Comparing Private Payer and Medicare Payment Rates for Select Inpatient Hospital Services
| Appendix Table 1: Distribution of Private Payer and Medicare Payment Rates for Select Diagnoses, 2017 | |||||||||
| Medicare | Private Payer | Private-to-Medicare Mean Payment Ratio | |||||||
| Diagnosis | 25th percentile | Median | 75th percentile | Mean | 25th percentile | Median | 75th percentile | Mean | |
| Angioplasty (DRG 247) |
$13,337 | $15,005 |
$17,402
|
$15,782
|
$24,045
|
$32,544 |
$42,663
|
$35,321
|
2.24 |
| Bariatric (DRG 621) |
$9,854
|
$11,229
|
$12,955
|
$11,531
|
$15,843
|
$21,092
|
$27,143
|
$22,179
|
1.92 |
| Bowel (DRG 330) |
$15,314
|
$17,116
|
$20,083
|
$18,940
|
$20,205
|
$28,655
|
$39,926
|
$32,733
|
1.73 |
| Cellulitis (DRG 603) |
$5,310
|
$5,928
|
$7,019
|
$6,511
|
$6,678
|
$9,416
|
$13,647
|
$10,980
|
1.69 |
| Gastroenteritis (DRG 392) |
$4,759
|
$5,304
|
$6,322
|
$5,872
|
$6,655
|
$9,341
|
$13,224
|
$11,055
|
1.88 |
| Knee and Hip (DRG 470) |
$12,643
|
$14,084
|
$16,259
|
$14,747
|
$21,519
|
$27,812
|
$35,704
|
$30,099
|
2.04 |
| Respiratory Infection (DRG 177)* |
$10,825
|
$12,124
|
$14,263
|
$13,297
|
$15,160
|
$24,134
|
$39,543
|
$33,786
|
2.54 |
| Respiratory with ventilator <=96 hours (DRG 208)* |
$14,173
|
$15,960
|
$19,061
|
$17,437
|
$20,025
|
$29,639
|
$43,140
|
$36,758
|
2.11 |
| Respiratory with ventilator >96 hours (DRG 207)* |
$31,836
|
$37,291
|
$45,324
|
$40,218
|
$50,435
|
$77,902
|
$124,532
|
$100,461
|
2.50 |
| Uterus (DRG 743) |
$7,457
|
$8,505
|
$9,967
|
$9,232
|
$9,550
|
$13,168
|
$17,750
|
$14,444
|
1.56 |
| NOTES: *Denotes a DRG that includes inpatient services requiring similar treatments to COVID-19. SOURCE: KFF analysis of IBM MarketScan Commercial Claims and Encounters Database (IBM Corporation), and Medicare Provider Payment and Utilization Data public use files for inpatient hospital services (Centers for Medicare and Medicaid Services), for 2017. |
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