commercial insurers
State-wide rate setting for Medicaid or Commercial insurers.
For the price, are Vermonters receiving high quality care?

Other statewide reporting provides in-depth evaluation of health system quality and hospital-based quality metrics which should be used in consideration with any reimbursement data to begin to consider value. Some of these such reports and evaluations include but are not limited to:

Interpretation

This report is not inclusive of all Vermonters' care, of all episodes or service types, or of all occurrences for each episode. The report is limited to Vermonters with insurances that submit data to VHCURES.

The report includes episodes of care for certain medical services determined appropriate for comparison between providers. It is limited to the types of services that can be aggregated in the inpatient setting, outpatient setting, and some commonly occurring outpatient diagnostic episode service types, but does not include all services occurring in office (sometimes referred to as "professional" or "non-facility" settings). Lastly, service types where a provider delivered at least 30 episodes of care are included, and for many types of care, this limits the final dataset.

For example, deliveries are limited to cesarean and vaginal deliveries which took place in the inpatient setting with low severity and where at least 30 deliveries were performed in that year, at that hospital facility, for that insurer. The net result is that the report compares a subset, not the totality of, of all deliveries that took place in the year for Vermonters.

Refer to the Technical Documentation within Tableau for more detailed information about the data and its limitations.