Posted Date: October 26, 2023
The Annual Insights Symposium (AIS) 2023 presentation titled Under the Microscope: Medical Trends in Comp Guide described changes in the utilization of physician services over time, from 2012 to 2022. During that period, average utilization per claim over studied states increased modestly. A decrease in utilization due to less severe diagnoses and fewer major surgeries was more than offset by increased physical therapy. NCCI’s Physician Service Utilization—A Multistate Review extends the AIS research to consider variations in the utilization of physician services across states in a given year.
NCCI’s Physician Service Utilization—A Multistate Review webinar examines an analytic method to deconstruct differences in physician service utilization between states into contributions from differences in injury mix and medical treatment. The Physician Service Utilization—A Multistate Review Guide provides a slide-by-slide examination of the key insights, data sources, and background underlying the presentation.
As you review the information contained in this Guide, it may be useful to keep in mind the following main takeaways that NCCI’s Physician Service Utilization—A Multistate Review highlights:
We hope you find the Physician Service Utilization—A Multistate Review Guide a beneficial and informative resource.
Physician payments per claim in 2022 vary across states.They range from a low of $800 to around $3,000, with the all-state average right about $1,800.
This map illustrates the physician payments per claim in 2022.
Source: NCCI’s Medical Data Call (MDC)
You can download the underlying data values for the map by clicking here.
Two factors affect annual physician cost per claim—price and utilization. This presentation focuses on utilization.
In this presentation, our focus is on utilization. To illustrate, let us consider two hypothetical claims: Claim 1 and Claim 2, both with detailed services and associated payments. Claim 1 totals $4,123, while Claim 2, just slightly higher (7% more, to be precise), is $4,411.
These payments represent a compilation of services, forming what we refer to as “utilization.” We have established a relative measure among services, similar to weighing them. This measure remains consistent, regardless of the state, date, or year in which the service is provided. Think of it as the number of pounds of produce in your shopping basket—three pounds of potatoes remain the same, regardless of where or when you buy them.
Examining the details, we observe that Claim 2 shares some services with Claim 1, but not all. For instance, surgery under Claim 1 costs about $2,000, while under Claim 2, it is cheaper at $1,760. Despite the difference in cost, it is the same surgery and requires the same extent of resources, equivalent to 1,600 units. When we tally it up, we find that Claim 2’s utilization exceeds that of Claim 1 by 18%.
While the cost difference or the paid amount stands at 7%, after factoring in the 18% utilization difference, we discern that the prices paid for Claim 1 are, on the whole, about 9% lower than those for Claim 2.
NCCI developed a measure of units of physician service utilization. This measure relies on CMS Relative Value Units multiplied by an NCCI-calculated conversion factor. These units measure the resources required for a medical service or procedure. This chart illustrates the physician service utilization per claim in 2022 by state, based on those units of physician service utilization.
Source: NCCI’s Medical Data Call (MDC)
You can download the underlying data values for the chart by clicking here.
This chart illustrates the range in physician service utilization per claim between 2012 and 2022 by state.
Source: NCCI’s Medical Data Call (MDC)
You can download the underlying data values for the chart by clicking here.
There is a notable disparity in the percentage difference from the all-state average units of physician service utilization across states, ranging from just below 40% to slightly over 50% higher than the all-state average units.
This chart illustrates the percent difference from the all-state average units of physician service utilization by state.
Source: NCCI’s Medical Data Call (MDC)
You can download the underlying data values for the chart by clicking here.
The analysis is based on dividing the factors driving utilization into two broad classes: injury mix and medical treatment. Injury mix consists of body system and diagnosis. Medical treatment consists of surgery rate and medical service intensity.
Understanding the variation in physician service utilization depends on the nature of the injury or medical condition. For instance, a sprained ankle typically necessitates fewer physician services compared to a fracture. This distinction emphasizes the importance of identifying both the injured body part and the specific diagnosis, forming what we term as the “injury mix.” This mix comprises two key elements: the body system affected and the corresponding diagnosis.
Once the diagnosis is established, the focus shifts to comprehending the associated treatments. For example, a fracture may or may not require surgery. Depending on this decision, the intensity of treatment becomes a crucial factor in explaining the extent of services provided. Questions arise:
This analytical framework enables us to deconstruct utilization into these vital components, offering a comprehensive understanding of the factors that drive the observed differences in physician services.
This chart shows that utilization variations reflect state differences in injury mix, likelihood of major surgery, and service intensity. The sum of the components (postive or negative) equals the deviation in state utilization per claim.
Source: NCCI’s Medical Data Call (MDC)
You can download the underlying data values for the chart by clicking here.
In many states, physical therapy(PT) drives physician service intensity–especially for claims without surgery.
This chart illustrates the contributions to physician service intensity differences between states, highlighting various types of physician services. The abbreviation PT represents physical medicine, while the category All Other encompasses services like office visits and imaging.
Source: NCCI’s Medical Data Call (MDC)
You can download the underlying data values for the chart by clicking here.
While physician service intensity accounts for the majority of interstate variations in physician utilization across many states, in some states, the mix of physician services (specifically related to body systems and diagnoses) is the primary contributing factor.
This chart shows the contribution to interstate variations in physician utilization from the mix of injuries (body system and diagnoses).
Source: NCCI’s Medical Data Call (MDC)
You can download the underlying data values for the chart by clicking here.
This chart shows the contribution to physician service mix from different types of body systems.
Source: NCCI’s Medical Data Call (MDC)
You can download the underlying data values for the chart by clicking here.
In most states, surgery rates contribute the least to interstate variations in physician utilization. Typically, states with higher utilization show a positive correlation with surgery rates; while states with lower utilization exhibit a negative correlation. However, there are exceptions to this general observation.
The term Surgery Rate refers to the probability, or frequency, of major surgery for a given diagnosis. A reduction (or an increase) in surgery rates significantly affects medical utilization per claim. This chart shows the contribution to interstate variations in physician utilization from surgery rates.
Source: NCCI’s Medical Data Call (MDC)
You can download the underlying data values for the chart by clicking here.
Diagnosis Group | Body System | Examples |
---|---|---|
Nerve Injury Upper Extremity | Arm |
Lesion of radial nerve, unspecified upper limb (G56.3) Lesion of ulnar nerve (G56.2) |
Carpal Tunnel Syndrome | Hand/Wrist |
Carpal tunnel syndrome (G56.0) Carpal tunnel syndrome, bilateral upper limbs (G56.03) |
Hand/Wrist Fracture | Hand/Wrist |
Displaced fracture of distal phalanx of finger (S62.63) Fracture of hook process of hamate [unciform] bone (S62.15) |
Minor Forearm Injury | Arm |
Other superficial injuries of forearm (S50.8) Injury of other extensor muscle, fascia and tendon at forearm level (S56.5) |
Cervical Spine Degeneration | Neck |
Spinal stenosis, occipito-atlanto-axial region (M48.01) Spondylolysis, occipito-atlanto-axial region ( M43.01) |
Elbow Forearm Fracture | Arm |
Fracture of upper end of ulna (S52.0) Fracture of shaft of radius (S52.3) |
Lumbosacral Intervertebral Disc Disorders | Lumbar Spine |
Intervertebral disc disorders with myelopathy, lumbar region (M51.06) Other thoracic, thoracolumbar and lumbosacral intervertebral disc displacement (M51.2) |
Low Back Pain | Lumbar Spine |
Sacroiliitis, not elsewhere classified (M46.1) Contusion of lower back and pelvis (S30.0) |
Lumbar Radiculopathy/Sciatica | Lumbar Spine |
Sciatica (M54.3) Lumbosacral root disorders, not elsewhere classified (G54.4) |
Ankle Fracture | Ankle/Foot |
Fracture of lateral malleolus (S82.6) Nondisplaced fracture of medial malleolus of unspecified tibia (S82.56) |
Neck Pain | Neck |
Dislocation and sprain of joints and ligaments at neck level (S13) Superficial injury of other specified parts of neck (S10.8) |
Cervical Disc Disorders | Neck |
Cervical disc disorder with radiculopathy (M50.1) Cervical disc disorder, unspecified (M50.9) |
Crush Injury, Hand/Wrist | Hand/Wrist |
Crushing injury of other and unspecified finger(s) (S67.1) Crushing injury of left hand (S67.22) |
Adhesive Capsulitis, Shoulder | Shoulder |
Adhesive capsulitis of shoulder (M75.0) Adhesive capsulitis of left shoulder (M75.02) |
Eye Injury Minor | Eye |
Injury of conjunctiva and corneal abrasion without foreign body (S05.0) Injury of conjunctiva and corneal abrasion without foreign body, right eye (S05.01) |
Conjunctivitis | Eye |
Conjunctivitis (H10) Chronic conjunctivitis (H10.4) |
Head Injury Minor | Head |
Superficial injury of head (S00) Superficial injury of lip and oral cavity (S00.5) |
Shoulder Impingement Syndrome | Shoulder |
Impingement syndrome of shoulder (M75.4) Impingement syndrome of right shoulder (M75.41) |
Minor Thigh Injury | Hip/Pelvis |
Pain in hip (M25.55) Blister (nonthermal) of hip (S70.2) |
Concussion/Minor Traumatic Brain Injury | Head |
Concussion (S06.0) Concussion with loss of consciousness of unspecified duration (S06.0X9) |
Open wound of knee and lower leg | Leg |
Open wound of lower leg (S81.8) Laceration without foreign body, left lower leg (S81.812) |
Open wound of ankle, foot and toes | Ankle/Foot |
Open wound of toe with damage to nail (S91.2) Laceration without foreign body of ankle (S91.01) |
Synovitis/Tenosynovitis, Hand/Wrist | Hand/Wrist |
Crepitant synovitis (acute) (chronic) of hand and wrist (M70.0 ) Radial styloid tenosynovitis (M65.4) |
Traumatic Amputation, Hand/Wrist | Hand/Wrist | Partial traumatic transphalangeal amputation of other and unspecified finger (S68.62) Traumatic amputation of wrist, hand and fingers (S68) |
Lumbar Spine Degeneration | Lumbar Spine |
Spondylolysis, lumbosacral region (M43.07) Congenital spondylolisthesis (Q76.2) |
Minor Shoulder Injury | Shoulder |
Contusion of shoulder (S40.01) Contusion of left shoulder (S40.012) |
Inguinal Hernia | Abdomen |
Inguinal hernia (K40) Bilateral inguinal hernia, with gangrene, recurrent (K40.11) |
Open wound of elbow and forearm | Arm |
Open wound of elbow and forearm (S51) Open wound of forearm (S51.8) |
Degenerative Shoulder | Shoulder |
Loose body in shoulder (M24.01) Post-traumatic osteoarthritis, shoulder (M19.11) |
Minor Lower Leg Injury | Leg |
Blister (nonthermal) of lower leg (S80.82) Other specified injuries of left lower leg (S89.82) |
SLAP Lesion | Shoulder | Superior glenoid labrum lesion (S43.43) |
Minor Elbow Injury | Elbow |
Contusion of elbow (S50.0) Olecranon bursitis, unspecified elbow (M70.20) |
Cervical Radiculopathy/Myelopathy | Neck |
Other spondylosis with myelopathy, occipito-atlanto-axial region (M47.11) Cervical root disorders, not elsewhere classified (G54.2) |
Upper Back Pain | Chest/Upper Torso |
Sprain of ligaments of thoracic spine (S23.3) Sprain of ligaments of thoracic spine, initial encounter (S23.3XXA) |
Knee Internal Derangement - Cruciate Ligament Tear | Knee |
Sprain of cruciate ligament of knee (S83.5) Sprain of posterior cruciate ligament of right knee (S83.521 ) |
Rotator Cuff Tear | Shoulder |
Shoulder lesions (M75) Other shoulder lesions (M75.8) |
Lower Extremity Sprain/Strain | Leg |
Injury of muscle(s) and tendon(s) of anterior muscle group at lower leg level (S86.2) Other injury of muscle(s) and tendon(s) of anterior muscle group at lower leg level, left leg ( S86.292) |
Head/Face Wound | Head |
Open wound of unspecified part of head (S01.9) Laceration without foreign body of unspecified part of head, initial encounter (S01.91XA) |
Head Injury NOC | Head |
Other and unspecified injuries of head (S09) Unspecified injury of face and head (S09.9) |
Dorsalgia | Lumbar Spine |
Dorsalgia (M54) Radiculopathy (M54.1) |
Minor Ankle/Foot Injuries | Ankle/Foot |
Superficial injury of ankle, foot and toes (S90) Contusion of foot (S90.3) |
Knee Internal Derangement - Meniscus Injury | Knee |
Tear of meniscus, current injury (S83.2) Bucket-handle tear of medial meniscus, current injury (S83.21) |
Bicipital Tendinitis | Shoulder |
Bicipital tendinitis (M75.2) Bicipital tendinitis, unspecified shoulder (M75.20 ) |
Muscle/Tendon Injury, Hand/Wrist | Hand/Wrist | Injury of unspecified muscle, fascia and tendon at wrist and hand level (S66.9) Strain of unspecified muscle, fascia and tendon at wrist and hand level (S66.91) |
Hip/Pelvis | Leg |
Fracture of lesser trochanter of femur (S72.12) Displaced fracture of lesser trochanter of left femur (S72.122 ) |
Minor Knee Injury | Knee |
Sprain of collateral ligament of knee (S83.4) Sprain of unspecified collateral ligament of unspecified knee (S83.409) |
Minor Hand/Wrist Injuries | Hand/Wrist |
Other and unspecified sprain of wrist (S63.5) Sprain of carpal (joint) (S63.51) |
Dislocation and sprain of joints and ligaments of thorax | Chest/Upper Torso |
Dislocation and sprain of joints and ligaments of thorax (S23) Subluxation and dislocation of thoracic vertebra (S23.1) |
Elbow Epicondylitis | Elbow |
Medial epicondylitis (M77.0) Medial epicondylitis, right elbow (M77.01) |
Knee Degenerative/Overuse Injuries | Knee |
Chondromalacia patellae (M22.4) Chondromalacia, knee (M94.26) |
Heel/Midfoot Fracture | Ankle/Foot |
Intraarticular fracture of calcaneus (S92.06) Fracture of calcaneus (S92.0) |
Foreign body on external eye | Eye |
Foreign body on external eye (T15) Foreign body in conjunctival sac (T15.1) |
Minor Hip/Pelvis Injuries | Hip/Pelvis |
Laceration with foreign body, unspecified hip (S71.029) Iliac crest spur, right hip (M76.21) |
Tibia Fibula Fracture | Leg |
Unspecified fracture of shaft of unspecified tibia (S82.209) Fracture of shaft of fibula (S82.4) |
Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders | Lumbar Spine |
Thoracic, thoracolumbar and lumbosacral intervertebral disc disorders with radiculopathy (M51.1) Other thoracic, thoracolumbar and lumbosacral intervertebral disc disorders (M51.8) |