MANAGED CARE DIGEST SERIES®
H O S P I T A L S / S Y S T E M S D I G E S T P U B L I C P A Y E R D I G E S T H M O - P P O D I G E S TSINCE 1987
Health Care Data Summary|2014
NATIONAL
www.managedcaredigest.com
2 National Health Care Data Summary 2014 Managed Care digest series®
NATIONAL HEALTH CARE DATA SUMMARY
CONTACTS
CONTENTS
Amy Nguyen Howell, MD, MBA [email protected] Chief Medical Officer, CAPG
Kelvin Yamashita [email protected] Account Executive, Sanofi U.S.
Provided by Sanofi U.S.
Bridgewater, NJ
Developed and produced by Forte Information Resources LLC
Denver, CO
www.forteinformation.com
Data provided by IMS Health
Parsippany, NJ
www.managedcaredigest.com
MANAGED CARE DIGEST SERIES
®
SINCE 1987
West RegionHealth Plan Demographics. . . . . . . . . . . 3
HMO Measures . . . . . . . . . . . . . . . . . . . 4–9
Medical Groups . . . . . . . . . . . . . . . . 10–11
Hospital Utilization . . . . . . . . . . . . . . . . . 12
Central RegionHealth Plan Demographics. . . . . . . . . . 13
HMO Measures . . . . . . . . . . . . . . . . . 14–19
Medical Groups . . . . . . . . . . . . . . . . 20–21
Hospital Utilization . . . . . . . . . . . . . . . . . 22
East RegionHealth Plan Demographics. . . . . . . . . . 23
HMO Measures . . . . . . . . . . . . . . . . . 24–29
Medical Groups . . . . . . . . . . . . . . . . 30–31
Hospital Utilization . . . . . . . . . . . . . . . . . 32
Diabetes . . . . . . . . . . . . . . . . . . . . . . 33–35
ADA/EASD Guidelines . . . . . . . . . . . . . . 36
Regional Definitions: Pages 2–32Central Arkansas, Illinois, Iowa, Kansas, Michigan, Minnesota, Nebraska, North Dakota, Texas and
Wisconsin
East Florida, Georgia, Kentucky, New Jersey, New York, North Carolina, Ohio, Pennyslvania, South Carolina and Tennessee
West Alaska, Arizona, California, Colorado, Montana, Nevada, New Mexico, Oregon, Utah and Washington
Regional Definitions: Pages 33–35Midwest Iowa, Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, North Dakota, Nebraska, Ohio,
South Dakota, Wisconsin
Northeast Connecticut, Massachusetts, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont
South Alabama, Arkansas, Washington, D.C., Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennesseee, Texas, Virginia, West Virginia
West Nevada, Alaska, Arizona, California, Colorado, Hawaii, Idaho, Mountana, New Mexico, Oregon, Utah, Washington, Wyoming
IntroductionCAPG is the largest physician association in the country and the voice of physician
organizations practicing capitated, coordinated care. CAPG’s membership comprises more than
180 multi-specialty medical groups and independent practice associations (IPAs) across 30 states
and Puerto Rico. Our members provide comprehensive health care through coordinated and
accountable physician groups and IPAs, successfully practicing this model for many years and
deploying effective risk-based contracts in commercial and Medicare Advantage plans.
We strongly believe that patient-centered, primary care-focused, coordinated and
accountable care offers the highest quality, the most efficient delivery mechanism and the
greatest value for our patients. CAPG organizational members have successfully operated
under this budget-responsible model for over two decades. Together with its member groups
and strategic partners, CAPG will continue driving the evolution, quality and transformation of
healthcare delivery across the nation.
We are pleased to present, alongside Sanofi, the inaugural 2014 CAPG National Health Care Data Summary, an overview of demographic, financial, utilization and pharmacy measures for
health plans, hospitals and medical group practices in key states with a CAPG presence. The 2014
Summary also provides regional Type 2 diabetes benchmarks that can help payers and providers
identify better opportunities to serve the needs of their patients. Independent, third-party data
are drawn from the Sanofi Managed Care Digest Series®.
The Summary is designed to provide organizations and employers with key information about
health plans, hospitals and medical group practices, and to promote the cost-effective delivery
of quality health care to the benefit of local communities.
The data in this report were gathered by IMS Health, Parsippany, NJ, a recognized leader in
the health care information market, providing comprehensive profiling solutions to health care
marketing business problems.
A review process takes place, before and during production of this report, between IMS Health
and Forte Information Resources LLC.
Sanofi, as sponsor of this report, maintains an arm’s-length relationship with the organizations
that prepare the Summary and carry out the research. The desire of Sanofi is that the information
in the Summary be completely independent and objective.
Managed Care digest series® National Health Care Data Summary 2014 3
WEST REGION
HEALTH INSURANCE EXCHANGE ENROLLMENT, 20143
MARKET Unsubsidized Subsidized Total
Arizona 27,368 92,703 120,071
California4 154,047 1,250,817 1,405,102
Colorado 50,774 74,628 125,402
Montana 5,132 31,452 36,584
Nevada 8,092 37,298 45,390
New Mexico 6,686 25,376 32,062
Oregon 13,645 54,663 68,308
Utah 11,174 73,427 84,601
Washington 40,972 122,235 163,207
NATION4 1,201,105 6,670,458 8,019,763
HEALTH PLAN DEMOGRAPHICS
Data source: IMS Health © 2014
HMO ENROLLMENT REBOUNDS IN FIVE STATES AFTER REGION-WIDE DECLINES
Even though total HMO
enrollment declined in eight
of the nine featured West
region states from 2011 to
2012 (Nevada excepted),
HMOs serving five of these
states—Arizona, Colorado,
New Mexico, Oregon and
Washington—recovered
portions of their lost enrollment
the following year.
GOVERNMENT ENROLLMENT EXPANDS IN HMOs SERVING MOST WEST REGION STATES
Government enrollment in
HMOs grew in seven of the
eight featured West region
states, excepting California,
from 2012 to 2013. Growth
rates for this type of member
surpassed the national annual
rate of 6.0% in Colorado
(30.1%), Nevada (7.8%),
New Mexico (8.2%) and
Washington state (13.8%).
2+ MILLION WESTERNERS ENROLL IN HEALTH INSURANCE EXCHANGES
As of April 19, 2014, 2.1 million
individuals across the nine
profiled West region states
enrolled in a plan offered
by a state or federal health
insurance exchange (25.9%
of national health insurance
exchange enrollment). Of
these, 1.8 million (84.7%)
enrolled using subsidies.
HMO ENROLLMENT
MARKET
2011 2012 2013
Total # of Enrollees
Avg. # of Enrollees
Total # of Enrollees
Avg. # of Enrollees
Total # of Enrollees
Avg. # of Enrollees
Arizona 1,768,275 147,356.3 1,662,105 127,854.2 1,710,633 142,552.8
California 15,705,930 392,648.3 15,385,780 452,523.0 14,588,150 429,063.3
Colorado 1,445,501 120,458.4 1,261,148 114,649.8 1,363,014 123,910.4
Montana 183,327 45,831.8 59,637 29,818.5 — —
Nevada 572,066 71,508.3 576,866 72,108.3 477,772 68,253.1
New Mexico 725,054 120,842.3 633,608 126,721.6 669,828 167,457.0
Oregon 750,157 107,165.3 632,666 105,444.3 652,260 108,710.0
Utah 1,101,414 275,353.5 915,299 183,059.8 903,482 150,580.3
Washington 1,915,195 191,519.5 1,693,465 153,951.4 1,783,194 178,319.4
NATION 79,478,570 179,815.8 80,545,040 187,314.0 80,056,080 182,776.4
1 Federal Employees Health Benefit Program2 Government enrollees include Medicare Risk, Medicare Cost, Medicaid and Federal Employees Health Benefit Program
(FEHBP) members.3 Data are from the U.S. Department of Health and Human Services and reflect figures from October 1, 2013, through April 19, 2014.4 Total health insurance exchange enrollment includes individuals whose subsidy status is unknown.
NOTE: Throughout this Data Summary, data include all HMOs serving the profiled states. In some cases, HMOs did not report their data. There were no HMOs serving the state of Alaska, and some data were unavailable for the selected markets.
Data source: U.S. Department of Health and Human Services © 2014
ENROLLMENT OF HMOs WITH GOVERNMENT BENEFICIARIES
MARKET
Medicare Medicaid FEHBP1 Total Government Enrollees2
2012 2013 2012 2013 2012 2013 2012 2013
Arizona 511,935 499,054 339,748 408,763 23,226 18,693 874,909 926,510
California 1,838,243 2,014,867 4,396,457 4,047,805 333,135 315,402 6,567,835 6,378,074
Colorado 165,589 228,421 35,350 37,286 28,537 32,898 229,476 298,605
Nevada 120,321 152,568 172,660 191,576 38,711 13,260 331,692 357,404
New Mexico 59,869 59,472 382,827 422,895 25,283 24,117 467,979 506,484
Oregon 139,399 149,018 79,389 80,529 18,939 21,847 237,727 251,394
Utah 56,369 66,248 137,829 139,979 26,334 21,497 220,532 227,724
Washington 279,184 306,975 456,116 537,689 60,744 61,414 796,044 906,078
NATION 8,624,740 9,602,636 26,862,850 28,177,990 1,419,562 1,328,414 36,907,160 39,109,036
Health Insurance Exchanges
4 National Health Care Data Summary 2014 Managed Care digest series®
WEST REGION
UTILIZATION RATES FOR COMMERCIAL HMO/POS MEMBERS1
Hospital Admissions per 1,000 Members
Hospital Days per 1,000 Members
ALOS per Hospital
Admission
Physician Encounters
per Member
Ambulatory Visits per Member2
MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013
Arizona 57.1 55.8 226.1 227.2 3.9 4.1 4.0 5.3 1.8 2.3
California 56.7 58.2 205.1 210.3 3.6 3.6 3.7 4.3 1.5 2.1
Colorado 39.3 41.6 155.7 166.5 4.0 4.0 4.9 4.9 1.4 1.5
Nevada 56.5 57.2 215.4 199.9 3.7 3.5 5.5 4.5 1.9 0.9
New Mexico 63.7 61.3 275.0 279.6 3.9 4.1 5.2 5.0 2.7 2.5
Oregon 42.7 40.3 145.5 154.7 3.4 3.9 3.2 3.8 1.4 1.9
Utah 55.0 53.3 209.7 195.0 3.8 3.7 4.7 5.0 1.6 1.8
Washington 39.6 41.6 136.0 166.2 3.5 4.0 3.0 3.9 1.9 1.9
NATION 58.4 58.0 239.1 246.9 4.2 4.3 4.7 4.7 1.7 1.9
COMMERCIAL: HMO/HOSPITAL MEDICAL UTILIZATION
DAYS/1,000 COMMERCIAL MEMBERS RATIO IN THE WEST REGION LAGS THAT OF THE U.S.
For seven of the eight profiled
West region states (New
Mexico excluded), there were
fewer hospital days per 1,000
commercial members than
the corresponding national
average of 246.9 in 2013. This
occurred despite a minor
increase in this measure for
six of the eight profiled states
from 2012 to 2013.
ALOS IS LOW VS. U.S. AVG. FOR WEST REGION STATES
Average lengths of stay (ALOS)
per hospital admission for
commercial members of HMOs
serving any of the eight West
region states featured were
less than the national average
for such patients (4.3 days) in
2013. Nevada (3.5 days) plans
recorded the lowest average
among these states, followed
by California (3.6 days). Data source: IMS Health © 2014
NUMBER OF HOSPITAL ADMISSIONS PER 1,000 COMMERCIAL HMO/POS MEMBERS, 20131
Arizona California Colorado Nevada New Mexico Oregon Utah Washington Nation0
16
32
48
64
Ho
spita
l Ad
miss
ion
s
55.858.2
41.6
57.261.3
40.3
53.3
41.6
58.0
AVERAGE LENGTH OF STAY PER HOSPITAL ADMISSION, COMMERCIAL HMO/POS MEMBERS, 20131
1
2
3
4
5
Ave
rag
e L
en
gth
of S
tay
(Da
ys)
4.1
3.6
4.0
3.5
4.13.9
3.7
4.0
4.3
Arizona California Colorado Nevada New Mexico
Oregon Utah Washington Nation
1 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s office
that do not require the services of a physician. Such visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory.
NOTE: HMO hospital/medical utilization data were unavailable for Montana.
Managed Care digest series® National Health Care Data Summary 2014 5
WEST REGION
0
2
4
6
8
Ave
rag
e L
en
gth
of S
tay
(Da
ys)
4.3 4.2
2.9
3.9
3.3
6.0
3.3
5.1
4.4
Arizona California Colorado Nevada New Mexico
Oregon Utah Washington Nation
MEDICAID HOSPITAL ADMIT RATIOS ARE LOW FOR MOST WEST REGION STATES
In five of the eight profiled
states, the numbers of hospital
admissions per 1,000 Medicaid
HMO members were below
the national mean of 98.8 in
2013. Of these eight states,
Nevada HMOs recorded the
lowest hospital admissions ratio
in 2013, at 74.0, followed by
those serving California (81.1).
ALOS IS BELOW U.S. AVG. FOR MEDICAID HMO HOSPITAL ADMITS IN MOST WEST STATES
Average lengths of stay
(ALOS) for Medicaid member
hospital admissions were lower
than the overall national
average in 2013 for HMOs
serving six of the eight states
shown. For example, ALOS
per Medicaid HMO hospital
admission was 2.9 days in
Colorado, 34.1% lower than
the overall national average
of 4.4 days.
Data source: IMS Health © 2014
NUMBER OF HOSPITAL ADMISSIONS PER 1,000 MEDICAID HMO MEMBERS1
0
50
100
150
200
Ho
spita
l Ad
miss
ion
s
—186.7—
86.8 81.1
134.0 136.0
82.374.0
102.990.5
61.8
93.0
75.1
—
55.5
96.5 97.6 98.8
2012 2013
Arizona California Colorado Nevada New Mexico Oregon Utah Washington Nation
AVERAGE LENGTH OF STAY PER HOSPITAL ADMISSION, MEDICAID HMO MEMBERS, 20131
MEDICAID: HMO/HOSPITAL MEDICAL UTILIZATION
UTILIZATION RATES FOR MEDICAID HMO MEMBERS1
Hospital Admissions per 1,000 Members
Hospital Days per 1,000 Members
ALOS per Hospital
Admission
Physician Encounters
per Member
Ambulatory Visits per Member2
MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013
Arizona 186.7 186.7 — — 4.3 4.3 — — — —
California 86.8 81.1 296.2 325.0 3.9 4.2 3.6 4.0 1.2 1.8
Colorado 134.0 136.0 381.0 395.0 2.8 2.9 — — — —
Nevada 82.3 74.0 298.8 287.0 3.7 3.9 1.9 4.8 1.4 1.5
New Mexico 102.9 90.5 431.5 298.4 4.7 3.3 6.1 3.9 2.9 2.8
Oregon 61.8 93.0 249.5 551.2 4.0 6.0 2.0 — 1.3 3.8
Utah 75.1 — 270.3 534.3 3.6 3.3 4.0 5.0 2.6 3.1
Washington 55.5 96.5 221.1 498.8 4.1 5.1 2.6 4.9 1.7 3.7
NATION 97.6 98.8 380.5 395.3 4.2 4.4 4.4 4.6 2.3 2.6
1 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s office
that do not require the services of a physician. Such visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory.
NOTE: Some data were unavailable for the selected markets.
6 National Health Care Data Summary 2014 Managed Care digest series®
WEST REGION
MA ENROLLMENT EXPANDS AT A RAPID PACE IN WEST REGION STATES AND U.S.
In all 10 profiled states,
Medicare Advantage (MA)
enrollment expanded from
2011 to 2013; all but two
states—Arizona and Utah—
recorded double-digit growth
in this measure. Nationally, the
growth rate for MA enrollment
was 18.2% during this time, a
rate that was outstripped in
Alaska and New Mexico.
MEDICARE ADVANTAGE PENETRATION, WEST REGION, 20131,2
Data source: Centers for Medicare and Medicaid Services and IMS Health © 2014
MEDICARE ADVANTAGE ENROLLMENT/PENETRATION1,2
2011 2012 2013
MARKET Enrollment Penetration Enrollment Penetration Enrollment Penetration
Alaska 41 0.1% 18 0.0% 79 0.1%
Arizona 359,889 37.2 378,636 37.4 391,070 37.0
California 1,766,531 35.5 1,899,968 36.7 2,032,183 38.0
Colorado 225,202 34.0 237,047 34.0 260,998 35.6
Montana 26,503 15.0 25,088 13.6 30,741 16.1
Nevada 118,696 31.5 121,819 30.7 133,754 32.1
New Mexico 88,062 26.9 95,079 27.9 106,103 30.1
Oregon 266,123 41.0 281,653 41.5 301,867 42.8
Utah 103,185 34.7 98,530 31.7 107,709 33.2
Washington 276,743 27.1 293,407 27.4 320,668 28.8
NATION 12,454,064 25.7% 13,278,369 26.4% 14,724,574 28.4%
HI45.3%AK
0.1%
CA38.0%
OR42.8%
WA28.8%
UT33.2%
MT16.1%
NATION: 28.4%
CO35.6%
AZ37.0% NM
30.1%
NV32.1%
South CentralRegion
CA38.0%
MD8.6%
MEDICARE ADVANTAGE
1 MA enrollment includes members of HMOs, PPOs, private fee-for-service (PFFS) plans and other plan types.2 The penetration rate reflects the percentage of the Medicare population enrolled in Medicare Advantage plans.
Managed Care digest series® National Health Care Data Summary 2014 7
WEST REGION
HMO/HOSPITAL UTILIZATION AND COST MEASURES
Commercial HMO Hospital Days/1,000
Medicare HMO Hospital Days/1,000
Medicare Fee-for-Service
Discharges/1,0003
Medicare Fee-for-Service
Hospital Days/1,0003
Medicare Fee-for-Service Payments per
Hospital Discharge3
Medicare Fee-for-Service
Payments per Enrollee3
MARKET 2011 2012 2011 2012 2011 2012 2011 2012 2011 2012 2011 2012
Arizona 243 226 1,556 1,325 283 263 1,348 1,236 $10,844 $11,201 $2,967 $2,808
California 199 224 1,156 1,046 277 264 1,508 1,415 13,930 14,526 3,712 3,624
Colorado 175 156 1,155 1,082 256 240 1,193 1,124 10,179 10,716 2,553 2,502
Montana 194 — 1,830 2,312 202 196 942 926 10,115 10,621 1,966 1,949
Nevada 219 215 1,390 1,255 278 264 1,572 1,497 11,164 11,663 3,022 2,936
New Mexico 234 275 1,518 1,545 239 229 1,188 1,125 10,319 10,695 2,411 2,368
Oregon 165 146 1,035 840 208 200 955 902 11,352 11,679 2,337 2,248
Utah 176 210 2,223 1,406 238 233 1,020 982 9,847 10,089 2,259 2,230
Washington 157 136 891 1,043 238 233 1,130 1,099 11,047 11,527 2,601 2,616
NATION 236 239 1,643 1,602 323 307 1,734 1,634 $10,362 $10,674 $3,281 $3,176
MEDICARE MD UTILIZATION RATES RISE FOR MANY WEST REGION STATES IN 2013
In Arizona, Colorado,
Nevada, Oregon, Utah
and nationally, Medicare
HMO members visited their
physicians more often in 2013
than in 2012. Furthermore,
such members in Arizona,
Colorado, New Mexico and
Utah encountered physicians
more often than their peers
nationwide in 2013.
HOSPITAL UTILIZATION RATIOS ARE LOW FOR HMOs IN MUCH OF THE WEST REGION
Hospital admissions per 1,000
Medicare members ratios were
below the U.S. average of
275.6 for HMOs serving seven
of the eight profiled West
region states in 2013 (Nevada
excepted). Medicare hospital
days ratios for all of these
states were also low versus the
overall U.S. mean.
MEDICARE: HMO/HOSPITAL MEDICAL UTILIZATION
Data source: Centers for Medicare and Medicaid Services and IMS Health © 2014
UTILIZATION RATES FOR MEDICARE MEMBERS1
Hospital Admissions per 1,000 Members
Hospital Days per 1,000 Members
ALOS per Hospital
Admission
Physician Encounters
per Member
Ambulatory Visits per Member2
MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013
Arizona 249.6 258.5 1,325.2 1,498.1 5.3 5.8 10.5 11.7 4.6 3.6
California 215.4 221.9 1,045.6 1,184.7 5.2 5.5 8.4 8.2 3.5 4.0
Colorado 182.9 193.2 1,082.1 1,347.3 5.9 6.8 10.8 12.2 3.1 4.5
Montana 262.7 — 2,311.8 — 8.8 — — — 6.8 —
Nevada 250.5 283.0 1,255.3 1,238.4 5.2 4.5 9.0 10.2 3.6 4.3
New Mexico 185.9 229.1 1,545.4 1,389.4 7.6 6.0 11.2 10.7 7.2 6.0
Oregon 193.3 183.6 839.8 958.2 4.5 5.1 6.4 7.3 3.5 3.9
Utah 225.8 230.4 1,406.4 1,496.2 6.1 6.3 11.5 11.8 7.7 7.6
Washington 203.6 201.1 1,042.8 1,160.4 4.7 5.2 8.5 8.5 4.6 3.5
NATION 265.8 275.6 1,602.4 1,727.1 6.1 6.3 9.9 10.4 4.4 4.5
NUMBER OF HOSPITAL ADMISSIONS PER 1,000 MEDICARE HMO MEMBERS, 20131
Arizona California Colorado Nevada New Mexico
Oregon Utah Washington Nation0
75
150
225
300
Ho
spita
l Ad
miss
ion
s
258.5
221.9
193.2
283.0
229.1
183.6
230.4
201.1
275.6
Managed Care vs. Fee-for-Service MeasuresData source: IMS Health © 2014
1 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s office that do not require the services of a physician. Such
visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory.3 Discharges, hospital days per 1,000, payments per hospital discharge and payments per enrollee for Medicare fee-for-service come from the Medicare and Medicaid Research
Review Statistical Supplement.
NOTE: Some utilization data were unavailable for the selected markets.
8 National Health Care Data Summary 2014 Managed Care digest series®
WEST REGION
Data source: IMS Health © 2014
HMO PREMIUMS
INDIVIDUAL PREMIUMS TRAIL NATION IN AZ, CO, NM AND WA
Compared with the U.S.
average of $531.82, individual
premiums were lower at plans
serving Arizona, Colorado,
New Mexico and Washington.
Family premiums were below
the U.S. average in Colorado,
Nevada, New Mexico and
Utah. Premiums increased in
all markets (excepting New
Mexico) from 2011 to 2013.
CA HMO MEMBERS PAY LESS THAN U.S. AVG. FOR RX PREMIUMS
Individual ($34.56) and
family ($95.88) members of
HMOs serving the state of
California had lower monthly
premiums for outpatient
pharmacy benefits than such
members in plans across the
nation in 2013 ($40.71 and
$103.04, respectively).
Arizona California Colorado Montana Nevada New Mexico Oregon Utah Washington Nation$200
$315
$430
$545
$660
Avg
. In
div
idu
al P
rem
ium
($)
$468
$526$510
$595
$451
$491
$358
$587
$515
$557
$494 $494
$542
$592
$460
$552
$497
$527
$486
$532
2012 2013
AVERAGE INDIVIDUAL PREMIUM PER MONTH1
AVERAGE PREMIUM RATES PER MONTH1
Average Individual Premium Average Family Premium
MARKET 2011 2012 2013 2011 2012 2013
Arizona $446.44 $468.46 $526.11 $1,162.01 $1,192.80 $1,339.17
California 472.01 509.96 595.48 1,231.85 1,350.67 1,456.56
Colorado 451.16 450.64 491.38 1,151.41 1,143.52 1,209.37
Montana 521.98 357.50 587.00 1,282.98 1,327.00 1,327.00
Nevada 461.09 515.42 556.69 1,138.13 1,187.72 1,293.80
New Mexico 503.59 493.84 493.84 1,239.98 1,201.44 1,201.44
Oregon 473.95 541.79 591.62 1,237.62 1,396.47 1,367.88
Utah 452.37 459.61 551.86 1,026.35 1,048.54 1,194.24
Washington 433.96 497.01 526.91 1,170.72 1,349.29 1,332.14
NATION $464.75 $486.48 $531.82 $1,189.17 $1,237.31 $1,313.03
PREMIUMS PER MEMBER PER MONTH FOR OUTPATIENT PHARMACY BENEFITS
Average Individual Premium Average Family Premium
MARKET 2012 2013 2012 2013
Arizona $37.32 $37.32 $109.78 $109.78
California 34.56 34.56 95.88 95.88
Colorado 43.98 43.98 115.76 115.76
Nevada 47.29 48.63 116.72 133.07
New Mexico 37.00 37.00 117.50 117.50
Oregon 40.48 40.48 — —
Utah 44.62 44.62 100.36 100.36
Washington 50.74 50.74 184.00 184.00
NATION $40.21 $40.71 $101.80 $103.04
1 Averages represent the flat charge for medical health coverage and do not include charges for pharmacy, dental or other services. Also, employee contributions are not included. Numbers of options and levels of coverage may account for significant differences between an individual company’s premium rates and the average.
NOTE: Outpatient pharmacy premium data were unavailable for Montana; some data were unavailable for the selected markets.
Managed Care digest series® National Health Care Data Summary 2014 9
WEST REGION
1 This average is derived by dividing HMO pharmacy expenses by the total number of prescriptions dispensed. Expenses do not include administration or copayment costs.
2 Rounded to the nearest dollar. Expenditures do not include administration and copayment costs.
NOTE: Some data were unavailable for the selected markets.
HMO PHARMACY UTILIZATION AND EXPENDITURES
PRESCRIPTIONS DISPENSED PER COMMERCIAL HMO MEMBER PER YEAR
6
7
8
9
10
Ave
rag
e R
xs/P
MPY
8.88.6
—7.7—
8.58.4
—6.3—
8.4
8.1
—8.9—
8.1
7.8
8.6
8.38.1
7.8
9.1 9.0
2012 2013
Arizona California Colorado NevadaMontana New Mexico
Oregon Utah Washington Nation
Data source: IMS Health © 2014
INGREDIENT COSTS PER RX FALL IN MOST WEST REGION STATES, ARE LOWEST IN CA
From 2011 to 2013, average
ingredient costs for
prescriptions dispensed by
HMOs serving eight of the nine
profiled states (Washington
excepted) declined, and
were lowest, by state, in
California ($43.51) in 2013. Five
of the profiled states recorded
such costs that were below
the U.S. average in 2013.
RX FILL RATES DIP FOR COMMERCIAL HMOs IN MOST WEST REGION STATES
On average, commercial
members of HMOs serving
six of the nine profiled West
region states filled fewer
prescriptions in 2013 than they
did in 2012, while fill rates for
such members in the other
three states held steady.
In 2013, commercial HMO
members in Montana filled just
6.3 prescriptions per year.
RX COST PORTION OF HMO OPERATING EXPENSES IS LOW IN WEST REGION STATES
In 2013, the portions of
operating expenses devoted
to drug costs were lower
than the U.S. rate (14.7%) for
HMOs serving eight of the nine
profiled West region states
(Colorado excluded). From
2012 to 2013, per-member
per-year drug expenses fell
for HMOs serving California,
Montana and New Mexico.
PRESCRIPTIONS DISPENSED AND AVERAGE INGREDIENT COST1
Rxs Dispensed per Commercial HMO Member per Year Average Ingredient Cost
MARKET 2011 2012 2013 2011 2012 2013
Arizona 9.2 8.8 8.6 $60.29 $57.54 $55.32
California 8.5 7.7 7.7 51.10 43.26 43.51
Colorado 8.7 8.5 8.4 61.73 55.62 56.05
Montana 7.1 6.3 6.3 66.98 51.00 51.00
Nevada 8.7 8.4 8.1 63.49 58.09 58.17
New Mexico 9.1 8.9 8.9 60.56 54.63 54.63
Oregon 8.8 8.1 7.8 70.85 59.32 61.24
Utah 9.0 8.6 8.3 68.73 65.52 66.80
Washington 8.8 8.1 7.8 60.64 59.32 61.24
NATION 9.4 9.1 9.0 $58.95 $55.73 $56.70
HMO DRUG EXPENDITURES
Drug Costs as a Percentage of Operating Expenses
Expenditures per Member per Year for Drugs2
MARKET 2011 2012 2013 2011 2012 2013
Arizona 12.5% 12.2% 12.4% $511 $558 $671
California 12.8 12.4 12.4 518 578 531
Colorado 14.1 14.4 15.3 485 524 605
Montana 13.7 14.5 13.0 672 831 —
Nevada 13.7 13.9 14.3 546 576 654
New Mexico 11.3 11.8 13.0 436 474 411
Oregon 12.0 11.3 11.5 704 693 712
Utah 12.3 11.6 12.3 450 504 505
Washington 12.7 11.6 12.0 631 643 682
NATION 13.9% 14.5% 14.7% $578 $605 $609
10 National Health Care Data Summary 2014 Managed Care digest series®
WEST REGIONMEDICAL GROUPS: DEMOGRAPHICS
Data source: IMS Health © 2014
NUMBER OF MEDICAL GROUPS WITH FIVE OR MORE FTE PHYSICIANS, 2013
SIZE (# of MDs)Alaska Arizona Califor-
niaColo-rado Montana Nevada New
Mexico Oregon Utah Washing-ton NATION
5–6 7 89 499 106 25 32 42 94 41 169 5,729
7–9 14 43 339 61 16 32 20 87 26 97 3,266
10–14 4 20 222 29 15 12 14 36 20 66 1,786
15–19 3 11 81 9 3 6 5 7 9 25 630
20+ 2 16 233 32 4 10 3 36 14 57 1,478
TOTAL 30 179 1,374 237 63 92 84 260 110 414 12,889
SPECIALTY COMPOSITION
Single Specialty 15 100 545 161 23 50 41 150 48 222 7,161
Multispecialty 15 79 829 76 40 42 43 110 62 192 5,728
AVG. VISITS PER WEEK
Under 250 3 8 106 19 8 3 5 16 8 33 1,029
250–499 6 24 163 27 16 13 10 35 20 54 2,052
500–749 3 29 156 40 8 14 14 47 10 53 2,022
750+ 9 38 231 51 21 16 19 51 33 84 2,728
Unknown 9 79 697 100 9 46 34 110 38 180 4,932
TOTAL 30 179 1,374 237 63 92 84 260 110 414 12,889
PERCENTAGE OF MEDICAL GROUP PRACTICES BY AFFILIATION
Corporate Affiliation Independent
MARKET 2012 2013 2012 2013
Alaska 23.3% 23.3% 76.7% 76.7%
Arizona 29.2 29.1 70.8 70.9
California 43.1 43.4 56.9 56.6
Colorado 35.7 35.9 64.3 64.1
Montana 35.5 36.5 64.5 63.5
Nevada 29.3 29.3 70.7 70.7
New Mexico 51.8 51.2 48.2 48.8
Oregon 39.0 38.8 61.0 61.2
Utah 39.4 39.1 60.6 60.9
Washington 44.3 45.7 55.7 54.3
NATION 42.7% 42.7% 57.3% 57.3%
PERCENTAGE OF MEDICAL GROUP PRACTICES BY SPECIALTY, 2013
0%
20%
40%
60%
80%
Perc
en
tag
e o
f Gro
up
s
—50.0%—55.9%
44.1%39.7%
60.3%
67.9%
32.1%36.5%
63.5%
54.3%
45.7%
48.8%
51.2%
57.7%
42.3%
43.6%
56.4%53.6%
46.4%
55.6%
44.4%
Single Specialty Multispecialty
ArizonaAlaska Califor-nia
Colo-rado
NevadaMon-tana
New Mexico
Oregon Utah Wash-ington
Nation
WEST REGION GROUP PRACTICE SIZES MIRROR NATIONAL DISTRIBUTION
Apart from Alaska and
Nevada, medical group
practice sizes in the West
region, by number of FTE
physicians, followed the same
distribution as those of their
national counterparts. The
highest numbers of medical
groups in eight of 10 profiled
states were comprised of five
to six physicians, followed by
medical groups with seven to
nine physicians. Alaska was
the only state with more groups
of seven to nine physicians
than any other FTE range.
FOUR STATES HAVE LARGER SHARES OF MULTI- VERSUS SINGLE-SPECIALTY GROUPS
California, Montana, New
Mexico and Utah had higher
percentages of multispecialty
medical group practices
than single-specialty medical
group practices in 2013.
Nationally, 55.6% of medical
groups were single specialty.
HIGH SHARES OF WEST REGION PRACTICES ARE INDEPENDENT VS. U.S. AVG.
In 2013, the percentages
of medical group practices
with no corporate affiliation
were higher in Alaska (76.7%),
Arizona (70.9%), Colorado
(64.1%), Montana (63.5%),
Nevada (70.7%), Oregon
(61.2%) and Utah (60.9%) than
the national average of 57.3%.
New Mexico reported the
highest share of corporate-
affiliated practices (51.2%).
NOTE: IMS Health defines the medical groups represented on pages 10–11 of this Data Summary as those with five or more full-time equivalent (FTE) physicians whose primary business is seeing regularly scheduled patients for nonsurgical services other than imaging. Physicians must have a share in the practice and offer outpatient care, and the practice must be physically separate from a hospital. Anesthesiology and pathology groups are excluded.
Managed Care digest series® National Health Care Data Summary 2014 11
WEST REGION
PERCENTAGE OF MEDICAL GROUPS, BY TYPE OF SERVICE
Groups That Perform Surgery (%)
Groups That Have Clinical Labs (%)
Groups That Offer Imaging Services (%)
MARKET 2012 2013 2012 2013 2012 2013
Alaska 58.6% 58.6% 68.2% 68.2% 64.3% 64.3%
Arizona 60.6 60.9 44.0 43.6 64.6 64.9
California 52.5 52.7 40.7 40.7 54.3 54.4
Colorado 67.3 67.3 47.5 47.5 62.8 62.8
Montana 61.4 62.1 69.4 67.6 78.0 78.4
Nevada 42.5 42.5 41.8 41.8 65.8 65.8
New Mexico 58.9 59.5 56.4 54.5 63.9 63.0
Oregon 65.5 65.7 56.9 57.1 64.5 64.6
Utah 77.3 77.6 62.7 61.9 65.9 66.3
Washington 67.8 68.1 58.5 58.8 69.3 69.7
NATION 54.7% 54.3% 49.8% 49.5% 64.5% 64.0%
SHARES OF GROUPS THAT PERFORM SURGERY ARE HIGH IN MOST WEST REGION STATES
The percentages of medical
group practices that perform
surgery were higher in eight of
10 profiled West region states
in 2013 than that of the nation
(54.3%). Utah state had the
highest share of such group
practices (77.6%), by profiled
West region state, followed
by Washington state (68.1%),
Colorado (67.3%) and
Oregon (65.7%).
MT HAS HIGHEST SHARE OF WEST REGION GROUP PRACTICES WITH RX SERVICES
Of the 10 profiled West region
states, Montana (73.0%)
had the highest share of
medical group practices with
pharmacy services in 2013,
while Nevada (37.7%) had the
lowest. Alaska (40.9%), Arizona
(45.5%) and Colorado’s (49.4%)
shares were also under 50%.
HIGH SHARES OF WEST REGION GROUPS OFFER FULL PHARMACY VS. NATION
In eight of 10 West region
states, higher percentages
of medical group practices
offered full pharmacy services
than their counterparts
nationwide (18.9%) in 2013.
That year, medical group
practices in Alaska (44.4%)
and Arizona (44.0%) offered
such services at more than
double the national rate.
MEDICAL GROUPS: SERVICES
1 Medical groups with full pharmacies offer a complete range of medication types; those with limited pharmacy services offer a smaller range, often in particular therapeutic classes; others provide patients only with samples of medications.
NOTE: Some medical group practice data were unavailable for the selected states.
Data source: IMS Health © 2014
PERCENTAGE OF MEDICAL GROUPS, BY TYPE OF PHARMACY SERVICE1
Full Pharmacy Limited Pharmacy Samples
MARKET 2012 2013 2012 2013 2012 2013
Alaska 44.4% 44.4% 22.2% 22.2% 33.3% 33.3%
Arizona 44.9 44.0 6.1 8.0 51.0 52.0
California 33.4 33.1 17.5 17.9 51.3 51.2
Colorado 21.8 21.8 16.1 16.1 64.4 64.4
Montana 15.4 14.8 3.8 3.7 84.6 85.2
Nevada 15.0 15.0 10.0 10.0 80.0 80.0
New Mexico 34.5 35.7 17.2 14.3 51.7 53.6
Oregon 20.9 20.9 6.6 6.6 72.5 72.5
Utah 22.9 22.9 — — 77.1 77.1
Washington 32.7 32.9 8.0 7.9 61.3 61.2
NATION 18.4% 18.9% 9.7% 10.0% 75.0% 74.3%
0%
20%
40%
60%
80%
Perc
en
tag
e o
f Gro
up
s
—40.9%—45.0%
45.5% 50.4%50.5%
—49.4%—
72.2%73.0%
—37.7%—
51.8%50.0% 58.0%
57.6%58.5%
57.8%
53.0%53.3% 60.7%
60.2%
2012 2013
ArizonaAlaska Califor-nia
Colo-rado
NevadaMon-tana
New Mexico
Oregon Utah Wash-ington
Nation
PERCENTAGE OF MEDICAL GROUPS WITH PHARMACY SERVICES
12 National Health Care Data Summary 2014 Managed Care digest series®
WEST REGIONHOSPITAL UTILIZATION
SELECTED UTILIZATION STATISTICS FOR HOSPITALS, 20121
MEASUREAlaska Arizona Califor-
niaColo-rado
Mon-tana Nevada New
Mexico Oregon Utah Wash-ington NATION
Total Facility Admissions per Hospital
2,696 10,569 8,813 5,110 1,683 7,727 4,977 5,697 5,743 6,987 7,143
Total Facility Patient-Days per Hospital
18,360 44,743 43,482 26,325 7,803 37,269 24,325 22,490 22,546 28,755 35,791
Total FacilityALOS perHospital
10.9 4.1 5.6 6.2 3.6 4.2 4.2 3.3 3.8 3.6 5.3
Inpatient Surg./ Staffed Bed 10.9 17.0 11.5 10.4 11.5 13.3 12.1 17.2 12.0 14.5 11.8
Outpatient Surg. per Day 6.1 9.5 9.1 5.6 3.8 9.8 8.0 10.8 10.8 9.8 10.6
Outpatient Surg. as a Percentage of Total Surg.
77.1% 57.2% 56.8% 67.5% 75.9% 63.9% 68.6% 71.3% 73.9% 67.4% 70.9%
SELECTED FINANCIAL RATIOS FOR HOSPITALS (IN THOUSANDS), 2012MEASURE Alaska Arizona California Colorado Montana Nevada New Mexico Oregon Utah Washington NATION
Total Costs/Occupied Bed $1,726.8 $2,017.2 $1,926.9 $2,398.8 $3,048.1 $2,165.3 $2,369.8 $3,057.4 $2,188.5 $2,795.6 $1,847.4
Total Costs/Admission 36.9 19.5 24.1 30.3 34.7 23.2 25.3 29.5 20.6 26.7 22.3
Total Costs/ Patient-Day 4.7 5.5 5.3 6.6 9.2 5.9 6.5 8.7 6.5 7.8 5.2
Labor Costs/Patient-Day 1.9 2.3 2.5 2.6 3.0 2.1 2.5 3.5 2.3 3.1 2.1
Salary Costs/FTE4 66.8 65.9 83.4 61.6 54.9 67.8 61.5 72.5 54.9 68.8 57.4
Total Costs/FTE4 174.1 176.8 206.3 164.9 135.4 203.3 169.8 175.1 161.5 167.2 152.7
Data source: IMS Health © 2014
TOTAL FACILITY ADMITS FOR AZ, CA AND NV HOSPITALS EXCEED U.S. AVERAGE
Compared with the national
mean of 7,143, the average
hospital in Arizona (10,569),
California (8,813) and Nevada
(7,727) reported a higher
number of total facility
admissions per hospital in
2012. Of the 10 states profiled,
Montana reported the fewest
total facility admissions per
hospital in 2012, at 1,683,
less than a quarter of the
national average that year.
PATIENT-DAY AVERAGES TRAIL U.S. IN MOST OF THE PROFILED WEST REGION STATES
In seven of the 10 featured
West region states, hospitals
recorded fewer total facility
patient-days than the national
average of 35,791 in 2012.
ALOS TRAILS NATION FOR MOST WEST HOSPITALS
For 12 of the 14 West region
hospital systems shown,
average length of stay trailed
the national average of
5.3 days in 2012.
1 Total facility figures reflect all portions of the hospital’s occupancy.2 Hospital All-Cause Readmission Rate figures come from the Centers for Medicare and Medicaid Services Hospital Compare database and are measured from July 2012 through
June 2013. Unless otherwise noted, scores are averaged across all facilities within the specified system.3 The figures listed are for an individual hospital, rather than an average.4 “FTE” is full-time equivalent.
NOTE: Hospital utilization data represent patients of all payer types.
SELECTED UTILIZATION MEASURES, CAPG AND CATHOLIC HEALTH INITIATIVES AFFILIATES, 20121
SYSTEM NAME
Number of Staffed Beds
Average Number
of Hospital Admissions
Average Total Facility Occupancy
Average Length of
Stay (Days)
All-Cause Readmission
Rate2
Catholic Health Initiatives 131.6 6,808.1 50.3% 5.1 15.1%
Cedars-Sinai Medical Center3 957 49,190 76.2 5.4 16.3
Centura Health 93.0 5,184.0 55.2 4.2 14.1
Dignity Health 246.6 11,083.4 55.0 4.1 15.3
Franciscan Health System 132.8 9,810.6 65.9 3.3 15.2
MemorialCare 249.2 11,660.7 51.9 4.3 15.8
Orange Coast Memorial Medical Center3 218 12,326 56.4 3.6 16.1
Presbyterian Intercommunity Hospital3 444 18,991 52.0 4.1 15.0
Providence Health and Services 223.5 11,077.1 56.2 4.0 14.8
Scripps Health 272.2 14,279.6 64.9 4.2 14.7
Sharp HealthCare 395.7 15,351.7 67.5 4.8 15.6
St. Joseph Health System 195.7 8,926.8 49.3 4.8 14.9
Sutter Health 178.5 6,989.4 47.6 4.1 14.9
UCLA Healthcare 401.0 19,095.5 78.6 6.0 17.2
NATION 150.4 7,142.9 48.5% 5.3 15.6%
Managed Care digest series® National Health Care Data Summary 2014 13
CENTRAL REGIONHEALTH PLAN DEMOGRAPHICS
HEALTH INSURANCE EXCHANGE ENROLLMENT, BY STATE, 20143
MARKET Unsubsidized Subsidized Total
Arkansas 4,392 39,054 43,446
Illinois 49,307 168,185 217,492
Iowa 4,678 24,485 29,163
Kansas 12,144 44,869 57,013
Michigan 35,202 237,337 272,539
Minnesota — — 48,495
Nebraska 5,528 37,447 42,975
North Dakota 1,596 9,001 10,597
Texas 119,131 614,626 733,757
Wisconsin 12,824 126,991 139,815
NATION4 1,201,105 6,670,458 8,019,763
Data source: IMS Health © 2014
NUMBER OF HMO ENROLLEES INCREASES IN FOUR CENTRAL REGION STATES
From 2011 to 2013, the total
number of HMO enrollees
rose in four of the 10 profiled
states: Arkansas (0.9%),
Kansas (15.3%), North Dakota
(3.6%) and Wisconsin (31.4%).
Nationally, enrollment grew
0.7%. Minnesota recorded the
largest average number of
enrollees per plan in 2013, at
406,012.2; the smallest was in
Nebraska (76,065.0).
NUMBERS OF GOVERNMENT HMO ENROLLEES CLIMB IN SIX FEATURED STATES
Of the six profiled Central
region states that recorded
an increase in total HMO
government enrollees from
2012 to 2013, Arkansas noted
the largest rise (30.9%),
followed by Iowa (25.0%),
Wisconsin (15.1%), North
Dakota (5.6%), Michigan
(3.8%) and Texas (0.4%).
Nationally, the number of
HMO government enrollees
climbed 6.0%. Four states
recorded decreases in the
total number of government
HMO enrollees from 2012 to
2013: Illinois (15.5%), Kansas
(30.9%), Minnesota (3.9%)
and Nebraska (20.8%).
HMO ENROLLMENT
MARKET
2011 2012 2013
Total # of Enrollees
Avg. # of Enrollees
Total # of Enrollees
Avg. # of Enrollees
Total # of Enrollees
Avg. # of Enrollees
Arkansas 459,904 114,976.0 342,051 85,512.8 463,898 92,779.6
Illinois 2,200,647 104,792.7 2,359,665 117,983.3 2,194,005 121,889.2
Iowa 1,095,660 109,566.0 922,555 92,255.5 970,702 88,245.6
Kansas 919,599 102,177.7 1,337,784 133,778.4 1,060,184 151,454.9
Michigan 3,321,865 168,992.9 3,867,310 203,542.6 3,078,994 181,117.3
Minnesota 2,455,238 272,804.2 2,563,620 256,362.0 2,436,073 406,012.2
Nebraska 358,522 119,507.3 319,784 79,946.0 228,195 76,065.0
North Dakota 889,977 296,659.0 895,256 298,418.7 922,232 307,410.7
Texas 4,598,372 131,382.1 4,251,927 128,846.3 4,114,855 128,589.2
Wisconsin 3,409,547 162,359.4 4,279,480 203,784.8 4,481,408 213,400.4
NATION 79,478,570 179,815.8 80,545,040 187,314.0 80,056,080 182,776.4
Data source: U.S. Department of Health and Human Services © 2014
ENROLLMENT OF HMOs WITH GOVERNMENT BENEFICIARIES
MARKET
Medicare Medicaid FEHBP1 Total Government Enrollees2
2012 2013 2012 2013 2012 2013 2012 2013
Arkansas 62,430 74,627 — — — 7,738 62,906 82,365
Illinois 278,201 187,898 198,548 219,341 28,368 19,703 505,117 426,942
Iowa 146,162 157,355 126,379 188,154 12,384 10,566 284,925 356,075
Kansas 65,009 62,653 501,250 324,808 14,054 13,431 580,313 400,892
Michigan 208,491 234,811 1,352,804 1,390,726 44,596 42,091 1,605,891 1,667,628
Minnesota 325,024 340,404 491,134 442,918 3,078 4,011 819,236 787,333
Nebraska 16,559 11,554 180,269 144,317 — — 196,828 155,871
North Dakota 142,853 158,574 113,436 112,034 146 152 256,435 270,760
Texas 533,244 595,093 2,429,209 2,379,699 18,806 17,508 2,981,259 2,992,300
Wisconsin 455,477 506,495 863,543 1,014,329 15,883 16,167 1,334,903 1,536,991
NATION 8,624,740 9,602,636 26,862,850 28,177,986 1,419,562 1,328,414 36,907,160 39,109,036
Health Insurance Exchanges
1 Federal Employees Health Benefit Program2 Government enrollees include Medicare
Risk, Medicare Cost, Medicaid and Federal Employees Health Benefit Program (FEHBP) members.
3 Data are from the Department of Health and Human Services and reflect figures from October 1, 2013, through April 19, 2014.
4 Total health insurance exchange enrollment includes individuals whose subsidy status is unknown.
NOTE: Throughout this Data Summary, data include all HMOs serving the profiled states. In some cases, HMOs did not report their data. Some enrollment data were unavailable for the selected markets.
14 National Health Care Data Summary 2014 Managed Care digest series®
CENTRAL REGIONCOMMERCIAL: HMO/HOSPITAL MEDICAL UTILIZATION
UTILIZATION RATES FOR COMMERCIAL HMO/POS MEMBERS1
Hospital Admissions per 1,000 Members
Hospital Days per 1,000 Members
ALOS per Hospital
Admission
Physician Encounters
per Member
Ambulatory Visits per Member2
MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013
Arkansas 58.8 58.8 230.5 235.7 3.9 4.0 3.2 3.1 1.3 1.8
Illinois 70.5 68.8 269.9 288.7 3.9 4.3 5.4 4.9 1.7 2.5
Iowa 50.1 50.9 203.1 213.0 4.2 4.2 3.3 3.8 1.3 1.7
Kansas 74.3 67.6 281.7 299.4 3.9 4.5 5.0 4.7 1.7 2.5
Michigan 64.9 71.9 282.8 293.8 4.2 4.0 5.2 4.8 1.9 1.5
Minnesota 58.2 54.4 210.7 204.7 3.6 3.8 4.2 5.1 1.8 1.7
Nebraska 42.8 48.0 183.8 212.8 4.4 4.4 3.4 4.8 0.8 1.6
North Dakota 54.6 59.1 178.3 213.5 3.0 3.5 2.0 3.7 1.5 1.6
Texas 45.7 48.7 206.0 230.3 4.4 4.9 3.5 3.9 1.7 1.6
Wisconsin 54.0 54.3 220.4 221.6 4.0 4.0 4.4 4.7 2.1 2.1
NATION 58.4 58.0 239.1 246.9 4.2 4.3 4.7 4.7 1.7 1.9
HOSPITAL DAYS RATIOS ARE LOW IN SEVEN PROFILED CENTRAL REGION STATES
In 2013, the number of hospital
days per 1,000 commercial
HMO members was lower
than that of the nation (246.9)
in Arkansas (235.7), Iowa
(213.0), Minnesota (204.7),
Nebraska (212.8), North
Dakota (213.5), Texas (230.3)
and Wisconsin (221.6). Of
the states that recorded a
higher-than-average number
of such days, Kansas had
the largest ratio (299.4).
AVERAGE LENGTH OF STAY IS LOWER THAN U.S. AVG. IN SIX CENTRAL REGION STATES
The average length of stay
(ALOS) per hospital admission
for commercial HMO/POS
members was lower than
that of the nation (4.3 days)
in Arkansas (4.0), Iowa (4.2),
Michigan (4.0), Minnesota
(3.8), North Dakota (3.5) and
Wisconsin (4.0) in 2013.
Data source: IMS Health © 2014
NUMBER OF HOSPITAL ADMISSIONS PER 1,000 COMMERCIAL HMO/POS MEMBERS, 20131
Arkansas Illinois Iowa Kansas Michigan Minnesota Nebraska North Dakota
Texas Wisconsin Nation0
20
40
60
80
Ho
spita
l Ad
miss
ion
s
58.8
68.8
50.9
67.671.9
54.4
48.0
59.1
48.7
54.358.0
AVERAGE LENGTH OF STAY PER HOSPITAL ADMISSION, COMMERCIAL HMO/POS MEMBERS, 20131
1
2
3
4
5
Ave
rag
e L
en
gth
of S
tay
(Da
ys)
4.04.3 4.2
4.5
4.03.8
4.4
3.5
4.9
4.04.3
Arkansas Illinois Iowa Kansas Michigan Minn-esota
Nebraska North Dakota
Texas Wisconsin Nation
1 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s
office that do not require the services of a physician. Such visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory.
Managed Care digest series® National Health Care Data Summary 2014 15
CENTRAL REGIONMEDICAID: HMO/HOSPITAL MEDICAL UTILIZATION
0.0
1.5
3.0
4.5
6.0
Ave
rag
e L
en
gth
of S
tay
(Da
ys)
4.6
3.7
4.5
4.0
5.0
4.1
4.8 4.7
3.8
4.4
Illinois Iowa Kansas Michigan Minn-esota
Nebraska NorthDakota
Texas Wisconsin Nation
Data source: IMS Health © 2014
HOSPITAL DAYS PER 1,000 MEDICAID HMO MEMBERS RATIO IS LOW IN SEVEN STATES
In 2013, the average number
of hospital days per 1,000
Medicaid HMO members
was lower than that of
the nation (395.3) in Illinois
(274.9), Iowa (360.1), Kansas
(277.9), Nebraska (329.5),
North Dakota (329.5), Texas
(393.1) and Wisconsin (304.7).
Hospital admissions per 1,000
Medicaid HMO members
were lower than that of the
nation in four profiled states.
ALOS IS LOW VS. U.S. AVG. IN FOUR CENTRAL REGION STATES
The average length of stay
(ALOS) per Medicaid HMO
hospital admission in Iowa
(3.7 days), Michigan (4.0),
Nebraska (4.1) and Wisconsin
(3.8) was lower than that
of the nation (4.4) in 2013.
Additionally, the number of
physician encounters per
Medicaid HMO member
decreased in five Central
region states from 2012 to 2013.
NUMBER OF HOSPITAL ADMISSIONS PER 1,000 MEDICAID HMO MEMBERS1
0
38
76
114
152
Ho
spita
l Ad
miss
ion
s
Illinois Iowa Kansas Michigan Minnesota Nebraska North Dakota Texas Wisconsin Nation
69.7
84.177.8
119.7111.2
—
110.5 111.6
145.1137.4
102.0
80.673.2
69.2
83.091.6
82.1
100.4 97.6 98.8
2012 2013
ALOS PER HOSPITAL ADMISSION, MEDICAID HMO MEMBERS, 20131
UTILIZATION RATES FOR MEDICAID HMO MEMBERS1
Hospital Admissions per 1,000 Members
Hospital Days per 1,000 Members
ALOS per Hospital
Admission
Physician Encounters
per Member
Ambulatory Visits per Member2
MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013
Illinois 69.7 84.1 287.1 274.9 4.6 4.6 3.8 3.7 1.2 2.1
Iowa 77.8 119.7 236.0 360.1 3.1 3.7 4.0 4.3 1.4 2.6
Kansas 111.2 — 333.5 277.9 3.0 4.5 5.4 4.2 2.6 —
Michigan 110.5 111.6 444.0 434.8 4.0 4.0 5.2 4.8 3.2 3.0
Minnesota 145.1 137.4 486.9 499.6 4.5 5.0 2.9 5.5 2.3 3.3
Nebraska 102.0 80.6 339.5 329.5 3.5 4.1 5.2 5.0 2.5 2.1
North Dakota 73.2 69.2 342.6 329.5 4.7 4.8 — — — —
Texas 83.0 91.6 331.1 393.1 4.3 4.7 4.4 4.3 2.2 2.4
Wisconsin 82.1 100.4 294.3 304.7 3.7 3.8 4.0 4.4 2.3 2.6
NATION 97.6 98.8 380.5 395.3 4.2 4.4 4.4 4.6 2.3 2.6
1 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s
office that do not require the services of a physician. Such visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory.
NOTE: Some data were unavailable for the selected markets.
16 National Health Care Data Summary 2014 Managed Care digest series®
CENTRAL REGION
NJ14.1%
HI45.3%
NATION: 28.4%
RI35.7%
MA19.5%
NH6.1%
AR18.1%
IL11.6%
IA13.8%
MI28.1%
NE11.3%
ND13.1%
MN50.7%
KS12.7%
TX28.2%
WI34.4%
MEDICARE ADVANTAGE
MEDICARE ADVANTAGE PENETRATION, CENTRAL REGION, 20131,2
MEDICARE ADVANTAGE ENROLLMENT/PENETRATION1,2
2011 2012 2013
MARKET Enrollment Penetration Enrollment Penetration Enrollment Penetration
Arkansas 85,514 15.5% 93,914 16.6% 104,854 18.1%
Illinois 183,983 9.7 201,007 10.3 232,238 11.6
Iowa 70,212 13.3 72,335 13.3 76,541 13.8
Kansas 51,736 11.6 51,619 11.2 59,838 12.7
Michigan 425,400 24.7 456,502 25.7 513,928 28.1
Minnesota 375,104 46.0 402,753 47.7 442,017 50.7
Nebraska 33,847 11.8 32,267 11.0 33,965 11.3
North Dakota 11,500 10.4 12,965 11.5 14,973 13.1
Texas 699,329 22.1 777,658 23.5 968,610 28.2
Wisconsin 295,741 31.4 311,907 32.0 346,161 34.4
NATION 12,454,064 25.7% 13,278,369 26.4% 14,724,574 28.4%
MA PENETRATION RISES IN MOST PROFILED CENTRAL REGION STATES
Medicare Advantage (MA)
penetration expanded in all
of the profiled Central region
states, except Nebraska,
as well as across the nation
between 2011 and 2013.
Minnesota (50.7%) and
Wisconsin (34.4%) had the
highest MA penetration in
2013, and both exceeded the
national average (28.4%).
1 MA enrollment includes members of HMOs, PPOs, private fee-for-service (PFFS) plans and other plan types.2 The penetration rate reflects the percentage of the Medicare population enrolled in Medicare Advantage plans.
Data source: Centers for Medicare and Medicaid Services and IMS Health © 2014
Managed Care digest series® National Health Care Data Summary 2014 17
CENTRAL REGIONMEDICARE: HMO/HOSPITAL MEDICAL UTILIZATION
UTILIZATION RATES FOR MEDICARE MEMBERS1
Hospital Admissions per 1,000 Members
Hospital Days per 1,000 Members
ALOS per Hospital
Admission
Physician Encounters
per Member
Ambulatory Visits per Member2
MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013
Arkansas 321.4 392.2 2,182.9 2,740.5 7.1 7.6 — 9.3 6.8 6.6
Illinois 268.4 260.2 1,702.6 1,642.6 6.2 6.5 8.9 7.8 3.5 3.5
Iowa 324.6 286.5 2,537.5 2,299.3 8.1 8.2 11.1 9.2 5.6 5.2
Kansas 386.0 399.3 2,089.5 3,336.0 6.5 — 10.0 9.3 6.3 7.3
Michigan 331.2 330.8 2,238.4 1,950.6 5.9 5.8 10.8 10.3 4.1 4.2
Minnesota 321.5 249.8 1,729.0 1,385.5 5.7 5.7 11.0 9.6 4.1 2.7
Nebraska 388.0 272.3 2,787.0 2,433.8 7.3 — 12.3 11.4 6.0 5.9
North Dakota 229.6 247.0 1,800.3 1,833.7 8.1 7.6 10.5 8.3 2.2 1.8
Texas 221.1 240.8 1,453.5 1,786.9 6.6 7.1 9.4 10.6 5.0 5.8
Wisconsin 252.6 271.3 1,519.7 1,798.3 6.1 6.7 11.4 10.6 4.7 4.6
NATION 265.8 275.6 1,602.4 1,727.1 6.1 6.3 9.9 10.4 4.4 4.5
HMO/HOSPITAL UTILIZATION AND COST MEASURES
Commercial HMO Hospital Days/1,000
Medicare HMO Hospital Days/1,000
Medicare Fee-for-Service
Discharges/1,0003
Medicare Fee-for-Service
Hospital Days/1,0003
Medicare Fee-for-Service Payments per
Hospital Discharge3
Medicare Fee-for-Service
Payments per Enrollee3
MARKET 2011 2012 2011 2012 2011 2012 2011 2012 2011 2012 2011 2012
Arkansas 262 231 1,309 2,183 322 313 1,704 1,611 $8,560 $8,708 $2,715 $2,664
Illinois 268 270 1,473 1,703 364 341 1,871 1,738 9,829 10,092 3,521 3,378
Iowa 217 203 2,497 2,538 265 252 1,335 1,267 9,450 9,971 2,430 2,398
Kansas 294 282 2,394 2,090 286 275 1,468 1,388 9,265 9,580 2,584 2,531
Michigan 294 283 1,923 2,238 369 352 1,975 1,857 10,386 10,586 3,806 3,680
Minnesota 232 211 2,269 1,729 378 378 1,767 1,762 10,675 11,061 3,955 4,043
Nebraska 197 184 2,987 2,787 267 253 1,313 1,235 9,796 10,170 2,557 2,477
North Dakota 253 178 1,484 1,800 248 258 1,244 1,304 10,617 10,894 2,533 2,607
Texas 201 206 1,539 1,454 321 309 1,709 1,629 9,887 10,097 3,103 3,030
Wisconsin 229 220 1,716 1,520 276 270 1,354 1,288 10,207 10,356 2,789 2,732
NATION 236 239 1,643 1,602 323 307 1,734 1,634 $10,362 $10,674 $3,281 $3,176
NUMBER OF HOSPITAL ADMISSIONS PER 1,000 MEDICARE HMO MEMBERS, 20131
180
240
300
360
420
Ho
spita
l Ad
miss
ion
s
392.2
260.2
286.5
399.3
330.8
249.8
272.3
247.0 240.8
271.3 275.6
Arkansas Illinois Iowa Kansas Michigan Minn-esota
Nebraska NorthDakota
Texas Wisconsin Nation
Managed Care vs. Fee-for-Service Measures
Data source: Centers for Medicare and Medicaid Services and IMS Health © 20141 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s office that do not require the services of a physician.
Such visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory. 3 Discharges, hospital days per 1,000, payments per hospital discharge and payments per enrollee for Medicare fee-for-service come from the Medicare and Medicaid Research Review
Statistical Supplement.
NOTE: Some utilization data were unavailable for the selected markets.
ADMISSIONS PER 1,000 MEDICARE MEMBERS RISE IN FIVE OF 10 PROFILED STATES
From 2012 to 2013, the hospital
admissions per 1,000 Medicare
HMO members count
increased in five of the 10
profiled Central region states:
Arkansas (22.0%), Kansas
(3.4%), North Dakota (7.6%),
Texas (8.9%) and Wisconsin
(7.4%). Meanwhile, average
length of stay rose in five of the
profiled states and exceeded
the U.S. mean (6.3 days) in six.
HOSPITAL DAYS RATIO FOR MEDICARE HMO PATIENTS IS LOW IN THREE STATES
In 2012, the average number
of hospital days per 1,000
Medicare patients was lower
for those in HMO plans than
for those in fee-for-service
plans in Illinois, Minnesota,
Texas and across the nation.
Data source: IMS Health © 2014
18 National Health Care Data Summary 2014 Managed Care digest series®
CENTRAL REGIONHMO PREMIUMS
Arkansas Illinois Iowa Kansas Michigan Minnesota Nebraska North Dakota Texas Wisconsin Nation$200
$315
$430
$545
$660
Avg
. In
div
idu
al P
rem
ium
($)
$301
$338
$461
$535
$456
$501$472
$514
$484$511
$614
$644
$456
$498
$627$647
$460 $469 $468$488 $486
$532
2012 2013
INDIVIDUAL HMO PREMIUMS ARE LOW IN SEVEN PROFILED STATES
In 2013, average individual
HMO premiums per month
were lower than that of the
nation ($531.82) in Arkansas
($338.40), Iowa ($500.79),
Kansas ($513.84), Michigan
($510.63), Nebraska ($498.01),
Texas ($468.53) and Wisconsin
($487.63). Average family HMO
premiums were lower in eight
of the 10 Central region states.
AVERAGE INDIVIDUAL PREMIUM PER MONTH1
Data source: IMS Health © 2014
RX BENEFIT PREMIUMS CHANGE LITTLE OR NOT AT ALL IN MOST FEATURED STATES
From 2012 to 2013, average
individual monthly premiums
for HMO outpatient pharmacy
benefits declined or were
unchanged in eight of the 10
featured Central region states.
In the case of family premiums,
seven states recorded lower
or unchanged premiums.
Nationally, such premiums
edged up 1.2% for individuals.
AVERAGE PREMIUM RATES PER MONTH1
Average Individual Premium Average Family Premium
MARKET 2011 2012 2013 2011 2012 2013
Arkansas $310.78 $301.25 $338.40 $911.01 $984.28 $1,006.21
Illinois 460.05 460.51 534.91 1,138.67 1,125.24 1,270.08
Iowa 439.09 456.39 500.79 1,071.42 1,076.44 1,164.80
Kansas 416.90 472.22 513.84 1,058.99 1,157.72 1,226.19
Michigan 473.08 484.30 510.63 1,196.35 1,226.36 1,271.80
Minnesota 574.03 614.02 643.51 1,397.59 1,443.55 1,506.04
Nebraska 401.01 455.57 498.01 966.50 1,063.53 1,198.30
North Dakota 600.66 627.33 646.66 1,418.96 1,487.30 1,537.30
Texas 449.49 459.68 468.53 1,121.07 1,140.70 1,146.69
Wisconsin 453.81 468.06 487.63 1,158.14 1,183.83 1,231.25
NATION $464.75 $486.48 $531.82 $1,189.17 $1,237.31 $1,313.03
PREMIUMS PER MEMBER PER MONTH FOR OUTPATIENT PHARMACY BENEFITS1
Average Individual Premium Average Family Premium
MARKET 2012 2013 2012 2013
Arkansas $50.00 $34.00 $113.00 $77.50
Illinois 30.84 30.21 97.61 92.02
Iowa 34.07 34.07 82.81 82.81
Kansas 31.78 26.54 93.12 71.43
Michigan 45.37 49.49 126.09 139.78
Minnesota 37.83 20.74 137.25 —
Nebraska 37.86 — 78.99 —
North Dakota 41.83 41.83 105.38 105.38
Texas 41.73 41.73 103.89 103.89
Wisconsin 18.90 18.90 40.14 40.14
NATION $40.21 $40.71 $101.80 $103.04
1 Averages represent the flat charge for medical health coverage and do not include charges for pharmacy, dental or other services. Also, employee contributions are not included. Numbers of options and levels of coverage may account for significant differences between an individual company’s premium rates and the average.
NOTE: Some data were unavailable for the selected markets.
Managed Care digest series® National Health Care Data Summary 2014 19
CENTRAL REGIONHMO PHARMACY UTILIZATION AND EXPENDITURES
PRESCRIPTIONS DISPENSED AND AVERAGE INGREDIENT COST1
Rxs Dispensed per Commercial HMO Member per Year Average Ingredient Cost
MARKET 2011 2012 2013 2011 2012 2013
Arkansas 9.3 8.9 8.7 $57.14 $52.32 $48.16
Illinois 9.6 9.4 9.3 63.77 60.16 60.03
Iowa 8.1 7.9 7.8 52.36 50.68 54.63
Kansas 9.6 9.4 9.2 59.87 57.46 56.58
Michigan 9.5 9.5 9.4 48.79 51.16 45.95
Minnesota 8.1 7.8 8.4 53.76 48.55 46.63
Nebraska 8.6 8.2 7.5 50.11 46.90 48.24
North Dakota 8.2 8.2 8.2 52.66 52.66 52.66
Texas 9.3 9.0 9.0 67.56 62.29 61.34
Wisconsin 8.8 9.0 8.9 43.11 44.18 44.48
NATION 9.4 9.1 9.0 $58.95 $55.73 $56.70
PRESCRIPTIONS DISPENSED PER COMMERCIAL HMO MEMBER PER YEAR
6
7
8
9
10
Ave
rag
e R
xs/P
MPY
Arkansas Illinois Iowa Kansas Michigan Minn-esota
Nebraska NorthDakota
Texas Wisconsin Nation
8.98.7
9.4 9.3
7.9 7.8
9.49.2
9.5 9.4
7.8
8.48.2
7.5
—8.2—
—9.0— 9.08.9
9.1 9.0
2012 2013
HMO DRUG EXPENDITURESDrug Costs as a Percentage
of Operating ExpensesExpenditures per Member
per Year for Drugs2
MARKET 2011 2012 2013 2011 2012 2013
Arkansas 18.5% 16.0% 16.0% $690 $838 $733
Illinois 14.3 15.4 15.0 645 621 623
Iowa 13.7 13.8 14.8 403 494 428
Kansas 15.7 17.8 15.2 567 596 696
Michigan 13.1 14.0 13.1 467 550 509
Minnesota 12.1 12.2 11.2 608 826 649
Nebraska 11.0 12.0 — 227 339 209
North Dakota 12.0 12.0 12.5 424 683 563
Texas 12.3 13.8 14.5 608 548 524
Wisconsin 9.5 9.6 9.5 394 482 413
NATION 13.9% 14.5% 14.7% $578 $605 $609
Data source: IMS Health © 2014
NUMBERS OF RXs PER HMO MEMBER PER YEAR DECLINE IN SEVEN STATES
Between 2011 and 2013,
the numbers of prescriptions
dispensed per commercial
HMO member per year
decreased in seven of 10
profiled Central region states
and across the U.S. Of the
states that recorded declines,
Illinois (9.3), Kansas (9.2) and
Michigan (9.4) exceeded the
U.S. mean (9.0).
DRUG COSTS AS A SHARE OF OPERATING EXPENSES ARE LOW IN SIX FEATURED STATES
In 2013, HMO drug costs as
a percentage of operating
expenses were lower than
those nationally (14.7%) in
Michigan (13.1%), Minnesota
(11.2%), North Dakota (12.5%),
Texas (14.5%) and Wisconsin
(9.5%). This share was highest
among the Central region
states in Arkansas (16.0%).
RX COSTS PER HMO MEMBER ARE LOWER THAN U.S. AVG. IN FIVE PROFILED STATES
In Iowa ($428), Michigan
($509), Nebraska ($209),
North Dakota ($563), Texas
($524) and Wisconsin ($413),
average expenditures per
HMO member per year for
drugs were lower than those
nationally ($609) in 2013.
Furthermore, such expenses
decreased from 2012 to 2013
in eight of the 10 featured
Central region states.
1 This average is derived by dividing HMO pharmacy expenses by the total number of prescriptions dispensed. Expenses do not include administration or copayment costs.
2 Rounded to the nearest dollar. Expenditures do not include administration and copayment costs.
NOTE: Some data were unavailable for the selected markets.
20 National Health Care Data Summary 2014 Managed Care digest series®
CENTRAL REGIONMEDICAL GROUPS: DEMOGRAPHICS
DISTRIBUTION OF CENTRAL REGION GROUP PRACTICES, BY SIZE, IS SIMILAR TO U.S.’s
Across the Central region
states, medical group
practice sizes, by number
of FTE physicians, closely
followed the same distribution
as those of their national
counterparts in 2013.
The largest numbers of
medical groups in nine of
the 10 profiled states were
comprised of five to six
physicians. North Dakota was
the exception, where the
number of groups with seven
to nine physicians was the
same as those with five to six.
THREE STATES NOTE LARGER MULTISPECIALTY SHARES AMONG GROUPS
In 2013, of the profiled
Central region states and the
nation, only Illinois (57.6%),
North Dakota (55.1%) and
Wisconsin (59.7%) recorded
higher percentages of
multispecialty practices than
single-specialty practices.
SHARES OF GROUPS WITH CORPORATE TIES INCREASE SLIGHTLY IN FOUR STATES
In Arkansas (0.5 percentage
points), Illinois (0.2 points),
Michigan (0.2 points and
Texas (0.1 points), the
corporate-affiliated portion
of medical group practices
rose fractionally. In Minnesota
(–0.9 percentage points) and
Wisconsin (–2.5 points), these
portions of corporate-affiliated
practices edged down.
Data source: IMS Health © 2014
PERCENTAGE OF MEDICAL GROUP PRACTICES BY AFFILIATION
Corporate Affiliation Independent
MARKET 2012 2013 2012 2013
Arkansas 42.0% 42.5% 58.0% 57.5%
Illinois 51.2 51.4 48.8 48.6
Iowa 63.9 63.9 36.1 36.1
Kansas 30.2 30.2 69.8 69.8
Michigan 45.4 45.6 54.6 54.4
Minnesota 59.5 58.6 40.5 41.4
Nebraska 33.0 33.0 67.0 67.0
North Dakota 75.5 75.5 24.5 24.5
Texas 41.0 41.1 59.0 58.9
Wisconsin 70.5 68.0 29.5 32.0
NATION 42.7% 42.7% 57.3% 57.3%
0%
18%
36%
54%
72%
Perc
en
tag
e o
f Gro
up
s
61.1%
38.9%42.4%
57.6% 58.3%
41.7%
58.6%
41.4%
60.1%
39.9%
54.5%
45.5%
60.6%
39.4%44.9%
55.1% 57.6%
42.4%40.3%
59.7%55.6%
44.4%
Single Specialty Multispecialty
Arkansas Illinois Iowa Kansas Michigan Minn-esota
Nebraska NorthDakota
Texas Wisconsin Nation
NUMBER OF MEDICAL GROUPS WITH FIVE OR MORE FTE PHYSICIANS, 2013
SIZE (# of MDs)Arkan-
sas Illinois Iowa Kansas Michi-gan
Minne-sota
Ne-braska
North Dakota Texas Wiscon-
sin NATION
5–6 62 225 84 52 221 138 66 13 266 111 5,729
7–9 18 121 47 27 121 89 20 13 178 110 3,266
10–14 18 71 21 15 63 81 11 9 88 57 1,786
15–19 5 22 9 10 20 37 4 3 30 22 630
20+ 10 75 19 12 51 70 8 11 68 75 1,478
TOTAL 113 514 180 116 476 415 109 49 630 375 12,889
SPECIALTY COMPOSITION
Single Specialty 69 218 105 68 286 226 66 22 363 151 7,161
Multispecialty 44 296 75 48 190 189 43 27 267 224 5,728
AVG. VISITS PER WEEK
Under 250 4 34 9 5 50 38 7 3 29 30 1,029
250–499 17 68 22 12 87 58 21 8 95 49 2,052
500–749 17 65 37 24 95 41 22 4 80 54 2,022
750+ 29 101 39 29 115 97 23 9 159 86 2,728
Unknown 45 236 73 46 127 177 36 25 262 151 4,932
TOTAL 113 514 180 116 476 415 109 49 630 375 12,889
PERCENTAGE OF MEDICAL GROUP PRACTICES BY SPECIALTY, 2013
NOTE: IMS Health defines the medical groups represented on pages 20–21 of this Data Summary as those with five or more full-time equivalent (FTE) physicians whose primary business is seeing regularly scheduled patients for nonsurgical services other than imaging. Physicians must have a share in the practice and offer outpatient care, and the practice must be physically separate from a hospital. Anesthesiology and pathology groups are excluded.
Managed Care digest series® National Health Care Data Summary 2014 21
CENTRAL REGIONMEDICAL GROUPS: SERVICES
PERCENTAGE OF MEDICAL GROUPS, BY TYPE OF SERVICE
Groups That Perform Surgery (%)
Groups That Have Clinical Labs (%)
Groups That Offer Imaging Services (%)
MARKET 2012 2013 2012 2013 2012 2013
Arkansas 55.0% 54.5% 51.8% 51.8% 74.5% 74.8%
Illinois 53.9 54.1 57.5 57.8 66.3 66.5
Iowa 67.7 67.7 69.2 69.2 70.2 70.2
Kansas 76.4 76.4 58.8 58.8 79.8 79.8
Michigan 55.0 54.9 44.1 44.1 67.3 67.2
Minnesota 71.2 70.1 66.0 69.1 75.8 74.7
Nebraska — — 61.0 61.0 68.1 68.1
North Dakota 80.4 80.4 86.1 86.1 88.9 88.9
Texas 47.6 47.6 52.7 52.8 64.0 64.0
Wisconsin 74.9 72.5 76.8 73.8 79.7 77.6
NATION 54.7% 54.3% 49.8% 49.5% 64.5% 64.0%
CENTRAL REGION GROUP PRACTICES ARE LIKELY TO OFFER IMAGING SERVICES
In 2013, the shares of medical
group practices in nine of
the 10 profiled Central region
states that offered imaging
services exceeded that of the
nation (64.0%). This portion
was highest in North Dakota
(88.9%). Also, in most of the
featured states, the portions
of practices that had clinical
labs or performed surgery
topped the U.S. averages.
MEDICAL GROUPS IN MOST PROFILED STATES ARE LIKELY TO HAVE PHARMACIES
In 2013, medical group
practices in Arkansas (65.9%),
Illinois (60.5%), Iowa (71.3%),
Kansas (72.5%), Michigan
(63.7%), Minnesota (64.8%),
Nebraska (63.0%), North
Dakota (77.8%) and Wisconsin
(79.7%) were more likely
than those nationally to
offer pharmacy services.
RATES OF FULL RX SERVICE AMONG GROUPS IN FIVE STATES TOP THE U.S. MEAN
The shares of medical group
practices in Illinois (23.2%),
Minnesota (23.9%), North
Dakota (35.7%), Texas (27.2%)
and Wisconsin (29.4%) that
offered full pharmacy services
exceeded that of the nation
(18.9%) in 2013. The provision
of samples was the most
common pharmacy service in
all 10 Central region states.
1 Medical groups with full pharmacies offer a complete range of medication types; those with limited pharmacy services offer a smaller range, often in particular therapeutic classes; others provide patients only with samples of medications.
NOTE: Some data were unavailable for the selected markets.
Data source: IMS Health © 2014
PERCENTAGE OF MEDICAL GROUPS, BY TYPE OF PHARMACY SERVICE1
Full Pharmacy Limited Pharmacy Samples
MARKET 2012 2013 2012 2013 2012 2013
Arkansas 3.7% 3.7% 1.9% 1.9% 98.1% 98.1%
Illinois 23.2 23.2 8.7 8.5 72.5 72.5
Iowa 17.2 17.2 1.1 1.1 82.8 82.8
Kansas 8.6 8.6 1.7 1.7 89.7 89.7
Michigan 15.0 14.9 5.9 5.9 83.4 83.5
Minnesota 22.7 23.9 4.2 4.9 74.8 73.5
Nebraska 9.8 9.8 3.9 3.9 92.2 92.2
North Dakota 35.7 35.7 7.1 7.1 71.4 71.4
Texas 26.9 27.2 13.7 13.6 64.6 64.3
Wisconsin 28.1 29.4 3.2 3.5 71.1 69.7
NATION 18.4% 18.9% 9.7% 10.0% 74.9% 74.3%
40%
50%
60%
70%
80%
Perc
en
tag
e o
f Gro
up
s
—65.9%—
60.6%60.5%
—71.3%— —72.5%—
63.8%63.7% 65.9%
64.8%
—63.0%—
—77.8%—
52.2%52.3%
77.4%79.7%
60.7%60.2%
2012 2013
Arkansas Illinois Iowa Kansas Michigan Minn-esota
Nebraska NorthDakota
Texas Wisconsin Nation
PERCENTAGE OF MEDICAL GROUPS WITH PHARMACY SERVICES
22 National Health Care Data Summary 2014 Managed Care digest series®
CENTRAL REGIONHOSPITAL UTILIZATION
SELECTED UTILIZATION STATISTICS FOR HOSPITALS, 20121
MEASUREArkan-
sas Illinois Iowa Kansas Michi-gan
Minne-sota
Ne-braska
North Dakota Texas Wiscon-
sin NATION
Total Facility Admissions per Hospital
4,849 7,881 2,959 2,231 8,198 4,250 2,498 2,501 6,323 4,445 7,143
Total Facility Patient-Days per Hospital
22,942 36,570 18,365 10,475 37,712 18,441 14,528 17,365 30,042 19,939 35,791
Total FacilityALOS perHospital
4.9 4.5 10.0 6.3 4.3 3.7 6.3 9.9 4.4 4.4 5.3
Inpatient Surg./ Staffed Bed 10.4 9.3 6.5 7.8 10.8 10.4 6.3 8.3 13.4 13.1 11.8
Outpatient Surg. per Day 5.7 8.5 6.1 4.3 10.4 7.4 4.3 4.6 9.0 9.2 10.6
Outpatient Surg. as a Percentage of Total Surg.
75.1% 71.1% 84.9% 82.9% 71.9% 78.8% 82.5% 86.0% 67.0% 77.1% 70.9%
AVERAGE TOTAL FACILITY OCCUPANCY, 20121
0%
15%
30%
45%
60%
Oc
cu
pa
nc
y (%
)
48.8% 51.3%
39.5%34.1%
41.0%
31.1% 31.5%37.1%
43.2%47.2% 48.5%
Arkansas Illinois Iowa Kansas Michigan Minn-esota
Nebraska NorthDakota
Texas Wisconsin Nation
SELECTED FINANCIAL RATIOS FOR HOSPITALS (IN THOUSANDS), 2012
MEASUREArkansas Illinois Iowa Kansas Michigan Minnesota Nebraska North
Dakota Texas Wisconsin NATION
Total Costs/Occupied Bed $1,315.9 $1,965.4 $1,961.1 $1,818.8 $2,270.5 $2,866.3 $2,248.4 $1,825.3 $1,795.8 $2,779.2 $1,847.4
Total Costs/ Admission 15.7 22.1 29.1 23.6 25.1 29.9 28.4 28.2 20.2 30.1 22.3
Total Costs/ Patient-Day 3.6 5.5 5.5 5.1 6.3 8.3 6.3 5.2 5.0 7.8 5.2
Labor Costs/Patient-Day 1.5 2.3 2.1 2.2 2.6 3.1 2.5 2.0 2.0 2.9 2.1
Salary Costs/FTE3 46.5 55.6 50.6 48.5 56.5 60.3 51.0 47.8 53.8 62.5 57.4
Total Costs/FTE3 125.3 149.4 126.0 122.1 147.0 144.2 125.9 106.5 163.1 162.6 152.7
HOSPITAL FACILITY PATIENT-DAYS AND ADMISSIONS ARE HIGH IN MI
In 2012, Michigan recorded
the highest number of total
facility admissions (8,198)
and total facility patient-days
(37,712), per hospital, of the
10 Central region states.
Both also exceeded the U.S.
means (7,143 and 35,791,
respectively). The average
length of stay in Michigan
hospitals (4.3 days) was lower
than that of the nation (5.3).
TOTAL COSTS PER HOSPITAL ADMISSION IN WISCONSIN EXCEED THE NATIONAL AVG.
Total costs per hospital
admission in Wisconsin
($30,141) exceeded those
of the nine other states
listed and of the nation
($22,286) in 2012. However,
Texas hospitals recorded the
highest total costs per full-
time-equivalent employee
($163,103). Wisconsin had the
second-highest such costs
($162,594). Both topped the
national average ($152,715).
SELECTED UTILIZATION MEASURES, CATHOLIC HEALTH INITIATIVES AFFILIATES, 20121
SYSTEM NAME
Average Number of
Staffed Beds
Average Number
of Hospital Admissions
Average Total Facility Occupancy
Average Length of
Stay (Days)
All-Cause Readmission
Rate2
Alegent Creighton Health 113.3 4,951.4 36.9% 5.7 15.3%
Mercy Health Network 139.7 7,245.6 49.3 6.0 15.4
St. Luke’s Health System 186.3 9,022.8 53.7 4.1 15.5
NATION 150.4 7,142.9 48.5% 5.3 15.6%
Data source: IMS Health © 20141 Total facility figures reflect all portions of the hospital’s occupancy.2 Hospital All-Cause Readmission Rate figures come from the Centers for Medicare and Medicaid Services Hospital Compare database and are measured from July 2012 through
June 2013. Unless otherwise noted, scores are averaged across all facilities within the specified system.3 “FTE” is full-time equivalent.
NOTE: Hospital utilization data represent patients of all payer types.
Managed Care digest series® National Health Care Data Summary 2014 23
EAST REGIONHEALTH PLAN DEMOGRAPHICS
HEALTH INSURANCE EXCHANGE ENROLLMENT, 2013–20143
MARKET Unsubsidized Subsidized Total
Florida 90,120 893,655 983,775
Georgia 41,165 275,378 316,543
Kentucky 22,994 59,753 82,747
New Jersey 25,484 136,291 161,775
New York 96,611 273,840 370,451
North Carolina 32,479 325,105 357,584
Ohio 23,153 131,515 154,668
Pennsylvania 59,622 258,455 318,077
South Carolina 14,691 103,633 118,324
Tennessee 30,787 120,565 151,352
NATION4 1,201,105 6,670,458 8,019,763
Data source: IMS Health © 2014
HMO ENROLLEE COUNT FALLS IN SEVEN EAST REGION STATES, RISES NATIONALLY
Between 2011 and 2013,
the total numbers of HMO
enrollees decreased in
Kentucky, New Jersey, New
York, North Carolina, Ohio,
Pennsylvania and Tennessee,
even as it increased by
nearly 600,000 nationally, to
80.1 million from 79.5 million.
However, between 2012 and
2013, the pattern was reversed,
with HMO enrollment rising
in six of the 10 profiled states
while falling 0.6% nationally.
NUMBERS OF GOVERNMENT BENEFICIARIES IN HMOs RISE IN SEVEN PROFILED STATES
The total number of Medicare,
Medicaid and FEHBP HMO
members increased in seven
of the 10 profiled East region
states from 2012 to 2013.
Nationally, the number of
these beneficiaries in HMOs
climbed 6.0%, to 39.1 million
from 36.9 million the prior year.
SUBSIDIZED SHARES OF EXCHANGE ENROLLEES IN EAST REGION STATES TOP U.S.
The percentages of health
insurance exchange enrollees
in 2014 whose coverage was
subsidized led that of the
nation (83.2%) in six of the 10
profiled East region states.
HMO ENROLLMENT
MARKET
2011 2012 2013
Total # of Enrollees
Avg. # of Enrollees
Total # of Enrollees
Avg. # of Enrollees
Total # of Enrollees
Avg. # of Enrollees
Florida 5,028,438 128,934.3 4,980,528 134,608.9 5,050,417 136,497.8
Georgia 2,406,419 200,534.9 3,418,517 310,774.3 3,443,647 313,058.8
Kentucky 2,218,127 170,625.2 2,031,073 156,236.4 1,860,966 186,096.6
New Jersey 3,552,849 355,284.9 3,109,606 345,511.8 3,479,925 347,992.5
New York 6,974,744 268,259.4 7,819,855 300,763.7 6,220,602 259,191.8
North Carolina 1,064,066 133,008.3 914,538 130,648.3 961,118 137,302.6
Ohio 4,034,270 201,713.5 3,913,500 195,675.0 3,427,300 214,206.3
Pennsylvania 4,080,913 194,329.2 3,825,633 191,281.7 4,026,262 201,313.1
South Carolina 943,908 104,878.7 794,594 99,324.3 957,478 119,684.8
Tennessee 1,873,419 187,341.9 1,488,670 165,407.8 1,475,397 184,424.6
NATION 79,478,570 179,815.8 80,545,040 187,314.0 80,056,080 182,776.4
1 Federal Employees Health Benefit Program2 Government enrollees include Medicare
Risk, Medicare Cost, Medicaid and Federal Employees Health Benefit Program (FEHBP) members.
3 Data are from the Department of Health and Human Services and reflect figures from October 1, 2013, through April 19, 2014.
4 Total health insurance exchange enrollment includes individuals whose subsidy status is unknown.
NOTE: Data include all HMOs serving the profiled states. Some data were unavailable for the selected states.
ENROLLMENT OF HMOs WITH GOVERNMENT BENEFICIARIES
MARKET
Medicare Medicaid FEHBP1 Total Government Enrollees2
2012 2013 2012 2013 2012 2013 2012 2013
Florida 836,417 947,373 1,138,778 1,229,813 17,832 17,053 1,993,027 2,194,239
Georgia 65,599 96,432 979,529 971,601 39,076 37,419 1,084,204 1,105,452
Kentucky 132,530 132,370 730,229 546,097 1,354 2,036 864,113 680,503
New Jersey 288,636 369,406 1,517,366 2,133,221 13,545 11,607 1,819,547 2,514,234
New York 874,836 886,400 2,419,010 1,968,100 101,446 66,536 3,395,292 2,921,036
North Carolina 183,946 212,853 — — — — 183,946 212,853
Ohio 454,053 370,881 1,875,902 1,719,948 36,233 10,984 2,366,188 2,101,813
Pennsylvania 606,230 641,127 1,083,692 1,337,390 35,157 27,013 1,725,079 2,005,530
South Carolina 58,493 57,254 457,708 609,808 — — 516,201 667,062
Tennessee 228,315 255,804 1,166,235 1,149,726 4,179 2,687 1,398,729 1,408,217
NATION 8,624,740 9,602,636 26,862,850 28,177,986 1,419,562 1,328,414 36,907,160 39,109,036
Health Insurance Exchanges
Data source: U.S. Department of Health and Human Services © 2014
24 National Health Care Data Summary 2014 Managed Care digest series®
EAST REGIONCOMMERCIAL: HMO/HOSPITAL MEDICAL UTILIZATION
UTILIZATION RATES FOR COMMERCIAL HMO/POS MEMBERS1
Hospital Admissions per 1,000 Members
Hospital Days per 1,000 Members
ALOS per Hospital
Admission
Physician Encounters
per Member
Ambulatory Visits per Member2
MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013
Florida 47.3 52.8 189.4 212.2 3.9 4.1 5.2 4.2 1.4 1.3
Georgia 45.7 43.1 203.5 190.7 4.5 4.5 5.4 5.7 1.5 1.1
Kentucky 53.1 52.3 211.9 218.1 4.0 4.2 4.5 4.7 2.8 2.5
New Jersey 65.1 63.7 326.9 289.4 5.0 4.4 6.5 5.3 2.5 1.8
New York 64.9 75.2 287.0 318.0 4.5 4.4 5.5 5.7 1.7 1.9
North Carolina 47.3 44.0 197.9 190.6 4.3 4.4 4.6 4.5 1.3 0.9
Ohio 64.0 64.3 323.7 293.8 4.8 4.5 4.8 4.5 2.2 2.2
Pennsylvania 58.8 58.2 268.2 273.5 4.5 4.6 5.5 5.5 2.0 2.2
South Carolina 54.2 46.4 277.0 187.6 4.9 4.1 5.2 3.7 1.0 1.0
Tennessee 91.9 56.0 229.5 266.8 5.0 4.9 5.4 5.5 1.8 1.2
NATION 58.4 58.0 239.1 246.9 4.2 4.3 4.7 4.7 1.7 1.9
HOSPITAL ADMISSIONS PER 1,000 HMO MEMBERS ARE DOWN IN SEVERAL STATES
Between 2012 and 2013, the
number of hospital admissions
per 1,000 commercial HMO
members decreased in seven
of 10 profiled states. This
measure dropped 39.1% in
Tennessee (the most of any of
the featured states) and 14.4%
in South Carolina. New York
reported the highest number
of hospital admissions per 1,000
HMO members (75.2) in 2013.
ALOS CONTRACTS IN FIVE FEATURED STATES
The average length of stay
(ALOS) per hospital admission
dropped for commercial HMO
members in New Jersey (to 4.4
from 5.0), New York (to 4.4 from
4.5), Ohio (to 4.5 from 4.8),
South Carolina (to 4.1 from 4.9)
and Tennessee (to 4.9 from 5.0)
from 2012 to 2013.
Data source: IMS Health © 2014
NUMBER OF HOSPITAL ADMISSIONS PER 1,000 COMMERCIAL HMO/POS MEMBERS, 20131
50
40
60
70
80
Ho
spita
l Ad
miss
ion
s
52.8
43.1
52.3
63.7
75.2
44.0
64.3
58.2
46.4
56.058.0
Florida Georgia Kentucky New Jersey New York North Carolina
Ohio Pennsylvania South Carolina
Tennessee Nation
ALOS PER HOSPITAL ADMISSION, COMMERCIAL HMO/POS MEMBERS, 20131
1
2
3
4
5
Ave
rag
e L
en
gth
of S
tay
(Da
ys)
4.1
4.5
4.24.4 4.4 4.4 4.5 4.6
4.1
4.9
4.3
Florida Georgia Ken-tucky
NewJersey
NewYork
North Carolina
Ohio Penn-sylvania
South Carolina
Tenn-essee
Nation
1 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s office
that do not require the services of a physician. Such visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory.
Managed Care digest series® National Health Care Data Summary 2014 25
EAST REGIONMEDICAID: HMO/HOSPITAL MEDICAL UTILIZATION
Data source: IMS Health © 2014
0
2
4
6
8
Ave
rag
e L
en
gth
of S
tay
(Da
ys)
4.1
4.75.0 4.9
4.64.9
4.44.8
6.3
4.4
Florida Georgia Kentucky NewJersey
New York Ohio Pennsylvania South Carolina
Tennessee Nation
MEDICAID HMO ADMISSIONS PER 1,000 MEMBERS DECLINE
Hospital admissions per 1,000
Medicaid HMO members
decreased in nine of 10 East
region states from 2012 to
2013 (Tennessee excepted).
However, in 2013 this ratio
remained higher than that of
the nation (98.8) in Kentucky
(117.4), New York (123.5), Ohio
(106.0), Pennsylvania (119.4),
South Carolina (114.9) and
Tennessee (100.3).
MEDICAID HMO HOSPITAL DAYS RATIO CLIMBS IN FIVE PROFILED STATES
From 2012 to 2013, hospital
days per 1,000 Medicaid
HMO members grew in five
of the nine profiled East
region states for which data
were available: Georgia (to
320.7), Kentucky (587.7), Ohio
(508.4), Pennsylvania (489.0)
and South Carolina (510.7).
NUMBER OF HOSPITAL ADMISSIONS PER 1,000 MEDICAID HMO MEMBERS1
0
40
80
120
160
Ho
spita
l Ad
miss
ion
s
79.472.0 70.1 68.1
120.4 117.4
83.5
74.1
139.8
123.5
110.1106.0
128.2119.4
133.2
114.9
99.9 100.3 97.6 98.8
2012 2013
Florida Georgia Kentucky New Jersey New York Ohio Pennsylvania South Carolina
Tennessee Nation
ALOS PER HOSPITAL ADMISSION, MEDICAID HMO MEMBERS, 20131
UTILIZATION RATES FOR MEDICAID HMO MEMBERS1
Hospital Admissions per 1,000 Members
Hospital Days per 1,000 Members
ALOS per Hospital
Admission
Physician Encounters
per Member
Ambulatory Visits per Member2
MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013
Florida 79.4 72.0 310.4 292.2 3.9 4.1 4.0 3.4 2.2 2.2
Georgia 70.1 68.1 310.9 320.7 4.5 4.7 3.7 4.3 1.7 1.9
Kentucky 120.4 117.4 526.9 587.7 4.4 5.0 6.1 6.1 5.3 4.3
New Jersey 83.5 74.1 518.2 367.0 5.4 4.9 5.4 5.6 6.7 4.8
New York 139.8 123.5 624.0 518.8 4.5 4.6 6.6 6.5 2.9 3.7
Ohio 110.1 106.0 494.8 508.4 4.6 4.9 5.1 5.4 3.2 3.7
Pennsylvania 128.2 119.4 487.6 489.0 4.7 4.4 4.3 5.0 2.1 2.2
South Carolina 133.2 114.9 445.2 510.7 4.4 4.8 6.4 5.8 1.6 1.5
Tennessee 99.9 100.3 567.1 552.9 6.6 6.3 5.3 6.4 2.7 3.4
NATION 97.6 98.8 380.5 395.3 4.2 4.4 4.4 4.6 2.3 2.6
1 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s office
that do not require the services of a physician. Such visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory.
NOTE: HMO/hospital medical utilization data were unavailable for North Carolina.
26 National Health Care Data Summary 2014 Managed Care digest series®
EAST REGIONMEDICARE ADVANTAGE
MEDICARE ADVANTAGE ENROLLMENT/PENETRATION1,2
2011 2012 2013
MARKET Enrollment Penetration Enrollment Penetration Enrollment Penetration
Florida 1,170,000 33.4% 1,284,469 35.3% 1,400,809 37.1%
Georgia 298,426 22.8 331,923 24.2 302,804 21.1
Kentucky 128,838 16.3 119,860 14.7 196,234 23.5
New Jersey 190,967 13.9 215,529 15.2 203,522 14.1
New York 983,196 31.9 1,036,867 32.7 1,136,877 35.1
North Carolina 290,165 18.6 317,551 19.6 464,028 27.6
Ohio 690,094 35.2 732,376 36.2 782,196 37.7
Pennsylvania 900,995 38.5 922,040 38.3 962,954 39.2
South Carolina 139,954 17.2 156,452 18.4 186,830 21.1
Tennessee 293,760 26.7 326,218 28.5 368,202 31.2
NATION 12,454,064 25.7% 13,278,369 26.4% 14,724,574 28.4%
HI45.3%
NATION: 28.4%
South CentralRegion
VT6.5%
PA39.2% NJ
14.1%
NY35.1%
OH37.7%
NC27.6%
SC21.1%
FL 37.1%
GA21.1%
TN31.2%
KY23.5%
Data source: IMS Health and Centers for Medicare and Medicaid Services © 2014
MA ENROLLMENT AND PENETRATION CLIMB
From 2011 to 2013, enrollment
in Medicare Advantage
(MA) plans grew in all 10
profiled East region states,
and MA penetration rose in
nine (Georgia excepted).
MA penetration led that
of the nation (28.4%) in
Florida (37.1%), New York
(35.1%), Ohio (37.7%),
Pennsylvania (39.2%) and
Tennessee (31.2%) in 2013.
MEDICARE ADVANTAGE PENETRATION, EAST REGION, 20131
1 MA enrollment includes members of HMOs, PPOs, private fee-for-service (PFFS) plans and other plan types.2 The penetration rate reflects the percentage of the Medicare population enrolled in Medicare Advantage plans.
Managed Care digest series® National Health Care Data Summary 2014 27
EAST REGIONMEDICARE HMO/HOSPITAL MEDICAL UTILIZATION
NUMBER OF HOSPITAL ADMISSIONS PER 1,000 MEDICARE HMO MEMBERS, 20131
0
125
250
375
500
Ho
spita
l Ad
miss
ion
s
266.2 257.5
359.9
301.3326.1
261.8
391.5
352.1
451.9
331.3
275.6
Florida Georgia Ken-tucky
NewJersey
NewYork
NorthCarolina
Ohio Penn-sylvania
South Carolina
Tenn-essee
Nation
UTILIZATION RATES FOR MEDICARE HMO/POS MEMBERS1
Hospital Admissions per 1,000 Members
Hospital Days per 1,000 Members
ALOS per Hospital
Admission
Physician Encounters
per Member
Ambulatory Visits per Member2
MARKET 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013
Florida 226.1 266.2 1,264.2 1,429.5 5.4 5.4 11.6 11.2 3.7 3.8
Georgia 237.2 257.5 1,485.8 2,002.6 6.1 7.1 9.9 10.3 4.3 3.9
Kentucky 327.6 359.9 1,634.7 2,246.5 5.8 6.2 11.9 11.0 7.1 4.4
New Jersey 333.3 301.3 2,472.7 2,150.2 6.8 7.2 14.1 12.3 5.6 5.0
New York 302.9 326.1 1,983.6 2,305.0 7.0 7.3 11.7 12.2 4.2 4.1
North Carolina 323.9 261.8 2,694.1 2,002.1 8.4 6.9 — 10.3 5.4 5.1
Ohio 368.1 391.5 2,410.9 2,146.3 6.5 6.3 9.4 10.2 4.6 4.9
Pennsylvania 368.3 352.1 2,236.3 2,264.0 7.3 7.3 12.7 13.6 4.4 4.3
South Carolina 262.7 451.9 2,311.8 2,408.9 8.8 6.8 — 11.4 6.8 4.3
Tennessee 276.0 331.3 1,740.1 1,938.2 6.2 6.8 11.4 13.9 5.6 5.4
NATION 265.8 275.6 1,602.4 1,727.1 6.1 6.3 9.9 10.4 4.4 4.5
HMO/HOSPITAL UTILIZATION AND COST MEASURES, BY REGION AND STATE1
Commercial HMO Hospital Days/1,000
Medicare HMO Hospital Days/1,000
Medicare Fee-for-Service
Discharges/1,0003
Medicare Fee-for-Service
Hospital Days/1,0003
Medicare Fee-for-Service Payments per
Hospital Discharge3
Medicare Fee-for-Service
Payments per Enrollee3
MARKET 2011 2012 2011 2012 2011 2012 2011 2012 2011 2012 2011 2012Florida 191 189 1,205 1,264 349 338 1,885 1,803 $9,129 $9,290 $3,127 $3,026Georgia 201 204 1,497 1,486 315 300 1,699 1,602 9,425 9,650 2,915 2,800Kentucky 216 212 2,187 1,635 365 345 1,890 1,777 8,910 9,232 3,224 3,126
New Jersey 268 327 2,313 2,473 344 321 2,023 1,868 11,170 11,437 3,760 3,572New York 293 287 2,255 1,984 348 329 2,349 2,199 12,941 13,212 4,442 4,229North Carolina 199 198 2,729 2,694 315 302 1,664 1,582 10,128 10,292 3,132 3,004
Ohio 344 324 2,335 2,411 374 358 1,892 1,788 9,203 9,404 3,416 3,306Pennsylvania 247 268 2,151 2,236 360 337 1,979 1,828 9,753 10,084 3,466 3,315South Carolina 278 277 — 2,312 305 287 1,727 1,592 9,878 10,075 2,963 2,804Tennessee 240 230 1,912 1,740 347 332 1,846 1,757 8,584 8,837 2,911 2,819
NATION 236 239 1,643 1,602 323 307 1,734 1,634 $10,362 $10,674 $3,281 $3,176
HOSPITAL ADMISSION RATES ARE RELATIVELY HIGH FOR EASTERN MEDICARE HMOs
With the exception of those
serving Florida (266.2), Georgia
(257.5) and North Carolina
(261.8), HMOs operating in
any of the other profiled East
region states reported higher
numbers of hospital admissions
per 1,000 Medicare members
than the national mean of
275.6 in 2013. Florida also had
a lower hospital-days ratio
than the U.S. average in 2013.
HOSPITAL-DAYS RATIO TRAILS FFS AVG. FOR MEDICARE HMOs IN SOME EAST STATES
In 2012, Medicare HMOs in
Florida, Georgia, Kentucky,
New York, Tennessee and
nationally reported fewer
hospital days per 1,000
members than Medicare
fee-for-service plans in
those states. This ratio fell in
five of 10 featured East region
states from 2011 to 2012.
Data source: IMS Health and Centers for Medicare and Medicaid Services © 2014
1 All HMO utilization data exclude well baby, neonatal ICU and psychiatric patients.2 Ambulatory visits differ from physician encounters. Ambulatory visits are visits by an HMO member to an HMO clinic or physician’s office that do not require the services of a physician. Such
visits are usually made for tests, prescription refills, immunizations, etc. The term “physician encounter” is self-explanatory.3 Discharges, hospital days per 1,000, payments per hospital discharge and payments per enrollee for Medicare fee-for-service come from the Medicare and Medicaid Research Review
Statistical Supplement.
NOTE: Some HMO/hospital medical utilization data were unavailable for the selected markets.
Managed Care vs. Fee-for-Service MeasuresData source: IMS Health © 2014
28 National Health Care Data Summary 2014 Managed Care digest series®
EAST REGIONHMO PREMIUMS
AVERAGE PREMIUM RATES PER MONTH1
Average Individual Premium Average Family Premium
MARKET 2011 2012 2013 2011 2012 2013
Florida $486.00 $505.47 $551.53 $1,174.88 $1,228.62 $1,426.56
Georgia 474.41 479.33 582.62 1,155.73 1,175.76 1,277.16
Kentucky 481.09 511.74 493.58 1,115.63 1,281.29 1,272.65
New Jersey 528.51 546.87 612.43 1,319.47 1,399.11 1,502.07
New York 547.84 573.75 595.46 1,372.98 1,488.95 1,515.36
North Carolina 369.12 383.42 506.15 1,032.30 1,106.81 1,241.14
Ohio 512.46 521.15 603.09 1,269.69 1,373.32 1,456.93
Pennsylvania 498.06 507.26 555.14 1,322.91 1,351.20 1,378.71
South Carolina 351.40 370.71 448.75 1,022.48 1,084.91 1,335.67
Tennessee 401.48 375.10 455.03 1,111.84 1,069.77 1,363.82
NATION $464.75 $486.48 $531.82 $1,189.17 $1,237.31 $1,313.03
Florida Georgia Kentucky New Jersey New York North Carolina
Ohio Pennsylvania South Carolina
Tennessee Nation$300
$400
$500
$600
$700
Avg
. In
div
idu
al P
rem
ium
($)
$505
$552
$479
$583
$512$494
$547
$612
$574$595
$383
$506$521
$603
$507
$555
$371
$449
$375
$455
$486
$532
2012 2013
AVERAGE INDIVIDUAL PREMIUM PER MONTH1
PREMIUMS PER MEMBER PER MONTH FOR OUTPATIENT PHARMACY BENEFITS
Average Individual Premium Average Family Premium
MARKET 2012 2013 2012 2013
Florida $37.24 $39.76 $109.23 $109.23
Georgia 38.84 38.84 126.54 126.54
Kentucky 34.77 34.77 79.04 79.04
New Jersey 44.84 39.88 126.69 102.27
New York 63.09 61.21 141.81 133.50
North Carolina 43.84 43.84 136.02 136.02
Ohio 49.77 54.92 142.36 170.45
Pennsylvania 33.21 33.21 72.26 72.26
South Carolina 21.33 25.00 75.00 120.00
Tennessee 47.18 47.18 131.02 131.02
NATION $40.21 $40.71 $101.80 $103.04
Data source: IMS Health © 2014
INDIVIDUAL RX PREMIUMS ARE BELOW U.S. AVG. IN MANY EASTERN STATES
Average monthly individual
pharmacy benefit premiums
in Florida ($39.76), Georgia
($38.84), Kentucky ($34.77),
New Jersey ($39.88),
Pennsylvania ($33.21) and
South Carolina ($25.00) were
all below that of the nation
($40.71) in 2013. Conversely,
such premiums were higher
in New York ($61.21), Ohio
($54.92), Tennessee ($47.18)
and North Carolina ($43.84).
INDIVIDUAL AND FAMILY PREMIUMS ARE LOWER IN KY AND NC THAN U.S. OVERALL
Of the 10 East region states
profiled, only Kentucky
($493.58 and $1,272.65) and
North Carolina ($506.15 and
$1,241.14) reported both
individual and family average
monthly HMO premiums
that were lower than the
corresponding national
rates ($531.82 and $1,313.03,
respectively) in 2013.
1 Averages represent the flat charge for medical health coverage and do not include charges for pharmacy, dental or other services. Also, employee contributions are not included. Numbers of options and levels of coverage may account for significant differences between an individual company’s premium rates and the average.
Managed Care digest series® National Health Care Data Summary 2014 29
EAST REGIONHMO PHARMACY UTILIZATION AND EXPENDITURES
Data source: IMS Health © 2014
PRESCRIPTIONS DISPENSED AND AVERAGE INGREDIENT COST1
Rxs Dispensed per Commercial HMO Member per Year Average Ingredient Cost
MARKET 2011 2012 2013 2011 2012 2013
Florida 9.7 9.3 9.3 $63.52 $63.79 $65.24
Georgia 9.8 9.6 9.5 70.05 68.69 69.22
Kentucky 10.3 10.2 9.7 59.99 57.53 61.66
New Jersey 10.7 10.6 9.5 74.26 70.33 62.91
New York 10.1 9.9 9.8 55.17 53.54 51.87
North Carolina 10.2 10.0 9.8 68.18 63.03 63.80
Ohio 9.6 9.6 9.9 61.13 58.98 62.21
Pennsylvania 8.8 8.6 8.4 56.04 52.67 53.22
South Carolina 8.3 7.7 7.6 50.49 39.23 43.84
Tennessee 9.5 9.1 9.2 71.62 66.05 63.18
NATION 9.4 9.1 9.0 $58.95 $55.73 $56.70
PRESCRIPTIONS DISPENSED PER COMMERCIAL HMO MEMBER PER YEAR
0
3
6
9
12
Ave
rag
e R
xs/P
MPY
—9.3— 9.6 9.510.2
9.7
10.6
9.59.9 9.8 10.0 9.8 9.6 9.9
8.6 8.47.7 7.6
9.1 9.2 9.1 9.0
2012 2013
Florida Georgia Kentucky NewJersey
New York NorthCarolina
Ohio Penn-sylvania
SouthCarolina
Tennessee Nation
HMO DRUG EXPENDITURES
Drug Costs as a Percentage of Operating Expenses
Expenditures per Member per Year for Drugs2
MARKET 2011 2012 2013 2011 2012 2013
Florida 14.2% 14.1% 15.3% $691 $576 $642
Georgia 14.5 15.2 15.6 480 505 501
Kentucky 16.6 15.3 16.3 586 589 618
New Jersey 13.0 14.1 13.7 552 588 682
New York 13.8 15.1 15.5 707 751 820
North Carolina 14.7 16.6 16.7 615 673 733
Ohio 13.9 15.4 15.0 548 719 603
Pennsylvania 14.8 15.8 16.1 626 708 729
South Carolina 15.1 15.3 15.4 562 635 579
Tennessee 15.5 15.1 17.7 692 768 621
NATION 13.9% 14.5% 14.7% $578 $605 $609
PMPY COMMERCIAL RXs DECLINE IN SEVEN OF 10 PROFILED STATE MARKETS
From 2012 to 2013, the
numbers of prescriptions
dispensed per commercial
HMO member per year
(PMPY) dropped in seven
of 10 profiled East region
states, Ohio and Tennessee
excepted, and remained the
same in Florida. The largest
declines were reported in
New Jersey (to 9.5 PMPY from
10.6) and Kentucky (to 9.7
from 10.2).
DRUG COST SHARES OF OPERATING EXPENSES RISE ACROSS PROFILED MARKETS
The percentages of annual
HMO operating expenses
represented by drug spending
grew in all but two profiled
East region states from 2012
to 2013. The exceptions were
New Jersey (to 13.7% from
14.1%) and Ohio (to 15.0% from
15.4%), which both reported
a 0.4-percentage-point
decline. Nationally, drug costs
accounted for 14.7% of HMO
operating expenses in 2013.
PMPY HMO DRUG SPENDING FALLS IN GA, OH, SC AND TN
HMO PMPY expenditures for
prescription drugs decreased
in Georgia (0.8%), Ohio
(16.1%), South Carolina
(8.8%) and Tennessee (19.1%)
between 2012 and 2013.
Meanwhile, PMPY drug
spending across the nation
increased 0.7%, to $609 in
2013 from $605 in 2012.
1 This average is derived by dividing HMO pharmacy expenses by the total number of prescriptions dispensed. Expenses do not include administration or copayment costs.
2 Rounded to the nearest dollar. Expenditures do not include administration and copayment costs.
30 National Health Care Data Summary 2014 Managed Care digest series®
EAST REGIONMEDICAL GROUP: DEMOGRAPHICS
PERCENTAGE OF MEDICAL GROUP PRACTICES BY AFFILIATION
Corporate Affiliation Independent
MARKET 2012 2013 2012 2013
Florida 36.7% 37.1% 63.3% 62.9%
Georgia 47.2 47.4 52.8 52.6
Kentucky 29.0 29.3 71.0 70.7
New Jersey 30.5 30.6 69.5 69.4
New York 38.1 36.7 61.9 63.3
North Carolina 48.5 48.5 51.5 51.5
Ohio 47.9 48.3 52.1 51.7
Pennsylvania 40.9 41.1 59.1 58.9
South Carolina 47.3 47.3 52.7 52.7
Tennessee 38.2 37.7 61.8 62.3
NATION 42.7% 42.7% 57.3% 57.3%
PERCENTAGE OF MEDICAL GROUP PRACTICES BY SPECIALTY, 2013
0%
20%
40%
60%
80%
Perc
en
tag
e o
f Gro
up
s
53.0%47.0%
64.4%
35.6%
59.8%
40.2%
64.4%
35.6%
54.2%
45.8%
70.7%
29.3%
57.6%
42.4%
63.1%
36.9%
74.7%
25.3%
61.2%
38.8%
55.6%
44.4%
Single Specialty Multispecialty
Florida Georgia Kentucky NewJersey
New York NorthCarolina
Ohio Penn-sylvania
South Carolina
Tennessee Nation
Data source: IMS Health © 2014
NUMBER OF MEDICAL GROUPS WITH FIVE OR MORE FTE PHYSICIANS, 2013
SIZE (# of MDs)Florida Georgia
Ken-tucky
New Jersey
New York
North Carolina
OhioPenn-
sylvaniaSouth
CarolinaTenn-essee
NATION
5–6 295 177 89 155 308 223 231 354 98 124 5,729
7–9 156 104 55 69 153 127 113 185 56 70 3,266
10–14 70 54 21 41 80 51 63 82 13 39 1,786
15–19 21 20 5 4 33 17 18 32 10 11 630
20+ 62 33 14 15 75 29 59 68 5 37 1,478
TOTAL 604 388 184 284 649 447 484 721 182 281 12,889
SPECIALTY COMPOSITION
Single Specialty 320 250 110 183 352 316 279 455 136 172 7,161
Multispecialty 284 138 74 101 297 131 205 266 46 109 5,728
AVG. VISITS PER WEEK
Under 250 59 28 17 35 51 26 47 98 14 16 1,029
250–499 95 80 36 75 118 71 85 148 35 43 2,052
500–749 98 73 20 47 107 96 81 122 39 38 2,022
750+ 128 94 48 35 131 131 106 121 40 72 2,728
Unknown 219 111 62 90 236 122 159 223 54 110 4,932
TOTAL 604 388 184 284 649 447 484 721 182 281 12,889
HALF OF EAST REGION STATES HAVE LESS THAN 100 GROUPS WITH 750+ VISITS PER WEEK
In five of the 10 profiled
East region states in 2013,
there were more than 100
medical group practices that
recorded 750 or more patient
visits per week. New York and
North Carolina each reported
131 such medical groups,
followed by Florida (128),
Pennsylvania (121) and Ohio
(106). New Jersey reported
the lowest number of medical
group practices in the
750-or-more-visits range (35),
followed by South Carolina
(40) and Kentucky (48).
MORE THAN 70% OF NC AND SC GROUP PRACTICES ARE SINGLE SPECIALTY
Medical group practices in all
but two profiled East region
states were more likely to be
single specialty than their
national counterparts (55.6%)
in 2013. The single-specialty
share was highest, of these
states, in South Carolina and
North Carolina in 2013.
INDEPENDENT GROUP SHARES ARE HIGH IN EAST REGION STATES
In 2013, the independent
percentages of medical group
practices were higher than
that of the nation (57.3%)
in six of the 10 profiled East
region states. Georgia (52.6%),
South Carolina (52.7%), Ohio
(51.7%) and North Carolina
(51.5%) reported the lowest
independent group practice
shares that year.
NOTE: IMS Health defines the medical groups represented on pages 30-31 of this Data Summary as those with five or more FTE physicians whose primary business is seeing regularly scheduled patients for nonsurgical services other than imaging. Physicians must have a share in the practice and offer outpatient care, and the practice must be physically separate from a hospital. Anesthesiology and pathology groups are excluded.
Managed Care digest series® National Health Care Data Summary 2014 31
EAST REGIONMEDICAL GROUPS: SERVICES
PERCENTAGE OF MEDICAL GROUPS, BY TYPE OF SERVICE
Groups That Perform Surgery (%)
Groups That Have Clinical Labs (%)
Groups That Offer Imaging Services (%)
MARKET 2012 2013 2012 2013 2012 2013
Florida 48.2% 48.4% 41.4% 41.3% 67.9% 68.0%
Georgia 53.1 53.1 43.3 43.5 72.4 72.6
Kentucky 48.3 48.0 51.1 51.1 59.6 59.9
New Jersey 38.0 37.7 32.6 32.5 56.0 55.7
New York 43.1 41.7 42.2 44.4 65.6 64.4
North Carolina 54.9 55.0 50.0 50.0 66.6 66.7
Ohio 47.3 47.5 42.1 42.2 57.6 57.5
Pennsylvania 49.8 49.7 38.9 38.9 52.2 52.1
South Carolina 52.0 52.0 41.0 41.0 61.8 61.8
Tennessee 52.1 52.3 48.4 49.0 66.1 66.2
NATION 54.7% 54.3% 49.8% 49.5% 64.5% 64.0%
1 Medical groups with full pharmacies offer a complete range of medication types; those with limited pharmacy services offer a smaller range, often in particular therapeutic classes; others provide patients only with samples of medications.
Data source: IMS Health © 2014
PERCENTAGE OF MEDICAL GROUPS, BY TYPE OF PHARMACY SERVICE1
Full Pharmacy Limited Pharmacy Samples
MARKET 2012 2013 2012 2013 2012 2013
Florida 17.4% 17.2% 27.3% 27.3% 63.2% 63.7%
Georgia 12.5 12.5 9.7 9.7 84.0 84.0
Kentucky 10.4 10.4 4.2 4.2 87.5 87.5
New Jersey 9.6 9.6 16.9 16.9 75.9 75.9
New York 19.4 20.8 12.8 14.2 69.9 67.2
North Carolina 5.7 5.7 3.1 3.1 92.2 92.2
Ohio 17.6 17.3 3.2 3.1 84.2 84.5
Pennsylvania 10.2 10.4 10.2 10.1 84.2 84.0
South Carolina 5.2 5.2 10.3 10.3 86.2 86.2
Tennessee 9.7 9.6 11.5 11.3 82.3 82.6
NATION 18.4% 18.9% 9.7% 10.0% 75.0% 74.3%
20%
35%
50%
65%
80%
Perc
en
tag
e o
f Gro
up
s 69.9%70.1%
67.3%67.0%
—73.3%—
44.1%43.9%
51.7%49.6%
—59.8%—
69.5%69.8%
—60.7%—
—55.2%—59.8%
60.2%60.7%
60.2%
2012 2013
Florida Georgia Kentucky NewJersey
New York NorthCarolina
Ohio Penn-sylvania
South Carolina
Tennessee Nation
PERCENTAGE OF MEDICAL GROUPS WITH PHARMACY SERVICES
LOW PERCENTAGES OF PRACTICES IN EAST REGION STATES PERFORM SURGERY
In nine of 10 profiled East
region states, medical group
practices were less likely to
perform surgery than their
national counterparts in both
2012 and 2013 (54.7% and
54.3%, respectively). Only in
North Carolina did the share
of medical groups performing
surgery (54.9% in 2012 and
55.0% in 2013) exceed that of
the nation in either year.
SHARES OF MEDICAL GROUPS WITH RX SERVICES ARE MIXED IN EAST REGION STATES
In 2013, the percentages of
medical group practices in
the profiled East region states
offering pharmacy services
varied from a low of 43.9% in
New Jersey to a high of 73.3%
in Kentucky. More than 50%
of medical groups offered
pharmacy services in eight of
the 10 profiled states.
PORTIONS OF MEDICAL GROUPS WITH FULL RX TRAIL U.S. IN EAST REGION STATES
Among medical group
practices with any pharmacy
services, the shares of those
offering full pharmacy service
were lower in nine of 10
profiled East region states
than the national portion
(18.9%) in 2013. Meanwhile,
the percentages of medical
groups that offered samples
were higher in eight of these
states than the U.S. average.
32 National Health Care Data Summary 2014 Managed Care digest series®
EAST REGIONHOSPITAL UTILIZATION
SELECTED UTILIZATION MEASURES, CATHOLIC HEALTH INITIATIVES AFFILIATES, 20121
SYSTEM NAME
Average Number of
Staffed Beds
Average Number
of Hospital Admissions
Average Total Facility Occupancy
Average Length of
Stay (Days)
All-Cause Readmission
Rate2
KentuckyOne Health 152.5 7,300.8 56.1% 4.2 15.6%
TriHealth 439.5 28,769.5 74.3 4.1 15.3
NATION 150.4 7,142.9 48.5% 5.3 15.6%
SELECTED UTILIZATION STATISTICS FOR HOSPITALS, 20121
MEASUREFlorida Geor-
giaKen-tucky
New Jersey
New York
North Caro-lina
OhioPenn-sylva-
nia
South Caro-lina
Tennes-see NATION
Total Facility Admissions per Hospital
12,754 6,570 5,769 14,441 14,207 8,857 8,775 9,619 7,188 6,211 7,143
Total Facility Patient-Days per Hospital
61,707 31,579 27,049 70,210 94,147 45,800 37,161 48,197 34,423 31,445 35,791
Total FacilityALOS perHospital
5.0 5.3 4.4 5.0 7.6 4.9 4.1 5.0 4.4 5.2 5.3
Inpatient Surg./ Staffed Bed 14.1 12.6 9.7 16.5 11.3 11.4 11.3 16.2 14.6 10.2 11.8
Outpatient Surg. per Day 11.9 12.3 9.4 17.5 22.5 12.1 12.3 18.3 12.7 9.0 10.6
Outpatient Surg. as a Percentage of Total Surg.
58.9% 73.8% 74.4% 61.6% 73.6% 69.7% 73.0% 70.3% 68.4% 72.2% 70.9%
AVERAGE TOTAL FACILITY OCCUPANCY, 20121
0%
20%
40%
60%
80%
Oc
cu
pa
nc
y (%
)
Florida Georgia Kentucky NewJersey
NewYork
NorthCarolina
Ohio Penn-sylvania
SouthCarolina
Tenn-essee
Nation
60.3%
49.6% 46.3%
62.6%67.0%
55.1%46.8%
54.7%45.5%
49.6% 48.5%
SELECTED FINANCIAL RATIOS FOR HOSPITALS (IN THOUSANDS), 2012
MEASURE Florida Georgia Kentucky New Jersey New York North Carolina Ohio Penn-
sylvaniaSouth
Carolina Tennessee NATION
Total Costs/ Occupied Bed $1,312.0 $1,700.4 $1,692.3 $1,570.3 $1,158.0 $1,664.6 $2,057.9 $1,609.7 $1,909.6 $1,455.9 $1,847.4
Total Costs/ Admission 16.1 20.3 19.0 19.3 20.4 20.4 21.9 20.0 22.0 17.5 22.3
Total Costs/ Patient-Day 3.6 4.7 4.7 4.3 3.4 4.8 5.7 4.4 5.4 4.1 5.2
Labor Costs/Patient-Day 1.5 2.0 1.9 2.1 1.7 2.1 2.4 2.0 2.0 1.7 2.1
Salary Costs/FTE3 58.0 51.6 48.1 66.0 63.1 52.9 53.8 55.7 53.2 49.0 57.4
Total Costs/FTE3 169.3 137.6 135.8 162.2 140.2 140.0 160.7 167.0 153.1 141.6 152.7
Data source: IMS Health © 2014
EAST REGION HOSPITALS ADMIT LARGE NUMBERS OF INPATIENTS IN 2012
On average, hospitals in seven
of the 10 profiled East region
states reported higher numbers
of total facility admissions in
2012 than the national mean
of 7,143. This number was
highest, among the profiled
East region states, in New
Jersey, at 14,441, followed
by New York (14,207). New
York hospitals recorded
the highest number of
patient-days in 2012, at 94,147.
Total facility patient-days per
hospital trailed the U.S. rate
of 35,791 in four East region
states that year: Georgia
(31,579), Kentucky (27,049),
South Carolina (34,423) and
Tennessee (31,445).
IN NY HOSPITALS, MORE THAN TWO-THIRDS OF STAFFED BEDS ARE OCCUPIED
In 2012, hospitals in the
state of New York operated
at 67.0% occupancy, the
highest rate of the 10 profiled
East region states, and well
above the overall national
average rate of 48.5%.
1 Total facility figures reflect all portions of the hospital’s occupancy.2 Hospital All-Cause Readmission Rate figures come from the Centers for Medicare and Medicaid Services Hospital Compare database and are measured from July 2012 through June
2013. Unless otherwise noted, scores are averaged across all facilities within the specified system.3 “FTE” is full-time equivalent.
NOTE: Hospital utilization data represent patients of all payer types.
Managed Care digest series® National Health Care Data Summary 2014 33
DIABETESDIABETES: DEMOGRAPHICS
Data source: IMS Health © 2014
Inpatient Outpatient0
8
16
24
32
Nu
mb
er o
f Ca
ses
(in M
illio
ns)
6.3 6.4 6.2
23.1
25.628.0
2010 2011 2012
TOTAL NUMBER OF INPATIENT AND OUTPATIENT CASES, NATION, DIABETES MELLITUS (IN MILLIONS)1
PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY AGE, 20132
REGION 0–17 18–35 36–64 65–79 80+
West 0.4% 3.0% 44.2% 38.6% 13.8%
Midwest 0.5 3.1 46.2 36.8 13.4
Northeast 0.4 2.8 45.4 36.8 14.6
South 0.4 2.8 45.5 39.1 12.2
NATION 0.4% 2.9% 45.4% 38.1% 13.2%
PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY TYPE OF COMPLICATION, 20132,3
REGIONCardiovascular
Disease Neuropathy Nephropathy Retinopathy Hypoglycemia
West 51.2% 32.8% 33.6% 17.9% 8.4%
Midwest 56.5 32.2 29.9 18.1 8.1
Northeast 60.2 31.1 26.0 23.2 7.6
South 58.5 33.5 32.9 16.6 7.8
NATION 57.4% 32.7% 31.0% 18.5% 7.9%
West Midwest Northeast South Nation0%
10%
20%
30%
40%
Perc
en
tag
e o
f Pa
tien
ts
25.0% 26.1% 26.0% 26.9%
30.2% 31.1%29.5%
31.1%28.1% 29.4%
2012 2013
PERCENTAGE OF TYPE 2 DIABETES PATIENTS WITH TWO OR MORE COMPLICATIONS2,3
1 Inpatient/outpatient case count data come from IMS Health’s Hospital Procedure/Diagnosis (HPD) database and are current as of calendar year 2012.
2 On pages 33–35, the percentages are representative of the universe of Type 2 diabetes patients on whom claims data have been collected in a given year.
3 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular disease, hypoglycemia, nephropathy, neuropathy and retinopathy.
OUTPATIENT DIABETES MELLITUS CASE COUNT EXPANDS BY MORE THAN 21%
Between 2010 and 2012,
the number of diabetes
mellitus cases nationally that
were treated in the hospital
outpatient setting climbed
21.2%, to 28.0 million from
23.1 million. Meanwhile, such
cases treated in the inpatient
setting declined 1.6%, to
6.2 million from 6.3 million.
PERCENTAGES OF TYPE 2 DIABETES PTS. WITH TWO OR MORE COMPLICATIONS RISE
The shares of Type 2 diabetes
patients with two or more
complications grew in every
region from 2012 to 2013. The
rates of such patients were
highest in the Northeast and
South regions (both 31.1%),
and lowest in the West region
(26.1%). In 2013, among
Type 2 diabetes patients with
complications, cardiovascular
(CV) disease was the most
common, affecting 57.4%
nationally. In the Northeast,
60.2% of such patients had
CV disease, the highest
percentage of all regions.
TYPE 2 DIABETES PATIENTS ARE APT TO BE WORKING AGE
In 2013, Type 2 diabetes
patients across all regions
were most likely to be
18–64 years old, followed by
those 65–79 years old and
those 80-plus years old. The
share of Type 2 diabetes
patients who were 18–64
was highest in the Midwest.
34 National Health Care Data Summary 2014 Managed Care digest series®
DIABETESDIABETES: USE OF SERVICES
Data source: IMS Health © 2014
PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY SERVICE
A1c Test1Blood
Glucose Test
Serum Cholesterol
Test
Ophthalmologic Exam
Urine Microalbumin
Test
REGION 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013
West 73.7% 73.8% 87.1% 87.1% 84.4% 84.5% 68.0% 67.8% 70.2% 70.1%
Midwest 77.1 77.3 86.1 86.2 84.2 84.2 69.5 69.6 73.5 73.5
Northeast 75.3 75.4 89.1 89.0 87.9 87.9 71.3 71.2 78.5 78.4
South 72.0 72.1 85.7 85.7 82.6 82.6 69.5 69.4 67.6 67.5
NATION 74.1% 74.2% 86.7% 86.8% 84.4% 84.4% 69.6% 69.6% 71.5% 71.5%
West Midwest Northeast South Nation60%
66%
72%
78%
84%
Perc
en
tag
e o
f Pa
tien
ts
75.7%74.7%
71.3%
80.7%
79.2%
72.9%
77.1%78.3%
71.9%
75.8%
74.5%
67.9%
77.1% 76.7%
70.3%
Commercial Insurance2 Medicaid Medicare
PERCENTAGE OF TYPE 2 DIABETES PATIENTS RECEIVING A1c TESTS, BY PAYER TYPE, 20131
PERCENTAGE OF TYPE 2 DIABETES PATIENTS, BY A1c LEVEL RANGE1
≤7.0% 7.1–7.9% 8.0–9.0% >9.0%
REGION 2012 2013 2012 2013 2012 2013 2012 2013
West 51.4% 51.6% 20.2% 20.4% 12.9% 12.8% 15.5% 15.2%
Midwest 50.6 47.7 21.1 21.5 12.9 13.9 15.4 16.9
Northeast 50.7 50.0 21.4 20.9 12.8 13.1 15.1 16.0
South 50.3 49.1 20.5 20.8 13.0 13.6 16.2 16.5
NATION 50.6% 49.5% 20.6% 20.8% 13.0% 13.4% 15.9% 16.3%
1 The A1c test measures the amount of glucose present in the blood during the past 2–3 months. Figures reflect the percentage of Type 2 diabetes patients who have had at least one A1c test in a given year.
2 Includes HMOs, PPOs, point-of-service plans and exclusive provider organizations.
NOTE: Medicare data include both fee-for-service and Medicare managed care.
TYPE 2 DIABETES PATIENTS IN THE SOUTH ARE LESS APT TO HAVE CERTAIN TESTS DONE
In 2013, Type 2 diabetes
patients in the South region
were less likely than their
peers nationally to receive
any one of five tests. For
instance, 72.1% of such
patients in the South had
an A1c test, compared with
74.2% nationally, and 67.5%
in the South had a urine
microalbumin test versus 71.5%
across the U.S. Meanwhile,
of Type 2 diabetes patients
who received an A1c test in
2013, those in the Northeast
region were most apt to
be covered by Medicaid
(78.3%) instead of commercial
insurance (77.1%) or Medicare
(71.9%). In all other regions
and nationally, such patients
were more likely to have
commercial insurance.
TYPE 2 DIABETES PATIENTS IN THE MIDWEST AND SOUTH HAVE HIGH A1c LEVELS
In 2013, the percentages
of Type 2 diabetes patients
in the Midwest and South
regions who had A1c levels
of 8.0% to 9.0% or above 9.0%
exceeded those of the nation.
For instance, 16.9% of such
patients in the Midwest and
16.5% in the South had A1c
levels above 9.0%, versus 16.3%
of such patients across the U.S.
Managed Care digest series® National Health Care Data Summary 2014 35
DIABETESDIABETES: PHARMACOTHERAPY
Data source: IMS Health © 2014
PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING INSULIN THERAPIES, 20131
Any Insulin Products
Long-Acting Insulin Short-Acting Insulin Rapid-Acting Insulin Mixed Insulin
REGION Pens Vials Pens Vials Pens Vials Pens Vials
West 35.4% 15.7% 13.9% 9.3% 11.4% 9.3% 9.6% 1.7% 2.6%
Midwest 36.2 18.9 10.7 12.0 9.6 12.0 8.1 2.4 2.6
Northeast 32.3 18.1 8.0 10.6 7.1 10.6 6.0 3.0 2.3
South 33.7 16.4 9.8 9.3 8.7 9.3 7.0 2.9 3.8
NATION 34.3% 17.2% 10.3% 10.1% 9.0% 10.1% 7.5% 2.6% 3.0%
PERCENTAGE OF TYPE 2 DIABETES PATIENTS USING NON-INSULIN ANTIDIABETIC THERAPIES1
Any Non-InsulinAntidiabetic
ProductSulfonylureas DPP-4 Inhibitors Insulin Sensitizing
AgentsGLP-1 Receptor
Agonists
REGION 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013
West 84.4% 84.3% 34.5% 33.5% 12.6% 12.7% 9.3% 7.3% 4.7% 5.1%
Midwest 82.9 83.0 34.8 33.7 10.8 10.8 6.7 5.4 4.8 5.2
Northeast 85.8 85.8 35.6 34.9 15.8 15.6 6.9 5.0 4.5 4.8
South 84.8 85.2 33.6 32.9 12.2 12.1 6.4 5.0 5.4 5.8
NATION 84.6% 84.7% 34.4% 33.6% 12.8% 12.7% 7.1% 5.5% 4.9% 5.3%
1 Patients who filled prescriptions for any insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa.
2 Figures reflect the percentages of Type 2 diabetes patients who were readmitted to an inpatient facility in the three-year period between 2011 and 2013. These percentages include patients who filled multiple prescriptions. Readmissions are not necessarily due to Type 2 diabetes.
Dipeptidyl Peptidase 4 (DPP-4) Inhibitors Inhibit DPP-4 enzymes and slow inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels.
GLP-1 Receptor Agonists Used in conjunction with oral agents; increase glucose-dependent insulin secretion and pancreatic beta-cell sensitivity, reduce glucagon production, slow rate of absorption of glucose in the digestive tract by slowing gastric emptying, and suppress appetite.
Insulin Sensitizing Agents Increase insulin sensitivity by improving response to insulin in liver, adipose tissue, and skeletal muscle, resulting in decreased production of glucose by the liver and increased peripheral uptake and use of circulating glucose.
Sulfonylureas Stimulate the release of insulin in the pancreas.
INSULIN USE IN SOUTH, NORTHEAST REGIONS TRAILS NATIONAL AVG.
The percentages of Type 2
diabetes patients dispensed
any insulin products in 2013
were lower than that of the
nation (34.3%) in the South
(33.7%) and Northeast (32.3%)
regions. The South (16.4%)
and West (15.7%) regions also
recorded lower portions of
Type 2 diabetes patients who
received long-acting insulin
pens than the U.S. rate of
17.2%. Meanwhile, the shares
of such patients dispensed
any non-insulin antidiabetic
product were higher than
that of the U.S. (84.7%) in the
Northeast and South regions.
READMIT RATES ARE LOW IN SEVERAL REGIONS FOR TYPE 2 PTS. PRESCRIBED INSULIN PENS
In the Mid-Atlantic, Midwest
and Northeast regions, three-
and 30-day readmission rates
for Type 2 diabetes patients
treated in the inpatient
hospital setting were lowest for
those prescribed insulin pens
than any other profiled insulin
or non-insulin antidiabetic
therapy in the three years
from 2011 to 2013. In the
Pacific region, the three-day
readmit rate was lower for
such patients dispensed insulin
pens than any other insulin
or non-insulin therapy shown,
and the 30-day rates were the
same for insulin pens and vials.
READMISSION RATES FOR PATIENTS DIAGNOSED WITH TYPE 2 DIABETES, BY TYPE OF THERAPY, 2011–20131,2
REGION
Three-Day Readmissions 30-Day Readmissions
Any Insulin Products
InsulinPens
InsulinVials
Three Non-Insulin Products
Any Insulin Products
Insulin Pens
InsulinVials
Three Non-Insulin Products
Mid-Atlantic 10.2% 7.7% 10.4% 13.9% 19.4% 16.1% 19.0% 25.0%
Midwest 9.4 5.5 9.6 11.4 19.4 15.2 19.4 21.6
Northeast 10.2 6.0 10.5 13.8 20.2 15.2 20.1 24.9
Pacific 8.4 6.8 8.2 11.7 16.5 15.5 15.5 22.0
Southeast 10.0 9.9 9.3 13.9 18.9 18.5 17.6 23.6
Southwest 9.7 11.8 7.2 14.8 17.9 19.6 14.8 24.7
NATION 9.9% 9.0% 9.3% 13.6% 18.9% 17.6% 17.8% 23.9%
36 National Health Care Data Summary 2014 Managed Care digest series®
915 Wilshire Boulevard, Suite 1620 Los Angeles, CA 90017(213) 624-CAPG
© 2014 sanofi-aventis U.S. LLC, A SANOFI COMPANY US.NMH.15.01.106
Initial drugmonotherapy Efficacy (�HbA1c) Hypoglycemia Weight Side Effects Costs
Two-drugcombinationsa
Efficacy (�HbA1c) Hypoglycemia Weight Major Side Effect(s) Costs
Three-drugcombinations
More complexinsulin strategies
Healthy eating, weight control, increased physical activity
Metforminhigh
low riskneutral/loss
GI/lactic acidosislow
If needed to reach individualized HbA1c target after ≈3 months, proceed to two-drug combination(order not meant to denote any specific preference):
Metformin+
Sulfonylureab
highmoderate risk
gainhypoglycemiac
low
Metformin+
Thiazolidinedione
highlow risk
gainedema, HF, Fxsc
high
Metformin+
DPP-4 Inhibitor
intermediatelow riskneutralrarec
high
Metformin+
GLP-1 Receptor Agonist
highlow risk
lossGIc
high
Metformin+
Insulin (Usually Basal)
highesthigh risk
gainhypoglycemiac
variable
If needed to reach individualized HbA1c target after ≈3 months, proceed to three-drug combination(order not meant to denote any specific preference):
Metformin+
Sulfonylureab
+TZD
or DPP-4or GLP-1-RAor Insulind
Metformin+
Thiazolidinedione+
Sulfonylureab
or DPP-4or GLP-1-RAor Insulind
Metformin+
DPP-4 Inhibitor+
Sulfonylureab
or TZDor Insulind
Metformin+
GLP-1 Receptor Agonist+
Sulfonylureab
or TZDor Insulind
Metformin+
Insulin (Usually Basal)+
TZDor DPP-4
or GLP-1-RA
If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3–6 months,proceed to a more complex insulin strategy, usually in combination with one or two non-insulin agents:
Insuline
(multiple daily doses)
Antihyperglycemic therapy in Type 2 diabetes: general recommendations. Moving from the top to the bottom
of the figure, potential sequences of antihyperglycemic therapy. In most patients, begin with lifestyle changes;
metformin monotherapy is added at, or soon after, diagnosis (unless there are explicit contraindications). If the
HbA1c target is not achieved after approximately 3 months, consider one of the five treatment options combined
with metformin: a sulfonylurea, TZD, DPP-4 inhibitor, GLP-1 receptor agonist, or basal insulin. (The order in
the chart is determined by historical introduction and route of administration and is not meant to denote any
specific preference.) Choice is based on patient and drug characteristics, with the overriding goal of improving
glycemic control while minimizing side effects. Shared decision making with the patient may help in the selection
of therapeutic options. The figure displays drugs commonly used both in the U.S. and/or Europe. Rapid-acting
secretagogues (meglitinides) may be used in place of sulfonylureas. Other drugs not shown (a-glucosidase
inhibitors, colesevelam, dopamine agonists, pramlintide) may be used where available in selected patients but
have modest efficacy and/or limiting side effects. In patients intolerant of, or with contraindications for, metformin,
select initial drug from other classes depicted and proceed accordingly. In this circumstance, while published trials
are generally lacking, it is reasonable to consider three-drug combinations other than metformin. Insulin is likely
to be more effective than most other agents as a third-line therapy, especially when HbA1c is very high (e.g.,
≥9.0%). The therapeutic regimen should include some basal insulin before moving to more complex insulin
strategies. Dashed arrow line on the left-hand side of the figure denotes the option of a more rapid progression
from a two-drug combination directly to multiple daily insulin doses, in those patients with severe hyperglycemia
(e.g., HbA1c ≥10.0–12.0%). a Consider beginning at this stage in patients with very high HbA1c (e.g., ≥9.0%). b Consider rapid-acting, non-sulfonylurea secretagogues (meglitinides) in patients with irregular meal schedules
or who develop late postprandial hypoglycemia on sulfonylureas. c See Table 1 of the Position Statement for additional potential adverse effects and risks. d Usually a basal insulin in combination with non-insulin agents. e Certain non-insulin agents may be continued with insulin. Consider beginning at this stage if patient presents
with severe hyperglycemia (≥16.7–19.4 mmol/L [≥300–350 mg/dL]; HbA1c ≥10.0–12.0%) with or without catabolic features (weight loss, ketosis, etc.).
Key: DPP-4=DPP-4 inhibitor; Fxs=bone fractures; GI=gastrointestinal; GLP-1-RA=GLP-1 receptor agonist; HF=heart failure; TZD=thiazolidinedione.
Adapted from the 2012 ADA/EASD Position Statement
Inzucchi, S. E., et al. (2012). Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach: Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. Retrieved from http://care.diabetesjournals.org/content/early/2012/04/17/dc12-0413.full.pdf+html
MethodologyGENERAL DATA
IMS Health gathered national-, state- and local-level data included in this Summary from a variety of sources between February 2011 and June 2014, by contacting each state’s department of insurance, mailing a survey to each plan and following up, when necessary, with a telephone or email survey.
Most data in this Summary are from a census of health plans. When data were not available from all plans, a smaller sample was used.
In addition, IMS Health compares its data with those published in other sources, including trade associations in the managed care industry, state regulatory agencies, and periodicals and journals. Doing so provides an additional check on the accuracy of its database of operating health plans. Hospital data for this report are based on information from the IMS Health Hospital Procedure/Diagnosis (HPD) database.
IMS Health generated Type 2 diabetes data for this Summary out of health care professional and institutional insurance claims, representing more than 7.7 million unique Type 2 diabetes patients nationally in 2013 with a diagnosis in the 250.00–250.92 range. Data from physicians of all specialties and from all hospital types are included.
IMS Health also gathers data on prescription activity from the National Council for Prescription Drug Programs (NCPDP). These data represent some 2 billion prescription claims annually, or more than 50% of the prescription universe. These data represent the sampling of prescription activity from a variety of sources, including retail chains, mass merchandisers and pharmacy benefit managers. Cash, mail-order, Medicaid and third-party transactions are tracked.
MARKET DEFINITIONS
IMS Health gathered information on the service areas of every health plan—commercial, Medicare and Medicaid—during the survey process, then aggregated it to the appropriate metropolitan statistical area (MSA) and state level. Finally, to ensure the integrity of the data, MSA data are reported only for those areas served by five or more health plans. All health plan demographic and utilization data in this Summary include members in point-of-service (POS) plans.
Unless otherwise noted, data provided in this Summary are based on total health plan enrollment, including Medicare beneficiaries and Medicaid recipients. Utilization data provided on Medicare beneficiaries and Medicaid recipients enrolled in health plans were gathered only from those plans in each state that have such members.