Are There UnnAre There UnnIn WorkerIn Worker

ecessary Medical Costs ecessary Medical Costs yrs’ Compensation?

yrs’ Compensation?

OutlineOutline

Great Recession funnecessary costsunnecessary costsDefining “unneceUsing interstate bUsing interstate bopportunities

focuses attention on s in all public programss in all public programsssary” costsbenchmarks to focus onbenchmarks to focus on

Where Might TheWhere Might TheWhere Might TheMedical Costs?Where Might TheMedical Costs?

Unnecessarily higUnnecessarily hig

U dUnnecessary med

ere Be Unnecessaryere Be Unnecessaryere Be Unnecessary ere Be Unnecessary

gh/low medical prices?gh/low medical prices?

di l ?dical care?

40 States Regul40 States RegulInpatient Hospit

Regulation, 2009

No Regulation

latedlated tal Prices

Hospital InpatieHospital InpatieHospital InpatiePer Diem RatesHospital InpatiePer Diem Rates

Range of Per D

Lowest State9 State Median Highest StateHighest State

Rates are from the Guide for Pohospital (200–900 beds) in a laare for the first two days of the

ent Fee Schedules –ent Fee Schedules –ent Fee Schedules s – High/Low = 6xent Fee Schedules s – High/Low = 6x

Diem Rates (2009)

Surgical Stay$1,338$ ,$2,059 $8,906$8,906

Policymakers, calculated for a large arge city in 9 states. Per diem rates e inpatient stay.

Wide Range ofWide Range ofWide Range of Fee Schedules –Wide Range of Fee Schedules –Range of DRG Rates 2009

13 State Median

2009

Georgia

IllinoisIllinois

Rates are from the GuidRates are from the Guidfor a large hospital (200

Hospital InpatientHospital InpatientHospital Inpatient – DRG Rates Hospital Inpatient – DRG Rates

Knee

Procedures(DRG 489)

Back & Neck

Procedures(DRG 491)(DRG 489) (DRG 491)

$9,473 $7,662

$8,969 $7,254

$30 185 $16 524$30,185 $16,524

de for Policymakers, calculatedde for Policymakers, calculated 0–900 beds) in a large city.

41 States Regula41 States RegulaHospital Outpatie

Regulation, 2009

No Regulation

atedated ent Prices

Fee Schedule forFee Schedule forRanges From $10

Level I APC 41

e eArthroscopy

CPT 29881

Hernia Repair CPT 49505

APC 154

Median, 2009

$0 $1000

Rates are from the Guide for Polihospital (200–900 beds) in a larstates for CPT.

r Arthroscopyr Arthroscopy 000 to $8000

0 $2000 $3000 $4000 $5000 $6000 $7000 $8000

licymakers, calculated for a large rge city in 11 states for APC and 7

43 States Reg43 States RegNon-hospital P

Regulation, 2009

No Regulation

gulatedgulated Provider Prices

Most Non hospitaMost Non-hospita40% To 90% Abo

175%

200%

225%

re-2

009

125%

150%

175%

ate

Med

icar

50%

75%

100%

er T

han

Sta

0%

25%

MA FL CA MD NY HI

NC

WV UT MI

PA SC KY CO OK

OH%

Gre

ate

M W O

Source: Benc

al Fee Schedules Wereal Fee Schedules Were ove Medicare In 2009

OH TX VT KS AR SD NM

WA LA ME

MN

GA TN MS

WY AL

ND AZ

CT

NE

MT

OR

NV ID DE IL AK

O N W M W

hmarking FS 2009

Vicodin Cost 50%Vicodin Cost 50%

$0 50

$0.60

$0.70

ll P

aid

s

$0.30

$0.40

$0.50

ice

Per

Pi

har

mac

ies

$0.10

$0.20

vera

ge P

riTo

Ph

$0.00MA PA WI CA* M

Claims With >7 Days Of Los

Av

September 2006, Prescr

* CA And NY Data BeforePharmac

% More An LA As PA, Why?% More An LA As PA, Why?

MI FL IA MD NJ TN IL IN NC TX NY* LA

st Time, Injuries From October 2005 To riptions Filled Through March 2007

e Major Statutory Changes Affecting cy Reimbursements

Where Might TheWhere Might TheWhere Might TheMedical Costs?Where Might TheMedical Costs?

Unnecessarily higUnnecessary medUnnecessary med

ere Be Unnecessaryere Be Unnecessaryere Be Unnecessary ere Be Unnecessary

gh/low medical prices?dical care?dical care?

Might There Be MoMight There Be MoMight There Be MoStates with HigherMight There Be MoStates with Higher

40%

50%

kSu

rger

y

20%

30%

Wit

h B

ack

10%

20%

Dis

c C

ases

0%CA TX FL PA MD MA%

Of

2000 2003 Claims With > 72000-2003 Claims With > 7Up To 12 Months

ore Unnecessary Surgery inore Unnecessary Surgery inore Unnecessary Surgery in r Surgery Rates?ore Unnecessary Surgery in r Surgery Rates?

IL CT WI MI LA GA IN NC AR TN

7 Days Of Lost Time In 16 States7 Days Of Lost Time In 16 States, s Of Medical Treatment

M F t UM F t UMore Frequent UsInconsistent With More Frequent UsInconsistent With

40%

45%

50%

With

MRIs

20%

25%

30%

35%

LBP C

ases

Wit

5%

10%

15%

20%

% O

f NSL

0%MA WI CT MD CA I

2000 2003 Claims With > 72000-2003 Claims With > 7Up To 12 Months

Of MRIOf MRIse Of MRIs, Evidence-Based Guidelines

se Of MRIs, Evidence-Based Guidelines

N MI GA PA IL TX NC TN FL LA AR

7 Days Of Lost Time In 16 States7 Days Of Lost Time In 16 States, s Of Medical Treatment

Pain ManagemePain ManagemePain ManagemeTwice As Often Pain ManagemeTwice As Often

60%

70%

anag

emen

t

30%

40%

50%

With

Pai

n M

a

njec

tion

s

10%

20%

30%

Of Dis

c Cas

es W

In

0%CT MA MI CA MD T

% O

f

2000 2003 Claims With > 72000-2003 Claims With > 7Up To 12 Months

ent Injections Usedent Injections Usedent Injections Used in IN, GA vs. CT, MA

ent Injections Used in IN, GA vs. CT, MA

TX PA FL LA TN NC WI AR IL GA IN

7 Days Of Lost Time In 16 States7 Days Of Lost Time In 16 States, s Of Medical Treatment

Average NumbAverage NumbAverage NumbWith Rx HigherAverage NumbWith Rx Higher

m

500

600

Per

Cla

im

300

400

er O

f P

ills

ith

Rx

100

200

ge N

umbe W

i

0NJ MI MA WI IL INA

vera

g

Claims With > 7 Days Of LoClaims With > 7 Days Of LoSeptember 2006, Presc

* CA and NY Data BeforePharmac

er Of Pills Per Claimer Of Pills Per Claimer Of Pills Per Claim r In LA And TXer Of Pills Per Claim

r In LA And TX

N IA TN PA MD NC NY* FL CA* TX LA

st Time Injuries From October 2005 Tost Time, Injuries From October 2005 To criptions Filled Through March 2007

e Major Statutory Changes Affecting cy Reimbursements

Physician DispPhysician DispPhysician DispMost CommonPhysician DispMost Common

50%

60%

Wer

e si

cian

s

30%

40%

All

Rx

That

ed

By

Ph

ys

10%

20%

% O

f A

Dis

pen

se

0%MA NY TX WI IA LA

Claims With > 7 Days Of Lost Time, I2006, Prescriptions F

*Prior to law change that

ensing Rx Drugsensing Rx Drugsensing Rx Drugs In IL, MD, MI & FLensing Rx Drugs In IL, MD, MI & FL

A NC TN IN NJ PA IL MD MI FL CA*

Injuries From October 2005 To September Filled Through March 2007

t reduced physician dispensing

Physician-DispensePhysician-DispensePhysician DispenseThan Pharmacies FPhysician DispenseThan Pharmacies F

Top 7 DrugsTop 7 Drugs

HydrocodoneHydrocodone--Acetamin (VicodinAcetamin (Vicodin®®))

Ibuprofen (MotrinIbuprofen (Motrin®®))Ibuprofen (MotrinIbuprofen (Motrin ))Cyclobenzaprine HCl (FlexerilCyclobenzaprine HCl (Flexeril®®))Naproxen (AleveNaproxen (Aleve®®))P hP h N APAP(D tN APAP(D t®®))PropoxyphenePropoxyphene--N APAP(DarvocetN APAP(Darvocet®®))Carisoprodol (SomaCarisoprodol (Soma®®))Ranitidine HCl (ZantacRanitidine HCl (Zantac®®)*)*

•This drug was available over-the-co(Source: Walgreens.com, 10/28/200

ers Received Higher Pricesers Received Higher Pricesers Received Higher Prices For Same Rx: FL Exampleers Received Higher Prices For Same Rx: FL Example

% Of Rx % Of Rx Dispensed Dispensed

By PhysicianBy Physician

Price Per PillPrice Per PillIn FloridaIn Florida

% Diff.% Diff.

Ph i iPh i i PhPhy yy y PhysicianPhysician PharmacyPharmacy

12%12% $0.96$0.96 $0.46$0.46 +109%+109%

47%47% $0 49$0 49 $0 34$0 34 +44%+44%47%47% $0.49$0.49 $0.34$0.34 +44%+44%33%33% $1.33$1.33 $1.19$1.19 +12%+12%49%49% $1.58$1.58 $1.17$1.17 +35%+35%19%19% $1 00$1 00 $0 63$0 63 59%59%19%19% $1.00$1.00 $0.63$0.63 +59%+59%54%54% $3.05$3.05 $0.62$0.62 +392%+392%95%95% $3.15$3.15 $1.46$1.46 +116%+116%

unter 35 cents per pill09, bottle of 24 pills of Zantac® 150mg)

OutlineOutline

Great recession founnecessary costsunnecessary costsDefining “unneceUsing interstate bUsing interstate bopportunities

ocuses attention on s in all public programss in all public programsssary” costsbenchmarks to focus onbenchmarks to focus on

Questions?Questions?

Richi t @rvictor@

617.66

hard Victor@ i t@wcrinet.org61.9274 x274