Information for Health Professionals
Introduction
As the WV state health data repository, the role of the West Virginia Health Care Authority is to make health care financial information available to the public. In pursuit of this effort, CompareCareWV™ presents average gross charge information by facility. In CompareCareWV™ version one, the consumer will find acute care hospitals with the average aggregate professional charges associated with the selected procedure or discharge. CompareCareWV™ will publish additional provider types including ambulatory surgery centers, ambulatory care centers and independent laboratories within the next five site versions.
What charges are being published?
The average gross technical and aggregate professional charges are being displayed for frequent and/or common inpatient and outpatient services.
Why publish this information?
Consumers are requesting it. Consumer health decisions are becoming increasingly price sensitive due to the continuing shift of cost sharing to the patient. In addition, uninsured consumers need a tool to manage the financial decisions related to their care. This site is intended to assist consumer awareness and decision-making.
Where is the data coming from?
The average gross charge is calculated from State payor claims data including PEIA, Medicaid and other state payors. We have utilized publicly available claims grouping software tools to aggregate procedures to commonly termed reimbursed items. These groupers include the CMS Diagnosis Related Group (DRG) grouper and the AHRQ Clinical Classification Software (CCS) grouper.
Data are dependent on the accuracy and completeness of the data submitted by the payors. Data collection may not be the same for all payors. There may be some variability in assigning diagnoses and categorizing the amounts for the claims.
What does this mean to our facility?
Average gross patient charges are now available for public review. Facilities may receive inquiry about gross charges from consumers or other professionals. These contacts may be an opportunity to expand the patient base or to initiate patient services activity within the revenue cycle. Providers can view this publication as a tool to assist patients and professionals with decision making.
What are the detailed calculations for average gross price?
The outpatient hospital costs listed on the ComparecareWV web site are the total costs for all services associated with the episode of care. Once the episode of care is identified, the primary procedure is identified and grouped using the Clinical Classifications Software for CPT®/HCPCS software from the Healthcare Cost and Utilization Project (HCUP).
An episode of care can be thought of as all of the services (both facility and professional providers) performed for an individual in a facility setting for a specific reason, between specific dates. For example:
• Patient John Doe had a broken arm treated at Hospital A on June 1, 2006. Because his physician was concerned about damage to his wrist,
an MRI was ordered. For this episode, the services would include:
o The hospital charges such as supplies, MRI, and X-Ray.
o The professional charges associated with the interpretation of the MRI and interpretation of the X-Ray.
• Patient Jane Doe had a routine mammography performed at Hospital B on May 1, 2006. Since no other services were required,
the services for this episode included:
o The hospital charges for the mammography itself.
o The professional charges for the interpretation of the mammography.
The above examples would be represented as two distinct episodes in the CompareCareWV database. In the event either of the patients would have received care for different reasons (diagnosis codes) at different facilities, those other services would have been interpreted as separate episodes.
Another feature of the episode approach is the determination of the primary procedure. The procedure with the highest professional charge during the episode is selected as such for the episode. Using the “John Doe” example, assume the following service line items:
• MRI interpretation: 300.00 charge
• X-Ray interpretation: 50.00 charge
Based upon the above professional charge data, the MRI interpretation would be selected as the primary procedure. The summary record in the database for this episode would include (but not limited to):
• Patient ID (John Doe)
• Hospital ID (Hospital A)
• Diagnostic Category (Muscles, Bones, Joints)
• Primary Procedure (MRI Interpretation)
• Facility Charge (2,000 – the sum of all institutional charges)
• Professional Charge (350.00 – the sum of all professional charges)
In summary, the episode is an inclusive summary of all expenses related to treatment. While the facility portion of the episode is related to one event in a facility, there may be one or more professional services associated with the encounter.
What is included in the WV Hospital Services & Departments section?
The American Hospital Association's annual survey reports numerous patient services provided by hospitals completing the questionnaire. CompareCareWV™ displays a subset of these categories in both a map and a grid format, allowing consumers to choose a facility based on services offered.
Using the map display, consumers can select a category and drill down to the street level to find an exact location. Both pages show street address, web address and phone number for each facility.
What are the detailed calculations for average gross price?
Adjudicated hospital and professional State payor claims are used to calculate the averages. At the claim detail level, the site of service selected is "Hospital". HCA segregated technical and professional charges by the bill type, modifier or revenue code. These selected claims were grouped using standard grouping software utilized for payment or public health purposes. The total average charge is the addition of professional and facility charges. The version one average is over a twenty-four month historical period ending 06/30/2006. Outlier cases are included in the average. For the purposes of computing an average, the population must exceed 30. If a facility did not have greater than 30 occurrences, it is not displayed in certain selected CompareCareWV™ procedure choices.
Where is additional information on the groupers?
CCS categories are available at www.hcup-us-ahrq.gov/toolssoftware/ccs-cpt/ccscpt.jsp. The CMS DRG grouping methodology is available at www.cms.gov.
Why is quality of care data not included?
Quality of care measures are publicly reported at the national level. West Virginia desires to bring together public and private sector representatives of patients, physicians, hospitals, long-term care providers, pharmacists, payors, and other stakeholders to identify appropriate quality measures for use in West Virginia in a later version of CompareCareWV™. Links to recognized national agencies that rate patient care are available in the CompareCareWV™ section titled "Hospital Quality of Care Reports."
When will the next update occur?
The first quarterly update will occur in April 2007. Please be aware, though, that each update will still reflect a 24-month look back period.
Definitions
ADJUDICATED CLAIMS: Paid hospital and provider claims
CCS: Diagnosis and procedure categorization scheme for a uniform and standardized coding system, the Internal Classification of Diseases, 9th Revision, clinical modification (ICD-9-CM). Over 12,000 diagnosis codes and 3,500 procedure codes are grouped into 244 clinically meaningful categories useful for presenting descriptive statistics rather than individual ICD-9-CM codes. CCS stands for Clinical Classifications Software, developed by the Agency for Healthcare Research and Quality (AHRQ).
CPT: A proprietary coding system developed by the American Medical Association for coding services provided by health care professionals. CPT is also referred to as HCPCS Level I. CPT stands for Current Procedural Terminology.
DRG: DRG stands for Diagnosis Related Group. It is a system that organizes medical diagnoses and procedures into groups based on estimated hospital resources and length of stay.
HCPCS: Health Care Common Procedure Coding System is a supplementary coding system developed by the Centers for Medicare and Medicaid Services (CMS) to account for supplies and services not included in CPT. The procedure categories are identical to the CCS with the addition of specific categories unique to the professional services and supply codes in CPT/HCPCS.
OUTLIER: Unusually high or low charges
PROCEDURE CODE: Procedure codes are based on the International Classification of Diseases Version 9 (clinical modification) that providers use to code medical procedures.
REVENUE CODE: Uniform Billing revenue code, used to report a code that defines a specific accommodation, ancillary services, or billing calculation related to the services being billed.