The way costs are calculated varies depending on the type of procedure, service or item. Below is information about the methodology used to calculate cost estimates for each category.

Note: Keep in mind that cost estimates are based on contract rates for Medica's Choice® network and may not reflect the costs for health benefit plans that utilize a different network.

Also, costs for individual cases will vary depending on the severity of illness and/or complexity of the procedure performed.

 

Clinic Services
This information shows a clinic's total cost for treating a specific condition. The average cost and cost range are listed which reflect the fees associated with the facility, the physician, office visits, ancillary services and medications. The conditions are categorized by Episode Treatment Groups (ETGs).

Medica's commercial claims data was used as the basis of this analysis. To help ensure comparability of the findings, only complete, non-outlier episodes for commercial members who had pharmacy benefits were included in the analysis. Episodes with the highest severity level were also excluded in an effort to represent costs typical of a condition.

The episodes were assigned to a provider at a tax identification number (TIN) level using an attribution methodology. The methodology assigned the entire episode to the provider that accounted for the highest dollar professional fees with at least 30 percent of the professional fees associated with that episode. The types of providers who were eligible for attribution (assignment) varied by condition.

The episodes were assigned to a provider at a tax identification number (TIN) level using an attribution methodology. The methodology assigned the entire episode to any and all providers that accounted for at least 30 percent of the professional fees associated with that episode. The types of providers who were eligible for attribution (assignment) varied by condition.

In order for a provider to be listed for a given condition, they must have had 15 or more episodes for that condition. The average cost associated with a provider was a case-mix adjusted mean.

The cost range is defined by the 25th percentile (the low end of the range) and the 75th percentile (the high end of the range). For a given condition, the clinics were then ordered by the case-mix adjusted mean cost and segmented by cost category. Cost categories were defined as follows:

Low cost - at or below the 25th percentile;
Middle cost - above the 25th percentile to at or below the 75th percentile; and
High cost - above the 75th percentile.

 

Imaging Services
This information shows a facility's average cost range for performing a specific imaging service such as X-rays, CT scans and MRIs. The cost ranges reflect fees for the facility as well as the radiologist who reads (or interprets) the image.

Medica Choice commercial claims data was used to calculate an average allowed amount for each contracted rate per federal tax id. For a given procedure, a minimum of 10 claims were required for a federal tax id to be included in the analysis. Claims that included emergency room or urgent care codes were removed from the data, along with outliers. If fees for the radiologist who reads the image were not already part of the bill, they were added into the total cost.

Cost ranges were developed based on the distribution of provider average costs. Providers were then put into one of three cost ranges based on their average costs. Providers with average costs that fell within the middle cost range are considered middle cost. Providers with costs below the minimum value of the middle cost range are displayed as lower cost. Those with costs above the maximum value of the middle cost range are displayed as higher cost.

The overall results are then reviewed and adjustments made as needed to reflect natural breaks in the pricing.

 

Inpatient Services
This information shows a facility's average cost range for treating a specific condition and reflect the fees associated with the facility physician and other professional fees are not included. The procedures are categorized by Diagnosis-Related Group (DRG). A DRG is a statistical system used to classify an inpatient stay into a group for the purposes of payment.

Twelve months of Medica's commercial claims data was used as the basis of this analysis.

In order for a provider to be listed for a given condition, they must have had five or more hospitalizations. For each DRG, the median was identified for each provider. High, medium and low cost categories were determined using the 25th and 75th percentiles of all provider medians.
The facilities were ordered by their median cost and segmented into a cost category. Cost ranges were determined based on the low and high median values within each cost category.

Cost categories were defined as follows:

Low cost - at or below the 25th percentile;
Middle cost - above the 25th percentile to at or below the 75th percentile; and
High cost - above the 75th percentile.

 

Outpatient Services
This information shows the median cost and range for specific outpatient procedures and includes the professional and facility fees for the surgery itself, as well as the care prior to and following the surgery (including professional, facility and RX fees).

The costs are determined by using two years of historical Medica Choice® commercial claims data. For a given procedure, a provider must have a minimum of ten claims to be included in the analysis. Costs for surgeries that were outliers were removed from the analysis.

For each provider procedure combination, the median cost was calculated and the 25th and 75th percentiles for that provider were used as the range.

For a given procedure, the facilities are ordered by the median cost and segmented cost category. Cost categories were defined as follows:

Low cost - at or below the 25th percentile;
Middle cost - above the 25th percentile to at or below the 75th percentile; and
High cost - above the 75th percentile.

 

Supplies & Other Services
This information shows a supplier's average cost range for a specific item. Twelve months of Medica Choice commercial claims data was used to calculate an average allowed amount for each contracted rate per federal tax id. For a given item, a minimum of 10 claims were required for a federal tax id to be included in the analysis.

Cost ranges were developed based on the distribution of provider average costs. Providers were then put into one of three cost ranges based on their average costs. Providers with average costs that fell within the middle cost range are considered middle cost. Providers with costs below the minimum value of the middle cost range are displayed as lower cost. Those with costs above the maximum value of the middle cost range are displayed as higher cost.

The overall results are then reviewed and adjustments made as needed to reflect natural breaks in the pricing.