CENTERFORHEALTH INFORMATIONANDANALYSIS
ANNUALREPORTON THEPERFORMANCEOFTHEMASSACHUSETTSHEALTHCARESYSTEM
SUPPLEMENT4:COMMERCIALTOTAL MEDICALEXPENSES
CommercialTotalMedicalExpenses
CommercialTotalMedicalExpenses(TME)is onecomponentofTotalHealth
CareExpenditures(THCE).Itincludesexpendituresbycommercialpayers onbehalf offully-insuredandself-insuredmembers in Massachusetts. Theseexpendituresconsistofclaimsandnon-claims(suchasperformance paymentstohealthcareprovidersbycommercialpayers),aswell as
membercost-sharing(deductibles,co-payments,andco-insurance).1TMEis measuredonapermemberpermonth(PMPM)basis.
KeyFindings:
Overallcommercialhealthcare expendituresgrew to$18.4billionin2013,anincreaseof2.2%.
Total MedicalExpensespercommercially-insured memberpermonthgrewby1.7%to$430.
Commercialspendingforhospitaloutpatient servicesgrew3.8%,thehighestrateofgrowth amongallservicecategories.
BlueCrossBlueShieldofMassachusettshadthe
highestrate ofgrowth(3.65%)amongallpayersinhealth statusadjustedTotalMedicalExpenses,exceedingthe state’sspendinggrowthbenchmarkof3.6%.
TotalSpendingfor
CommerciallyInsuredMembers
Healthcareexpendituresforthe Commonwealth’scommercially-insured populationgrewfrom$18.1billionin2012to
$18.4billionin2013,a2.2%increase(Figure
4.1).TMEforcommercialpayersrepresents thelargestcomponentofcommercial expendituresincludedinTHCE.
4.1
Total Spending forCommercially Insured Members 2012 – 2013
Totalspendingincreasedby+3.5%forfull- claimmembers(forwhomthepayersareable tocollectandreportspendinginformation
foracomprehensivesetofbenefits).Forthe partial-claimmembers(forwhomthepayers areunabletocollectandreportspending informationforcarvedoutservicessuchas behavioralhealthandprescriptiondrugs),total spendingdecreasedbyanestimated1.2%.2
Expendituresforthecommercialpayersthat arenotrequiredtoreportTMEdatatoCHIA butarelicensedtoofferhealthinsurancein Massachusettswereestimated;theseestimated expendituresdeclinedby18.6%,from$17.7 millionin2012to$14.4millionin2013.34
Figure4.1:TotalSpendingfor
CommerciallyInsuredMembers
2012–2013
1TheprimarydatasourceforthiscategoryistheTotal MedicalExpense(TME)datareportedtoCHIAannuallybylargecommercialpayersthatarelicensedinMassachusetts.Pleasesee TechnicalAppendixforthelistofcommercialpayersannuallyreportingTMEdatatoCHIA.TME includesspendingforMassachusettsresidentsonly.
2Theestimatesforthepartialclaimsspendingwere developedforeachapplicablepayer’s partial-claimpopulationbaseduponitsfull-claimpopulation.
3Thesepayerscollectivelyrepresent lessthan1%ofcommercialmarketenrollment.
I.TotalMedical
ExpensesforCommercial
Full-Claim Members
StatewidecommercialTMEforthefull-claim memberswas$430permemberpermonth (PMPM)in2013,a1.7%increasefromthe
$423PMPMin2012(Figure4.2).56
CommercialTME byServiceCategory TMEiscomposedprimarilyofpayments madetohospitalsandphysicians.In2013,
asin2012,hospitalandphysicianservices
includingnon-claimpaymentsaccountedfor
75%ofstatewide commercialTME(full-claim populationsonly).7Allservicecategories exceptOtherMedicalgrewmoderatelyfrom
2012to2013.Spendingforhospitaloutpatient serviceshadthegreatestincreaseofallservice categoriesfrom2012to2013at3.8%.This growthcouldberelatedtoanincreasein outpatientvolumeand/oranincreaseinprices paidforhospitaloutpatientservices.Other servicecategorieswithnotableincreasesin growthratesfrom2012to2013include:non- claims(1.5%)andnon-physicianprofessional services(3.7%).
Figure4.2:StatewideCommercial FullClaimsTMEPMPMbyServiceCategory 2012-20138
4.2 / Statewide Commercial Full ClaimsTME PMPM by Service Category 2012 - 2013 / CommercialTME byPayerAfteradjustingTMEforpayer-reported
changesinhealthstatusofthefull-claim
members,9theonlypayerthatreportedhealth
statusadjusted(H.S.A.)TMEgrowthbetween
2012and2013exceedingthe3.6%benchmark
wasBlueCrossBlueShieldofMassachusetts
ofMA(BCBS),thelargestcommercialpayer
intheCommonwealth(Table4.1).BCBS
H.S.A.TMEincreasedby3.65%.BCBSalso
reportedaslightdecreaseof1.5%inmember
healthstatusscore,indicatinganimprovement
4See TechnicalAppendixandtheTotalHealthCare ExpendituresMethodologyPaper.Availablefrom:
http://www.mass.gov/chia/docs/r/pubs/13/thce-methodology.pdf(AccessedAugust19,2014).
5StatewideTMEisnotadjustedforthehealthstatusofpayers’coveredmemberpopulations sincethetoolsusedforsuchadjustmentsvaryamongpayersresultinginadjustmentsthatare notuniformordirectlycomparableacrosspayers.
6Thisinitialassessmentincorporatesuptofourmonthsofclaimsrun-out,andincludesestimates
forclaims completionand projectedfinancialsettlements.
7Non-claimspaymentsaregenerallymadetophysiciangroupsandhospitalsforquality
performance, financialsettlements,and other purposes.
inoverallhealthstatusofitsmembers,which maycontributetoalargerproportionalgrowth inBCBS’H.S.A.TME.Withoutadjusting
formemberhealthstatus,TMEforBCBS
increasedby2.1%.
Table4.1:UnadjustedandHealth- StatusAdjustedTMEforCommercial Full-ClaimMembersbyPayer
4.1
Unadjusted andHealth-StatusAdjustedTMEforCommercial Full-Claim Members byPayer
a.Commercialpartialclaims arenotshown due tothevariabilityofcoveredbenefits/servicesbetweenpayers.
b.Cigna reportedonenewlineofcommercialbusinessfor2013whichwasnotincludedinthetable.Pleasesee theDataAppendixfordetailedinformation.
c.CeltiCarealsohadasmallsizeofcommercialbusinesswithtotalof6,060membermonthsin2012and7,379 membermonthsin2013.
d.BMCHealthNetand Network Healthbeganofferingcommercialfull-claimproductsin2013. Thesizeofthe
commercialbusinessisverysmallforthesetwopayers:totalof5,020membermonthsforBMCHealthNetand
2,609membermonthsforNetworkHealth.
8NotethatthepercentagechangesinFigure1.2arecalculatedfromthefulldollarvalues,and maynotmatchtheroundedvaluespresentedinthechart.
9ThetoolsusedforadjustingTMEforhealthstatusofapayer’scoveredmembersvaryamong payerssothatadjustmentsarenotuniformordirectlycomparableacrosspayers.Pleasenote that TMEdataisnotadjustedfordifferencesincoveredbenefits withinpayersand between
payers. Thus,theunadjusted TMEreflectstheactual spendingforeachpayer’smemberswithout adjustingfordifferencesinbenefits and member health status.Healthstatusadjusted(H.S.A.) TMEforthecommercialpartial-claimpopulationsarenotcomparablebetweenpayersduetowidevariationincoveredservices,andthelackofuniformityinhealthstatusriskadjustments.
For more information, please contact:
CENTERFORHEALTH INFORMATIONANDANALYSIS
TwoBoylstonStreet
Boston,MA02116
617.988.3100 www.mass.gov/chia
Publication Number14-245-CHIA-05