Health Care Reimbursement

Resources that explain the various aspects of health care reimbursement and help researchers find sources of information on payment rates

HealthCare.Gov

The federal website HealthCare.gov provides state by state information on available health plans and other state-specific issues.  For certain purposes, it can be a valuable resource.

State Health Insurance Regulating Agencies

Commercial health insurance is generally regulated at the state level.  Therefore, information about the insurance plans operating in a particular state fall under the auspices of the state's insurance commissioner or equivalent agency.  Some states have lots of information (report cards, complaints, etc.), while others only list the bare bones.

Introduction

While Medicare and Medicaid fees are a matter of public record,  the amounts paid for care by private commercial insurers is much harder to come by.  The good news is that there are some governmental agencies and private organizations that have gathered some useful information on health care utilization and costs (i.e., charges) for this group.  Make yourself familiar with the resources on this page, then return to them when you have a specific question that needs answering.

How to Search for CPT Codes

Current Procedural Terminology (CPT) codes are an AMA-developed and maintained coding system used for billing for medical procedures (surgeries, office visits, and virtually any procedure a physician or Nurse Practitioner can perform).  While Medicare has its own coding system (HCPCS) for billing Medicare for procedures (based on CPT codes), the vast majority of commercial insurers still rely on CPT. The AMA maintains a keyword-searchable database for determing which code(s) are relevant for a given procedure.  Results even include related procedures, plus charges associated with each procedure.

Healthcare Cost and Utilization Project (HCUP)

This is a vast, ongoing data-gathering initiative managed by the federal Agency for Healthcare Research and Quality (AHRQ) in partnership with state governments and the healthcare industry itself.  While the most detailed data is incorporated into datasets requiring statistical software such as SPSS, SAS, and STATA to analyze, HCUP also makes an extensive range of summary tables available on its website.

HCUP Homepage

A good starting point for exploring health care service utilization statistics.  Focus especially on HCUPNet, the online summary report generator.

HCUP Reports Homepage

Use this page to access all the web-based reports available from HCUP.  Insurance coverage statistics are included here.  Use the "Reports" tab to find topic-based and chronological lists of readily accessible statistical reports.

Population Data Resources

This PDF file contains an impressive collection of links, with explanatory information, to all sorts of population statistics from a wide variety of sources for the United States.  These statistics can be used in conjunction with utilization figures to create usage rates and other useful indicators.

HCUP Datasets

For those comfortable with statistical packages such as SPSS, SAS, and STATA, HCUP provides raw data for download.

ICPSR

The HCUP, Medicare, and other datasets are not always in readily usable format.  If that is the case, check out ICPSR, a database of datasets (many of which originate with federal and state agencies) to which JHU has a subscription.  Here you can search by topic, choose software package format, and generally have a much easier time of it--if ICPSR has the data you need.

Health Facilities Licensing Agencies by State

The following state agencies are responsible for health facilities licensure, which is a state-by-state function.  Often, these agencies include counts of providers, numbers of beds for inpatient facilities, patients served, and other information.