• Exclusive Provider Organization (EPO) - An Exclusive Provider Organization is a network of individual medical care providers, or groups of medical care providers, who have entered into written agreements with an insurer to provide health insurance to subscribers. In an EPO, medical care providers enter a mutually beneficial relationship with an insurer. The insurer reimburses an insured subscriber only if the medical expenses are derived from the designated network of medical care providers. The established network of medical care providers in turn provide subscribed patients medical services at significantly lower rates than what would have been under normal circumstances. In exchange for reduced rates of medical services, medical care providers get a steady stream of business. (Source: http://www.healthinsurance.info)
• Facility - Facility refers to a hospital, surgical center, nursing home, hospice agency, home health agency or any other entity required to file a claim for all non-professional services rendered using an UB-04 claim.
• Health Maintenance Organization (HMO) - In a HMO policy patients typically select one primary care physician from within the HMO's network of contracted providers. The primary care physician will then refer you to any specialists that might be required. With an HMO you are limited to visiting doctors, hospitals, and clinics that are part of the provider network. There is no deductible, but you may or may not be responsible for a co-payment, depending on your coverage. If you choose to visit a provider from outside the HMO network, your insurance will not cover the fees. (Source: http://www.healthinsurance.info)
• Indemnity - Also known as fee-for-service or traditional health insurance, indemnity health plans typically offer the most choice of doctors and hospitals; they require no utilization reviews, provider pre-certification, or specialist referrals. With traditional health insurance, you can visit any doctor or healthcare provider, change providers at any time, and enjoy national coverage. You will pay a premium for this type of freedom, as traditional plans are more costly for both individuals and employers than managed care plans. Many of these policies also require underwriting. In other words, a medical background and lifestyle check is typically conducted to determine if your plan enrollment will be accepted and if any pre-existing condition riders will be attached to your policy. (Source: http://www.healthinsurance.info)
• Point of Service (POS) - This managed plan aims to provide care at the lowest possible cost. For plan participants to get the most benefit from one of these plans, and to spend the least amount of their own money while doing so, they must follow certain rules like obtaining specialist referrals and seeing only in-network doctors. Participants pay monthly premiums and may also pay copays. Generally, these policies provide coverage for a wide range of services and treatments such as dental, vision, lab/x-ray, surgical, hospitalization, preventive care, prescription drugs, mental health, and skilled nursing. (Source: http://www.healthinsurance.info)
• Preferred Provider Organization (PPO) - The designated "preferred" medical care providers provide insured patients medical services at significantly lower rates than what would have been under normal circumstances. The PPO is mutually beneficial for insurers and medical care providers alike because the latter can get a steady stream of business in exchange for lower rates of services. Although restrictive, PPO allows subscribers more freedom than HMO subscribers. If a PPO member chooses to go to a non-network provider, he or she will still be reimbursed for the bills - although it may be a lower rate that may include higher deductibles or co-payments, lower reimbursement percentages, or a combination of these disadvantages. (Source: http://www.healthinsurance.info)
• Professional - Professional refers to an individual physician or healthcare practitioner providing direct services to a patient.

About this website
The Maine HealthCost website has been developed by the Maine Health Data Organization in accordance with its mandate to produce reports related to health care facility and professional payments for services rendered to Maine residents. The methodology used is described below and is similar to that used on New Hampshire's HealthCost website (link).

Payment Calculation
The HealthCost website displays total payment information on procedures performed for Maine citizens. This means that the HealthCost website does not separate the facility and professional claim parts. Consiquently, both must be included in order to compare different provider's data equitably. The total payment is dependent on a number of factors including, but not limited to: the procedure provided, complexity of the specific event compared to other events, frequency and efficiency of the procedure performed by the provider, and payer and plan negotiated rates for the provider.

In order to report total payments, we must acknowledge and accommodate the various ways claims are produced and/or processed. For example, one patient encounter at a facility being billed to Payer A may require the creation of multiple professional claims associated with a single facility claim, multiple facility claims, or a single facility claim that includes all associated professional fees. Payer B may have a different billing scenario but is equally valid. Once all of the claims for a specific patient encounter are found in the data, the events are placed in a HealthCost staging table for further analysis.

In addition, the way in which procedures are performed needs to be taken into consideration. For example, a total hip replacement will typically be the major (most expensive) procedure in an event, but an X-Ray is typically performed either during an emergency room event or an outpatient visit. For a total hip replacement, all procedures associated with that member and date are considered. In the later case, X-Ray dollars may be a small portion of the patient encounter. To accommodate this difference, when searching for an X-Ray, the professional and technical portions for the X-Ray are used and not emergency or subsequent evaluation and management portions. By summarizing the events this way, HealthCost displays information based on a single elective procedure.

Median vs. Mean
Even though HealthCost removes outliers that could drastically alter the results, the median was determined to most accurately display an estimated payment. This is because of the closely normalized, but positively skewed data that is common with health care data. Because of the skewness, the average would overestimate the dollars that someone would expect to pay for a normal procedure, whereas the median puts more emphasis on frequency and is therefore a better representation of what payment can be "expected". The following example is presented below to explain this rationale:

Reimbursement Rates for Same Procedure at Different Providers
Number of Patient Encounters	Provider 1 Rates	Provider 2 Rates
30	$ 50	$ 50
60	$100	$100
10	$150	$300
Median =	$100	$100
Mean =	$ 90	$ 105
In this example, the first 90 out of 100 reimbursements for the two providers are identical. However, because the reimbursement rate for the last 10 encounters are $300 for Provider 2 vs $150 for Provider 1, the mean is 17% higher, whereas the median is unchanged. It is this slight difference that makes the median the better estimation of what the majority of people should expect to pay based on the data.

Lead Provider
The "Lead Provider" is selected for each patient encounter based on the facility where the claim(s) occurred. All professional claims associated with that event are then attributed to that facility. In the event that there are two facilities associated with a patient encounter, the lead provider is determined by the highest dollars charged.

In addition, it is possible to have a facility with a presence in more than one zip code. For these facilities the address associated with the largest number of claims is listed in all tables. These facilities will be identified with a note listed under that facility in the Providers/Procedures (link) webpage.

Inappropriate Data
After the HealthCost data is collected, there are processes that attempt to ensure the validity of the median reported. This is done in three steps: removing incomplete patient encounters (widows and orphans), removing outliers, removing indeterminate procedures. If less than 5 events are found, the patient encounter is removed from the report.

• Incomplete Encounters: Patient encounters that only include the facility portion ("widows") or the professional portion ("orphans") are completely removed. This is done because these encounters would inaccurately lower the expected median. A certain level of widows and orphans can be found in any all payer claims database.
• Outliers: Even though Maine HealthCost displays the median payments and is therefore not as affected by outliers, extreme patient encounters (either very low or very high paid dollar amount) could tug the median higher or lower by one encounter each. To minimize the possible impact of this, the bottom cutoff percentile is set at 1% and the top is set at 5%. Since these patient encounters are decidedly not common, any patient encounter that is outside of the cutoff range is removed.
• Indeterminate Procedures: The final step is to remove any patient encounters that are determined to be abnormal. An example of an abnormal patient encounter is someone who enters into a hospital for a breast scan and also has an augmentation. The result is a patient encounter that has more than one high dollar procedure, each of which could be considered a "lead procedure". Since the ancillary payments cannot be accurately divided between these "lead procedures", the entire encounter is removed.

Precision Estimate
Due to the variability of the patient encounters and the complexity of how payments are affected, HealthCost displays a column on each report showing how precise the payment estimate is. The calculation of precision is first quantified numerically by combining the coefficient of variance of charges for each facility in the report. Next, the median of charges for the facility is compared to the median charges for each product type offered by each payer for that facility. The two numbers are combined and are then divided into quartiles and the appropriate precision is assigned. If the variability is low, the precision will be reported as "HIGH". This represents how precise the estimate reported is to the payments you can expect, based on the criteria selected.

Patient Complexity
Patient complexity is a risk assessment value that is also used in the production of HealthCost tables. This value protrays how "sick" the patients are at a given facility for a specific procedure. A "sicker" patient would be expected to cost more because their history has more complex or extensive diagnoses. This value is calculated by looking at all patients' age, gender and diagnostic history for a 12 month period. The range is then broken into 5 segments using the 10, 25, 75, 90 percentile breakpoints for the patient weight. The average weight for the patients having a procedure at a facility is then compared to the breakpoints and assigned to a "Very High", "High", "Medium", "Low" or "Very Low" category. Comparing patients to one another in this way provides additional information so the payments reported are evaluated in a fair and accurate manner.

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