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Note: This report is greater than 5 years old. Findings may be used for research purposes but should not be considered current.

This report is from AHRQ's Data Points Publication Series.

Overview

In 2009, Medicare reimbursement for inpatient claims totaled $126.7 billion, more than 25 percent of which was for circulatory diseases. The total per claim reimbursement was greatest for congenital anomalies, about $15,600 per inpatient claim.

In 2009, Medicare reimbursement for noninstitutional outpatient (Carrier) claims totaled $81.7 billion, about 15 percent of which was for circulatory diseases. The total per claim reimbursement was greatest for neoplasms, about $225 per Carrier claim.

In 2009, Medicare reimbursement for skilled nursing facility claims totaled $25.5 billion, more than 30 percent of which was for supplementary classification of factors influencing health status and contact with health services (V-codes). The total per claim reimbursement was also greatest for V-codes, nearly $5,200 per skilled nursing facility claim.

The United States spends more on health care per capita than any other developed country in the world. Health care is currently responsible for 16.2 percent of the Gross Domestic Product (GDP) in the United States but is expected to rise to 25.2 percent by 2025. Chronic diseases account for the greatest surge in spending. High costs are associated with many chronic diseases that are increasing in prevalence, including mental disorders, hypertension, heart disease, pulmonary disorders, spine-related care, gastrointestinal upset, and kidney disease.

Chronic diseases disproportionately affect older adults. Among the Medicare population, 10 conditions account for half of the inflation-adjusted growth in spending for Medicare in the past two decades. Specifically, the most notable increases in recent spending are attributable to diabetes, chronic obstructive pulmonary disease, kidney disease, hyperlipidemia, hypertension, mental disorders, and arthritis. Hypertension alone has been associated with $108.8 billion in expenditures. Multiple comorbidities further contribute to high spending by Medicare; heart failure and diabetes together result in greater Medicare spending than either condition alone. These pervasive conditions require considerable care in inpatient, outpatient, and skilled nursing home settings. Also, specific conditions are more burdensome in a particular setting, rather than across settings. For example, wound care is most prevalent in skilled nursing home facilities and comprises a large portion of Medicare reimbursement.

The goal of this Data Points is to examine disease burden among Medicare beneficiaries and associated reimbursement costs within inpatient, outpatient, and skilled nursing facility claims. Further, we examine geographic trends in reimbursement per claim for high-cost conditions that are common in the Medicare population.

Maps and Tables

Maps

Average Medicare Reimbursement per Claim for Specified Diagnoses* by Hospital Referral Region, 2006-2009. Select for Excel File (2.3 MB), or PDF (2.3 MB).

*Specified diagnoses include:

• Cardiac Dysrhythmias as a Principal Diagnosis on All Claims and on Inpatient Claims
• Pneumonia (Organism Unspecified) as a Principal Diagnosis on All Claims and on Skilled Nursing Facility Claims
• Other Disorders of Urethra and Urinary Tract as a Principal Diagnosis on All Claims and on Inpatient Claims
• Osteoarthrosis and Allied Disorders as a Principal Diagnosis on All Claims and on Carrier Claims
• Care Involving Use of Rehabilitation Procedures as a Principal Diagnosis on All Claims and on Skilled Nursing Facility Claims

Tables

Beneficiary and Claim Counts, by File Type and Category of Primary Diagnosis Code: Summary Statistics. Select for Excel File (68 kB), or PDF (124 kB).

The following files contain data on the number of beneficiaries, claims, and total Medicare reimbursements for 2006-2009 for:

• 5-Digit ICD-9 Code of Principal Diagnosis
• 3-Digit ICD-9 Category of Principal Diagnosis
• ICD-9 Subchapter of Principal Diagnosis
• ICD-9 Chapter of Principal Diagnosis
• Provider Hospital Referral Region and ICD-9 Chapter of Principal Diagnosis

Inpatient Claims. Select for Excel File (2.7 MB), or PDF (8.5 MB).

Outpatient Claims. Select for Excel File (3.3 MB), or PDF (11.6 MB).

Skilled Nursing Facility Claims. Select for Excel File (3.0 MB), or PDF (7.4 MB).

Home Health Claims. Select for Excel File (2.8 MB), or PDF (7.0 MB).

Hospice Claims. Select for Excel File (1.9 MB), or PDF (4.1 MB).

Durable Medical Equipment Claims. Select for Excel File (3.8 MB), or PDF (9.6 MB).

Carrier Claims. Select for Excel File (6.1 MB), or PDF (14.4 MB).