HEALTHCARE PAYMENTS DATA (HPD) INPATIENT STAY AND OUTPATIENT VISITS REPORT

The following information was released by the California Department of Health Care Access and Information (HCAI):

Introduction#

The Healthcare Payments Data (HPD) Inpatient Stay and Outpatient Visits Report allows users to explore the most common types of healthcare visits and stays experienced by insured Californians each year and the out-of-pocket cost from those occurrences.

A "visit" (referring to both inpatient stays and outpatient visits in this report) refers to a single instance or event during which a person receives medical care and can consist of multiple medical services. For this report, information about medical services reported on medical claims ("claims" refers to both claims and encounters here) is used to identify visits, determine their type, and categorize them into Inpatient Stays, Diagnostic or Surgical Outpatient Visits, or Professional Visits. The metrics reported for the selected visit type(s) include the total number of visits, visit rate per 1,000 members, and median out-of-pocket (OOP) cost per visit, broken down by geographic area.

The filtering options and available metrics on the HPD Inpatient Stay and Outpatient Visits Report can help to answer a variety of different questions, such as:

What types of healthcare visits are most frequently used by Californians? What types are most commonly seen in my county?

How is the utilization rate for certain visit types, such as mammograms or behavioral health visits, changing over time?

What is the utilization rate of office visits for new patients in the commercial market compared to Medicare or Medi-Cal?

The glossary below the dashboard provides a description of each visit category and other data elements. More details on how the information found on medical claims is used to identify the visit type and categorize visits can be found in the accompanying Technical Note. The underlying data is also available for download (Click on "Access Underlying Data" below the visualization).

These visualizations are made possible by data collected as part of HCAI's Healthcare Payments Data (HPD) program. For more information about the HPD:

Visit the HPD Public Reporting Webpage

Visit the HPD Program Overview Webpage

Key Findings#

The Urgent Care visit rate is much higher in Santa Barbara and San Luis Obispo Counties (110.2 and 98.5 per 1,000 members respectively) than anywhere else in the state, with no other county exceeding a rate of 57.8 visits per 1,000 members. These counties have consistently had a high rate of urgent care visits. More research would be needed to determine if this the result of effective Emergency Department diversion, inadequate primary care access, or some other factor.

From 2018-2023, the highest median OOP costs for inpatient stays for vaginal deliveries appear concentrated around the northern counties within California (Glenn, Shasta, Siskiyou, Sutter, etc.), reaching upwards of over $3,000 in some cases.

Median Out-of-Pocket costs for Upper Endoscopy visits exhibit significantly higher amounts in northern and eastern counties in California in the Medicare market. Most notably, Siskiyou County has a median OOP cost of $2,086 in 2023, with the next highest county being Modoc at $1,103. Most other counties range from $125 to $526. A similar trend appears in earlier years; in 2018 Siskiyou exhibited the highest Medicare costs for this visit type with $1,329, with the next highest being Inyo at $520.

The rates of telehealth visits are vastly different across California and also differ by payer. In 2023, the telehealth utilization rate in the commercial market ranges from 2.05 to 42.60 per 1,000 members, depending on the county. Medicare and Medi-Cal rates for that year also varied greatly, ranging from 0.81 to 74.96 and 0 to 62.87 per 1,000 members, respectively. Notably, rates were much lower in pre-pandemic years; in 2019, commercial market rates for telehealth visits ranged from 0 to 4.30 per 1,000 members.

Visualization#

Access Underlying Data

Feedback#

HCAI anticipates continuing to advance the accessibility and usefulness of HPD as the database becomes more comprehensive and complete and HCAI builds its capacity over time.

HCAI wants your feedback about how you are or are planning to use HPD data and what you would like to see in the future from the HPD Program. Share your feedback with HCAI staff by clicking the button below.

Glossary#

Population

The data displayed in the HPD Inpatient Stay and Outpatient Visits Report is from medical claims records that are available within HPD, California's All-Payer Claims Database (APCD), covering 2018-2023.

Data Elements

Reporting Year: The year of the first service date of the visit.

County/Service Planning Area (SPA): Residential ZIP codes are used to assign visits to a county and/or Los Angeles SPA.

Visit Type: The specific kind of care a person receives during a healthcare visit, such as a hip replacement, MRI of the spine, or hearing test. Note: Not all types of visits are included in the report. The list of visits reported on here represents a subset of common medical events. See the Technical Note for more details.

Metrics

Total Visits: The total number of visits incurred by members in the reporting population during the reporting year. Visits with multiple payers are counted only once under the primary payer.

Visit Rate per 1,000 Members: Calculated by dividing the total count of visits during the reporting year by the total sum of member enrollment months and multiplying the result by 12,000. This helps adjust for differences in populations and length of time enrolled.

Total Out-of-Pocket Costs: Calculated as the sum of the copay, coinsurance and deductible amounts paid for services incurred during a visit.

Visit Categories

Setting and procedure codes are used to group visits and categorize them into visit types. Not all types of visits are included in the report. The visits reported on here represents a subset of common medical events. Visits are grouped into four major categories:

Inpatient: Inpatient stays include all medical services provided during a hospitalization (e.g., bariatric surgery or spinal fusion). The reported out-of-pocket (OOP) cost includes all OOP costs from facility, professional, and other medical claims incurred during the stay.

Outpatient Diagnostic: Outpatient diagnostic visits include medical services from a diagnostic procedure provided in an outpatient setting (e.g., bone mineral density scan or X-ray of the knee). For instance, the OOP cost of a visit for a magnetic resonance imaging (MRI) scan of the spine includes the OOP portions of the facility claim cost to use the MRI machine and of the professional claim cost of a clinician interpreting the results.

Outpatient Surgical: Outpatient surgical visits include all services associated with a surgical procedure performed in an outpatient setting (e.g., gastric bypass or a colonoscopy). The reported OOP cost includes all OOP costs from facility and professional claims incurred on the date of the procedure.

Professional: Professional visits (e.g., preventive visit or physical therapy) include medical services provided by healthcare professionals during an outpatient office visit.

Payer Types

Payers are the companies, programs, and organizations that oversee insurance plans and reimburse healthcare providers. The payer assignments are determined based on the primary payer reported only. Three main types of payers make up the majority of the insurance market.

Medicare: A federal health insurance program funded by the Centers for Medicare and Medicaid Services under the Social Security Amendments of 1965 that provides healthcare benefits to those aged 65 years and over or to disabled beneficiaries of any age. Includes Medicare Fee-for-Service (Traditional Medicare) and Medicare Advantage.

Medi-Cal: A public health insurance program that provides free or low-cost medical services and healthcare benefits to low-income individuals, financed from state and federal funds; California's version of Medicaid. Includes Medi-Cal Fee-for-Service (FFS) and Medi-Cal Managed Care.

Commercial: Insurance products for which the coverage premium is paid by a private party, such as an employer, individual, or other entity. The HPD currently includes very limited data for Employee Retirement Income Security Act (ERISA) self-funded health plans.

How HCAI Created This Product#

The HPD Inpatient Stay and Outpatient Visits Report categorizes visits using Onpoint Health Data's Service-Focused Episode (SFE) Grouper, an open-source healthcare analytics tool used to organize medical services into specific episodes of care based on the procedures and/or services provided. Visit Onpoint Health Data's website for more information about the grouper.

The payer type filter includes a Commercial + Medicare option. Since Medi-Cal out-of-pocket costs are usually $0, this additional option allows users to view visit rates and median out-of-pocket cost amounts of 'all' payers with Medi-Cal observations excluded.

Only claims that were paid as primary are included in the Inpatient Stay and Outpatient Visits Report. Other exclusions include adjusted claim records with no corresponding original claim record, records for a member with a missing, invalid, or non-California ZIP code, and claims incurred by a member with a missing or invalid insurance code.

The HPD Inpatient Stay and Outpatient Visits Report follows California Health and Human Services Agency's Data De-Identification Guidelines. Data from any group with less than 30 individuals is removed from the analyses and suppressed in the visualization. This will result in some error in the reported rates, especially in counties with small populations (