Professional fee ratios for US hospital discharge data.

Peterson, Cora; Xu, Likang; Florence, Curtis; Grosse, Scott D.; Annest, Joseph L.

doi:10.1097/mlr.0000000000000410

Cited by 89Healthcare Policy and ManagementMedical Coding and Health InformationHealth Systems, Economic Evaluations, Quality of Life

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Professional fee ratios for US hospital discharge data.

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Peterson, Cora, Xu, Likang, Florence, Curtis, Grosse, Scott D., Annest, Joseph L.·2015·Medical Care

DOI 10.1097/mlr.0000000000000410PMC PMC4681390

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Abstract

BACKGROUND: US hospital discharge datasets typically report facility charges (ie, room and board), excluding professional fees (ie, attending physicians' charges). OBJECTIVES: We aimed to estimate professional fee ratios (PFR) by year and clinical diagnosis for use in cost analyses based on hospital discharge data. SUBJECTS: The subjects consisted of a retrospective cohort of Truven Health MarketScan 2004-2012 inpatient admissions (n=23,594,605) and treat-and-release emergency department (ED) visits (n=70,771,576). MEASURES: PFR per visit was assessed as total payments divided by facility-only payments. RESEARCH DESIGN: Using ordinary least squares regression models controlling for selected characteristics (ie, patient age, comorbidities, etc.), we calculated adjusted mean PFR for admissions by health insurance type (commercial or Medicaid) per year overall and by Major Diagnostic Category (MDC), Diagnostic Related Group, Healthcare Cost and Utilization Project Clinical Classification Software, and primary International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis, and for ED visits per year overall and by MDC and primary ICD-9-CM diagnosis. RESULTS: Adjusted mean PFR for 2012 admissions, including preceding ED visits, was 1.264 (95% CI, 1.264, 1.265) for commercially insured admissions (n=2,614,326) and 1.177 (1.176, 1.177) for Medicaid admissions (n=816,503), indicating professional payments increased total per-admission payments by an average 26.4% and 17.7%, respectively, above facility-only payments. Adjusted mean PFR for 2012 ED visits was 1.286 (1.286, 1.286) for commercially insured visits (n=8,808,734) and 1.440 (1.439, 1.440) for Medicaid visits (n=2,994,696). Supplemental tables report 2004-2012 annual PFR estimates by clinical classifications. CONCLUSIONS: Adjustments for professional fees are recommended when hospital facility-only financial data from US hospital discharge datasets are used to estimate health care costs.

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Authors: Peterson, C., Xu, L., Florence, C., Grosse, S. D., & Annest, J. L.
Affiliations: Centers for Disease Control and Prevention (US)
National Center for Injury Prevention and Control (US)
Corresponding author: Peterson, Cora
Xu, Likang
Florence, Curtis
Annest, Joseph L.
ORCID: Peterson, Cora
Xu, Likang
Florence, Curtis
Grosse, Scott D.
Venue: Medical Care
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2015-10
Volume: 53
Issue: 10
Pages: 840-849
ISSN: 0025-7079 (ISSN-L)
DOI: 10.1097/mlr.0000000000000410
PMC: PMC4681390
OpenAlex: W1238951602
Cited by: 88
References: 18
Citations by year: 2026: 1 · 2025: 12 · 2024: 11 · 2023: 12 · 2022: 11 · 2021: 9 · 2020: 7 · 2019: 6 · 2018: 10 · 2017: 6 · 2016: 2 · 2015: 1
FWCI: 15.30
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Locations: Medical Care (publishedVersion)
PubMed (publishedVersion)
Europe PMC (PubMed Central) (acceptedVersion)
PubMed Central (acceptedVersion)
Funders: National Institutes of Health (CC999999)
Topics: Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
Keywords: hospital discharge data, physician fees, hospital reimbursement, emergency department visits, hospitalization, Medicaid, private insurance, health care costs, major diagnostic categories, cost adjustment
MeSH terms: Adolescent, Adult, Age Factors, Aged, Aged, 80 and over, Child, Child, Preschool, Costs and Cost Analysis, Diagnosis-Related Groups, Emergency Service, Hospital, Fees, Medical, Female, Humans, Infant, Infant, Newborn, Insurance Claim Review, Insurance, Health, Male, Medicaid, Middle Aged, Patient Discharge, Retrospective Studies, Sex Factors, United States, Comorbidity, International Classification of Diseases, Racial Groups, Young Adult

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Professional fee ratios for US hospital discharge data.

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