Affordable and accessible health care is essential for the health of all Coloradans, and with transparent health care data, we can all play a role in making the system better for everyone. At the Center for Improving Value in Health Care (CIVHC), we leverage tools and data from the Colorado All Payer Claims Database (CO APCD) to shed light on the often opaque world of health care costs. Through this comprehensive approach, we aim to equip everyone—from patients to policymakers—to make informed health care decisions that improve outcomes and control costs.
Two Tools, Two PerspectivesUnderstanding the complexities of health care pricing and payment requires diverse perspectives, which is why CIVHC offers two distinct tools: the Shop for Care Tool and the Provider Payment Tool. While each serves a unique purpose, together they provide a fuller picture of the financial dynamics within Colorado’s health care system.
The Shop for Care Tool is tailored for consumers looking to navigate health care costs associated with different facilities. It shows the total payments made to facilities for specific services, which is the combined amount that insurers pay and the portion that patients are responsible for out-of-pocket. This tool focuses on the facility side of health care costs, providing insight into what consumers might pay when they use a hospital, outpatient center, or other facility. It is important to note, however, that these figures do not account for professional fees charged by individual health care providers, such as doctors or specialists.
In contrast, the Provider Payment Tool offers insights into what health care providers are reimbursed for their services by various health insurance payers, including Commercial, Medicaid, Medicare Advantage, and Medicare Fee-for-Service. This tool focuses on professional fees and does not include any facility charges, making it an invaluable resource for understanding provider reimbursement patterns across different payer types. It reveals payments across different provider types and care settings as well, which can vary widely statewide and by county
Why Different Viewpoints Matter
Although both tools provide essential information about health care costs, they are designed to focus on different aspects of the billing process. The Shop for Care Tool captures the payments made to facilities, reflecting the costs associated with using a hospital or outpatient center. On the other hand, the Provider Payment Tool focuses on the reimbursements to health care providers for their services. Because each tool is tailored to different segments of health care expenses, they highlight separate pieces of the overall cost structure.
This separation is intentional, as it provides clarity into each part of the billing process. Facility payments and professional fees are managed independently, involving different billing practices and payer negotiations. Therefore, comparing the data from these tools directly does not offer a complete or accurate picture of total health care costs in Colorado. Instead, each tool provides valuable insights tailored to different groups: consumers can use the Shop for Care Tool to estimate and compare their potential out-of-pocket expenses at various facilities, while providers, payers, and policymakers can rely on the Provider Payment Tool to understand reimbursement rates and payment patterns across different payer types. By using each tool according to their unique needs, different audiences can gain a clearer understanding of their role and the financial dynamics within the health care system.
Driving Change Through Transparency
By offering these distinct but complementary views, the Shop for Care and Provider Payment tools contribute to a deeper understanding of payment variation in Colorado. This enhanced transparency is key to driving positive change within the system, fostering a more affordable, equitable, and accessible for everyone. When patients, providers, and policymakers have access to clear, detailed information about health care costs, they are better equipped to make informed decisions that improves the health care system for everyone.
As CIVHC continues to champion health care improvements in Colorado, these tools serve as vital resources for everyone involved in the health care system. By illuminating opportunities for action and transforming outcomes, these tools help us move toward a more equitable, affordable, and healthier Colorado for all.