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CMS-specified shoppable services accounted for 12% of 2017 health care spending among individuals with employer-sponsored insurance

% Total Medical Spending % Out-of-Pocket Medical Spending % Medical Charges% Medical  Utilization
All Medical Care 11.8 15.6 12.317.2
Inpatient Care7.95.68.04.8
Outpatient Care13.116.513.717.2

In response to high and growing health care spending, policymakers have proposed improving price transparency as a solution. Several such proposals rely on consumers taking action on publicly available information for shoppable services – generally, non-emergency services that a person could choose more deliberately.

In 2021, hospitals will be required to display, in a consumer-friendly manner, standard charges for at least 300 shoppable services. The Centers for Medicare & Medicaid Services (CMS) defines a shoppable service as "a service package that can be scheduled by a healthcare consumer in advance." In the implementing regulation, CMS specifies 70 services for which hospitals must make price information available for if they provide them (the remaining 230 will be selected by hospitals). These services are defined by diagnosis-related group (DRG) and Current Procedural Terminology (CPT) / Healthcare Common Procedure Coding System (HCPCS) codes.

Our analysis shows that the 70 CMS-specified shoppable services totaled 12 percent of 2017 medical spending (excluding prescription drug spending from the denominator) among individuals with employer-sponsored insurance. These services made up 16 percent of out-of-pocket medical spending (see table).

As these 70 services (74 codes) accounted for just over one fifth of the services hospitals will have to report (300), we also updated our previous, broad analysis of shoppable services which includes 429 codes. We estimate that approximately 36 percent of 2017 total spending (including prescription drug spending) and 43 percent of out-of-pocket spending was attributed to shoppable services. This is in comparison to our 2016 analysis of 2011 employer-sponsored insurance data that found that, at most, 43 percent of total health care spending (including prescription drug spending) was spent on shoppable services and just under half (approximately 47 percent) of out-of-pocket spending was on shoppable services.

This lower estimate of spending on shoppable services in 2017 compared to 2011 is likely driven by the growth in spending on point-of-sale drug prices (drug spending rose 25% between 2013 to 2017) and an increase in rebates as a share of pharmacy spending for commercial health insurance plans. Additionally, new medical services may have been introduced between 2011 and 2017, some of which may be considered shoppable. 

This analysis, like those that preceded it, suggest that, while the amount of total health care spending that is shoppable is not trivial, is does limit the potential impact of consumer-focused initiatives.

Methods Note

We replicated the methodology used in the 2016 HCCI issue brief, which drew heavily from a National Institute for Health Care Reform Research Brief authored by Chapin White and Megan Eguchi. To update the analysis, we used 2017 HCCI data instead 2011 data. To account for 2011 codes that were revised or replaced and no longer appear in 2017 data, we included new codes that corresponded to the deleted codes to the best of our ability with physician and certified professional coder consultation. We did not, however, attempt to categorize new codes that were present in 2017 that did not correspond to a 2011 code as shoppable or not. Additional work can be done to update and refine the approach we used here. The codes included in 2011 and 2017 are listed in the appendix tables. Shoppable services that were preceded by an emergency room-related claim (identified by presence of place of service code ‘23’ or revenue code ‘0450’, ‘0451’, ‘0452’, ‘0456’, or ‘0459’) up to three days before the first date of an inpatient, outpatient, or professional service were flagged as non-shoppable. This was to indicate that claims that were preceded by an emergency event could not be deemed as shoppable.

We limited our sample to people covered by employer-sponsored insurance between the ages of 0-64. People who were enrolled in multiple health plans or moved between metro areas within a month were excluded. Claims with inpatient lengths of stay over 180 days or outpatient/professional lengths of stay over 2 days were excluded. Claims with no DRG, CPT, or HCPCS code on the claim line level were excluded.

We first collapsed claim lined to distinct combinations of a person, date, and DRG code for inpatient claims and distinct combinations of person, date, CPT/HCPCS code, and procedure modifier codes for outpatient and professional claims. For allowed amounts and out-of-pocket amounts, we summed up all eligible claims for people with admit dates or first dates of service in 2017.

Appendices

Appendix A: CMS-specified shoppable services codes

DRG Codes: 216, 460, 470, 473, 743

CPT/HCPCS Codes: 19120, 29826, 29881, 42820, 43235, 43239, 45378, 45380, 45385, 45391, 47562, 49505, 55700, 55866, 59400, 59510, 59610, 62322, 62323, 64483, 66821, 66984, 70450, 70553, 72110, 72148, 72193, 73721, 74177, 76700, 76805, 76830, 77065, 77066, 77067, 80048, 80053, 80055, 80061, 80069, 80076, 81000, 81001, 81002, 81003, 84153, 84154, 84443, 85025, 85027, 85610, 85730, 90832, 90834, 90837, 90846, 90847, 90853, 93000, 93452, 95810, 97110, 99203, 99204, 99205, 99243, 99244, 99385, 99386

Appendix B: Codes used in 2016 (2011 data) and 2019 (2017 data) issue briefs

2011:

DRG: 005, 009, 023, 025, 026, 027, 039,  101, 163, 164, 165, 166, 190, 191, 216, 217, 219, 227, 228, 229, 233, 234, 237, 238, 246, 247, 249, 251, 253, 254, 286, 287, 310, 314, 326, 327, 328, 329, 330, 331, 392, 405, 406, 454, 455, 457, 460, 462, 466, 467, 468, 469, 470, 472, 473, 484, 490, 491, 493, 494, 620, 621, 627, 641, 708, 742, 743, 765, 766, 775, 795, 847, 945

CPT/HCPCS: 00142, 00170, 00300, 00320, 00400, 00670, 00740, 00790, 00810, 00840, 00952, 01400, 01402, 01480, 01630, 01810, 01967, 11042, 11100, 17000, 17110, 19103, 19120, 19125,              19318, 20610, 20680, 22612, 23412, 26055, 27130, 27447, 28296, 29824, 29826, 29827, 29877, 29880, 29881, 29888, 30520, 33240, 33249, 36415, 42820, 43235, 43239, 45378, 45380, 45384, 45385, 47562, 47563, 49505, 49585, 49650, 50590, 52000, 52332, 52353, 55866, 57288, 58558, 58563, 58661, 58662, 59400, 62310, 62311, 63030, 63047, 63685, 64483, 64622, 64721, 66984, 69436, 70450, 70486, 70491, 70544, 70551, 70553, 71020, 71250, 71260, 72110, 72141, 72146, 72148, 72156, 72158, 73221, 73562, 73630, 73721, 74160, 74170, 74176, 74177, 74178, 74183, 76536, 76645, 76700, 76705, 76770, 76830, 76856, 76942, 77052, 77057, 77059, 77080, 77290, 77295, 77300, 77301, 77334, 77336, 77413, 77414, 77421, 77427, 78223, 78306, 78452, 78815, 80048, 80050, 80053, 80061, 80101, 82306, 83036, 84153, 84439, 84443, 85025, 88175, 88304, 88305, 88307, 88342, 90471, 90658, 90670, 90716, 90801, 90805, 90806, 90807, 90847, 90853, 90862, 90935, 90999, 92004, 92012, 92014, 92083, 92250, 92980, 93000, 93005, 93015, 93017, 93306, 93320, 93325, 93350, 93620, 93651, 93798, 93880, 93970, 93971, 94060, 95004, 95117, 95165, 95810, 95811, 95861, 95900, 95903, 95904, 97001, 97014, 97035, 97110, 97112,  97140, 97530, 98941, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99222, 99223, 99231, 99232, 99233, 99238, 99243, 99244, 99245, 99385, 99386, 99391, 99392, 99393, 99394, 99395, 99396, A0428, A4253, A7034, A9500, A9502, A9552, C1300, C1874, D0120, D1110, D2140, D2150, D2750, D2790, D3330, D4910, D8080, E0784, E1390, G0105, G0121, G0151, G0154, G0202, G0204, G0206, G0290, J0129, J0585, J0878, J1559, J1561, J1569, J1745, J2323, J2353, J2357, J2469, J2505, J3487, J3490, J7325, J9033, J9035, J9041, J9055, J9171, J9201, J9263, J9305, J9310, J9355, Q4081, Q9967, S3820, S9083                    

2017:

DRG: 005, 009, 023, 025, 026, 027, 039, 101, 163, 164, 165, 166, 190, 191, 216, 217, 219, 227, 228, 229, 233, 234, 237, 238, 246, 247, 249, 251, 253, 254, 286, 287, 310, 314, 326, 327, 328, 329, 330, 331, 392, 405, 406, 454, 455, 457, 460, 462, 466, 467, 468, 469, 470, 472, 473, 484, 490, 491, 493, 494, 620, 621, 627, 641, 708, 742, 743, 765, 766, 775, 795, 847, 945, 518, 519, 520, 483, 014, 016, 017, 266, 267, 268, 269, 270, 271, 272, 273, 274

CPT/HCPCS: 00142, 00170, 00300, 00320, 00400, 00670, 00740, 00790, 00810, 00840, 00952, 01400, 01402, 01480, 01630, 01810, 01967, 11042, 11100, 17000, 17110, 19103, 19120, 19125, 19318, 20610, 20680, 22612, 23412, 26055, 27130, 27447, 28296, 29824, 29826, 29827, 29877, 29880, 29881, 29888, 30520, 33240, 33249, 36415, 42820, 43235, 43239, 45378, 45380, 45384, 45385, 47562, 47563, 49505, 49585, 49650, 50590, 52000, 52332, 52353, 55866, 57288, 58558, 58563, 58661, 58662, 59400, 62310, 62311, 63030, 63047, 63685, 64483, 64622, 64721, 66984, 69436, 70450, 70486, 70491, 70544, 70551, 70553, 71020, 71250, 71260, 72110, 72141, 72146, 72148, 72156, 72158, 73221, 73562, 73630, 73721, 74160, 74170, 74176, 74177, 74178, 74183, 76536, 76645, 76700, 76705, 76770, 76830, 76856, 76942, 77052, 77057, 77059, 77080, 77290, 77295, 77300, 77301, 77334, 77336, 77413, 77414, 77421, 77427, 78223, 78306, 78452, 78815, 80048, 80050, 80053, 80061, 80101, 82306, 83036, 84153, 84439, 84443, 85025, 88175, 88304, 88305, 88307, 88342, 90471, 90658, 90670, 90716, 90801, 90805, 90806, 90807, 90847, 90853, 90862, 90935, 90999, 92004, 92012, 92014, 92083, 92250, 92980, 93000, 93005, 93015, 93017, 93306, 93320, 93325, 93350, 93620, 93651, 93798, 93880, 93970, 93971, 94060, 95004, 95117, 95165, 95810, 95811, 95861, 95900, 95903, 95904, 97001, 97014, 97035, 97110, 97112, 97140, 97530, 98941, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99222, 99223, 99231, 99232, 99233, 99238, 99243, 99244, 99245, 99385, 99386, 99391, 99392, 99393, 99394, 99395, 99396,  A0428,  A4253, A7034,  A9500,  A9502,  A9552,  C1300,  C1874, , D0120,  D1110,  D2140,  D2150,  D2750,  D2790, D3330,  D4910,  D8080,  E0784,  E1390,  G0105, , G0121,  G0151,  G0154,  G0202,  G0204,  G0206, G0290,  J0129,  J0585, J0878, J1559, J1561, J1569, J1745,  J2323,  J2353,  J2357,  J2469,  J2505,  J3487, J3490,  J7325,  J9033,  J9035,  J9041,  J9055,  J9171, J9201,  J9263,  J9305,  J9310,  J9355,  Q4081,  Q9967, S3820,  S9083, 19081, 19082, 19083, 19084, 19085, 19086, , 64636, 64635, , 76641, 76642, 77412, 77387, 8226, 78227, 90791, 90792, 90832, 90833, 90834, 90836, , 90863, 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944, 93653, 93654, 93656, 93657, 95907, 95908, 95909, 95910, 95911, 95912, 95913, G0277,  C9600, J3489, 81211 , 81213 , 81162