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GAO-14-56R: 

[End of section] 

GAO:
United States Government Accountability Office: 
441 G St. N.W. 
Washington, DC 20548: 

January 6, 2014: 

Congressional Committees: 

Medicaid: Use of Claims Data for Analysis of Provider Payment Rates: 

Within the Medicaid program, federal law requires that state Medicaid 
payments to providers be consistent with efficiency, economy, and 
quality of care; and be sufficient to enroll enough providers so that 
services are available to beneficiaries at least to the extent that 
they are available to the general population in the same geographic 
area.[Footnote 1] 

Two frequently cited studies of Medicaid payments have been conducted 
by the American Academy of Pediatrics (AAP) and the Urban Institute, 
both of which obtained state-specific fee schedule data for selected 
services and procedures through surveys of state Medicaid officials 
and from state websites.[Footnote 2] These studies shed some light on 
potential Medicaid payments for selected services; however, they 
provide little information on the extent to which states vary their 
payment for a service based on the circumstances in which that service 
was provided--such as whether the state pays a different amount 
depending on characteristics of the provider, setting, or beneficiary. 
These studies also provide little information on how often the payment 
rates they selected from the fee schedules were actually used in 
practice. Without such information, it may be difficult for the 
Centers for Medicare & Medicaid Services (CMS)--the agency within the 
Department of Health and Human Services that oversees the joint 
federal-state Medicaid program--or other policy makers to fully assess 
the adequacy of Medicaid payments. One potentially useful source of 
more comprehensive information on provider payments is claims data. 
Assessing Medicaid fee schedules against Medicaid claims data can 
serve to cross validate both data sources, and provide new insights 
into the robustness of claims data for payment analyses. 

We prepared this report under the authority of the Comptroller General 
to conduct work on GAO's initiative to assist Congress with its 
oversight responsibilities for the Medicaid program. In this report, 
we provide information on: (1) the extent to which state Medicaid 
programs vary the rates paid to providers for a given service and the 
basis for the variation; and (2) the extent to which Medicaid provider 
payment rates calculated from claims data confirm rates reported in 
studies of states' fee schedules. 

Scope and Methodology: 

To conduct this work, we examined 2010 Medicaid fee-for-service (FFS) 
claims data for selected professional services and states. We selected 
35 professional services from among those included in the studies by 
the AAP and the Urban Institute. The services were chosen to represent 
a range of professional service categories--including evaluation and 
management, imaging, laboratory, and maternal health. We selected 9 
states from among the 26 states with available 2010 claims data as of 
October 2012. We chose states that represented different regions of 
the country and that served a relatively large proportion of their 
Medicaid population through FFS arrangements rather than through 
managed care.[Footnote 3] 

To determine the extent to which state Medicaid programs varied the 
rate they paid for a given service, we calculated the percentage 
difference between the 10th and 90th percentile of claims' payment 
rates. We excluded claims for beneficiaries in demonstration programs, 
claims where Medicaid was not the only payer, and claims that were 
adjusted. We performed a regression analysis to examine the extent to 
which variations in payments could be explained by differences in 
provider type, service setting, and patient age; and to determine the 
magnitude of variation associated with each factor. We selected these 
factors because previous studies by the Urban Institute found them to 
be present in fee schedules and they could be extracted from the 
claims data. To determine the extent to which Medicaid provider 
payment rates calculated from claims data confirmed rates reported in 
studies of states' fee schedules, we calculated median payment rates 
from the claims data and compared these to fee schedule rates reported 
by AAP and the Urban Institute. To help ensure comparability, we 
restricted the claims in this part of our analysis to those most 
comparable to the fees used by the AAP and the Urban Institute 
studies. Generally, this involved restricting those claims to the 
service provided by a physician or dentist, in an office, and to a 
child. To the extent that the rates calculated from claims data 
differed from the reported rates based on fee schedule data, we used 
information obtained from state Medicaid program websites to explore 
potential reasons for any differences we observed. A more detailed 
discussion of our scope and methodology can be found in enclosure 1. 
Tables detailing the results of our analysis can be found in enclosure 
2. 

We conducted our work from September 2012 to January 2014 in 
accordance with all sections of GAO's Quality Assurance Framework that 
are relevant to our objectives. The framework requires that we plan 
and perform the engagement to obtain sufficient and appropriate 
evidence to meet our stated objectives and to discuss any limitations 
in our work. We believe that the information and data obtained, and 
the analysis conducted, provide a reasonable basis for any findings 
and conclusions in this product. 

Results in Brief: 

Among the states and services we examined, our analysis indicated that 
all states varied Medicaid payments for at least some services based 
on the circumstances under which the services were provided. However, 
the states differed in the number of services for which they varied 
payments, in the factors that accounted for variation, and in the 
magnitude of the variation. Many of the states varied payment rates by 
at least one of the factors we were able to explore in detail: 
provider type, service setting, and/or patient age. Some states also 
varied their payment rates for other reasons, such as by geographic 
region or by physician specialty. We also found that most of the 
median Medicaid payment rates calculated from claims data generally 
confirmed payment rates published in studies of fee schedules; 
however, some of the published fee schedule rates were rarely used in 
practice as the selected circumstance--such as the service being 
provided by a physician--rarely occurred. As a result, our findings 
demonstrate that Medicaid FFS claims data is a valid source of 
information on Medicaid provider payments, which have the potential to 
provide a more complete representation of provider payments than do 
fee schedules, as claims data can capture both the distribution and 
frequency of actual payments to providers. 

All States Varied Medicaid Provider Payment Rates for Some Services, 
but Reasons for Variation Differed: 

Among the states and services we examined, all states varied Medicaid 
provider payment rates for at least some services. However, the states 
differed in the number of services for which they varied payments, in 
the factors that accounted for variation, and in the magnitude of the 
variation. As shown in table 1, among the 9 states we examined, the 
most variation in payments was in Texas, where payments varied by more 
than 10 percent for 22 services, and by more than 50 percent for 7 
services. The least variation in payments was in Nebraska and 
Pennsylvania, where payment rates varied by more than 10 percent for 
just 4 services. (See table 5 in enclosure 2 for more detail on the 
variation in provider payments for each state and service.) 

Table 1: Number of Medicaid Services for Which States Varied Provider 
Payment Rates and Magnitude of Variation, by State, Calendar Year 2010: 

States included in analysis: Number of services for which data were 
available; 
Alabama: 32; 
Iowa: 34; 
Illinois: 31; 
Louisiana: 31; 
Montana: 31; 
Nebraska: 32; 
Pennsylvania: 30; 
South Carolina: 32; 
Texas: 31. 

States included in analysis: Number of services with variation greater 
than 10 percent; 
Alabama: 32: 15; 
Iowa: 21; 
Illinois: 10; 
Louisiana: 22; 
Montana: 16; 
Nebraska: 4; 
Pennsylvania: 4; 
South Carolina: 8; 
Texas: 22. 

States included in analysis: Number of services with variation greater 
than 25 percent; 
Alabama: 32: 13; 
Iowa: 11; 
Illinois: 7; 
Louisiana: 10; 
Montana: 14; 
Nebraska: 3; 
Pennsylvania: 3; 
South Carolina: 5; 
Texas: 11. 

States included in analysis: Number of services with variation greater 
than 50 percent; 
Alabama: 32: 7; 
Iowa: 5; 
Illinois: 7; 
Louisiana: 1; 
Montana: 3; 
Nebraska: 1; 
Pennsylvania: 2; 
South Carolina: 0; 
Texas: 7. 

Source: GAO analysis of Centers for Medicare & Medicaid Services data. 

Note: We selected 35 professional medical services from among those 
included in recent studies by the American Academy of Pediatrics and 
the Urban Institute. We chose these services to represent a range of 
professional medical service categories--including evaluation and 
management, imaging, laboratory, and maternal health. We determined 
the level of variation in payment by comparing the 90th and 10th 
percentiles of payment rates for all Medicaid claims for each service. 

[End of table] 

States also differed in the factors that contribute to payment rate 
variation and in the proportion of payment variation associated with 
each factor. In most states, some of the variation in payment rates 
could be explained by differences in provider type, service setting, 
and patient age. In 3 of the states with substantial variation in 
provider payment rates--Louisiana, Montana, and Texas--much of the 
variation could be accounted for by these 3 factors. For example, in 
Montana, more than half of the variation in payment rates could be 
explained by these factors in 56 percent of services. In 3 other 
states--Alabama, Iowa, and Illinois--very little of the variation in 
payment rates could be attributed to provider type, setting, and 
patient age. Less than 25 percent of the variation in payments was due 
to these factors in over 80 percent of services in these states. (See 
table 6 in enclosure 2 for more detail on the variation in Medicaid 
provider payment accounted for by provider type, service setting, and 
patient age for each service and state.) An examination of states' fee 
schedules indicated that states also varied their payment rates for 
reasons beyond the 3 factors we explored. For example, for certain 
services, Alabama varied payment rates by geographic region, Montana 
varied rates for certain services by provider specialty, and Illinois 
varied rates depending on whether providers were enrolled in a special 
primary health care program. 

Furthermore, even among states that varied payments on the same 
factor, the states differed in the magnitude of the variation 
associated with that factor. For example, non-physicians were paid 
about 21 percent less than physicians on average in Louisiana, while 
they were paid about 8 percent less in Texas, according to our 
analysis of claims data. In Montana, services provided in a facility 
(inpatient hospital, outpatient hospital, or emergency department) 
were reimbursed about 32 percent less than those provided in an 
office, while in Louisiana, there was no difference in payment by 
setting. Payment rates for services provided to adults were generally 
less than for those provided to children, but the difference varied 
among states. On average, services provided to adults were reimbursed 
12 percent less in Louisiana, 3 percent less in Montana, and 9 percent 
less in Texas. 

Medicaid Provider Payment Rates Calculated from Claims Data Generally 
Confirmed Rates Reported in Fee Schedule Studies, but Some Rates Were 
Rarely Used: 

The median Medicaid payment rates calculated from claims data 
generally confirmed payment rates published in studies of fee 
schedules, once we restricted claims to those most comparable to the 
fees used by the studies.[Footnote 4] Specifically, of the 257 state 
and service combinations for which we had both claims and fee schedule 
data, 148 (58 percent) had median claims payment rates that were 
within 1 percent of the published fee schedule rates, and another 71 
(28 percent) had median payments within 10 percent. (See table 7 in 
enclosure 2 for the median payment rate calculated from claims data 
for each service and state. See table 8 in enclosure 2 for a 
comparison of the rates calculated in claims with those reported in 
studies of fee schedules for each service and state.) 

Where the median payment rate calculated from claims data differed 
from that published in the fee schedule studies, we were generally 
able to identify the source of the difference. For example, for the 
two emergency department (ED) services shown in table 2, the AAP study 
reported fee schedule rates in Texas of $46 and $62. However, the 
current Texas fee schedule specifies that if the enrollee's diagnosis 
is nonemergency, Medicaid pays just 60 percent of the standard rate 
for these services. In that case, the rates for these services would 
be $28 and $37, which essentially equaled the median payment rates we 
calculated from the claims data. Thus, while the rate reported by AAP 
was consistent with the current Texas fee schedule, it did not reflect 
the number of ED visits in Texas that were paid at a reduced rate. 

Table 2: Percentage Difference between Medicaid Provider Payment Rates 
Calculated from Claims Data and Rates Reported in Fee Schedule 
Studies, Selected Services and States, Calendar Year 2010: 

Selected Medicaid Services: Initial hospitalization, per day, moderate 
complexity; 
Percent difference between median claims payments and fee schedule 
rates: 
Alabama: 15%; 
Iowa: 0; 
Illinois: -1%; 
Louisiana: 13%; 
Montana: -1%; 
Nebraska: -1%; 
Pennsylvania: 2%; 
South Carolina: -1%; 
Texas: 0. 

Selected Medicaid Services: Subsequent hospitalization, per day, low 
complexity; 
Percent difference between median claims payments and fee schedule 
rates: 
Alabama: 20%; 
Iowa: 0; 
Illinois: -2%; 
Louisiana: 16%; 
Montana: 0; 
Nebraska: -2%; 
Pennsylvania: 0; 
South Carolina: -2%; 
Texas: 0. 

Selected Medicaid Services: Subsequent hospitalization, per day, 
moderate complexity; 
Percent difference between median claims payments and fee schedule 
rates: 
Alabama: 0; 
Iowa: -1%; 
Illinois: 0; 
Louisiana: 12%; 
Montana: 1%; 
Nebraska: -1%; 
Pennsylvania: 0; 
South Carolina: -1%; 
Texas: -1%. 

Selected Medicaid Services: Emergency department visit, problem 
focused; 
Percent difference between median claims payments and fee schedule 
rates: 
Alabama: 0; 
Iowa: 1%; 
Illinois: -1%; 
Louisiana: 18%; 
Montana: -1%; 
Nebraska: -1%; 
Pennsylvania: 1%; 
South Carolina: -2%; 
Texas: -69%. 

Selected Medicaid Services: Emergency department visit, expanded; 
Percent difference between median claims payments and fee schedule 
rates: 
Alabama: 0; 
Iowa: 1%; 
Illinois: -1%; 
Louisiana: 15%; 
Montana: 3%; 
Nebraska: -1%; 
Pennsylvania: 0; 
South Carolina: -1%; 
Texas: -66%. 

Source: GAO analysis of Centers for Medicare & Medicaid Services, 
American Academy of Pediatrics (AAP), and Urban Institute data. 

Notes: A positive value indicates that the median payment rate 
calculated from Medicaid claims data is higher than the payment rate 
presented in recent AAP and Urban Institute studies using fee schedule 
data. To help ensure comparability, we restricted the claims in this 
part of our analysis to those most comparable to the fees used by the 
AAP and the Urban Institute studies. Generally, this involved 
restricting those claims to the service provided by a physician or 
dentist, in an office, and to a child. (See table 4 in enclosure 1. 
See table 8 in enclosure 2 for data from all services included in our 
analysis.) 

[End of table] 

The difference between claims data and fee schedule rates for some 
services in Alabama may reflect differing rates for rural and non-
rural areas, a factor we did not account for in our analysis. For 
example, for the initial hospitalization service, we calculated a 
median claims payment of $95, which is the rate shown in the current 
state fee schedule for rural areas. The AAP and Urban Institute both 
reported a payment rate of $81 for this same service, which is the 
rate shown in Alabama's fee schedule for non-rural areas. In the case 
of Louisiana, the difference between the median payment rates we 
calculated for children and the fee schedule rates reported by the AAP 
and Urban Institute appear to be due to the AAP having reported 
payment rates for adults for at least some services. The median 
payment rates that we calculated were consistent with the Louisiana 
fee schedule rates for children.[Footnote 5] 

We also examined how frequently the fee schedule rates reported in the 
AAP and Urban Institute studies were actually used to pay claims, and 
found that some were rarely used in practice. For example, the fee 
schedule rate reported by the Urban Institute in Texas for a CAT scan 
of the head or brain was $169.[Footnote 6] However, that rate applied 
to fewer than 10 percent of actual payments for the service, and was 
less than half the $357 overall median payment for the service we 
calculated from claims data.[Footnote 7] In Montana, the fee schedule 
rate for a 40 to 50 minute individual, face-to-face psychotherapy 
session reported by AAP was $90. However, this rate applied to fewer 
than 10 percent of the payments Montana made for the service, and it 
was nearly twice the overall median payment of $57 calculated from 
claims data. This discrepancy is likely due to AAP reporting the 
enhanced rate for psychiatrists over other physicians, while the much 
lower rate we found in the claims more closely corresponded to the 
rate paid to non-physician mental health providers. 

Agency Comments: 

The Department of Health and Human Services reviewed a draft of this 
report and provided technical comments, which we incorporated as 
appropriate. 

For further information regarding this report, please contact me at 
(202) 512-7114 or YocomC@gao.gov. Copies of this report will be sent 
to the Secretary of Health and Human Services. In addition, the report 
will be available at no charge on the GAO website at [hyperlink, 
http://www.gao.gov]. Contact points for our Offices of Congressional 
Relations and Public Affairs may be found on the last page of this 
report. Major contributors to this report were Christine Brudevold, 
Assistant Director; Eric Anderson; Alison Binkowski; William Black; 
Greg Dybalski; Nancy Fasciano; Sandra George; Drew Long; and Hemi 
Tewarson. 

Signed by: 

Carolyn L. Yocom: 
Director, Health Care: 

List of Congressional Committees: 

The Honorable Max Baucus: 
Chairman: 
The Honorable Orrin G. Hatch: 
Ranking Member: 
Committee on Finance: 
United States Senate: 

The Honorable Thomas Carper: 
Chairman: 
The Honorable Tom Coburn: 
Ranking Member: 
Committee on Homeland Security and Governmental Affairs: 
United States Senate: 

The Honorable Fred Upton: 
Chairman: 
The Honorable Henry Waxman: 
Ranking Member: 
Committee on Energy and Commerce: 
House of Representatives: 

The Honorable Darrell E. Issa: 
Chairman: 
The Honorable Elijah Cummings: 
Ranking Member: 
Committee on Oversight and Government Reform: 
House of Representatives: 

[End of section] 

Enclosure I: Scope and Methodology: 

We prepared this report under the authority of the Comptroller General 
to conduct work on GAO's initiative to assist Congress with its 
oversight responsibilities for the Medicaid program. In this report, 
we provide information on: (1) the extent to which state Medicaid 
programs vary the rates paid to providers for a given service and the 
basis for the variation; and (2) the extent to which Medicaid provider 
payment rates calculated from claims data confirm rates reported in 
studies of states' fee schedules. 

To conduct this work, we examined 2010 Medicaid fee-for-service (FFS) 
claims data for selected professional services and states. States 
submit Medicaid eligibility and claims data to the Centers for 
Medicare & Medicaid Services' (CMS) Medicaid Statistical Information 
System (MSIS) on a quarterly basis. We used 2010 claims data from the 
Medicaid Analytic Extract to calculate median payment rates for 35 
services in 9 states. The Medicaid Analytic Extract (MAX) data is a 
set of person-level data files on Medicaid eligibility, service 
utilization, and payment, which are based on data extracted from the 
Medicaid Statistical Information System. The MAX data are created 
specifically to support research and policy analysis, and combine 
initial claims and adjustments for a given service into final action 
claims arrayed on a calendar year basis.[Footnote 8] The payments in 
the MAX data represent the actual amounts Medicaid paid to providers 
and do not include beneficiary cost-sharing.[Footnote 9] To assess the 
reliability of the claims data we used in our analyses, we reviewed 
related documentation, interviewed knowledgeable officials from CMS 
and its contractor responsible for processing these data, and compared 
our results to published sources. 

We selected 35 professional services from among those included in the 
studies by the American Academy of Pediatrics (AAP) and the Urban 
Institute. Both studies relied on surveys of states' fee schedules. As 
part of its effort to monitor the impact of the Medicaid program on 
pediatrics, AAP has periodically conducted a survey of states to 
collect Medicaid fee schedule data. The most recent published survey 
requested payment rates effective July 1, 2010, and reported data from 
the 46 states that responded. For those states, the study reported on 
payment rates for 235 pediatric services and, with a few exceptions, 
reported the rate applicable when the service was provided by a 
physician, in an office, and to a child. Since 1993, the Urban 
Institute has conducted its study of Medicaid fee schedules 
approximately every 5 years. The authors shared unpublished results 
from their 2010 survey for our analysis. The Urban Institute study 
collected physician fee schedule data on 32 services for all 49 states 
that have a FFS program. The survey focused on rates for services 
provided by a physician in an office; if a state otherwise had 
multiple payment rates for the same service--for example, different 
rates for urban and rural areas--the authors reported the average of 
those rates. Together, the AAP and Urban Institute studies included 
255 services--235 in the AAP study and 32 in the Urban study, with 12 
appearing in both. From those 255 services, we selected 35 services 
across a range of professional service categories--including 
evaluation and management, imaging, laboratory, and maternal health. 
(See table 3.) 

Table 3: Selected Services and Service Categories: 

Service Category: Office visits; 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Established patient, problem-focused. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Check]; 
Service: Established patient, low complexity. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Check]; 
Service: Established patient, moderate complexity. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Check]; 
Service: New patient, low complexity. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Check]; 
Service: New patient, moderate complexity. 

Service Category: Preventive services; 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: One immunization administration. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Established patient, under 1 year. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Established patient, 1 through 4 years. 

Service Category: Cardiovascular; 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Routine venipuncture. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Check]; 
Service: Echocardiography, with image documentation. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Doppler echocardiograph. 

Service Category: Emergency department/critical care; 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Emergency department visit, problem focused. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Check]; 
Service: Emergency department visit, expanded. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Emergency department visit, detailed. 

Service Category: Inpatient/non-emergency department; 

Appears in: AAP: [Check]; 
Appears in: Urban: [Check]; 
Service: Initial hospitalization, per day, moderate complexity. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Subsequent hospitalization, per day, low complexity. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Check]; 
Service: Subsequent hospitalization, per day, moderate complexity. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Subsequent hospitalization, per day, high complexity. 

Service Category: Eye, ear, nose and throat; 

Appears in: AAP: [Empty]; 
Appears in: Urban: [Check]; 
Service: Ophthalmological services, new patient. 

Appears in: Urban: [Check]; 
Service: Ophthalmological services, established patient. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Screening test, hearing evaluation. 

Service Category: Maternal/newborn care; 

Appears in: AAP: [Empty]; 
Appears in: Urban: [Check]; 
Service: Vaginal delivery only, no postpartum care. 

Appears in: AAP: [Empty]; 
Appears in: Urban: [Check]; 
Service: Vaginal delivery and postpartum care. 

Appears in: AAP: [Empty]; 
Appears in: Urban: [Check]; 
Service: Cesarean delivery and no postpartum care. 

Service Category: Mental/behavioral health; 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Individual psychotherapy, 20-30 minutes face-to-face. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Individual psychotherapy, 45-50 minutes face-to-face. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Pharmacologic management. 

Service Category: Pathology/laboratory; 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Urinalysis, non-auto., without microscopy. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Rapid Streptococcus screen. 

Service Category: Radiology; 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Frontal chest x-ray. 

Appears in: AAP: [Empty]; 
Appears in: Urban: [Check]; 
Service: X-ray, chest, two views. 

Appears in: AAP: [Empty]; 
Appears in: Urban: [Check]; 
Service: CAT scan, head or brain. 

Service Category: Dental; 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Periodic exam. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Prophylaxis, child. 

Appears in: AAP: [Check]; 
Appears in: Urban: [Empty]; 
Service: Sealant, per tooth. 

Source: GAO analysis of Centers for Medicare & Medicaid Services, 
American Academy of Pediatrics (AAP), and Urban Institute data. 

Note: We selected 35 professional services from among those included 
in the studies by the AAP and the Urban Institute. Together, the AAP 
and Urban Institute studies included 255 services--235 in the AAP 
study and 32 in the Urban Institute study, with 12 appearing in both. 

[End of table] 

We selected 9 states from among the 26 states with available 2010 MAX 
data as of October 2012. We chose states that represented different 
regions of the country and that served a relatively large proportion 
of their Medicaid population through FFS arrangements rather than 
through managed care. We first eliminated 2 states that were not 
included in the AAP or Urban Institute studies-Georgia and Tennessee. 
We then grouped states by Census region such that our sample 
represented a sizable proportion of the total Medicaid enrollment. 
When selecting states within each region, we gave preference to states 
with higher enrollment. However, we also sought to ensure that the 
sample included states with relatively small as well as large 
enrollment. Given that our study focused on FFS rates, we gave 
preference to states that had higher percentages of enrollees--
particularly higher percentages of children--in FFS arrangements, as 
opposed to comprehensive risk-based managed care arrangements. The 9 
states we selected based on these criteria were Alabama, Illinois, 
Iowa, Louisiana, Montana, Nebraska, Pennsylvania, South Carolina, and 
Texas. 

To determine the extent to which state Medicaid programs varied the 
rate they paid for a given service, we calculated the median payment 
amount and the percentage difference between the 10th and 90th 
percentile of claims payment rates (P90/P10) for each 
service.[Footnote 10] To further explore this variation and examine 
the extent to which variations in payment could be explained by 
differences in provider type, service setting, and patient age, we 
performed a regression analysis.[Footnote 11] Selected regression 
results are presented in table 6 in enclosure 2.[Footnote 12] 

To determine the extent to which Medicaid provider payment rates 
calculated from claims data confirmed rates reported in existing 
studies of states' fee schedules, we calculated median payment rates 
from the claims data and compared these to fee schedule rates reported 
by the AAP and the Urban Institute. To help ensure comparability, we 
restricted the claims in this part of our analysis to those most 
comparable to the fees used by the AAP and the Urban Institute 
studies. Generally, this involved restricting those claims to the 
service provided by a physician or dentist, in an office, and to a 
child. For 8 services for which we had fee schedule data from both the 
AAP and Urban Institute studies, we used the AAP rate in our analysis. 
See table 4 for fee schedule rates and claims restrictions used in the 
comparative analysis. To the extent that claims payments differed from 
fee schedule data, we used fee schedule information obtained from 
state Medicaid program websites to explore potential reasons for any 
differences we observed. 

Table 4: Fee Schedule Rates and Claims Restrictions Used in 
Comparative Analysis: 

Service: Established patient, problem-focused; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: Established patient, low complexity; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: Established patient, moderate complexity; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: New patient, low complexity; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: New patient, moderate complexity; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: One immunization administration; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: Established patient, under 1 year; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: Established patient, 1 through 4 years; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: Routine venipuncture; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: Echocardiography, with image documentation; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: Doppler echocardiograph; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: Emergency department visit, problem focused; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-F-C. 

Service: Emergency department visit, expanded; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-F-C. 

Service: Emergency department visit, detailed; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-F-C. 

Service: Initial hospitalization, per day, moderate complexity; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-F-C. 

Service: Subsequent hospitalization, per day, low complexity; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-F-C. 

Service: Subsequent hospitalization, per day, moderate complexity; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-F-C. 

Service: Subsequent hospitalization, per day, high complexity; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-F-C. 

Service: Ophthalmological services, new patient; 
Fee schedule rate used: Urban; 
Restrictions applied to claims[A]: P-O-C. 

Service: Ophthalmological services, established patient; 
Fee schedule rate used: Urban; 
Restrictions applied to claims[A]: P-O-C. 

Service: Screening test, hearing evaluation; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: Vaginal delivery only, no postpartum care; 
Fee schedule rate used: Urban; 
Restrictions applied to claims[A]: P-F-A. 

Service: Vaginal delivery and postpartum care; 
Fee schedule rate used: Urban; 
Restrictions applied to claims[A]: P-F-A. 

Service: Cesarean delivery and no postpartum care; 
Fee schedule rate used: Urban; 
Restrictions applied to claims[A]: P-F-A. 

Service: Individual psychotherapy, 20-30 minutes face-to-face; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: Individual. psychotherapy, 45-50 minutes face-to-face; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: Pharmacologic management; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: Urinalysis, non-auto., without microscopy; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: NP-O-C. 

Service: Rapid Streptococcus screen; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: NP-O-C. 

Service: Frontal chest x-ray; 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: NP-O-C. 

Service: X-ray, chest, two views; 
Fee schedule rate used: Urban; 
Restrictions applied to claims[A]: NP-O-C. 

Service: CAT scan, head or brain; 
Fee schedule rate used: Urban; 
Restrictions applied to claims[A]: NP-O-C. 

Service: Periodic exam (dental); 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: Prophylaxis, child (dental); 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Service: Sealant, per tooth (dental); 
Fee schedule rate used: AAP; 
Restrictions applied to claims[A]: P-O-C. 

Source: GAO analysis of Centers for Medicare & Medicaid Services, 
American Academy of Pediatrics (AAP), and Urban Institute data. 

Note: For 8 services for which we had fee schedule data from both the 
AAP and Urban Institute studies, we used the AAP rate in our analysis. 

[A] P = physician/dentist; NP = non-physician; F = facility (inpatient 
hospital, outpatient hospital, or emergency department); O = office; A 
= adult; C = child. 

[End of table] 

[End of section] 

Enclosure II: 

This enclosure includes the following detailed data tables: 

Table 5-A: Distribution of Medicaid Provider Payment Rates, by State 
and Service, Calendar Year 2010 (Alabama, Iowa, and Illinois): 

Table 5-B: Distribution of Medicaid Provider Payment Rates, by State 
and Service, Calendar Year 2010 (Louisiana, Montana, and Nebraska): 

Table 5-C: Distribution of Medicaid Provider Payment Rates, by State 
and Service, Calendar Year 2010 (Pennsylvania, South Carolina, and 
Texas): 

Table 6: Percent Difference in Medicaid Provider Payment Rates 
Accounted for by Provider Type, Service Setting, and Patient Age, 
Selected States and Services, Calendar Year 2010: 

Table 7: Median Medicaid Provider Payment Rates Calculated from 
Claims, Selected States and Services, Calendar Year 2010: 

Table 8: Percentage Difference between Medicaid Provider Payment Rates 
Published in Previous Studies Based on Fee Schedules and Rates 
Calculated from Claims Data, Selected States and Services, Calendar 
Year 2010: 

Table 5: Distribution of Medicaid Provider Payment Rates, by State and 
Service, Calendar Year 2010 (Alabama, Iowa, and Illinois): 

Service: Routine venipuncture; 
Alabama: Median: [Empty]; 
Alabama: P10: [Empty]; 
Alabama: P90: [Empty]; 
Alabama: P90/10: [Empty]; 
Iowa: Median: 3; 
Iowa: P10: 3; 
Iowa: P90: 6; 
Iowa: P90/10: 2.00; 
Illinois: Median: [Empty]; 
Illinois: P10: [Empty]; 
Illinois: P90: [Empty]; 
Illinois: P90/10: [Empty]. 

Service: Vaginal delivery only, no postpartum care; 
Alabama: Median: 1,041; 
Alabama: P10: 950; 
Alabama: P90: 1,250; 
Alabama: P90/10: 1.32; 
Iowa: Median: 759; 
Iowa: P10: 759; 
Iowa: P90: 759; 
Iowa: P90/10: 1.00; 
Illinois: Median: 924; 
Illinois: P10: 924; 
Illinois: P90: 924; 
Illinois: P90/10: 1.00. 

Service: Vaginal delivery and postpartum care; 
Alabama: Median: 1,161; 
Alabama: P10: 1,000; 
Alabama: P90: 1,300; 
Alabama: P90/10: 1.30; 
Iowa: Median: 836; 
Iowa: P10: 836; 
Iowa: P90: 836; 
Iowa: P90/10: 1.00; 
Illinois: Median: 924; 
Illinois: P10: 924; 
Illinois: P90: 924; 
Illinois: P90/10: 1.00. 

Service: Cesarean delivery and no postpartum care; 
Alabama: Median: 1,041; 
Alabama: P10: 950; 
Alabama: P90: 1,250; 
Alabama: P90/10: 1.32; 
Iowa: Median: 893; 
Iowa: P10: 889; 
Iowa: P90: 893; 
Iowa: P90/10: 1.00; 
Illinois: Median: 1,070; 
Illinois: P10: 1,070; 
Illinois: P90: 1,070; 
Illinois: P90/10: 1.00. 

Service: CAT scan, head or brain; 
Alabama: Median: 158; 
Alabama: P10: 158; 
Alabama: P90: 273; 
Alabama: P90/10: 1.73; 
Iowa: Median: 199; 
Iowa: P10: 196; 
Iowa: P90: 199; 
Iowa: P90/10: 1.02; 
Illinois: Median: 247; 
Illinois: P10: 247; 
Illinois: P90: 247; 
Illinois: P90/10: 1.00. 

Service: Frontal chest x-ray; 
Alabama: Median: 20; 
Alabama: P10: 20; 
Alabama: P90: 34; 
Alabama: P90/10: 1.70; 
Iowa: Median: 25; 
Iowa: P10: 13; 
Iowa: P90: 25; 
Iowa: P90/10: 1.92; 
Illinois: Median: 17; 
Illinois: P10: 17; 
Illinois: P90: 17; 
Illinois: P90/10: 1.00. 

Service: X-ray, chest, two views; 
Alabama: Median: 23; 
Alabama: P10: 23; 
Alabama: P90: 23; 
Alabama: P90/10: 1.00; 
Iowa: Median: 32; 
Iowa: P10: 27; 
Iowa: P90: 32; 
Iowa: P90/10: 1.19; 
Illinois: Median: 22; 
Illinois: P10: 22; 
Illinois: P90: 22; 
Illinois: P90/10: 1.00. 

Service: Urinalysis, non-auto., without microscopy; 
Alabama: Median: 3; 
Alabama: P10: 3; 
Alabama: P90: 3; 
Alabama: P90/10: 1.00; 
Iowa: Median: 4; 
Iowa: P10: 3; 
Iowa: P90: 8; 
Iowa: P90/10: 2.67; 
Illinois: Median: 3; 
Illinois: P10: 3; 
Illinois: P90: 3; 
Illinois: P90/10: 1.00. 

Service: Rapid Streptococcus screen; 
Alabama: Median: 14; 
Alabama: P10: 14; 
Alabama: P90: 14; 
Alabama: P90/10: 1.00; 
Iowa: Median: 17; 
Iowa: P10: 13; 
Iowa: P90: 17; 
Iowa: P90/10: 1.31; 
Illinois: Median: 16; 
Illinois: P10: 16; 
Illinois: P90: 16; 
Illinois: P90/10: 1.00. 

Service: One immunization administration; 
Alabama: Median: 5; 
Alabama: P10: 5; 
Alabama: P90: 5; 
Alabama: P90/10: 1.00; 
Iowa: Median: 7; 
Iowa: P10: 4; 
Iowa: P90: 17; 
Iowa: P90/10: 4.25; 
Illinois: Median: [Empty]; 
Illinois: P10: [Empty]; 
Illinois: P90: [Empty]; 
Illinois: P90/10: [Empty]. 

Service: Individual psychotherapy, 20-30 minutes face-to-face; 
Alabama: Median: 47; 
Alabama: P10: 47; 
Alabama: P90: 47; 
Alabama: P90/10: 1.00; 
Iowa: Median: 33; 
Iowa: P10: 33; 
Iowa: P90: 55; 
Iowa: P90/10: 1.67; 
Illinois: Median: 68; 
Illinois: P10: 28; 
Illinois: P90: 68; 
Illinois: P90/10: 2.43. 

Service: Individual psychotherapy, 45-50 minutes face-to-face; 
Alabama: Median: 71; 
Alabama: P10: 71; 
Alabama: P90: 71; 
Alabama: P90/10: 1.00; 
Iowa: Median: 86; 
Iowa: P10: 77; 
Iowa: P90: 87; 
Iowa: P90/10: 1.13; 
Illinois: Median: 68; 
Illinois: P10: 68; 
Illinois: P90: 102; 
Illinois: P90/10: 1.50. 

Service: Pharmacologic management; 
Alabama: Median: 37; 
Alabama: P10: 37; 
Alabama: P90: 37; 
Alabama: P90/10: 1.00; 
Iowa: Median: 43; 
Iowa: P10: 43; 
Iowa: P90: 46; 
Iowa: P90/10: 1.07; 
Illinois: Median: 22; 
Illinois: P10: 22; 
Illinois: P90: 68; 
Illinois: P90/10: 3.09. 

Service: Ophthalmological services, new patient; 
Alabama: Median: 84; 
Alabama: P10: 75; 
Alabama: P90: 84; 
Alabama: P90/10: 1.12; 
Iowa: Median: 96; 
Iowa: P10: 65; 
Iowa: P90: 96; 
Iowa: P90/10: 1.48; 
Illinois: Median: 46; 
Illinois: P10: 37; 
Illinois: P90: 46; 
Illinois: P90/10: 1.24. 

Service: Ophthalmological services, established patient; 
Alabama: Median: 62; 
Alabama: P10: 61; 
Alabama: P90: 62; 
Alabama: P90/10: 1.02; 
Iowa: Median: 70; 
Iowa: P10: 67; 
Iowa: P90: 70; 
Iowa: P90/10: 1.04; 
Illinois: Median: 44; 
Illinois: P10: 44; 
Illinois: P90: 44; 
Illinois: P90/10: 1.00. 

Service: Screening test, hearing evaluation; 
Alabama: Median: 16; 
Alabama: P10: 10; 
Alabama: P90: 16; 
Alabama: P90/10: 1.60; 
Iowa: Median: 14; 
Iowa: P10: 14; 
Iowa: P90: 14; 
Iowa: P90/10: 1.00; 
Illinois: Median: 20; 
Illinois: P10: 15; 
Illinois: P90: 32; 
Illinois: P90/10: 2.13. 

Service: Echocardiography, with image documentation; 
Alabama: Median: 134; 
Alabama: P10: 125; 
Alabama: P90: 134; 
Alabama: P90/10: 1.07; 
Iowa: Median: [Empty]; 
Iowa: P10: [Empty]; 
Iowa: P90: [Empty]; 
Iowa: P90/10: 
Illinois: Median: 91; 
Illinois: P10: 91; 
Illinois: P90: 91; 
Illinois: P90/10: 1.00. 

Service: Doppler echocardiograph; 
Alabama: Median: 71; 
Alabama: P10: 71; 
Alabama: P90: 106; 
Alabama: P90/10: 1.49; 
Iowa: Median: 88; 
Iowa: P10: 78; 
Iowa: P90: 116; 
Iowa: P90/10: 1.49; 
Illinois: Median: 20; 
Illinois: P10: 20; 
Illinois: P90: 40; 
Illinois: P90/10: 2.00. 

Service: New patient, low complexity; 
Alabama: Median: 78; 
Alabama: P10: 77; 
Alabama: P90: 79; 
Alabama: P90/10: 1.03; 
Iowa: Median: 81; 
Iowa: P10: 77; 
Iowa: P90: 81; 
Iowa: P90/10: 1.05; 
Illinois: Median: 42; 
Illinois: P10: 40; 
Illinois: P90: 44; 
Illinois: P90/10: 1.10. 

Service: New patient, moderate complexity; 
Alabama: Median: 111; 
Alabama: P10: 110; 
Alabama: P90: 113; 
Alabama: P90/10: 1.03; 
Iowa: Median: 117; 
Iowa: P10: 114; 
Iowa: P90: 117; 
Iowa: P90/10: 1.03; 
Illinois: Median: 68; 
Illinois: P10: 64; 
Illinois: P90: 70; 
Illinois: P90/10: 1.09. 

Service: Established patient, problem-focused; 
Alabama: Median: 31; 
Alabama: P10: 30; 
Alabama: P90: 38; 
Alabama: P90/10: 1.27; 
Iowa: Median: 31; 
Iowa: P10: 28; 
Iowa: P90: 31; 
Iowa: P90/10: 1.11; 
Illinois: Median: 26; 
Illinois: P10: 22; 
Illinois: P90: 26; 
Illinois: P90/10: 1.18. 

Service: Established patient, low complexity; 
Alabama: Median: 42; 
Alabama: P10: 34; 
Alabama: P90: 43; 
Alabama: P90/10: 1.26; 
Iowa: Median: 43; 
Iowa: P10: 36; 
Iowa: P90: 43; 
Iowa: P90/10: 1.19; 
Illinois: Median: 47; 
Illinois: P10: 28; 
Illinois: P90: 47; 
Illinois: P90/10: 1.68. 

Service: Established patient, moderate complexity; 
Alabama: Median: 67; 
Alabama: P10: 61; 
Alabama: P90: 68; 
Alabama: P90/10: 1.11; 
Iowa: Median: 66; 
Iowa: P10: 58; 
Iowa: P90: 66; 
Iowa: P90/10: 1.14; 
Illinois: Median: 71; 
Illinois: P10: 41; 
Illinois: P90: 73; 
Illinois: P90/10: 1.78. 

Service: Initial hospitalization, per day, moderate complexity; 
Alabama: Median: 95; 
Alabama: P10: 81; 
Alabama: P90: 145; 
Alabama: P90/10: 1.79; 
Iowa: Median: 106; 
Iowa: P10: 98; 
Iowa: P90: 106; 
Iowa: P90/10: 1.08; 
Illinois: Median: 51; 
Illinois: P10: 51; 
Illinois: P90: 51; 
Illinois: P90/10: 1.00. 

Service: Subsequent hospitalization, per day, low complexity; 
Alabama: Median: 24; 
Alabama: P10: 24; 
Alabama: P90: 44; 
Alabama: P90/10: 1.83; 
Iowa: Median: 33; 
Iowa: P10: 31; 
Iowa: P90: 37; 
Iowa: P90/10: 1.19; 
Illinois: Median: 16; 
Illinois: P10: 16; 
Illinois: P90: 16; 
Illinois: P90/10: 1.00. 

Service: Subsequent hospitalization, per day, moderate complexity; 
Alabama: Median: 40; 
Alabama: P10: 40; 
Alabama: P90: 72; 
Alabama: P90/10: 1.80; 
Iowa: Median: 51; 
Iowa: P10: 50; 
Iowa: P90: 55; 
Iowa: P90/10: 1.10; 
Illinois: Median: 25; 
Illinois: P10: 25; 
Illinois: P90: 25; 
Illinois: P90/10: 1.00. 

Service: Subsequent hospitalization, per day, high complexity; 
Alabama: Median: 102; 
Alabama: P10: 57; 
Alabama: P90: 102; 
Alabama: P90/10: 1.79; 
Iowa: Median: 72; 
Iowa: P10: 69; 
Iowa: P90: 76; 
Iowa: P90/10: 1.10; 
Illinois: Median: 35; 
Illinois: P10: 35; 
Illinois: P90: 35; 
Illinois: P90/10: 1.00. 

Service: Emergency department visit, problem focused; 
Alabama: Median: 21; 
Alabama: P10: 21; 
Alabama: P90: 21; 
Alabama: P90/10: 1.00; 
Iowa: Median: 29; 
Iowa: P10: 29; 
Iowa: P90: 29; 
Iowa: P90/10: 1.00; 
Illinois: Median: 24; 
Illinois: P10: 24; 
Illinois: P90: 24; 
Illinois: P90/10: 1.00. 

Service: Emergency department visit, expanded; 
Alabama: Median: 42; 
Alabama: P10: 42; 
Alabama: P90: 42; 
Alabama: P90/10: 1.00; 
Iowa: Median: 59; 
Iowa: P10: 59; 
Iowa: P90: 59; 
Iowa: P90/10: 1.00; 
Illinois: Median: 32; 
Illinois: P10: 32; 
Illinois: P90: 32; 
Illinois: P90/10: 1.00. 

Service: Emergency department visit, detailed; 
Alabama: Median: 66; 
Alabama: P10: 66; 
Alabama: P90: 66; 
Alabama: P90/10: 1.00; 
Iowa: Median: 90; 
Iowa: P10: 90; 
Iowa: P90: 90; 
Iowa: P90/10: 1.00; 
Illinois: Median: 44; 
Illinois: P10: 44; 
Illinois: P90: 44; 
Illinois: P90/10: 1.00. 

Service: Established patient, under 1 year; 
Alabama: Median: [Empty]; 
Alabama: P10: [Empty]; 
Alabama: P90: [Empty]; 
Alabama: P90/10: [Empty]; 
Iowa: Median: 72; 
Iowa: P10: 51; 
Iowa: P90: 72; 
Iowa: P90/10: 1.41; 
Illinois: Median: [Empty]; 
Illinois: P10: [Empty]; 
Illinois: P90: [Empty]; 
Illinois: P90/10: [Empty]. 

Service: Established patient, 1 through 4 years; 
Alabama: Median: [Empty]; 
Alabama: P10: [Empty]; 
Alabama: P90: [Empty]; 
Alabama: P90/10: [Empty]; 
Iowa: Median: 75; 
Iowa: P10: 56; 
Iowa: P90: 79; 
Iowa: P90/10: 1.41; 
Illinois: Median: [Empty]; 
Illinois: P10: [Empty]; 
Illinois: P90: [Empty]; 
Illinois: P90/10: [Empty]. 

Service: Periodic exam (dental); 
Alabama: Median: 18; 
Alabama: P10: 18; 
Alabama: P90: 18; 
Alabama: P90/10: 1.00; 
Iowa: Median: 18; 
Iowa: P10: 16; 
Iowa: P90: 19; 
Iowa: P90/10: 1.19; 
Illinois: Median: 28; 
Illinois: P10: 28; 
Illinois: P90: 28; 
Illinois: P90/10: 1.00. 

Service: Prophylaxis, child (dental); 
Alabama: Median: 28; 
Alabama: P10: 28; 
Alabama: P90: 28; 
Alabama: P90/10: 1.00; 
Iowa: Median: 23; 
Iowa: P10: 21; 
Iowa: P90: 26; 
Iowa: P90/10: 1.24; 
Illinois: Median: 41; 
Illinois: P10: 41; 
Illinois: P90: 41; 
Illinois: P90/10: 1.00. 

Service: Sealant, per tooth (dental); 
Alabama: Median: 26; 
Alabama: P10: 26; 
Alabama: P90: 26; 
Alabama: P90/10: 1.00; 
Iowa: Median: 20; 
Iowa: P10: 17; 
Iowa: P90: 23; 
Iowa: P90/10: 1.35; 
Illinois: Median: 36; 
Illinois: P10: 36; 
Illinois: P90: 36; 
Illinois: P90/10: 1.00. 

Source: GAO analysis of Centers for Medicare & Medicaid Services' data. 

Note: For each service, the table displays the median payment, payment 
rates at the 10th percentile (P10) and 90th percentile (P90), and the 
ratio of the 90th to the 10th percentiles (P90/P10). 

[End of table] 

Table 5-B: Distribution of Medicaid Provider Payment Rates, by State 
and Service, Calendar Year 2010 (Louisiana, Montana, and Nebraska): 

Service: Routine venipuncture; 
Louisiana: Median: [Empty]; 
Louisiana: P10: [Empty]; 
Louisiana: P90: [Empty]; 
Louisiana: P90/P10: [Empty]; 
Montana: Median: 3; 
Montana: P10: 3; 
Montana: P90: 3; 
Montana: P90/P10: 1.00; 
Nebraska: Median: 4; 
Nebraska: P10: 4; 
Nebraska: P90: 4; 
Nebraska: P90/P10: 1.00. 

Service: Vaginal delivery only, no postpartum care; 
Louisiana: Median: 581; 
Louisiana: P10: 522; 
Louisiana: P90: 653; 
Louisiana: P90/P10: 1.25; 
Montana: Median: 831; 
Montana: P10: 831; 
Montana: P90: 866; 
Montana: P90/P10: 1.04; 
Nebraska: Median: 810; 
Nebraska: P10: 806; 
Nebraska: P90: 810; 
Nebraska: P90/P10: 1.00. 

Service: Vaginal delivery and postpartum care; 
Louisiana: Median: 671; 
Louisiana: P10: 671; 
Louisiana: P90: 755; 
Louisiana: P90/P10: 1.13; 
Montana: Median: 1,002; 
Montana: P10: 970; 
Montana: P90: 1,002; 
Montana: P90/P10: 1.03; 
Nebraska: Median: 960; 
Nebraska: P10: 960; 
Nebraska: P90: 965; 
Nebraska: P90/P10: 1.01. 

Service: Cesarean delivery and no postpartum care; 
Louisiana: Median: 687; 
Louisiana: P10: 687; 
Louisiana: P90: 687; 
Louisiana: P90/P10: 1.00; 
Montana: Median: 986; 
Montana: P10: 354; 
Montana: P90: 1,025; 
Montana: P90/P10: 2.90; 
Nebraska: Median: 1,119; 
Nebraska: P10: 1,113; 
Nebraska: P90: 1,119; 
Nebraska: P90/P10: 1.01. 

Service: CAT scan, head or brain; 
Louisiana: Median: 160; 
Louisiana: P10: 153; 
Louisiana: P90: 167; 
Louisiana: P90/P10: 1.09; 
Montana: Median: [Empty]; 
Montana: P10: [Empty]; 
Montana: P90: [Empty]; 
Montana: P90/P10: [Empty]; 
Nebraska: Median: 197; 
Nebraska: P10: 197; 
Nebraska: P90: 198; 
Nebraska: P90/P10: 1.01. 

Service: Frontal chest x-ray; 
Louisiana: Median: 18; 
Louisiana: P10: 14; 
Louisiana: P90: 19; 
Louisiana: P90/P10: 1.36; 
Montana: Median: [Empty]; 
Montana: P10: [Empty]; 
Montana: P90: [Empty]; 
Montana: P90/P10: [Empty]; 
Nebraska: Median: 23; 
Nebraska: P10: 23; 
Nebraska: P90: 23; 
Nebraska: P90/P10: 1.00. 

Service: X-ray, chest, two views; 
Louisiana: Median: 23; 
Louisiana: P10: 20; 
Louisiana: P90: 25; 
Louisiana: P90/P10: 1.25; 
Montana: Median: [Empty]; 
Montana: P10: [Empty]; 
Montana: P90: [Empty]; 
Montana: P90/P10: [Empty]; 
Nebraska: Median: 30; 
Nebraska: P10: 30; 
Nebraska: P90: 31; 
Nebraska: P90/P10: 1.03. 

Service: Urinalysis, non-auto., without microscopy; 
Louisiana: Median: 3; 
Louisiana: P10: 2; 
Louisiana: P90: 3; 
Louisiana: P90/P10: 1.50; 
Montana: Median: 4; 
Montana: P10: 4; 
Montana: P90: 4; 
Montana: P90/P10: 1.00; 
Nebraska: Median: 4; 
Nebraska: P10: 4; 
Nebraska: P90: 4; 
Nebraska: P90/P10: 1.00. 

Service: Rapid Streptococcus screen; 
Louisiana: Median: 14; 
Louisiana: P10: 12; 
Louisiana: P90: 15; 
Louisiana: P90/P10: 1.25; 
Montana: Median: 17; 
Montana: P10: 17; 
Montana: P90: 17; 
Montana: P90/P10: 1.00; 
Nebraska: Median: 17; 
Nebraska: P10: 17; 
Nebraska: P90: 17; 
Nebraska: P90/P10: 1.00. 

Service: One immunization administration; 
Louisiana: Median: 15; 
Louisiana: P10: 15; 
Louisiana: P90: 15; 
Louisiana: P90/P10: 1.00; 
Montana: Median: 16; 
Montana: P10: 14; 
Montana: P90: 16; 
Montana: P90/P10: 1.14; 
Nebraska: Median: 6; 
Nebraska: P10: 6; 
Nebraska: P90: 6; 
Nebraska: P90/P10: 1.00. 

Service: Individual psychotherapy, 20-30 minutes face-to-face; 
Louisiana: Median: 50; 
Louisiana: P10: 50; 
Louisiana: P90: 50; 
Louisiana: P90/P10: 1.00; 
Montana: Median: 41; 
Montana: P10: 41; 
Montana: P90: 41; 
Montana: P90/P10: 1.00; 
Nebraska: Median: 35; 
Nebraska: P10: 35; 
Nebraska: P90: 35; 
Nebraska: P90/P10: 1.00. 

Service: Individual psychotherapy, 45-50 minutes face-to-face; 
Louisiana: Median: 76; 
Louisiana: P10: 76; 
Louisiana: P90: 76; 
Louisiana: P90/P10: 1.00; 
Montana: Median: 57; 
Montana: P10: 57; 
Montana: P90: 58; 
Montana: P90/P10: 1.02; 
Nebraska: Median: 64; 
Nebraska: P10: 64; 
Nebraska: P90: 64; 
Nebraska: P90/P10: 1.00. 

Service: Pharmacologic management; 
Louisiana: Median: 48; 
Louisiana: P10: 46; 
Louisiana: P90: 48; 
Louisiana: P90/P10: 1.04; 
Montana: Median: 71; 
Montana: P10: 52; 
Montana: P90: 72; 
Montana: P90/P10: 1.38; 
Nebraska: Median: 42; 
Nebraska: P10: 37; 
Nebraska: P90: 42; 
Nebraska: P90/P10: 1.14. 

Service: Ophthalmological services, new patient; 
Louisiana: Median: 107; 
Louisiana: P10: 85; 
Louisiana: P90: 107; 
Louisiana: P90/P10: 1.26; 
Montana: Median: 96; 
Montana: P10: 65; 
Montana: P90: 112; 
Montana: P90/P10: 1.72; 
Nebraska: Median: 35; 
Nebraska: P10: 35; 
Nebraska: P90: 55; 
Nebraska: P90/P10: 1.57. 

Service: Ophthalmological services, established patient; 
Louisiana: Median: 87; 
Louisiana: P10: 59; 
Louisiana: P90: 87; 
Louisiana: P90/P10: 1.47; 
Montana: Median: 89; 
Montana: P10: 67; 
Montana: P90: 92; 
Montana: P90/P10: 1.37; 
Nebraska: Median: 35; 
Nebraska: P10: 35; 
Nebraska: P90: 47; 
Nebraska: P90/P10: 1.34. 

Service: Screening test, hearing evaluation; 
Louisiana: Median: 7; 
Louisiana: P10: 6; 
Louisiana: P90: 7; 
Louisiana: P90/P10: 1.17; 
Montana: Median: 10; 
Montana: P10: 10; 
Montana: P90: 10; 
Montana: P90/P10: 1.00; 
Nebraska: Median: 13; 
Nebraska: P10: 13; 
Nebraska: P90: 13; 
Nebraska: P90/P10: 1.00. 

Service: Echocardiography, with image documentation; 
Louisiana: Median: 120; 
Louisiana: P10: 120; 
Louisiana: P90: 128; 
Louisiana: P90/P10: 1.07; 
Montana: Median: [Empty]; 
Montana: P10: [Empty]; 
Montana: P90: [Empty]; 
Montana: P90/P10: [Empty]; 
Nebraska: Median: 224; 
Nebraska: P10: 224; 
Nebraska: P90: 224; 
Nebraska: P90/P10: 1.00. 

Service: Doppler echocardiograph; 
Louisiana: Median: 63; 
Louisiana: P10: 53; 
Louisiana: P90: 63; 
Louisiana: P90/P10: 1.19; 
Montana: Median: 65; 
Montana: P10: 65; 
Montana: P90: 75; 
Montana: P90/P10: 1.15; 
Nebraska: Median: 106; 
Nebraska: P10: 106; 
Nebraska: P90: 106; 
Nebraska: P90/P10: 1.00. 

Service: New patient, low complexity; 
Louisiana: Median: 77; 
Louisiana: P10: 62; 
Louisiana: P90: 78; 
Louisiana: P90/P10: 1.26; 
Montana: Median: 94; 
Montana: P10: 72; 
Montana: P90: 97; 
Montana: P90/P10: 1.35; 
Nebraska: Median: 69; 
Nebraska: P10: 69; 
Nebraska: P90: 70; 
Nebraska: P90/P10: 1.01. 

Service: New patient, moderate complexity; 
Louisiana: Median: 118; 
Louisiana: P10: 101; 
Louisiana: P90: 121; 
Louisiana: P90/P10: 1.20; 
Montana: Median: 147; 
Montana: P10: 118; 
Montana: P90: 152; 
Montana: P90/P10: 1.29; 
Nebraska: Median: 104; 
Nebraska: P10: 102; 
Nebraska: P90: 104; 
Nebraska: P90/P10: 1.02. 

Service: Established patient, problem-focused; 
Louisiana: Median: 31; 
Louisiana: P10: 25; 
Louisiana: P90: 31; 
Louisiana: P90/P10: 1.24; 
Montana: Median: 38; 
Montana: P10: 24; 
Montana: P90: 38; 
Montana: P90/P10: 1.58; 
Nebraska: Median: 30; 
Nebraska: P10: 30; 
Nebraska: P90: 30; 
Nebraska: P90/P10: 1.00. 

Service: Established patient, low complexity; 
Louisiana: Median: 52; 
Louisiana: P10: 42; 
Louisiana: P90: 52; 
Louisiana: P90/P10: 1.24; 
Montana: Median: 63; 
Montana: P10: 45; 
Montana: P90: 65; 
Montana: P90/P10: 1.44; 
Nebraska: Median: 45; 
Nebraska: P10: 45; 
Nebraska: P90: 45; 
Nebraska: P90/P10: 1.00. 

Service: Established patient, moderate complexity; 
Louisiana: Median: 76; 
Louisiana: P10: 63; 
Louisiana: P90: 79; 
Louisiana: P90/P10: 1.25; 
Montana: Median: 95; 
Montana: P10: 67; 
Montana: P90: 98; 
Montana: P90/P10: 1.46; 
Nebraska: Median: 68; 
Nebraska: P10: 68; 
Nebraska: P90: 68; 
Nebraska: P90/P10: 1.00. 

Service: Initial hospitalization, per day, moderate complexity; 
Louisiana: Median: 103; 
Louisiana: P10: 89; 
Louisiana: P90: 107; 
Louisiana: P90/P10: 1.20; 
Montana: Median: 130; 
Montana: P10: 130; 
Montana: P90: 131; 
Montana: P90/P10: 1.01; 
Nebraska: Median: 83; 
Nebraska: P10: 83; 
Nebraska: P90: 84; 
Nebraska: P90/P10: 1.01. 

Service: Subsequent hospitalization, per day, low complexity; 
Louisiana: Median: 27; 
Louisiana: P10: 27; 
Louisiana: P90: 32; 
Louisiana: P90/P10: 1.19; 
Montana: Median: 49; 
Montana: P10: 39; 
Montana: P90: 49; 
Montana: P90/P10: 1.26; 
Nebraska: Median: 29; 
Nebraska: P10: 28; 
Nebraska: P90: 29; 
Nebraska: P90/P10: 1.04. 

Service: Subsequent hospitalization, per day, moderate complexity; 
Louisiana: Median: 49; 
Louisiana: P10: 49; 
Louisiana: P90: 58; 
Louisiana: P90/P10: 1.18; 
Montana: Median: 71; 
Montana: P10: 70; 
Montana: P90: 88; 
Montana: P90/P10: 1.26; 
Nebraska: Median: 45; 
Nebraska: P10: 45; 
Nebraska: P90: 46; 
Nebraska: P90/P10: 1.02. 

Service: Subsequent hospitalization, per day, high complexity; 
Louisiana: Median: 79; 
Louisiana: P10: 70; 
Louisiana: P90: 83; 
Louisiana: P90/P10: 1.19; 
Montana: Median: 102; 
Montana: P10: 101; 
Montana: P90: 127; 
Montana: P90/P10: 1.26; 
Nebraska: Median: 76; 
Nebraska: P10: 52; 
Nebraska: P90: 76; 
Nebraska: P90/P10: 1.46. 

Service: Emergency department (ED) visit, problem focused; 
Louisiana: Median: 35; 
Louisiana: P10: 29; 
Louisiana: P90: 35; 
Louisiana: P90/P10: 1.21; 
Montana: Median: 41; 
Montana: P10: 41; 
Montana: P90: 42; 
Montana: P90/P10: 1.02; 
Nebraska: Median: 34; 
Nebraska: P10: 34; 
Nebraska: P90: 34; 
Nebraska: P90/P10: 1.00. 

Service: ED visit, expanded; 
Louisiana: Median:53; 
Louisiana: P10: 43; 
Louisiana: P90: 54; 
Louisiana: P90/P10: 1.26; 
Montana: Median: 65; 
Montana: P10: 63; 
Montana: P90: 65; 
Montana: P90/P10: 1.03; 
Nebraska: Median: 51; 
Nebraska: P10: 51; 
Nebraska: P90: 51; 
Nebraska: P90/P10: 1.00. 

Service: ED visit, detailed; 
Louisiana: Median: 84; 
Louisiana: P10: 84; 
Louisiana: P90: 101; 
Louisiana: P90/P10: 1.20; 
Montana: Median: 119; 
Montana: P10: 119; 
Montana: P90: 122; 
Montana: P90/P10: 1.03; 
Nebraska: Median: 60; 
Nebraska: P10: 60; 
Nebraska: P90: 61; 
Nebraska: P90/P10: 1.02. 

Service: Established patient, under 1 year; 
Louisiana: Median: 61; 
Louisiana: P10: 61; 
Louisiana: P90: 64; 
Louisiana: P90/P10: 1.05; 
Montana: Median: 76; 
Montana: P10: 52; 
Montana: P90: 77; 
Montana: P90/P10: 1.48; 
Nebraska: Median: [Empty]; 
Nebraska: P10: [Empty]; 
Nebraska: P90: [Empty]; 
Nebraska: P90/P10: [Empty]. 

Service: Established patient, 1 through 4 years; 
Louisiana: Median: 68; 
Louisiana: P10: 68; 
Louisiana: P90: 71; 
Louisiana: P90/P10: 1.04; 
Montana: Median: 85; 
Montana: P10: 61; 
Montana: P90: 86; 
Montana: P90/P10: 1.41; 
Nebraska: Median: [Empty]; 
Nebraska: P10: [Empty]; 
Nebraska: P90: [Empty]; 
Nebraska: P90/P10: [Empty]. 

Service: Periodic exam (dental); 
Louisiana: Median: [Empty]; 
Louisiana: P10: [Empty]; 
Louisiana: P90: [Empty]; 
Louisiana: P90/P10: [Empty]; 
Montana: Median: 23; 
Montana: P10: 23; 
Montana: P90: 23; 
Montana: P90/P10: 1.00; 
Nebraska: Median: 17; 
Nebraska: P10: 17; 
Nebraska: P90: 17; 
Nebraska: P90/P10: 1.00. 

Service: Prophylaxis, child (dental); 
Louisiana: Median: [Empty]; 
Louisiana: P10: [Empty]; 
Louisiana: P90: [Empty]; 
Louisiana: P90/P10: [Empty]; 
Montana: Median: 33; 
Montana: P10: 33; 
Montana: P90: 33; 
Montana: P90/P10: 1.00; 
Nebraska: Median: 21; 
Nebraska: P10: 21; 
Nebraska: P90: 22; 
Nebraska: P90/P10: 1.05. 

Service: Sealant, per tooth (dental); 
Louisiana: Median: [Empty]; 
Louisiana: P10: [Empty]; 
Louisiana: P90: [Empty]; 
Louisiana: P90/P10: [Empty]; 
Montana: Median: 26; 
Montana: P10: 26; 
Montana: P90: 26; 
Montana: P90/P10: 1.00; 
Nebraska: Median: [Empty]; 
Nebraska: P10: [Empty]; 
Nebraska: P90: [Empty]; 
Nebraska: P90/P10: [Empty]. 

Source: GAO analysis of Centers for Medicare & Medicaid Services' data. 

Note: For each service, the table displays the median payment, payment 
rates at the 10th percentile (P10) and 90th percentile (P90), and the 
ratio of the 90th to the 10th percentiles (P90/P10). 

[End of table] 

Table 5-C: Distribution of Medicaid Provider Payment Rates, by State 
and Service, Calendar Year 2010 (Pennsylvania, South Carolina, and 
Texas): 

Service: Routine venipuncture; 
Pennsylvania: Median: [Empty]; 
Pennsylvania: P10: [Empty]; 
Pennsylvania: P90: [Empty]; 
Pennsylvania: P90/P10: [Empty]; 
South Carolina: Median: 2; 
South Carolina: P10: 2; 
South Carolina: P90: 2; 
South Carolina: P90/P10: 1.00; 
Texas: Median: [Empty]; 
Texas: P10: [Empty]; 
Texas: P90: [Empty]; 
Texas: P90/P10: [Empty]. 

Service: Vaginal delivery only, no postpartum care; 
Pennsylvania: Median: 1,200; 
Pennsylvania: P10: 1,200; 
Pennsylvania: P90: 1,200; 
Pennsylvania: P90/P10: 1.00; 
South Carolina: Median: 1,200; 
South Carolina: P10: 1,200; 
South Carolina: P90: 1,200; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 567; 
Texas: P10: 561; 
Texas: P90: 668; 
Texas: P90/P10: 1.19. 

Service: Vaginal delivery and postpartum care; 
Pennsylvania: Median: 1,200; 
Pennsylvania: P10: 1,200; 
Pennsylvania: P90: 1,200; 
Pennsylvania: P90/P10: 1.00; 
South Carolina: Median: [Empty]; 
South Carolina: P10: [Empty]; 
South Carolina: P90: [Empty]; 
South Carolina: P90/P10: [Empty]; 
Texas: Median: 689; 
Texas: P10: 656; 
Texas: P90: 746; 
Texas: P90/P10: 1.14. 

Service: Cesarean delivery and no postpartum care; 
Pennsylvania: Median: 1,200; 
Pennsylvania: P10: 1,200; 
Pennsylvania: P90: 1,200; 
Pennsylvania: P90/P10: 1.00; 
South Carolina: Median: 1,200; 
South Carolina: P10: 1,200; 
South Carolina: P90: 1,200; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 674; 
Texas: P10: 667; 
Texas: P90: 700; 
Texas: P90/P10: 1.05. 

Service: CAT scan, head or brain; 
Pennsylvania: Median: 78; 
Pennsylvania: P10: 78; 
Pennsylvania: P90: 117; 
Pennsylvania: P90/P10: 1.50; 
South Carolina: Median: 168; 
South Carolina: P10: 168; 
South Carolina: P90: 168; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 357; 
Texas: P10: 175; 
Texas: P90: 553; 
Texas: P90/P10: 3.16. 

Service: Frontal chest x-ray; 
Pennsylvania: Median: 12; 
Pennsylvania: P10: 11; 
Pennsylvania: P90: 19; 
Pennsylvania: P90/P10: 1.73; 
South Carolina: Median: 18; 
South Carolina: P10: 18; 
South Carolina: P90: 18; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 27; 
Texas: P10: 19; 
Texas: P90: 69; 
Texas: P90/P10: 3.63. 

Service: X-ray, chest, two views; 
Pennsylvania: Median: 15; 
Pennsylvania: P10: 14; 
Pennsylvania: P90: 25; 
Pennsylvania: P90/P10: 1.79; 
South Carolina: Median: 24; 
South Carolina: P10: 24; 
South Carolina: P90: 24; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 28; 
Texas: P10: 25; 
Texas: P90: 96; 
Texas: P90/P10: 3.84. 

Service: Urinalysis, non-auto., without microscopy; 
Pennsylvania: Median: 4; 
Pennsylvania: P10: 4; 
Pennsylvania: P90: 4; 
Pennsylvania: P90/P10: 1.00; 
South Carolina: Median: 3; 
South Carolina: P10: 3; 
South Carolina: P90: 3; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 4; 
Texas: P10: 3; 
Texas: P90: 4; 
Texas: P90/P10: 1.33. 

Service: Rapid Streptococcus screen; 
Pennsylvania: Median: 6; 
Pennsylvania: P10: 6; 
Pennsylvania: P90: 6; 
Pennsylvania: P90/P10: 1.00; 
South Carolina: Median: 15; 
South Carolina: P10: 15; 
South Carolina: P90: 15; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 16; 
Texas: P10: 16; 
Texas: P90: 17; 
Texas: P90/P10: 1.06. 

Service: One immunization administration; 
Pennsylvania: Median: [Empty]; 
Pennsylvania: P10: [Empty]; 
Pennsylvania: P90: [Empty]; 
Pennsylvania: P90/P10: [Empty]; 
South Carolina: Median: 13; 
South Carolina: P10: 13; 
South Carolina: P90: 13; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 8; 
Texas: P10: 8; 
Texas: P90: 8; 
Texas: P90/P10: 1.00. 

Service: Individual psychotherapy, 20-30 minutes face-to-face; 
Pennsylvania: Median: [Empty]; 
Pennsylvania: P10: [Empty]; 
Pennsylvania: P90: [Empty]; 
Pennsylvania: P90/P10: [Empty]; 
South Carolina: Median: 59; 
South Carolina: P10: 59; 
South Carolina: P90: 59; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 35; 
Texas: P10: 35; 
Texas: P90: 36; 
Texas: P90/P10: 1.03. 

Service: Individual psychotherapy, 45-50 minutes face-to-face; 
Pennsylvania: Median: [Empty]; 
Pennsylvania: P10: [Empty]; 
Pennsylvania: P90: [Empty]; 
Pennsylvania: P90/P10: [Empty]; 
South Carolina: Median: 77; 
South Carolina: P10: 77; 
South Carolina: P90: 77; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 70; 
Texas: P10: 61; 
Texas: P90: 81; 
Texas: P90/P10: 1.33. 

Service: Pharmacologic management; 
Pennsylvania: Median: [Empty]; 
Pennsylvania: P10: [Empty]; 
Pennsylvania: P90: [Empty]; 
Pennsylvania: P90/P10: [Empty]; 
South Carolina: Median: 45; 
South Carolina: P10: 37; 
South Carolina: P90: 45; 
South Carolina: P90/P10: 1.22; 
Texas: Median: 45; 
Texas: P10: 42; 
Texas: P90: 46; 
Texas: P90/P10: 1.10. 

Service: Ophthalmological services, new patient; 
Pennsylvania: Median: 56; 
Pennsylvania: P10: 48; 
Pennsylvania: P90: 59; 
Pennsylvania: P90/P10: 1.23; 
South Carolina: Median: 103; 
South Carolina: P10: 74; 
South Carolina: P90: 103; 
South Carolina: P90/P10: 1.39; 
Texas: Median: 100; 
Texas: P10: 88; 
Texas: P90: 105; 
Texas: P90/P10: 1.19. 

Service: Ophthalmological services, established patient; 
Pennsylvania: Median: 45; 
Pennsylvania: P10: 43; 
Pennsylvania: P90: 45; 
Pennsylvania: P90/P10: 1.05; 
South Carolina: Median: 84; 
South Carolina: P10: 75; 
South Carolina: P90: 84; 
South Carolina: P90/P10: 1.12; 
Texas: Median: 86; 
Texas: P10: 65; 
Texas: P90: 86; 
Texas: P90/P10: 1.32. 

Service: Screening test, hearing evaluation; 
Pennsylvania: Median: 8; 
Pennsylvania: P10: 8; 
Pennsylvania: P90: 8; 
Pennsylvania: P90/P10: 1.00; 
South Carolina: Median: 8; 
South Carolina: P10: 8; 
South Carolina: P90: 8; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 16; 
Texas: P10: 16; 
Texas: P90: 16; 
Texas: P90/P10: 1.00. 

Service: Echocardiography, with image documentation; 
Pennsylvania: Median: 139; 
Pennsylvania: P10: 137; 
Pennsylvania: P90: 140; 
Pennsylvania: P90/P10: 1.02; 
South Carolina: Median: 136; 
South Carolina: P10: 136; 
South Carolina: P90: 136; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 122; 
Texas: P10: 115; 
Texas: P90: 161; 
Texas: P90/P10: 1.40. 

Service: Doppler echocardiograph; 
Pennsylvania: Median: 65; 
Pennsylvania: P10: 62; 
Pennsylvania: P90: 65; 
Pennsylvania: P90/P10: 1.05; 
South Carolina: Median: 70; 
South Carolina: P10: 60; 
South Carolina: P90: 70; 
South Carolina: P90/P10: 1.17; 
Texas: Median: 53; 
Texas: P10: 53; 
Texas: P90: 82; 
Texas: P90/P10: 1.55. 

Service: New patient, low complexity; 
Pennsylvania: Median: 54; 
Pennsylvania: P10: 51; 
Pennsylvania: P90: 54; 
Pennsylvania: P90/P10: 1.06; 
South Carolina: Median: 74; 
South Carolina: P10: 59; 
South Carolina: P90: 74; 
South Carolina: P90/P10: 1.25; 
Texas: Median: 61; 
Texas: P10: 55; 
Texas: P90: 62; 
Texas: P90/P10: 1.13. 

Service: New patient, moderate complexity; 
Pennsylvania: Median: 87; 
Pennsylvania: P10: 87; 
Pennsylvania: P90: 90; 
Pennsylvania: P90/P10: 1.03; 
South Carolina: Median: 115; 
South Carolina: P10: 113; 
South Carolina: P90: 115; 
South Carolina: P90/P10: 1.02; 
Texas: Median: 83; 
Texas: P10: 74; 
Texas: P90: 90; 
Texas: P90/P10: 1.22. 

Service: Established patient, problem-focused; 
Pennsylvania: Median: 26; 
Pennsylvania: P10: 24; 
Pennsylvania: P90: 26; 
Pennsylvania: P90/P10: 1.08; 
South Carolina: Median: 29; 
South Carolina: P10: 27; 
South Carolina: P90: 29; 
South Carolina: P90/P10: 1.07; 
Texas: Median: 25; 
Texas: P10: 23; 
Texas: P90: 25; 
Texas: P90/P10: 1.09. 

Service: Established patient, low complexity; 
Pennsylvania: Median: 35; 
Pennsylvania: P10: 33; 
Pennsylvania: P90: 35; 
Pennsylvania: P90/P10: 1.06; 
South Carolina: Median: 50; 
South Carolina: P10: 40; 
South Carolina: P90: 50; 
South Carolina: P90/P10: 1.25; 
Texas: Median: 38; 
Texas: P10: 34; 
Texas: P90: 38; 
Texas: P90/P10: 1.12. 

Service: Established patient, moderate complexity; 
Pennsylvania: Median: 51; 
Pennsylvania: P10: 51; 
Pennsylvania: P90: 54; 
Pennsylvania: P90/P10: 1.06; 
South Carolina: Median: 75; 
South Carolina: P10: 73; 
South Carolina: P90: 75; 
South Carolina: P90/P10: 1.03; 
Texas: Median: 52; 
Texas: P10: 47; 
Texas: P90: 53; 
Texas: P90/P10: 1.13. 

Service: Initial hospitalization, per day, moderate complexity; 
Pennsylvania: Median: 28; 
Pennsylvania: P10: 28; 
Pennsylvania: P90: 30; 
Pennsylvania: P90/P10: 1.07; 
South Carolina: Median: 101; 
South Carolina: P10: 101; 
South Carolina: P90: 101; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 105; 
Texas: P10: 95; 
Texas: P90: 105; 
Texas: P90/P10: 1.11. 

Service: Subsequent hospitalization, per day, low complexity; 
Pennsylvania: Median: 16; 
Pennsylvania: P10: 16; 
Pennsylvania: P90: 17; 
Pennsylvania: P90/P10: 1.06; 
South Carolina: Median: 30; 
South Carolina: P10: 30; 
South Carolina: P90: 30; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 35; 
Texas: P10: 31; 
Texas: P90: 35; 
Texas: P90/P10: 1.13. 

Service: Subsequent hospitalization, per day, moderate complexity; 
Pennsylvania: Median: 16; 
Pennsylvania: P10: 16; 
Pennsylvania: P90: 17; 
Pennsylvania: P90/P10: 1.06; 
South Carolina: Median: 55; 
South Carolina: P10: 55; 
South Carolina: P90: 77; 
South Carolina: P90/P10: 1.40; 
Texas: Median: 50; 
Texas: P10: 45; 
Texas: P90: 50; 
Texas: P90/P10: 1.11. 

Service: Subsequent hospitalization, per day, high complexity; 
Pennsylvania: Median: 17; 
Pennsylvania: P10: 16; 
Pennsylvania: P90: 17; 
Pennsylvania: P90/P10: 1.06; 
South Carolina: Median: 79; 
South Carolina: P10: 79; 
South Carolina: P90: 110; 
South Carolina: P90/P10: 1.39; 
Texas: Median: 67; 
Texas: P10: 61; 
Texas: P90: 68; 
Texas: P90/P10: 1.11. 

Service: Emergency department visit, problem focused; 
Pennsylvania: Median: 27; 
Pennsylvania: P10: 25; 
Pennsylvania: P90: 27; 
Pennsylvania: P90/P10: 1.08; 
South Carolina: Median: 32; 
South Carolina: P10: 32; 
South Carolina: P90: 32; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 27; 
Texas: P10: 25; 
Texas: P90: 46; 
Texas: P90/P10: 1.84. 

Service: Emergency department visit, expanded; 
Pennsylvania: Median: 35; 
Pennsylvania: P10: 35; 
Pennsylvania: P90: 35; 
Pennsylvania: P90/P10: 1.00; 
South Carolina: Median: 50; 
South Carolina: P10: 50; 
South Carolina: P90: 50; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 37; 
Texas: P10: 34; 
Texas: P90: 62; 
Texas: P90/P10: 1.82. 

Service: Emergency department visit, detailed; 
Pennsylvania: Median: 50; 
Pennsylvania: P10: 48; 
Pennsylvania: P90: 50; 
Pennsylvania: P90/P10: 1.04; 
South Carolina: Median: 94; 
South Carolina: P10: 94; 
South Carolina: P90: 94; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 81; 
Texas: P10: 49; 
Texas: P90: 90; 
Texas: P90/P10: 1.84. 

Service: Established patient, under 1 year; 
Pennsylvania: Median: 20; 
Pennsylvania: P10: 20; 
Pennsylvania: P90: 20; 
Pennsylvania: P90/P10: 1.00; 
South Carolina: Median: [Empty]; 
South Carolina: P10: [Empty]; 
South Carolina: P90: [Empty]; 
South Carolina: P90/P10: [Empty]; 
Texas: Median: [Empty]; 
Texas: P10: [Empty]; 
Texas: P90: [Empty]; 
Texas: P90/P10: [Empty]. 

Service: Established patient, 1 through 4 years; 
Pennsylvania: Median: 20; 
Pennsylvania: P10: 20; 
Pennsylvania: P90: 20; 
Pennsylvania: P90/P10: 1.00; 
South Carolina: Median: [Empty]; 
South Carolina: P10: [Empty]; 
South Carolina: P90: [Empty]; 
South Carolina: P90/P10: [Empty]; 
Texas: Median: [Empty]; 
Texas: P10: [Empty]; 
Texas: P90: [Empty]; 
Texas: P90/P10: [Empty]. 

Service: Periodic exam (dental); 
Pennsylvania: Median: 20; 
Pennsylvania: P10: 19; 
Pennsylvania: P90: 20; 
Pennsylvania: P90/P10: 1.05; 
South Carolina: Median: 23; 
South Carolina: P10: 23; 
South Carolina: P90: 23; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 29; 
Texas: P10: 29; 
Texas: P90: 29; 
Texas: P90/P10: 1.00. 

Service: Prophylaxis, child (dental); 
Pennsylvania: Median: 30; 
Pennsylvania: P10: 30; 
Pennsylvania: P90: 30; 
Pennsylvania: P90/P10: 1.00; 
South Carolina: Median: 29; 
South Carolina: P10: 29; 
South Carolina: P90: 29; 
South Carolina: P90/P10: 1.00; 
Texas: Median: 38; 
Texas: P10: 37; 
Texas: P90: 38; 
Texas: P90/P10: 1.03. 

Service: Sealant, per tooth (dental); 
Pennsylvania: Median: 25; 
Pennsylvania: P10: 25; 
Pennsylvania: P90: 25; 
Pennsylvania: P90/P10: 1.00; 
South Carolina: Median: 24; 
South Carolina: P10: 24; 
South Carolina: P90: 24; 
South Carolina: P90/P10: 1.00; 
Texas: Median: [Empty]; 
Texas: P10: [Empty]; 
Texas: P90: [Empty]; 
Texas: P90/P10: [Empty]. 

Source: GAO analysis of Centers for Medicare & Medicaid Services' data. 

Note: For each service, the table displays the median payment, payment 
rates at the 10th percentile (P10) and 90th percentile (P90), and the 
ratio of the 90th to the 10th percentiles (P90/P10). 

[End of table] 

Table 6: Percent Difference in Medicaid Provider Payment Rates 
Accounted for by Provider Type, Service Setting, and Patient Age, 
Selected States and Services, Calendar Year 2010: 

Services: Established patient, low complexity; 
State: Alabama; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: [Empty]; 
Facility vs. office: 0.30; 
Adult vs. child: -0.01; 
Percent of payment rate variation due to 3 factors: 0.46; 
Mean payment rate[B]: 41.84. 

Services: Established patient, moderate complexity; 
State: Alabama; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: [Empty]; 
Facility vs. office: 0.08; 
Adult vs. child: -0.01; 
Percent of payment rate variation due to 3 factors: 0.27; 
Mean payment rate[B]: 67.09. 

Services: Established patient, low complexity; 
State: Iowa; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.15; 
Facility vs. office: 0.02; 
Adult vs. child: -0.05; 
Percent of payment rate variation due to 3 factors: 0.52; 
Mean payment rate[B]: 41.78. 

Services: Established patient, moderate complexity; 
State: Iowa; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.13; 
Facility vs. office: 0.01; 
Adult vs. child: -0.03; 
Percent of payment rate variation due to 3 factors: 0.30; 
Mean payment rate[B]: 64.16. 

Services: Ind. psychotherapy, 20-30 minutes face-to-face; 
State: Illinois; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: [Empty]; 
Facility vs. office: -0.01; 
Adult vs. child: 0.01; 
Percent of payment rate variation due to 3 factors: 0.79; 
Mean payment rate[B]: 64.85. 

Services: Pharmacologic management; 
State: Illinois; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: [Empty]; 
Facility vs. office: 0.26; 
Adult vs. child: 0.05; 
Percent of payment rate variation due to 3 factors: 0.64; 
Mean payment rate[B]: 30.50. 

Services: Vaginal delivery and postpartum care; 
State: Louisiana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.22; 
Facility vs. office: 0.01; 
Adult vs. child: -0.03; 
Percent of payment rate variation due to 3 factors: 0.37; 
Mean payment rate[B]: 678.37. 

Services: Frontal chest x-ray; 
State: Louisiana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: [Empty]; 
Facility vs. office: [Empty]; 
Adult vs. child: 0.05; 
Percent of payment rate variation due to 3 factors: 0.67; 
Mean payment rate[B]: 18.20. 

Services: Doppler echocardiograph; 
State: Louisiana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: [Empty]; 
Facility vs. office: [Empty]; 
Adult vs. child: -0.19; 
Percent of payment rate variation due to 3 factors: 0.28; 
Mean payment rate[B]: 63.19. 

Services: New patient, low complexity; 
State: Louisiana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.18; 
Facility vs. office: -0.01; 
Adult vs. child: -0.12; 
Percent of payment rate variation due to 3 factors: 0.41; 
Mean payment rate[B]: 71.93. 

Services: New patient, moderate complexity; 
State: Louisiana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.19; 
Facility vs. office: -0.02; 
Adult vs. child: -0.12; 
Percent of payment rate variation due to 3 factors: 0.47; 
Mean payment rate[B]: 110.60. 

Services: Established patient, problem-focused; 
State: Louisiana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.19; 
Facility vs. office: 0.00; 
Adult vs. child: -0.16; 
Percent of payment rate variation due to 3 factors: 0.69; 
Mean payment rate[B]: 29.04. 

Services: Established patient, low complexity; 
State: Louisiana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.20; 
Facility vs. office: 0.00; 
Adult vs. child: -0.17; 
Percent of payment rate variation due to 3 factors: 0.61; 
Mean payment rate[B]: 48.56. 

Services: Established patient, moderate complexity; 
State: Louisiana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.22; 
Facility vs. office: -0.02; 
Adult vs. child: -0.10; 
Percent of payment rate variation due to 3 factors: 0.48; 
Mean payment rate[B]: 73.25. 

Services: Initial hospitalization, per day, moderate complexity; 
State: Louisiana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.19; 
Facility vs. office: 0.02; 
Adult vs. child: -0.14; 
Percent of payment rate variation due to 3 factors: 0.56; 
Mean payment rate[B]: 98.97. 

Services: Subsequent hospitalization, per day, low complexity; 
State: Louisiana; 
Percent difference in payment rate[A]:
Non-physician vs. physician: -0.20; 
Facility vs. office: 0.00; 
Adult vs. child: -0.14; 
Percent of payment rate variation due to 3 factors: 0.58; 
Mean payment rate[B]: 28.83. 

Services: Subsequent hospitalization, per day, moderate complexity; 
State: Louisiana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.22; 
Facility vs. office: 0.00; 
Adult vs. child: -0.12; 
Percent of payment rate variation due to 3 factors: 0.52; 
Mean payment rate[B]: 52.31. 

Services: Subsequent hospitalization, per day, high complexity; 
State: Louisiana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.23; 
Facility vs. office: -0.01; 
Adult vs. child: -0.12; 
Percent of payment rate variation due to 3 factors: 0.33; 
Mean payment rate[B]: 75.28. 

Services: Emergency department visit, problem focused; 
State: Louisiana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.22; 
Facility vs. office: [Empty]; 
Adult vs. child: -0.17; 
Percent of payment rate variation due to 3 factors: 0.63; 
Mean payment rate[B]: 32.74. 

Services: Emergency department visit, expanded; 
State: Louisiana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.21; 
Facility vs. office: [Empty]; 
Adult vs. child: -0.16; 
Percent of payment rate variation due to 3 factors: 0.69; 
Mean payment rate[B]: 49.33. 

Services: Emergency department visit, detailed; 
State: Louisiana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.22; 
Facility vs. office: [Empty]; 
Adult vs. child: -0.14; 
Percent of payment rate variation due to 3 factors: 0.67; 
Mean payment rate[B]: 89.31. 

Services: Pharmacologic management; 
State: Montana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.26; 
Facility vs. office: -0.19; 
Adult vs. child: 0.00; 
Percent of payment rate variation due to 3 factors: 0.83; 
Mean payment rate[B]: 65.86. 

Services: New patient, low complexity; 
State: Montana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.04; 
Facility vs. office: -0.27; 
Adult vs. child: -0.03; 
Percent of payment rate variation due to 3 factors: 0.88; 
Mean payment rate[B]: 89.00. 

Services: New patient, moderate complexity; 
State: Montana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.06; 
Facility vs. office: -0.24; 
Adult vs. child: -0.02; 
Percent of payment rate variation due to 3 factors: 0.81; 
Mean payment rate[B]: 140.69. 

Services: Established patient, problem-focused; 
State: Montana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.03; 
Facility vs. office: -0.45; 
Adult vs. child: -0.03; 
Percent of payment rate variation due to 3 factors: 0.95; 
Mean payment rate[B]: 34.14. 

Services: Established patient, low complexity; 
State: Montana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.01; 
Facility vs. office: -0.32; 
Adult vs. child: -0.03; 
Percent of payment rate variation due to 3 factors: 0.82; 
Mean payment rate[B]: 57.72. 

Services: Established patient, moderate complexity; 
State: Montana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.04; 
Facility vs. office: -0.33; 
Adult vs. child: -0.03; 
Percent of payment rate variation due to 3 factors: 0.77; 
Mean payment rate[B]: 89.59. 

Services: Subsequent hospitalization, per day, low complexity; 
State: Montana; 
Percent difference in payment rate[A]:
Non-physician vs. physician: -0.11; 
Facility vs. office: [Empty]; 
Adult vs. child: -0.09; 
Percent of payment rate variation due to 3 factors: 0.55; 
Mean payment rate[B]: 44.62. 

Services: Subsequent hospitalization, per day, moderate complexity; 
State: Montana; 
Percent difference in payment rate[A]:
Non-physician vs. physician: -0.07; 
Facility vs. office: [Empty]; 
Adult vs. child: -0.02; 
Percent of payment rate variation due to 3 factors: 0.32; 
Mean payment rate[B]: 73.58. 

Services: Subsequent hospitalization, per day, high complexity; 
State: Montana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.05; 
Facility vs. office: [Empty]; 
Adult vs. child: -0.02; 
Percent of payment rate variation due to 3 factors: 0.32; 
Mean payment rate[B]: 108.31. 

Services: Established patient, under 1 year; 
State: Montana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.04; 
Facility vs. office: -0.39; 
Adult vs. child: [Empty]; 
Percent of payment rate variation due to 3 factors: 0.73; 
Mean payment rate[B]: 67.45. 

Services: Established patient, 1 through 4 years; 
State: Montana; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.03; 
Facility vs. office: -0.34; 
Adult vs. child: [Empty]; 
Percent of payment rate variation due to 3 factors: 0.64; 
Mean payment rate[B]: 76.17. 

Services: CAT scan, head or brain; 
State: Pennsylvania; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: [Empty]; 
Facility vs. office: -0.36; 
Adult vs. child: -0.02; 
Percent of payment rate variation due to 3 factors: 0.44; 
Mean payment rate[B]: 85.03. 

Services: Frontal chest x-ray; 
State: Pennsylvania; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: [Empty]; 
Facility vs. office: -0.42; 
Adult vs. child: -0.01; 
Percent of payment rate variation due to 3 factors: 0.44; 
Mean payment rate[B]: 12.84. 

Services: X-ray, chest, two views; 
State: Pennsylvania; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: [Empty]; 
Facility vs. office: -0.44; 
Adult vs. child: -0.04; 
Percent of payment rate variation due to 3 factors: 0.72; 
Mean payment rate[B]: 18.57. 

Services: Pharmacologic management; 
State: South Carolina; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: [Empty]; 
Facility vs. office: -0.18; 
Adult vs. child: 0.00; 
Percent of payment rate variation due to 3 factors: 0.76; 
Mean payment rate[B]: 43.86. 

Services: Doppler echocardiograph; 
State: South Carolina; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: [Empty]; 
Facility vs. office: [Empty]; 
Adult vs. child: -0.13; 
Percent of payment rate variation due to 3 factors: 0.30; 
Mean payment rate[B]: 68.49. 

Services: New patient, low complexity; 
State: South Carolina; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.11; 
Facility vs. office: -0.28; 
Adult vs. child: -0.02; 
Percent of payment rate variation due to 3 factors: 0.79; 
Mean payment rate[B]: 71.84. 

Services: Established patient, low complexity; 
State: South Carolina; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.14; 
Facility vs. office: -0.29; 
Adult vs. child: -0.02; 
Percent of payment rate variation due to 3 factors: 0.76; 
Mean payment rate[B]: 48.76. 

Services: Subsequent hospitalization, per day, high complexity; 
State: South Carolina; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.23; 
Facility vs. office: [Empty]; 
Adult vs. child: -0.19; 
Percent of payment rate variation due to 3 factors: 0.38; 
Mean payment rate[B]: 88.71. 

Services: CAT scan, head or brain; 
State: Texas; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: [Empty]; 
Facility vs. office: 0.79; 
Adult vs. child: 0.00; 
Percent of payment rate variation due to 3 factors: 0.31; 
Mean payment rate[B]: 377.67. 

Services: Frontal chest x-ray; 
State: Texas; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: [Empty]; 
Facility vs. office: 0.98; 
Adult vs. child: -0.05; 
Percent of payment rate variation due to 3 factors: 0.75; 
Mean payment rate[B]: 38.55. 

Services: X-ray, chest, two views; 
State: Texas; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: [Empty]; 
Facility vs. office: 1.03; 
Adult vs. child: -0.05; 
Percent of payment rate variation due to 3 factors: 0.78; 
Mean payment rate[B]: 48.59. 

Services: New patient, low complexity; 
State: Texas; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.06; 
Facility vs. office: -0.40; 
Adult vs. child: -0.11; 
Percent of payment rate variation due to 3 factors: 0.76; 
Mean payment rate[B]: 58.46. 

Services: New patient, moderate complexity; 
State: Texas; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.08; 
Facility vs. office: -0.41; 
Adult vs. child: -0.11; 
Percent of payment rate variation due to 3 factors: 0.79; 
Mean payment rate[B]: 82.23. 

Services: Established patient, low complexity; 
State: Texas; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.07; 
Facility vs. office: -0.38; 
Adult vs. child: -0.11; 
Percent of payment rate variation due to 3 factors: 0.75; 
Mean payment rate[B]: 36.79. 

Services: Established patient, moderate complexity; 
State: Texas; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.08; 
Facility vs. office: -0.38; 
Adult vs. child: -0.11; 
Percent of payment rate variation due to 3 factors: 0.74; 
Mean payment rate[B]: 50.36. 

Services: Initial hospitalization, per day, moderate complexity; 
State: Texas; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.08; 
Facility vs. office: [Empty]; 
Adult vs. child: -0.10; 
Percent of payment rate variation due to 3 factors: 0.55; 
Mean payment rate[B]: 102.54. 

Services: Subsequent hospitalization, per day, low complexity; 
State: Texas; 
Percent difference in payment rate[A]: 
Non-physician vs. physician:-0.09; 
Facility vs. office: [Empty]; 
Adult vs. child: -0.10; 
Percent of payment rate variation due to 3 factors: 0.87; 
Mean payment rate[B]: 33.70. 

Services: Subsequent hospitalization, per day, moderate complexity; 
State: Texas; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.08; 
Facility vs. office: [Empty]; 
Adult vs. child: -0.11; 
Percent of payment rate variation due to 3 factors: 0.84; 
Mean payment rate[B]: 48.38. 

Services: Subsequent hospitalization, per day, high complexity; 
State: Texas; 
Percent difference in payment rate[A]: 
Non-physician vs. physician: -0.09; 
Facility vs. office: [Empty]; 
Adult vs. child: -0.10; 
Percent of payment rate variation due to 3 factors: 0.85; 
Mean payment rate[B]: 65.71. 

Source: GAO analysis of Centers for Medicare & Medicaid Services' data. 

Note: Table includes only those services with payment variation of at 
least 10 percent between the 90th and 10th percentiles and where at 
least 25 percent of the variation could be explained by the 3 factors 
in our regression analysis--provider type (physician/dentist vs. non-
physician), service setting (facility vs. office), and patient age 
(adult vs. child). Percentage difference in payment rate is shown as 
missing when there was insufficient variation in that factor (N < 30 
for one or more values of the factor); services where all factors had 
insufficient variation were not included in the table. Facilities 
included inpatient hospital, outpatient hospital, and emergency 
department. 

[A] The percent difference in payments are relative to the second 
value listed in the column. For example, a percentage difference of 
0.30 in the facility vs. office column implies that the payment rate 
when the service was provided in a facility was, on average, 30 
percent more than the rate when the service was performed in an office. 

[B] The mean payment is the rate paid for services provided by a 
physician or dentist, in an office, and to a child. 

[End of table] 

Table 7: Median Medicaid Provider Payment Rates Calculated from 
Claims, Selected States and Services, Calendar Year 2010: 

Service: Routine venipuncture; 
Alabama: [Empty]; 
Iowa: 3; 
Illinois: [Empty]; 
Louisiana: [Empty]; 
Montana: 3; 
Nebraska: 4; 
Pennsylvania: [Empty]; 
South Carolina: 2; 
Texas: [Empty]. 

Service: Vaginal delivery, no postpartum care; 
Alabama: 1,041; 
Iowa: 759; 
Illinois: 924; 
Louisiana: 581; 
Montana: 831; 
Nebraska: 810; 
Pennsylvania: 1,200; 
South Carolina: 1,200; 
Texas: 567. 

Service: Vaginal delivery and postpartum care; 
Alabama: 1,161; 
Iowa: 836; 
Illinois: 924; 
Louisiana: 671; 
Montana: 1,002; 
Nebraska: 960; 
Pennsylvania: 1,200; 
South Carolina: [Empty]; 
Texas: 663. 

Service: Cesarean delivery, no postpartum care; 
Alabama: 1,041; 
Iowa: 893; 
Illinois: 1,070; 
Louisiana: 687; 
Montana: 986; 
Nebraska: 1,119; 
Pennsylvania: 1,200; 
South Carolina: 1,200; 
Texas: 674. 

Service: CAT scan, head or brain; 
Alabama: 158; 
Iowa: 199; 
Illinois: 247; 
Louisiana: 160; 
Montana: [Empty]; 
Nebraska: 197; 
Pennsylvania: 117; 
South Carolina: 168; 
Texas: 174. 

Service: Frontal chest x-ray; 
Alabama: 20; 
Iowa: 25; 
Illinois: 17; 
Louisiana: 18; 
Montana: [Empty]; 
Nebraska: [Empty]; 
Pennsylvania: 19; 
South Carolina: 18; 
Texas: 19. 

Service: X-ray, chest, two views; 
Alabama: 23; 
Iowa: 32; 
Illinois: 22; 
Louisiana: 23; 
Montana: [Empty]; 
Nebraska: 30; 
Pennsylvania: 25; 
South Carolina: 24; 
Texas: 25. 

Service: Urinalysis, non-auto., without microscopy; 
Alabama: 3; 
Iowa: 4; 
Illinois: 3; 
Louisiana: 3; 
Montana: [Empty]; 
Nebraska: [Empty]; 
Pennsylvania: 4; 
South Carolina: 3; 
Texas: 4. 

Service: Rapid Streptococcus screen; 
Alabama: 14; 
Iowa: 17; 
Illinois: 16; 
Louisiana: 14; 
Montana: [Empty]; 
Nebraska: [Empty]; 
Pennsylvania: 6; 
South Carolina: 15; 
Texas: 16. 

Service: One immunization administration; 
Alabama: 5; 
Iowa: 7; 
Illinois: [Empty]; 
Louisiana: [Empty]; 
Montana: 16; 
Nebraska: 6; 
Pennsylvania: [Empty]; 
South Carolina: 13; 
Texas: 8. 

Service: Individual psychotherapy, 20-30 min; 
Alabama: 47; 
Iowa: [Empty]; 
Illinois: 28; 
Louisiana: [Empty]; 
Montana: [Empty]; 
Nebraska: 35; 
Pennsylvania: [Empty]; 
South Carolina: 55; 
Texas: 50. 

Service: Individual psychotherapy, 45-50 min; 
Alabama: 71; 
Iowa: [Empty]; 
Illinois: 48; 
Louisiana: [Empty]; 
Montana: [Empty]; 
Nebraska: 64; 
Pennsylvania: [Empty]; 
South Carolina: 77; 
Texas: 70. 

Service: Pharmacologic management; 
Alabama: 37; 
Iowa: [Empty]; 
Illinois: 22; 
Louisiana: 48; 
Montana: 71; 
Nebraska: 42; 
Pennsylvania: [Empty]; 
South Carolina: 45; 
Texas: 45. 

Service: Ophthalmological services, new patient; 
Alabama: 84; 
Iowa: 96; 
Illinois: 46; 
Louisiana: 107; 
Montana: 130; 
Nebraska: 45; 
Pennsylvania: 59; 
South Carolina: 103; 
Texas: 104. 

Service: Ophthalmological services, established patient; 
Alabama: 62; 
Iowa: 70; 
Illinois: 44; 
Louisiana: 87; 
Montana: 106; 
Nebraska: 47; 
Pennsylvania: 45; 
South Carolina: 84; 
Texas: 86. 

Service: Screening test, hearing evaluation; 
Alabama: 16; 
Iowa: 14; 
Illinois: [Empty]; 
Louisiana: [Empty]; 
Montana: 10; 
Nebraska: 13; 
Pennsylvania: 8; 
South Carolina: 8; 
Texas: 16. 

Service: Echocardiography; 
Alabama: 134; 
Iowa: [Empty]; 
Illinois: 91; 
Louisiana: 144; 
Montana: [Empty]; 
Nebraska: [Empty]; 
Pennsylvania: 140; 
South Carolina: [Empty]; 
Texas: 122. 

Service: Doppler echocardiograph; 
Alabama: 71; 
Iowa: 88; 
Illinois: 20; 
Louisiana: 63; 
Montana: 65; 
Nebraska: 106; 
Pennsylvania: 65; 
South Carolina: 70; 
Texas: 53. 

Service: New patient, low complexity; 
Alabama: 78; 
Iowa: 81; 
Illinois: 44; 
Louisiana: 77; 
Montana: 97; 
Nebraska: 69; 
Pennsylvania: 54; 
South Carolina: 74; 
Texas: 62. 

Service: New patient, moderate complexity; 
Alabama: 111; 
Iowa: 117; 
Illinois: 70; 
Louisiana: 118; 
Montana: 152; 
Nebraska: 104; 
Pennsylvania: 90; 
South Carolina: 115; 
Texas: 90. 

Service: Established patient, problem-focused; 
Alabama: 31; 
Iowa: 31; 
Illinois: 26; 
Louisiana: 31; 
Montana: 38; 
Nebraska: 30; 
Pennsylvania: 26; 
South Carolina: 29; 
Texas: 25. 

Service: Established patient, low complexity; 
Alabama: 42; 
Iowa: 43; 
Illinois: 47; 
Louisiana: 52; 
Montana: 63; 
Nebraska: 45; 
Pennsylvania: 35; 
South Carolina: 50; 
Texas: 38. 

Service: Established patient, moderate complexity; 
Alabama: 67; 
Iowa: 66; 
Illinois: 73; 
Louisiana: 76; 
Montana: 98; 
Nebraska: 68; 
Pennsylvania: 54; 
South Carolina: 75; 
Texas: 53. 

Service: Initial hospitalization per day, moderate complexity; 
Alabama: 95; 
Iowa: 106; 
Illinois: 51; 
Louisiana: 103; 
Montana: 130; 
Nebraska: 83; 
Pennsylvania: 30; 
South Carolina: 101; 
Texas: 105. 

Service: Subsequent hospitalization, per day, low complexity; 
Alabama: 30; 
Iowa: 33; 
Illinois: 16; 
Louisiana: 32; 
Montana: 39; 
Nebraska: 28; 
Pennsylvania: 17; 
South Carolina: 30; 
Texas: 35. 

Service: Subsequent hospitalization, per day, moderate complexity; 
Alabama: 40; 
Iowa: 51; 
Illinois: 25; 
Louisiana: 55; 
Montana: 71; 
Nebraska: 45; 
Pennsylvania: 17; 
South Carolina: 55; 
Texas: 50. 

Service: Subsequent hospitalization, per day, high complexity; 
Alabama: 102; 
Iowa: 72; 
Illinois: 35; 
Louisiana: 79; 
Montana: 102; 
Nebraska: 76; 
Pennsylvania: 17; 
South Carolina: 110; 
Texas: 68. 

Service: Emergency department visit, problem focused; 
Alabama: 21; 
Iowa: 29; 
Illinois: 24; 
Louisiana: 35; 
Montana: 41; 
Nebraska: 34; 
Pennsylvania: 27; 
South Carolina: 32; 
Texas: 27. 

Service: Emergency department visit, expanded; 
Alabama: 42; 
Iowa: 59; 
Illinois: 32; 
Louisiana: 53; 
Montana: 65; 
Nebraska: 51; 
Pennsylvania: 35; 
South Carolina: 50; 
Texas: 37. 

Service: Emergency department visit, detailed; 
Alabama: 66; 
Iowa: 90; 
Illinois: 44; 
Louisiana: 97; 
Montana: 122; 
Nebraska: 60; 
Pennsylvania: 50; 
South Carolina: 94; 
Texas: 89. 

Service: Established patient, under 1 year; 
Alabama: [Empty]; 
Iowa: 72; 
Illinois: [Empty]; 
Louisiana: 61; 
Montana: 77; 
Nebraska: [Empty]; 
Pennsylvania: 20; 
South Carolina: [Empty]; 
Texas: [Empty]. 

Service: Established patient, 1 through 4 years; 
Alabama: [Empty]; 
Iowa: 76; 
Illinois: [Empty]; 
Louisiana: 68; 
Montana: 85; 
Nebraska: [Empty]; 
Pennsylvania: 20; 
South Carolina: [Empty]; 
Texas: [Empty]. 

Service: Periodic exam (dental); 
Alabama: 18; 
Iowa: 18; 
Illinois: 28; 
Louisiana: [Empty]; 
Montana: [Empty]; 
Nebraska: 17; 
Pennsylvania: 20; 
South Carolina: 23; 
Texas: 29. 

Service: Prophylaxis, child (dental); 
Alabama: 28; 
Iowa: 23; 
Illinois: 41; 
Louisiana: [Empty]; 
Montana: [Empty]; 
Nebraska: 21; 
Pennsylvania: 30; 
South Carolina: 29; 
Texas: 38. 

Service: Sealant, per tooth (dental); 
Alabama: 26; 
Iowa: 20; 
Illinois: 36; 
Louisiana: [Empty]; 
Montana: [Empty]; 
Nebraska: [Empty]; 
Pennsylvania: 25; 
South Carolina: 24; 
Texas: [Empty]. 

Source: GAO analysis of Centers for Medicare & Medicaid Services' data. 

Notes: (1) To help ensure comparability, we restricted the claims in 
this part of our analysis to those most comparable to the fees used by 
the American Academy of Pediatrics and the Urban Institute studies. 
Generally, this involved restricting those claims to the service 
provided by a physician or dentist, in an office, and to a child. (See 
table 4 in enclosure 1.) (2) Missing data for a particular state and 
service could be due to (a) the states' Medicaid fee-for-service 
program never providing the service in the selected circumstances, or 
(b) limitations of the claims data that make it difficult to 
definitively identify all services that were provided in the selected 
circumstances. 

[End of table] 

Table 8: Percentage Difference between Medicaid Provider Payment Rates 
Published in Previous Studies Based on Fee Schedules and Rates 
Calculated from Claims Data, Selected States and Services, Calendar 
Year 2010: 

Services: Routine venipuncture; 
Percentage Difference: 
AL: [Empty]; 
IA: -5%; 
IL: [Empty]; 
LA: [Empty]; 
MT: 0%; 
NE: -10%; 
PA: [Empty]; 
SC: -29%; 
TX: [Empty]. 

Services: Vaginal delivery only, no postpartum care; 
Percentage Difference: 
AL: 9%; 
IA: 0%; 
IL: 0%; 
LA: -12%; 
MT: 0%; 
NE: 0%; 
PA: 0%; 
SC: 0%; 
TX: -2%. 

Services: Vaginal delivery and postpartum care; 
Percentage Difference: 
AL: 1%; 
IA: 0%; 
IL: 0%; 
LA: -12%; 
MT: 3%; 
NE: 0%; 
PA: -35%; 
SC: [Empty]; 
TX: -2%. 

Services: Cesarean delivery and no postpartum care; 
Percentage Difference: 
AL: 9%; 
IA: 0%; 
IL: 0%; 
LA: -6%; 
MT: 0%; 
NE: 0%; 
PA: 0%; 
SC: 0%; 
TX: -2%. 

Services: CAT scan, head or brain; 
Percentage Difference: 
AL: 37%; 
IA: 0%; 
IL: 0%; 
LA: 7%; 
MT: [Empty]; 
NE: 0%; 
PA: 0%; 
SC: 0%; 
TX: 3%. 

Services: Frontal chest x-ray; 
Percentage Difference: 
AL: 0%; 
IA: 65%; 
IL: 0%; 
LA: 2%; 
MT: [Empty]; 
NE: [Empty]; 
PA: 0%; 
SC: -4%; 
TX: 1%. 

Services: X-ray, chest, two views; 
Percentage Difference: 
AL: 40%; 
IA: 2%; 
IL: 2%; 
LA: 0%; 
MT: [Empty]; 
NE: -2%; 
PA: 0%; 
SC: -3%; 
TX: 2%. 

Services: Urinalysis, non-auto., without microscopy; 
Percentage Difference: 
AL: 0%; 
IA: 10%; 
IL: 13%; 
LA: 4%; 
MT: [Empty]; 
NE: [Empty]; 
PA: 11%; 
SC: -7%; 
TX: 12%. 

Services: Rapid Streptococcus screen; 
Percentage Difference: 
AL: 0%; 
IA: 40%; 
IL: 2%; 
LA: -6%; 
MT: [Empty]; 
NE: [Empty]; 
PA: -5%; 
SC: 0%; 
TX: -3%. 

Services: One immunization administration; 
Percentage Difference: 
AL: 0%; 
IA: 28%; 
IL: [Empty]; 
LA: [Empty]; 
MT: 3%; 
NE: 3%; 
PA: [Empty]; 
SC: 0%; 
TX: 0%. 

Services: Individual psychotherapy, 20-30 minutes face-to-face; 
Percentage Difference: 
AL: 0%; 
IA: [Empty]; 
IL: 2%; 
LA: [Empty]; 
MT: [Empty]; 
NE: [Empty]; 
PA: [Empty]; 
SC: [Empty]; 
TX: -1%. 

Services: Individual psychotherapy, 45-50 minutes face-to-face; 
Percentage Difference: 
AL: 0%; 
IA: [Empty]; 
IL: 1%; 
LA: [Empty]; 
MT: [Empty]; 
NE: [Empty]; 
PA: [Empty]; 
SC: [Empty]; 
TX: 0%. 

Services: Pharmacologic management; 
Percentage Difference: 
AL: 0%; 
IA: [Empty]; 
IL: -2%; 
LA: [Empty]; 
MT: 20%; 
NE: [Empty]; 
PA: [Empty]; 
SC: [Empty]; 
TX: 1%. 

Services: Ophthalmological services, new patient; 
Percentage Difference: 
AL: 0%; 
IA: 0%; 
IL: -1%; 
LA: 8%; 
MT: -1%; 
NE: -22%; 
PA: 0%; 
SC: 0%; 
TX: 1%. 

Services: Ophthalmological services, established patient; 
Percentage Difference: 
AL: 0%; 
IA: 0%; 
IL: -1%; 
LA: 8%; 
MT: -2%; 
NE: -1%; 
PA: -1%; 
SC: 0%; 
TX: 2%. 

Services: Screening test, hearing evaluation; 
Percentage Difference: 
AL: 69%; 
IA: 0%; 
IL: [Empty]; 
LA: [Empty]; 
MT: 2%; 
NE: -2%; 
PA: 0%; 
SC: 0%; 
TX: 2%. 

Services: Echocardiography, with image documentation; 
Percentage Difference: 
AL: 0%; 
IA: --; 
IL: 0%; 
LA: 17%; 
MT: [Empty]; 
NE: [Empty]; 
PA: 0%; 
SC: [Empty]; 
TX: 0%. 

Services: Doppler echocardiograph; 
Percentage Difference: 
AL: 0%; 
IA: 74%; 
IL: -99%; 
LA: 16%; 
MT: 1%; 
NE: 0%; 
PA: 0%; 
SC: 14%; 
TX: -1%. 

Services: New patient, low complexity; 
Percentage Difference: 
AL: 0%; 
IA: 1%; 
IL: 1%; 
LA: 16%; 
MT: 0%; 
NE: -1%; 
PA: 0%; 
SC: 0%; 
TX: 1%. 

Services: New patient, moderate complexity; 
Percentage Difference: 
AL: 0%; 
IA: 0%; 
IL: 0%; 
LA: 14%; 
MT: 0%; 
NE: 0%; 
PA: 0%; 
SC: 0%; 
TX: 0%. 

Services: Established patient, problem-focused; 
Percentage Difference: 
AL: 0%; 
IA: 0%; 
IL: 1%; 
LA: 16%; 
MT: -1%; 
NE: 1%; 
PA: 0%; 
SC: -3%; 
TX: 0%. 

Services: Established patient, low complexity; 
Percentage Difference: 
AL: 0%; 
IA: 0%; 
IL: 1%; 
LA: 16%; 
MT: -4%; 
NE: 0%; 
PA: 0%; 
SC: 0%; 
TX: 1%. 

Services: Established patient, moderate complexity; 
Percentage Difference: 
AL: 0%; 
IA: 0%; 
IL: 0%; 
LA: 14%; 
MT: 0%; 
NE: 0%; 
PA: -1%; 
SC: 0%; 
TX: 0%. 

Services: Initial hospitalization, per day, moderate complexity; 
Percentage Difference: 
AL: 15%; 
IA: 0%; 
IL: -1%; 
LA: 13%; 
MT: -1%; 
NE: -1%; 
PA: 2%; 
SC: -1%; 
TX: 0%. 

Services: Subsequent hospitalization, per day, low complexity; 
Percentage Difference: 
AL: 20%; 
IA: 0%; 
IL: -2%; 
LA: 16%; 
MT: 0%; 
NE: -2%; 
PA: 0%; 
SC: -2%; 
TX: 0%. 

Services: Subsequent hospitalization, per day, moderate complexity; 
Percentage Difference: 
AL: 0%; 
IA: -1%; 
IL: 0%; 
LA: 12%; 
MT: 1%; 
NE: -1%; 
PA: 0%; 
SC: -1%; 
TX: -1%. 

Services: Subsequent hospitalization, per day, high complexity; 
Percentage Difference: 
AL: 44%; 
IA: 0%; 
IL: 0%; 
LA: 12%; 
MT: 1%; 
NE: 0%; 
PA: 0%; 
SC: 28%; 
TX: 0%. 

Services: Emergency department visit, problem focused; 
Percentage Difference: 
AL: 0%; 
IA: 1%; 
IL: -1%; 
LA: 18%; 
MT: -1%; 
NE: -1%; 
PA: 1%; 
SC: -2%; 
TX: -69%. 

Services: Emergency department visit, expanded; 
Percentage Difference: 
AL: 0%; 
IA: 1%; 
IL: -1%; 
LA: 15%; 
MT: 3%; 
NE: -1%; 
PA: 0%; 
SC: -1%; 
TX: -66%. 

Services: Emergency department visit, detailed; 
Percentage Difference: 
AL: 0%; 
IA: 0%; 
IL: 0%; 
LA: 14%; 
MT: 3%; 
NE: -1%; 
PA: 0%; 
SC: -1%; 
TX: -1%. 

Services: Established patient, under 1 year; 
Percentage Difference: 
AL: [Empty]; 
IA: 0%; 
IL: [Empty]; 
LA: -4%; 
MT: 1%; 
NE: [Empty]; 
PA: 0%; 
SC: [Empty]; 
TX: [Empty]. 

Services: Established patient, 1 through 4 years; 
Percentage Difference: 
AL: [Empty]; 
IA: -4%; 
IL: [Empty]; 
LA: -5%; 
MT: 0%; 
NE: [Empty]; 
PA: 0%; 
SC: [Empty]; 
TX: [Empty]. 

Services: Periodic exam (dental); 
Percentage Difference: 
AL: 0%; 
IA: 10%; 
IL: 0%; 
LA: [Empty]; 
MT: [Empty]; 
NE: 0%; 
PA: 0%; 
SC: -2%; 
TX: -2%. 

Services: Prophylaxis, child (dental); 
Percentage Difference: 
AL: 0%; 
IA: -6%; 
IL: 0%; 
LA: [Empty]; 
MT: [Empty]; 
NE: -5%; 
PA: 0%; 
SC: -3%; 
TX: 1%. 

Services: Sealant, per tooth (dental); 
Percentage Difference: 
AL: 0%; 
IA: -1%; 
IL: 0%; 
LA: [Empty]; 
MT: [Empty]; 
NE: [Empty]; 
PA: 0%; 
SC: 0%; 
TX: [Empty]. 

Source: GAO analysis of Centers for Medicare & Medicaid Services, 
American Academy of Pediatrics (AAP), and Urban Institute data. 

Note: A positive value indicates that the median payment rate 
calculated from Medicaid claims data is higher than the payment rate 
presented in recent AAP and Urban Institute studies using fee schedule 
data. To help ensure comparability, we restricted the claims in this 
part of our analysis to those most comparable to the fees used by the 
AAP and the Urban Institute studies. Generally, this involved 
restricting those claims to the service provided by a physician or 
dentist, in an office, and to a child. (See table 4 in enclosure 1.) 

[End of table] 

[End of section] 

Footnotes: 

[1] See 42 U.S.C. § 1396a(a)(30)(A). 

[2] American Academy of Pediatrics, Medicaid Reimbursement Survey, 
2010/11, American Academy of Pediatrics (Elk Grove, IL, 2011). 
Zuckerman S. et al., Trends in Medicaid Physician Fees, 2003-2008, 
(Washington, D.C.: Health Affairs, Vol. 28, No.3, 2009), w510-w519. 

[3] The nine states selected were Alabama, Iowa, Illinois, Louisiana, 
Montana, Nebraska, Pennsylvania, South Carolina, and Texas. 

[4] Generally, this involved restricting the claims to the service 
provided by a physician or dentist, in an office, and to a child. (See 
table 4 in enclosure 1.) 

[5] According to the Louisiana Medicaid fee schedule in effect from 
August 1, 2010 through November 30, 2010. 

[6] The fee schedule rate reported by the Urban Institute was for 
services provided by a physician in an office. 

[7] The overall median payment for a CAT scan of the head or brain in 
Texas--not limited to a specific provider type, setting, or 
beneficiary age--was $357 in 2010 as calculated from claims data. The 
median payment we calculated from claims data for services limited to 
those provided by a non-physician, in an office, and to a child was 
$174. 

[8] We restricted our analysis to the MAX other claims file, which 
contains claims for physician and other outpatient services. We 
excluded three additional MAX claims files: inpatient hospital, long-
term care, and prescription drugs. 

[9] In some cases, states may require beneficiaries to pay 
deductibles, copayments and similar charges for certain Medicaid 
services. Federal law generally restricts such cost-sharing to nominal 
amounts; however, states may impose additional cost-sharing on certain 
populations and for certain services. 

[10] To calculate payment rates from the claims for our selected 
services and states, we first identified claims in the MAX file that 
represented (1) FFS payment; (2) full, final payment; and (3) payment 
for services provided to the general Medicaid population. We developed 
criteria to exclude claims that did not meet these requirements. We 
excluded claims for beneficiaries in demonstration programs, claims 
where Medicaid was not the only payer, and claims that were adjusted. 

[11] Specifically, our dependent variable was the log of the Medicaid 
payment rate and our independent variables were binary indicator 
variables for (i) whether the service was provided by a physician or 
dentist (reference category), non-physician, or other health 
professional; (ii) whether the service was provided in an 
office(reference category), facility (inpatient hospital, outpatient 
hospital, or emergency department), or other setting; and (iii) 
whether the service was provided to a child (reference category 
defined as less than 18 years old and basis of eligibility was child), 
adult (defined as greater than 21 years old and basis of eligibility 
was adult), or a patient of other/unknown age. By specifying a log-
linear model, the resulting regression coefficients represent the 
percentage difference in mean payment rates associated with changing 
the specified independent variable. 

[12] We only presented results where (i) there was sufficient 
variation in the dependent variable (which we defined as P90/P10  
greater than or = 1.1); (ii) there was sufficient variation in the 
independent variable (which we defined as N greater than or = 30 for 
each value of the indicator variable); and (iii) the r2 of the 
regression was at least 0.25. 

[End of section] 

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