Health Costs

How We Compute Average Total Costs Associated with Complex Tests and Services

Episodes of Care

In most cases, CompareMaine reports the average costs for a single procedure, which may include both a professional and a facility component. For example, if you go to the hospital for an MRI, there will be a cost that is paid to the hospital (facility) and a cost that is paid to the radiologist (professional) that reads the MRI. When more than one facility provides care, the facility with the largest part of the bill is the "Lead Provider" and all costs are attributed to them.

Episodes of care are created by software that organizes claims data into a set of services provided to treat a clinical condition or procedure – this is referred to as a bundled payment. The surgical procedures reported on CompareMaine are outpatient procedures and include the primary procedure plus all related procedures or services that took place 30 days prior and 30 days after the main procedure, with the exception of the following codes, that are limited to the day of the procedure:

  • Colonoscopy with biopsy for noncancerous growth
  • Colonoscopy without biopsy for encounter for preventative health services
  • Colonoscopy with removal of polyps or growths using an endoscope
  • Upper gastrointestinal (GI) endoscopy without biopsy
  • Upper gastrointestinal (GI) endoscopy with biopsy
  • Repair of groin hernia patient age 5 years or older
  • Removal of tonsils and adenoid glands patient younger than age 12

For example, a C-section may include the costs of ultrasounds, doctor appointments, blood work, surgeon fees, medications used before, during, and after surgery (like an epidural), a hospital stay, and follow-up appointments.

CompareMaine release 7.0 was the first time MHDO used Optum’s Symmetry® Episode Treatment Groups® (ETG) grouper. The ETG software is an illness classification tool that groups medical and pharmacy claim line information together into episodes of care. To ensure that only relevant services are included, the episodes are built from the CPT codes that appear on the claim lines and are associated with the complex procedure of interest. Services received at the same time but not associated with the complex procedure are not grouped into the episode. Once the episodes are created MHDO uses custom logic to produce cost estimates.

The ETG is used for the following procedures:

  • Carpal tunnel release surgery
  • C-section (Cesarean delivery)
  • Colonoscopy with biopsy for noncancerous growth
  • Colonoscopy without biopsy for encounter for preventative health services
  • Colonoscopy with removal of polyps or growths using an endoscope
  • Gallbladder removal
  • Hip replacement
  • Knee replacement
  • Surgical arthroscopy of knee
  • Surgical arthroscopy of shoulder
  • Upper gastrointestinal (GI) endoscopy without biopsy
  • Upper gastrointestinal (GI) endoscopy with biopsy
  • Vaginal delivery
  • Repair of groin hernia patient age 5 years or older
  • Removal of tonsils and adenoid glands patient younger than age 12

The median payments are calculated by considering all eligible episodes, regardless of severity. However, since we use the median to calculate the average cost and the median episode tends to be the most common type, the episode typically has no complications or problems and minimal severity.

Emergency Department Visits

There are five Emergency Department (ED) CPT Codes:

  • Emergency department visit, very minor (CPT Code 99281) – represents 1.1% of ED claims in Maine’s APCD
  • Emergency department visit, low complexity (CPT Code 99282) – represents 13.2% of ED claims in Maine’s APCD
  • Emergency department visit, moderate severity (CPT Code 99283) – represents 29.1% of ED claims in Maine’s APCD
  • Emergency department visit, problem of high severity (CPT Code 99284) – represents 35.7% of ED claims in Maine’s APCD
  • Emergency department visit, problem with significant threat to life or function (CPT Code 99285) – represents 21.0% of ED claims in Maine’s APCD

We calculate estimates for ED visits based on claims from the same member on the same day that have any of the five ED CPT Codes. The “lead code” is the CPT Code associated with the facility component of the claim, while the professional component can be any of the five ED CPT Codes. For example, if the facility component of an ED episode is CPT Code 99283, the claim will be associated with that CPT Code, regardless of if the professional component is CPT Code 99821, 99282, 99283, 99284 or 99285.