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Variation in Hospital Inpatient Prices Across Small Geographic Areas
Jared Lane K. Maeda, PhD, MPH; Rachel Mosher Henke, PhD; William D. Marder, PhD; Zeynal Karaca, PhD; Bernard S. Friedman, PhD; and Herbert S. Wong, PhD
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Variation in Hospital Inpatient Prices Across Small Geographic Areas

Jared Lane K. Maeda, PhD, MPH; Rachel Mosher Henke, PhD; William D. Marder, PhD; Zeynal Karaca, PhD; Bernard S. Friedman, PhD; and Herbert S. Wong, PhD
Greater geographic variation was found among private than public payers in the inpatient price per discharge for most hospital services.
A potential confounding issue is the impact that Accountable Care Organizations (ACOs) may have on hospital prices. ACOs encourage greater integration between physicians and hospitals; this may lead to the unintended consequence of increased provider leverage and market concentration that further drives higher prices paid by private payers.1,9,25 Hospitals may also increase specialization along certain service lines and begin to compete more intensely for lucrative privately insured cases. Finally, as suggested by MedPAC, higher prices from private payers may reduce the pressure on hospitals in concentrated markets to constrain their costs that lead to higher spending. This may result in an ever-escalating cycle of higher payments, which lead to higher costs.7 Therefore, policies aimed at increasing market forces or that consider payment reforms, such as price regulation or bundled payments, may help to moderate hospital price variation and price increases.

Our study has several limitations. First, the PCR assumes that all payers within a payer category are discount- ed at an equivalent amount and it does not distinguish between different discounting methods within a payer group, such as negotiated rates from charges, per diem rates, or DRG-based payments.17 To the extent that prices for managed care plans are set differently from fee-for-service or other payers’ plans within the same payer group, the resulting PCR may be distorted for any particular discharge.17 We also only examined the variation in hospital prices for all discharges combined and 2 specific conditions; these do not reflect the full range of hospital services. The conditions examined, however, represent common types of discharges that are treated at acute care hospitals.

Another limitation is that net revenue was only available from the inpatient setting. Capturing prices in the outpatient setting may yield additional insights. We were also not able to observe hospital margins or the difference between net revenue and total expenses. Lastly, data were available from only 6 states and 1 data year. Data from 2006 may not reflect current inpatient prices. However, the states we examined are geographically dispersed. Despite some limitations, our price estimates are able to capture adjustments made to the claim after it was paid, contain payment from managed care, and include public and private payers. We were also able to control for a number of patient comorbidities and disease severity.


We find greater price variation among private than public payers for different hospital services. Hospital market competition may be partly responsible for driving price variations. Because payment policies from Medicare ultimately affect private payers, public policy efforts that take into consideration market-based approaches or payment reform may help reduce price variations.


We gratefully acknowledge Minya Sheng for her excellent statistical programming and Linda Lee, PhD, for editorial review. We also acknowledge the following HCUP partners: California Office of Statewide Health Planning and Development, Florida Agency for Health Care Administration, Massachusetts Division of Health Care Finance and Policy, New Jersey Department of Health and Senior Services, and Wisconsin Department of Health Services.

Author Affiliations: Truven Health Analytics, Analytic Consulting & Research Services, Cambridge, MA (RMH, WDM); Agency for Healthcare Research and Quality, Center for Delivery, Organization, and Markets, Rockville, MD (BSF, HSW, ZK); and formerly of Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, MD (JLKM).

Source of Funding: This study was sponsored by the Agency for Healthcare Research and Quality (AHRQ) under contract number HHSA-290-2006-00009-C with Truven Health Analytics. The views expressed herein are those of the authors. No official endorsement by any agency of the federal government or of a state government is intended or should be inferred.

Author Disclosures: Authors (JLKM, RMH, WDM, ZK, HSW, BSF) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JLKM, RMH, WDM, ZK, HSW); acquisition of data (RMH, ZK, HSW); analysis and interpretation of data (JLKM, RMH, WDM, ZK, HSW, BSF); drafting of the manuscript (JLKM, RMH, ZK, HSW); critical revision of the manuscript for important intellectual content (JLKM, RMH, ZK, HSW, BSF); statistical analysis (JLKM, RMH, WDM, ZK, HSW); provision of study materials or patients (HSW); obtaining funding (RMH, ZK, HSW); administrative, technical, or logistic support (JLKM, RMH, ZK, HSW, BSF); and supervision (JLKM, RMH, ZK, HSW, BSF).

Address correspondence to: Jared Lane K. Maeda, PhD, MPH, Mid-Atlantic Permanente Research Institute, Kaiser Permanente, 2101 E Jefferson St, 3-West, Rockville, MD 20852. E-mail:

1. Paul B Ginsburg; Center for Studying Health System Change. Wide variation in hospital and physician payment rates evidence of provider market power. HSC Research Brief No. 16. http://www.hschange .com/CONTENT/1162/. Published November 2010. Accessed May 17, 2013.

2. Lemieux J, MulliganT.Trends in inpatient hospital prices, 2008 to 2010. Am J Manag Care. 2013;19(3):e106-e113.

3. Kliff S, Keating D. One hospital charges $8,000 – another, $38,000. Washington Post. May 8, 2013. blogs/wonkblog/wp/2013/05/08/one-hospital-charges-8000-another-38000/?hpid=z2. Accessed May 17, 2013.

4. Daly R. Senators seek overhaul of hospital payment system. Modern Healthcare. May 2013. article/20130516/NEWS/305169945/senators-seek-overhaul-of-hospital-payment-system&template=mobile. Accessed May 17, 2013.

5. Robinson JC. Variation in hospital costs, payments, and profitability for cardiac valve replacement surgery. Health Serv Res. 2011;46(6, pt 1):1928-1945.

6. Berenson RA, Ginsburg PB, Kemper N. Unchecked provider clout in California foreshadows challenges to health reform. Health Aff (Millwood). 2010;29(4):699-705.

7. Stensland J, Gaumer ZR, Miller ME. Private-payer profits can induce negative Medicare margins. Health Aff (Millwood). 2010;29(5): 1045-1051.

8. Robinson J. Hospitals respond to Medicare payment shortfalls by both shifting costs and cutting them, based on market concentration. Health Aff (Millwood). 2011;30(7):1265-1271.

9. Frakt AB. How much do hospitals cost shift? a review of the evidence. Milbank Q. 2011;89(1):90-130.

10. Agency for Healthcare Research and Quality. Overview of the State Inpatient Databases. Accessed October 17, 2011.

11. Agency for Healthcare Research and Quality. HCUP facts and figures: statistics on hospital-based care in the United States, 2009. http:// Published 2011. Accessed January 23, 2012.

12. Agency for Healthcare Research and Quality. Clinical classifications software (CCS) for ICD-9-CM. toolssoftware/ccs/ccs.jsp. Accessed January 23, 2012.

13. Baicker K, Buckles KS, Chandra A. 2006. Geographic variation in the appropriate use of cesarean delivery. Health Aff (Millwood). 2006; 25(5):w355-w367.

14. Franzini L, Mikhail OI, Skinner JS. McAllen and El Paso revisited: Medicare variations not always reflected in the under-sixty-five population. Health Aff (Millwood). 2010;29(12):2302-2309.

15. Franzini L, Mikhail OI, Zezza M, Chan I, Shen S, Smith JD. Compar- ing variation in Medicare and private insurance spending inTexas. Am J Manag Care. 2011;17(12):e488-e495.

16. Wong HS, Zhan C, Mutter R. Do different measures of hospital competition matter in empirical investigations of hospital behavior? Rev Indus Organ. 2005;26(1):61-87.

17. Levit KR, Friedman B, Wong HS. Estimating inpatient hospital prices from state administrative data and hospital financial reports. Health Serv Res. 2013;48(5):1779-1797.

18. Agency for Healthcare Research and Quality. Hospital market structure files. .jsp. Accessed October 17, 2011.

19. US Department of Justice and the FederalTrade Commission. Horizontal merger guidelines. .pdf. Published August 19, 2010. Accessed March 28, 2013.

20. Robinson JC. Hospital market concentration, pricing, and profit- ability in orthopedic surgery and interventional cardiology. Am J Manag Care. 2011;17(6 Spec No):e241-e248.

21. Holland PW, Welsch RE. Robust regression using iteratively reweighted least squares. Commun StatTheory Methods. 1977;6(9): 813-827.

22. Chernew ME, Sabik LM, Chandrah A, Gibson TB, Newhouse JP. Geographic correlation between large-firm commercial spending and Medicare spending. Am J Manag Care. 2010;16(2):131-138.

23. US Government Accountability Office. Legislative modifications have resulted in payment adjustments for most hospitals. http://www Published April 2013. Accessed May 17, 2013.

24. Gadzinski AJ, Dimick JB, Ye Z, Miller DC. Utilization and outcomes of inpatient surgical care at critical access hospitals in the United States. JAMA Surg. 2013;148(7):589-596.

25. US FederalTrade Commission; US Department of Justice–Antitrust Division. Statement of antitrust enforcement policy regarding accountable care organizations participating in the Medicare shared savings program; notice. Federal Register. 76(209):67026-67032. http://www.ftc .gov/os/fedreg/2011/10/111020aco.pdf. Published October 28, 2011. Accessed August 24, 2012.

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