2013 Health Care Cost and Utilization Report October 2014 www.healthcostinstitute.org Copyright 2014 Health Care Cost Institute Inc. Unless explicitly noted, the content of this report is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 4.0 License 2013 Health Care Cost and Utilization Report Letter from the Executive Director The Health Care Cost Institute (HCCI) is pleased to release the 2013 Health Care Cost and Utilization Report. This report is the first examination of 2013 data, and it details the health care cost and utilization trends for Americans younger than age 65 and covered by employer sponsored insurance (ESI). In 2013, health care spending for the national ESI population grew 3.9%. This growth rate was similar to the rates observed in 2011 (4.0%) and 2012 (3.7%). Spending growth for 2013 was driven mainly by rising prices rather than by utilization, as use of many services declined. As in previous years, this growth in spending was not consistent across various ESI population groups. For this report, HCCI detailed the health care cost and utilization trends across age, gender, and geographic sub- populations. We hope that you find the report informative. In reviewing the last year, HCCI has engaged in numerous efforts we want to make sure you are aware of.  Medicare data: The Centers for Medicare & Medicaid Services (CMS) certified HCCI as the first national Qualified Entity, granting HCCI access to use for quality reporting Medicare Parts A, B, and D data for the entire country.  APCD collaboration: HCCI’s ongoing partnership with Vermont yielded the first HCCI-produced public report for the state’s all payer claims database (APCD). This report, the 2007-2011 Vermont Health Care Cost and Utilization Re- port, described health care cost and use trends for Vermonters covered by ESI and compared these trends to the nation- al ESI population for the years 2007 through 2011.  Academic research: The HCCI dataset is being validated as a recognized data source for academic research. In the Octo- ber 2013 issue of Health Affairs, HCCI published an article examining the longitudinal health care trends of the ESI population. The August 2014 issue of Health Affairs included the first article published by academic researchers us- ing HCCI’s dataset, “Health Spending Slowdown is Mostly Due to Economic Factors, Not Structural Change in the Health Care Sector.”  Dataset access: HCCI created the Academic Research Partnership program to expand access by academic researchers to HCCI-held claims data. The initial partners included major public and private universities, two actuarial associations, and two government agencies.  State health reform grants: HCCI and the National Academy for State Health Policy (NASHP), with funding from the Laura and John Arnold Foundation, launched a grant program designed to promote academic research of state health reform efforts.  Transparency initiative: HCCI has partnered with our data contributors and other stakeholders to develop a free Web- based portal to provide health care price and quality information to the public. More information can be found on the HCCI Website (www.healthcostinstitute.org). In addition to these activities, HCCI continues to be a source of public reporting on spending and utilization trends of the ESI population younger than age 65. Along with this report, HCCI recently produced the Children’s Health Spending: 2009-2012 report and an issue brief on the medical health care trends for young adults (ages 19–25). Our work over the last year would not have been possible without ongoing support from our stakeholders and partners. We look forward to continue working with them on our expanding agenda of activities in 2015. David Newman Executive Director, HCCI www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report i Executive Summary BY THE NUMBERS: 2013 This report, 2013 Health Care Costs expenditure growth for the ESI popu- and Utilization, is the fourth in a series lation. of annual reports by the Health Care Cost Institute (HCCI) on the health A number of spending trends from 3.9% 2011 and 2012 continued in 2013. care activity of individuals who are The increase in per capita health care The Northeast region of the county younger than age 65 and covered by spending per insured. continued to have the highest per cap- employer-sponsored health insurance ita expenditures ($5,037 per insured) (ESI). The report’s study period (2011 and the highest rate of spending -2013) covers the years after passage of the Affordable Care Act (ACA) and growth (4.8%). The West continued -0.5% & 5.8% to have the lowest expenditures prior to the opening of health insur- The decline in utilization and increase ($4,542 per insured) and lowest ance exchanges. As in previous years, in price paid for outpatient services. growth rate (3.0%). Children (ages 0– the report details the levels and 18) and young adults (ages 19–25) changes in per capita expenditures continued to have the lowest per capi- (“spending”), utilization (“use”), and prices of medical and prescription ta expenditures ($2,574 and $2,676, -15.5% & 21.2% respectively) and the fastest expendi- services used by the ESI population. The decline in utilization and increase ture growth (4.6% and 4.5%). 1,2 Also, for the first time, it details pat- in price paid for brand prescriptions. terns of spending and service use by A number of earlier trends, however, age-gender groups of the ESI popula- did not persist in 2013. Spending in the West grew faster in 2013 than in tion. 4.5% & -0.5% previous years. Spending growth in In 2013, spending for the national ESI the South experienced the highest The increase in utilization and decline population grew 3.9% (Table 1). rate in 2012 but slowed to 3.6% in in prices paid for generic prescrip- Spending was driven up by rising 2013, the second lowest growth rate. tions. prices of medical services and brand For young adults and intermediate prescriptions (see “Key definitions”), adults (ages 26–44), spending growth while use of inpatient and outpatient services and brand prescriptions fell also slowed by more than a percent- 0.8% & 2.5% age point, whereas spending growth (Table 2). Separately, the use of filled The increase in utilization and in- for pre-Medicare adults (ages 55–64) days of generic prescriptions grew crease in price paid for professional grew faster than in 2012 by nearly 4.5%, while the average price fell by services. two percentage points. Per capita 0.5%. health care spending for women Despite uneven growth among ($5,403) remained higher than spend- ESI sub-populations, national ing for men ($4,305), but the growth 8.0% trend remained stable rate for men accelerated while the rate for women slowed. The increase in utilization of specialist In 2013, ESI health care expenditures office visits. increased by 3.9% ($183 per capita) Spending on medical services to $4,864 per insured (Table 1). Since and prescriptions continued to 2010, per capita ESI health spending rise in 2013 grew by an average 3.9% per year. Spending trends in 2013 were similar This health care spending trend is to those observed in 2011 and 2012, considerably slower than historical with 20% of expenditures on acute www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report ii inpatient admissions, 28% of expend- Inpatient, outpatient, and brand scriptions. Professional services itures on outpatient care, 34% of ex- prescription use fell showed increases in both average penditures on professional services, price and utilization, whereas higher In 2013, medical service use fell for and the remaining 17% of expendi- use of generic prescriptions offset the acute inpatient admissions, outpa- tures on prescriptions. Spending on effects of a lower average price.2013 tient visits, and outpatient-other ser- acute inpatient care (3.9%) and pro- vices (Table 3). Acute inpatient ad- Notable trends: use of services by fessional procedures (3.3%) grew faster in 2013 than in 2012 (1.7% and missions per 1,000 declined 2.3% due age-gender groups; emergency to lower medical (-5.1%) and surgical room spending; brand prescrip- 2.9%, respectively). Outpatient ser- (-3.7%) admissions per 1,000 in- tion spending; CNS agents; de- vices continued to be the fastest- sureds (Appendix Table A5). Driving mographics of generic prescrip- growing medical service category in the decline in the number of outpa- tion use terms of spending, but between 2012 tient visits (-0.8%, or 3 visits per and 2013, growth slowed from 6.3% Utilization by adult women higher 1,000 insureds; Table 2) were de- to 5.2%. Prescriptions spending rose than that of men until age 55. clines in outpatient surgery and emer- by 3.1%, with a spending growth fast- gency room visits (Appendix Table In 2013 adult women (ages 19–54) er on generic (3.9%) than on brand A5). Use of outpatient-other services had levels of outpatient and profes- (2.4%) prescriptions. declined by 0.5% (Table 3) due to sional service use higher than those of Professional service and generic fewer ancillary and lab/path adult men (Appendix Table A10a). In prescription use rose (Appendix Table A5) services used. particular, use of outpatient and pro- In 2013, professional service use rose Also in 2013, use of brand prescrip- fessional lab/path and radiology ser- 0.8% (Table 3), due to rising utiliza- tions fell sharply by 15.5% (Table 3). vices was higher for women than for tion of commonly used services, such Continuing a multiyear trend, use de- men within the same age group. After as office visits to specialists (1,493 clined for the most commonly filled age 54, pre-Medicare adult men and services per 1,000 insureds; Appendix detailed categories (see “Key defini- women used these services at rela- Table A5) and laboratory and pathol- tions”) of brand prescriptions tively similar rates. ogy (lab/path) services (4,719 ser- (hormones and synthetic substitutes, Spending levels for emergency room vices per 1,000 insureds). Office visits cardiovascular drugs, CNS, and gas- visits similar across adult age groups, to specialists grew by 8.0%, and use trointestinal drugs; Appendix Table despite differences in use. of lab/path services increased by A5). In 2013, spending on emergency 1.9%. Increases in the use of these Rising prices pushed up medical room (ER) visits for young adults was detailed categories offset declining use in other professional detailed ser- and brand prescription spending $310 per capita and $314 per capita for pre-Medicare adults. Overall, ER vice categories, such as office visits to In our annual analyses of ESI health use rates declined with age; however, primary care providers (-3.8%). care spending, HCCI examines chang- the average price paid by older adults es in utilization rates and prices paid Also in 2013, generic prescriptions was higher than that paid by young for care. Our findings for 2013 spend- use increased by 4.5% (Table 3), the adults, due to both higher prices and ing are consistent with those for 2011 lowest growth rate observed since higher intensity of care for older and 2012: that rising prices, rather 2011. Generics accounted for 83.3% adults. than utilization, were the primary of prescription filled days in 2013. drivers of spending growth for all Brand spending highest for antirheu- The four mostly commonly filled de- medical service categories and brand matic agents. tailed categories of generic prescrip- prescriptions (Table 2 and Table 3). tions were central nervous system In 2013, the top four classes of brand For acute inpatient, outpatient, and (CNS) agents, cardiovascular drugs, prescriptions, by per capita spending, brand prescriptions, expenditures hormones and synthetic substitutes, were antirheumatic agents, biologic rose owing to rising prices and that and anti-infective agents (Appendix response modifiers, insulins, and an- growth was moderated by falling uti- Table A5). Of these prescriptions, only tiretrovirals (Table 4). Spending on lization. Exceptions to this trend were use of anti-infective agents declined (- brand antirheumatic agents was $49 professional services and generic pre- 1.8%). per capita. Collectively, spending on www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report iii these drugs was $154 per insured, women (Tables 9–12). For girls, rate similar to those in 2011 and totaling 28% of ESI spending on young adult women, and intermediate 2012. In each of those years, rising brand prescriptions. adult women the most commonly medical and brand prescription prices used class of generics was contracep- led to spending growth. However, CNS prescriptions dominated generic tives. unlike in 2011 and 2012, declining usage. utilization in 2013 offset price in- In 2013, spending per insured on CNS Conclusions creases, keeping expenditure growth agents, drugs that affect the brain and Differences in spending and use historically slow. spinal column, was $90 (Appendix across these groups are relevant not Table A4). CNS agents accounted for only to the insureds, but also to em- 31.4% of generic drug spending per ployers and policymakers interested capita and 27.1% of the generic filled in health care trends during this pre- days (Appendix Table A5). Antide- exchange period. For 2013, HCCI pressants were the most commonly found that utilization rose for some filled class of CNS generic prescrip- services and populations affected by tions (Table 6) and the most used ge- the ACA, including preventive visits neric drug class for young adult men, and contraception, but these services intermediate adult men, middle age generally contributed little to overall adult women, and pre-Medicare adult spending. ESI spending increased, at a KEY DEFINITIONS What is per capita spending? Per capita spending in this report is the estimate of total expenditures paid divided by the employer-sponsored in- sured population. What are medical service, subservice, and detailed categories? Three medical service categories are identified: inpatient facility, outpatient facility, and professional procedures. HCCI also reports on three facility subservice categories: acute inpatient, which includes labor and delivery, medical, mental health and substance use, newborn, and surgery claims; outpatient visits; and outpatient-other services.7 These are further classified into “detailed service” categories. What are prescription service, subservice, detailed service categories, and subclasses? HCCI analyzes prescription drug and device claims from pharmacies. The prescription service category is further clas- sified by brand and generic drug subservice categories. These are further classified into “detailed service” categories, and further into subclasses.7 What is intensity? Intensity is a measure of the complexity of a service, including the length of time, the severity of the illness addressed, and the amount of resources required for treatment. Many factors can account for changes in the intensity of services, including new and better forms of treatment, the health status of the population receiving services, and reimburse- ment system modifications that either encourage or discourage one form of treatment over another. HCCI does not currently calculate intensity of prescriptions. What is an intensity-adjusted price? Isolating the effect of intensity on the price paid per service allows for the calculation of an intensity-adjusted price. The patient never sees this price directly. In metrics, intensity equal to 1 would lead to no difference between prices paid and intensity-adjusted prices. Intensity greater than 1 would lead to intensity-adjusted prices being higher than prices paid; and an intensity-level less than 1 would mean that intensity-adjusted prices were less than the prices paid. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 1 Annual Health Care Expenditures KEY FINDINGS: 2013 Per Capita In this report, annual health care ex- encing this trend, including slower penditures per capita consist of the economic growth, changing benefit Growth rate remained spending on medical and pharmacy designs, and health system reform.3,4,5 stable claims by individuals covered by ESI. Growth in per capita spending was Per capita expenditures were calcu- Between 2012 and 2013, per capita 3.9%, a similar rate to 2011 (4.0%) lated for the national ESI population, expenditures for people age 65 or and 2012 (3.7%). across detailed sub-populations younger and covered by ESI rose (including regions, genders, age $183 per person to $4,864 (Table 1 groups, age-gender groups), and and Figure 1). This reflects a growth across broad and detailed service cat- rate of 3.9%, similar to the rats ob- $4,864 egories (see “Key definitions”). served in 2011 and 2012. The spending per capita for the nation- Although the annual spending growth al ESI population For third year, national expendi- rate was similar across these years, tures growth remained stable the underlying trends for those years For the three years of the study peri- were quite different. As shown in Ta- $2,574 & 4.6% od, per capita health spending by the ble 1, 2013 health care expenditures ESI population grew at rates faster per capita grew for all sub- The spending per capita and growth than those in 2010 but slower than populations examined (regions, age rate for children, the lowest per capita rates between 2007 and 2009. This groups, and genders), but at rates spending and highest growth rate of report does not investigate the rea- different from those in 2011 and any age group. sons for that slower growth, but other 2012. research suggests many factors influ- $5,037 & 4.8% The spending per capita and growth rate for the Northeast, the highest re- gional per capita spending and growth rate. $849 & 5.5% The spending per capita and growth rate for outpatient visits, the highest service category growth rate. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 2 spending for any other sub- populations, followed by spending for girls and boys. Conversely, spending for intermediate adult men grew the slowest of the age-gender groups studied, followed by intermediate adult women. Between 2012 and 2013, per capita spending increased in every region (Table 1). However, during this time, spending growth slowed considerably in the South (from 4.6% to 3.6%), and sped up by more than a percentage point in the West (from 1.7% in 2012 to 3.0%). For the third consecutive year, the Northeast had the highest regional Health care expenditures grew dren and 4.5% for young adults) but per capita expenditures ($5,037) and the lowest per capita spending levels. the fastest spending growth (4.8%). fastest for men, children, and Per capita expenditure growth was The West continued to have the low- young adult men the slowest for intermediate adults est regional per capita expenditures Spending per capita in 2013 was (3.2%); spending for this group rose ($4,542) and the slowest expendi- more than $1,000 higher for women $131 to $4,258. tures growth (3.0%). Between 2012 than for men ($5,403 versus $4,305), and 2013, per capita spending in the consistent with prior years. Per capita Within each age group in 2013, South increased by $173 to $4,964. spending rose $173 for men and $192 spending growth rates also varied by Per capita spending in the Midwest for women. However, per capita gender (Figure 3). Spending for young increased 4.2% to $4,871, a $196 in- spending for men (4.2%) grew faster adult men grew more quickly than crease. as compared with the rate for women (3.7%), which was also true in 2011. In 2013, pre-Medicare adults had the highest expenditures per capita ($9,232) and the largest dollar in- crease per capita ($334; Table 1). They also had a growth rate higher than that in 2012: 3.7% versus 2.0% (Figure 2). Middle age adults experi- enced the second highest spending at $6,314 per capita and a $220 increase (3.6%) over 2012. The increases in per capita spending for the youngest age groups (children and young adults) were $113 and $115, respectively. These age groups experienced the highest per capita spending growth rates (4.6% for chil- www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 3 Per capita expenditures rose 66% of which was on outpatient vis- Per capita spending generally slowest for brand prescriptions its, with the rest on outpatient-other higher for adult women than services. adult men Per capita spending in 2013 increased across all service categories. The dis- Per capita expenditures on profes- In 2013, per capita spending for every tribution of per capita spending on sional procedures increased $53 and service category was higher for boys these categories was similar to that of grew more rapidly than in the previ- than for girls, with the largest spend- the previous two years (Table 1). Pro- ous year (3.3% versus 2.9%). Con- ing differential for brand prescrip- fessional procedures continued to sistent with the previous two years, tions (an $81 difference) and the account for the largest share of professional procedures also account- smallest for outpatient-other services spending, approximately 34% of the ed for the most per capita dollars (a $2 difference; Appendix Tables A9a total. Acute inpatient admissions re- spent in 2013 ($1,651). and A9b). However, girls had higher mained at 20% of expenditures, while growth rates for most services. Only outpatient services and prescriptions Per capita spending on prescriptions on acute inpatient admissions did accounted for the remaining 28% and grew somewhat more slowly in 2013 spending for boys (7.1%) grow faster 17% of expenditures, respectively. as compared with 2012 (3.1% versus than spending for girls (4.6%). De- 3.8%), following substantially slower spite faster spending growth for girls, Between 2012 and 2013, spending on growth in 2011 (1.7%). In 2013, per the overall spending differential be- acute inpatient admissions grew from capita spending on brand prescrip- tween boys and girls widened in 1.7% to 3.9% (Table 1 and Figure 4). tions grew $13 to $550, a 2.4% in- 2013. The spending increase in this catego- crease, following a 0.6% decrease in ry was $37 per capita, more than 2012. Brand prescriptions had the Across all service categories in 2013, twice the $16 increase seen between lowest growth rate in 2013 of any per capita expenditures were notably 2011 and 2012. subservice category. Expenditures on higher for young adult and intermedi- generic prescriptions grew 3.9%, af- ate adult women than for men in the Between 2012 and 2013, per capita ter spending declined in 2011 (-3.0%) same age groups. Per capita spending spending on outpatient services and grew 13.4% in 2012. Per capita on acute inpatient services for young slowed, including on both outpatient expenditures on generics ($287) were adult women was $642 and $1,088 visits and outpatient-other services. about half that of brand prescription for intermediate adult women as In 2013, expenditures per capita for expenditures ($550) in 2013. compared to $390 for young adult all outpatient services increased $68, men and $485 for intermediate adult men. These represented gender dif- ferences of $252 for young adults and $603 for intermediate adults. Per capita spending on most service categories was higher for middle age adult women and pre-Medicare adult women than for men in those age groups. Spending for middle age adult and pre-Medicare men was higher on acute inpatient admissions than for women, and spending on admissions grew more rapidly for the men. The differences in spending between men and women were smaller for these age groups than for intermediate adults. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 4 Summary groups were generally smaller than those in the younger age groups. Between 2012 and 2013, growth in HCCI AGE GROUPS total ESI spending persisted at a rate Consistent with findings in other HCCI similar to that of the two previous reports, this report found that spend- Children years, rising 3.9%. These expendi- ing levels and growth rates varied across age and gender.3 In 2013, Ages 0 through 18. tures rose across all regions, age groups, and genders. The Northeast spending for children was higher for continued to have the highest spend- boys than for girls, and was lower for Young Adults ing levels and growth, while the West men ages 19 to 54 than for women in continued to have the lowest spend- those age groups. For the oldest age Ages 19 through 25. ing levels and growth. group, spending was similar for pre- Medicare and women. Intermediate Adults Among the different age groups in 2013, children experienced the fastest Ages 26 through 44. expenditure growth but the lowest per capita spending levels. Pre- Medicare adults had the highest per Middle-Age Adults capita spending but, unlike spending in 2011 and 2012, the spending Ages 45 through 54. growth rate for this age group was not the lowest. Women’s per capita Pre-Medicare Adults spending remained higher than men’s, but men’s expenditures grew Ages 55 through 64. more quickly. Spending tended to increase with age, but the gender dif- ferentials in the older adult age www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 5 Table 1: Annual Expenditures Per Capita (2011—2013) Percent Percent Percent Change Change Change 2011 2012 2013 2010 / 2011 2011 / 2012 2012 / 2013 Per Capita $4,514 $4,681 $4,864 4.0% 3.7% 3.9% Per Capita by Region Northeast $4,601 $4,805 $5,037 4.5% 4.4% 4.8% Midwest $4,512 $4,675 $4,871 4.0% 3.6% 4.2% South $4,581 $4,791 $4,964 4.2% 4.6% 3.6% West $4,337 $4,409 $4,542 3.5% 1.7% 3.0% Per Capita by Age 18 and Younger $2,356 $2,461 $2,574 7.9% 4.5% 4.6% 19-25 $2,427 $2,561 $2,676 7.9% 5.5% 4.5% 26-44 $3,945 $4,127 $4,258 3.4% 4.6% 3.2% 45-54 $5,867 $6,094 $6,314 3.6% 3.9% 3.6% 55-64 $8,727 $8,898 $9,232 3.1% 2.0% 3.7% Per Capita by Gender Men $3,997 $4,132 $4,305 4.6% 3.4% 4.2% Women $5,011 $5,211 $5,403 3.6% 4.0% 3.7% Per Capita by Service Category Inpatient $947 $962 $999 3.7% 1.6% 3.8% Acute Inpatient $933 $949 $986 4.3% 1.7% 3.9% Outpatient $1,230 $1,308 $1,376 5.9% 6.3% 5.2% Visits $750 $804 $849 6.5% 7.2% 5.5% Other $481 $504 $528 4.8% 4.8% 4.7% Professional Procedures $1,553 $1,598 $1,651 4.0% 2.9% 3.3% Prescriptions $783 $813 $838 1.7% 3.8% 3.1% Brands $540 $537 $550 4.0% -0.6% 2.4% Generics $243 $276 $287 -3.0% 13.4% 3.9% Source: HCCI, 2014. Notes: Data represents the population of insureds 0-64 covered by ESI. Actuarial completion was performed on data from 2012 and 2013. All per capita dollars calculated from allowed amounts. All figures rounded. Skilled nursing facility (SNF), hospice, and ungroupable claims were excluded from analysis of acute inpatient trends due to the lack of claims in this population. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 6 Drivers of Spending Growth Health care cost growth is the result would pay for a given service categories, while utilization declined of changes in the number of services (“intensity-adjusted price”). HCCI us- for these categories, except for a small provided (“utilization”) and the prices es intensity-adjusted prices to deter- increase in use of professional ser- paid by insurers for those services. mine whether prices changed owing vices (0.8%; Table 2). While the Because changes in price or utiliza- to differences in service intensity (the spending growth rate for 2013 (3.9%) tion might reflect changes in how care resources used to treat patients) or to was very similar to the growth rate in is delivered, HCCI’s analyses also con- changes in other factors. 2012 (3.7%), the components of the sider a third factor – changes in ser- 2013 trend – specifically, use of medi- In the following sections of the report, vice intensity – the complexity of ser- cal services – differed from those in HCCI analyzes how the different com- vices used to provide care. Intensity is 2012. ponents of spending affected health used to adjust utilization metrics (see care trends for each of the subservice “Key definitions”) or to adjust prices categories. For 2013, HCCI found that paid to a base price that all patients prices grew for all medical subservice Table 2: Decomposition of Spending Changes (2013) Components of 2013 Components of 2013 2013 Expenditures Trend Price Trend Expenditures Per Capita Utilization Prices Paid Intensity Unit Price Inpatient 3.8% -2.7% 6.7% N/A N/A Acute Inpatient 3.9% -2.3% 6.3% 1.7% 4.5% Outpatient 5.2% -0.5% 5.8% 0.2% 5.5% Visits 5.5% -0.8% 6.4% -0.5% 6.9% Other 4.7% -0.5% 5.2% 1.8% 3.4% Professional Procedures 3.3% 0.8% 2.5% 1.8% 0.7% Prescriptions - Filled Days 3.1% 0.7% 2.3% N/A N/A Brands 2.4% -15.5% 21.2% N/A N/A Generics 3.9% 4.5% -0.5% N/A N/A Source: HCCI, 2014. Notes: Data represents the population of insureds 0-64 covered by ESI. Actuarial completion was performed on data from 2012 and 2013. All per capita dollars calculated from allowed amounts. All figures rounded. Skilled nursing facility (SNF), hospice, and ungroupable claims were excluded from analysis of acute inpatient trends due to the lack of claims in this population. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 7 Acute Inpatient Services Inpatient facility claims are submitted Use continued to decline for most increase was $1,067 over 2012. Acute for facility charges associated with a insureds inpatient prices rose in 2013 at a rate hospital admission.7 In this section, HCCI Consistent with previous years’ trends, (6.3%) faster than in 2011 (5.9%) or analyzed trends for acute inpatient ad- acute inpatient utilization declined in 2012 (5.5%). Rising prices offset the fall missions (labor and delivery, medical, 2013, falling by 2.3% (Table 3 and Fig- in utilization, which led to the faster mental health and substance use, new- ure 5). This decrease in admissions is spending growth in 2013 compared to borns, and surgery). For information equivalent to fewer admissions per the two prior years. about the non-acute inpatient admis- 1,000 insureds, which declined from 56 The faster growth in prices was driven sions (hospice and skilled nursing facili- admissions per 1,000 in 2012 to 55 per in part by rising intensity of care. In ty), see “Non-acute inpatient services”.8 1,000 in 2013. 2013, the average intensity (see “Key Acute inpatient spending grew fast- In 2013, acute admission rates declined definitions” and “Drivers of spending er in 2013 for most age groups and for both gen- growth”) rose 1.7%, suggesting that the ders (Appendix Tables A10a and A10b). resources used to treat patients in an Between 2012 and 2013, spending on The largest decline in admissions was acute inpatient setting increased. This acute inpatient admissions increased for middle age and pre-Medicare wom- followed two years of decreased re- 3.9% to $986 per capita (Table 1). This en, whose use decreased by 4 admis- source use; in 2011, there was a 4.4% $37 per capita increase accounted for sions per 1,000 insured. However, girls decrease in intensity, and that intensity 20% of the ESI population’s total spend- experienced an increase of 1 admission level persisted through 2012. In 2013, ing increase. The increases in the spend- per 1,000. the average intensity-adjusted price in- ing level and growth rate for acute inpa- Prices jumped in 2013 due to rising creased by $594 (4.5%) to $13,812. tient admissions were higher for 2013 intensity of care Medical and surgical admissions as compared with 2011 and 2012. In contrast to the falling utilization rate, declined; prices and intensity in- the average price per acute inpatient creased admission rose for the third consecutive In 2013, about 62% of acute inpatient year, to $18,030 in 2013 (Table 3). This admissions were for medical and sur- gery services (Appendix Table A5 and Figure 5). Since 2011, however, utiliza- tion of medical and surgical admissions decreased (Figure 6). Between 2011 and 2013, medical admissions dropped from 21 medical admissions per 1,000 in- sureds to 19 admissions per 1,000. Simi- larly during this period, surgery admis- sions dropped from 16 per 1,000 in- sureds to 15 per 1,000. Although medical and surgery admis- sions decreased, the average prices for those services rose (Appendix Table A6). In 2013, the average price of an inpatient surgery admission rose 8.5% ($2,720) to $34,583. The average price www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 8 Summary In 2013, utilization of acute inpatient services declined (Table 3). This over- all decrease was observed for most age-gender groups, whereas girls had an increase of 1 admission per 1,000 (Appendix Table A10a). While utiliza- tion declined, the average price per acute inpatient admission rose 6.3% (Table 3). Accompanying the rise in prices was a rise in the average inten- sity of resource use. As a result, in 2013, the fastest acute inpatient spending growth was observed dur- ing the study period. of a medical admission rose 7.4% newborns, and mental health and Across the study period, trends for ($1,059) to $15,413. The medical and substance use (MHSU) remained con- the detailed categories of admissions surgical service categories also ac- stant (Appendix Table A5). Addition- remained nearly the same for most counted for the largest increases in ally, in 2013, average prices for LD types of admissions. Most of the de- acute inpatient intensity, at 2.4% and and newborn admissions rose (4.6% cline in utilization and increase in 3.3%, respectively (Appendix Table and 4.0%, respectively) at rates much prices in 2013 came from the most A7). Thus, after accounting for service slower than those in the previous two commonly used admissions: medical intensity, the average intensity- years (Appendix Table A6). The aver- and surgery (Appendix Table A5). adjusted prices for medical and sur- age price for a MHSU admission rose Prices and intensity for these services gery admissions also rose (4.9% and very slightly (0.4%). Intensity of care rose, driving the rise in prices and 5.1%, respectively; Appendix Table remained constant for LD admissions intensity for the overall acute inpa- A8). since 2011 (Appendix Table A7), tient service category (Appendix Ta- while intensity increased slightly for bles A6 and A7). Little change in labor, delivery, MHSU and newborn admissions, newborn, and behavioral health which contributed slightly to the in- admission rates crease in prices paid for those ser- For the third year in a row, admis- vices. sions for labor and delivery (LD), NON-ACUTE INPATIENT SERVICES Skilled nursing facility (SNF) and hospice inpatient admissions differ in scope from the acute inpatient detailed catego- ries. Inpatient SNF care includes claims for skilled professional care such as skilled nursing and rehabilitation. Inpa- tient hospice claims are for palliative care to terminally ill individuals. Hospice services can also be provided within an individual’s home, but those services are not included in the HCCI hospice inpatient category. These two categories had consistently low per capita expenditures over time (Appendix Table A5). During the study period, per capita annual expenditures were $7 for SNF admissions and $2 for hospice admissions. One reason for these comparatively low spending levels was low utilization. SNF and hospice admissions accounted for very few ad- missions in the younger than 65 ESI population. Combined, these two categories accounted for 2 admissions per 1,000 insureds in each year studied (Appendix Table A6). www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 9 Table 3: Changes in Utilization, Prices, Intensity, and Intensity- Adjusted Prices by Service Category (2011—2013) Percent Change Percent Change Percent Change 2011 2012 2013 2010 / 2011 2011 / 2012 2012 / 2013 Utilization per 1,000 insureds by Service Category Inpatient 61 59 57 -1.7% -3.5% -2.7% Acute Inpatient 58 56 55 -1.5% -3.5% -2.3% Outpatient 2,936 2,948 2,933 1.0% 0.4% -0.5% Visits 324 328 325 1.6% 1.3% -0.8% Other 2,612 2,620 2,608 0.9% 0.3% -0.5% Professional Procedures 16,133 16,452 16,579 1.1% 2.0% 0.8% Prescriptions - Filled Days 278,316 279,959 282,012 0.1% 0.6% 0.7% Brands 69,484 55,028 46,497 -12.0% -20.8% -15.5% Generics 208,802 224,883 235,017 4.9% 7.7% 4.5% Average Price Paid per Service by Service Category Inpatient $15,627 $16,452 $17,553 5.5% 5.3% 6.7% Acute Inpatient $16,086 $16,963 $18,030 5.9% 5.5% 6.3% Outpatient $419 $444 $469 4.8% 5.8% 5.8% Visits $2,315 $2,450 $2,607 4.8% 5.8% 6.4% Other $184 $192 $202 3.9% 4.4% 5.2% Professional Procedures $96 $97 $100 2.9% 0.9% 2.5% Prescriptions - Filled Days $3 $3 $3 1.6% 3.2% 2.3% Brands $8 $10 $12 18.2% 25.6% 21.2% Generics $1 $1 $1 -7.5% 5.3% -0.5% Average Intensity per Service by Service Category Acute Inpatient 1.28 1.28 1.31 -4.4% -0.1% 1.7% Outpatient 2.96 2.90 2.91 -1.2% -1.9% 0.2% Visits 16.79 16.07 16.00 -2.9% -4.2% -0.5% Other 1.24 1.25 1.27 0.9% 0.6% 1.8% Professional Procedures 1.91 1.89 1.93 0.1% -0.9% 1.8% Average Intensity-Adjusted Price per Service by Service Category Acute Inpatient $12,528 $13,218 $13,812 10.8% 5.5% 4.5% Outpatient $142 $153 $161 6.1% 7.9% 5.5% Visits $138 $152 $163 8.0% 10.5% 6.9% Other $148 $154 $159 3.0% 3.8% 3.4% Professional Procedures $50 $51 $52 2.8% 1.8% 0.7% Source: HCCI, 2014. Notes: Data represents the population of insureds 0-64 covered by ESI. Actuarial completion was performed on data from 2012 and 2013. All per capita dollars calculated from allowed amounts. All figures rounded. Skilled nursing facility (SNF), hospice, and ungroupable claims were excluded from analysis of acute inpatient trends due to the lack of claims in this population. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 10 Outpatient Visits Between 2012 and 2013, per capita spending on outpatient visits (emergency rooms, observation, and outpatient surgery) rose by $45 to $849, a 5.5% increase (Table 1). As in 2012, outpatient visits had the highest spend- ing growth rate of any of the service cat- egories. In 2013, per capita spending on outpatient visits accounted for 17.5% of total per capita spending, a small in- crease over 2012 and nearly 25% of the rise in per capita spending. Between 2012 and 2013, per capita ex- penditures grew for the three detailed service categories (ER visits, observa- tion, and outpatient surgery; Appendix Table A4). Per capita spending on obser- vation visits rose at the fastest rate, the study period in which the number of adults, and intermediate adult men and 9.3%, compared with that of emergency visits declined. women (Appendix Tables A16a-A18a). room (ER) visits (5.9%) and surgical Men and women over age 44 had fewer visits (5.0%). In contrast, observation There were fewer ER and outpatient ER visits relative to those of younger visits remained a very small share of surgery visits in 2013. ER visits fell by 3 ages, while surgery visits dominated overall outpatient visit spending at 4.8% visits per 1,000 insureds (-1.6%) to 176, older adults’ outpatient visit usage ($41 per capita), compared with the while outpatient surgeries fell by 1 visit (Appendix Tables A19a and A20a). share of surgery visits at 61.9% ($526 to 128 per 1,000 insureds (-0.7%; Ap- per capita) and the share of ER visits at pendix Table A5 and Figure 7). In con- Overall, use of observation services rose 33.1% ($281 per capita). trast, observation visits rose by 1 visit with age. Between 2012 and 2013, use (4.6%) to 21 per 1,000 insureds. increased for both men and women in Outpatient prices continued to rise the two oldest age groups. Use increased Visits rose with age, but use dif- The average price for an outpatient visit by 3 visits to 40 visits per 1,000 for pre- rose 6.4% between 2012 and 2013 fered by gender Medicare men and by 3 visits to 41 visits (Table 3), from $2,450 to $2,607. The In 2013, the number of outpatient visits per 1,000 for pre-Medicare women. Use average price (unadjusted for intensity generally increased with age, but the increased by 1 visit to 21 visits per of care) for ER visits grew by 7.6% to number of services used differed by gen- 1,000 for middle age men and by 2 visits $1,595 (Appendix Table A6); for outpa- der, as adult women had more visits to 29 visits per 1,000 for middle age tient surgery visits by 5.7% to $4,107; than did men (Figure 8). Girls had the women. Use among the other groups and for observation visits by 4.5% to lowest use of outpatient visits (219 per remained constant at the levels ob- $1,945. 1,000), followed by young adult men served in 2012. (220 visits per 1,000; Appendix Table Outpatient visits fell slightly in Between 2012 and 2013, outpatient sur- A10a). Use of outpatient visits was high- 2013 gery use levels also increased with age, er for pre-Medicare women (496 visits while declining slightly for the national Between 2012 and 2013, the number of per 1,000) than for pre-Medicare men ESI population (-0.7%; Appendix Table outpatient visits declined (-0.8%), fall- (454 visits per 1,000). A5). The younger groups (younger than ing from 328 visits per 1,000 insureds to ER visits accounted for most of the out- age 45) had the lowest rates of outpa- 325 (Table 3). This was the first year in patient visits among children, young tient surgery use and larger reductions www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 11 ages, while surgery visits dominated older adults’ outpatient visit usage (Appendix Tables A19a and A20a). Summary Outpatient visits (ER, outpatient sur- gery, and observation visits) constituted the fastest growing category of medical spending for all three study years and totaled 17.5% of ESI per capita health care spending in 2013 (Table 1). At 6.4% growth in 2013, prices for these services rose faster than in 2011 or 2012 (Table 3). However, for the first time in the study period, in 2013 the number of visits per 1,000 fell. As in 2011 and 2012, relatively few outpa- tient visits were for observation stays in 2013 (Appendix Table A5). Among peo- in use. Outpatient surgery use increased visits accounted for about 40% of the ple younger than age 45, ER visits ac- for the pre-Medicare adults (3 visits per visits for middle age adults (Appendix counted for 60% of outpatient visits, 1,000 pre-Medicare men and 1 visit per Table A19a) and for about 30% of visits whereas for those age 45 and older, out- 1,000 pre-Medicare women) and was for pre-Medicare adults (Appendix Ta- patient surgeries made up the most of stable for middle age adult men. ble A20a). Young adult women had the the outpatient visit use (Appendix Ta- highest number of ER visits (258 per bles A16a-A20a). Although spending on ER visits was sim- 1,000 young adult women; Appendix ilar across age groups, spending does Outpatient visits use varied by gender Table A17a), while pre-Medicare adult not fully reflect utilization trends. In within age groups. Adult women, gener- men had the lowest number (143 per 2013, use of ER visits decreased with ally, used more outpatient services than 1,000 men; Appendix Table A20a). age, and the number of visits differed by adult men in the same age cohort. For gender. ER visits accounted for nearly ER visits accounted for most of the out- observation and outpatient surgeries, 80% of the outpatient visits for children patient visits among children, young spending reflected these differences in and young adults (Appendix Tables adults, and intermediate adult men and use by gender and age. However, per A16a and A17a) and for about 60% of women (Appendix Tables A16a-A18a). capita spending on adult ER visits was the visits for intermediate adults ages Men and women over age 44 had fewer similar across adult age groups despite (Appendix Table A18a). In contrast, ER ER visits relative to those of younger differences in utilization. WHY IS ER SPENDING HIGH FOR OLDER ADULTS WHEN ITS USE BY THIS AGE GROUP IS RELATIVELY LOW? In 2013, ER spending for the oldest adults was similar to that for the youngest adults – $326 per pre-Medicare woman as compared to $374 per young adult woman and it was $302 per pre-Medicare man and $246 per young adult man (Appendix Tables A12a and A15a). However, young adult women had 95 visits per 1,000 insureds more than pre- Medicare women; young adult men had 34 visits per 1,000 more than pre-Medicare men (Appendix Tables A18a and A20a). Health care spending rises and falls as prices and utilization rise and fall, which helps explain the levels of ER use. The average intensity-adjusted prices for ER visits for the oldest adults and young adults was similar ($263 per visits as compared to $269 per visit; data not shown), but the intensity of care was different. ER visit service intensity (resources used) for pre-Medicare adults was 47% higher than that for young adults. Because of the higher intensity, the average ER price paid for young adults was $628 lower than the average price paid for the oldest adults. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 12 Outpatient Other Services In 2013, per capita spending for outpa- tient-other services (ancillary, lab/path, radiology services, and miscellaneous outpatient services) accounted for 10.9% of total per capita ESI spending (Table 1). Between 2012 and 2013, per capita spending on outpatient-other services rose by $24 to $528. Spending for this service category grew 4.7% ($24), accounting for 13.1% of total per capita ESI spending growth. Per capita spending grew in 2013 for all four outpatient-other detailed service categories (Appendix Table A4). Ancil- lary services spending per insured grew by 3.7% to $80, and lab/path services spending per insured rose by 2.3% to $72. Together, these two categories made up 28.8% of outpatient-other erage prices grew most rapidly for ancil- (Appendix Table A5). Ancillary service spending. Miscellaneous services (e.g., lary services (5.5%) and miscellaneous use fell by 1.7% (7 fewer services per outpatient dialysis services, rehabilita- services (5.9%; Appendix Table A6). 1,000 insureds), while lab/path use fell tion, and mental health and substance Prices for radiology services also grew, by 2.0% (23 fewer services per 1,000 use services) made up 33.7% ($178 per by 2.2% to $501, while the average price insureds). However, lab/path services capita) of outpatient-other spending per for lab/path services grew by 4.4% towere still the most used of any of the insured. The largest share of spending $62. outpatient-other services: 1,147 ser- was on radiology services ($198 per vices per 1,000 insureds. At the same capita). Although radiology made up Outpatient-other services use fell time, use of miscellaneous and radiology 37.5% of per capita spending for outpa- Between 2012 and 2013, outpatient- services increased 2.6% and 0.5%, re- tient-other services, spending on radiol- other service use fell by -0.5% from spectively (Figure 9). ogy services grew relatively slowly 2,620 services per 1,000 insureds to (2.7%). Outpatient-other spending rose with 2,608 services per 1,000 insureds (Table Outpatient prices continued to rise 3). The 2013 decline in outpatient-other age services was due to declines in use of In 2013, per capita spending on outpa- The average price across all outpatient- ancillary and lab/path services tient-other services was highest for the other services rose 5.2% (Table 3). Av- REGIONAL VARIATIONS IN OUTPATIENT-OTHER SPENDING Regionally, over the three-year study period, outpatient-other spending in the West grew the slowest (an average 3.4% per year) and fastest in the Northeast (an average 5.4% per year; Appendix Table A1). The 2013 outpatient- other per capita spending was lowest in the West ($431 per person) and highest in the Midwest ($622 per person). Changes in spending levels for the West were also low in comparison to the other regions. Between 2011 and 2013, per capita spending on outpatient-other services rose by $59 in the Midwest and the Northeast and by $42 in the South, but rose by $28 in the West. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 13 pre-Medicare group and lowest for children (Appendix Table A2 and Fig- ure 10). Spending growth for young adult men, however, rose the most quickly – by 15.9% –to $255 per young adult man (Appendix Tables A9a and A9b). Spending grew the slowest for intermediate adult wom- en – at 2.8% – to $516 per intermedi- ate adult woman. For the three oldest age groups (intermediate adults, middle age adults, and pre-Medicare adults), women had the highest per capita spending on radiology services, whereas men had the highest spend- ing on miscellaneous services. Pre- Medicare women experienced the Summary other services (Appendix Table A5) highest per capita spending for any and were used most by adult women age-gender group on radiology ser- In 2013, outpatient-other services (Appendix Tables A17a-A20a). Radi- vices ($517; Appendix Table A15a). accounted for about 11% of total per ology services, which had the lowest Pre-Medicare men experienced the capita ESI spending (Table 1). Spend- levels of utilization per 1,000 in- highest per capita spending on mis- ing on this category grew 4.7% over sureds, were also used most frequent- cellaneous services ($411). For all spending in 2012. Prices also in- ly by adult women and at rates much children and young adults, the highest creased; however, for the first time in higher than those of adult men. The per capita spending was on miscella- the three-year study period, the num- gender differences in outpatient- neous services (Appendix Tables ber of services used per 1,000 de- other service use drove spending for A11a and A12a). creased (Table 3). women on this category to $115 per In 2013, lab/path services were the insured greater than spending for most commonly used outpatient- men (Appendix Table A3). ADULT WOMEN THROUGH AGE 54 HAD RATES OF SERVICE USE HIGHER THAN THOSE OF MEN Compared to adult men, adult women through age 54 had higher rates of utilization for most outpatient-other detailed categories. In 2013, these differences are observable in use of lab/path and radiology services. For young adult women, the use of lab/path services was nearly three times higher than men’s use in the same age group (1,020 per 1,000 women versus 346 per 1,000 men; Appendix Table A17a). Similarly, for radiology services, young adult women’s use was two times higher than young adult men’s use (156 per 1,000 women versus 74 per 1,000 men). These differences in use by gen- der continued in the older age groups. Intermediate adult women used 2.4 times more lab/path services and nearly 4 times more radiology services than did men in the same age group (Appendix Table A18a). Middle age adult women used 1.3 times more lab/path services and nearly 4 times more radiology services than did men in the same age group (Appendix Table A19a). Women’s higher use of radiology services continued, even as they neared Medicare-eligibility, with pre-Medicare women using more than 2.5 times more radiology services than did men in that age group (Appendix Table A20a). However, pre-Medicare women and men used nearly identical rates of lab/path services (2,213 per 1,000 men and 2,235 per 1,000 women). This study did not investigate which types of lab/path or radiology services drove these patterns or whether the spe- cific services in question were gender-specific. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 14 Professional Procedures Spending for women on profes- sional procedures was nearly $600 more than for men In 2013, both men’s and women’s spending on professional procedures grew by 3.3% (Appendix Table A3). However, spending for women reached $1,939 per capita, $586 more than per capita spending for men. Professional services expenditures were highest among pre-Medicare adults, at $2,781 per capita, and lowest among young adults, at $931 per capita (Appendix Table A2). However, spend- ing growth was fastest for young adults (4.2%), whereas it rose 3.4% for pre- In 2013, per capita spending on profes- ita more than the next highest spend- Medicare adults. sional procedures was $1,651 (Table 1 ing region (the South) and grew 1.9 and Figure 11). Spending increased percentage points faster than the next- Highest use of professional proce- slightly – by $53 per capita – over fastest region (the Midwest). In 2012, dures by pre-Medicare women 2012, which accounted for 29% of the the South had the fastest-growing pro- In all age groups, women used more total ESI spending increase. Profes- fessional services spending (4.0%) and professional services as compared with sional services grew at the lowest rate second highest spending per capita men (Appendix Table A10a). This gen- (3.3%) of any of the medical service ($1,641); in 2013, the South saw der differential was minimal for chil- categories spending rise by 2.7% to $1,686 per dren, with 301 per 1,000 more services capita. for girls than for boys. Among young Unlike in 2012, rising prices in 2013 contributed more than did utilization adults and intermediate adults, use by to increased spending on professional services (Table 2). Prices for profes- sional services grew by 2.5% (Table 3). This price growth equaled a $3 in- crease in the average price per service, which rose to $100. At the same time, use of professional services increased slightly by 127 services (0.8%), to 16,579 services per 1,000 insureds. Spending on professional services rose 5.1% in Northeast In 2013, professional services spend- ing rose in all four regions but grew most rapidly in the Northeast, up 5.1% to $1,855 per insured (Appendix Table A1). Spending was about $169 per cap- www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 15 women was nearly twice the use by and patterns, physician supply, and Table A17a), and more than children of men. Use was highest among the pre- population health. both genders. The pattern of substan- Medicare adults, but the gender differ- Of the non-visit detailed categories tially higher lab/path services use by ence in use in that age group was the within the professional procedures women within an age group persisted smallest of the adult age groups. Pre- category, utilization of three service for all of the adult age groups Medicare men’s utilization was 23,025 types declined between 2102 and 2013 (Appendix Tables A18a-A20a) services per 1,000, compared to (Appendix Table A5): miscellaneous Summary 28,177 services for pre-Medicare services (-0.3% - the most used profes- As in prior years, in 2013, the ESI pop- women. sional service); radiology (-1.2%); and ulation spent more on professional surgery (-0.1%). In contrast, use in- Office visits to specialists in- services per capita than on other medi- creased for other services, including creased by 8.0% cal services (Table 1). Professional preventive visits to PCPs (5.0%) and procedure spending growth (3.3%) In 2013, specialist office visits rose lab/path services (1.9%). was similar to the growth in 2012 8.0% (an increase of 111 visits per In 2013, lab/path services were the (2.9%), but utilization growth (0.8%) 1,000 insureds) to 1,493 services per second-most commonly used profes- was slower than in 2012 (2.0%; Table 1,000 insureds (Appendix Table A5 sional services (4,719 per 1,000 in- 3). and Figure 12); spending on these vis- sured). As with office visits, the use of its rose by 10.6% to $150 per capita Analysis of professional services lab/path services varied by age and (Appendix Table A4). Conversely, of- trends found distinct utilization differ- gender. Among children, per 1,000, fice visits to a primary care provider ences between women and men. Utili- boys used fewer lab/path services than (PCP) fell by 3.8% to 1,472 per 1,000 zation of lab/path services continued did girls (1,524 and 1,996 services, insured. This was the first year in to rise and, within each age group, respectively; Appendix Table A16a). which the number of specialists’ office women used more of these services Young adult women utilized substan- visits per 1,000 insureds was higher than did men. Additionally, specialist tially more lab/path services (5,044 than the number of PCP office visits. office visit use increased in 2013, sur- per 1,000) than men did (1,982 per Many factors influence trends in physi- passing the use of PCP office visits for 1,000) in that age group (Appendix cian visits, including billing practices the first time in the study period. VARIATION IN SPECIALIST OFFICE VISITS From 2012 to 2013, specialist office visits rose by 111 visits per 1,000 insureds, while PCP visits declined by 58 visits per 1,000 insureds (Appendix Table A5). On net, over the study period, the total number of office visits per 1,000 insureds grew by 1.3%, but this over- all rate obscures important utilization trends for these services. For example, in 2013, children’s office visits to PCPs were more common than were specialist visits (Appendix Table A16a), whereas for adults, specialist office visits were generally more common than PCP visits (Appendix Tables A17a-A20a and Figure 13). PCP office visits are among the most common services used by children, with use rates in 2013 of about 1,600 visits per 1,000 girls or boys – nearly twice as many as specialist visits (Appendix Table A16a). In contrast, for adult women, specialist visits outnumbered PCP office visits. Of all of the adult groups, only intermediate adult men used PCP visits more often than specialist visits (Appendix Table A18a). Use of specialist office visits increased for all age-gender groups more than in previous years in the study period. This report did not examine what factors may have influenced the increase in specialist office visits. Physician billing and coding practices, insurance benefit struc- tures, and patient preferences, among other factors, may have influenced the trends observed in utilization rates. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 16 Brand Prescriptions In 2013, spending on brand Spending on hormones continued per insured) and increased by 10.0% prescriptions rose 2.4% to $550 per to rise (Figure 14). Per capita spending on capita (Table 1), and made up 11.3% of gastrointestinal brand prescriptions HCCI classified brand prescriptions total per capita ESI spending ($4,864). was the lowest ($33 per capita) and into nine HCCI detailed categories that In 2011 and 2012, spending on brand rose 7.9%. Conversely, between 2012 were further subdivided into sub- prescriptions rose 4.0% to $540 per and 2013, per capita spending on CNS classes using the American Hospital capita and then declined slightly (- agents and cardiovascular drugs de- Formulary System (AHFS) classifica- 0.6%) to $537. Between 2012 and clined (-2.0% and -10.5%, respective- tions. Of the nine detailed brand cate- 2013, spending increased by $13 per ly). Insureds spent $89 per capita on gories, the four with the highest num- capita and made up 7.1% of the total CNS agents and $58 per capita on car- ber of filled days in 2013 are the focus spending growth for the national ESI diovascular drugs. of this section (excluding the “other population. therapeutic classes” detailed category, For the first time, HCCI examined sub- Between 2012 and 2013, the number which is composed of multiple thera- classes of prescriptions within the de- of filled days of brand prescriptions peutic drug types). These four were tailed categories. Table 4 displays the per 1,000 insureds declined 15.5%, or cardiovascular drugs, hormones and four subclasses of brand prescriptions 8,531 filled days per 1,000 insureds to synthetic substitutes (“hormones”), with the highest per capita spending 46,497 (Table 3). Brand filled days central nervous system (CNS) agents, for the ESI population in 2013. Of these made up only a small percentage and gastrointestinal drugs (Appendix classes, only insulins is contained in (16.5%) of total filled days of Table A5). one of the top four detailed categories prescriptions (282,012 filled days per (hormones). In 2013, spending on the 1,000 insureds). At the same time, the In 2013, spending on cardiovascular four subclasses made up 28.0% of ESI average price per filled day of brand drugs, hormones, CNS agents, and gas- spending on brand prescriptions. prescriptions increased 21.2%, to $12. trointestinal drugs made up 50.9% ($280 per capita) of brand prescription Use of cardiovascular brand drugs spending (Appendix Table A4). Of declined 21.2% in 2013 these four categories, per capita spend- In 2013, the top four brand detailed ing was highest for hormones ($100 categories constituted 73.2% of the total filled days per 1,000 insureds of brand prescriptions (Appendix Table A5). However, use of these categories declined. The most filled days was for hormones (11,426 filled days per 1,000 insureds), which declined 6.6%. The largest decline in the number of filled days was for cardiovascular drugs, at 21.2% to 10,763 filled days per 1,000 insureds. Use of CNS agents declined 13.4% to 8,732 filled days per 1,000 insureds. Use of gastrointestinal drugs declined 4.9% to 3,124 filled days. Table 5 displays the four subclasses of brand prescriptions with the highest number of filled days per 1,000 in- sureds for the ESI population in 2013. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 17 Of these subclasses, only corticoster- adult women compared to 7,801 filled men whereas women in that age group oids is not in one of the top four de- days per 1,000 young adult men used 88,099 days per 1,000 women tailed categories; two of the classes are (Appendix Table A17a). Intermediate (Appendix Table A20a). For men in in the cardiovascular category. Only adults’ use of the top four categories these two age groups, the most highly insulins showed both high per capita was 26,427 filled days per 1,000 wom- used category was cardiovascular spending and high use. Together, the en and 17,493 filled days per 1,000 drugs (24,856 days per 1,000 middle top four used subclasses accounted for men (Appendix Table A18a). age adult men and 48,624 days per 25.4% of total brand filled days by the 1,000 pre-Medicare adult men). For Among children, use of the top four ESI population. women in these age groups, the highest brand categories amounted to 10,442 use was of hormones (17,077 filled Brand prescription use varied with filled days per 1,000 boys and 7,312 days per middle age adult women and age and gender per 1,000 girls (Appendix Table A16a). 31,262 filled days per pre-Medicare Nearly 82% of those filled days for Generally, prescription use levels rose adult women). boys were CNS agents (8,498 days per with age, and use was higher for wom- 1,000 boys); 12.0% were hormones Summary en. In 2013, however, for the top four (1,249 days per 1,000 boys). In con- brand categories, women’s use was In 2013, spending on brand prescrip- trast, 51.4% of filled days for girls were only higher than men’s use among tions rose 2.4% to $550 per capita CNS agents (3,761 days per 1,000 young adults (a 15,734 filled day dif- (Table 1), and the average price paid girls), while 40.7% were hormones ference; Appendix Table A17a) and per brand prescription day rose 21.2% (2,978 days per 1,000 girls). intermediate adults (an 8,934 filled (Table 3). Use of brand prescriptions day difference; Appendix Table A18a In 2013, both middle age adult men declined for the third consecutive year, and Figure 15). and pre-Medicare men used more filled down 15.5% to 46,497 filled days per days than did women in the same age 1,000 insureds. Among the top four brand categories, groups. Middle age adult men used the difference in filled days between About 72% of spending on brand pre- 50,142 filled days per 1,000 men as men and women for young adults and scriptions was accounted for by 4 cate- compared to 49,437 filled days per intermediate adults was due largely to gories of brand prescriptions 1,000 middle age adult women women’s use of hormones. Young (cardiovascular drugs, hormones, CNS (Appendix Table A19a). Pre-Medicare adults’ use of the top four categories agents, and gastrointestinal drugs) and men used 89,359 filled days per 1,000 was 23,535 filled days per 1,000 young three subclasses (antirheumatic agents, biologics, and antiretrovirals). Similarly, 79% of filled days of brand prescriptions were for the same four categories and the corticosteroids sub- class. Overall, the highest use of brand pre- scriptions by the ESI population was for hormones; however, this was due mainly to use of this category by young adult and intermediate adult women. The second-most highly used category was cardiovascular drugs, largely ow- ing to use by adult men older than age 25. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 18 Table 4: Top 4 Highest Spending Per Capita Brand Prescription Subclasses: 2013 ESI Filled Days Subclass Name HCCI Detailed Expenditures per 1,000 (Number) Category Common Use Per Capita Insureds Disease-Modifying Other Various types of arthritis, such as $49.31 543 Antirheumatic Agents Therapeutic rheumatoid arthritis and psoriatic (92:36.00) Classes arthritis Biologic Response Other Autoimmune conditions, such as $39.23 250 Modifiers (92:20.00) Therapeutic multiple sclerosis, rheumatoid Classes arthritis, Crohn's disease Insulins (68:20.08) Hormones and $35.48 3,136 Manage blood sugar levels, type Synthetic 1 and type 2 diabetes Substitutes Antiretrovirals Prescribed for HIV infections and $29.87 752 Anti-Infective (08:18.08) prevention of HIV infection after Agents virus exposure Source: HCCI, 2014. Table 5: Top 4 Brand Prescription Subclasses Used per 1,000 Insureds: 2013 ESI Popu- lation Filled Days Subclass Name HCCI Detailed per 1,000 Expenditures (Number) Category Common Use Insureds Per Capita HMG-CoA Reductase Cardiovascular Management of high cholesterol 3,226 $17.31 Inhibitors (24:06.08) Drugs Insulins (68:20.08) Hormones and Manage blood sugar levels, type 1 3,136 $35.48 Synthetic and type 2 diabetes Substitutes Corticosteroids Respiratory Reduce inflammation related to 2,821 $20.89 (48:10.08) Agents respiratory conditions, such as asthma and chronic obstructive pulmonary disorder Contraceptives Hormones and Commonly known as “birth control”, 2,620 $8.50 (68:12.00) Synthetic includes oral, intravaginal, and Substitutes transdermal forms Source: HCCI, 2014. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 19 TOTAL PRESCRIPTION FILLED DAY USE IN 2013 In 2013, use of filled days of prescriptions by the ESI population increased 0.7%, equaling 2,053 more filled days per 1,000 insureds (Figure 16). Use of generic prescription filled days increased 4.5%, equaling 10,134 filled days per 1,000 insureds (Figure 17). Offsetting this increase in generic prescription use was a 15.5% decline in the use of brand prescription filled days. Changes in use of prescriptions between 2012 and 2013 varied by age group and gender (Appendix Table A10b). Use of prescriptions declined for children and for pre-Medicare adults, with the largest de- cline in filled days use per 1,000 insureds for pre-Medicare adult women (17,059 filled days). The other three age groups – young adults, intermediate adults, and middle age adults – increased their use of prescriptions. The largest increase was for young adult women (6,342 filled days), followed by middle age adult women (3,576 filled days). www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 20 Generic Prescriptions In 2013, national ESI spending on ge- neric prescriptions constituted 5.9% of total per capita ESI spending and 34.2% of total prescription spending (Table 1). Between 2012 and 2013, per capita spending on generic prescrip- tions grew 3.9%, from $276 to $287, an $11 increase that accounted for 6.0% of the total increase in spending for the national ESI population. In 2013, about 83% of prescription filled days were for generics (Table 3), up from 75% of filled days in 2011. Over the study period, the number of filled days of generic prescriptions per 1,000 insureds rose in each year, with the largest increase (7.7%) occurring in 2012. In 2013, use of generic pre- scriptions rose 4.5% to 235,017 filled days per 1,000 insureds. Additionally, CNS agents accounted for 31% of ries, and subdivided them into sub- the average price per filled day of ge- generic prescription spending in classes to better understand the driv- neric prescriptions rose in 2012 2013 ers of generic prescription trends. (5.3%) but declined slightly in 2013 (- Analysis of generics focused on those 0.5%). In both years, the average price HCCI classified generic prescriptions four detailed categories having the per day was less than $1.50. into nine detailed prescription catego- highest number of filled days per 1,000 insureds in 2013 (excluding the “other therapeutic classes” detailed category). Three of the top four generic prescrip- tion categories – cardiovascular drugs, hormones, and CNS agents – were also among the highest used categories of brand prescriptions. The fourth high- use generic category was anti-infective agents (Appendix Table A5). Spending on the top four categories made up 66.9% of the total per capita spending on generic prescriptions (Appendix Table A4). In 2012 and 2013, spending per capita for three of the top four generic detailed categories increased (Figure 18). The highest per capita spending in 2013 was on CNS agents; spending increased 2.8% to $90 per capita, which accounted for www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 21 31.4% of spending on generics. Spend- The highest per capita spending in Generic hormone use rose 5% in ing on hormones (9.3%) and anti- 2013 was on antidepressants ($18.48), 2013 infective agents (4.6%) also rose, to which also had the highest use of any In 2013, the top four detailed catego- $36 and $26 per capita, respectively. subclass – 24,223 filled days per 1,000 ries of generic prescriptions (CNS Cardiovascular drug spending dropped insureds. This accounted for 10.3% of agents, hormones, cardiovascular 8.2% to $40 per capita. all generic prescription filled days. The drugs, and anti-infectives) made up other three subclasses (amphetamines, Table 6 displays the four subclasses 75.3% of filled days (Appendix Table opiate agonists, and anticonvulsants) with the highest per capita spending A5). Filled days of three of these cate- had similar per capita spending, be- for the ESI population in 2013. All four gories increased, while use of anti- tween $12 and $13, and lower rates of subclasses are in the CNS agents cate- infective agents declined 1.8%, to use as compared to antidepressants. gory. 11,096 filled days per 1,000 insureds. ANTIDEPRESSANT USE BY THE ESI POPULATION (2009-2013) In each of the previous five years (2009-2013), generic antidepressants were the subclass of generic prescriptions most used by the national ESI population. In 2009, generic antidepressant use was 18.1 filled days per person; by 2013, this had increased to 24.2 filled days per person (Table 7). Use of generic prescriptions increased every year during this period, with the largest increase occurring in 2012. During that same period, use of brand antidepressants decreased in every year, with the largest decrease seen in 2012. In 2009, there were 6.4 filled days of brand antide- pressants per person; use of declined to 2.3 filled days by 2013. Overall, every year between 2009 and 2013, there was a net increase in the use of antidepressants (combined brand and generic) by the ESI population. In 2009, there were 24.5 filled days per person of antidepressants and 26.6 filled days in 2013. Over that period, antidepressants also made up an increasing share of all prescriptions. In 2009, filled days of antidepressants made up 8.8% of filled days of all prescriptions for the ESI population. By 2013, filled days of antidepressants were nearly 10% of all prescription filled days. Table 6: Use of brand and generic antidepressants in filled days per 1,000 insureds for the national ESI population: 2009—2013 Antidepressants (28:16.04) 2009 2010 2011 2012 2013 Brand Filled Days per 1,000 6,439 6,035 4,918 2,985 2,345 Percent Change in Use * -6.3% -18.5% -39.3% -21.4% Generic Filled Days per 1,000 18,058 18,801 20,522 23,138 24,223 Percent Change in Use * 4.1% 9.2% 12.7% 4.7% Combined Filled Days per 1,000 24,497 24,836 25,440 26,123 26,568 Percent Change in Use * 1.4% 2.4% 2.7% 1.7% Difference from Previous Year of Filled Days * 339 604 683 445 All Prescriptions Filled Days per 1,000 276,821 278,065 278,316 279,959 282,012 Antidepressants Share of All Prescriptions 8.8% 8.9% 9.1% 9.3% 9.4% Source: HCCI, 2014. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 22 The generic category used most was women’s filled days were higher than more than a third of total spending on CNS agents, use of which increased men’s for each age group. The differ- prescriptions. The relatively low per 3.5%, to 63,670 filled days per 1,000 ence in use between genders was larg- capita spending on generic prescrip- insureds. Use of cardiovascular drugs est for young adults (97,205 filled tions, however, as compared to brand increased 4.9%, to 61,668 filled days, days; Appendix Table A17a) and inter- prescriptions, masks the higher use the largest increase in the number of mediate adults (93,622 filled days; Ap- rates of generics. filled days between 2012 and 2013 pendix Table A18a), due mainly to the Generic prescription use by the ESI (2,869 filled days). number of filled days of hormone use population rose every year between among women in those age groups Hormone use rose 5.0%, to 40,457 2011 and 2013. At the same time, the (78,194 filled days per 1,000 young filled days per 1,000 insureds. The average price paid per generic filled adult women and 70,786 filled days most commonly filled subclass was day remained below $1.50. CNS agents per 1,000 intermediate adult women; contraceptives, which made up 30.8% had the highest per capita spending of Figure 19). The smallest gender differ- of filled days in the hormones category the top four categories and included ence in generic prescription use was (12,469 filled days per 1,000 insureds; antidepressants, the subclass with the seen between girls and boys – 5,784 data not shown). highest per capita spending and high- more filled days for girls (Appendix est use. For most common classes of ge- Table A16a ). nerics, women used more generic Summary drugs than men of the same age In 2013, spending on generic prescrip- For each of the top four detailed cate- tions increased, constituting slightly gories of generic prescriptions in 2013, Table 7: Top 4 Highest Spending Per Capita Generic Prescription Subclasses for ESI Population: 2013 Subclass Name HCCI Detailed Expenditures Filled Days Per (Number) Category Common Use Per Capita 1,000 Insureds Antidepressants CNS Agents Management of various $18.48 24,223 (28:16.04) conditions including depression, anxiety disorders, obsessive compulsive disorder Amphetamines CNS Agents Primarily used for narcolepsy $12.96 2,939 (28:20.04) and ADHD Opiate Agonists CNS Agents Pain killers $12.68 7,227 (28:08.08) Anticonvulsants, CNS Agents Treatment of seizure disorders $12.07 6,104 Miscellaneous (28:12.92) Source: HCCI, 2014. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 23 Special Supplement: 2013 Generic Prescription Use by Age and Gender As part of the 2013 analysis of pre- The 13 subclasses were contained CNS agents were the most com- scription use by the ESI population, within 5 of HCCI’s 9 detailed categories mon drug category used by chil- HCCI analyzed filled days of generic of drugs: dren prescriptions for men and women by  Anti-infective agents (penicillins); For both boys and girls, the category of age group. This analysis reflects a growing interest at HCCI in how differ- drugs used most was CNS agents (18.5  Cardiovascular drugs (angiotensin filled days per boy and 14.1 per girl; ent age-gender groups covered by ESI -converting enzyme inhibitors, used prescriptions in 2013 and wheth- Appendix Table A16a and Figure 20). dihydropyridines, HMG-CoA re- For boys, the second most-used catego- er patterns emerged in prescription ductase inhibitors, β-adrenergic use as insureds aged. HCCI did not ex- ry of drugs was anti-infective agents blocking agents); (8.7 filled days per boy). The second amine changes in use over time. most-used category of drugs for girls In this supplement, HCCI described for  CNS agents (amphetamines, mis- was hormones (12.4 filled days per generic prescriptions the four detailed cellaneous anticonvulsants, antide- girl). categories and four subclasses used pressants, opiate agonists, and most commonly for each age-gender respiratory and CNS stimulants); The first and third most used subclass group. All the statistics in this supple- of drugs for boys and second most  Hormones (contraceptives and used for girls were in the CNS agent ment have been converted from filled thyroid agents); and category (Table 8). For boys, the sub- days per 1,000 insureds to filled days per person. class used most was respiratory and  Respiratory agents (leukotriene CNS stimulants (5.7 days per boy), Only 13 subclasses made up the pre- modifiers). which made up 30.8% of the CNS filled scription classes most commonly used, days for boys. Filled days of antide- representing 31% to 62% of generic pressants constituted 24.3% of CNS prescription use by the different age- use for boys (4.5 days per boy) and gender groups. 39.7% for girls (5.6 days per girl). For girls, the subclass used most was contraceptives (9.5 days per girl), which made up 76.6% of girls’ hor- mone use. Penicillins were the third most-used subclass for girls (3.5 days per girl) and fourth most used for boys (3.5 days per boy); this subclass ac- counted for 38.5% and 40.2% of anti- infective agent use for girls and boys, respectively. Leukotriene modifiers were the second most-used subclass for boys (4.6 days per boy) and fourth most-used for girls (3.2 days per girl). Young adult women used more prescriptions than young adult men Young adult women had more filled days of the top four detailed categories www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 24 MOST COMMON ON-LABEL USES OF SELECTED AHFS SUBCLASSES9,10 Anti-infective agents Penicillins are a group of antibiotics that treat a large range of bacterial infections, including pneumonia, strep throat, and staph infection. Respiratory agents Leukotriene modifiers are a type of respiratory agent taken to control the symptoms of mild-to-severe asthma. Hormones and synthetic substitutes Thyroid agents are used to treat both diminished and increased thyroid function. Cardiovascular drugs HMG-CoA reductase inhibitors, more commonly known as statins, are one of the primary ways to manage high cholesterol levels. In addition, they may be prescribed to prevent heart disease and heart attack in individuals who have multiple risk factors, such as smoking and age. In 2013, the American Heart Association and the American Col- lege of Cardiology revised the recommendations for statin therapy, which increased the importance of physicians considering risk factors (such as age, gender, race, smoking habits, etc.) rather than focusing on cholesterol levels. This revision in the recommendations increased the number of individuals said to benefit from statin therapy to about one-third of Americans.11 Angiotensin-converting enzyme inhibitors, more commonly known as ACE inhibitors, are used to treat high blood pressure, often in conjunction with other drugs. These drugs can also be used to treat congestive heart failure and general chest pain that is associated with restricted blood flow to the heart. CNS agents Antidepressants are used to treat many conditions, including depression, anxiety disorders, obsessive com- pulsive disorder, and many others. Opiate agonists are mainly opiate pain killers, such as codeine and morphine, used to treat mild-to-severe pain. Amphetamines are a type of stimulant primarily used to treat narcolepsy and attention deficit hyperactivi- ty disorder (ADHD) in adults and children. Anticonvulsants are primarily used to treat a broad range of seizure disorders; they can also treat agitation or epi- sodes associated with mental health disorders such as schizophrenia or bi-polar disorder. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 25 of generic prescriptions as compared woman (Appendix Table A18a). For reductase inhibitors (“statins”; 37.0 with the number for young adult men. both intermediate adult men and days per man), which made up 29.7% Young adult women had the most women, the subclass of CNS agent of their cardiovascular filled days. filled days of hormones, 78.2 filled used most was antidepressants (15.0 Statins were the third most-used sub- days per young adult woman days per man and 34.2 days per wom- class for middle age adult women (Appendix Table A17a). Of these filled an; Table 10). Within this age group, (21.0 days per woman) and made up days of hormones, 69.0 (88.2%) were use of antidepressants accounted for 25.4% of their cardiovascular filled for contraceptives, the subclass most 34.5% of CNS use by men and 43.1% days. commonly used by young adult wom- of CNS use by women. Use of antide- CNS agents were the category used en (Table 9). Use of contraceptives pressants made up 14.7% of total most by middle age adult women made up 43.7% of filled days of ge- filled days of generic prescriptions for (126.5 days per woman) and the sec- neric prescriptions for young adult intermediate adult women and 12.2% ond most-used category for men of women. The most-used detailed cate- of generic days for intermediate adult the same age group (66.7 days per gory for young adult men and the sec- men. man). The most used subclass for ond most-used detailed category for The second most-used detailed cate- middle age adult women was antide- young adult women were CNS agents gory of generic prescriptions for in- pressants (52.2 days per woman), (27.0 days per young adult man and termediate adult women was hor- accounting for 41.3% of their CNS 41.4 filled days per young adult wom- mones (70.8 filled days per interme- use. Antidepressants were also the an). diate adult woman). The most com- third most-used class for middle age For young adult men, the four sub- mon type of hormone, and the most adult men (21.6 days per man), ac- classes of generic prescriptions used used subclass, for intermediate adult counting for 32.4% of their CNS filled most were all CNS agents. Antidepres- women was contraceptives (43.3 days days. sants – the subclass used most by per intermediate adult woman), con- young adult men – constituted 31.5% stituting 61.2% of the hormone use The second most-used category for of the CNS filled days for young adult for this group. middle age women was hormones, at men (8.5 days per man), and 16.5% of 77.4 filled days per woman. The most For intermediate adult men, the sec- total generic prescription days. For used subclass of hormone by middle ond most-used detailed category was young adult women, three of the four age adult women, and the second cardiovascular drugs (31.4 filled days most used subclass overall for these most-used subclasses were CNS per man). The most common subclass agents; the most commonly used CNS women, was thyroid agents (33.3 of cardiovascular drugs for men in agent (and second most common sub- days per woman), which made up this age group was angiotensin- class) was antidepressants (17.7 days 43.0% of their filled days of hor- converting enzyme inhibitors (“ACE per young adult woman), which made mones. inhibitors”; 9.0 days per man), which up 42.8% of CNS use. Before Medicare eligibility, cardi- accounted for 28.7% of their cardio- Antidepressants accounted for vascular use. ovascular generic use rose for nearly 15% of generic filled days group Cardiovascular drugs were most for intermediate adult women common generics for middle age The category most used by pre- Similar to use among young adults, adult men Medicare adult men and women was intermediate adult women had higher cardiovascular drugs (244.2 filled Middle age adult men used more filled days per man and 178.0 filled days use of three of the top four detailed days of cardiovascular drugs than any per woman; Appendix Table A20a). categories, while men of this age co- other category (124.5 per man; Ap- Likewise, all of the top four subclasses hort had higher use of cardiovascular pendix Table A19a); this category for men in this age cohort were in the drugs. The highest-used category for contained three of the top four sub- cardiovascular category (Table 12). both intermediate adult men and classes used by these men (Table 11). The most common subclass for pre- women was CNS agents: 43.5 filled The most commonly used subclass for Medicare adult men, as with middle days per intermediate adult man and middle age adult men was HMG-CoA age adult men, was statins (71.7 days 79.4 days per intermediate adult www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 26 per man), accounting for 29.4% of cardi- Summary four for nearly all age-gender groups. ovascular filled days for men in this age Cardiovascular drugs were common in Thirteen therapeutic subclasses consti- group. Statins were also the second the adult populations, more predomi- tuted the top four most commonly filled most used drug class for pre-Medicare nantly for men. generics for the age-gender groups. adult women (52.9 days per woman), These classes were drawn from five of At the subclass level several other pat- accounting for 29.7% of their cardiovas- the nine HCCI detailed drug categories: terns emerged. Antidepressants were in cular filled days. anti-infective agents, cardiovascular the top four most-used subclasses for The second most-used detailed category drugs, CNS agents, hormones, and res- nearly all age-gender groups. The only of generic prescriptions for both pre- piratory agents. exception was use by pre-Medicare men, Medicare men and women was CNS whose top four subclasses were all car- These findings document how generic agents: 87.3 filled days per man and diovascular drugs. Within the cardiovas- prescription use in filled days varied by 150.5 filled days per woman. Overall, cular category, statins and ACE inhibi- age and gender among the ESI popula- antidepressants were the most used tors were prevalent in the older age tion. HCCI found several patterns among subclass by pre-Medicare adult women groups, for both men and women. Hor- the detailed categories used most com- (61.5 days per woman), and it made up mone use by women was common in monly. Subclasses of drugs that were in 40.9% of CNS filled days for this group. every age group; however, use transi- the respiratory and anti-infective agent For pre-Medicare women, as with mid- tioned from contraceptives before age categories were commonly used only dle age adult women, the subclass of 45 to thyroid medications after age 25. among boys and girls. Hormone sub- hormones used most commonly was classes ranked highest in use for women thyroid agents (47.6 days per woman), of each age group but not for men in any which constituted 49.6% of their hor- age group. CNS agents were in the top mone use. Table 8: Top 4 Highest Used per 1,000 Insureds Generic Prescription Subclasses for Children: 2013 Subclass Name Utilization Filled Days Spending per (Number) HCCI Detailed Category per Boy/Girl Boy/Girl Boys (ages 0-18) Respiratory and CNS CNS Agents 5.68 $25.12 Stimulants (28:20.32) Leukotriene Modifiers Respiratory Agents 4.57 $5.52 (48:10.24) Antidepressants CNS Agents 4.53 $2.92 (28:16.04) Penicillins (08:12.16) Anti-Infective Agents 3.46 $5.27 Girls (ages 0-18) Contraceptives Hormones 9.51 $8.66 (68:12.00) Antidepressants CNS Agents 5.56 $3.32 (28:16.04) Penicillins (08:12.16) Anti-Infective Agents 3.49 $5.16 Leukotriene Modifiers Respiratory Agents 3.21 $3.79 (48:10.24) Source: HCCI, 2014. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 27 Table 9: Top 4 Highest Used per 1,000 Insureds Generic Prescription Subclasses for Young Adults: 2013 Subclass Name Utilization Filled Days Spending per (Number) HCCI Detailed Category per Man/Woman Man/Woman Men (ages 19-25) Antidepressants CNS Agents 8.51 $6.52 (28:16.04) Amphetamines CNS Agents 5.24 $22.25 (28:20.04) Anticonvulsants, CNS Agents 3.08 $11.40 Miscellaneous (28:12.92) Opiate Agonists CNS Agents 1.71 $2.99 (28:08.08) Women (ages 19-25) Contraceptives Hormones and Synthetic 69.03 $66.35 (68:12.00) Substitutes Antidepressants CNS Agents 17.74 $11.49 (28:16.04) Amphetamines CNS Agents 5.93 $24.39 (28:20.04) Anticonvulsants, CNS Agents 4.70 $11.33 Miscellaneous (28:12.92) Source: HCCI, 2014. Table 10: Top 4 Highest Used per 1,000 Insureds Generic Prescription Subclasses for Intermediate Adults: 2013 Subclass Name Utilization Filled Days Spending per (Number) HCCI Detailed Category per Man/Woman Man/Woman Men (ages 26-44) Antidepressants CNS Agents 15.01 $10.93 (28:16.04) Angiotensin-Converting Cardiovascular Drugs 8.99 $2.40 Enzyme Inhibitors (24:32.04) HMG-CoA Reductase Cardiovascular Drugs 8.01 $4.89 Inhibitors (24:06.08) Opiate Agonists CNS Agents 6.06 $9.97 (28:08.08) Women (ages 26-44) Contraceptives Hormones and Synthetic 43.25 $41.76 (68:12.00) Substitutes Antidepressants CNS Agents 34.19 $24.88 (28:16.04) Thyroid Agents Hormones and Synthetic 16.35 $7.57 (68:36.04) Substitutes Anticonvulsants, CNS Agents 8.05 $14.42 Miscellaneous (28:12.92) Source: HCCI, 2014. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 28 Table 11: Top 4 Highest Used per 1,000 Insureds Generic Prescription Subclasses for Middle Age Adults: 2013 Subclass Name Utilization Filled Days Spending per (Number) HCCI Detailed Category per Man/Woman Man/Woman Men (ages 45-54) HMG-CoA Reductase Cardiovascular Drugs 36.96 $24.94 Inhibitors (24:06.08) Angiotensin-Converting Cardiovascular Drugs 30.55 $8.58 Enzyme Inhibitors (24:32.04) Antidepressants CNS Agents 21.62 $16.54 (28:16.04) β-Adrenergic Blocking Cardiovascular Drugs 18.53 $9.94 Agents (24:24.00) Women (ages 45-54) Antidepressants CNS Agents 52.20 $41.81 (28:16.04) Thyroid Agents Hormones and Synthetic 33.33 $14.71 (68:36.04) Substitutes HMG-CoA Reductase Cardiovascular Drugs 21.02 $12.83 Inhibitors (24:06.08) Angiotensin-Converting Cardiovascular Drugs 18.60 $5.06 Enzyme Inhibitors (24:32.04) Source: HCCI, 2014. Table 12: Top 4 Highest Used per 1,000 Insureds Generic Prescription Subclasses for Pre-Medicare Adults: 2013 Subclass Name Utilization Filled Days Spending per (Number) HCCI Detailed Category per Man/Woman Man/Woman Men (ages 55-64) HMG-CoA Reductase Cardiovascular Drugs 71.68 $53.06 Inhibitors (24:06.08) Angiotensin-Converting Cardiovascular Drugs 53.12 $15.78 Enzyme Inhibitors (24:32.04) β-Adrenergic Blocking Cardiovascular Drugs 41.24 $21.81 Agents (24:24.00) Dihydropyridines Cardiovascular Drugs 27.28 $14.46 (24:28.08) Women (ages 55-64) Antidepressants CNS Agents 61.45 $50.45 (28:16.04) HMG-CoA Reductase Cardiovascular Drugs 52.90 $35.91 Inhibitors (24:06.08) Thyroid Agents Hormones and Synthetic 47.58 $19.20 (68:36.04) Substitutes Angiotensin-Converting Cardiovascular Drugs 34.33 $10.08 Enzyme Inhibitors (24:32.04) Source: HCCI, 2014. www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 29 Data & Methods Data cated. Claims for years 2009 through Limitations 2011 were not adjusted and were HCCI’s dataset contains several billion This report, like all research, had sev- considered 100% adjudicated. de-identified commercial health in- eral limitations that affect the gener- surance claims for the years 2009 HCCI used the weighted, actuarially alizability and interpretation of the through 2013. Three major health completed dataset to estimate per findings. For this reason, HCCI consid- insurers contributed data to HCCI for capita health expenditures, average ers the work a starting point for anal- the purposes of producing a national, prices, utilization of services, unit ysis and research on individuals cov- multi-payer, commercial health care prices, and service intensity for 2009 ered by ESI rather than as a conclu- claims database. These data include through 2013. HCCI did not correct sive analysis of the ESI population’s claims for individuals covered by dollars for inflation; thus, all reported effect on health care in the United group insurance (fully insured and expenditures and prices were in nom- States. administrative services only), individ- inal dollars. First, our findings were estimates for ual insurance, and Medicare Ad- HCCI analyzed four major categories the US ESI population ages 0 to 64 vantage plans. The claims data in- of services, several subservice catego- based on a sample of approximately clude prices paid to providers by both ries, and detailed service categories. 27% of these insureds. insurers and insureds and details about the services used. Furthermore, Inpatient facility claims were from Second, the analysis and results were HCCI’s claims data are compliant with hospitals, skilled nursing facilities descriptive, and the findings were not the Health Insurance Portability and (SNFs), and hospices where detail causal and cannot be used to deter- Accountability Act (HIPAA). was sufficient to identify an overnight mine causal relationships. stay by an insured. Outpatient facility For the 2013 Health Care Cost and Third, the effect of individual or popu- claims did not entail an overnight Utilization Report, HCCI performed lation health status, such as existence stay, and include observation and analysis on a subset of data for ap- of chronic conditions, was not specifi- emergency room services. Both out- proximately 40 million insureds per cally investigated or discussed in the patient and inpatient claims consisted year (2009-2013), totaling approxi- report. of only the facility charges associated mately 5 billion claim lines.12 This with such claims. Professional proce- A note on premiums analytic subset consisted of all claims dures included claims billed by physi- for insureds younger than age 65 and cians and non-physicians according to HCCI does not report on premiums or covered by ESI. The data set used for their determinants. For more infor- the industry’s standard procedure this report represented about 27% of mation on health insurance premiums coding practices. Prescription data the national ESI population, making are prescriptions filled at both retail and the multiple factors that affect this one of the largest datasets on the them (including health care expendi- and mail order pharmacies. privately insured ever assembled. ture; beneficiary, group, and market For a more detailed description of characteristics; benefit design; and Methods HCCI’s methodology and dataset, see the regulatory environment) see Con- The analytic subset was weighted the Analytic Methodology on HCCI’s gressional Research Service, Private website. 7 Health Insurance Premiums and Rate using U.S. Census Bureau age-gender- Reviews, 2011; American Academy of geographic-based estimates of the ESI HCCI recognizes that the terms “heath Actuaries, Critical Issues in Health population to make the analytic sub- care spending” and “health spending” Reform: Premium Setting in the Indi- set representative of the national ESI could be interpreted differently; how- vidual Market, 2010; and Congression- population. Claims in the analytic sub- ever, they were used interchangeably al Budget Office, Key Issues in Ana- set from 2012 and 2013 were actuari- in this report. lyzing Major Health Insurance Pro- ally completed to account for claims posals, Chapter 3, Factors Affecting that had been incurred but not adjudi- Insurance Premiums, 2008.13,14,15 www.healthcostinstitute.org 2013 Health Care Cost and Utilization Report 30 Changes in 2013 detailed pharmaceutical categories. See “ungroupable”. These are not consid- the 2013 Health Care Cost and Utiliza- ered acute or non-acute inpatient ad- HCCI’s analytic methodology underwent tion Report Methodology for more infor- missions. a number of changes to enhance report- mation. 9 McEvoy, Gerald K., ed. AHFS Drug In- ing for the 2013 Health Care Cost and formation. Bethesda, MD: American So- Utilization Report. See the methodology Suggested citation for 2013 report: ciety of Health-System Pharmacists, document available on HCCI’s Website for details on these changes. 7 “2013 Health Care Cost and Utilization 2014. PEPID. Web. 10 Details about common uses of pre- Report.” Health Care Cost Institute, Inc., Data changes. Oct. 2014. Web. scription drug classes is for information- al purposes only, and is not medical ad- In the 2013 report, new data were pro- Endnotes vice. vided for 2011 through 2013 from the 11 American Heart Association. “Doctor data contributors, resulting in changes Health Care Cost Institute. 2012 Health 1 Discussion is Key for Cholesterol Treat- in the membership, expenditures, utili- Care Cost and Utilization Report. HCCI, ment.” Blog.heart.org. 30 Nov. 2013. zation, and prices in all years. This is an Sep. 2013. Web. Web. unavoidable consequence of updating Herrera, Carolina-Nicole, Martin Gay- 12 2 Health Care Cost Institute, Inc. Aggre- and refining the dataset over time. As a nor, David Newman, Robert J. Town, and gated ESI Cost and Utilization Dataset result, the trends reported in the 2013 Stephen Parente. “Trends Underlying (2009-2013). Health Care Cost Institute, report are somewhat different from Employer-Sponsored Health Insurance those in the 2012 report. Growth for Americans Younger Than 2014. Digital file. Age 65.” Health Affairs. 32.10 (2013): 13 Congressional Research Service. Pri- The data were adjusted to account for 1715-1722. Print. vate Health Insurance Premiums and new and revised data for 2013. For the 3 Dranove, David, Craig Garthwaite, and Rate Reviews [Internet]. Washington 2013 analytic dataset, 2009 through Christopher Ody. "Health Spending (DC): CRS; 2011 Jan. Web. 2011 data were considered complete, Slowdown Is Mostly Due To Economic 14 American Academy of Actuaries. Criti- and no actuarial adjustment was per- Factors, Not Structural Change In The cal Issues in Health Reform: Premium formed. The 2012 and 2013 claims were Health Care Sector." Health Affairs 33.8 Setting in the Individual Market. Wash- actuarially completed using the new (2014): 1399-1406. ington (DC): AAA; 2010 March. Web. data. The average intensity weights 4 Ryu, Alexander J., et al. "The slowdown 15 Congressional Budget Office. Key Is- were changed for some of the outpatient in health care spending in 2009–11 re- sues in Analyzing Major Health Insurance and professional procedure subservice flected factors other than the weak Proposals, Chapter 3, Factors Affecting categories due to improved imputation economy and thus may persist." Health Insurance Premiums. Washington (DC): for missing weights and the introduction Affairs 32.5 (2013): 835-840. CBO; 2008 December. Web. of some new weights in 2013. 5 Council of Economic Advisors. “Recent Trends in Health Care Costs, Their Im- Weighting methodology was updated. pact on the Economy, and the Role of the The weighting methodology was updat- Affordable Care Act.” 2014 Economic ed to reflect the national ESI population Report to the President (2014): 147- younger than age 65 as measured by the 178. Web. American Community Survey. The meth- 6 Yamamoto, Dale H. "Health Care Costs - odology was also updated to better ac- From Birth to Death." Health Care Cost count for fluctuations in the population Institute (2013): 1-39. Society of Actuar- within a year. ies. Web. Analysis changes. For the 2013 report, 7 Health Care Cost Institute. 2013 Health HCCI reported on health care trends by Care Cost and Utilization Report Analyt- age-gender groups, further enhancing ic Methodology v.3.3. Health Care Cost the specificity of the analysis. In re- Institute, Oct. 2014. Web. sponse to public inquires about the data, 8 All inpatient admissions that could not HCCI enhanced the reporting on pre- be classified as any of the detailed cate- scriptions by reporting on even more gories of admissions were considered www.healthcostinstitute.org Trend to Watch In 2013, there was a notable break in trend for out-of-pocket spending growth for adult women (ages 19–44). Out of pocket spending growth slowed considerably for young adult women (ages 19–25) and intermediate adult women (ages 26–44) compared to the two prior years. For the first time in 2013, HCCI observed that there was no increase in out-of-pocket expenditures for young adult women (0.0% growth). For intermediate adult women, out-of-pocket spending growth slowed considerably, increasing by 3.2% as compared to 6.4% growth the previous year. Driving these breaks in trends were changes in out-of-pocket spending on contraceptive prescriptions. Out-of-pocket spending per capita by young adult and intermediate adult women on generic contraceptives fell by 61% to $20, and brand contraceptive spending fell by 21% to $33 (Appendix Table A29). At the same time, use of contraceptives increased by 4% for young adult women and 2% for intermediate adult women (Appendix Table A30). Lower out-of-pocket spending and rising contraceptive use coincided with the first full calendar year of Affordable Care Act (ACA) provisions requiring full coverage (no cost-sharing) of some preventive services, such as contraceptives, prenatal screenings and tests, cervical cancer screenings, diabetes and blood pressure screenings. Although the ACA was likely a large influence on the 2013 per capita out-of-pocket spending trends, other factors also influence spending and use trends. For example, in 2011, changes in out-of-pocket spending on contraceptives were observed following launches of generic versions of brand-name contraceptives, such as Yaz™ and Seasonique™. Additional details and further discussion of out-of-pocket spending are discussed in Out-of-Pocket Spending Trends (2013). 1310 G Street NW, Suite 720 Washington, DC 20005 202-803-5200 Copyright 2014 Health Care Cost Institute Inc. Unless explicitly noted, the content of this report is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 4.0 License