2007–2011 Vermont Health Care Cost and Utilization Report Revised December 2014 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 2007-2011 Vermont Health Care Cost and Utilization Report 1 Executive Summary This is the first report by the Health Care Cost In- Utilization, prices, and resource intensity stitute (HCCI) in cooperation with the Green HCCI also examined expenditures by service cate- Mountain Care Board (GMCB) about the health gory, medical services—inpatient facility, outpa- care trends of employer-sponsor insured Ver- tient facility (including outpatient visits and out- monters (VESI) younger than age 65. For this pro- patient-other services), and professional claims— ject, HCCI relied on 2007–2011 data from the Ver- and pharmacy services (see “Definitions”). Gener- mont Healthcare Claims Uniform Reporting and ally, VESI spending on inpatient facility services, Evaluation System (VHCURES) all-payers claims outpatient visit facility claims, professional ser- data base maintained by the GMCB. This dataset vices, and generic prescriptions grew more quick- provided HCCI with claims from more than 90 ly than did ESI spending nationally, whereas VESI percent of the VESI population, or about 305,000 spending on outpatient-other facility services and Vermonters per year. brand prescriptions grew more slowly compara- The primary aim of the HCCI-GMCB collaboration tively. was to investigate the drivers of VESI health care Together, inpatient admissions and outpatient spending and examine those trends over time. visits constituted about 30 percent of VESI health The secondary aim of the collaboration was to care spending per capita. VESI per capita spend- compare Vermont findings to the employer- ing on inpatient admissions rose at a pace faster sponsored (ESI) population nationally. Therefore, than that of the national ESI average and was metrics in this report were designed to be compa- driven primarily by rising prices, as VESI admis- rable to HCCI’s 2012 Health Care Cost and Utiliza- sion rates per 1,000 insureds were lower than the tion Report.1 All national statistics reported in this national average. Similarly, expenditures per VESI document come from that report and the underly- on outpatient visits grew more quickly than the ing dataset associated with it.2 national ESI average, and rising visit prices ac- Spending trends counted for most of this growth. Additionally, the intensity—that is, the complexity of services—of In national reporting, HCCI identified the North- VESI outpatient visits was somewhat higher than east census region as having the highest per capi- the national ESI average. ta ESI spending in the United States in 2011. However, per capita VESI spending was lower Outpatient-other facility and professional claims than the national average for all years of the accounted for nearly 50 percent of VESI health study. VESI paid out of pocket a percentage of care spending. VESI outpatient-other facility and their health care spending smaller than the ESI professional claims had relatively high intensity- national average. Nevertheless, VESI spending adjusted prices, compared to these ESI claims na- per capita and out-of-pocket spending per capita tionally. rose in every year and grew more rapidly than The remaining 20 percent of VESI per capita ex- did ESI spending nationally. penditures was for prescriptions. During the www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 2 study period, brand prescription spending fell same time, young adult VESI were also paying a owing to declining use over time. In contrast, ge- share of their out-of-pocket health care spending neric prescription spending rose, although much greater than that of the average Vermonter with of that annual growth came from a spike in pre- VESI. Whether the young adult VESI expenditures scription prices and use in 2009. For both the VE- were a reflection of a post-recessionary rebound SI and ESI national populations, the price per ge- in health care spending, an artifact of benefit de- neric filled day remained at about $1 throughout sign, or a result of the introduction of new in- the study period. sureds under the Affordable Care Act’s extension of parental coverage was unclear and deserves Emerging trends further investigation. HCCI identified a number of emerging trends of potential interest to policy makers, researchers, Acute care. VESI’s relatively higher use and and the public: intensity of services for outpatient facility care combined with lower use and service intensity for Bending the cost curve. The health care cost inpatient admissions bear watching. On average, slowdown of 2010 and 2011 was less pronounced VESI used more outpatient services and had few- in Vermont than nationally. In 2010, spending per er inpatient stays than ESI nationally. What effect VESI grew at a pace slower than that of Vermont’s these care patterns have on VESI health status is nominal gross domestic product. However, unknown and requires analysis of health out- spending per VESI outpaced Vermont’s economic comes to determine whether national lessons can growth by 1 percent in 2011. This trend should be learned from the Vermont experience. be watched carefully not only to help forecast health expenditures by employers and insureds Imaging and radiology. VESI billing trends for but to test whether the slowdown was driven by imaging and radiology practices were somewhat the recession or whether spending growth was different from those observed nationally. More ameliorated by health reforms. VESI imaging and radiology claims came through outpatient facilities than came from profession- Lower out-of-pocket spending. VESI spent few- als. The relatively high number of outpatient- er out-of-pocket dollars per insured and directly other facility claims for these services may be due paid a smaller share of the costs for their care as to the structure of the Vermont health care deliv- compared to their national counterparts. Health ery system. Given that the average VESI outpa- plan design was likely playing a role in lower, di- tient-other facility claim costs more than the av- rect consumer payments for care in Vermont. erage VESI professional claim, investigation of However, this study did not examine the use of this provider practice structure and comparison high deductible plans in Vermont, nor could it de- with health outcomes could be useful in identify- termine whether VESI had benefits designs differ- ing high-value low-cost care. ent from the average ESI population. Generic drug spending. In 2007–2008, VESI per Young adult spending. Analysts should contin- -capita spending on generics was lower than the ue to watch the young adult VESI population and national ESI average; after 2009, VESI spending their expenditures. The VESI young adult popula- was higher than the national average. This report tion’s health care spending was higher than the did not examine the reasons why a change in VESI national average for ESI young adults. At the generic spending occurred during the recession. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 3 Conclusions should receive further study. If the data permit, Several conclusions from this report should be some of these factors should be investigated to noted. First, during the study period, VESI health help future researchers, policy makers, and care spending per person was lower than spend- health care leaders to understand the determi- ing by ESI nationally, but spending grew more nants of health care costs and utilization for Ver- rapidly in Vermont. Second, Vermont’s medical mont’s VESI population. Moreover, this study did and pharmacy practice and billing patterns were not seek to determine whether differences ob- somewhat different from the U.S. average. Third, served in use trends between ESI in Vermont and VESI outpatient health care use was higher and those in the United States as a whole have impli- had greater average intensity than that of ESI na- cations for health care quality and outcomes; fur- tionally. Nonetheless, as was true nationally, VESI ther investigation of this question is warranted. medical expenditure growth was driven by rising prices, not increased utilization. This study did not explore the roles of health sta- tus, age, chronic conditions, the recession, or Ver- mont’s ongoing experiment with universal health insurance coverage. These factors may be playing a role in the trends observed in this report and ON THE UPDATED REPORT The initial 2007–2012 Vermont Health Care Cost and Utilization Report was published in August, 2014. In September, researchers at Brandeis University and Truven used the associated Methodology to reproduce some of the statistics in the report. They found inconsistencies between their numbers and those reported by HCCI. The researchers contacted HCCI about the inpatient utiliza- tion, price, and intensity metrics reported, and HCCI began an investigation to see why the metrics were not the same. HCCI reviewed the methods used to calculate inpatient admissions and found that all rules were followed as discussed in the Methodology. However, HCCI found that a programming error had occurred during data cleaning that resulted in an over- estimate of the number of admissions per 1,000 insured Vermonters. HCCI informed the Green Mountain Care Board of the prob- lems and promptly removed the report from the HCCI website. In December 2014, HCCI released an updated and corrected report. The only statistics that changed in the report were for Ver- mont inpatient care: admissions per 1,000 insured, average price paid, average intensity per admission, average intensity- adjusted price per admission, and length of stay. A few stylistic changes were also incorporated in the revised version. In brief, VESI had fewer admissions per 1,000 insured in all years than previously reported, and fewer than the national average. For 2011, this resulted in 44 admissions per 1,000 VESI in the revised report, compared to 68 per 1,000 VESI in the original. Fewer inpatient admissions led to a higher price per admission in all years than previously reported for Vermont (about $5,380 higher in the revised report for 2011). With the revision, average intensity of inpatient care dropped and was lower than the national aver- age in all years, and the intensity-adjusted prices for inpatient care were therefore nearly twice as much per admission than pre- viously reported. Length of stay per admission in Vermont was revised to nearly the same as the national average, whereas it was nearly a day shorter in the original report. The VESI price per admitted day was already lower than the national average and fell further to $3,754 per day in the revised report. Due to these corrections, the decline in VESI inpatient admissions over the study period (2007-2011) was more pronounced and inpatient prices grew faster than originally estimated. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 4 DEFINITIONS COINSURANCE PAYMENTS. Coinsurance is the portion of covered health care costs borne by an insured. After the insured meets a deductible requirement, insurers typically apply coinsurance according to a fixed percentage of the prices paid. COPAYS. Copays are a cost-sharing arrangement in which the insured pays a specified charge for a specified service. Insurers typically set copays as fixed flat amounts for physician office visits, prescriptions, or hospital services. DEDUCTIBLES. Deductibles are the amount that the insured must pay out of pocket to providers before the health plan makes any reimbursement. For example, an insured with a $1,000 deductible would pay the first $1,000 of service costs in the given year. After the deductible is satisfied, the insured and the health plan jointly pay further expenses according to the insurance contract. INTENSITY. Intensity is a measure of the complexity of a service, including the length of time, the severity of the illness ad- dressed, and the amount of resources required for treatment. Many reasons can explain changes in the intensity of services, in- cluding new and better forms of treatment, the health status of the population receiving services, and modifications in the reim- bursement system that either encourage or discourage one form of treatment over another. HCCI measures intensity by assign- ing a weight designed by the Centers for Medicare and Medicaid Services and commercially adjusted to each medical service, when possible. HCCI does not calculate intensity of prescriptions, as the dosage levels and days are fully captured by the price. INTENSITY-ADJUSTED PRICE. Isolating the effect of intensity on the price paid per service allows for the calculation of an inten- sity-adjusted price. The patient never sees this price directly. The intensity-adjusted price, or unit price, is calculated by dividing the price paid for the service by the intensity of the service. For example, intensity equal to one would lead to no difference be- tween prices paid and intensity-adjusted prices. Intensity greater than one would lead to intensity-adjusted prices being higher than prices paid; and an intensity-level less than one would mean that intensity-adjusted prices were less than the prices paid. Using this metric, HCCI is able to determine how much of the change in price growth came from changes in resource use (intensity growth) and how much came from changes in other factors influencing prices (intensity-adjusted price growth). MEDICAL SERVICE, SUBSERVICE, AND DETAILED CATEGORIES. Three medical service categories are identified: inpatient facility, outpatient facility, and professional. HCCI reports on three facility subservice categories: acute inpatient (which excludes skilled nursing facilities, hospice care, and ungroupable claims); outpatient facility visits; and outpatient-other facility services.4 These categories are then further classified into “detailed service” categories. OUT-OF-POCKET EXPENDITURES PER CAPITA. Insureds make out-of-pocket payments directly to a health care provider; these expenditures include any copayments, coinsurance payments, and deductible payments. Any health care payments made out of pocket were not included in this metric if no claim was filed (as would be the case with over-the-counter medicines). HCCI calcu- lated out-of-pocket expenditures per capita by dividing total out-of-pocket expenditures by the insured population. PAYER EXPENDITURES PER CAPITA. Payer expenditures are dollars paid by the insurer directly to a health care provider on behalf of the insured. Any rebates, discounts, incentive payments, or administrative costs that are not captured by the claims system were excluded. HCCI calculated payer expenditures per capita by dividing total payer expenditures by the insured popula- tion. PRESCRIPTION SERVICE, SUBSERVICE, AND DETAILED SERVICE CATEGORIES. HCCI analyzes prescription drug and device claims from pharmacies. The prescription service category is further classified by brand and generic drug subservice categories. SPENDING PER CAPITA. Per capita health spending is an estimate of total expenditures paid for individuals younger than age 65 and covered by ESI divided by the population of insured individuals. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 5 Vermont ESI Health Care Cost and Utilization: Key Findings for 2011 Percentage point Difference from U.S. Change difference from U.S. 2011 average average 2010/2011 Per Capita Spending Vermonter $4,408  –$112 4.2%  +0.1 Male Vermonter $3,876  –$101 4.8%  +0.2 Female Vermonter $4,918  –$116 3.9%  +0.2 Child (0–18) $2,080  –$259 7.7%  –0.1 Young adult (19–25) $2,423  +$5 10.2%  +1.9 Adult (26–44) $3,738  –$196 4.3%  +1.0 Adult (45–54) $5,482  –$383 3.3%  –0.5 Pre–Medicare adult (55–64) $7,734  –$973 3.5%  +0.4 Medical Care Acute Inpatient facility claims Spending per Vermonter $656  –$282 3.4%  –1.2 Average price paid per day $3,754  –$160 0.8%  –3.5 Days per 1,000 insured 175  –65 2.6%  +2.3 Outpatient Visits (ER, Surgery, Observation) facility claims Spending per Vermonter $802  +$49 7.0%  +0.3 Average price paid per visit $2,414  +$95 2.9%  –2.0 Visits per 1,000 insured 332  +7 4.0%  +2.3 Outpatient–Other facility claims Spending per Vermonter $811  $329 4.1%  –1.0 Average price paid per procedure $160  –$25 4.4%  +0.4 Procedures per 1,000 insured 5,067  +2,457 –0.3%  –1.4 Professional Procedure claims Spending per Vermonter $1,354  –$195 5.9%  +2.1 Average price paid per procedure $113  +$17 2.9%  0 Procedures per 1,000 insured 11,941  –4,139 2.9%  +2.0 Pharmacy Claims Brand Prescriptions Spending per Vermonter $498  –$45 –0.1%  –4.1 Average price paid per filled day $8  0 20.2%  +2.0 Filled days per 1,000 insured 62,966  –6,978 –16.9%  –4.9 Generic Prescriptions Spending per Vermonter $277  +$33 –0.8%  +2.4 Average price paid per filled day $1  0 –2.6%  +5.1 Filled days per 1,000 insured 261,397  +51,294 1.9%  –3.0 www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 6 Annual Health Care Expenditures Per Capita Between 2007 and 2011, VESI spending per capita During the 5 years studied, VESI health care ex- on combined medical and pharmacy services rose penditure growth slowed from 6.9 percent to 4.2 from $3,549 to $4,408 (Figure 1 and Table 1). Gen- percent (Figure 2 and Table 2). During this period, erally, VESI had per capita health expenditures the average annual per capita growth rate for VESI lower than those of ESI nationally. This was true in was 5.6 percent. Consistent with the national ESI all years of the study (2007–2011), which spanned trend, the year of lowest spending growth in Ver- the national and state recession and recovery peri- mont was 2010, when health spending per VESI ods. However, the per capita spending gap between slowed by 4.0 percentage points (to 3.6 percent). the national ESI and VESI shrank by $91 over the Per capita spending for VESI grew more rapidly period. than national ESI spending rates in every year be- tween 2007 and 2011 (Figure 2). Vermont, like the national ESI population, experienced a slowdown in ESI expenditure growth during and after the KEY FINDINGS Great Recession. During the recession (2007– 2009), per capita VESI spending grew more rapidly HEALTH CARE SPENDING PER VERMONT ESI than per capita ESI spending nationally. In 2010, GREW FASTER THAN THE NATIONAL AVERAGE the first year of the economic recovery, VESI spending grew at 3.6 percent, which was 0.7 per-  Of interest to many state and federal policy centage points faster than the national ESI spend- makers is how Vermont’s efforts to “bend the ing growth rate. In 2011, the rates of growth for the cost curve” are working and how these efforts national and Vermont ESI populations were 4.1 compare to the nation as a whole. percent and 4.2 percent, respectively.  Less was spent per VESI as compared to ESI na- tionally ($4,408 and $4,520, respectively, in 2011).  However, in most years, spending on VESI young adults was higher than the national ESI young adult average ($2,423 and $2,418, re- spectively, in 2011).  Between 2007 and 2011, VESI health care spending slowed by 2.7 percentage points from 6.9% per year to 4.2% per year.  Annually, VESI spending per capita grew more quickly than national spending per ESI. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 7 VESI expenditures grew more slowly than the Similar to national ESI spending trends, VESI Vermont economy (as measured by gross domes- spending was lowest for children and highest for tic product) in 2010 but grew more rapidly than pre-Medicare adults (Table 1 and Figure 4). Be- Vermont’s economy in 2011 (Figure 3). Ver- tween 2007 and 2011, per capita VESI spending mont’s health care spending growth in 2011 was on children rose by $430 (to $2,080). During higher than the increase in national spending in those years, spending per VESI young adult rose that year, in part because, in 2010, VESI spending by $379 (to $2,423) and by $646 (to $3,738) for did not slow as dramatically as did national ESI adults ages 26 to 44. Spending on VESI adults ag- spending. es 45 to 54 rose by $814 (to $5,482) and from $1,347 to $7,734 for pre-Medicare adults. Spending by age HCCI analyzed health care spending per VESI by Figures 5–9 compare VESI and ESI spending by age group (Table 1). The five analyzed age groups age group. In all years, VESI spending per child were children (ages 0–18), young adults (ages 19 and per adult ages 26 to 64 was lower than the –25), adult groups (ages 26–44 and 45–54), and respective national ESI spending levels for those pre-Medicare adults (ages 55–64). age groups. For young adults, per capita spending www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 8 levels were higher in Vermont than nationally in year, about 1.7 percentage points slower than the all years except 2010. national ESI young adult rate. Spending on VESI adults ages 26 to 44 and on pre-Medicare adults Per capita health care spending in Vermont grew grew by 4.9 percent per year, with spending on at a faster rate than the national average, likely both groups slowing down after 2009. For adults owing to the spending growth rates for most VESI ages 26 to 44, estimates of average annual growth adults (Table 2 and Table 3). Over the 2007–2011 rates for the ESI populations in Vermont and in study period, VESI children’s health expenditures the United States were nearly the same. VESI grew an average 6.0 percent per year as com- spending for pre-Medicare adults grew about 0.8 pared with the national ESI children’s average of percent more rapidly than did the national ESI 6.6 percent per year. Expenditures on VESI young average. VESI spending grew most slowly for adults rose more slowly than for all other VESI adults ages 45 to 54 at an average 4.1 percent per age groups until 2011, when the VESI young adult year, which was 0.4 percentage points slower growth rate increased by 10.2 percent. Nationally, than the national ESI growth rate for that age young adult ESI spending growth also spiked in group. 2011.1 The average annual growth rate for VESI spending on young adults was 4.3 percent per www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 9 Spending by gender Between 2007 and 2011, per capita spending on VESI men rose by $785 (to $3,876), while per capita spending on VESI women rose by $927 (to $4,918).3 Growth in VESI expenditures slowed for both genders after 2009 (Table 2). Men’s spend- ing grew at 5.8 percent per year, while women’s spending grew at 5.4 percent per year (Table 3). Despite women’s slightly slower spending growth, the gap in spending levels between men and women widened between 2007 and 2011 (from $900 to $1,042). VESI annual spending levels were consistently lower than those for ESI men and women nation- ally (Figures 10 and 11). However the gap be- tween Vermont’s and national spending levels for men and women shrank over time. In 2007, VESI spending on men was about $186 less than that for ESI men nationally; by 2011, the gap had shrunk to $101. For women, the spending gap be- tween VESI and ESI nationally narrowed during the 2007–2011 period, from a $210 difference to a $116 difference. Compared to national ESI spending levels, VESI spending on men and wom- en grew on average about 0.8 percentage points more quickly (Table 3). www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 10 Out-of-Pocket Spending The dollars paid to providers for health care ser- of the insured. The payments consist of deducti- vices for the ESI come either from employers and bles, co-payments, and co-insurance. Nationally, health plans (“payers”) or directly from the in- as benefit packages change, the risk associated sured. Those direct, or “out-of-pocket,” payments with the burden of health care payments has are often negotiated by the health plans on behalf shifted away from payers to the insured (for ex- ample, through high deductible plans), with in- sureds paying more out of pocket for their health KEY FINDINGS care. In 2007, VESI paid to providers about $449 per MOST ESI VERMONTERS HAD LOWER SPENDING person out of pocket; by 2011, this amount had increased to $595 per person (Table 4). In all OUT OF POCKET THAN DID ESI NATIONALLY years, VESI paid about 13 percent of per capita VESI bear slightly less of their care costs directly, as health care spending out of pocket. Employers compared to their national counterparts. and health plans paid the remaining 87 percent  Out-of-pocket per capita health care spending ($3,813 per VESI in 2011) to providers (Table 5). was lower for VESI ($595 per capita in 2011) VESI out-of-pocket spending grew at an average than for the national ESI population ($733 per annual rate of 7.3 percent (Table 6), which was capita in 2011). faster than aggregate annual VESI spending growth.  VESI paid a smaller portion of their health care bill out of pocket (13.5% in 2011) than did the Compared to ESI nationally, VESI paid less out of average person covered by ESI (16.2% in 2011). pocket and a smaller share of their spending out of pocket. In 2011, the national ESI population  In 2011, VESI paid about 3% of inpatient paid an average $733 per person out of pocket,1 spending out of pocket ($20 per capita), which was $138 more per person than for VESI. compared to 9% paid out of pocket for However, VESI saw their annual out-of-pocket outpatient visits ($79 per capita). spending grow about 1.8 percentage points more  VESI paid about 13% of other-outpatient claims rapidly per year than the national ESI average ($108 per capita) and 18% of professional (Table 6). claims ($238 per capita) out of pocket in that Out-of-pocket spending by gender year. In 2011, VESI out-of-pocket spending was $669  VESI paid out of pocket about 15% of brand per woman, compared with $517 per man (Table prescription spending ($76 per capita) and 26% 4). With the exception of 2010, when both men of generic prescription spending ($73 per and women paid about 13.2 percent of their capita) in 2011. health care bill out of pocket, VESI women paid a www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 11 larger share of their health care bills out of pocket capita) of their inpatient care out of pocket, com- than did VESI men. In 2011, women paid 13.6 pared with 10 percent ($79 per capita) for outpa- percent out of pocket, compared with 13.3 per- tient visits. Between 2007 and 2011, the share of cent paid by men. VESI out-of-pocket spending on outpatient-other facility claims rose from 11 percent to 13 percent VESI out-of-pocket spending growth was faster ($108 per capita). In 2011, VESI out-of-pocket for men before 2010 and faster for women after spending for professional claims was $238 per 2010 (Table 7). The difference in out-of-pocket capita, or about 18 percent of the professional spending by gender widened between 2007 and bill. Between 2007 and 2011, out-of-pocket 2011. In 2007, VESI men paid about $122 less out spending for brand prescriptions fell from 17 per- of pocket than did VESI women; in 2011, the out- cent to 15 percent ($76 per VESI). During that pe- of-pocket difference was $152 more for women riod, average out-of-pocket spending by VESI on than for men (Table 4). Changes in spending by generic prescriptions fell from 30 percent of the VESI payers are presented in Table 8. bill to 26 percent ($73 per VESI). For both genders, VESI out-of-pocket spending in 2011 was lower than the ESI national average. Nonetheless, out-of-pocket spending by VESI men and women grew at a pace faster than that of their respective national ESI averages (Table 6). Out-of-pocket spending by service category To determine where the VESI population spent its out-of-pocket dollars, HCCI analyzed out-of- pocket spending by health care service categories. For the ESI populations nationally and in Ver- mont in all years, most of the out-of-pocket spending was for professional claims; spending out of pocket was least for inpatient care (Table 9). In 2011, VESI paid about 3 percent ($20 per OUT-OF-POCKET SPENDING BY YOUNG ADULTS Relative to other age groups in Vermont, young adult VESI paid the largest share of their health care spending out of pocket (Table 4). Young adults paid about $413 out of pocket, or 17.0% of their health care bill in 2011, as compared to the Vermont average of 13%. This was a relative easing of their cost burden, as the share that young adults paid out of pocket in 2011 was down from 2009 and 2010, when they paid 17.4% and 18.0%, respectively. Young adult VESI out-of-pocket spending grew more slowly than the national average for that age group (Table 6). Young adults in Vermont saw their out-of-pocket spending rise 4.8% per year during the study period, whereas young adults nationally saw spending rising 6.3% per year. One possible reason why young adults paid relatively more out of pocket than the average VESI is that they may have used ser- vices that, under the ESI benefit design, were less covered. HCCI did not have information about benefit design and, therefore, could not determine how benefit design effected young adult spending. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 12 Inpatient Admissions and Outpatient Visits Hospitalizations and outpatient visits are the two by that facility directly. This includes hospitaliza- most expensive categories of medical care on a tions for medical, surgical, labor and delivery, service-by-service basis. Inpatient care is any skilled nursing, hospice, substance use, and men- care delivered in an inpatient facility and billed tal health care. Outpatient visits occur when a pa- tient receives care in an outpatient care facility KEY FINDINGS for three major categories of service: emergency room care, outpatient surgery, and observation. For the purposes of analysis, only the bills paid to VESI INPATIENT ADMISSION AND OUTPATIENT the facility that delivered the care are considered VISIT TRENDS DIFFER FROM THOSE OF THE part of an inpatient admission or outpatient visit. Any claims made by other care providers (such as AVERAGE ESI medical groups, technicians, or external labs) ap-  Spending for inpatient care and outpatient vis- pear in other medical service categories. its made up about 33% of health care spending Inpatient admissions per VESI, compared with 38% of spending per ESI nationally (2011). In 2011, VESI had 44 inpatient admissions per 1,000 at an average price of $15,109 per admis-  VESI spent less than ESI nationally on admis- sion (Table 10). Between 2007 and 2011, per VE- sions ($663 and $950, respectively, in 2011). SI spending on inpatient care rose from $494 to  Despite similar lengths of stay, VESI spent less $663 (Table 11) but was consistently lower than than ESIs nationally on acute inpatient visits, in the national ESI average (Figure 12), which was part owing to lower prices paid per day for care $950 in 2011.1 (annual averages of $202 less per day in Ver- Per capita VESI spending for inpatient care grew mont) and fewer inpatient admissions than at an average annual rate of 7.7 percent; per capi- ESIs nationally. ta spending for acute inpatient care without skilled nursing and hospice claims grew an aver-  Visit spending per VESI was higher than that of age of 7.6 percent per year (Table 12). Inpatient ESI nationally ($802 and $753, respectively, in spending growth slowed every year during the 2011), largely owing to more Vermonter visits period (Figure 13). Inpatient per capita spending (annual averages of 3 visits per 1,000 insured grew much more rapidly for VESI as compared to more in Vermont) and higher prices (annual the national ESI average spending in all years averages of $96 more per visit in Vermont). (except 2011).1  VESI visits had higher intensity of care– Three major factors played a role in inpatient meaning that those services required more re- spending trends: admissions rates, price growth, sources than those in the national average. and length of stay. Generally, health care spend- www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 13 ing growth is driven by changes in prices and 1,000 VESI declined at an average 0.8 percent per changes in the number of services used. Under- year. standing how changes in prices and use interact- Acute inpatient price growth. To simplify its ed to create spending growth helps to explain analysis, HCCI also examined acute inpatient ad- what drives up health care costs. For inpatient missions (inpatient admissions excluding skilled care, this explanation is complicated by the length nursing facilities and hospice claims) between of time a person stays in the hospital. 2007 and 2011 for the ESI populations in Ver- Admissions. VESI inpatient admission trends mont and those nationally. For VESI, acute inpa- over the time period were quite different from tient care utilization declined by 1.0 percent per ESI trends nationally. There were an average of year, while prices rose at 8.8 percent per year 45 admissions per 1,000 VESI per year compared (Table 12). The intensity of VESI admissions was with 63 admissions per 1,000 ESI per year.1 If somewhat lower than that of the national ESI Vermont’s prices paid per admission matched na- population. As a result, after adjustment for inten- tional average prices, Vermont would have had sity of care, acute admission prices grew by 5.7 higher spending per capita on inpatient care. percent per year—barely higher than the national However, Vermont’s prices paid per admission rate. ($15,109 in 2011; Table 10) were slightly lower Length of stay. In Vermont, the average length than the national average ($15,582 in 2011). of stay for acute care facilities was 4.1 days as Inpatient price growth. For all years of the compared with 3.9 days nationally (Table 13). study, VESI inpatient spending growth was driven Over the study period, VESI acute inpatient ad- more by increasing prices than by changes in use, mission price per day was on average $202 less as the prices paid per admission in Vermont grew than the national ESI inpatient admission price more rapidly than did admissions (Table 12). Be- per day (Vermont data, Table 13; national data tween 2007 and 2011, the price per inpatient ad- not shown). Despite the similar lengths of stay for mission grew an average 8.5 percent per year, these populations, the lower price per admitted whereas the number of inpatient admissions per day and fewer admissions per 1,000 helped to www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 14 keep Vermont inpatient spending per person low- (Table 12). In 2007, the average VESI price for an er than that per national ESI person. outpatient visit was $1,766; by 2011, it was $2,414 (Table 10). The intensity of VESI outpa- Outpatient visit spending trends tient visits rose slightly over time at an average Between 2007 and 2011, per capita VESI spend- annual rate of 0.8 percent, indicating that rela- ing on outpatient visits (emergency rooms, obser- tively little of the increase in outpatient visit pric- vation, and outpatient surgery) rose from $561 to es came from changes in the intensity of care. $802 (Table 11). For these services, per capita Generally, VESI used more outpatient visits and VESI spending was higher than ESI spending na- paid higher outpatient visit prices than those of tionally (Figure 14). the national ESI population.1 During the study pe- Growth in VESI spending on outpatient visits rose riod, VESI had 3 visits per 1,000 more per year at an average annual rate of 9.3 percent. This rate than the national ESI average (data not shown). was higher than national ESI trends, which grew The VESI price for outpatient visits was about $96 at an average annual rate of 9.1 percent.1 VESI more per visit than for the national ESI average. spending growth for these services slowed be- Much of the difference in prices had to do with tween 2009 and 2011 (Table 14). the intensity of care. VESI had higher care intensi- ty per outpatient visit (annual average of 16.4) Outpatient visits grew during the 2007–2011 pe- than did the average ESI visit nationally (annual riod, rising from 318 visits per 1,000 VESI to 332 average of 15.7). The intensity-adjusted average visits per 1,000 VESI (Table 11). Visit growth price of an outpatient visit in both Vermont and slowed between 2008 and 2010 and then rose the nation was the same—about $129 per visit sharply in 2011 (Figure 15). In 2008, utilization during the study period. grew by about 2.3 percent; it fell by 2.4 percent in 2010 and rose by 4.0 percent in 2011. Over the study period, VESI outpatient visits grew at an average annual rate of 1.1 percent (Table 15). Visit prices for VESI rose throughout the period, growing at an average annual rate of 8.1 percent www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 15 Outpatient-Other and Professional Claims Some of the services provided by outpatient- als in private practice. Outpatient facilities and other facilities (such as labs, imaging, and radiolo- physician offices, however, can have different bill- gy) and medical professionals (such as physi- ing codes and different prices for what appear to cians, nurse practitioners, and therapists) are be similar services. substitutable. Outpatient facilities may perform Outpatient-other claim trends laboratory tests and imaging, as may profession- Between 2007 and 2011, per capita VESI spend- ing on outpatient-other facility care rose from $659 to $811 (Table 15 and Figure 16). On an av- KEY FINDINGS erage annual basis, VESI spending on these ser- vices was about $325 greater per person than the VESI SPENT MORE THAN ESI NATIONALLY ON national ESI average.1 OUTPATIENT-OTHER FACILITY USE AND LESS ON VESI spending on outpatient-other care grew at PROFESSIONAL CLAIMS an average annual rate of 5.3 percent (Table 16), Vermont practice or billing patterns may have driv- slowing from 13.2 percent in 2008 to 4.1 percent en this trend. in 2011 (Table 15 and Figure 17). By comparison, over the study period, per capita ESI spending  Outpatient-other facility use and professional nationally for these services grew at an average spending made up about 49% of the dollars annual rate of 5.7 percent.1 spent per VESI (2011). Rising prices helped to drive outpatient-other fa-  Compared to ESI nationally, VESI spent more cility spending growth. Prices for these services per person on outpatient-other facilities grew an average of 4.8 percent annually (Table (annual average of $325 more per VESI than ESI 14). In 2011, the VESI average price paid for out- nationally).  Compared to ESI nationally, outpatient-other VESI prices and utilization were higher by an annual average of $25 per claim and 2.6 claims per insured.  VESI spent less on professional claims than ESI nationally (annual average of $209 less per VE- SI).  Lower VESI professional spending was due to lower use than ESI nationally (4 claims less per VESI in 2011). www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 16 patient-other ($160) was lower than the national ESI average ($185).1 As seen in Table 16, outpatient-other utilization rose at a rate of 0.5 percent per year. In 2011, there were about 5.1 claims per VESI, down from a high of 5.3 claims per VESI in 2009. VESI had 2.6 more outpatient-other claims per capita annually than did the national ESI average.1 The differences in use of outpatient-other care between VESI and ESI nationally was more dis- tinct when examined by outpatient-other detailed service categories (Figure 18). In 2011, VESI had about 3.2 lab/pathology claims per person, com- pared to 1.2 claims per person for ESI nationally. VESI also had considerably more claims per per- son for radiology in that year. Together, the high- er volumes for lab/pathology and radiology ac- counted for most of the difference between VESI and ESI nationally for the outpatient-other cate- gory as a whole. During this period, the intensity of those claims fell by 0.9 percent per year. Nonetheless, the av- erage VESI intensity-adjusted price of an outpa- tient-other claim in 2011 was higher—at $195— than the ESI national average at $143. Professional claim trends Between 2007 and 2011, per capita VESI spend- ing on professional claims rose from $1,149 to $1,354 (Table 15 and Figure 19). On average, VE- SI per capita spending on professional claims was lower than the national ESI average by about $209 per insured.1 VESI spending for professional claims grew at an average annual rate of 4.2 percent, which in- creased during the study period from 3.2 percent in 2008 to 5.9 percent in 2011 (Table 14, Table 16, and Figure 20). In contrast, national ESI spending on professional claims slowed over time and grew at an average annual rate of 3.7 percent, www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 17 which was slower than VESI spending growth for these services. VESI claims for professional services grew by 1.0 percent per year during the study period (Table 16). In 2011, VESI use of these services (12 claims per person) was somewhat lower than ESI use nationally (16 claims per person).1 Professional claim prices grew steadily at an av- erage annual rate of 3.2 percent (Table 16), while intensity declined over time. After adjusting for intensity, prices rose at an annual rate of 3.8 per- cent. On average, VESI prices for professional ser- vices were somewhat higher than ESI prices na- tionally. In 2011, the average VESI price for pro- fessional procedures was $113, whereas the in- tensity-adjusted price was about $65 (Table 14). By comparison, the average ESI price nationally for professional procedures was $96, and the in- tensity-adjusted price was about $56.1 Utilization differences between VESI and ESI na- tionally were clear with respect to professional lab/pathology detailed service category claims. As seen in Figure 21, 2011 saw about 1.3 lab/ pathology professional claims per VESI as com- pared with 4.4 claims per ESI nationally. This dif- ference in lab/pathology claims alone makes up 75 percent of the difference in the professional procedures utilization differences between VESI and ESI nationally. WHY DID VESI, ON AVERAGE, USE FEWER PROFESSIONAL SERVICES THAN DID ESI NATIONALLY? The use of outpatient-other facility services helps explain why the professional claim use rates were relatively lower for VESI as compared to the ESI national average. Some services (including laboratory testing and radiology) are delivered in various settings, such as hospital-based ambulatory care centers or in physician offices. Vermont may be a state in which billing, practice patterns or local markets encourage insureds to seek care in outpatient facilities. This study did not explore what policy, practice, or bene- fit mechanisms might influence the choice of provider or testing facility nor did it explore whether services performed in one setting or another resulted in higher or lower care quality or cost. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 18 Brand and Generic Prescriptions KEY FINDINGS Not every employer offers prescription coverage as part of ESI.2 In 2007, about 93 percent of VESI with medical coverage also had prescription cov- VESIS SPENT MORE PER PERSON ON GENERICS erage. By 2011, about 79 percent of VESI had pre- AND LESS ON BRAND PRESCRIPTIONS THAN ESIS scription coverage, and the remainder had pre- NATIONALLY scription coverage through a carve-out or no-  Annually, VESI spent an average of $12 more prescription coverage. Therefore, HCCI’s findings per insured on generic and $29 less per insured are not representative of individuals who had ESI on brand prescriptions than ESI nationally. medical coverage and received prescription cov- erage through other means.  Unlike national ESI trends, VESI had declining Brand prescriptions per capita brand prescription spending (annual average rates of 1.3% and –0.5%, respectively). Between 2007 and 2011, VESI per capita spend- Declining VESI brand spending was due to ing on brand prescriptions fell from $508 to $498 falling brand prescription use (annual average per person (Table 17). On average, VESI spent rate of –14.5%). about $29 less on brand prescriptions per person per year than did ESI nationally (Figure 22).  VESI used 51.3 more filled generic days than did ESI nationally in 2011. During the study period, VESI spending on brand prescriptions declined at an average annual rate  Prices paid per day for brand and generic drugs of 0.5 percent, although that spending briefly rose rose over time for VESI (annual average rates of by 7.9 percent in 2010 (Table 17 and Table 18). 16.4% and 4.7%, respectively). In contrast, national ESI spending on brand pre- scriptions grew at 1.3 percent annually during the same period (Figure 23). As seen in Table 19, the number of brand-filled days fell every year of the study. Between 2007 and 2011, the number of filled days of brand pre- scriptions per VESI fell from 117 to 63. During this period, brand prescription use declined at an average annual rate of 14.5 percent per year. Compared to ESI nationally, VESI filled fewer brand prescription days. In 2011, ESI nationally filled about 70 brand days per insured.1 However, as in Vermont, the number of brand-filled days per ESI fell during the study period (Table 19). www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 19 The price paid per filled brand prescription day rose over time. Between 2007 and 2011, the VESI price of a filled day of brand prescriptions on av- erage rose from $4 per day to $8 per day (Table 19). Similarly, during this period, ESI prices for brand prescriptions nationally rose from $5 per day $8 per day.1 VESI prices per day of brand pre- scriptions rose at an average annual rate of 16.4 percent as compared with 14.2 percent for na- tional ESI prices. Generic prescriptions Between 2007 and 2011, VESI per capita spend- ing on generic prescriptions rose from $176 to $277 (Table 17). Annually, about $12 more per VESI was spent on generic drugs relative to the national average ESI (Figure 24). VESI per capita spending grew at an average annual rate of 12.0 percent, though spiking in 2009 to 49.3 percent. (Table 17 and Table 18). By comparison, national ESI spending on generics grew at an average an- nual rate of 8.0 percent while also spiking in 2009 (Figure 25). Table 19 shows that VESI use of generic prescrip- tions rose during this period from 200.2 generic prescription filled days per person (37 more days than ESI nationally) to 261.4 filled days per per- son (51 days more than ESI nationally).1 VESI use grew at an average annual rate of 6.9 percent, though use spiked in 2009 and slowed in 2011. VESI prices per day for generic prescriptions grew by 4.7 percent per year (Table 19). Prices rose by 2.4 percent in 2008, spiked by 27 percent in 2009, and declined by 5.0 percent in 2010 and by 2.6 percent in 2011. In all years, the average price paid by VESI and ESI nationally for a generic prescription was about $1 per day. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 20 About this Project The Green Mountain Care Board (GMCB) and the mont, although independently calculated from a Health Care Cost Institute (HCCI) entered into a 3 different dataset, are comparable to the 2012 -year collaboration to advance public reporting findings for ESI nationally as reported by HCCI. on health care spending in the state of Vermont. HCCI analyzed health spending per ESI Vermont- In the first year of collaboration (2013–2014), the er by claim type (inpatient, outpatient, profes- goal was to produce this document: the 2007– sional claims, and prescriptions). HCCI decom- 2011 Vermont Health Cost and Utilization Report. posed spending into two primary components: Work on this project began in March 2013. HCCI utilization and prices. HCCI further decomposed finished preparing preliminary report tables, a prices into intensity-adjusted prices using the in- report draft, and draft methodology in December tensity of care for each service. These metrics 2013. A final draft was completed and approved were presented by claim-type service category, by the GMCB in August 2014. subservice category, and detailed service catego- This study had three goals. The first goal was to ry. More information on the data and methods is benchmark health care coverage and per capita available in the Methodology.5 spending for Vermonters younger than age 65 and covered by employer sponsored insurance Endnotes (ESI) as a primary health insurer. The second goal 1. Health Care Cost Institute. 2012 Health care cost and utilization report [Internet]. Washington (DC): HCCI; 2013. was to identify the drivers of health care spend- 2. Any administered drugs appear as professional claims. No information on non-brand, non-generic prescriptions appears in this report. ing (utilization, prices, and intensity) and to 3. In our analysis of VESI spending by gender (Table 1), HCCI used the self- benchmark those trends over time. The third goal reported gender on the claims and did not seek to correct any gender misattributions. was to compare Vermont’s ESI benchmarks to 4. Health Care Cost Institute. Aggregated ESI cost and utilization dataset (2007–2012). Washington (DC): HCCI; 2013. those in the 2012 Health Cost and Utilization Re- 5. Health Care Cost Institute. 2007–2011 Vermont health care cost and port.1,4 The authors hope that Vermonters, the utilization report methodology [Internet]. Washington (DC): HCCI; 2014. GMCB, and others find this report a starting point for further analyses of health care trends in Ver- mont. ACKNOWLEDGEMENTS For this report, HCCI used data from VHCURES. This project was made possible through collaboration be- We analyzed VHCURES data from an average of tween HCCI and the GMCB. HCCI thanks Dian Kahn, Direc- tor of Analysis and Data Management and VHCURES Pro- 305,000 ESI Vermonters per year between 2007 gram Director, and her team at the GMCB for their sup- and 2011. The paid, consolidated claims from port and feedback. HCCI also thanks both Steven Kappel, VHCURES were cleaned and actuarially adjusted for his ongoing insight into the Vermont claims data, and using methods similar to those in the 2012 re- Andrew Bourret, formerly of Onpoint Health Data. HCCI port. HCCI calculated the metrics in this report also thanks the research teams at Brandeis and Truven for using the same methods as used for the 2012 re- their timely and helpful feedback on the August 2014 ver- sion of this report. port. Therefore, the findings in this report on Ver- www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 21 Appendix TABLE 1 Annual expenditures per capita by age and gender, 2007–2011 2007 2008 2009 2010 2011 Per capita $3,549 $3,794 $4,082 $4,229 $4,408 Per capita by age 18 and younger $1,650 $1,822 $1,843 $1,932 $2,080 19-25 $2,044 $2,115 $2,275 $2,200 $2,423 26-44 $3,092 $3,287 $3,513 $3,583 $3,738 45-54 $4,668 $4,880 $5,160 $5,309 $5,482 55-64 $6,387 $6,788 $7,305 $7,474 $7,734 Per capita by gender Men $3,091 $3,329 $3,608 $3,700 $3,876 Women $3,991 $4,244 $4,535 $4,733 $4,918 Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: All figures rounded. All per capita dollars calculated from allowed amounts. TABLE 2 Changes in annual expenditure per capita by age group and gender, 2007–2011 Percent Change Percent Change Percent Change Percent Change 2007/ 2008 2008 / 2009 2009 / 2010 2010/2011 Per capita 6.9% 7.6% 3.6% 4.2% Per capita by age 18 and younger 10.4% 1.2% 4.8% 7.7% 19-25 3.4% 7.6% -3.3% 10.2% 26-44 6.3% 6.9% 2.0% 4.3% 45-54 4.5% 5.7% 2.9% 3.3% 55-64 6.3% 7.6% 2.3% 3.5% Per capita by gender Men 7.7% 8.4% 2.5% 4.8% Women 6.4% 6.9% 4.4% 3.9% Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: All figures rounded. All per capita dollars calculated from allowed amounts. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 22 TABLE 3 Average annual per capita spending growth by age group and gender, 2007–2011 Vermont Spending US Spending Vermont Difference Per Capita Per Capita (Percentage Points) Age Children (ages 0-18) 6.0% 6.6% -0.6 Young Adults (ages 19-25) 4.3% 6.0% -1.7 Adults (ages 26-44) 4.9% 4.8% +0.1 Adults (ages 45-54) 4.1% 4.5% -0.4 Pre-Medicare adults (ages 55-64) 4.9% 4.1% +0.8 Gender Men 5.8% 5.0% +0.8 Women 5.4% 4.6% +0.8 Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Note: All figures rounded. Average annual growth rates calculated using geometric means. TABLE 4 Annual out-of-pocket expenditures per capita by age group and gender, 2007–2011 2007 2008 2009 2010 2011 Out-of-pocket per capita $449 $487 $538 $558 $595 Out-of-pocket per capita by age 18 and younger $231 $259 $282 $301 $327 19-25 $342 $359 $395 $395 $413 26-44 $419 $463 $508 $523 $578 45-54 $564 $599 $653 $668 $714 55-64 $719 $757 $828 $850 $875 Out-of-pocket per capita by gender Men $387 $422 $470 $488 $517 Women $509 $549 $603 $626 $669 Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: All figures rounded. All per capita dollars calculated from allowed amounts. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 23 TABLE 5 Annual expenditures per capita for payers by age group and gender, 2007–2011 2007 2008 2009 2010 2011 Payer per capita $3,099 $3,308 $3,544 $3,670 $3,813 Payer per capita by age 18 and younger $1,420 $1,563 $1,561 $1,631 $1,753 19-25 $1,702 $1,756 $1,880 $1,805 $2,010 26-44 $2,673 $2,824 $3,005 $3,061 $3,161 45-54 $4,104 $4,281 $4,507 $4,640 $4,768 55-64 $5,668 $6,030 $6,477 $6,623 $6,860 Payer per capita by gender Men $2,704 $2,906 $3,139 $3,212 $3,359 Women $3,481 $3,695 $3,932 $4,107 $4,249 Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: All figures rounded. All per capita dollars calculated from allowed amounts. TABLE 6 Average annual changes in out-of-pocket per capita spending, 2007–2011 Out-of-Pocket Spending Per Capita Vermont Difference (Percentage Points) Vermont US All (ages 0-64) 7.3% 5.5% +1.8 Men 7.5% 5.6% +1.9 Women 7.1% 5.4% +1.7 Young adults 4.8% 6.3% -1.5 Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: All figures rounded. Average annual growth rates calculated using geometric means. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 24 TABLE 7 Changes in annual out-of-pocket expenditures per capita by age group and gender, 2007–2011 Percent Change Percent Change Percent Change Percent Change 2007/ 2008 2008 / 2009 2009 / 2010 2010/2011 Out-of-pocket per capita 8.4% 10.5% 3.8% 6.6% Out-of-pocket per capita by age 18 and younger 12.2% 9.1% 6.5% 8.7% 19-25 4.8% 10.1% 0.1% 4.5% 26-44 10.4% 9.8% 2.8% 10.5% 45-54 6.2% 9.0% 2.3% 6.8% 55-64 5.3% 9.4% 2.7% 2.9% Out-of-pocket per capita by gender Men 9.2% 11.2% 3.8% 6.1% Women 7.8% 9.8% 3.8% 6.9% Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: All figures rounded. All per capita dollars calculated from allowed amounts. TABLE 8 Changes in annual expenditures per capita for payers by age group and gender, 2007–2011 Percent Change Percent Change Percent Change Percent Change 2007/ 2008 2008 / 2009 2009 / 2010 2010/2011 Payer per capita 6.7% 7.2% 3.6% 3.9% Payer per capita by age 18 and younger 10.1% -0.1% 4.5% 7.5% 19-25 3.2% 7.1% -4.0% 11.4% 26-44 5.6% 6.4% 1.9% 3.3% 45-54 4.3% 5.3% 3.0% 2.8% 55-64 6.4% 7.4% 2.3% 3.6% Payer per capita by gender Men 7.5% 8.0% 2.3% 4.6% Women 6.1% 6.4% 4.4% 3.4% Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: All figures rounded. All per capita dollars calculated from allowed amounts. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 25 TABLE 9 Annual out-of-pocket expenditures per capita and changes in out-of-pocket expenditures by service category, 2007–2011 2007 2008 2009 2010 2011 Inpatient (all) $15 $16 $17 $20 $20 4.3% 5.7% 17.1% 4.3% Acute Inpatient $15 $16 $17 $19 $20 4.2% 5.6% 17.6% 3.7% Outpatient Visits $49 $59 $63 $69 $79 19.2% 8.4% 8.4% 15.1% Outpatient-Other $71 $82 $92 $97 $108 16.4% 12.3% 5.5% 10.9% Professional $170 $191 $204 $213 $238 12.4% 6.4% 4.4% 12.2% Prescriptions (all) $144 $139 $162 $160 $149 -3.5% 16.5% -1.1% -7.0% Brand $90 $83 $82 $86 $76 -8.1% -0.8% 4.9% -11.7% Generics $54 $56 $80 $74 $73 4.4% 41.8% -7.3% -1.5% Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: All figures rounded. All per capita dollars calculated from allowed amounts. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 26 TABLE 10 Utilization, prices, intensity, and unit prices in Vermont for inpatient admissions and outpatient visits, 2007–2011 2007 2008 2009 2010 2011 Utilization per 1,000 insured Inpatient 45 46 44 43 44 1.0% -3.1% -2.5% 1.5% Acute Inpatient 44 45 43 42 43 0.9% -4.9% -1.6% 1.5% Outpatient Visits 318 325 327 319 332 2.3% 0.7% -2.4% 4.0% Average prices per service Inpatient $10,886 $12,375 $13,637 $14,836 $15,109 13.7% 10.2% 8.8% 1.8% Acute Inpatient $11,006 $12,521 $14,041 $15,128 $15,404 13.8% 12.1% 7.7% 1.8% Outpatient Visits $1,766 $1,917 $2,121 $2,346 $2,414 8.5% 10.6% 10.6% 2.9% Average intensity per service Acute Inpatient 1.05 1.12 1.18 1.19 1.18 6.8% 4.9% 0.9% -0.7% Outpatient Visits 15.90 15.84 16.72 16.97 16.41 -0.4% 5.6% 1.5% -3.3% Average intensity-adjusted price per service Acute Inpatient $10,485 $11,164 $11,931 $12,739 $13,067 6.5% 6.9% 6.8% 2.6% Outpatient Visits $111 $121 $127 $138 $147 8.9% 4.8% 9.0% 6.4% Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: The inpatient metrics in this table were updated in November 2014. All figures rounded. All per capita dollars calculated from allowed amounts. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 27 TABLE 11 Annual expenditures per capita and changes in expenditures on inpatient admissions and outpatient visits, 2007–2011 2007 2008 2009 2010 2011 Inpatient (all) $494 $567 $605 $642 $663 14.8% 6.7% 6.0% 3.4% Acute Inpatient $489 $561 $599 $635 $656 14.8% 6.6% 6.0% 3.4% Outpatient Visits $561 $623 $694 $750 $802 11.0% 11.4% 8.0% 7.0% Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: All figures rounded. All per capita dollars calculated from allowed amounts. TABLE 12 Average annual changes in the components of spending on inpatient admissions and outpatient visits, 2007–2011 Spending Per Capita Components of Spending Trend Components of Price Trend Per Capita Utilization Prices Paid Intensity Unit Price Inpatient 7.7% -0.8% 8.5% N/A N/A Acute Inpatient 7.6% -1.0% 8.8% 2.9% 5.7% Outpatient Visits 9.3% 1.1% 8.1% 0.8% 7.3% Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: The inpatient metrics in this table were updated in November 2014. All figures rounded. All per capita dollars calculated from allowed amounts. TABLE 13 Acute Inpatient length of stay and price per day in Vermont, 2007–2011 2007 2008 2009 2010 2011 Length of Stay (Days) 3.8 3.9 3.9 4.1 4.1 1.7% 1.5% 3.5% 1.0% Average Price per day $2,894 $3,237 $3,577 $3,723 $3,754 11.8% 10.5% 4.1% 0.8% Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: The inpatient metrics in this table were updated in November 2014. All figures rounded. All per capita dollars calculated from allowed amounts. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 28 TABLE 14 Utilization, prices, intensity, and unit prices in Vermont for outpatient-other facility and professional services, 2007–2011 2007 2008 2009 2010 2011 Utilization per 1,000 insured Outpatient-other 4,975 5,199 5,271 5,082 5,067 4.5% 1.4% -3.6% -0.3% Professional 11,476 11,832 11,865 11,604 11,941 3.1% 0.3% -2.2% 2.9% Average prices per service Outpatient-other $133 $144 $153 $153 $160 8.3% 6.7% 0.1% 4.4% Professional $100 $100 $104 $110 $113 0.1% 3.5% 6.2% 2.9% Average intensity per service Outpatient-other 0.85 0.84 0.81 0.84 0.82 -0.9% -3.6% 2.6% -1.5% Professional 1.79 1.77 1.77 1.74 1.75 -1.3% -0.1% -1.4% 0.5% Average intensity-adjusted price per service Outpatient-other $156 $170 $188 $184 $195 9.3% 10.7% -2.5% 6.0% Professional $56 $57 $59 $63 $65 1.4% 3.7% 7.7% 2.4% Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Note: All figures rounded. TABLE 15 Annual expenditures per capita and changes in expenditures on outpatient-other facility and professional services, 2007–2011 2007 2008 2009 2010 2011 Outpatient-other $659 $746 $807 $779 $811 13.2% 8.2% -3.5% 4.1% Professional $1,149 $1,186 $1,232 $1,279 $1,354 3.2% 3.8% 3.9% 5.9% Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: All figures rounded. All per capita dollars calculated from allowed amounts. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 29 TABLE 16 Average annual changes in the components of spending on outpatient-other facility and professional services, 2007–2011 Spending Per Capita Components of Spending Trend Components of Price Trend Utilization Prices Paid Intensity Adjusted Price Outpatient-other 5.3% 0.5% 4.8% -0.9% 5.7% Professional 4.2% 1.0% 3.2% -0.6% 3.8% Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: All figures rounded. Average annual growth rates calculated using geometric means. TABLE 17 Annual expenditures per capita and changes in expenditures on prescriptions, 2007–2011 2007 2008 2009 2010 2011 Prescriptions (all) $685 $672 $744 $779 $777 -1.9% 10.7% 4.8% -0.4% Brand $508 $483 $462 $499 $498 -4.9% -4.3% 7.9% -0.1% Generics $176 $188 $280 $279 $277 6.5% 49.3% -0.4% -0.8% Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: All figures rounded. All per capita dollars calculated from allowed amounts. TABLE 18 Average annual changes in the components of spending on prescriptions, 2007–2011 Spending Per Capita Components of Spending Trend Utilization Prices Paid Prescriptions (all) 3.2% Brand -0.5% -14.5% 16.4% Generics 12.0% 6.9% 4.7% Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Notes: All figures rounded. Average annual growth rates calculated using geometric means. www.healthcostinstitute.org 2007-2011 Vermont Health Care Cost and Utilization Report 30 TABLE 19 Utilization, prices, intensity, and unit prices in Vermont for brand and generic prescriptions, 2007–2011 2007 2008 2009 2010 2011 Filled days per 1,000 insured Brand 117,581 96,491 81,576 75,784 62,966 -17.9% -15.5% -7.1% -16.9% Generic 200,176 208,246 244,817 256,617 261,397 4.0% 17.6% 4.8% 1.9% Average prices per service Brand $4 $5 $6 $7 $8 15.9% 13.2% 16.2% 20.2% Generic $1 $1 $1 $1 $1 2.4% 27.0% -5.0% -2.6% Source: HCCI, 2014. Data: VHCURES all-payer claims data set (2007–2011). Data pulled in June 2013. Note: All figures rounded. www.healthcostinstitute.org 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 www.healthcostinstitute.org Creative Commons Attribution Non-Commercial No Derivatives 4.0 License