Health Policy Commission (HPC) DataPoints Series

Read online briefs that spotlight new research and findings about health care costs in Massachusetts.
HPC DataPoints

HPC DataPoints showcases brief overviews and interactive graphics on relevant health policy topics. The analysis underlying these briefs is conducted by HPC research staff. As you read through HPC DataPoints, we encourage you to engage with the interactive graphics by hovering your mouse over different data points to obtain additional information. 

Issue 26: Trends in Ambulatory Surgical Centers in Massachusetts (February 15, 2024)

  • Massachusetts has the fourth fewest number of ASCs per capita among all states, likely due to historical regulatory barriers to entry.
  • GastrointestinaI procedures, orthopedic procedures, and eye surgeries account for about 90% of commercial and MassHealth ASC volume.
  • Commercial prices for procedures performed in ASCs are typically 30-55% lower than prices for procedures in HOPDs and also typically result in lower patient cost sharing.
  • Among procedures routinely performed in both ASCs and HOPDs, the vast majority are performed in HOPDs for both commercial and MassHealth patients. For most procedures, MassHealth patients have a substantially smaller share performed in ASCs than commercial patients.

Issue 25: Not Throwing Away My Shot: Shifts in Where People Get Flu Vaccines in Massachusetts (November 15, 2023)

  • Between 2017 and 2021, flu vaccine administration among commercially-insured residents shifted dramatically from doctor’s offices to pharmacies. By 2021, most flu vaccines among commercially-insured residents who had an insurance claim were administered in pharmacies (60%).
  • The increasing proportion of flu vaccines occurring in pharmacies occurred among commercially-insured residents of all ages and community income levels, and was particularly pronounced among children.
  • Geographic access to pharmacies varies by region and community income in Massachusetts, with areas with lower community income less likely to have a pharmacy within the bounds of their zip code.
  • In 2021, the price for a flu vaccine at a hospital outpatient department ($108) was almost double the price at an office ($56), and the price at an office was double the price at a pharmacy ($28).

Issue 24: Persistent Cost-sharing for Contraception in Massachusetts, 2017-2020 (May 10, 2023)

  • Cost-sharing for oral contraceptive prescriptions is rare. From 2017-2020, under 2% of oral contraceptive prescriptions had cost-sharing, nearly all of which were for branded drugs.
  • For implant, IUD, IUD follow-up, and contraceptive options counseling services received in encounters with health care providers, the share of commercially insured Massachusetts residents paying cost-sharing fell from 16% in 2017 to 12% in 2020.  
  • IUD follow-up services were the most common source of cost-sharing. Patients paid cost-sharing in nearly one-third of IUD follow-up visits as of 2020, compared to under 10% of visits for other services.
  • Although a decreasing share of Massachusetts residents pay out-of-pocket costs for contraceptive services received in encounters with health care providers, those who do face cost-sharing are paying more over time. Average per-person out-of-pocket costs rose from $60 in 2017 to $103 in 2020, due to increasing deductible payment amounts.

Issue 23: Update on Trends in Urgent Care Centers and Retail Clinics (Part Two) (September 19, 2022)

  • Significant changes in care delivery trends occurred during the pandemic. Between 2019 and 2020, in-person visits among commercially insured patients dropped by 36% to physician offices, 39% to hospital outpatient departments (HOPDs), and 20% to EDs, while visits to urgent care centers rose by 6%.
  • The increase in visits to urgent centers was not evenly distributed across areas. From 2019 to 2020, the growth in use of urgent care centers for E&M visits among commercially insured patients was concentrated among residents living in areas with the highest incomes in the state, increasing 6% among residents in the fourth highest income quintile and 20% among residents in the highest income quintile.
  • Average commercial spending for a low-acuity visit in an ED was seven times higher than in an urgent care center and more than 10 times higher than in a retail clinic. Cost-sharing in an ED was six times higher than in an urgent care center or a retail clinic.
  • Some urgent care centers that are part of major health systems and are licensed as hospital satellites may bill a visit as a HOPD or an ED, resulting in a lack of transparency and potentially unforeseen costs for patients.

Issue 23: Update on Trends in Urgent Care Centers and Retail Clinics (Part One) (September 12, 2022)

  • Urgent care centers and retail clinics offer convenient alternatives to the traditional hours, access, and costs of physician offices and EDs.
  • In 2021, 45% of urgent care centers in Massachusetts were operated by major health systems, 36% were part of large chains, and 18% were other / independent. In recent years, most new centers have been affiliated with large chains or major health systems. All retail clinics in Massachusetts are part of CVS MinuteClinic.
  • Most urgent care centers offered testing for COVID-19 in 2021, and only 4% did not. All retail clinics offered COVID-19 testing. While all urgent care centers served patients on a walk-in basis, most also offered telemedicine and online appointment scheduling.
  • Urgent care centers and retail clinics are disproportionately located in higher income areas: 54% of retail clinics and 50% of urgent care centers in 2021 were in zip codes representing residents with the highest incomes (the 4th and 5th income quintiles comprising 40% of the state population). Among urgent care centers that opened between 2019 and 2021, 63% were located in these highest income zip codes.

Issue 22: Growth in Out-of-pocket Spending for Pregnancy, Delivery, and Postpartum Care in Massachusetts (March 29, 2022)

  • Commercially-insured patients, especially those employed at smaller firms, are bearing a growing share of the cost of pregnancy, delivery, and postpartum care
  • This trend is driven by spending on deductibles, reflecting growth in high-deductible health plan enrollment as health insurance premiums have become increasingly unaffordable
  • High OOP spending is particularly burdensome for lower-income residents, who are also disproportionately likely to forgo needed care due to cost
  • HPC findings indicate that solutions to rising out-of-pocket costs for pregnancy, delivery, and postpartum care will be found in insurance design rather than care delivery
  • Watch the HPC Short

Issue 21: The Quality Measure Alignment Taskforce’s Evaluation of Payer Adherence to the Massachusetts Aligned Measure Set (February 9, 2022)

  • The 2021 Massachusetts Aligned Measure Set has 25 Core and Menu measures for voluntary adoption by providers and payers in their global budget-based risk contracts. 
  • Overall, voluntary adherence to the Massachusetts Aligned Measure Set has increased from 65% in 2019 to 83% in 2021; however, there is wide variation in adherence among payers.
  • Use of behavioral health measures has been low overall, with only two out of eight included in contracts by more than one payer.

Issue 20: Oral Health Access and Equity in the Commonwealth (July 14, 2021)

  • ED visits for non-traumatic dental conditions (NTDCs) vary by race and ethnicity, age, income, region, and payer type, suggesting disparities in access to preventive care and treatment for dental conditions.
  • In 2019, Black Massachusetts residents had the highest rate of ED visits for NTDCs per 1,000 population (9.6), followed by Hispanic/Latino residents (6.5), White residents (3.5) and Asian residents (1.2). 
  • MassHealth was the most common payer for Massachusetts residents with ED visits for NTDCs in 2019, accounting for 45% of ED visits. 
  • In 2019, 65% of ED visits for NTDCs were by Massachusetts residents in the lowest two community income quintiles. 

Issue 19: Persistently High Out-of-Pocket Costs Make Health Care Increasingly Unaffordable and Perpetuate Inequalities in Massachusetts (January 13, 2021)

  • For the population with persistently high out-of-pocket (OOP) spending, cost-sharing for prescription drugs comprised a larger portion of total OOP spending (27.2%) than for other individuals.
  • In 2017, OOP spending for members with persistently high OOP spending would consume almost 8% of income in the lowest-income areas of the state (areas in the bottom 10% by income), versus just over 2% among members living in the highest-income areas in the state (areas in the top 10% by income).
  • Individuals with persistently high OOP were more likely to have a chronic condition, be employed by a smaller firm, and live in the Cape and Islands region.

Issue 18: HPC-Certified Accountable Care Organizations in Massachusetts (October 13, 2020)

  • 2.6 million (91%) of ACO-attributed patients fall under contracts that include downside risk.
  • Every HPC-certified ACO reported having strategies to address unnecessary utilization in at least two areas of low-value care.
  • 12 of the 14 HPC-certified ACOs reported having a strategy for the integration of behavioral health services into primary care.

Issue 17: Changes in the Massachusetts Physician Market: Data from the Massachusetts Registration of Provider Organizations (MA-RPO) Program (June 23, 2020)

  • The share of Massachusetts physicians affiliated with the largest provider organizations is significant and increasing. The share of physicians in the 10 largest provider organizations in Massachusetts was 88.7% in 2015 and 90.3% in 2018. 
  • Of the 21,358 physicians in the 2018 MA-RPO physician roster, 5,908 (27.7%) were PCPs and 15,450 (72.3%) were specialists. 
  • Since 2015, the number of physicians in the MA-RPO roster increased 3.0%. The number of specialists increased more than the number of PCPs (3.4% compared to 2.0%), with pediatricians increasing 9% during the same period. 

Issue 16: The Doctor Will (Virtually) See You Now (March 12, 2020)

  • Commercially-insured patients who had at least one telehealth visit in 2017 were more likely to be women and younger than the overall population
  • More than half of all telehealth visits were for mental health services, with generalized anxiety disorder as the most common diagnosis 
  • The highest volume service delivered in 2017 as a 45-minute psychotherapy session
  • The median cost of a telehealth visit was $77 and the median patient cost-sharing amount was $20
    • Cost-sharing for telehealth visits was generally quite low, with 23 percent of visits in 2017 delivered with zero cost-sharing
  • Variation was widespread across the insurers and providers analyzed

Issue 15: Mother and Infant-Focused Neonatal Abstinence Syndrome Investments (September 30, 2019)

  • Hospitals have seen a 53% reduction in median hospital length of stay for infants. Median length of stay decreased from 17 days to 8 days over the 24 months following the launch of the program.
  • Hospitals identified a reduced need for pharmacologic therapy. Need for pharmacologic therapy decreased significantly from 66% of infants to 42% of infants, as a result of the enhanced non-pharmacologic care methods deployed by these initiatives.
  • Infants requiring care in the NICU decreased by 23%. Due to the decrease in pharmacologic therapy, which is often administered in the NICU, hospitals decreased the percentage of infants needing care in the NICU or special care nursery.
  • Enhanced non-pharmacologic care for opioid-exposed newborns could have significant implications for cost savings. Shorter length of stay and a decreased reliance on the NICU or special care nursery could have an impact on the cost of care for this population.

Issue 14: Variation in Potential Out-of-Network Provider Payment Benchmarks (August 14, 2019)

Issue 13: Opioid-Related Emergency Department Utilization (June 26, 2019)

Issue 12: Cracking Open the Black Box of Pharmacy Benefit Managers (June 5, 2019)

  • In 2018, MCO/PBM drug prices were higher than the acquisition prices for 95% of the unique drugs analyzed by the HPC and exceeded FFS prices for 42% of unique drugs.
  • For the drugs where the MCO/PBM price was higher than the FFS price, the difference was often substantial, leading to higher average drug prices overall. MCO prices exceeded FFS prices by an average of $15.97 per unique drug.
  • For several widely prescribed generic drugs, a drop in acquisition costs has not translated to lower prices for the MassHealth MCO program. For example, from 2016 Q1 to 2018 Q4, the average acquisition cost for Buprenorphine fell by 60% while the MCO/PBM price increased by 13%.
  • PBM prices for generic drugs were markedly higher than the drugs’ acquisition costs in the commercial market. The price for generic Gleevec, used in treatment of leukemia, was an average of $1,811 more per prescription than the pharmacy acquisition cost. This per prescription difference translated to more than $278,000 in aggregate spending above acquisition cost.

Issue 11: Insulin Price Growth and Patient Out-of-Pocket Spending (May 1, 2019)

  • Annual health care spending increased by $4,016 (31%) per person between 2013 and 2016 for individuals who use insulin to manage their diabetes.
  • Annual spending on insulin for this population increased by $1,562 (50%), accounting for 39% of the total spending increase.
  • In 2016, average out-of-pocket spending for insulin was $28 per month, or $340 per year; 18% of individuals paid more than $500 annually on insulin.
  • Although Massachusetts residents paid relatively similar amounts out-of-pocket for their care, the affordability of care varied by region.

Issue 10: Health Care Cost Growth Benchmark (February 11, 2019)

Issue 9: Office of Patient Protection Medical Necessity Appeals (December 20, 2018)

  • Since 2014, the total number of internal appeals has increased each year, and the percentage of consumers who have received a favorable outcome (i.e., coverage for treatment) from the internal appeal process increased from 44% in 2014 to 57% in 2017.
  • Despite the increase in the total number of internal appeals filed between 2014 and 2017, there was a decrease in both the total number of internal appeals related to coverage of BH treatment, and the percentage of appeals related to BH treatment compared to medical/surgical treatment.
  • Between 2014 and 2017, OPP received fewer eligible requests for external reviews related to BH treatment.
  • While OPP reported a declining percentage of external reviews regarding BH treatment resolved in favor of the consumer from 2014-2016, in 2017, 59% of those external reviews were resolved in favor of the consumer, the highest percentage in the past four years.

Issue 8: Urgent Care Centers and Retail Clinics (August 9, 2018)

  • The number of retail clinics in Massachusetts nearly tripled from 20 in 2010 to 57 in 2018. The number of urgent care centers increased eight-fold from 18 in 2010 to 145 at the end of 2017.
  • The average ED visit costs just over $1200 with the patient copayment averaging $164, compared to the average urgent care center cost of $172 with patient copayments averaging $35, and $69 at retail clinics with patient copayments averaging $20. (ED and urgent care center figures were updated in December 2018)
  • Sore throats and acute sinusitis accounted for 30 percent of the conditions that retail clinics saw during visits. Urgent care centers treated a wider range of conditions but also saw sore throats (and upper respiratory infections a close second) as the top condition for visits.

Issue 7: Variation in Imaging Spending (May 4, 2018)

  • Massachusetts ranks as the 4th highest spending state for imaging services with $892 in annual costs per Medicare beneficiary, 14 percent higher than the U.S. average. This is a contributing factor to higher overall health care costs in Massachusetts.
  • Massachusetts has relatively high facility use for imaging procedures, ranking 18th among states.
  • Prices are typically more than twice as high when the service is provided in a hospital outpatient department or other facility, compared to the same service performed in a doctor’s office or other non-facility setting. For example, the average price in Massachusetts for an MRI of the brain with contrast was more than twice as expensive at a facility setting ($699), compared to a non-facility setting ($337).

Issue 6: Provider Organization Performance Variation (March 1, 2018)

  • After adjusting for differing health needs, spending for patients in the highest-cost organization was 32 percent higher than in the lowest-cost organization. 
  • Among categories of service, hospital outpatient services saw the greatest spending variation, both in total spending and across provider groups. 
  • Patients whose PCPs are associated with the Southcoast Health System are from the lowest-income areas in the state and have the highest health risk, 9 percent above the statewide average. These patients also had the highest rates of hypertension (18.5 percent), cardiovascular disease (15.6 percent), and diabetes (6.7 percent).

Issue 5: Quality Measurement Misalignment in Massachusetts (January 10, 2018)

  • The three largest MA commercial payers vary in their scope of quality measure use in APM contracts; one payer reported use of 26 measures in at least ten APM contracts while the others reported use of over 40 measures in at least ten APM contracts.
  • Only 17 quality measures are used in at least ten APM contracts by all three payers, including two common outcome measures.

Issue 4: The Growing Opioid Epidemic in Massachusetts Hospitals (July 26, 2017)

  • Between 2014 and 2015, the number of opioid-related hospital (ED and inpatient) discharges grew drastically, by 18%.
  • A new, interactive map displays the rate of opioid-related hospital discharges by zip code and provides new insights into the disproportionate impact of the opioid epidemic on certain residents, communities, and hospitals.
  • Young adults experienced the sharpest increase in discharges, rising by 192% from 2011 to 2015.

Issue 3: The ACA’s Preventative Coverage Mandate and MA (June 26, 2017)

  • Average out-of-pocket spending by women for prescription drugs declined 14.2% from 2011-2014.

Issue 2: Avoidable Emergency Department Use in Massachusetts (May 23, 2017)

  • 42% of all ED visits in Massachusetts in 2015 were avoidable with fairly consistent rates throughout the Commonwealth in 2015.

Issue 1: Update on Preventable Oral Health ED Visits in MA (April 27, 2017)

  • The HPC identified 33,467 oral health ED visits in Massachusetts in 2015.
  • The HPC found a five-fold regional variation in the number of oral health ED visits per population.

Contact   for Health Policy Commission (HPC) DataPoints Series

Help Us Improve  with your feedback

Please do not include personal or contact information.