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United States Government Accountability Office: 
GAO: 

Private Health Insurance: 

Geographic Variation in Spending for Certain High-Cost Procedures 
Driven by Inpatient Prices: 

Geographic Variation: 

Report to the Ranking Member, Committee on Energy and Commerce, House 
of Representatives: 

December 2014: 

GAO-15-214: 

GAO Highlights: 

Highlights of GAO-15-214, a report to the Ranking Member, Committee on 
Energy and Commerce, House of Representatives. 

Why GAO Did This Study: 

Research shows that spending on health care varies by geographic area
and that higher spending in an area is not always associated with better
quality of care. While a substantial body of research exists on 
geographic variation in spending in Medicare, less research has been 
done on variation in private sector health care spending, although 
this spending accounts for about a third of overall health care 
spending. As U.S. health expenditures continue to rise, policymakers and
others have expressed interest in better understanding spending
variation and how health care systems can operate efficiently-—that is,
providing equivalent or higher quality care while maintaining or 
lowering current spending levels. 

GAO was asked to examine geographic variation in private sector health 
care spending. GAO examined (1) how spending per episode of care for 
certain high-cost procedures varies across geographic areas for private
payers, and (2) how the mix of service types, and the volume, 
intensity, and price of services contribute to variation in episode 
spending across geographic areas for private payers. Using a large 
private sector claims database for 2009 and 2010, GAO examined
spending by MSA for episodes of care for three commonly performed
inpatient procedures and examined spending by hospital inpatient, 
hospital outpatient, postdischarge, professional, and ancillary 
service categories. For inpatient and professional services, GAO 
examined the volume, intensity, and price of services. GAO's findings
may not be generalizable to all private insurers due to data 
limitations. 

What GAO Found: 

Spending for an episode of care in the private sector varied across 
metropolitan statistical areas (MSA) for coronary stent placement, 
laparoscopic appendectomy, and Total hip replacement, even after GAO 
adjusted for geographic differences in the cost of doing business and 
differences in enrollee demographics and health status. MSAs in the 
highest-spending quintile had average adjusted episode spending that 
was 74 to 94 percent higher than MSAs in the lowest-spending quintile, 
depending on the procedure. MSAs with higher spending on one procedure 
generally had higher spending on the other two procedures. High- or 
low-spending MSAs were not concentrated in particular regions of the 
nation. 

The price of the initial hospital inpatient admission accounted for 91 
percent or more of the difference in episode spending between MSAs in 
the lowest- and highest-spending quintiles. The price of the initial 
admission was the largest contributor to the difference for two 
reasons. First, it represented the largest percentage of adjusted 
episode spending. For example, for Total hip replacement, the average 
price of the initial admission was $17,134, representing 76 percent
of the $22,463 in Total episode spending for MSAs in the lowest-
spending quintile and $30,332, representing 82 percent of the $36,969 
in Total episode spending for MSAs in the highest-spending quintile. 
Second, the price of the initial admission varied considerably across 
MSAs. For MSAs in the highest-spending quintile, the average price of 
the initial admission for Total hip replacement was 77 percent higher 
than for MSAs in the lowest-spending quintile. Professional services—-
office visits and other services provided by a physician or other health
professional—-were the second largest contributor to geographic 
differences in episode spending, but accounted for 7 percent or less 
of the difference in episode spending between MSAs in the lowest- and 
highest-spending quintiles. (See table.) MSAs in the highest-spending 
quintile had higher average prices and intensity (a measure of the 
resources needed to provide a service) but fewer services (volume) 
than MSAs in the lowest-spending quintile for all three procedures. 

Table: Contributions of Each Service Category to Differences in 
Average Episode Spending between MSAs in Lowest- and Highest-Spending 
Quintiles: 

Service category: Hospital inpatient—-Price of initial admission
Coronary stent placement: 92%: 
Laparoscopic appendectomy: 96%: 
Total hip replacement: 91%. 

Service category: Hospital inpatient-—Readmissions 
Coronary stent placement: 1%: 
Laparoscopic appendectomy: 0%: 
Total hip replacement: 0%. 

Service category: Hospital outpatient: 
Coronary stent placement: 1%: 
Laparoscopic appendectomy: 1%: 
Total hip replacement: 1%. 

Service category: Postdischarge: 
Coronary stent placement: 0%: 
Laparoscopic appendectomy: 0%: 
Total hip replacement: 0%. 

Service category: Professional: 
Coronary stent placement: 5%: 
Laparoscopic appendectomy: 3%: 
Total hip replacement: 7%. 

Service category: Ancillary and unclassified: 
Coronary stent placement: 1%: 
Laparoscopic appendectomy: 0%: 
Total hip replacement: 1%. 

Service category: Total; 
Coronary stent placement: 100%: 
Laparoscopic appendectomy: 100%: 
Total hip replacement: 100%. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

[End of table] 

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

View [hyperlink, http://www.gao.gov/products/GAO-15-214]. For more 
information, contact James Cosgrove at (202) 512-7114 or 
cosgrovej@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Episode Spending Was 74 to 94 Percent Higher in Highest-Compared with 
Lowest-Spending Areas, with High-Spending Areas Generally High for All 
Three Procedures: 

Price per Initial Inpatient Admission Was Largest Contributor to 
Geographic Differences in Episode Spending: 

Agency Comments: 

Appendix I: Data and Methods: 

Appendix II: Episode Spending, by Procedure, within Metropolitan 
Statistical Areas GAO Analyzed: 

Appendix III: Distribution of Episode Spending: 

Appendix IV: Episode Spending, by Procedure, for Metropolitan 
Statistical Areas in Lowest-and Highest-Spending Quintiles: 

Appendix V: Hospital Inpatient Spending and Other Information, by 
Metropolitan Statistical Area and Procedure: 

Appendix VI: Professional Services Spending and Other Information, by 
Metropolitan Statistical Area and Procedure: 

Appendix VII: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Contributions of Each Service Category to Differences in 
Average Episode Spending between Metropolitan Statistical Areas (MSA) 
in the Lowest-and Highest-Spending Quintiles: 

Table 2: Professional Services: Difference in Average Spending, 
Volume, Intensity, and Price: 

Table 3: Ranking of Metropolitan Statistical Areas (MSA) by Adjusted 
Episode Spending for Coronary Stent Placement Episodes: 

Table 4: Ranking of Metropolitan Statistical Areas (MSA) by Adjusted 
Episode Spending for Laparoscopic Appendectomy Episodes: 

Table 5: Ranking of Metropolitan Statistical Areas (MSA) by Adjusted 
Episode Spending for Total Hip Replacement Episodes: 

Table 6: Average Adjusted Episode Spending for Coronary Stent 
Placement, Metropolitan Statistical Areas (MSA) in Lowest-and Highest-
Spending Quintiles: 

Table 7: Average Adjusted Episode Spending for Laparoscopic 
Appendectomy, Metropolitan Statistical Areas (MSA) in Lowest-and 
Highest-Spending Quintiles: 

Table 8: Average Adjusted Episode Spending for Total Hip Replacement, 
Metropolitan Statistical Areas (MSA) in Lowest-and Highest-Spending 
Quintiles: 

Table 9: Hospital Inpatient Spending, Initial Admission Price, and 
Number of Days, by Metropolitan Statistical Area (MSA), for Coronary 
Stent Placement Episodes: 

Table 10: Hospital Inpatient Spending, Initial Admission Price, and 
Number of Days, by Metropolitan Statistical Area (MSA), for 
Laparoscopic Appendectomy Episodes: 

Table 11: Hospital Inpatient Spending, Initial Admission Price, and 
Number of Days, by Metropolitan Statistical Area (MSA), for Total Hip 
Replacement Episodes: 

Table 12: Professional Services Spending, Number of Services, 
Intensity, and Price, by Metropolitan Statistical Area (MSA), for 
Coronary Stent Placement Episodes: 

Table 13: Professional Services Spending, Number of Services, 
Intensity, and Price, by Metropolitan Statistical Area (MSA), for 
Laparoscopic Appendectomy Episodes: 

Table 14: Professional Services Spending, Number of Services, 
Intensity, and Price, by Metropolitan Statistical Area (MSA), for 
Total Hip Replacement Episodes: 

Figures: 

Figure 1: Distribution of Average Episode Spending Across Metropolitan 
Statistical Areas (MSA): 

Figure 2: Correlation of Average Episode Spending between Procedures: 

Figure 3: Average Prices of Initial Hospital Inpatient Admissions for 
Metropolitan Statistical Areas (MSA) in the Lowest-and Highest-
Spending Quintiles: 

Figure 4: Average Spending on Professional Services in Metropolitan 
Statistical Areas (MSA) in the Lowest-and Highest-Spending Quintiles: 

Abbreviations: 

GDP: gross domestic product: 

IOM: Institute of Medicine: 

MedPAC: Medicare Payment Advisory Commission: 

MSA: metropolitan statistical area: 

RVU: relative value unit: 

[End of section] 

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

December 29, 2014: 

The Honorable Henry A. Waxman: 
Ranking Member: 
Committee on Energy and Commerce: 
House of Representatives: 

Dear Mr. Waxman: 

National health expenditures are projected to grow from $2.8 trillion 
in 2012 to over $5 trillion in 2023, outpacing gross domestic product 
(GDP) growth over this period, and accounting for almost 20 percent of 
GDP by 2023.[Footnote 1] The United States spends significantly more 
on health care than any other nation, yet health outcomes in the 
United States are not necessarily better than those of other nations 
with lower spending. Further, research on U.S. health care spending 
has shown that spending can vary by geographic area and that this 
variation remains even after accounting for important differences 
across areas, such as differing health status of populations and 
differing costs of doing business. Studies have also shown that higher 
spending is not always associated with better quality of 
care.[Footnote 2] As U.S. health expenditures continue to rise, there 
is widespread interest among policymakers and others in improving 
their understanding of drivers of spending and in learning more about 
where and how health care systems operate efficiently--that is, 
provide equivalent or higher quality care while maintaining or 
lowering current spending levels. 

While researchers have developed a substantial body of work on 
geographic variation in Medicare spending,[Footnote 3] less research 
has been done on geographic variation in private sector health care 
spending. Researchers have primarily focused on Medicare spending 
because of the availability of Medicare spending data. However, 
private sector spending on health care accounts for about one-third of 
U.S. health expenditures and more comprehensive private sector data 
has become available in recent years.[Footnote 4] Additional research 
on private sector spending will provide important contributions to an 
overall understanding of geographic variation in health care spending. 

A useful framework for exploring geographic variation and reasons 
behind geographic spending differences is examining spending within an 
episode of care--defined as the care and services provided for a 
specific medical problem, condition, or illness during a specific time 
period. Using the episode, we can examine the contribution of 
components that drive spending variation. These components include the 
mix of services provided--hospital inpatient, hospital outpatient, 
physician and other professional services, postdischarge, and 
ancillary services--and the volume, intensity, and price of those 
services.[Footnote 5] A greater understanding of the reasons for 
higher or lower spending in certain areas may provide insights into 
the policy options that are most likely to be effective at promoting 
efficiencies and cost savings. 

You asked us to examine geographic variation in private sector health 
care spending. We examined: 

* how spending per episode of care for certain high-cost procedures 
varies across geographic areas for private payers and: 

* how the mix of service types, and the volume, intensity, and price 
of services contribute to variation in episode spending across 
geographic areas for private payers. 

To examine how spending per episode of care for certain high-cost 
procedures varies across geographic areas, we calculated average 
episode spending by metropolitan statistical areas (MSA).[Footnote 6] 
We created episodes based on an inpatient admission for each of the 
following procedures: coronary stent placement, Laparoscopic 
appendectomy, and Total hip replacement.[Footnote 7] For the years we 
analyzed in the private sector database--2009 and 2010--these 
procedures were commonly performed and associated with high levels of 
national spending.[Footnote 8] These procedures also represent 
different medical specialties. In addition, we selected hospital-based 
procedures because the United States spends more nationally on 
hospital services than any other type of health care service.[Footnote 
9] To create the episodes, which included all services from the day of 
admission to 30 days after discharge and certain services in the 3 
days prior to admission,[Footnote 10] we used private sector health 
insurance claims and enrollment data from the Truven Health Analytics 
MarketScan® Commercial Claims and Encounters Database for 2009 and 
2010. This database contains claims for over 50 million enrollees paid 
by over 100 private insurers across 50 states and the District of 
Columbia in 2009 and 2010. We assigned episodes to MSAs based on the 
location of the hospital inpatient admission, keeping only MSAs that 
had a sufficient number of episodes to support our analyses.[Footnote 
11] We calculated unadjusted spending by using the payment amounts on 
the claims. We then adjusted spending for geographic differences in 
the cost of doing business and differences in the demographics and 
health status of enrollees in each MSA.[Footnote 12] Using all MSAs 
included in our analyses, we determined the distribution of average 
episode spending for each procedure, and, using the 78 MSAs with a 
sufficient number of episodes for all three procedures, we calculated 
the extent to which MSAs with high or low episode spending for one 
procedure also had high or low episode spending for another procedure. 

To examine how the mix of service types, and the volume, intensity, 
and price of services contribute to variation in episode spending 
across geographic areas, we calculated and reported on differences in 
these components for the 78 MSAs with a sufficient number of episodes 
for all three procedures, focusing on MSAs in the lowest-and highest-
spending quintile for each procedure. We analyzed the mix of service 
types by assigning all spending within an episode to one of five 
service categories: (1) hospital inpatient, (2) hospital outpatient, 
(3) postdischarge, (4) professional, and (5) ancillary.[Footnote 13] 
For hospital inpatient and professional services, we also examined 
volume, intensity, and price of services.[Footnote 14] For hospital 
inpatient services, we measured volume as the number of days in the 
hospital stay, and we measured price by the amount spent on the 
initial hospital inpatient admission (which excluded spending on any 
subsequent readmissions), because hospitals are generally paid one 
amount per admission regardless of the patient's length of stay or the 
services delivered. For professional services, we measured volume as 
the number of services provided, and we measured intensity by using 
the relative value unit (RVU), which is an estimate of the resources 
needed to provide a given service.[Footnote 15] We calculated the 
price per unit of intensity by dividing average spending on 
professional services by the Total units of intensity (number of RVUs) 
associated with those services. See appendix I for a more detailed 
description of our methodology. 

We assessed the reliability of the MarketScan database by reviewing 
documentation, discussing the database with knowledgeable officials, 
and performing data reliability checks, and we determined the data 
were sufficiently reliable for our purposes. 

Our study had some limitations. We reported results only for those 
MSAs in which we had a sufficient number of episodes to ensure the 
reliability of our results for each procedure, but our results 
included MSAs that constituted a majority of the U.S. population. 
Depending on the procedure, 60 to 63 percent of the U.S. population 
lives in the MSAs included.[Footnote 16] In addition, although we 
chose procedures that were commonly performed and associated with high 
levels of national spending, our results may not be generalizable to 
other procedures not included in our analysis. Also, while the data 
used for our analyses were from one of the largest private insurance 
data sources, the data did not include all private payers and are not 
necessarily representative of the private health insurance market in 
the United States. As such, our findings may not be generalizable to 
this broader private health insurance market. For example, in 2009 and 
2010, the percentage of enrollees in the data were disproportionately 
from large self-insured firms, which tend to have more generous 
benefit packages compared with other payers, and they were also 
disproportionately from the South. Finally, 2009 and 2010 data do not 
reflect the impact of more recent policy or other changes potentially 
affecting private sector health care spending, such as the 
implementation of the Patient Protection and Affordable Care Act. 

We conducted our work from January 2012 to December 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. 

Background: 

Private sector data have become increasingly available to researchers, 
and several studies have established that significant geographic 
variation in spending exists in the private sector. For example, in a 
recent comprehensive assessment of geographic variation in private 
sector spending, the Institute of Medicine (IOM) reported on the 
presence of substantial spending variation, concluding that a large 
amount of the variation remained unexplained after adjusting for 
enrollee demographic and health status factors, insurance plan 
factors, and market-level factors, and suggesting that inefficiency is 
one of the causes of the current levels of variation.[Footnote 17] 
Using private sector claims data from two nationwide databases from 
2007 through 2009, IOM found unadjusted spending for the area at the 
90th percentile was 36 to 42 percent higher than the area at the 10th 
percentile, depending on the database used.[Footnote 18] The spending 
differences existed at all levels of geography IOM studied, including 
MSAs, and these differences persisted over time. IOM also found that 
price is a major determinant of geographic variation in the private 
sector, and estimated that, after adjusting for underlying costs, 
price accounted for 70 percent of the geographic variation in private 
sector spending. The researchers attributed the large impact of price 
in explaining private sector geographic spending variation to the 
relatively strong market power of providers in some areas. 

Other studies, including one by GAO, have reached similar conclusions. 
The Medicare Payment Advisory Commission (MedPAC) examined geographic 
variation in private sector spending and estimated that in 2008, 
hospital inpatient spending for the MSA at the 90th percentile was 90 
percent higher than for the MSA at the 10th percentile.[Footnote 19] 
MedPAC also found that spending for physician services varied, but 
less so than hospital inpatient spending. Physician spending at the 
90th percentile was 50 percent higher than that at the 10th 
percentile. Early work by GAO analyzing 2001 private sector claims in 
the Federal Employees Health Benefits Program also found substantial 
geographic variation in private sector hospital inpatient prices, 
physician prices, and spending.[Footnote 20] 

IOM also found that areas with relatively high prices tended to have 
relatively low utilization and vice versa. In addition, IOM found that 
private sector utilization varied more for some service types than 
others. For example, emergency department use was 50 to 100 percent 
higher for the area at the 90th percentile of utilization relative to 
the 10th percentile, and hospital outpatient visits were 30 to 46 
percent higher. In addition, consistent with other research, use of 
discretionary services varied substantially. For example, the 
utilization rate for hip replacement, considered a discretionary 
procedure, for the area at the 90th percentile was 53 percent higher 
than the area at the 10th percentile, and other discretionary 
procedures, such as hysterectomies, lower back surgeries, and nuclear 
stress tests, had even larger differences.[Footnote 21] 

Researchers from the National Institute for Health Care Reform 
recently examined geographic variation in spending for hip and knee 
replacement episodes of care using 2011 claims data for autoworkers 
and their dependents in nine geographic areas in six states.[Footnote 
22] They defined episodes as those beginning with a hospital admission 
and including all services up to 30 days postdischarge. Average 
spending per episode across the nine markets ranged from below $25,000 
in Louisville, Kentucky, to above $30,000 in Buffalo, New York. 
[Footnote 23] However, variation across the 36 hospitals within these 
markets varied more than twofold, and all but one of the markets had a 
lower-spending hospital option, defined as having average episode 
spending below $25,000. To get a broader measure of variation in 
episode spending, these researchers also examined all episode types 
across hospitals. The spending variations observed for knee and hip 
replacements held true for other conditions, and hospitals with high 
spending for one service line (cardiology, orthopedics, etc.) were 
also likely to have high spending for other service lines. In 
addition, the price of the initial hospital stay accounted for more 
than 80 percent of the variation in overall spending. Variation in the 
prices and volume of physician and other services together accounted 
for less than one-tenth of the variation in episode spending. These 
researchers noted that reasons for higher-priced hospitals in some 
areas included their provision of specialized service lines that other 
nearby hospitals did not offer, being part of a local hospital system 
with greater bargaining clout, having unusually good clinical 
reputations, and being part of a large teaching hospital. 

Episode Spending Was 74 to 94 Percent Higher in Highest-Compared with 
Lowest-Spending Areas, with High-Spending Areas Generally High for All 
Three Procedures: 

Episode Spending Was 74 to 94 Percent Higher in the Highest-Compared 
with Lowest-Spending Areas, Depending on Procedure: 

We noted variation in episode spending across MSAs for all three 
procedures, even after adjusting for geographic differences in the 
cost of doing business and differences in demographics and health 
status of enrollees in each MSA. For example, average adjusted episode 
spending across all MSAs in our analysis for Laparoscopic appendectomy 
was $12,506; however, MSAs in the highest-spending quintile had 
average adjusted episode spending of $17,047, which was almost 94 
percent higher than the average adjusted episode spending of $8,802 
for MSAs in the lowest-spending quintile. Average adjusted episode 
spending for this procedure for individual MSAs ranged from $25,924 in 
Salinas, California, to $6,166 in Joplin, Missouri. We found similar 
results for the other two procedures we studied, coronary stent 
placement and Total hip replacement. Average adjusted episode spending 
for MSAs in the highest-spending quintile was about 84 percent and 74 
percent higher than for MSAs in the lowest-spending quintile, 
respectively. (See figure 1; also, see appendix II for complete 
rankings of MSAs by procedure.) We found greater geographic variation 
in average episode spending than the research from the National 
Institute for Health Care Reform, likely because our study included 
many more geographic areas.[Footnote 24] 

For all three procedures, adjustments to control for geographic 
differences in the cost of doing business and for differences in 
demographics and health status of enrollees reduced the extent of 
variation in spending across MSAs. For example, before adjustment, 
average episode spending for Laparoscopic appendectomy in the highest-
spending MSA (Salinas, California) was 511 percent higher than the 
lowest-spending MSA (Joplin, Missouri); and, after adjustment, 
spending was 320 percent higher. 

Figure 1: Distribution of Average Episode Spending Across Metropolitan 
Statistical Areas (MSA): 

[Refer to PDF for image: interactive graphic] 

Interactivity instructions: Roll over on one of the three procedures 
to see data. 

See appendix III for additional details. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 155 MSAs for coronary stent placement episodes, 
139 MSAs for Laparoscopic appendectomy episodes, and 141 MSAs for 
Total hip replacement episodes. For each procedure, we included all 
MSAs for which we had a sufficient number of episodes to support our 
analyses. Spending was adjusted to control for geographic differences 
in the cost of doing business and differences in demographics and 
health status of enrollees in each MSA. 

[End of figure] 

High-Spending Areas Generally Were High-Spending for All Three 
Procedures: 

MSAs with higher spending on one procedure generally had higher 
spending on the other two procedures. For example, Salinas, 
California, and Fort Wayne, Indiana, were among the highest-spending 
MSAs for all three procedures, while Hartford, Connecticut, and 
Youngstown, Ohio, were among the lowest-spending MSAs for all three 
procedures. We examined average adjusted episode spending in the 78 
MSAs that had a sufficient number of episodes for all three procedures 
and found that the extent of correlation for each pair of procedures 
for the 78 MSAs ranged from 0.68 to 0.83,[Footnote 25] consistent with 
the research from the National Institute for Health Care Reform. 
[Footnote 26] (See figure 2.) 

Figure 2: Correlation of Average Episode Spending between Procedures: 

[Refer to PDF for image: 3 plotted point graphs] 

Figure 2 has three graphs, each of which shows the relationship 
between average episode spending for two of the procedures in our 
analysis and is based on data for the 78 MSAs that had a sufficient 
number of episodes for all three procedures. 

In the first graph, there is one point for each MSA based on average 
episode spending for coronary stent placement along the vertical axis 
and average episode spending for Laparoscopic appendectomy along the 
horizontal axis. This cluster of points generally trends up and to the 
right, indicating that MSAs with high spending for coronary stent 
placement also tend to have high spending for Laparoscopic 
appendectomy, and vice versa. This relationship is described 
quantitatively as having a correlation of 0.72 on a scale of negative 
1 to 1. 

Each of the other two graphs also shows a cluster of points, one for 
each of the 78 MSA, that trends up and to the right, indicating a 
similar relationship between the other two combinations of procedures. 
In the second graph, the correlation between coronary stent placement 
episode spending along the vertical axis and Total hip replacement 
episode spending along the horizontal axis is 0.83. In the third 
graph, the correlation between Laparoscopic appendectomy episode 
spending along the vertical axis and Total hip replacement episode 
spending along the horizontal axis is 0.68. 

These graphs are based on the average adjusted episode spending 
amounts for each MSA, which are listed in Appendix V. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: All correlations shown are significant at p<0.0001. Data were 
from 78 MSAs. We included all MSAs with a sufficient number of 
episodes to support our analyses for all three procedures. Spending 
was adjusted to control for geographic differences in the cost of 
doing business and differences in demographics and health status of 
enrollees in each MSA. 

[End of figure] 

Despite the overall pattern that MSAs tended to be in the same 
spending quintiles for all three procedures, there were some 
exceptions. Notably, Albany, New York, was in the highest-spending 
quintile for coronary stent placement and Total hip replacement but 
was in the lowest-spending quintile for Laparoscopic appendectomy; San 
Antonio, Texas, was in the highest-spending quintile for Total hip 
replacement but was in the lowest-spending quintile for Laparoscopic 
appendectomy; and Allentown, Pennsylvania, was in the highest-spending 
quintile for coronary stent placement but was in the lowest-spending 
quintile for Total hip replacement. 

We also examined whether high-or low-spending MSAs were concentrated 
in particular regions of the nation, and we found that they were not. 
[Footnote 27] For example, we found 11 MSAs that were in the highest-
spending quintile for at least two of the three procedures we 
examined, and these MSAs were located in different regions of the 
nation, such as Albany, New York; Fort Wayne, Indiana; Houston, Texas; 
Madison, Wisconsin; Milwaukee, Wisconsin; Nashville, Tennessee; 
Salinas, California; and San Diego, California. In addition, some 
states had MSAs in both the highest- and lowest-spending quintiles for 
a given procedure. For example, in California, Salinas and San Diego 
were both in the highest-spending quintile for Laparoscopic 
appendectomy episode spending, whereas Fresno, Oxnard, Riverside, San 
Jose, and Santa Rosa were all in the lowest-spending quintile. 
Similarly, in New York, Albany was in the highest-spending quintile 
for Total hip replacement, whereas Rochester was in the lowest-
spending quintile. 

Price per Initial Inpatient Admission Was Largest Contributor to 
Geographic Differences in Episode Spending: 

The price of the initial hospital inpatient admission was the largest 
contributor to differences in private sector episode spending across 
MSAs.[Footnote 28] Differences in the price of the initial admission 
accounted for 91 percent or more of the difference in average adjusted 
episode spending between the lowest-and highest-spending quintiles. 
For example, for Total hip replacement, the difference in average 
adjusted episode spending in the MSAs in the lowest-and highest-
spending quintiles was $14,506, and $13,198 of that difference--or 91 
percent--was attributable to differences in the price of the initial 
inpatient admission. Similarly, differences in initial inpatient 
admission prices accounted for 92 and 96 percent of the differences in 
episode spending between MSAs in the lowest-and highest-spending 
quintiles for coronary stent placement and Laparoscopic appendectomy, 
respectively (see table 1). The role of inpatient admission price as 
the primary driver of geographic differences in spending in the 
private sector has been reported in the literature, such as by the 
National Institute for Health Care Reform. 

Table 1: Contributions of Each Service Category to Differences in 
Average Episode Spending between Metropolitan Statistical Areas (MSA) 
in the Lowest-and Highest-Spending Quintiles: 

Service category: Hospital inpatient--Price of initial admission[A]; 
Coronary stent placement: 92%; 
Laparoscopic appendectomy: 96%; 
Total hip replacement: 91%. 

Service category: Hospital inpatient--Readmissions; 
Coronary stent placement: 1%; 
Laparoscopic appendectomy: 0%; 
Total hip replacement: 0%. 

Service category: Hospital outpatient; 
Coronary stent placement: 1%; 
Laparoscopic appendectomy: 1%; 
Total hip replacement: 1%. 

Service category: Postdischarge; 
Coronary stent placement: 0%; 
Laparoscopic appendectomy: 0%; 
Total hip replacement: 0%. 

Service category: Professional; 
Coronary stent placement: 5%; 
Laparoscopic appendectomy: 3%; 
Total hip replacement: 7%. 

Service category: Ancillary and unclassified; 
Coronary stent placement: 1%; 
Laparoscopic appendectomy: 0%; 
Total hip replacement: 1%. 

Service category: Total; 
Coronary stent placement: 100%; 
Laparoscopic appendectomy: 100%; 
Total hip replacement: 100%. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 78 MSAs. We included all MSAs with a sufficient 
number of episodes to support our analyses for all three procedures. 
For each procedure, the lowest-and highest-spending quintiles each 
consist of 16 MSAs. Prices and spending were adjusted to control for 
geographic differences in the cost of doing business and differences 
in demographics and health status of enrollees in each MSA. 

[A] We identified price as the amount spent on the initial hospital 
inpatient admission (which excluded spending on any subsequent 
readmissions), because hospitals are generally paid one amount per 
admission regardless of the patient's length of stay or the services 
delivered. In addition, measures of intensity for hospital inpatient 
spending--such as diagnosis-related groups--are assigned based on the 
patient's clinical condition. Instead, we reported prices adjusted for 
differences in demographics and health status of enrollees in each MSA. 

[End of table] 

The price of the initial inpatient admission contributed most to 
geographic differences in average adjusted episode spending for two 
reasons. First, the price of the initial admission represented the 
largest percentage of adjusted episode spending. For the lowest-and 
highest-spending quintiles in each of the three procedures, at least 
two-thirds of episode spending was for the price of the hospital 
inpatient admission. For example, for Total hip replacement, the price 
of the initial admission was $17,134, representing 76 percent of the 
$22,463 in Total episode spending for MSAs in the lowest-spending 
quintile and $30,332, representing 82 percent of the $36,969 in Total 
episode spending for MSAs in the highest-spending quintile. Second, 
the average price of the initial inpatient admission varied 
considerably across MSAs.[Footnote 29] The difference in the price of 
the initial inpatient admission in MSAs in the lowest-and highest-
spending quintiles ranged from 77 percent to 121 percent, depending on 
the procedure. For example, for Laparoscopic appendectomy, the price 
of the initial admission was 121 percent higher for MSAs in the 
highest-spending quintile compared with MSAs in the lowest-spending 
quintile (see figure 3). Specifically, MSAs in the highest-spending 
quintile had an average price of $13,177 for the initial admission--
and ranged from $11,087 in Colorado Springs, Colorado, to $23,432 in 
Salinas, California--whereas MSAs in the lowest-spending quintile had 
an average price of $5,971 for the initial admission--and ranged from 
$4,528 in Las Vegas, Nevada, to $7,430 in San Antonio, Texas. (See 
appendix IV for average adjusted episode spending by procedure and 
service category, and appendix V for complete rankings of hospital 
inpatient spending, initial admission price, and number of days by MSA 
and procedure.) 

Figure 3: Average Prices of Initial Hospital Inpatient Admissions for 
Metropolitan Statistical Areas (MSA) in the Lowest-and Highest-
Spending Quintiles: 

[Refer to PDF for image: stacked vertical bar graph] 

Average MSA spending in dollars: 

Coronary stent placement: 

Lowest-spending quintile (Total episode of care: $21,540): 
Adjusted price of initial hospital inpatient admission: $17,639; 
Adjusted spending on all other categories: $3,901. 

Highest-spending quintile (Total episode of care: $37,996): 
Adjusted price of initial hospital inpatient admission: $32,809 (86% 
higher); 
Adjusted spending on all other categories: $5,186. 

Laparoscopic appendectomy: 

Lowest-spending quintile (Total episode of care: $8,839): 
Adjusted price of initial hospital inpatient admission: $5,971; 
Adjusted spending on all other categories: $2,868. 

Highest-spending quintile (Total episode of care: $16,314): 
Adjusted price of initial hospital inpatient admission: $13,177 (121% 
higher); 
Adjusted spending on all other categories: $3,136. 

Total hip replacement: 

Lowest-spending quintile (Total episode of care: $22,463): 
Adjusted price of initial hospital inpatient admission: $17,134; 
Adjusted spending on all other categories: $5,330. 

Highest-spending quintile (Total episode of care: $36,969): 
Adjusted price of initial hospital inpatient admission: $30,332 (77% 
higher); 
Adjusted spending on all other categories: $6,636. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 78 MSAs. We included all MSAs with a sufficient 
number of episodes to support our analyses for all three procedures. 
For each procedure, the lowest-and highest-spending quintiles each 
consist of 16 MSAs. Prices and spending were adjusted to control for 
geographic differences in the cost of doing business and differences 
in demographics and health status of enrollees in each MSA. Prices and 
spending may not add to totals because of rounding. 

[End of figure] 

Although professional services--office visits, hospital consultations, 
surgeries, and other services provided by a physician or other health 
professional--were the second largest contributor to geographic 
differences in average adjusted episode spending, they contributed to 
a much smaller extent than did the price of the initial inpatient 
admission. For each of the three procedures, differences in spending 
on professional services accounted for only 3 to 7 percent of the 
difference in overall episode spending between MSAs in the lowest-and 
highest-spending quintiles. First, professional services contributed a 
smaller amount to geographic differences in episode spending because 
they represented a much smaller percentage of episode spending than 
the price of the initial inpatient admission. For MSAs in the lowest-
and highest-spending quintiles in each of the three procedures, 10 to 
29 percent of episode spending was for professional services. For 
example, for Total hip replacement, spending on professional services 
was $4,157, representing 19 percent of the $22,463 in Total episode 
spending for MSAs in the lowest-spending quintile and $5,221, 
representing 14 percent of the $36,969 in Total episode spending for 
MSAs in the highest-spending quintile. Second, professional services 
contributed a smaller amount to geographic differences in episode 
spending because spending on professional services varied less across 
MSAs. Spending on professional services for MSAs in the highest-
spending quintile was between 8 percent and 26 percent higher than in 
the lowest-spending quintile, depending on the procedure (see figure 
4).[Footnote 30] Overall, spending on professional services ranged 
widely--for example, from $3,110 in Akron, Ohio, to $9,794 in Madison, 
Wisconsin, for Total hip replacement. (See appendix IV for average 
adjusted episode spending by procedure and service category, and 
appendix VI for complete rankings of professional services spending, 
number of services, intensity, and price by MSA and procedure.) 

Figure 4: Average Spending on Professional Services in Metropolitan 
Statistical Areas (MSA) in the Lowest-and Highest-Spending Quintiles: 

[Refer to PDF for image: stacked vertical bar graph] 

Average MSA spending in dollars: 

Coronary stent placement: 

Lowest-spending quintile (Total episode of care: $21,540): 
Adjusted spending on professional services: $3,099; 
Adjusted spending on all other categories: $18,441. 

Highest-spending quintile (Total episode of care: $37,996): 
Adjusted spending on professional services: $3,890 (26% higher); 
Adjusted spending on all other categories: $34,105. 

Laparoscopic appendectomy: 

Lowest-spending quintile (Total episode of care: $8,839): 
Adjusted spending on professional services: $2,535; 
Adjusted spending on all other categories: $6,304. 

Highest-spending quintile (Total episode of care: $16,314): 
Adjusted spending on professional services: $2,726 (8% higher); 
Adjusted spending on all other categories: $13,587. 

Total hip replacement: 

Lowest-spending quintile (Total episode of care: $22,463): 
Adjusted spending on professional services: $4,157; 
Adjusted spending on all other categories: $18,307. 

Highest-spending quintile (Total episode of care: $36,969): 
Adjusted spending on professional services: $5,221 (26% higher); 
Adjusted spending on all other categories: $31,747. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 78 MSAs. We included all MSAs with a sufficient 
number of episodes to support our analyses for all three procedures. 
For each procedure, the lowest-and highest-spending quintiles each 
consist of 16 MSAs. Spending was adjusted to control for geographic 
differences in the cost of doing business and differences in 
demographics and health status of enrollees in each MSA. Spending may 
not add to totals because of rounding. 

[End of figure] 

When we examined how volume, intensity, and prices contributed to 
differences in spending on professional services, we found that for 
all three procedures services in MSAs in the highest-spending quintile 
had higher average prices and higher average intensity than services 
in MSAs in the lowest-spending quintile, with price having a greater 
impact than intensity. However, MSAs in the highest-spending quintile 
used fewer services than MSAs in the lowest-spending quintile, 
somewhat offsetting the impact of prices on spending. For example, for 
coronary stent placement, MSAs in the highest-spending quintile had 
$791 more in spending, 11.4 percent lower volume, 4.0 percent higher 
intensity, and 39.8 percent higher prices, compared to MSAs in the 
lowest-spending quintile (see table 2). (See also appendix VI for 
complete rankings of professional services spending, number of 
services, intensity, and price by MSA and procedure.) These findings 
are consistent with our finding on hospital inpatient spending and 
with existing research on private sector data, which has generally 
found that variation in prices drives overall variation in spending 
across geographic areas. While high-priced areas tend to have lower 
utilization and vice versa, the variation in prices has a larger 
effect. 

Table 2: Professional Services: Difference in Average Spending, 
Volume, Intensity, and Price: 

Comparison of averages for MSAs in highest- and lowest-spending 
quintiles: 

Procedure: Coronary stent placement; 
Adjusted spending: $791 higher; 
Volume (number of services): 11.4% lower; 
Intensity: 4.0% higher; 
Comparison of averages for MSAs in highest- and lowest-spending 
quintiles: Price per unit of intensity: 39.8% higher. 

Procedure: Laparoscopic appendectomy; 
Adjusted spending: $191 higher; 
Volume (number of services): 12.6% lower; 
Intensity: 7.3% higher; 
Comparison of averages for MSAs in highest- and lowest-spending 
quintiles: Price per unit of intensity: 14.4% higher. 

Procedure: Total hip replacement; 
Adjusted spending: $1,064 higher; 
Volume (number of services): 14.8% lower; 
Intensity: 12.5% higher; 
Comparison of averages for MSAs in highest- and lowest-spending 
quintiles: Price per unit of intensity: 33.4% higher. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 78 MSAs. We included all MSAs with a sufficient 
number of episodes to support our analyses for all three procedures. 
For each procedure, the lowest-and highest-spending quintiles each 
consist of 16 MSAs. Spending, volume, and intensity were adjusted to 
control for geographic differences in demographics and health status 
of enrollees in each MSA; spending was also adjusted for differences 
in the cost of doing business. Intensity is measured by the relative 
value unit (RVU) assigned to each service. 

[End of table] 

Agency Comments: 

We provided a draft of this product to the Department of Health and 
Human Services, which did not comment on our findings but provided 
technical comments. We incorporated these technical comments as 
appropriate. 

As agreed with your office, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the report date. At that time, we will send copies to the 
Secretary of Health and Human Services and the Administrator of the 
Centers for Medicare & Medicaid Services. In addition, the report is 
available at no charge on the GAO website at [hyperlink, 
http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made major 
contributions to this report are listed in appendix VII. 

Sincerely yours, 

Signed by: 

James Cosgrove: 
Director, Health Care: 

[End of section] 

Appendix I: Data and Methods: 

This appendix describes the data and methods we used in our study. 

Creating Episodes of Care from Private Health Insurance Claims Data: 

We created episodes of care based on inpatient admissions for three 
procedures--coronary stent placement, Laparoscopic appendectomy, and 
Total hip replacement[Footnote 31]--using private health insurance 
claims and enrollment data from the Truven Health Analytics 
MarketScan® Commercial Claims and Encounters Database for 2009 and 
2010.[Footnote 32] We identified procedures based on the presence of 
specific procedure codes in the hospital inpatient and professional 
service claims.[Footnote 33] We selected these procedures because they 
were commonly performed in the years we analyzed and were associated 
with high levels of national spending in the MarketScan database. In 
addition, we selected procedures that were generally provided by 
different medical specialties,[Footnote 34] and we selected hospital-
based procedures because the United States spends more nationally on 
hospital services than any other type of health care service.[Footnote 
35] 

We included all services in the episode from the day of admission to 
30 days after discharge, and certain services in the 3 days prior to 
admission. Specifically, we included any outpatient services received 
by an enrollee in the 3 days prior to admission at the same hospital 
where the inpatient admission occurred, because those services may be 
related to the admission. In the episode, we included any drugs 
provided during the hospital inpatient admission because these drugs 
were part of the hospital inpatient claims. However, we excluded 
outpatient drugs, such as prescription drugs, due to limitations of 
the claims in the MarketScan database. 

We excluded enrollees from our study who had inpatient admissions for 
any of the three procedures outside the 50 states and the District of 
Columbia, had secondary insurance, or were enrolled in a managed care 
or other capitated plan.[Footnote 36] We also excluded enrollees with 
certain conditions that could increase spending for reasons unrelated 
to the procedure analyzed. For example, we excluded enrollees who 
received the procedure more than one time during the episode, 
enrollees whose overall initial hospital admission was coded as being 
for a reason unrelated to the procedure analyzed, enrollees with 
diagnoses of end-stage renal disease, enrollees who were pregnant, and 
enrollees with a hospice stay. In addition, we excluded enrollees 
under the age of 18 for coronary stent placement and Total hip 
replacement episodes, and we excluded enrollees with a diagnosis of 
appendix rupture for Laparoscopic appendectomy episodes. 

Analyzing Average Episode Spending across Geographic Areas: 

We analyzed average episode spending across metropolitan statistical 
areas (MSA) for each procedure.[Footnote 37] We assigned episodes to 
MSAs based on the location of the hospital inpatient admission, and we 
had a sufficient number of episodes to support our analyses of 
coronary stent placement in 155 MSAs, Laparoscopic appendectomy in 139 
MSAs, and Total hip replacement in 141 MSAs.[Footnote 38] For some 
analyses where we draw comparisons across procedures, we report data 
on only the 78 MSAs that had a sufficient number of episodes to 
support our analyses for all three procedures. 

For each procedure, we estimated unadjusted spending and spending 
adjusted for geographic differences in the cost of doing business and 
differences in the demographics and health status of enrollees in each 
MSA. To estimate unadjusted spending, we summed the insurer's allowed 
payment amount for all services within the episode, including the 
amount paid by the insurer and any cost-sharing paid by the enrollee. 
[Footnote 39] We adjusted for geographic differences in the cost of 
doing business by using Medicare's payment-adjustment methodology. For 
services provided by physicians and certain other health 
professionals, we applied the Geographic Practice Cost Index, which is 
Medicare's estimate of the geographic differences in the costs of 
operating a medical practice, to the unadjusted spending for 
professional services. For services provided by hospitals, such as 
during an inpatient admission, and by certain other facilities, we 
applied the Hospital Wage Index value, which is Medicare's estimate of 
differences in the wage-related component of the costs of doing 
business, to a portion of the unadjusted spending for those services. 
We additionally adjusted for differences in the demographics and 
health status of enrollees in each MSA by using a regression-based 
approach. In the regression, the dependent variable was Total cost-
adjusted episode spending, and the independent variables were enrollee-
level factors (such as age, gender, number of readmissions, and 
certain comorbidities) and MSA-level indicator variables to identify 
the portion of the remaining variation in episode spending that was 
attributable to specific geographic areas. 

Using all MSAs in our analyses, we reported the distribution of 
average adjusted episode spending for each procedure. Using the 78 
MSAs with a sufficient number of episodes for all three procedures, we 
reported the correlation coefficient to show the extent to which MSAs 
with high or low episode spending for one procedure also had high or 
low episode spending for another procedure.[Footnote 40] We also 
examined whether MSAs in the lowest-and highest-spending quintile were 
concentrated in particular regions of the nation. 

Analyzing Mix of Service Types: 

To examine how one of the components of spending--mix of service 
types--contributes to variation in episode spending across geographic 
areas, we assigned all adjusted spending within an episode to one of 
five service categories based on the procedure code for the service 
and place of service. The five service categories were (1) hospital 
inpatient, (2) hospital outpatient, (3) postdischarge, (4) 
professional, and (5) ancillary.[Footnote 41] 

For the 78 MSAs with a sufficient number of episodes for all three 
procedures, we compared the MSAs in the lowest-and highest-spending 
quintiles for each procedure, and we reported the extent to which 
those differences in spending for each service category contributed to 
differences in episode spending.[Footnote 42] We also reported the 
difference in adjusted spending by service category between the 
quintiles. 

Analyzing Volume, Intensity, and Price of Services: 

To examine how the other components of spending contribute to 
variation in episode spending for private payers, we analyzed volume, 
intensity, and price of services for hospital inpatient and 
professional services.[Footnote 43] 

For hospital inpatient services, we measured volume as the number of 
days of the hospital stay, and we measured price by the amount of 
spending on the initial hospital inpatient admission (which excluded 
spending on any subsequent readmissions) because hospitals are 
generally paid one amount per admission regardless of the patient's 
length of stay or the services delivered. In addition, we calculated 
the extent to which the price of the initial inpatient admission 
contributed to differences in episode spending between MSAs in the 
lowest-and highest-spending quintiles. 

For professional services, we measured volume as the number of 
services, measured intensity based on the relative value unit (RVU), 
which is an estimate of the resources needed to provide a given 
service,[Footnote 44] and calculated the price per unit of intensity 
by dividing average spending on professional services by the Total 
units of intensity (number of RVUs) associated with those services. 
[Footnote 45] Similar to our adjustments for spending, we used a 
regression-based approach to control for differences in the 
demographics and health status of enrollees in each MSA. In addition, 
we compared differences in volume, intensity, and price per unit of 
intensity between MSAs in the lowest-and highest-spending quintiles. 

[End of section] 

Appendix II: Episode Spending, by Procedure, within Metropolitan 
Statistical Areas GAO Analyzed: 

This appendix ranks metropolitan statistical areas (MSA) by average 
adjusted episode spending for each of the three procedures we analyzed-
-coronary stent placement, Laparoscopic appendectomy, and Total hip 
replacement. 

Table 3: Ranking of Metropolitan Statistical Areas (MSA) by Adjusted 
Episode Spending for Coronary Stent Placement Episodes: 

Rank: 1; 
MSA: Salinas, CA; 
Number of episodes: 38; 
Average adjusted episode spending: $60,375. 

Rank: 2; 
MSA: Albany, GA; 
Number of episodes: 48; 
Average adjusted episode spending: $45,204. 

Rank: 3; 
MSA: [A]; 
Number of episodes: 87; 
Average adjusted episode spending: $44,470. 

Rank: 4; 
MSA: [A]; 
Number of episodes: 51; 
Average adjusted episode spending: $43,824. 

Rank: 5; 
MSA: Asheville, NC; 
Number of episodes: 36; 
Average adjusted episode spending: $43,578. 

Rank: 6; 
MSA: Cape Girardeau-Jackson, MO-IL; 
Number of episodes: 42; 
Average adjusted episode spending: $42,318. 

Rank: 7; 
MSA: [A]; 
Number of episodes: 62; 
Average adjusted episode spending: $39,827. 

Rank: 8; 
MSA: Charleston, WV; 
Number of episodes: 134; 
Average adjusted episode spending: $39,782. 

Rank: 9; 
MSA: San Diego-Carlsbad-San Marcos, CA; 
Number of episodes: 80; 
Average adjusted episode spending: $39,683. 

Rank: 10; 
MSA: [A]; 
Number of episodes: 77; 
Average adjusted episode spending: $39,438. 

Rank: 11; 
MSA: [A]; 
Number of episodes: 165; 
Average adjusted episode spending: $39,339. 

Rank: 12; 
MSA: Rome, GA; 
Number of episodes: 59; 
Average adjusted episode spending: $39,248. 

Rank: 13; 
MSA: [A]; 
Number of episodes: 28; 
Average adjusted episode spending: $39,229. 

Rank: 14; 
MSA: Milwaukee-Waukesha-West Allis, WI; 
Number of episodes: 194; 
Average adjusted episode spending: $38,596. 

Rank: 15; 
MSA: Albany-Schenectady-Troy, NY; 
Number of episodes: 27; 
Average adjusted episode spending: $38,305. 

Rank: 16; 
MSA: York-Hanover, PA; 
Number of episodes: 56; 
Average adjusted episode spending: $38,198. 

Rank: 17; 
MSA: Mansfield, OH; 
Number of episodes: 39; 
Average adjusted episode spending: $37,808. 

Rank: 18; 
MSA: Valdosta, GA; 
Number of episodes: 26; 
Average adjusted episode spending: $37,748. 

Rank: 19; 
MSA: Lafayette, IN; 
Number of episodes: 47; 
Average adjusted episode spending: $37,612. 

Rank: 20; 
MSA: Johnson City, TN; 
Number of episodes: 36; 
Average adjusted episode spending: $37,363. 

Rank: 21; 
MSA: [A]; 
Number of episodes: 56; 
Average adjusted episode spending: $37,324. 

Rank: 22; 
MSA: Madison, WI; 
Number of episodes: 27; 
Average adjusted episode spending: $37,248. 

Rank: 23; 
MSA: [A]; 
Number of episodes: 163; 
Average adjusted episode spending: $36,858. 

Rank: 24; 
MSA: [A]; 
Number of episodes: 475; 
Average adjusted episode spending: $36,388. 

Rank: 25; 
MSA: Baton Rouge, LA; 
Number of episodes: 35; 
Average adjusted episode spending: $36,327. 

Rank: 26; 
MSA: [A]; 
Number of episodes: 42; 
Average adjusted episode spending: $36,222. 

Rank: 27; 
MSA: Duluth, MN-WI; 
Number of episodes: 34; 
Average adjusted episode spending: $36,123. 

Rank: 28; 
MSA: Houston-Sugar Land-Baytown, TX; 
Number of episodes: 634; 
Average adjusted episode spending: $36,097. 

Rank: 29; 
MSA: Winston-Salem, NC; 
Number of episodes: 38; 
Average adjusted episode spending: $36,029. 

Rank: 30; 
MSA: [A]; 
Number of episodes: 100; 
Average adjusted episode spending: $35,478. 

Rank: 31; 
MSA: Chico, CA; 
Number of episodes: 24; 
Average adjusted episode spending: $35,415. 

Rank: 32; 
MSA: Providence-New Bedford-Fall River, RI-MA; 
Number of episodes: 70; 
Average adjusted episode spending: $35,358. 

Rank: 33; 
MSA: Parkersburg-Marietta-Vienna, WV-OH; 
Number of episodes: 47; 
Average adjusted episode spending: $35,323. 

Rank: 34; 
MSA: Bowling Green, KY; 
Number of episodes: 31; 
Average adjusted episode spending: $34,847. 

Rank: 35; 
MSA: Appleton, WI; 
Number of episodes: 29; 
Average adjusted episode spending: $34,614. 

Rank: 36; 
MSA: Elkhart-Goshen, IN; 
Number of episodes: 53; 
Average adjusted episode spending: $34,607. 

Rank: 37; 
MSA: Green Bay, WI; 
Number of episodes: 68; 
Average adjusted episode spending: $34,539. 

Rank: 38; 
MSA: Seattle-Tacoma-Bellevue, WA; 
Number of episodes: 237; 
Average adjusted episode spending: $34,388. 

Rank: 39; 
MSA: Fort Wayne, IN; 
Number of episodes: 185; 
Average adjusted episode spending: $34,307. 

Rank: 40; 
MSA: Nashville-Davidson-Murfreesboro-Franklin, TN; 
Number of episodes: 253; 
Average adjusted episode spending: $34,258. 

Rank: 41; 
MSA: South Bend-Mishawaka, IN-MI; 
Number of episodes: 40; 
Average adjusted episode spending: $34,229. 

Rank: 42; 
MSA: Redding, CA; 
Number of episodes: 34; 
Average adjusted episode spending: $34,218. 

Rank: 43; 
MSA: [A]; 
Number of episodes: 302; 
Average adjusted episode spending: $33,974. 

Rank: 44; 
MSA: Athens-Clarke County, GA; 
Number of episodes: 46; 
Average adjusted episode spending: $33,528. 

Rank: 45; 
MSA: Evansville, IN-KY; 
Number of episodes: 70; 
Average adjusted episode spending: $33,510. 

Rank: 46; 
MSA: Allentown-Bethlehem-Easton, PA-NJ; 
Number of episodes: 244; 
Average adjusted episode spending: $33,398. 

Rank: 47; 
MSA: Winchester, VA-WV; 
Number of episodes: 46; 
Average adjusted episode spending: $33,041. 

Rank: 48; 
MSA: Santa Fe, NM; 
Number of episodes: 37; 
Average adjusted episode spending: $32,920. 

Rank: 49; 
MSA: Sacramento-Arden-Arcade-Roseville, CA; 
Number of episodes: 86; 
Average adjusted episode spending: $32,807. 

Rank: 50; 
MSA: Orlando-Kissimmee-Sanford, FL; 
Number of episodes: 180; 
Average adjusted episode spending: $32,605. 

Rank: 51; 
MSA: Tampa-St. Petersburg-Clearwater, FL; 
Number of episodes: 232; 
Average adjusted episode spending: $32,156. 

Rank: 52; 
MSA: Cape Coral-Fort Myers, FL; 
Number of episodes: 39; 
Average adjusted episode spending: $32,143. 

Rank: 53; 
MSA: Chattanooga, TN-GA; 
Number of episodes: 56; 
Average adjusted episode spending: $32,134. 

Rank: 54; 
MSA: Kansas City, MO-KS; 
Number of episodes: 183; 
Average adjusted episode spending: $32,068. 

Rank: 55; 
MSA: Raleigh-Cary, NC; 
Number of episodes: 63; 
Average adjusted episode spending: $31,879. 

Rank: 56; 
MSA: Dallas-Fort Worth-Arlington, TX; 
Number of episodes: 916; 
Average adjusted episode spending: $31,847. 

Rank: 57; 
MSA: San Jose-Sunnyvale-Santa Clara, CA; 
Number of episodes: 43; 
Average adjusted episode spending: $31,797. 

Rank: 58; 
MSA: Lincoln, NE; 
Number of episodes: 33; 
Average adjusted episode spending: $31,748. 

Rank: 59; 
MSA: Colorado Springs, CO; 
Number of episodes: 51; 
Average adjusted episode spending: $31,017. 

Rank: 60; 
MSA: Syracuse, NY; 
Number of episodes: 46; 
Average adjusted episode spending: $31,008. 

Rank: 61; 
MSA: [A]; 
Number of episodes: 255; 
Average adjusted episode spending: $30,680. 

Rank: 62; 
MSA: Memphis, TN-MS-AR; 
Number of episodes: 114; 
Average adjusted episode spending: $30,607. 

Rank: 63; 
MSA: Niles-Benton Harbor, MI; 
Number of episodes: 34; 
Average adjusted episode spending: $30,341. 

Rank: 64; 
MSA: Sherman-Denison, TX; 
Number of episodes: 35; 
Average adjusted episode spending: $30,269. 

Rank: 65; 
MSA: [A]; 
Number of episodes: 68; 
Average adjusted episode spending: $30,243. 

Rank: 66; 
MSA: [A]; 
Number of episodes: 89; 
Average adjusted episode spending: $30,156. 

Rank: 67; 
MSA: Hagerstown-Martinsburg, MD-WV; 
Number of episodes: 28; 
Average adjusted episode spending: $30,013. 

Rank: 68; 
MSA: Fresno, CA; 
Number of episodes: 62; 
Average adjusted episode spending: $29,925. 

Rank: 69; 
MSA: Grand Rapids-Wyoming, MI; 
Number of episodes: 48; 
Average adjusted episode spending: $29,684. 

Rank: 70; 
MSA: Ocala, FL; 
Number of episodes: 34; 
Average adjusted episode spending: $29,547. 

Rank: 71; 
MSA: Philadelphia-Camden-Wilmington, PA-NJ-DE-MD; 
Number of episodes: 389; 
Average adjusted episode spending: $29,489. 

Rank: 72; 
MSA: Worcester, MA; 
Number of episodes: 36; 
Average adjusted episode spending: $29,427. 

Rank: 73; 
MSA: [A]; 
Number of episodes: 142; 
Average adjusted episode spending: $29,393. 

Rank: 74; 
MSA: Ann Arbor, MI; 
Number of episodes: 67; 
Average adjusted episode spending: $29,302. 

Rank: 75; 
MSA: Bloomington-Normal, IL; 
Number of episodes: 40; 
Average adjusted episode spending: $29,073. 

Rank: 76; 
MSA: Columbia, MO; 
Number of episodes: 43; 
Average adjusted episode spending: $28,995. 

Rank: 77; 
MSA: [A]; 
Number of episodes: 54; 
Average adjusted episode spending: $28,717. 

Rank: 78; 
MSA: Denver-Aurora-Broomfield, CO; 
Number of episodes: 169; 
Average adjusted episode spending: $28,698. 

Rank: 79; 
MSA: Fayetteville-Springdale-Rogers, AR-MO; 
Number of episodes: 49; 
Average adjusted episode spending: $28,682. 

Rank: 80; 
MSA: Chicago-Joliet-Naperville, IL-IN-WI; 
Number of episodes: 1,944; 
Average adjusted episode spending: $28,640. 

Rank: 81; 
MSA: New York-Northern New Jersey-Long Island, NY-NJ-PA; 
Number of episodes: 1,066; 
Average adjusted episode spending: $28,629. 

Rank: 82; 
MSA: Lakeland-Winter Haven, FL; 
Number of episodes: 64; 
Average adjusted episode spending: $28,607. 

Rank: 83; 
MSA: Punta Gorda, FL; 
Number of episodes: 31; 
Average adjusted episode spending: $28,560. 

Rank: 84; 
MSA: Portland-Vancouver-Hillsboro, OR-WA; 
Number of episodes: 141; 
Average adjusted episode spending: $28,553. 

Rank: 85; 
MSA: Boston-Cambridge-Quincy, MA-NH; 
Number of episodes: 331; 
Average adjusted episode spending: $28,474. 

Rank: 86; 
MSA: [A]; 
Number of episodes: 192; 
Average adjusted episode spending: $28,276. 

Rank: 87; 
MSA: Decatur, IL; 
Number of episodes: 45; 
Average adjusted episode spending: $28,250. 

Rank: 88; 
MSA: Santa Rosa-Petaluma, CA; 
Number of episodes: 26; 
Average adjusted episode spending: $28,065. 

Rank: 89; 
MSA: Poughkeepsie-Newburgh-Middletown, NY; 
Number of episodes: 24; 
Average adjusted episode spending: $28,003. 

Rank: 90; 
MSA: Muncie, IN; 
Number of episodes: 54; 
Average adjusted episode spending: $27,822. 

Rank: 91; 
MSA: Huntington-Ashland, WV-KY-OH; 
Number of episodes: 153; 
Average adjusted episode spending: $27,705. 

Rank: 92; 
MSA: Detroit-Warren-Livonia, MI; 
Number of episodes: 376; 
Average adjusted episode spending: $27,544. 

Rank: 93; 
MSA: San Antonio-New Braunfels, TX; 
Number of episodes: 235; 
Average adjusted episode spending: $27,489. 

Rank: 94; 
MSA: New Orleans-Metairie-Kenner, LA; 
Number of episodes: 63; 
Average adjusted episode spending: $27,480. 

Rank: 95; 
MSA: Minneapolis-St. Paul-Bloomington, MN-WI; 
Number of episodes: 175; 
Average adjusted episode spending: $27,308. 

Rank: 96; 
MSA: Phoenix-Mesa-Glendale, AZ; 
Number of episodes: 263; 
Average adjusted episode spending: $27,067. 

Rank: 97; 
MSA: [A]; 
Number of episodes: 66; 
Average adjusted episode spending: $27,047. 

Rank: 98; 
MSA: [A]; 
Number of episodes: 673; 
Average adjusted episode spending: $26,746. 

Rank: 99; 
MSA: Oklahoma City, OK; 
Number of episodes: 551; 
Average adjusted episode spending: $26,468. 

Rank: 100; 
MSA: [A]; 
Number of episodes: 55; 
Average adjusted episode spending: $26,366. 

Rank: 101; 
MSA: [A]; 
Number of episodes: 87; 
Average adjusted episode spending: $26,349. 

Rank: 102; 
MSA: Tyler, TX; 
Number of episodes: 132; 
Average adjusted episode spending: $25,953. 

Rank: 103; 
MSA: Terre Haute, IN; 
Number of episodes: 54; 
Average adjusted episode spending: $25,896. 

Rank: 104; 
MSA: [A]; 
Number of episodes: 80; 
Average adjusted episode spending: $25,813. 

Rank: 105; 
MSA: Rochester, NY; 
Number of episodes: 83; 
Average adjusted episode spending: $25,523. 

Rank: 106; 
MSA: Riverside-San Bernardino-Ontario, CA; 
Number of episodes: 78; 
Average adjusted episode spending: $25,322. 

Rank: 107; 
MSA: St. Louis, MO-IL; 
Number of episodes: 500; 
Average adjusted episode spending: $25,288. 

Rank: 108; 
MSA: Fort Smith, AR-OK; 
Number of episodes: 33; 
Average adjusted episode spending: $25,286. 

Rank: 109; 
MSA: Toledo, OH; 
Number of episodes: 249; 
Average adjusted episode spending: $25,210. 

Rank: 110; 
MSA: Cincinnati-Middletown, OH-KY-IN; 
Number of episodes: 838; 
Average adjusted episode spending: $25,203. 

Rank: 111; 
MSA: Albuquerque, NM; 
Number of episodes: 220; 
Average adjusted episode spending: $25,015. 

Rank: 112; 
MSA: Cleveland-Elyria-Mentor, OH; 
Number of episodes: 494; 
Average adjusted episode spending: $24,914. 

Rank: 113; 
MSA: Washington-Arlington-Alexandria, DC-VA-MD-WV; 
Number of episodes: 210; 
Average adjusted episode spending: $24,872. 

Rank: 114; 
MSA: [A]; 
Number of episodes: 27; 
Average adjusted episode spending: $24,862. 

Rank: 115; 
MSA: Shreveport-Bossier City, LA; 
Number of episodes: 40; 
Average adjusted episode spending: $24,848. 

Rank: 116; 
MSA: [A]; 
Number of episodes: 280; 
Average adjusted episode spending: $24,753. 

Rank: 117; 
MSA: [A]; 
Number of episodes: 55; 
Average adjusted episode spending: $24,682. 

Rank: 118; 
MSA: [A]; 
Number of episodes: 39; 
Average adjusted episode spending: $24,456. 

Rank: 119; 
MSA: Columbus, OH; 
Number of episodes: 450; 
Average adjusted episode spending: $24,310. 

Rank: 120; 
MSA: Tulsa, OK; 
Number of episodes: 262; 
Average adjusted episode spending: $24,088. 

Rank: 121; 
MSA: [A]; 
Number of episodes: 146; 
Average adjusted episode spending: $23,938. 

Rank: 122; 
MSA: Knoxville, TN; 
Number of episodes: 102; 
Average adjusted episode spending: $23,935. 

Rank: 123; 
MSA: Reno-Sparks, NV; 
Number of episodes: 47; 
Average adjusted episode spending: $23,852. 

Rank: 124; 
MSA: Naples-Marco Island, FL; 
Number of episodes: 32; 
Average adjusted episode spending: $23,830. 

Rank: 125; 
MSA: San Luis Obispo-Paso Robles, CA; 
Number of episodes: 37; 
Average adjusted episode spending: $23,785. 

Rank: 126; 
MSA: [A]; 
Number of episodes: 32; 
Average adjusted episode spending: $23,665. 

Rank: 127; 
MSA: [A]; 
Number of episodes: 203; 
Average adjusted episode spending: $23,647. 

Rank: 128; 
MSA: Bridgeport-Stamford-Norwalk, CT; 
Number of episodes: 109; 
Average adjusted episode spending: $23,135. 

Rank: 129; 
MSA: [A]; 
Number of episodes: 55; 
Average adjusted episode spending: $22,848. 

Rank: 130; 
MSA: Springfield, MO; 
Number of episodes: 48; 
Average adjusted episode spending: $22,784. 

Rank: 131; 
MSA: Los Angeles-Long Beach-Santa Ana, CA; 
Number of episodes: 486; 
Average adjusted episode spending: $22,768. 

Rank: 132; 
MSA: Savannah, GA; 
Number of episodes: 57; 
Average adjusted episode spending: $22,585. 

Rank: 133; 
MSA: [A]; 
Number of episodes: 223; 
Average adjusted episode spending: $22,570. 

Rank: 134; 
MSA: Little Rock-North Little Rock-Conway, AR; 
Number of episodes: 69; 
Average adjusted episode spending: $22,439. 

Rank: 135; 
MSA: [A]; 
Number of episodes: 84; 
Average adjusted episode spending: $22,391. 

Rank: 136; 
MSA: Hartford-West Hartford-East Hartford, CT; 
Number of episodes: 353; 
Average adjusted episode spending: $22,357. 

Rank: 137; 
MSA: Columbus, GA-AL; 
Number of episodes: 37; 
Average adjusted episode spending: $22,336. 

Rank: 138; 
MSA: Bay City, MI; 
Number of episodes: 58; 
Average adjusted episode spending: $22,236. 

Rank: 139; 
MSA: Dayton, OH; 
Number of episodes: 174; 
Average adjusted episode spending: $22,073. 

Rank: 140; 
MSA: Oxnard-Thousand Oaks-Ventura, CA; 
Number of episodes: 40; 
Average adjusted episode spending: $22,023. 

Rank: 141; 
MSA: [A]; 
Number of episodes: 213; 
Average adjusted episode spending: $21,952. 

Rank: 142; 
MSA: Springfield, MA; 
Number of episodes: 50; 
Average adjusted episode spending: $21,937. 

Rank: 143; 
MSA: Joplin, MO; 
Number of episodes: 60; 
Average adjusted episode spending: $21,699. 

Rank: 144; 
MSA: [A]; 
Number of episodes: 1,585; 
Average adjusted episode spending: $21,664. 

Rank: 145; 
MSA: Akron, OH; 
Number of episodes: 128; 
Average adjusted episode spending: $21,664. 

Rank: 146; 
MSA: [A]; 
Number of episodes: 66; 
Average adjusted episode spending: $21,651. 

Rank: 147; 
MSA: Canton-Massillon, OH; 
Number of episodes: 55; 
Average adjusted episode spending: $21,225. 

Rank: 148; 
MSA: Las Vegas-Paradise, NV; 
Number of episodes: 115; 
Average adjusted episode spending: $20,969. 

Rank: 149; 
MSA: Lexington-Fayette, KY; 
Number of episodes: 196; 
Average adjusted episode spending: $20,602. 

Rank: 150; 
MSA: [A]; 
Number of episodes: 332; 
Average adjusted episode spending: $20,590. 

Rank: 151; 
MSA: Youngstown-Warren-Boardman, OH-PA; 
Number of episodes: 216; 
Average adjusted episode spending: $18,829. 

Rank: 152; 
MSA: Louisville-Jefferson County, KY-IN; 
Number of episodes: 277; 
Average adjusted episode spending: $18,677. 

Rank: 153; 
MSA: Birmingham-Hoover, AL; 
Number of episodes: 63; 
Average adjusted episode spending: $17,768. 

Rank: 154; 
MSA: [A]; 
Number of episodes: 39; 
Average adjusted episode spending: $17,710. 

Rank: 155; 
MSA: Huntsville, AL; 
Number of episodes: 33; 
Average adjusted episode spending: $14,448. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 155 MSAs. We included all MSAs with a sufficient 
number of coronary stent placement episodes to support our analyses. 
Spending was adjusted to control for geographic differences in the 
cost of doing business and differences in demographics and health 
status of enrollees in each MSA. 

[A] MSA name withheld to protect the confidentiality of entities that 
contributed private data. 

[End of table] 

Table 4: Ranking of Metropolitan Statistical Areas (MSA) by Adjusted 
Episode Spending for Laparoscopic Appendectomy Episodes: 

Rank: 1; 
MSA: Salinas, CA; 
Number of episodes: 68; 
Average adjusted episode spending: $25,924. 

Rank: 2; 
MSA: Janesville, WI; 
Number of episodes: 20; 
Average adjusted episode spending: $22,677. 

Rank: 3; 
MSA: Fort Collins-Loveland, CO; 
Number of episodes: 21; 
Average adjusted episode spending: $21,766. 

Rank: 4; 
MSA: Anchorage, AK; 
Number of episodes: 20; 
Average adjusted episode spending: $20,746. 

Rank: 5; 
MSA: Reading, PA; 
Number of episodes: 50; 
Average adjusted episode spending: $18,142. 

Rank: 6; 
MSA: Madison, WI; 
Number of episodes: 32; 
Average adjusted episode spending: $18,123. 

Rank: 7; 
MSA: Milwaukee-Waukesha-West Allis, WI; 
Number of episodes: 170; 
Average adjusted episode spending: $18,096. 

Rank: 8; 
MSA: [A]; 
Number of episodes: 26; 
Average adjusted episode spending: $18,085. 

Rank: 9; 
MSA: Lynchburg, VA; 
Number of episodes: 27; 
Average adjusted episode spending: $17,745. 

Rank: 10; 
MSA: Charleston, WV; 
Number of episodes: 33; 
Average adjusted episode spending: $17,640. 

Rank: 11; 
MSA: [A]; 
Number of episodes: 34; 
Average adjusted episode spending: $17,328. 

Rank: 12; 
MSA: Port St. Lucie, FL; 
Number of episodes: 21; 
Average adjusted episode spending: $17,104. 

Rank: 13; 
MSA: [A]; 
Number of episodes: 36; 
Average adjusted episode spending: $16,588. 

Rank: 14; 
MSA: [A]; 
Number of episodes: 83; 
Average adjusted episode spending: $16,323. 

Rank: 15; 
MSA: [A]; 
Number of episodes: 67; 
Average adjusted episode spending: $15,724. 

Rank: 16; 
MSA: Grand Rapids-Wyoming, MI; 
Number of episodes: 30; 
Average adjusted episode spending: $15,444. 

Rank: 17; 
MSA: Colorado Springs, CO; 
Number of episodes: 31; 
Average adjusted episode spending: $15,318. 

Rank: 18; 
MSA: Santa Barbara-Santa Maria-Goleta, CA; 
Number of episodes: 27; 
Average adjusted episode spending: $15,307. 

Rank: 19; 
MSA: Orlando-Kissimmee-Sanford, FL; 
Number of episodes: 215; 
Average adjusted episode spending: $15,267. 

Rank: 20; 
MSA: Farmington, NM; 
Number of episodes: 48; 
Average adjusted episode spending: $15,244. 

Rank: 21; 
MSA: [A]; 
Number of episodes: 134; 
Average adjusted episode spending: $15,202. 

Rank: 22; 
MSA: [A]; 
Number of episodes: 162; 
Average adjusted episode spending: $15,052. 

Rank: 23; 
MSA: San Diego-Carlsbad-San Marcos, CA; 
Number of episodes: 174; 
Average adjusted episode spending: $14,859. 

Rank: 24; 
MSA: Pensacola-Ferry Pass-Brent, FL; 
Number of episodes: 26; 
Average adjusted episode spending: $14,835. 

Rank: 25; 
MSA: [A]; 
Number of episodes: 106; 
Average adjusted episode spending: $14,761. 

Rank: 26; 
MSA: [A]; 
Number of episodes: 26; 
Average adjusted episode spending: $14,704. 

Rank: 27; 
MSA: Lakeland-Winter Haven, FL; 
Number of episodes: 56; 
Average adjusted episode spending: $14,678. 

Rank: 28; 
MSA: Seattle-Tacoma-Bellevue, WA; 
Number of episodes: 349; 
Average adjusted episode spending: $14,644. 

Rank: 29; 
MSA: Fort Wayne, IN; 
Number of episodes: 39; 
Average adjusted episode spending: $14,543. 

Rank: 30; 
MSA: Columbus, OH; 
Number of episodes: 164; 
Average adjusted episode spending: $14,478. 

Rank: 31; 
MSA: Portland-Vancouver-Hillsboro, OR-WA; 
Number of episodes: 219; 
Average adjusted episode spending: $14,337. 

Rank: 32; 
MSA: Nashville-Davidson-Murfreesboro-Franklin, TN; 
Number of episodes: 72; 
Average adjusted episode spending: $14,335. 

Rank: 33; 
MSA: Cape Coral-Fort Myers, FL; 
Number of episodes: 38; 
Average adjusted episode spending: $14,327. 

Rank: 34; 
MSA: Baton Rouge, LA; 
Number of episodes: 34; 
Average adjusted episode spending: $14,149. 

Rank: 35; 
MSA: [A]; 
Number of episodes: 110; 
Average adjusted episode spending: $14,115. 

Rank: 36; 
MSA: [A]; 
Number of episodes: 157; 
Average adjusted episode spending: $14,042. 

Rank: 37; 
MSA: Omaha-Council Bluffs, NE-IA; 
Number of episodes: 56; 
Average adjusted episode spending: $14,017. 

Rank: 38; 
MSA: Ann Arbor, MI; 
Number of episodes: 100; 
Average adjusted episode spending: $13,986. 

Rank: 39; 
MSA: [A]; 
Number of episodes: 42; 
Average adjusted episode spending: $13,933. 

Rank: 40; 
MSA: Kalamazoo-Portage, MI; 
Number of episodes: 17; 
Average adjusted episode spending: $13,926. 

Rank: 41; 
MSA: Lima, OH; 
Number of episodes: 35; 
Average adjusted episode spending: $13,851. 

Rank: 42; 
MSA: Deltona-Daytona Beach-Ormond Beach, FL; 
Number of episodes: 26; 
Average adjusted episode spending: $13,842. 

Rank: 43; 
MSA: Akron, OH; 
Number of episodes: 22; 
Average adjusted episode spending: $13,788. 

Rank: 44; 
MSA: Palm Bay-Melbourne-Titusville, FL; 
Number of episodes: 18; 
Average adjusted episode spending: $13,685. 

Rank: 45; 
MSA: Allentown-Bethlehem-Easton, PA-NJ; 
Number of episodes: 108; 
Average adjusted episode spending: $13,634. 

Rank: 46; 
MSA: Jacksonville, FL; 
Number of episodes: 95; 
Average adjusted episode spending: $13,618. 

Rank: 47; 
MSA: Tampa-St. Petersburg-Clearwater, FL; 
Number of episodes: 202; 
Average adjusted episode spending: $13,374. 

Rank: 48; 
MSA: El Paso, TX; 
Number of episodes: 93; 
Average adjusted episode spending: $13,229. 

Rank: 49; 
MSA: Lawton, OK; 
Number of episodes: 22; 
Average adjusted episode spending: $13,106. 

Rank: 50; 
MSA: Modesto, CA; 
Number of episodes: 34; 
Average adjusted episode spending: $13,103. 

Rank: 51; 
MSA: [A]; 
Number of episodes: 57; 
Average adjusted episode spending: $13,063. 

Rank: 52; 
MSA: [A]; 
Number of episodes: 20; 
Average adjusted episode spending: $13,004. 

Rank: 53; 
MSA: Dayton, OH; 
Number of episodes: 49; 
Average adjusted episode spending: $12,973. 

Rank: 54; 
MSA: Huntington-Ashland, WV-KY-OH; 
Number of episodes: 60; 
Average adjusted episode spending: $12,897. 

Rank: 55; 
MSA: Detroit-Warren-Livonia, MI; 
Number of episodes: 198; 
Average adjusted episode spending: $12,879. 

Rank: 56; 
MSA: Sacramento-Arden-Arcade-Roseville, CA; 
Number of episodes: 153; 
Average adjusted episode spending: $12,862. 

Rank: 57; 
MSA: Chicago-Joliet-Naperville, IL-IN-WI; 
Number of episodes: 1,398; 
Average adjusted episode spending: $12,800. 

Rank: 58; 
MSA: Salt Lake City, UT; 
Number of episodes: 44; 
Average adjusted episode spending: $12,655. 

Rank: 59; 
MSA: Kansas City, MO-KS; 
Number of episodes: 99; 
Average adjusted episode spending: $12,596. 

Rank: 60; 
MSA: Sioux City, IA-NE-SD; 
Number of episodes: 27; 
Average adjusted episode spending: $12,572. 

Rank: 61; 
MSA: Cincinnati-Middletown, OH-KY-IN; 
Number of episodes: 446; 
Average adjusted episode spending: $12,571. 

Rank: 62; 
MSA: Minneapolis-St. Paul-Bloomington, MN-WI; 
Number of episodes: 120; 
Average adjusted episode spending: $12,477. 

Rank: 63; 
MSA: Dallas-Fort Worth-Arlington, TX; 
Number of episodes: 1,033; 
Average adjusted episode spending: $12,413. 

Rank: 64; 
MSA: Raleigh-Cary, NC; 
Number of episodes: 42; 
Average adjusted episode spending: $12,403. 

Rank: 65; 
MSA: Providence-New Bedford-Fall River, RI-MA; 
Number of episodes: 103; 
Average adjusted episode spending: $12,394. 

Rank: 66; 
MSA: [A]; 
Number of episodes: 41; 
Average adjusted episode spending: $12,364. 

Rank: 67; 
MSA: [A]; 
Number of episodes: 67; 
Average adjusted episode spending: $12,358. 

Rank: 68; 
MSA: [A]; 
Number of episodes: 23; 
Average adjusted episode spending: $12,350. 

Rank: 69; 
MSA: [A]; 
Number of episodes: 197; 
Average adjusted episode spending: $12,336. 

Rank: 70; 
MSA: New York-Northern New Jersey-Long Island, NY-NJ-PA; 
Number of episodes: 1,711; 
Average adjusted episode spending: $12,252. 

Rank: 71; 
MSA: Spokane, WA; 
Number of episodes: 17; 
Average adjusted episode spending: $12,161. 

Rank: 72; 
MSA: [A]; 
Number of episodes: 20; 
Average adjusted episode spending: $12,088. 

Rank: 73; 
MSA: Shreveport-Bossier City, LA; 
Number of episodes: 31; 
Average adjusted episode spending: $12,011. 

Rank: 74; 
MSA: Miami-Fort Lauderdale-Pompano Beach, FL; 
Number of episodes: 562; 
Average adjusted episode spending: $11,985. 

Rank: 75; 
MSA: Birmingham-Hoover, AL; 
Number of episodes: 64; 
Average adjusted episode spending: $11,960. 

Rank: 76; 
MSA: [A]; 
Number of episodes: 67; 
Average adjusted episode spending: $11,865. 

Rank: 77; 
MSA: [A]; 
Number of episodes: 84; 
Average adjusted episode spending: $11,851. 

Rank: 78; 
MSA: [A]; 
Number of episodes: 122; 
Average adjusted episode spending: $11,851. 

Rank: 79; 
MSA: [A]; 
Number of episodes: 42; 
Average adjusted episode spending: $11,840. 

Rank: 80; 
MSA: Boulder, CO; 
Number of episodes: 22; 
Average adjusted episode spending: $11,715. 

Rank: 81; 
MSA: Atlanta-Sandy Springs-Marietta, GA; 
Number of episodes: 309; 
Average adjusted episode spending: $11,523. 

Rank: 82; 
MSA: Bloomington-Normal, IL; 
Number of episodes: 19; 
Average adjusted episode spending: $11,498. 

Rank: 83; 
MSA: Houston-Sugar Land-Baytown, TX; 
Number of episodes: 722; 
Average adjusted episode spending: $11,496. 

Rank: 84; 
MSA: [A]; 
Number of episodes: 24; 
Average adjusted episode spending: $11,478. 

Rank: 85; 
MSA: Boston-Cambridge-Quincy, MA-NH; 
Number of episodes: 384; 
Average adjusted episode spending: $11,417. 

Rank: 86; 
MSA: Phoenix-Mesa-Glendale, AZ; 
Number of episodes: 554; 
Average adjusted episode spending: $11,403. 

Rank: 87; 
MSA: Philadelphia-Camden-Wilmington, PA-NJ-DE-MD; 
Number of episodes: 440; 
Average adjusted episode spending: $11,351. 

Rank: 88; 
MSA: Tulsa, OK; 
Number of episodes: 143; 
Average adjusted episode spending: $11,314. 

Rank: 89; 
MSA: Rochester, NY; 
Number of episodes: 32; 
Average adjusted episode spending: $11,144. 

Rank: 90; 
MSA: Cleveland-Elyria-Mentor, OH; 
Number of episodes: 122; 
Average adjusted episode spending: $11,078. 

Rank: 91; 
MSA: [A]; 
Number of episodes: 80; 
Average adjusted episode spending: $11,037. 

Rank: 92; 
MSA: Springfield, MA; 
Number of episodes: 68; 
Average adjusted episode spending: $10,958. 

Rank: 93; 
MSA: Mobile, AL; 
Number of episodes: 22; 
Average adjusted episode spending: $10,957. 

Rank: 94; 
MSA: Stockton, CA; 
Number of episodes: 26; 
Average adjusted episode spending: $10,920. 

Rank: 95; 
MSA: Lexington-Fayette, KY; 
Number of episodes: 59; 
Average adjusted episode spending: $10,831. 

Rank: 96; 
MSA: Bridgeport-Stamford-Norwalk, CT; 
Number of episodes: 154; 
Average adjusted episode spending: $10,821. 

Rank: 97; 
MSA: Springfield, OH; 
Number of episodes: 30; 
Average adjusted episode spending: $10,804. 

Rank: 98; 
MSA: [A]; 
Number of episodes: 52; 
Average adjusted episode spending: $10,775. 

Rank: 99; 
MSA: Louisville-Jefferson County, KY-IN; 
Number of episodes: 90; 
Average adjusted episode spending: $10,771. 

Rank: 100; 
MSA: [A]; 
Number of episodes: 38; 
Average adjusted episode spending: $10,766. 

Rank: 101; 
MSA: New Orleans-Metairie-Kenner, LA; 
Number of episodes: 65; 
Average adjusted episode spending: $10,695. 

Rank: 102; 
MSA: Toledo, OH; 
Number of episodes: 89; 
Average adjusted episode spending: $10,693. 

Rank: 103; 
MSA: Madera-Chowchilla, CA; 
Number of episodes: 24; 
Average adjusted episode spending: $10,579. 

Rank: 104; 
MSA: [A]; 
Number of episodes: 32; 
Average adjusted episode spending: $10,555. 

Rank: 105; 
MSA: Waco, TX; 
Number of episodes: 52; 
Average adjusted episode spending: $10,505. 

Rank: 106; 
MSA: [A]; 
Number of episodes: 209; 
Average adjusted episode spending: $10,470. 

Rank: 107; 
MSA: Virginia Beach-Norfolk-Newport News, VA-NC; 
Number of episodes: 81; 
Average adjusted episode spending: $10,458. 

Rank: 108; 
MSA: [A]; 
Number of episodes: 52; 
Average adjusted episode spending: $10,393. 

Rank: 109; 
MSA: Denver-Aurora-Broomfield, CO; 
Number of episodes: 99; 
Average adjusted episode spending: $10,372. 

Rank: 110; 
MSA: Los Angeles-Long Beach-Santa Ana, CA; 
Number of episodes: 941; 
Average adjusted episode spending: $10,351. 

Rank: 111; 
MSA: Poughkeepsie-Newburgh-Middletown, NY; 
Number of episodes: 105; 
Average adjusted episode spending: $10,227. 

Rank: 112; 
MSA: Memphis, TN-MS-AR; 
Number of episodes: 60; 
Average adjusted episode spending: $10,191. 

Rank: 113; 
MSA: San Antonio-New Braunfels, TX; 
Number of episodes: 238; 
Average adjusted episode spending: $10,163. 

Rank: 114; 
MSA: [A]; 
Number of episodes: 60; 
Average adjusted episode spending: $10,116. 

Rank: 115; 
MSA: Riverside-San Bernardino-Ontario, CA; 
Number of episodes: 95; 
Average adjusted episode spending: $10,108. 

Rank: 116; 
MSA: Sherman-Denison, TX; 
Number of episodes: 23; 
Average adjusted episode spending: $9,889. 

Rank: 117; 
MSA: Knoxville, TN; 
Number of episodes: 29; 
Average adjusted episode spending: $9,887. 

Rank: 118; 
MSA: Santa Cruz-Watsonville, CA; 
Number of episodes: 50; 
Average adjusted episode spending: $9,789. 

Rank: 119; 
MSA: San Luis Obispo-Paso Robles, CA; 
Number of episodes: 44; 
Average adjusted episode spending: $9,584. 

Rank: 120; 
MSA: Hartford-West Hartford-East Hartford, CT; 
Number of episodes: 354; 
Average adjusted episode spending: $9,304. 

Rank: 121; 
MSA: Syracuse, NY; 
Number of episodes: 17; 
Average adjusted episode spending: $9,285. 

Rank: 122; 
MSA: Savannah, GA; 
Number of episodes: 44; 
Average adjusted episode spending: $9,281. 

Rank: 123; 
MSA: [A]; 
Number of episodes: 55; 
Average adjusted episode spending: $9,136. 

Rank: 124; 
MSA: Chico, CA; 
Number of episodes: 23; 
Average adjusted episode spending: $8,939. 

Rank: 125; 
MSA: Albany-Schenectady-Troy, NY; 
Number of episodes: 72; 
Average adjusted episode spending: $8,922. 

Rank: 126; 
MSA: [A]; 
Number of episodes: 1,122; 
Average adjusted episode spending: $8,880. 

Rank: 127; 
MSA: San Jose-Sunnyvale-Santa Clara, CA; 
Number of episodes: 115; 
Average adjusted episode spending: $8,848. 

Rank: 128; 
MSA: Tucson, AZ; 
Number of episodes: 84; 
Average adjusted episode spending: $8,776. 

Rank: 129; 
MSA: Youngstown-Warren-Boardman, OH-PA; 
Number of episodes: 53; 
Average adjusted episode spending: $8,747. 

Rank: 130; 
MSA: Santa Rosa-Petaluma, CA; 
Number of episodes: 19; 
Average adjusted episode spending: $8,618. 

Rank: 131; 
MSA: [A]; 
Number of episodes: 52; 
Average adjusted episode spending: $8,512. 

Rank: 132; 
MSA: Lafayette, LA; 
Number of episodes: 24; 
Average adjusted episode spending: $8,042. 

Rank: 133; 
MSA: Oxnard-Thousand Oaks-Ventura, CA; 
Number of episodes: 64; 
Average adjusted episode spending: $7,993. 

Rank: 134; 
MSA: Albuquerque, NM; 
Number of episodes: 276; 
Average adjusted episode spending: $7,989. 

Rank: 135; 
MSA: Las Vegas-Paradise, NV; 
Number of episodes: 179; 
Average adjusted episode spending: $7,773. 

Rank: 136; 
MSA: St. Louis, MO-IL; 
Number of episodes: 325; 
Average adjusted episode spending: $7,698. 

Rank: 137; 
MSA: Fresno, CA; 
Number of episodes: 33; 
Average adjusted episode spending: $7,096. 

Rank: 138; 
MSA: Trenton-Ewing, NJ; 
Number of episodes: 34; 
Average adjusted episode spending: $6,731. 

Rank: 139; 
MSA: Joplin, MO; 
Number of episodes: 33; 
Average adjusted episode spending: $6,166. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 139 MSAs. We included all MSAs with a sufficient 
number of Laparoscopic appendectomy episodes to support our analyses. 
Spending was adjusted to control for geographic differences in the 
cost of doing business and differences in demographics and health 
status of enrollees in each MSA. 

[A] MSA name withheld to protect the confidentiality of entities that 
contributed private data. 

[End of table] 

Table 5: Ranking of Metropolitan Statistical Areas (MSA) by Adjusted 
Episode Spending for Total Hip Replacement Episodes: 

Rank: 1; 
MSA: Salinas, CA; 
Number of episodes: 38; 
Average adjusted episode spending: $57,990. 

Rank: 2; 
MSA: Anchorage, AK; 
Number of episodes: 30; 
Average adjusted episode spending: $54,738. 

Rank: 3; 
MSA: Albany, GA; 
Number of episodes: 27; 
Average adjusted episode spending: $49,874. 

Rank: 4; 
MSA: [A]; 
Number of episodes: 49; 
Average adjusted episode spending: $45,491. 

Rank: 5; 
MSA: Santa Barbara-Santa Maria-Goleta, CA; 
Number of episodes: 34; 
Average adjusted episode spending: $42,976. 

Rank: 6; 
MSA: Michigan City-La Porte, IN; 
Number of episodes: 29; 
Average adjusted episode spending: $41,377. 

Rank: 7; 
MSA: Dallas-Fort Worth-Arlington, TX; 
Number of episodes: 954; 
Average adjusted episode spending: $41,129. 

Rank: 8; 
MSA: [A]; 
Number of episodes: 35; 
Average adjusted episode spending: $38,417. 

Rank: 9; 
MSA: San Diego-Carlsbad-San Marcos, CA; 
Number of episodes: 102; 
Average adjusted episode spending: $37,906. 

Rank: 10; 
MSA: [A]; 
Number of episodes: 262; 
Average adjusted episode spending: $37,669. 

Rank: 11; 
MSA: Wausau, WI; 
Number of episodes: 30; 
Average adjusted episode spending: $37,266. 

Rank: 12; 
MSA: [A]; 
Number of episodes: 65; 
Average adjusted episode spending: $36,936. 

Rank: 13; 
MSA: Madison, WI; 
Number of episodes: 26; 
Average adjusted episode spending: $36,258. 

Rank: 14; 
MSA: Lancaster, PA; 
Number of episodes: 106; 
Average adjusted episode spending: $36,049. 

Rank: 15; 
MSA: Milwaukee-Waukesha-West Allis, WI; 
Number of episodes: 272; 
Average adjusted episode spending: $35,963. 

Rank: 16; 
MSA: [A]; 
Number of episodes: 47; 
Average adjusted episode spending: $35,957. 

Rank: 17; 
MSA: New York-Northern New Jersey-Long Island, NY-NJ-PA; 
Number of episodes: 1,198; 
Average adjusted episode spending: $35,682. 

Rank: 18; 
MSA: [A]; 
Number of episodes: 49; 
Average adjusted episode spending: $35,421. 

Rank: 19; 
MSA: Houston-Sugar Land-Baytown, TX; 
Number of episodes: 603; 
Average adjusted episode spending: $35,332. 

Rank: 20; 
MSA: San Antonio-New Braunfels, TX; 
Number of episodes: 189; 
Average adjusted episode spending: $35,319. 

Rank: 21; 
MSA: [A]; 
Number of episodes: 53; 
Average adjusted episode spending: $34,965. 

Rank: 22; 
MSA: [A]; 
Number of episodes: 296; 
Average adjusted episode spending: $34,856. 

Rank: 23; 
MSA: Fort Wayne, IN; 
Number of episodes: 147; 
Average adjusted episode spending: $34,711. 

Rank: 24; 
MSA: Sacramento-Arden-Arcade-Roseville, CA; 
Number of episodes: 128; 
Average adjusted episode spending: $34,420. 

Rank: 25; 
MSA: Nashville-Davidson-Murfreesboro-Franklin, TN; 
Number of episodes: 196; 
Average adjusted episode spending: $34,311. 

Rank: 26; 
MSA: [A]; 
Number of episodes: 96; 
Average adjusted episode spending: $33,944. 

Rank: 27; 
MSA: [A]; 
Number of episodes: 50; 
Average adjusted episode spending: $33,899. 

Rank: 28; 
MSA: Elkhart-Goshen, IN; 
Number of episodes: 36; 
Average adjusted episode spending: $33,512. 

Rank: 29; 
MSA: Reading, PA; 
Number of episodes: 85; 
Average adjusted episode spending: $33,497. 

Rank: 30; 
MSA: South Bend-Mishawaka, IN-MI; 
Number of episodes: 73; 
Average adjusted episode spending: $33,235. 

Rank: 31; 
MSA: Salt Lake City, UT; 
Number of episodes: 43; 
Average adjusted episode spending: $33,057. 

Rank: 32; 
MSA: Jacksonville, FL; 
Number of episodes: 136; 
Average adjusted episode spending: $32,471. 

Rank: 33; 
MSA: Green Bay, WI; 
Number of episodes: 75; 
Average adjusted episode spending: $32,395. 

Rank: 34; 
MSA: Albany-Schenectady-Troy, NY; 
Number of episodes: 85; 
Average adjusted episode spending: $32,246. 

Rank: 35; 
MSA: Santa Fe, NM; 
Number of episodes: 35; 
Average adjusted episode spending: $32,035. 

Rank: 36; 
MSA: Macon, GA; 
Number of episodes: 34; 
Average adjusted episode spending: $31,877. 

Rank: 37; 
MSA: [A]; 
Number of episodes: 166; 
Average adjusted episode spending: $31,726. 

Rank: 38; 
MSA: Colorado Springs, CO; 
Number of episodes: 71; 
Average adjusted episode spending: $31,648. 

Rank: 39; 
MSA: [A]; 
Number of episodes: 154; 
Average adjusted episode spending: $31,550. 

Rank: 40; 
MSA: [A]; 
Number of episodes: 27; 
Average adjusted episode spending: $31,429. 

Rank: 41; 
MSA: Charleston, WV; 
Number of episodes: 68; 
Average adjusted episode spending: $31,376. 

Rank: 42; 
MSA: [A]; 
Number of episodes: 53; 
Average adjusted episode spending: $31,371. 

Rank: 43; 
MSA: Spokane, WA; 
Number of episodes: 34; 
Average adjusted episode spending: $31,076. 

Rank: 44; 
MSA: Boulder, CO; 
Number of episodes: 31; 
Average adjusted episode spending: $30,958. 

Rank: 45; 
MSA: Portland-Vancouver-Hillsboro, OR-WA; 
Number of episodes: 217; 
Average adjusted episode spending: $30,535. 

Rank: 46; 
MSA: Orlando-Kissimmee-Sanford, FL; 
Number of episodes: 153; 
Average adjusted episode spending: $30,473. 

Rank: 47; 
MSA: Athens-Clarke County, GA; 
Number of episodes: 57; 
Average adjusted episode spending: $30,424. 

Rank: 48; 
MSA: Cape Coral-Fort Myers, FL; 
Number of episodes: 67; 
Average adjusted episode spending: $30,422. 

Rank: 49; 
MSA: Seattle-Tacoma-Bellevue, WA; 
Number of episodes: 405; 
Average adjusted episode spending: $30,398. 

Rank: 50; 
MSA: Tampa-St. Petersburg-Clearwater, FL; 
Number of episodes: 173; 
Average adjusted episode spending: $30,380. 

Rank: 51; 
MSA: Springfield, MO; 
Number of episodes: 27; 
Average adjusted episode spending: $30,335. 

Rank: 52; 
MSA: Evansville, IN-KY; 
Number of episodes: 68; 
Average adjusted episode spending: $30,323. 

Rank: 53; 
MSA: [A]; 
Number of episodes: 88; 
Average adjusted episode spending: $30,205. 

Rank: 54; 
MSA: Ocala, FL; 
Number of episodes: 39; 
Average adjusted episode spending: $30,106. 

Rank: 55; 
MSA: [A]; 
Number of episodes: 54; 
Average adjusted episode spending: $30,072. 

Rank: 56; 
MSA: Lima, OH; 
Number of episodes: 33; 
Average adjusted episode spending: $30,003. 

Rank: 57; 
MSA: [A]; 
Number of episodes: 168; 
Average adjusted episode spending: $29,817. 

Rank: 58; 
MSA: [A]; 
Number of episodes: 29; 
Average adjusted episode spending: $29,692. 

Rank: 59; 
MSA: Lakeland-Winter Haven, FL; 
Number of episodes: 39; 
Average adjusted episode spending: $29,480. 

Rank: 60; 
MSA: Knoxville, TN; 
Number of episodes: 84; 
Average adjusted episode spending: $29,470. 

Rank: 61; 
MSA: Greensboro-High Point, NC; 
Number of episodes: 42; 
Average adjusted episode spending: $29,389. 

Rank: 62; 
MSA: Memphis, TN-MS-AR; 
Number of episodes: 87; 
Average adjusted episode spending: $29,073. 

Rank: 63; 
MSA: New Orleans-Metairie-Kenner, LA; 
Number of episodes: 41; 
Average adjusted episode spending: $29,035. 

Rank: 64; 
MSA: El Paso, TX; 
Number of episodes: 52; 
Average adjusted episode spending: $29,019. 

Rank: 65; 
MSA: Atlanta-Sandy Springs-Marietta, GA; 
Number of episodes: 863; 
Average adjusted episode spending: $28,927. 

Rank: 66; 
MSA: Asheville, NC; 
Number of episodes: 30; 
Average adjusted episode spending: $28,827. 

Rank: 67; 
MSA: Appleton, WI; 
Number of episodes: 30; 
Average adjusted episode spending: $28,648. 

Rank: 68; 
MSA: San Jose-Sunnyvale-Santa Clara, CA; 
Number of episodes: 88; 
Average adjusted episode spending: $28,626. 

Rank: 69; 
MSA: Oklahoma City, OK; 
Number of episodes: 295; 
Average adjusted episode spending: $28,597. 

Rank: 70; 
MSA: Raleigh-Cary, NC; 
Number of episodes: 80; 
Average adjusted episode spending: $28,162. 

Rank: 71; 
MSA: Davenport-Moline-Rock Island, IA-IL; 
Number of episodes: 67; 
Average adjusted episode spending: $28,098. 

Rank: 72; 
MSA: [A]; 
Number of episodes: 470; 
Average adjusted episode spending: $28,090. 

Rank: 73; 
MSA: Huntington-Ashland, WV-KY-OH; 
Number of episodes: 73; 
Average adjusted episode spending: $28,065. 

Rank: 74; 
MSA: Denver-Aurora-Broomfield, CO; 
Number of episodes: 252; 
Average adjusted episode spending: $28,042. 

Rank: 75; 
MSA: Providence-New Bedford-Fall River, RI-MA; 
Number of episodes: 86; 
Average adjusted episode spending: $27,936. 

Rank: 76; 
MSA: [A]; 
Number of episodes: 53; 
Average adjusted episode spending: $27,898. 

Rank: 77; 
MSA: Chicago-Joliet-Naperville, IL-IN-WI; 
Number of episodes: 1,965; 
Average adjusted episode spending: $27,774. 

Rank: 78; 
MSA: Kansas City, MO-KS; 
Number of episodes: 197; 
Average adjusted episode spending: $27,770. 

Rank: 79; 
MSA: Anderson, IN; 
Number of episodes: 25; 
Average adjusted episode spending: $27,753. 

Rank: 80; 
MSA: Binghamton, NY; 
Number of episodes: 24; 
Average adjusted episode spending: $27,721. 

Rank: 81; 
MSA: Ann Arbor, MI; 
Number of episodes: 104; 
Average adjusted episode spending: $27,709. 

Rank: 82; 
MSA: Miami-Fort Lauderdale-Pompano Beach, FL; 
Number of episodes: 228; 
Average adjusted episode spending: $27,551. 

Rank: 83; 
MSA: [A]; 
Number of episodes: 42; 
Average adjusted episode spending: $27,450. 

Rank: 84; 
MSA: Philadelphia-Camden-Wilmington, PA-NJ-DE-MD; 
Number of episodes: 533; 
Average adjusted episode spending: $27,354. 

Rank: 85; 
MSA: [A]; 
Number of episodes: 81; 
Average adjusted episode spending: $27,349. 

Rank: 86; 
MSA: Detroit-Warren-Livonia, MI; 
Number of episodes: 484; 
Average adjusted episode spending: $26,945. 

Rank: 87; 
MSA: Savannah, GA; 
Number of episodes: 114; 
Average adjusted episode spending: $26,937. 

Rank: 88; 
MSA: Cincinnati-Middletown, OH-KY-IN; 
Number of episodes: 549; 
Average adjusted episode spending: $26,868. 

Rank: 89; 
MSA: Bridgeport-Stamford-Norwalk, CT; 
Number of episodes: 153; 
Average adjusted episode spending: $26,858. 

Rank: 90; 
MSA: Phoenix-Mesa-Glendale, AZ; 
Number of episodes: 274; 
Average adjusted episode spending: $26,856. 

Rank: 91; 
MSA: Tulsa, OK; 
Number of episodes: 121; 
Average adjusted episode spending: $26,651. 

Rank: 92; 
MSA: Minneapolis-St. Paul-Bloomington, MN-WI; 
Number of episodes: 186; 
Average adjusted episode spending: $26,628. 

Rank: 93; 
MSA: Boston-Cambridge-Quincy, MA-NH; 
Number of episodes: 642; 
Average adjusted episode spending: $26,618. 

Rank: 94; 
MSA: Shreveport-Bossier City, LA; 
Number of episodes: 31; 
Average adjusted episode spending: $26,580. 

Rank: 95; 
MSA: [A]; 
Number of episodes: 304; 
Average adjusted episode spending: $26,557. 

Rank: 96; 
MSA: Albuquerque, NM; 
Number of episodes: 234; 
Average adjusted episode spending: $26,481. 

Rank: 97; 
MSA: Wichita, KS; 
Number of episodes: 46; 
Average adjusted episode spending: $26,355. 

Rank: 98; 
MSA: Peoria, IL; 
Number of episodes: 89; 
Average adjusted episode spending: $26,320. 

Rank: 99; 
MSA: Durham-Chapel Hill, NC; 
Number of episodes: 31; 
Average adjusted episode spending: $26,254. 

Rank: 100; 
MSA: North Port-Bradenton-Sarasota, FL; 
Number of episodes: 48; 
Average adjusted episode spending: $26,075. 

Rank: 101; 
MSA: Cleveland-Elyria-Mentor, OH; 
Number of episodes: 561; 
Average adjusted episode spending: $25,683. 

Rank: 102; 
MSA: Columbus, OH; 
Number of episodes: 442; 
Average adjusted episode spending: $25,627. 

Rank: 103; 
MSA: Kalamazoo-Portage, MI; 
Number of episodes: 27; 
Average adjusted episode spending: $25,413. 

Rank: 104; 
MSA: [A]; 
Number of episodes: 107; 
Average adjusted episode spending: $25,409. 

Rank: 105; 
MSA: Worcester, MA; 
Number of episodes: 44; 
Average adjusted episode spending: $25,125. 

Rank: 106; 
MSA: Los Angeles-Long Beach-Santa Ana, CA; 
Number of episodes: 711; 
Average adjusted episode spending: $24,972. 

Rank: 107; 
MSA: Springfield, MA; 
Number of episodes: 49; 
Average adjusted episode spending: $24,914. 

Rank: 108; 
MSA: Oxnard-Thousand Oaks-Ventura, CA; 
Number of episodes: 60; 
Average adjusted episode spending: $24,908. 

Rank: 109; 
MSA: Naples-Marco Island, FL; 
Number of episodes: 27; 
Average adjusted episode spending: $24,878. 

Rank: 110; 
MSA: Santa Rosa-Petaluma, CA; 
Number of episodes: 36; 
Average adjusted episode spending: $24,548. 

Rank: 111; 
MSA: Modesto, CA; 
Number of episodes: 31; 
Average adjusted episode spending: $24,539. 

Rank: 112; 
MSA: Las Vegas-Paradise, NV; 
Number of episodes: 113; 
Average adjusted episode spending: $24,490. 

Rank: 113; 
MSA: Grand Rapids-Wyoming, MI; 
Number of episodes: 62; 
Average adjusted episode spending: $24,475. 

Rank: 114; 
MSA: Rochester, NY; 
Number of episodes: 90; 
Average adjusted episode spending: $24,365. 

Rank: 115; 
MSA: Louisville-Jefferson County, KY-IN; 
Number of episodes: 213; 
Average adjusted episode spending: $24,199. 

Rank: 116; 
MSA: Redding, CA; 
Number of episodes: 29; 
Average adjusted episode spending: $24,169. 

Rank: 117; 
MSA: Allentown-Bethlehem-Easton, PA-NJ; 
Number of episodes: 215; 
Average adjusted episode spending: $24,117. 

Rank: 118; 
MSA: [A]; 
Number of episodes: 55; 
Average adjusted episode spending: $23,894. 

Rank: 119; 
MSA: St. Louis, MO-IL; 
Number of episodes: 434; 
Average adjusted episode spending: $23,816. 

Rank: 120; 
MSA: Dayton, OH; 
Number of episodes: 181; 
Average adjusted episode spending: $23,614. 

Rank: 121; 
MSA: Riverside-San Bernardino-Ontario, CA; 
Number of episodes: 84; 
Average adjusted episode spending: $23,361. 

Rank: 122; 
MSA: [A]; 
Number of episodes: 77; 
Average adjusted episode spending: $23,348. 

Rank: 123; 
MSA: [A]; 
Number of episodes: 243; 
Average adjusted episode spending: $23,314. 

Rank: 124; 
MSA: Akron, OH; 
Number of episodes: 69; 
Average adjusted episode spending: $23,100. 

Rank: 125; 
MSA: Tucson, AZ; 
Number of episodes: 47; 
Average adjusted episode spending: $23,076. 

Rank: 126; 
MSA: Hartford-West Hartford-East Hartford, CT; 
Number of episodes: 392; 
Average adjusted episode spending: $22,478. 

Rank: 127; 
MSA: Saginaw-Saginaw Township North, MI; 
Number of episodes: 40; 
Average adjusted episode spending: $22,396. 

Rank: 128; 
MSA: Lexington-Fayette, KY; 
Number of episodes: 87; 
Average adjusted episode spending: $22,274. 

Rank: 129; 
MSA: Toledo, OH; 
Number of episodes: 158; 
Average adjusted episode spending: $22,242. 

Rank: 130; 
MSA: Columbus, GA-AL; 
Number of episodes: 55; 
Average adjusted episode spending: $22,224. 

Rank: 131; 
MSA: [A]; 
Number of episodes: 80; 
Average adjusted episode spending: $21,834. 

Rank: 132; 
MSA: Reno-Sparks, NV; 
Number of episodes: 68; 
Average adjusted episode spending: $21,718. 

Rank: 133; 
MSA: Fresno, CA; 
Number of episodes: 82; 
Average adjusted episode spending: $20,508. 

Rank: 134; 
MSA: [A]; 
Number of episodes: 1,406; 
Average adjusted episode spending: $19,794. 

Rank: 135; 
MSA: Huntsville, AL; 
Number of episodes: 39; 
Average adjusted episode spending: $19,758. 

Rank: 136; 
MSA: Tyler, TX; 
Number of episodes: 90; 
Average adjusted episode spending: $19,731. 

Rank: 137; 
MSA: [A]; 
Number of episodes: 65; 
Average adjusted episode spending: $19,518. 

Rank: 138; 
MSA: Canton-Massillon, OH; 
Number of episodes: 36; 
Average adjusted episode spending: $19,300. 

Rank: 139; 
MSA: [A]; 
Number of episodes: 104; 
Average adjusted episode spending: $19,240. 

Rank: 140; 
MSA: Birmingham-Hoover, AL; 
Number of episodes: 74; 
Average adjusted episode spending: $19,166. 

Rank: 141; 
MSA: Youngstown-Warren-Boardman, OH-PA; 
Number of episodes: 132; 
Average adjusted episode spending: $19,164. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 141 MSAs. We included all MSAs with a sufficient 
number of Total hip replacement episodes to support our analyses. 
Spending was adjusted to control for geographic differences in the 
cost of doing business and differences in demographics and health 
status of enrollees in each MSA. 

[A] MSA name withheld to protect the confidentiality of entities that 
contributed private data. 

[End of table] 

[End of section] 

Appendix III: Distribution of Episode Spending: 

Range of average adjusted episode spending: $1 to 2,500; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 0; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 0. 

Range of average adjusted episode spending: $2,501 to 5,000; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 0; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 0. 

Range of average adjusted episode spending: $5,001 to 7,500; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 0; 
Laparoscopic appendectomy: 3; 
Total hip replacement: 0. 

Range of average adjusted episode spending: $7,501 to 10,000; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 0; 
Laparoscopic appendectomy: 21; 
Total hip replacement: 0. 

Range of average adjusted episode spending: $10,001 to 12,500; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 0; 
Laparoscopic appendectomy: 54; 
Total hip replacement: 0. 

Range of average adjusted episode spending: $12,501 to 15,000; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 1; 
Laparoscopic appendectomy: 39; 
Total hip replacement: 0. 

Range of average adjusted episode spending: $15,001 to 17,500; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 0; 
Laparoscopic appendectomy: 12; 
Total hip replacement: 0. 

Range of average adjusted episode spending: $17,501 to 20,000; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 4; 
Laparoscopic appendectomy: 6; 
Total hip replacement: 8. 

Range of average adjusted episode spending: $20,001 to 22,500; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 17; 
Laparoscopic appendectomy: 2; 
Total hip replacement: 8. 

Range of average adjusted episode spending: $22,501 to 25,000; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 22; 
Laparoscopic appendectomy: 1; 
Total hip replacement: 20. 

Range of average adjusted episode spending: $25,001 to 27,500; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 19; 
Laparoscopic appendectomy: 1; 
Total hip replacement: 23. 

Range of average adjusted episode spending: $27,501 to 30,000; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 25; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 26. 

Range of average adjusted episode spending: $30,001 to 32,500; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 17; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 25. 

Range of average adjusted episode spending: $32,501 to 35,000; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 17; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 11. 

Range of average adjusted episode spending: $35,001 to 37,500; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 14; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 10. 

Range of average adjusted episode spending: $37,501 to 40,000; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 13; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 3. 

Range of average adjusted episode spending: $40,001 to 42,500; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 1; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 2. 

Range of average adjusted episode spending: $42,501 to 45,000; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 3; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 1. 

Range of average adjusted episode spending: $45,001 to 47,500; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 1; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 1. 

Range of average adjusted episode spending: $47,501 to 50,000; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 0; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 1. 

Range of average adjusted episode spending: $50,001 to 52,500; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 0; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 0. 

Range of average adjusted episode spending: $52,501 to 55,000; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 0; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 1. 

Range of average adjusted episode spending: $55,001 to 57,500; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 0; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 0. 

Range of average adjusted episode spending: $57,501 to 60,000; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 0; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 1. 

Range of average adjusted episode spending: $60,001 to 62,500; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 1; 
Laparoscopic appendectomy: 0; 
Total hip replacement: 0. 

Range of average adjusted episode spending: $Total; 
Number of metropolitan statistical areas (MSA): 
Coronary stent placement: 155; 
Laparoscopic appendectomy: 139; 
Total hip replacement: 141. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 155 MSAs for coronary stent placement episodes, 
139 MSAs for Laparoscopic appendectomy episodes, and 141 MSAs for 
Total hip replacement episodes. For each procedure, we included all 
MSAs with a sufficient number of episodes to support our analyses. 
Spending was adjusted to control for geographic differences in the 
cost of doing business and differences in demographics and health 
status of enrollees in each MSA. 

[End of table] 

[End of section] 

Appendix IV: Episode Spending, by Procedure, for Metropolitan 
Statistical Areas in Lowest-and Highest-Spending Quintiles: 

This appendix presents average adjusted episode spending for each of 
the three procedures we analyzed--coronary stent placement, 
Laparoscopic appendectomy, and Total hip replacement--by service 
category for metropolitan statistical areas (MSA) in the lowest-and 
highest-spending quintiles. 

Table 6: Average Adjusted Episode Spending for Coronary Stent 
Placement, Metropolitan Statistical Areas (MSA) in Lowest-and Highest-
Spending Quintiles: 

Service category: Hospital inpatient; 
Lowest-spending quintile: $17,908; 
Highest-spending quintile: $33,297; 
Comparison: 86% higher. 

Service category: Hospital outpatient; 
Lowest-spending quintile: $353; 
Highest-spending quintile: $537; 
Comparison: 52% higher. 

Service category: Postdischarge; 
Lowest-spending quintile: $15; 
Highest-spending quintile: $13; 
Comparison: 13% lower. 

Service category: Professional; 
Lowest-spending quintile: $3,099; 
Highest-spending quintile: $3,890; 
Comparison: 26% higher. 

Service category: Ancillary and unclassified; 
Lowest-spending quintile: $165; 
Highest-spending quintile: $258; 
Comparison: 56% higher. 

Service category: Total, episode of care; 
Lowest-spending quintile: $21,540; 
Highest-spending quintile: $37,996; 
Comparison: 76% higher. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 78 MSAs. We included all MSAs with a sufficient 
number of episodes to support our analyses for all three procedures. 
The lowest-and highest-spending quintiles each consist of 16 MSAs. 
Spending was adjusted to control for geographic differences in the 
cost of doing business and differences in demographics and health 
status of enrollees in each MSA. Spending may not add to totals 
because of rounding. 

[End of table] 

Table 7: Average Adjusted Episode Spending for Laparoscopic 
Appendectomy, Metropolitan Statistical Areas (MSA) in Lowest-and 
Highest-Spending Quintiles: 

Service category: Hospital inpatient; 
Lowest-spending quintile: $6,113; 
Highest-spending quintile: $13,331; 
Comparison: 118% higher. 

Service category: Hospital outpatient; 
Lowest-spending quintile: $97; 
Highest-spending quintile: $159; 
Comparison: 64% higher. 

Service category: Postdischarge; 
Lowest-spending quintile: $9; 
Highest-spending quintile: $14; 
Comparison: 56% higher. 

Service category: Professional; 
Lowest-spending quintile: $2,535; 
Highest-spending quintile: $2,726; 
Comparison: 8% higher. 

Service category: Ancillary and unclassified; 
Lowest-spending quintile: $85; 
Highest-spending quintile: $83; 
Comparison: 2% lower. 

Service category: Total, episode of care; 
Lowest-spending quintile: $8,839; 
Highest-spending quintile: $16,314; 
Comparison: 85% higher. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 78 MSAs. We included all MSAs with a sufficient 
number of episodes to support our analyses for all three procedures. 
The lowest-and highest-spending quintiles each consist of 16 MSAs. 
Spending was adjusted to control for geographic differences in the 
cost of doing business and differences in demographics and health 
status of enrollees in each MSA. Spending may not add to totals 
because of rounding. 

[End of table] 

Table 8: Average Adjusted Episode Spending for Total Hip Replacement, 
Metropolitan Statistical Areas (MSA) in Lowest-and Highest-Spending 
Quintiles: 

Service category: Hospital inpatient; 
Lowest-spending quintile: $17,323; 
Highest-spending quintile: $30,570; 
Comparison: 76% higher. 

Service category: Hospital outpatient; 
Lowest-spending quintile: $113; 
Highest-spending quintile: $186; 
Comparison: 65% higher. 

Service category: Postdischarge; 
Lowest-spending quintile: $673; 
Highest-spending quintile: $700; 
Comparison: 4% higher. 

Service category: Professional; 
Lowest-spending quintile: $4,157; 
Highest-spending quintile: $5,221; 
Comparison: 26% higher. 

Service category: Ancillary and unclassified; 
Lowest-spending quintile: $199; 
Highest-spending quintile: $291; 
Comparison: 46% higher. 

Service category: Total, episode of care; 
Lowest-spending quintile: $22,463; 
Highest-spending quintile: $36,969; 
Comparison: 65% higher. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 78 MSAs. We included all MSAs with a sufficient 
number of episodes to support our analyses for all three procedures. 
The lowest-and highest-spending quintiles each consist of 16 MSAs. 
Spending was adjusted to control for geographic differences in the 
cost of doing business and differences in demographics and health 
status of enrollees in each MSA. Spending may not add to totals 
because of rounding. 

[End of table] 

[End of section] 

Appendix V: Hospital Inpatient Spending and Other Information, by 
Metropolitan Statistical Area and Procedure: 

This appendix presents hospital inpatient spending, initial admission 
price, and number of days, by metropolitan statistical area (MSA), for 
each of the three procedures we analyzed--coronary stent placement, 
Laparoscopic appendectomy, and Total hip replacement. 

Table 9: Hospital Inpatient Spending, Initial Admission Price, and 
Number of Days, by Metropolitan Statistical Area (MSA), for Coronary 
Stent Placement Episodes: 

Rank: 1; 
MSA: Salinas, CA[A]; 
Average adjusted spending: 
Episode: 60,375; 
Hospital inpatient services: 54,802; 
Average for initial admission: 
Price: $54,012; 
Days: 2.55. 

Rank: 2; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: 39,827; 
Hospital inpatient services: 36,068; 
Average for initial admission: 
Price: $35,345; 
Days: 2.98. 

Rank: 3; 
MSA: Charleston, WV[A]; 
Average adjusted spending: 
Episode: 39,782; 
Hospital inpatient services: 35,589; 
Average for initial admission: 
Price: $34,940; 
Days: 2.66. 

Rank: 4; 
MSA: San Diego-Carlsbad-San Marcos, CA[A]; 
Average adjusted spending: 
Episode: 39,683; 
Hospital inpatient services: 34,709; 
Average for initial admission: 
Price: $34,032; 
Days: 1.93. 

Rank: 5; 
MSA: Milwaukee-Waukesha-West Allis, WI[A]; 
Average adjusted spending: 
Episode: 38,596; 
Hospital inpatient services: 31,550; 
Average for initial admission: 
Price: $31,273; 
Days: 2.02. 

Rank: 6; 
MSA: Albany-Schenectady-Troy, NY[A]; 
Average adjusted spending: 
Episode: 38,305; 
Hospital inpatient services: 34,776; 
Average for initial admission: 
Price: $34,580; 
Days: 2.67. 

Rank: 7; 
MSA: Madison, WI[A]; 
Average adjusted spending: 
Episode: $37,248; 
Hospital inpatient services: $27,109
Average for initial admission: 
Price: $26,731; 
Days: 1.67. 

Rank: 8; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $36,858; 
Hospital inpatient services: $32,864
Average for initial admission: 
Price: $32,537; 
Days: 2.38. 

Rank: 9; 
MSA: Houston-Sugar Land-Baytown, TX[A]; 
Average adjusted spending: 
Episode: $36,097; 
Hospital inpatient services: $31,711
Average for initial admission: 
Price: $31,291; 
Days: 2.87. 

Rank: 10; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $35,478; 
Hospital inpatient services: $31,442
Average for initial admission: 
Price: $30,861; 
Days: 1.95. 

Rank: 11; 
MSA: Providence-New Bedford-Fall River, RI-MA[A]; 
Average adjusted spending: 
Episode: $35,358; 
Hospital inpatient services: $31,528
Average for initial admission: 
Price: $31,329; 
Days: 2.53. 

Rank: 12; 
MSA: Seattle-Tacoma-Bellevue, WA[A]; 
Average adjusted spending: 
Episode: $34,388; 
Hospital inpatient services: $30,169
Average for initial admission: 
Price: $29,391; 
Days: 2.19. 

Rank: 13; 
MSA: Fort Wayne, IN[A]; 
Average adjusted spending: 
Episode: $34,307; 
Hospital inpatient services: $30,059
Average for initial admission: 
Price: $29,655; 
Days: 2.13. 

Rank: 14; 
MSA: Nashville-Davidson-Murfreesboro-Franklin, TN[A]; 
Average adjusted spending: 
Episode: $34,258; 
Hospital inpatient services: $29,953
Average for initial admission: 
Price: $29,609; 
Days: 2.18. 

Rank: 15; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $33,974; 
Hospital inpatient services: $30,930
Average for initial admission: 
Price: $30,422; 
Days: 1.84. 

Rank: 16; 
MSA: Allentown-Bethlehem-Easton, PA-NJ[A]; 
Average adjusted spending: 
Episode: $33,398; 
Hospital inpatient services: $29,498
Average for initial admission: 
Price: $28,942; 
Days: 2.35. 

Rank: 17; 
MSA: Sacramento-Arden-Arcade-Roseville, CA; 
Average adjusted spending: 
Episode: $32,807; 
Hospital inpatient services: $28,396
Average for initial admission: 
Price: $28,232; 
Days: 1.91. 

Rank: 18; 
MSA: Orlando-Kissimmee-Sanford, FL; 
Average adjusted spending: 
Episode: $32,605; 
Hospital inpatient services: $29,032
Average for initial admission: 
Price: $28,711; 
Days: 2.37. 

Rank: 19; 
MSA: Tampa-St. Petersburg-Clearwater, FL; 
Average adjusted spending: 
Episode: $32,156; 
Hospital inpatient services: $28,796
Average for initial admission: 
Price: $28,488; 
Days: 2.21. 

Rank: 20; 
MSA: Cape Coral-Fort Myers, FL; 
Average adjusted spending: 
Episode: $32,143; 
Hospital inpatient services: $28,148
Average for initial admission: 
Price: $27,765; 
Days: 2.31. 

Rank: 21; 
MSA: Kansas City, MO-KS; 
Average adjusted spending: 
Episode: $32,068; 
Hospital inpatient services: $27,927
Average for initial admission: 
Price: $27,182; 
Days: 2.19. 

Rank: 22; 
MSA: Raleigh-Cary, NC; 
Average adjusted spending: 
Episode: $31,879; 
Hospital inpatient services: $27,839
Average for initial admission: 
Price: $27,612; 
Days: 2.62. 

Rank: 23; 
MSA: Dallas-Fort Worth-Arlington, TX; 
Average adjusted spending: 
Episode: $31,847; 
Hospital inpatient services: $28,020
Average for initial admission: 
Price: $27,729; 
Days: 2.47. 

Rank: 24; 
MSA: San Jose-Sunnyvale-Santa Clara, CA; 
Average adjusted spending: 
Episode: $31,797; 
Hospital inpatient services: $26,527
Average for initial admission: 
Price: $25,914; 
Days: 2.23. 

Rank: 25; 
MSA: Colorado Springs, CO; 
Average adjusted spending: 
Episode: $31,017; 
Hospital inpatient services: $27,341
Average for initial admission: 
Price: $26,959; 
Days: 1.88. 

Rank: 26; 
MSA: [B]; 
Average adjusted spending: 
Episode: $30,680; 
Hospital inpatient services: $26,833
Average for initial admission: 
Price: $26,425; 
Days: 2.28. 

Rank: 27; 
MSA: Memphis, TN-MS-AR; 
Average adjusted spending: 
Episode: $30,607; 
Hospital inpatient services: $25,683
Average for initial admission: 
Price: $25,308; 
Days: 2.39. 

Rank: 28; 
MSA: [B]; 
Average adjusted spending: 
Episode: $30,243; 
Hospital inpatient services: $26,522
Average for initial admission: 
Price: $26,355; 
Days: 2.16. 

Rank: 29; 
MSA: [B]; 
Average adjusted spending: 
Episode: $30,156; 
Hospital inpatient services: $23,922
Average for initial admission: 
Price: $23,796; 
Days: 2.36. 

Rank: 30; 
MSA: Fresno, CA; 
Average adjusted spending: 
Episode: $29,925; 
Hospital inpatient services: $26,998
Average for initial admission: 
Price: $26,704; 
Days: 1.73. 

Rank: 31; 
MSA: Grand Rapids-Wyoming, MI; 
Average adjusted spending: 
Episode: $29,684; 
Hospital inpatient services: $26,069
Average for initial admission: 
Price: $25,874; 
Days: 2.10. 

Rank: 32; 
MSA: Philadelphia-Camden-Wilmington, PA-NJ-DE-MD; 
Average adjusted spending: 
Episode: $29,489; 
Hospital inpatient services: $25,999
Average for initial admission: 
Price: $25,227; 
Days: 2.14. 

Rank: 33; 
MSA: [B]; 
Average adjusted spending: 
Episode: $29,393; 
Hospital inpatient services: $25,436
Average for initial admission: 
Price: $24,863; 
Days: 2.62. 

Rank: 34; 
MSA: Ann Arbor, MI; 
Average adjusted spending: 
Episode: $29,302; 
Hospital inpatient services: $25,518
Average for initial admission: 
Price: $25,033; 
Days: 2.39. 

Rank: 35; 
MSA: Denver-Aurora-Broomfield, CO; 
Average adjusted spending: 
Episode: $28,698; 
Hospital inpatient services: $24,578
Average for initial admission: 
Price: $24,085; 
Days: 2.36. 

Rank: 36; 
MSA: Chicago-Joliet-Naperville, IL-IN-WI; 
Average adjusted spending: 
Episode: $28,640; 
Hospital inpatient services: $24,452
Average for initial admission: 
Price: $24,048; 
Days: 2.30. 

Rank: 37; 
MSA: New York-Northern New Jersey-Long Island, NY-NJ-PA; 
Average adjusted spending: 
Episode: $28,629; 
Hospital inpatient services: $24,931
Average for initial admission: 
Price: $24,515; 
Days: 1.97. 

Rank: 38; 
MSA: Lakeland-Winter Haven, FL; 
Average adjusted spending: 
Episode: $28,607; 
Hospital inpatient services: $24,567
Average for initial admission: 
Price: $23,940; 
Days: 2.56. 

Rank: 39; 
MSA: Portland-Vancouver-Hillsboro, OR-WA; 
Average adjusted spending: 
Episode: $28,553; 
Hospital inpatient services: $23,916
Average for initial admission: 
Price: $23,726; 
Days: 2.06. 

Rank: 40; 
MSA: Boston-Cambridge-Quincy, MA-NH; 
Average adjusted spending: 
Episode: $28,474; 
Hospital inpatient services: $24,025
Average for initial admission: 
Price: $23,662; 
Days: 2.40. 

Rank: 41; 
MSA: [B]; 
Average adjusted spending: 
Episode: $28,276; 
Hospital inpatient services: $24,273
Average for initial admission: 
Price: $23,869; 
Days: 2.51. 

Rank: 42; 
MSA: Santa Rosa-Petaluma, CA; 
Average adjusted spending: 
Episode: $28,065; 
Hospital inpatient services: $23,103
Average for initial admission: 
Price: $22,956; 
Days: 2.08. 

Rank: 43; 
MSA: Huntington-Ashland, WV-KY-OH; 
Average adjusted spending: 
Episode: $27,705; 
Hospital inpatient services: $24,019
Average for initial admission: 
Price: $23,766; 
Days: 3.00. 

Rank: 44; 
MSA: Detroit-Warren-Livonia, MI; 
Average adjusted spending: 
Episode: $27,544; 
Hospital inpatient services: $24,443
Average for initial admission: 
Price: $23,744; 
Days: 2.48. 

Rank: 45; 
MSA: San Antonio-New Braunfels, TX; 
Average adjusted spending: 
Episode: $27,489; 
Hospital inpatient services: $24,032
Average for initial admission: 
Price: $23,618; 
Days: 2.45. 

Rank: 46; 
MSA: New Orleans-Metairie-Kenner, LA; 
Average adjusted spending: 
Episode: $27,480; 
Hospital inpatient services: $23,568
Average for initial admission: 
Price: $23,074; 
Days: 2.40. 

Rank: 47; 
MSA: Minneapolis-St. Paul-Bloomington, MN-WI; 
Average adjusted spending: 
Episode: $27,308; 
Hospital inpatient services: $21,497
Average for initial admission: 
Price: $21,057; 
Days: 1.98. 

Rank: 48; 
MSA: Phoenix-Mesa-Glendale, AZ; 
Average adjusted spending: 
Episode: $27,067; 
Hospital inpatient services: $22,739
Average for initial admission: 
Price: $22,222; 
Days: 2.05. 

Rank: 49; 
MSA: [B]; 
Average adjusted spending: 
Episode: $26,746; 
Hospital inpatient services: $22,779
Average for initial admission: 
Price: $22,545; 
Days: 2.16. 

Rank: 50; 
MSA: [B]; 
Average adjusted spending: 
Episode: $26,349; 
Hospital inpatient services: $22,732
Average for initial admission: 
Price: $21,887; 
Days: 2.85. 

Rank: 51; 
MSA: Rochester, NY; 
Average adjusted spending: 
Episode: $25,523; 
Hospital inpatient services: $22,354
Average for initial admission: 
Price: $22,015; 
Days: 1.96. 

Rank: 52; 
MSA: Riverside-San Bernardino-Ontario, CA; 
Average adjusted spending: 
Episode: $25,322; 
Hospital inpatient services: $21,342
Average for initial admission: 
Price: $20,944; 
Days: 2.37. 

Rank: 53; 
MSA: St. Louis, MO-IL; 
Average adjusted spending: 
Episode: $25,288; 
Hospital inpatient services: $21,714
Average for initial admission: 
Price: $21,294; 
Days: 2.39. 

Rank: 54; 
MSA: Toledo, OH; 
Average adjusted spending: 
Episode: $25,210; 
Hospital inpatient services: $21,601
Average for initial admission: 
Price: $21,371; 
Days: 2.34. 

Rank: 55; 
MSA: Cincinnati-Middletown, OH-KY-IN; 
Average adjusted spending: 
Episode: $25,203; 
Hospital inpatient services: $21,875
Average for initial admission: 
Price: $21,471; 
Days: 2.19. 

Rank: 56; 
MSA: Albuquerque, NM; 
Average adjusted spending: 
Episode: $25,015; 
Hospital inpatient services: $21,232
Average for initial admission: 
Price: $20,794; 
Days: 2.40. 

Rank: 57; 
MSA: Cleveland-Elyria-Mentor, OH; 
Average adjusted spending: 
Episode: $24,914; 
Hospital inpatient services: $21,232
Average for initial admission: 
Price: $20,836; 
Days: 2.35. 

Rank: 58; 
MSA: Shreveport-Bossier City, LA; 
Average adjusted spending: 
Episode: $24,848; 
Hospital inpatient services: $18,990
Average for initial admission: 
Price: $18,805; 
Days: 2.55. 

Rank: 59; 
MSA: [B]; 
Average adjusted spending: 
Episode: $24,753; 
Hospital inpatient services: $20,678
Average for initial admission: 
Price: $20,124; 
Days: 1.79. 

Rank: 60; 
MSA: Columbus, OH; 
Average adjusted spending: 
Episode: $24,310; 
Hospital inpatient services: $21,266
Average for initial admission: 
Price: $20,767; 
Days: 2.21. 

Rank: 61; 
MSA: Tulsa, OK; 
Average adjusted spending: 
Episode: $24,088; 
Hospital inpatient services: $20,619
Average for initial admission: 
Price: $20,108; 
Days: 2.45. 

Rank: 62; 
MSA: [B]; 
Average adjusted spending: 
Episode: $23,938; 
Hospital inpatient services: $19,648
Average for initial admission: 
Price: $19,401; 
Days: 2.23. 

Rank: 63; 
MSA: Knoxville, TN[C]; 
Average adjusted spending: 
Episode: $23,935; 
Hospital inpatient services: $19,013
Average for initial admission: 
Price: $18,768; 
Days: 2.43. 

Rank: 64; 
MSA: [B,C]; 
Average adjusted spending: 
Episode: $23,647; 
Hospital inpatient services: $20,084
Average for initial admission: 
Price: $19,776; 
Days: 2.43. 

Rank: 65; 
MSA: Bridgeport-Stamford-Norwalk, CT[C]; 
Average adjusted spending: 
Episode: $23,135; 
Hospital inpatient services: $19,218
Average for initial admission: 
Price: $18,995; 
Days: 2.18. 

Rank: 66; 
MSA: Los Angeles-Long Beach-Santa Ana, CA[C]; 
Average adjusted spending: 
Episode: $22,768; 
Hospital inpatient services: $19,135
Average for initial admission: 
Price: $18,815; 
Days: 1.98. 

Rank: 67; 
MSA: Savannah, GA[C]; 
Average adjusted spending: 
Episode: $22,585; 
Hospital inpatient services: $18,596
Average for initial admission: 
Price: $18,596; 
Days: 2.19. 

Rank: 68; 
MSA: Hartford-West Hartford-East Hartford, CT[C]; 
Average adjusted spending: 
Episode: $22,357; 
Hospital inpatient services: $18,511
Average for initial admission: 
Price: $18,279; 
Days: 2.27. 

Rank: 69; 
MSA: Dayton, OH[C]; 
Average adjusted spending: 
Episode: $22,073; 
Hospital inpatient services: $18,839
Average for initial admission: 
Price: $18,504; 
Days: 2.55. 

Rank: 70; 
MSA: Oxnard-Thousand Oaks-Ventura, CA[C]; 
Average adjusted spending: 
Episode: $22,023; 
Hospital inpatient services: $18,290
Average for initial admission: 
Price: $18,290; 
Days: 1.60. 

Rank: 71; 
MSA: Springfield, MA[C]; 
Average adjusted spending: 
Episode: $21,937; 
Hospital inpatient services: $17,580
Average for initial admission: 
Price: $17,159; 
Days: 2.96. 

Rank: 72; 
MSA: [B,C] 
Average adjusted spending: 
Episode: $21,664; 
Hospital inpatient services: $18,528
Average for initial admission: 
Price: $18,233; 
Days: 2.32. 

Rank: 73; 
MSA: Akron, OH[C]; 
Average adjusted spending: 
Episode: $21,664; 
Hospital inpatient services: $18,627
Average for initial admission: 
Price: $18,327; 
Days: 2.25. 

Rank: 74; 
MSA: Las Vegas-Paradise, NV[C]; 
Average adjusted spending: 
Episode: $20,969; 
Hospital inpatient services: $17,618
Average for initial admission: 
Price: $17,278; 
Days: 2.65. 

Rank: 75; 
MSA: Lexington-Fayette, KY[C]; 
Average adjusted spending: 
Episode: $20,602; 
Hospital inpatient services: $18,089
Average for initial admission: 
Price: $17,824; 
Days: 1.75. 

Rank: 76; 
MSA: Youngstown-Warren-Boardman, OH-PA[C]; 
Average adjusted spending: 
Episode: $18,829; 
Hospital inpatient services: $15,758
Average for initial admission: 
Price: $15,420; 
Days: 2.41. 

Rank: 77; 
MSA: Louisville-Jefferson County, KY-IN[C]; 
Average adjusted spending: 
Episode: $18,677; 
Hospital inpatient services: $15,706
Average for initial admission: 
Price: $15,447; 
Days: 2.66. 

Rank: 78; 
MSA: Birmingham-Hoover, AL[C]; 
Average adjusted spending: 
Episode: $17,768; 
Hospital inpatient services: $12,939
Average for initial admission: 
Price: $12,519; 
Days: 2.41. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 78 MSAs. We included all MSAs with a sufficient 
number of episodes to support our analyses for all three procedures. 
Spending and prices were adjusted to control for geographic 
differences in the cost of doing business and differences in 
demographics and health status of enrollees in each MSA. 

[A] MSA was in the highest-spending quintile. The 16 MSAs in the 
highest-spending quintile had an average of $33,297 in spending on 
hospital inpatient services. 

[B] MSA name withheld to protect the confidentiality of entities that 
contributed private data. 

[C] MSA was in the lowest-spending quintile. The 16 MSAs in the lowest-
spending quintile had an average of $17,908 in spending on hospital 
inpatient services. 

[End of table] 

Table 10: Hospital Inpatient Spending, Initial Admission Price, and 
Number of Days, by Metropolitan Statistical Area (MSA), for 
Laparoscopic Appendectomy Episodes: 

Rank: 1; 
MSA: Salinas, CA[A]; 
Average adjusted spending: 
Episode: $25,924; 
Hospital inpatient services: $23,432; 
Average for initial admission: 
Price: $23,432; 
Days: 1.56. 

Rank: 2; 
MSA: Madison, WI[A]; 
Average adjusted spending: 
Episode: $18,123; 
Hospital inpatient services: $13,671; 
Average for initial admission: 
Price: $13,480; 
Days: 1.22. 

Rank: 3; 
MSA: Milwaukee-Waukesha-West Allis, WI[A]; 
Average adjusted spending: 
Episode: $18,096; 
Hospital inpatient services: $14,070; 
Average for initial admission: 
Price: $13,873; 
Days: 1.44. 

Rank: 4; 
MSA: Charleston, WV[A]; 
Average adjusted spending: 
Episode: $17,640; 
Hospital inpatient services: $14,924; 
Average for initial admission: 
Price: $14,673; 
Days: 1.76. 

Rank: 5; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $16,588; 
Hospital inpatient services: $13,745; 
Average for initial admission: 
Price: $13,337; 
Days: 1.44. 

Rank: 6; 
MSA: a,b; 
Average adjusted spending: 
Episode: $16,323; 
Hospital inpatient services: $14,070; 
Average for initial admission: 
Price: $13,984; 
Days: 1.58. 

Rank: 7; 
MSA: Grand Rapids-Wyoming, MI[A]; 
Average adjusted spending: 
Episode: $15,444; 
Hospital inpatient services: $13,283; 
Average for initial admission: 
Price: $13,067; 
Days: 1.33. 

Rank: 8; 
MSA: Colorado Springs, CO[A]; 
Average adjusted spending: 
Episode: $15,318; 
Hospital inpatient services: $11,087; 
Average for initial admission: 
Price: $11,087; 
Days: 1.90. 

Rank: 9; 
MSA: Orlando-Kissimmee-Sanford, FL[A]; 
Average adjusted spending: 
Episode: $15,267; 
Hospital inpatient services: $12,638; 
Average for initial admission: 
Price: $12,501; 
Days: 1.90. 

Rank: 10; 
MSA: San Diego-Carlsbad-San Marcos, CA[A]; 
Average adjusted spending: 
Episode: $14,859; 
Hospital inpatient services: $11,527; 
Average for initial admission: 
Price: $11,345; 
Days: 1.70. 

Rank: 11; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $14,761; 
Hospital inpatient services: $12,619; 
Average for initial admission: 
Price: $12,534; 
Days: 1.38. 

Rank: 12; 
MSA: Lakeland-Winter Haven, FL[A]; 
Average adjusted spending: 
Episode: $14,678; 
Hospital inpatient services: $11,430; 
Average for initial admission: 
Price: $11,191; 
Days: 1.27. 

Rank: 13; 
MSA: Seattle-Tacoma-Bellevue, WA[A]; 
Average adjusted spending: 
Episode: $14,644; 
Hospital inpatient services: $11,654; 
Average for initial admission: 
Price: $11,491; 
Days: 1.37. 

Rank: 14; 
MSA: Fort Wayne, IN[A]; 
Average adjusted spending: 
Episode: $14,543; 
Hospital inpatient services: $11,690; 
Average for initial admission: 
Price: $11,690; 
Days: 1.44. 

Rank: 15; 
MSA: Columbus, OH[A]; 
Average adjusted spending: 
Episode: $14,478; 
Hospital inpatient services: $11,905; 
Average for initial admission: 
Price: $11,726; 
Days: 1.76. 

Rank: 16; 
MSA: Portland-Vancouver-Hillsboro, OR-WA[A]; 
Average adjusted spending: 
Episode: $14,337; 
Hospital inpatient services: $11,552; 
Average for initial admission: 
Price: $11,419; 
Days: 1.43. 

Rank: 17; 
MSA: Nashville-Davidson-Murfreesboro-Franklin, TN; 
Average adjusted spending: 
Episode: $14,335; 
Hospital inpatient services: $11,268; 
Average for initial admission: 
Price: $11,268; 
Days: 2.19. 

Rank: 18; 
MSA: Cape Coral-Fort Myers, FL; 
Average adjusted spending: 
Episode: $14,327; 
Hospital inpatient services: $11,706; 
Average for initial admission: 
Price: $11,585; 
Days: 2.32. 

Rank: 19; 
MSA: [B]; 
Average adjusted spending: 
Episode: $14,115; 
Hospital inpatient services: $11,711; 
Average for initial admission: 
Price: $11,625; 
Days: 1.67. 

Rank: 20; 
MSA: [B]; 
Average adjusted spending: 
Episode: $14,042; 
Hospital inpatient services: $11,450; 
Average for initial admission: 
Price: $11,341; 
Days: 1.90. 

Rank: 21; 
MSA: Ann Arbor, MI; 
Average adjusted spending: 
Episode: $13,986; 
Hospital inpatient services: $11,915; 
Average for initial admission: 
Price: $11,915; 
Days: 1.35. 

Rank: 22; 
MSA: [B]; 
Average adjusted spending: 
Episode: $13,933; 
Hospital inpatient services: $10,996; 
Average for initial admission: 
Price: $10,996; 
Days: 1.95. 

Rank: 23; 
MSA: Akron, OH; 
Average adjusted spending: 
Episode: $13,788; 
Hospital inpatient services: $11,251; 
Average for initial admission: 
Price: $11,251; 
Days: 2.64. 

Rank: 24; 
MSA: Allentown-Bethlehem-Easton, PA-NJ; 
Average adjusted spending: 
Episode: $13,634; 
Hospital inpatient services: $11,335; 
Average for initial admission: 
Price: $11,251; 
Days: 1.39. 

Rank: 25; 
MSA: Tampa-St. Petersburg-Clearwater, FL; 
Average adjusted spending: 
Episode: $13,374; 
Hospital inpatient services: $10,264; 
Average for initial admission: 
Price: $10,117; 
Days: 1.78. 

Rank: 26; 
MSA: Dayton, OH; 
Average adjusted spending: 
Episode: $12,973; 
Hospital inpatient services: $10,367; 
Average for initial admission: 
Price: $10,136; 
Days: 1.96. 

Rank: 27; 
MSA: Huntington-Ashland, WV-KY-OH; 
Average adjusted spending: 
Episode: $12,897; 
Hospital inpatient services: $10,320; 
Average for initial admission: 
Price: $10,320; 
Days: 1.73. 

Rank: 28; 
MSA: Detroit-Warren-Livonia, MI; 
Average adjusted spending: 
Episode: $12,879; 
Hospital inpatient services: $10,899; 
Average for initial admission: 
Price: $10,724; 
Days: 1.86. 

Rank: 29; 
MSA: Sacramento-Arden-Arcade-Roseville, CA; 
Average adjusted spending: 
Episode: $12,862; 
Hospital inpatient services: $9,362; 
Average for initial admission: 
Price: $9,311; 
Days: 1.42. 

Rank: 30; 
MSA: Chicago-Joliet-Naperville, IL-IN-WI; 
Average adjusted spending: 
Episode: $12,800; 
Hospital inpatient services: $10,152; 
Average for initial admission: 
Price: $10,038; 
Days: 1.76. 

Rank: 31; 
MSA: Kansas City, MO-KS; 
Average adjusted spending: 
Episode: $12,596; 
Hospital inpatient services: $9,867; 
Average for initial admission: 
Price: $9,689; 
Days: 1.99. 

Rank: 32; 
MSA: Cincinnati-Middletown, OH-KY-IN; 
Average adjusted spending: 
Episode: $12,571; 
Hospital inpatient services: $10,069; 
Average for initial admission: 
Price: $9,938; 
Days: 1.61. 

Rank: 33; 
MSA: Minneapolis-St. Paul-Bloomington, MN-WI; 
Average adjusted spending: 
Episode: $12,477; 
Hospital inpatient services: $9,379; 
Average for initial admission: 
Price: $9,336; 
Days: 1.39. 

Rank: 34; 
MSA: Dallas-Fort Worth-Arlington, TX; 
Average adjusted spending: 
Episode: $12,413; 
Hospital inpatient services: $9,273; 
Average for initial admission: 
Price: $9,193; 
Days: 1.64. 

Rank: 35; 
MSA: Raleigh-Cary, NC; 
Average adjusted spending: 
Episode: $12,403; 
Hospital inpatient services: $9,281; 
Average for initial admission: 
Price: $9,281; 
Days: 1.83. 

Rank: 36; 
MSA: Providence-New Bedford-Fall River, RI-MA; 
Average adjusted spending: 
Episode: $12,394; 
Hospital inpatient services: $9,978; 
Average for initial admission: 
Price: $9,813; 
Days: 2.00. 

Rank: 37; 
MSA: [B]; 
Average adjusted spending: 
Episode: $12,358; 
Hospital inpatient services: $10,014; 
Average for initial admission: 
Price: $9,845; 
Days: 1.72. 

Rank: 38; 
MSA: [B]; 
Average adjusted spending: 
Episode: $12,336; 
Hospital inpatient services: $9,554; 
Average for initial admission: 
Price: $9,458; 
Days: 1.66. 

Rank: 39; 
MSA: New York-Northern New Jersey-Long Island, NY-NJ-PA; 
Average adjusted spending: 
Episode: $12,252; 
Hospital inpatient services: $7,832; 
Average for initial admission: 
Price: $7,716; 
Days: 1.57. 

Rank: 40; 
MSA: Shreveport-Bossier City, LA; 
Average adjusted spending: 
Episode: $12,011; 
Hospital inpatient services: $8,831; 
Average for initial admission: 
Price: $8,706; 
Days: 2.13. 

Rank: 41; 
MSA: Birmingham-Hoover, AL; 
Average adjusted spending: 
Episode: $11,960; 
Hospital inpatient services: $8,853; 
Average for initial admission: 
Price: $8,759; 
Days: 2.05. 

Rank: 42; 
MSA: [B]; 
Average adjusted spending: 
Episode: $11,851; 
Hospital inpatient services: $9,524; 
Average for initial admission: 
Price: $9,524; 
Days: 2.19. 

Rank: 43; 
MSA: Houston-Sugar Land-Baytown, TX; 
Average adjusted spending: 
Episode: $11,496; 
Hospital inpatient services: $8,598; 
Average for initial admission: 
Price: $8,475; 
Days: 1.77. 

Rank: 44; 
MSA: Boston-Cambridge-Quincy, MA-NH; 
Average adjusted spending: 
Episode: $11,417; 
Hospital inpatient services: $8,412; 
Average for initial admission: 
Price: $8,310; 
Days: 1.52. 

Rank: 45; 
MSA: Phoenix-Mesa-Glendale, AZ; 
Average adjusted spending: 
Episode: $11,403; 
Hospital inpatient services: $7,978; 
Average for initial admission: 
Price: $7,833; 
Days: 1.59. 

Rank: 46; 
MSA: Philadelphia-Camden-Wilmington, PA-NJ-DE-MD; 
Average adjusted spending: 
Episode: $11,351; 
Hospital inpatient services: $8,910; 
Average for initial admission: 
Price: $8,828; 
Days: 1.53. 

Rank: 47; 
MSA: Tulsa, OK; 
Average adjusted spending: 
Episode: $11,314; 
Hospital inpatient services: $8,976; 
Average for initial admission: 
Price: $8,626; 
Days: 1.50. 

Rank: 48; 
MSA: Rochester, NY; 
Average adjusted spending: 
Episode: $11,144; 
Hospital inpatient services: $8,542; 
Average for initial admission: 
Price: $8,542; 
Days: 2.22. 

Rank: 49; 
MSA: Cleveland-Elyria-Mentor, OH; 
Average adjusted spending: 
Episode: $11,078; 
Hospital inpatient services: $8,537; 
Average for initial admission: 
Price: $8,537; 
Days: 1.86. 

Rank: 50; 
MSA: [B]; 
Average adjusted spending: 
Episode: $11,037; 
Hospital inpatient services: $8,807; 
Average for initial admission: 
Price: $8,679; 
Days: 1.71. 

Rank: 51; 
MSA: Springfield, MA; 
Average adjusted spending: 
Episode: $10,958; 
Hospital inpatient services: $8,113; 
Average for initial admission: 
Price: $8,113; 
Days: 1.69. 

Rank: 52; 
MSA: Lexington-Fayette, KY; 
Average adjusted spending: 
Episode: $10,831; 
Hospital inpatient services: $8,702; 
Average for initial admission: 
Price: $8,682; 
Days: 1.63. 

Rank: 53; 
MSA: Bridgeport-Stamford-Norwalk, CT; 
Average adjusted spending: 
Episode: $10,821; 
Hospital inpatient services: $7,604; 
Average for initial admission: 
Price: $7,554; 
Days: 1.51. 

Rank: 54; 
MSA: [B]; 
Average adjusted spending: 
Episode: $10,775; 
Hospital inpatient services: $8,969; 
Average for initial admission: 
Price: $8,908; 
Days: 2.19. 

Rank: 55; 
MSA: Louisville-Jefferson County, KY-IN; 
Average adjusted spending: 
Episode: $10,771; 
Hospital inpatient services: $8,562; 
Average for initial admission: 
Price: $8,412; 
Days: 2.20. 

Rank: 56; 
MSA: [B]; 
Average adjusted spending: 
Episode: $10,766; 
Hospital inpatient services: $8,413; 
Average for initial admission: 
Price: $8,085; 
Days: 1.47. 

Rank: 57; 
MSA: New Orleans-Metairie-Kenner, LA; 
Average adjusted spending: 
Episode: $10,695; 
Hospital inpatient services: $7,816; 
Average for initial admission: 
Price: $7,607; 
Days: 1.94. 

Rank: 58; 
MSA: Toledo, OH; 
Average adjusted spending: 
Episode: $10,693; 
Hospital inpatient services: $8,249; 
Average for initial admission: 
Price: $8,040; 
Days: 2.00. 

Rank: 59; 
MSA: [B]; 
Average adjusted spending: 
Episode: $10,470; 
Hospital inpatient services: $7,234; 
Average for initial admission: 
Price: $7,045; 
Days: 1.65. 

Rank: 60; 
MSA: Denver-Aurora-Broomfield, CO; 
Average adjusted spending: 
Episode: $10,372; 
Hospital inpatient services: $7,004; 
Average for initial admission: 
Price: $6,948; 
Days: 1.57. 

Rank: 61; 
MSA: Los Angeles-Long Beach-Santa Ana, CA; 
Average adjusted spending: 
Episode: $10,351; 
Hospital inpatient services: $7,117; 
Average for initial admission: 
Price: $7,010; 
Days: 1.61. 

Rank: 62; 
MSA: Memphis, TN-MS-AR; 
Average adjusted spending: 
Episode: $10,191; 
Hospital inpatient services: $6,880; 
Average for initial admission: 
Price: $6,796; 
Days: 1.90. 

Rank: 63; 
MSA: San Antonio-New Braunfels, TX[C]; 
Average adjusted spending: 
Episode: $10,163; 
Hospital inpatient services: $7,580; 
Average for initial admission: 
Price: $7,430; 
Days: 1.83. 

Rank: 64; 
MSA: [B,C]; 
Average adjusted spending: 
Episode: $10,116; 
Hospital inpatient services: $7,122; 
Average for initial admission: 
Price: $6,880; 
Days: 2.03. 

Rank: 65; 
MSA: Riverside-San Bernardino-Ontario, CA[C]; 
Average adjusted spending: 
Episode: $10,108; 
Hospital inpatient services: $6,935; 
Average for initial admission: 
Price: $6,728; 
Days: 1.72. 

Rank: 66; 
MSA: Knoxville, TN[C]; 
Average adjusted spending: 
Episode: $9,887; 
Hospital inpatient services: $6,890; 
Average for initial admission: 
Price: $6,564; 
Days: 2.38. 

Rank: 67; 
MSA: Hartford-West Hartford-East Hartford, CT[C]; 
Average adjusted spending: 
Episode: $9,304; 
Hospital inpatient services: $6,412; 
Average for initial admission: 
Price: $6,340; 
Days: 1.60. 

Rank: 68; 
MSA: Savannah, GA[C]; 
Average adjusted spending: 
Episode: $9,281; 
Hospital inpatient services: $6,727; 
Average for initial admission: 
Price: $6,575; 
Days: 2.18. 

Rank: 69; 
MSA: Albany-Schenectady-Troy, NY[C]; 
Average adjusted spending: 
Episode: $8,922; 
Hospital inpatient services: $6,456; 
Average for initial admission: 
Price: $6,261; 
Days: 1.57. 

Rank: 70; 
MSA: [B,C]; 
Average adjusted spending: 
Episode: $8,880; 
Hospital inpatient services: $6,787; 
Average for initial admission: 
Price: $6,672; 
Days: 1.77. 

Rank: 71; 
MSA: San Jose-Sunnyvale-Santa Clara, CA[C]; 
Average adjusted spending: 
Episode: $8,848; 
Hospital inpatient services: $5,302; 
Average for initial admission: 
Price: $5,302; 
Days: 1.43. 

Rank: 72; 
MSA: Youngstown-Warren-Boardman, OH-PA[C]; 
Average adjusted spending: 
Episode: $8,747; 
Hospital inpatient services: $6,857; 
Average for initial admission: 
Price: $6,857; 
Days: 1.72. 

Rank: 73; 
MSA: Santa Rosa-Petaluma, CA[C]; 
Average adjusted spending: 
Episode: $8,618; 
Hospital inpatient services: $5,608; 
Average for initial admission: 
Price: $5,202; 
Days: 1.47. 

Rank: 74; 
MSA: Oxnard-Thousand Oaks-Ventura, CA[C]; 
Average adjusted spending: 
Episode: $7,993; 
Hospital inpatient services: $5,377; 
Average for initial admission: 
Price: $5,290; 
Days: 1.30. 

Rank: 75; 
MSA: Albuquerque, NM[C]; 
Average adjusted spending: 
Episode: $7,989; 
Hospital inpatient services: $5,167; 
Average for initial admission: 
Price: $5,122; 
Days: 1.55. 

Rank: 76; 
MSA: Las Vegas-Paradise, NV[C]; 
Average adjusted spending: 
Episode: $7,773; 
Hospital inpatient services: $4,576; 
Average for initial admission: 
Price: $4,528; 
Days: 1.54. 

Rank: 77; 
MSA: St. Louis, MO-IL[C]; 
Average adjusted spending: 
Episode: $7,698; 
Hospital inpatient services: $5,014; 
Average for initial admission: 
Price: $4,905; 
Days: 1.70. 

Rank: 78; 
MSA: Fresno, CA[C]; 
Average adjusted spending: 
Episode: $7,096; 
Hospital inpatient services: $4,993; 
Average for initial admission: 
Price: $4,882; 
Days: 1.61. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 78 MSAs. We included all MSAs with a sufficient 
number of episodes to support our analyses for all three procedures. 
Spending and prices were adjusted to control for geographic 
differences in the cost of doing business and differences in 
demographics and health status of enrollees in each MSA. 

[A] MSA was in the highest-spending quintile. The 16 MSAs in the 
highest-spending quintile had an average of $13,331 in spending on 
hospital inpatient services. 

[B] MSA name withheld to protect the confidentiality of entities that 
contributed private data. 

[C] MSA was in the lowest-spending quintile. The 16 MSAs in the lowest-
spending quintile had an average of $6,113 in spending on hospital 
inpatient services. 

[End of table] 

Table 11: Hospital Inpatient Spending, Initial Admission Price, and 
Number of Days, by Metropolitan Statistical Area (MSA), for Total Hip 
Replacement Episodes: 

Rank: 1; 
MSA: Salinas, CA[A]; 
Average adjusted spending: 
Episode: $57,990; 
Hospital inpatient services: $52,757; 
Average for initial admission: 
Price: $52,757; 
Days: 3.39. 

Rank: 2; 
MSA: Dallas-Fort Worth-Arlington, TX[A]; 
Average adjusted spending: 
Episode: $41,129; 
Hospital inpatient services: $35,488; 
Average for initial admission: 
Price: $35,183; 
Days: 2.95. 

Rank: 3; 
MSA: San Diego-Carlsbad-San Marcos, CA[A]; 
Average adjusted spending: 
Episode: $37,906; 
Hospital inpatient services: $31,283; 
Average for initial admission: 
Price: $31,005; 
Days: 2.79. 

Rank: 4; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $37,669; 
Hospital inpatient services: $31,896; 
Average for initial admission: 
Price: $31,611; 
Days: 3.14. 

Rank: 5; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $36,936; 
Hospital inpatient services: $31,129; 
Average for initial admission: 
Price: $30,508; 
Days: 3.11. 

Rank: 6; 
MSA: Madison, WI[A]; 
Average adjusted spending: 
Episode: $36,258; 
Hospital inpatient services: $25,671; 
Average for initial admission: 
Price: $25,671; 
Days: 2.65. 

Rank: 7; 
MSA: Milwaukee-Waukesha-West Allis, WI[A]; 
Average adjusted spending: 
Episode: $35,963; 
Hospital inpatient services: $28,392; 
Average for initial admission: 
Price: $27,935; 
Days: 2.87. 

Rank: 8; 
MSA: New York-Northern New Jersey-Long Island, NY-NJ-PA[A]; 
Average adjusted spending: 
Episode: $35,682; 
Hospital inpatient services: $25,800; 
Average for initial admission: 
Price: $25,378; 
Days: 3.29. 

Rank: 9; 
MSA: Houston-Sugar Land-Baytown, TX[A]; 
Average adjusted spending: 
Episode: $35,332; 
Hospital inpatient services: $29,510; 
Average for initial admission: 
Price: $29,231; 
Days: 2.93. 

Rank: 10; 
MSA: San Antonio-New Braunfels, TX[A]; 
Average adjusted spending: 
Episode: $35,319; 
Hospital inpatient services: $30,041; 
Average for initial admission: 
Price: $29,734; 
Days: 2.93. 

Rank: 11; 
MSA: Fort Wayne, IN[A]; 
Average adjusted spending: 
Episode: $34,711; 
Hospital inpatient services: $30,406; 
Average for initial admission: 
Price: $30,140; 
Days: 2.45. 

Rank: 12; 
MSA: Sacramento-Arden-Arcade-Roseville, CA[A]; 
Average adjusted spending: 
Episode: $34,420; 
Hospital inpatient services: $27,594; 
Average for initial admission: 
Price: $27,594; 
Days: 2.93. 

Rank: 13; 
MSA: Nashville-Davidson-Murfreesboro-Franklin, TN[A]; 
Average adjusted spending: 
Episode: $34,311; 
Hospital inpatient services: $28,079; 
Average for initial admission: 
Price: $27,886; 
Days: 2.59. 

Rank: 14; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $33,899; 
Hospital inpatient services: $28,450; 
Average for initial admission: 
Price: $28,450; 
Days: 3.38. 

Rank: 15; 
MSA: Albany-Schenectady-Troy, NY[A]; 
Average adjusted spending: 
Episode: $32,246; 
Hospital inpatient services: $26,505; 
Average for initial admission: 
Price: $26,246; 
Days: 2.38. 

Rank: 16; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $31,726; 
Hospital inpatient services: $26,125; 
Average for initial admission: 
Price: $25,983; 
Days: 2.74. 

Rank: 17; 
MSA: Colorado Springs, CO; 
Average adjusted spending: 
Episode: $31,648; 
Hospital inpatient services: $26,345; 
Average for initial admission: 
Price: $26,135; 
Days: 2.49. 

Rank: 18; 
MSA: [B]; 
Average adjusted spending: 
Episode: $31,550; 
Hospital inpatient services: $25,757; 
Average for initial admission: 
Price: $25,360; 
Days: 2.78. 

Rank: 19; 
MSA: Charleston, WV; 
Average adjusted spending: 
Episode: $31,376; 
Hospital inpatient services: $25,999; 
Average for initial admission: 
Price: $25,604; 
Days: 2.46. 

Rank: 20; 
MSA: [B]; 
Average adjusted spending: 
Episode: $31,371; 
Hospital inpatient services: $25,170; 
Average for initial admission: 
Price: $24,840; 
Days: 3.25. 

Rank: 21; 
MSA: Portland-Vancouver-Hillsboro, OR-WA; 
Average adjusted spending: 
Episode: $30,535; 
Hospital inpatient services: $25,071; 
Average for initial admission: 
Price: $24,880; 
Days: 2.48. 

Rank: 22; 
MSA: Orlando-Kissimmee-Sanford, FL; 
Average adjusted spending: 
Episode: $30,473; 
Hospital inpatient services: $25,314; 
Average for initial admission: 
Price: $25,127; 
Days: 3.22. 

Rank: 23; 
MSA: Cape Coral-Fort Myers, FL; 
Average adjusted spending: 
Episode: $30,422; 
Hospital inpatient services: $25,235; 
Average for initial admission: 
Price: $25,103; 
Days: 2.75. 

Rank: 24; 
MSA: Seattle-Tacoma-Bellevue, WA; 
Average adjusted spending: 
Episode: $30,398; 
Hospital inpatient services: $24,612; 
Average for initial admission: 
Price: $24,406; 
Days: 2.75. 

Rank: 25; 
MSA: Tampa-St. Petersburg-Clearwater, FL; 
Average adjusted spending: 
Episode: $30,380; 
Hospital inpatient services: $24,265; 
Average for initial admission: 
Price: $23,762; 
Days: 3.16. 

Rank: 26; 
MSA: [B]; 
Average adjusted spending: 
Episode: $30,205; 
Hospital inpatient services: $22,953; 
Average for initial admission: 
Price: $22,389; 
Days: 3.02. 

Rank: 27; 
MSA: [B]; 
Average adjusted spending: 
Episode: $30,072; 
Hospital inpatient services: $24,631; 
Average for initial admission: 
Price: $24,210; 
Days: 3.20. 

Rank: 28; 
MSA: [B]; 
Average adjusted spending: 
Episode: $29,817; 
Hospital inpatient services: $24,239; 
Average for initial admission: 
Price: $24,154; 
Days: 2.86. 

Rank: 29; 
MSA: Lakeland-Winter Haven, FL; 
Average adjusted spending: 
Episode: $29,480; 
Hospital inpatient services: $23,488; 
Average for initial admission: 
Price: $23,127; 
Days: 2.82. 

Rank: 30; 
MSA: Knoxville, TN; 
Average adjusted spending: 
Episode: $29,470; 
Hospital inpatient services: $24,060; 
Average for initial admission: 
Price: $23,862; 
Days: 2.45. 

Rank: 31; 
MSA: Memphis, TN-MS-AR; 
Average adjusted spending: 
Episode: $29,073; 
Hospital inpatient services: $22,607; 
Average for initial admission: 
Price: $22,198; 
Days: 3.18. 

Rank: 32; 
MSA: New Orleans-Metairie-Kenner, LA; 
Average adjusted spending: 
Episode: $29,035; 
Hospital inpatient services: $23,439; 
Average for initial admission: 
Price: $22,986; 
Days: 3.05. 

Rank: 33; 
MSA: San Jose-Sunnyvale-Santa Clara, CA; 
Average adjusted spending: 
Episode: $28,626; 
Hospital inpatient services: $22,145; 
Average for initial admission: 
Price: $21,967; 
Days: 3.00. 

Rank: 34; 
MSA: Raleigh-Cary, NC; 
Average adjusted spending: 
Episode: $28,162; 
Hospital inpatient services: $22,407; 
Average for initial admission: 
Price: $22,407; 
Days: 3.03. 

Rank: 35; 
MSA: [B]; 
Average adjusted spending: 
Episode: $28,090; 
Hospital inpatient services: $22,561; 
Average for initial admission: 
Price: $22,368; 
Days: 2.62. 

Rank: 36; 
MSA: Huntington-Ashland, WV-KY-OH; 
Average adjusted spending: 
Episode: $28,065; 
Hospital inpatient services: $22,695; 
Average for initial admission: 
Price: $22,522; 
Days: 2.88. 

Rank: 37; 
MSA: Denver-Aurora-Broomfield, CO; 
Average adjusted spending: 
Episode: $28,042; 
Hospital inpatient services: $22,545; 
Average for initial admission: 
Price: $22,355; 
Days: 2.66. 

Rank: 38; 
MSA: Providence-New Bedford-Fall River, RI-MA; 
Average adjusted spending: 
Episode: $27,936; 
Hospital inpatient services: $21,568; 
Average for initial admission: 
Price: $21,392; 
Days: 3.64. 

Rank: 39; 
MSA: Chicago-Joliet-Naperville, IL-IN-WI; 
Average adjusted spending: 
Episode: $27,774; 
Hospital inpatient services: $21,231; 
Average for initial admission: 
Price: $21,060; 
Days: 2.95. 

Rank: 40; 
MSA: Kansas City, MO-KS; 
Average adjusted spending: 
Episode: $27,770; 
Hospital inpatient services: $22,098; 
Average for initial admission: 
Price: $21,944; 
Days: 2.84. 

Rank: 41; 
MSA: Ann Arbor, MI; 
Average adjusted spending: 
Episode: $27,709; 
Hospital inpatient services: $22,896; 
Average for initial admission: 
Price: $22,539; 
Days: 3.44. 

Rank: 42; 
MSA: Philadelphia-Camden-Wilmington, PA-NJ-DE-MD; 
Average adjusted spending: 
Episode: $27,354; 
Hospital inpatient services: $21,643; 
Average for initial admission: 
Price: $21,300; 
Days: 2.67. 

Rank: 43; 
MSA: Detroit-Warren-Livonia, MI; 
Average adjusted spending: 
Episode: $26,945; 
Hospital inpatient services: $21,762; 
Average for initial admission: 
Price: $21,404; 
Days: 3.10. 

Rank: 44; 
MSA: Savannah, GA; 
Average adjusted spending: 
Episode: $26,937; 
Hospital inpatient services: $20,052; 
Average for initial admission: 
Price: $19,912; 
Days: 2.12. 

Rank: 45; 
MSA: Cincinnati-Middletown, OH-KY-IN; 
Average adjusted spending: 
Episode: $26,868; 
Hospital inpatient services: $21,591; 
Average for initial admission: 
Price: $21,338; 
Days: 2.76. 

Rank: 46; 
MSA: Bridgeport-Stamford-Norwalk, CT; 
Average adjusted spending: 
Episode: $26,858; 
Hospital inpatient services: $19,894; 
Average for initial admission: 
Price: $19,823; 
Days: 3.33. 

Rank: 47; 
MSA: Phoenix-Mesa-Glendale, AZ; 
Average adjusted spending: 
Episode: $26,856; 
Hospital inpatient services: $20,222; 
Average for initial admission: 
Price: $19,995; 
Days: 2.55. 

Rank: 48; 
MSA: Tulsa, OK; 
Average adjusted spending: 
Episode: $26,651; 
Hospital inpatient services: $21,459; 
Average for initial admission: 
Price: $21,318; 
Days: 2.12. 

Rank: 49; 
MSA: Minneapolis-St. Paul-Bloomington, MN-WI; 
Average adjusted spending: 
Episode: $26,628; 
Hospital inpatient services: $19,928; 
Average for initial admission: 
Price: $19,649; 
Days: 2.78. 

Rank: 50; 
MSA: Boston-Cambridge-Quincy, MA-NH; 
Average adjusted spending: 
Episode: $26,618; 
Hospital inpatient services: $20,720; 
Average for initial admission: 
Price: $20,568; 
Days: 3.47. 

Rank: 51; 
MSA: Shreveport-Bossier City, LA; 
Average adjusted spending: 
Episode: $26,580; 
Hospital inpatient services: $20,471; 
Average for initial admission: 
Price: $20,181; 
Days: 2.94. 

Rank: 52; 
MSA: [B]; 
Average adjusted spending: 
Episode: $26,557; 
Hospital inpatient services: $20,284; 
Average for initial admission: 
Price: $20,093; 
Days: 3.21. 

Rank: 53; 
MSA: Albuquerque, NM; 
Average adjusted spending: 
Episode: $26,481; 
Hospital inpatient services: $20,098; 
Average for initial admission: 
Price: $20,001; 
Days: 3.22. 

Rank: 54; 
MSA: Cleveland-Elyria-Mentor, OH; 
Average adjusted spending: 
Episode: $25,683; 
Hospital inpatient services: $20,483; 
Average for initial admission: 
Price: $20,256; 
Days: 3.06. 

Rank: 55; 
MSA: Columbus, OH; 
Average adjusted spending: 
Episode: $25,627; 
Hospital inpatient services: $21,205; 
Average for initial admission: 
Price: $20,977; 
Days: 2.28. 

Rank: 56; 
MSA: [B]; 
Average adjusted spending: 
Episode: $25,409; 
Hospital inpatient services: $19,379; 
Average for initial admission: 
Price: $19,193; 
Days: 2.92. 

Rank: 57; 
MSA: Los Angeles-Long Beach-Santa Ana, CA; 
Average adjusted spending: 
Episode: $24,972; 
Hospital inpatient services: $19,558; 
Average for initial admission: 
Price: $19,380; 
Days: 2.66. 

Rank: 58; 
MSA: Springfield, MA; 
Average adjusted spending: 
Episode: $24,914; 
Hospital inpatient services: $19,062; 
Average for initial admission: 
Price: $18,964; 
Days: 3.37. 

Rank: 59; 
MSA: Oxnard-Thousand Oaks-Ventura, CA; 
Average adjusted spending: 
Episode: $24,908; 
Hospital inpatient services: $18,695; 
Average for initial admission: 
Price: $18,565; 
Days: 2.78. 

Rank: 60; 
MSA: Santa Rosa-Petaluma, CA; 
Average adjusted spending: 
Episode: $24,548; 
Hospital inpatient services: $17,284; 
Average for initial admission: 
Price: $17,284; 
Days: 2.78. 

Rank: 61; 
MSA: Las Vegas-Paradise, NV; 
Average adjusted spending: 
Episode: $24,490; 
Hospital inpatient services: $18,655; 
Average for initial admission: 
Price: $17,986; 
Days: 3.10. 

Rank: 62; 
MSA: Grand Rapids-Wyoming, MI; 
Average adjusted spending: 
Episode: $24,475; 
Hospital inpatient services: $19,899; 
Average for initial admission: 
Price: $19,580; 
Days: 2.76. 

Rank: 63; 
MSA: Rochester, NY[C]; 
Average adjusted spending: 
Episode: $24,365; 
Hospital inpatient services: $19,508; 
Average for initial admission: 
Price: $19,266; 
Days: 2.91. 

Rank: 64; 
MSA: Louisville-Jefferson County, KY-IN[C]; 
Average adjusted spending: 
Episode: $24,199; 
Hospital inpatient services: $19,258; 
Average for initial admission: 
Price: $19,155; 
Days: 2.84. 

Rank: 65; 
MSA: Allentown-Bethlehem-Easton, PA-NJ[C]; 
Average adjusted spending: 
Episode: $24,117; 
Hospital inpatient services: $18,181; 
Average for initial admission: 
Price: $17,938; 
Days: 3.00. 

Rank: 66; 
MSA: [B,C]; 
Average adjusted spending: 
Episode: $23,894; 
Hospital inpatient services: $17,750; 
Average for initial admission: 
Price: $17,457; 
Days: 2.85. 

Rank: 67; 
MSA: St. Louis, MO-IL[C]; 
Average adjusted spending: 
Episode: $23,816; 
Hospital inpatient services: $18,817; 
Average for initial admission: 
Price: $18,557; 
Days: 2.65. 

Rank: 68; 
MSA: Dayton, OH[C]; 
Average adjusted spending: 
Episode: $23,614; 
Hospital inpatient services: $18,820; 
Average for initial admission: 
Price: $18,670; 
Days: 2.80. 

Rank: 69; 
MSA: Riverside-San Bernardino-Ontario, CA[C]; 
Average adjusted spending: 
Episode: $23,361; 
Hospital inpatient services: $18,457; 
Average for initial admission: 
Price: $18,183; 
Days: 3.13. 

Rank: 70; 
MSA: [B,C]; 
Average adjusted spending: 
Episode: $23,314; 
Hospital inpatient services: $18,492; 
Average for initial admission: 
Price: $18,262; 
Days: 2.88. 

Rank: 71; 
MSA: Akron, OH[C]; 
Average adjusted spending: 
Episode: $23,100; 
Hospital inpatient services: $19,155; 
Average for initial admission: 
Price: $18,886; 
Days: 3.14. 

Rank: 72; 
MSA: Hartford-West Hartford-East Hartford, CT[C]; 
Average adjusted spending: 
Episode: $22,478; 
Hospital inpatient services: $16,600; 
Average for initial admission: 
Price: $16,388; 
Days: 2.86. 

Rank: 73; 
MSA: Lexington-Fayette, KY[C]; 
Average adjusted spending: 
Episode: $22,274; 
Hospital inpatient services: $17,646; 
Average for initial admission: 
Price: $17,646; 
Days: 2.75. 

Rank: 74; 
MSA: Toledo, OH[C]; 
Average adjusted spending: 
Episode: $22,242; 
Hospital inpatient services: $17,487; 
Average for initial admission: 
Price: $17,160; 
Days: 2.78. 

Rank: 75; 
MSA: Fresno, CA[C]; 
Average adjusted spending: 
Episode: $20,508; 
Hospital inpatient services: $16,380; 
Average for initial admission: 
Price: $16,352; 
Days: 2.04. 

Rank: 76; 
MSA: [B,C]; 
Average adjusted spending: 
Episode: $19,794; 
Hospital inpatient services: $14,410; 
Average for initial admission: 
Price: $14,243; 
Days: 3.09. 

Rank: 77; 
MSA: Birmingham-Hoover, AL[C]; 
Average adjusted spending: 
Episode: $19,166; 
Hospital inpatient services: $12,103; 
Average for initial admission: 
Price: $12,036; 
Days: 2.81. 

Rank: 78; 
MSA: Youngstown-Warren-Boardman, OH-PA[C]; 
Average adjusted spending: 
Episode: $19,164; 
Hospital inpatient services: $14,095; 
Average for initial admission: 
Price: $13,945; 
Days: 3.42. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 78 MSAs. We included all MSAs with a sufficient 
number of episodes to support our analyses for all three procedures. 
Spending and prices were adjusted to control for geographic 
differences in the cost of doing business and differences in 
demographics and health status of enrollees in each MSA. 

[A] MSA was in the highest-spending quintile. The 16 MSAs in the 
highest-spending quintile had an average of $30,570 in spending on 
hospital inpatient services. 

[B] MSA name withheld to protect the confidentiality of entities that 
contributed private data. 

[C] MSA was in the lowest-spending quintile. The 16 MSAs in the lowest-
spending quintile had an average of $17,323 in spending on hospital 
inpatient services. 

[End of table] 

[End of section] 

Appendix VI: Professional Services Spending and Other Information, by 
Metropolitan Statistical Area and Procedure: 

This appendix presents professional service spending, number of 
services, intensity, and price, by metropolitan statistical area 
(MSA), for each of the three high-cost procedures we analyzed--
coronary stent placement, Laparoscopic appendectomy, and Total hip 
replacement. 

Table 12: Professional Services Spending, Number of Services, 
Intensity, and Price, by Metropolitan Statistical Area (MSA), for 
Coronary Stent Placement Episodes: 

Rank: 1; 
MSA: Salinas, CA[A]; 
Average adjusted spending:
Episode: $60,375; 
Professional services: $4,454; 
Average for Professional services: 
Volume (number of services): 16.25; 
Intensity: 3.93; 
Price per unit of Intensity: 69.76. 

Rank: 2; 
MSA: [A,B]; 
Average adjusted spending:
Episode: $39,827; 
Professional services: $3,278; 
Average for Professional services: 
Volume (number of services): 14.22; 
Intensity: 4.02; 
Price per unit of Intensity: 57.34. 

Rank: 3; 
MSA: Charleston, WV[A]; 
Average adjusted spending:
Episode: $39,782; 
Professional services: $3,403; 
Average for Professional services: 
Volume (number of services): 15.28; 
Intensity: 5.04; 
Price per unit of Intensity: 44.16. 

Rank: 4; 
MSA: San Diego-Carlsbad-San Marcos, CA[A]; 
Average adjusted spending:
Episode: $39,683; 
Professional services: $4,481; 
Average for Professional services: 
Volume (number of services): 15.34; 
Intensity: 3.97; 
Price per unit of Intensity: 73.48. 

Rank: 5; 
MSA: Milwaukee-Waukesha-West Allis, WI[A]; 
Average adjusted spending:
Episode: $38,596; 
Professional services: $5,833; 
Average for Professional services: 
Volume (number of services): 14.65; 
Intensity: 3.93; 
Price per unit of Intensity: 101.21. 

Rank: 6; 
MSA: Albany-Schenectady-Troy, NY[A]; 
Average adjusted spending:
Episode: $38,305; 
Professional services: $2,614; 
Average for Professional services: 
Volume (number of services): 15.64; 
Intensity: 3.84; 
Price per unit of Intensity: 43.54. 

Rank: 7; 
MSA: Madison, WI[A]; 
Average adjusted spending:
Episode: $37,248; 
Professional services: $9,022; 
Average for Professional services: 
Volume (number of services): 11.60; 
Intensity: 4.18; 
Price per unit of Intensity: 186.03. 

Rank: 8; 
MSA: [A,B]; 
Average adjusted spending:
Episode: $36,858; 
Professional services: $3,422; 
Average for Professional services: 
Volume (number of services): 13.14; 
Intensity: 4.12; 
Price per unit of Intensity: 63.14. 

Rank: 9; 
MSA: Houston-Sugar Land-Baytown, TX[A]; 
Average adjusted spending:
Episode: $36,097; 
Professional services: $3,523; 
Average for Professional services: 
Volume (number of services): 16.80; 
Intensity: 3.87; 
Price per unit of Intensity: 54.13. 

Rank: 10; 
MSA: [A,B]; 
Average adjusted spending:
Episode: $35,478; 
Professional services: $3,054; 
Average for Professional services: 
Volume (number of services): 14.87; 
Intensity: 4.93; 
Price per unit of Intensity: 41.66. 

Rank: 11; 
MSA: Providence-New Bedford-Fall River, RI-MA[A]; 
Average adjusted spending:
Episode: $35,358; 
Professional services: $3,135; 
Average for Professional services: 
Volume (number of services): 17.87; 
Intensity: 3.53; 
Price per unit of Intensity: 49.67. 

Rank: 12; 
MSA: Seattle-Tacoma-Bellevue, WA[A]; 
Average adjusted spending:
Episode: $34,388; 
Professional services: $3,499; 
Average for Professional services: 
Volume (number of services): 10.37; 
Intensity: 3.71; 
Price per unit of Intensity: 91.05. 

Rank: 13; 
MSA: Fort Wayne, IN[A]; 
Average adjusted spending:
Episode: $34,307; 
Professional services: $3,373; 
Average for Professional services: 
Volume (number of services): 14.94; 
Intensity: 3.76; 
Price per unit of Intensity: 60.05. 

Rank: 14; 
MSA: Nashville-Davidson-Murfreesboro-Franklin, TN[A]; 
Average adjusted spending:
Episode: $34,258; 
Professional services: $3,356; 
Average for Professional services: 
Volume (number of services): 13.77; 
Intensity: 3.96; 
Price per unit of Intensity: 61.48. 

Rank: 15; 
MSA: [A,B]; 
Average adjusted spending:
Episode: $33,974; 
Professional services: $2,683; 
Average for Professional services: 
Volume (number of services): 11.22; 
Intensity: 4.43; 
Price per unit of Intensity: 53.92. 

Rank: 16; 
MSA: Allentown-Bethlehem-Easton, PA-NJ[A]; 
Average adjusted spending:
Episode: $33,398; 
Professional services: $3,117; 
Average for Professional services: 
Volume (number of services): 15.64; 
Intensity: 4.78; 
Price per unit of Intensity: 41.72. 

Rank: 17; 
MSA: Sacramento-Arden-Arcade-Roseville, CA; 
Average adjusted spending:
Episode: $32,807; 
Professional services: $4,006; 
Average for Professional services: 
Volume (number of services): 15.29; 
Intensity: 3.79; 
Price per unit of Intensity: 69.08. 

Rank: 18; 
MSA: Orlando-Kissimmee-Sanford, FL; 
Average adjusted spending:
Episode: $32,605; 
Professional services: $2,842; 
Average for Professional services: 
Volume (number of services): 15.88; 
Intensity: 3.90; 
Price per unit of Intensity: 45.93. 

Rank: 19; 
MSA: Tampa-St. Petersburg-Clearwater, FL; 
Average adjusted spending:
Episode: $32,156; 
Professional services: $2,765; 
Average for Professional services: 
Volume (number of services): 16.20; 
Intensity: 3.94; 
Price per unit of Intensity: 43.29. 

Rank: 20; 
MSA: Cape Coral-Fort Myers, FL; 
Average adjusted spending:
Episode: $32,143; 
Professional services: $3,020; 
Average for Professional services: 
Volume (number of services): 17.65; 
Intensity: 3.73; 
Price per unit of Intensity: 45.84. 

Rank: 21; 
MSA: Kansas City, MO-KS; 
Average adjusted spending:
Episode: $32,068; 
Professional services: $3,189; 
Average for Professional services: 
Volume (number of services): 14.34; 
Intensity: 3.98; 
Price per unit of Intensity: 55.90. 

Rank: 22; 
MSA: Raleigh-Cary, NC; 
Average adjusted spending:
Episode: $31,879; 
Professional services: $3,603; 
Average for Professional services: 
Volume (number of services): 14.89; 
Intensity: 4.07; 
Price per unit of Intensity: 59.49. 

Rank: 23; 
MSA: Dallas-Fort Worth-Arlington, TX; 
Average adjusted spending:
Episode: $31,847; 
Professional services: $3,021; 
Average for Professional services: 
Volume (number of services): 15.20; 
Intensity: 3.88; 
Price per unit of Intensity: 51.26. 

Rank: 24; 
MSA: San Jose-Sunnyvale-Santa Clara, CA; 
Average adjusted spending:
Episode: $31,797; 
Professional services: $4,464; 
Average for Professional services: 
Volume (number of services): 16.11; 
Intensity: 3.92; 
Price per unit of Intensity: 70.74. 

Rank: 25; 
MSA: Colorado Springs, CO; 
Average adjusted spending:
Episode: $31,017; 
Professional services: $2,902; 
Average for Professional services: 
Volume (number of services): 13.88; 
Intensity: 4.08; 
Price per unit of Intensity: 51.28. 

Rank: 26; 
MSA: [B]; 
Average adjusted spending:
Episode: $30,680; 
Professional services: $3,371; 
Average for Professional services: 
Volume (number of services): 16.00; 
Intensity: 4.83; 
Price per unit of Intensity: 43.58. 

Rank: 27; 
MSA: Memphis, TN-MS-AR; 
Average adjusted spending:
Episode: $30,607; 
Professional services: $4,178; 
Average for Professional services: 
Volume (number of services): 15.61; 
Intensity: 3.62; 
Price per unit of Intensity: 73.91. 

Rank: 28; 
MSA: [B]; 
Average adjusted spending:
Episode: $30,243; 
Professional services: $3,161; 
Average for Professional services: 
Volume (number of services): 14.67; 
Intensity: 3.74; 
Price per unit of Intensity: 57.67. 

Rank: 29; 
MSA: [B]; 
Average adjusted spending:
Episode: $30,156; 
Professional services: $4,544; 
Average for Professional services: 
Volume (number of services): 14.91; 
Intensity: 4.02; 
Price per unit of Intensity: 75.84. 

Rank: 30; 
MSA: Fresno, CA; 
Average adjusted spending:
Episode: $29,925; 
Professional services: $2,546; 
Average for Professional services: 
Volume (number of services): 15.63; 
Intensity: 3.96; 
Price per unit of Intensity: 41.08. 

Rank: 31; 
MSA: Grand Rapids-Wyoming, MI; 
Average adjusted spending:
Episode: $29,684; 
Professional services: $2,764; 
Average for Professional services: 
Volume (number of services): 14.31; 
Intensity: 3.80; 
Price per unit of Intensity: 50.83. 

Rank: 32; 
MSA: Philadelphia-Camden-Wilmington, PA-NJ-DE-MD; 
Average adjusted spending:
Episode: $29,489; 
Professional services: $2,899; 
Average for Professional services: 
Volume (number of services): 14.05; 
Intensity: 4.22; 
Price per unit of Intensity: 48.92. 

Rank: 33; 
MSA: [B]; 
Average adjusted spending:
Episode: $29,393; 
Professional services: $3,255; 
Average for Professional services: 
Volume (number of services): 13.94; 
Intensity: 3.89; 
Price per unit of Intensity: 60.06. 

Rank: 34; 
MSA: Ann Arbor, MI; 
Average adjusted spending:
Episode: $29,302; 
Professional services: $3,084; 
Average for Professional services: 
Volume (number of services): 16.60; 
Intensity: 3.67; 
Price per unit of Intensity: 50.59. 

Rank: 35; 
MSA: Denver-Aurora-Broomfield, CO; 
Average adjusted spending:
Episode: $28,698; 
Professional services: $3,157; 
Average for Professional services: 
Volume (number of services): 16.04; 
Intensity: 3.86; 
Price per unit of Intensity: 50.95. 

Rank: 36; 
MSA: Chicago-Joliet-Naperville, IL-IN-WI; 
Average adjusted spending:
Episode: $28,640; 
Professional services: $3,414; 
Average for Professional services: 
Volume (number of services): 16.08; 
Intensity: 3.94; 
Price per unit of Intensity: 53.85. 

Rank: 37; 
MSA: New York-Northern New Jersey-Long Island, NY-NJ-PA; 
Average adjusted spending:
Episode: $28,629; 
Professional services: $3,196; 
Average for Professional services: 
Volume (number of services): 15.31; 
Intensity: 3.93; 
Price per unit of Intensity: 53.15. 

Rank: 38; 
MSA: Lakeland-Winter Haven, FL; 
Average adjusted spending:
Episode: $28,607; 
Professional services: $3,538; 
Average for Professional services: 
Volume (number of services): 16.67; 
Intensity: 3.74; 
Price per unit of Intensity: 56.69. 

Rank: 39; 
MSA: Portland-Vancouver-Hillsboro, OR-WA; 
Average adjusted spending:
Episode: $28,553; 
Professional services: $4,179; 
Average for Professional services: 
Volume (number of services): 13.51; 
Intensity: 4.15; 
Price per unit of Intensity: 74.50. 

Rank: 40; 
MSA: Boston-Cambridge-Quincy, MA-NH; 
Average adjusted spending:
Episode: $28,474; 
Professional services: $3,648; 
Average for Professional services: 
Volume (number of services): 16.13; 
Intensity: 3.75; 
Price per unit of Intensity: 60.36. 

Rank: 41; 
MSA: [B]; 
Average adjusted spending:
Episode: $28,276; 
Professional services: $2,891; 
Average for Professional services: 
Volume (number of services): 15.47; 
Intensity: 3.82; 
Price per unit of Intensity: 48.88. 

Rank: 42; 
MSA: Santa Rosa-Petaluma, CA; 
Average adjusted spending:
Episode: $28,065; 
Professional services: $4,651; 
Average for Professional services: 
Volume (number of services): 16.24; 
Intensity: 3.82; 
Price per unit of Intensity: 75.05. 

Rank: 43; 
MSA: Huntington-Ashland, WV-KY-OH; 
Average adjusted spending:
Episode: $27,705; 
Professional services: $2,725; 
Average for Professional services: 
Volume (number of services): 15.73; 
Intensity: 4.08; 
Price per unit of Intensity: 42.42. 

Rank: 44; 
MSA: Detroit-Warren-Livonia, MI; 
Average adjusted spending:
Episode: $27,544; 
Professional services: $2,747; 
Average for Professional services: 
Volume (number of services): 17.27; 
Intensity: 3.67; 
Price per unit of Intensity: 43.28. 

Rank: 45; 
MSA: San Antonio-New Braunfels, TX; 
Average adjusted spending:
Episode: $27,489; 
Professional services: $2,688; 
Average for Professional services: 
Volume (number of services): 15.93; 
Intensity: 4.10; 
Price per unit of Intensity: 41.16. 

Rank: 46; 
MSA: New Orleans-Metairie-Kenner, LA; 
Average adjusted spending:
Episode: $27,480; 
Professional services: $3,324; 
Average for Professional services: 
Volume (number of services): 16.48; 
Intensity: 3.57; 
Price per unit of Intensity: 56.44. 

Rank: 47; 
MSA: Minneapolis-St. Paul-Bloomington, MN-WI; 
Average adjusted spending:
Episode: $27,308; 
Professional services: $4,788; 
Average for Professional services: 
Volume (number of services): 14.22; 
Intensity: 4.20; 
Price per unit of Intensity: 80.21. 

Rank: 48; 
MSA: Phoenix-Mesa-Glendale, AZ; 
Average adjusted spending:
Episode: $27,067; 
Professional services: $3,581; 
Average for Professional services: 
Volume (number of services): 15.22; 
Intensity: 4.33; 
Price per unit of Intensity: 54.31. 

Rank: 49; 
MSA: [B]; 
Average adjusted spending:
Episode: $26,746; 
Professional services: $2,991; 
Average for Professional services: 
Volume (number of services): 14.25; 
Intensity: 4.05; 
Price per unit of Intensity: 51.83. 

Rank: 50; 
MSA: [B]; 
Average adjusted spending:
Episode: $26,349; 
Professional services: $3,327; 
Average for Professional services: 
Volume (number of services): 15.23; 
Intensity: 3.51; 
Price per unit of Intensity: 62.27. 

Rank: 51; 
MSA: Rochester, NY; 
Average adjusted spending:
Episode: $25,523; 
Professional services: $2,587; 
Average for Professional services: 
Volume (number of services): 12.88; 
Intensity: 4.11; 
Price per unit of Intensity: 48.82. 

Rank: 52; 
MSA: Riverside-San Bernardino-Ontario, CA; 
Average adjusted spending:
Episode: $25,322; 
Professional services: $3,638; 
Average for Professional services: 
Volume (number of services): 15.48; 
Intensity: 4.16; 
Price per unit of Intensity: 56.53. 

Rank: 53; 
MSA: St. Louis, MO-IL; 
Average adjusted spending:
Episode: $25,288; 
Professional services: $2,982; 
Average for Professional services: 
Volume (number of services): 14.95; 
Intensity: 3.94; 
Price per unit of Intensity: 50.66. 

Rank: 54; 
MSA: Toledo, OH; 
Average adjusted spending:
Episode: $25,210; 
Professional services: $2,934; 
Average for Professional services: 
Volume (number of services): 14.42; 
Intensity: 3.95; 
Price per unit of Intensity: 51.58. 

Rank: 55; 
MSA: Cincinnati-Middletown, OH-KY-IN; 
Average adjusted spending:
Episode: $25,203; 
Professional services: $2,866; 
Average for Professional services: 
Volume (number of services): 15.18; 
Intensity: 3.90; 
Price per unit of Intensity: 48.42. 

Rank: 56; 
MSA: Albuquerque, NM; 
Average adjusted spending:
Episode: $25,015; 
Professional services: $3,264; 
Average for Professional services: 
Volume (number of services): 15.54; 
Intensity: 3.84; 
Price per unit of Intensity: 54.64. 

Rank: 57; 
MSA: Cleveland-Elyria-Mentor, OH; 
Average adjusted spending:
Episode: $24,914; 
Professional services: $3,004; 
Average for Professional services: 
Volume (number of services): 15.83; 
Intensity: 3.81; 
Price per unit of Intensity: 49.79. 

Rank: 58; 
MSA: Shreveport-Bossier City, LA; 
Average adjusted spending:
Episode: $24,848; 
Professional services: $4,818; 
Average for Professional services: 
Volume (number of services): 14.10; 
Intensity: 4.16; 
Price per unit of Intensity: 82.16. 

Rank: 59; 
MSA: [B]; 
Average adjusted spending:
Episode: $24,753; 
Professional services: $3,610; 
Average for Professional services: 
Volume (number of services): 12.93; 
Intensity: 4.29; 
Price per unit of Intensity: 65.07. 

Rank: 60; 
MSA: Columbus, OH; 
Average adjusted spending:
Episode: $24,310; 
Professional services: $2,476; 
Average for Professional services: 
Volume (number of services): 14.71; 
Intensity: 3.79; 
Price per unit of Intensity: 44.37. 

Rank: 61; 
MSA: Tulsa, OK; 
Average adjusted spending:
Episode: $24,088; 
Professional services: $2,990; 
Average for Professional services: 
Volume (number of services): 14.24; 
Intensity: 4.07; 
Price per unit of Intensity: 51.54. 

Rank: 62; 
MSA: [B]; 
Average adjusted spending:
Episode: $23,938; 
Professional services: $3,753; 
Average for Professional services: 
Volume (number of services): 11.93; 
Intensity: 4.44; 
Price per unit of Intensity: 70.79. 

Rank: 63; 
MSA: Knoxville, TN[C]; 
Average adjusted spending:
Episode: $23,935; 
Professional services: $4,027; 
Average for Professional services: 
Volume (number of services): 16.27; 
Intensity: 3.62; 
Price per unit of Intensity: 68.31. 

Rank: 64; 
MSA: [B,C]; 
Average adjusted spending:
Episode: $23,647; 
Professional services: $2,907; 
Average for Professional services: 
Volume (number of services): 17.21; 
Intensity: 4.70; 
Price per unit of Intensity: 35.90. 

Rank: 65; 
MSA: Bridgeport-Stamford-Norwalk, CT[C]; 
Average adjusted spending:
Episode: $23,135; 
Professional services: $3,248; 
Average for Professional services: 
Volume (number of services): 14.58; 
Intensity: 3.99; 
Price per unit of Intensity: 55.80. 

Rank: 66; 
MSA: Los Angeles-Long Beach-Santa Ana, CA[C]; 
Average adjusted spending:
Episode: $22,768; 
Professional services: $3,207; 
Average for Professional services: 
Volume (number of services): 15.49; 
Intensity: 3.91; 
Price per unit of Intensity: 53.00. 

Rank: 67; 
MSA: Savannah, GA[C]; 
Average adjusted spending:
Episode: $22,585; 
Professional services: $3,274; 
Average for Professional services: 
Volume (number of services): 13.78; 
Intensity: 4.13; 
Price per unit of Intensity: 57.51. 

Rank: 68; 
MSA: Hartford-West Hartford-East Hartford, CT[C]; 
Average adjusted spending:
Episode: $22,357; 
Professional services: $3,276; 
Average for Professional services: 
Volume (number of services): 16.07; 
Intensity: 3.65; 
Price per unit of Intensity: 55.83. 

Rank: 69; 
MSA: Dayton, OH[C]; 
Average adjusted spending:
Episode: $22,073; 
Professional services: $2,661; 
Average for Professional services: 
Volume (number of services): 15.17; 
Intensity: 4.02; 
Price per unit of Intensity: 43.64. 

Rank: 70; 
MSA: Oxnard-Thousand Oaks-Ventura, CA[C]; 
Average adjusted spending:
Episode: $22,023; 
Professional services: $3,465; 
Average for Professional services: 
Volume (number of services): 15.30; 
Intensity: 4.26; 
Price per unit of Intensity: 53.18. 

Rank: 71; 
MSA: Springfield, MA[C]; 
Average adjusted spending:
Episode: $21,937; 
Professional services: $3,593; 
Average for Professional services: 
Volume (number of services): 20.95; 
Intensity: 3.14; 
Price per unit of Intensity: 54.70. 

Rank: 72; 
MSA: [B,C]; 
Average adjusted spending:
Episode: $21,664; 
Professional services: $2,712; 
Average for Professional services: 
Volume (number of services): 16.72; 
Intensity: 4.90; 
Price per unit of Intensity: 33.10. 

Rank: 73; 
MSA: Akron, OH[C]; 
Average adjusted spending:
Episode: $21,664; 
Professional services: $2,506; 
Average for Professional services: 
Volume (number of services): 15.31; 
Intensity: 3.74; 
Price per unit of Intensity: 43.72. 

Rank: 74; 
MSA: Las Vegas-Paradise, NV[C]; 
Average adjusted spending:
Episode: $20,969; 
Professional services: $3,019; 
Average for Professional services: 
Volume (number of services): 20.50; 
Intensity: 3.61; 
Price per unit of Intensity: 40.78. 

Rank: 75; 
MSA: Lexington-Fayette, KY[C]; 
Average adjusted spending:
Episode: $20,602; 
Professional services: $2,140; 
Average for Professional services: 
Volume (number of services): 13.11; 
Intensity: 3.97; 
Price per unit of Intensity: 41.06. 

Rank: 76; 
MSA: Youngstown-Warren-Boardman, OH-PA[C]; 
Average adjusted spending:
Episode: $18,829; 
Professional services: $2,677; 
Average for Professional services: 
Volume (number of services): 18.54; 
Intensity: 3.97; 
Price per unit of Intensity: 36.34. 

Rank: 77; 
MSA: Louisville-Jefferson County, KY-IN[C]; 
Average adjusted spending:
Episode: $18,677; 
Professional services: $2,534; 
Average for Professional services: 
Volume (number of services): 17.94; 
Intensity: 3.62; 
Price per unit of Intensity: 38.97. 

Rank: 78; 
MSA: Birmingham-Hoover, AL[C]; 
Average adjusted spending:
Episode: $17,768; 
Professional services: $4,339; 
Average for Professional services: 
Volume (number of services): 14.59; 
Intensity: 4.27; 
Price per unit of Intensity: 69.64. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 78 MSAs. We included all MSAs with a sufficient 
number of episodes to support our analyses for all three procedures. 
Spending, volume, and intensity were adjusted to control for 
differences in demographics and health status of enrollees in each 
MSA; spending was also adjusted for geographic differences in the cost 
of doing business. Intensity was measured by the relative value unit 
(RVU) assigned to each service. 

[A] MSA was in the highest-spending quintile. The 16 MSAs in the 
highest-spending quintile had an average of $3,890 in spending on 
professional services. For those professional services, the 16 MSAs 
had an average of 14.48 services, average intensity of 4.13, and 
average price per unit of intensity of $68.27. 

[B] MSA name withheld to protect the confidentiality of entities that 
contributed private data. 

[C] MSA was in the lowest-spending quintile. The 16 MSAs in the lowest-
spending quintile had an average of $3,099 in spending on professional 
services. For those professional services, the 16 MSAs had an average 
of 16.35 services, average intensity of 3.97, and average price per 
unit of intensity of $48.84. 

[End of table] 

Table 13: Professional Services Spending, Number of Services, 
Intensity, and Price, by Metropolitan Statistical Area (MSA), for 
Laparoscopic Appendectomy Episodes: 

Rank: 1; 
MSA: Salinas, CA[A]; 
Average adjusted spending: 
Episode: $25,924; 
Professional services: $2,106; 
Average for professional services: 
Volume (number of services): 5.06; 
Intensity: 5.51; 
Price per unit of Intensity: 75.59. 

Rank: 2; 
MSA: Madison, WI[A]; 
Average adjusted spending: 
Episode: $18,123; 
Professional services: $4,090; 
Average for professional services: 
Volume (number of services): 4.45; 
Intensity: 5.67; 
Price per unit of Intensity: 161.98. 

Rank: 3; 
MSA: Milwaukee-Waukesha-West Allis, WI[A]; 
Average adjusted spending: 
Episode: $18,096; 
Professional services: $3,752; 
Average for professional services: 
Volume (number of services): 4.68; 
Intensity: 5.77; 
Price per unit of Intensity: 138.82. 

Rank: 4; 
MSA: Charleston, WV[A]; 
Average adjusted spending: 
Episode: $17,640; 
Professional services: $2,632; 
Average for professional services: 
Volume (number of services): 4.16; 
Intensity: 6.45; 
Price per unit of Intensity: 98.06. 

Rank: 5; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $16,588; 
Professional services: $2,613; 
Average for professional services: 
Volume (number of services): 4.75; 
Intensity: 5.77; 
Price per unit of Intensity: 95.28. 

Rank: 6; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $16,323; 
Professional services: $2,104; 
Average for professional services: 
Volume (number of services): 3.53; 
Intensity: 6.51; 
Price per unit of Intensity: 91.45. 

Rank: 7; 
MSA: Grand Rapids-Wyoming, MI[A]; 
Average adjusted spending: 
Episode: $15,444; 
Professional services: $2,058; 
Average for professional services: 
Volume (number of services): 4.54; 
Intensity: 6.42; 
Price per unit of Intensity: 70.67. 

Rank: 8; 
MSA: Colorado Springs, CO[A]; 
Average adjusted spending: 
Episode: $15,318; 
Professional services: $4,054; 
Average for professional services: 
Volume (number of services): 4.38; 
Intensity: 5.95; 
Price per unit of Intensity: 155.40. 

Rank: 9; 
MSA: Orlando-Kissimmee-Sanford, FL[A]; 
Average adjusted spending: 
Episode: $15,267; 
Professional services: $2,423; 
Average for professional services: 
Volume (number of services): 5.20; 
Intensity: 5.77; 
Price per unit of Intensity: 80.79. 

Rank: 10; 
MSA: San Diego-Carlsbad-San Marcos, CA[A]; 
Average adjusted spending: 
Episode: $14,859; 
Professional services: $3,130; 
Average for professional services: 
Volume (number of services): 5.19; 
Intensity: 5.64; 
Price per unit of Intensity: 106.89. 

Rank: 11; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $14,761; 
Professional services: $1,999; 
Average for professional services: 
Volume (number of services): 4.03; 
Intensity: 6.31; 
Price per unit of Intensity: 78.63. 

Rank: 12; 
MSA: Lakeland-Winter Haven, FL[A]; 
Average adjusted spending: 
Episode: $14,678; 
Professional services: $2,873; 
Average for professional services: 
Volume (number of services): 5.22; 
Intensity: 6.11; 
Price per unit of Intensity: 89.99. 

Rank: 13; 
MSA: Seattle-Tacoma-Bellevue, WA[A]; 
Average adjusted spending: 
Episode: $14,644; 
Professional services: $2,814; 
Average for professional services: 
Volume (number of services): 4.13; 
Intensity: 5.17; 
Price per unit of Intensity: 131.72. 

Rank: 14; 
MSA: Fort Wayne, IN[A]; 
Average adjusted spending: 
Episode: $14,543; 
Professional services: $2,178; 
Average for professional services: 
Volume (number of services): 4.37; 
Intensity: 6.02; 
Price per unit of Intensity: 82.70. 

Rank: 15; 
MSA: Columbus, OH[A]; 
Average adjusted spending: 
Episode: $14,478; 
Professional services: $2,153; 
Average for professional services: 
Volume (number of services): 4.80; 
Intensity: 5.62; 
Price per unit of Intensity: 79.83. 

Rank: 16; 
MSA: Portland-Vancouver-Hillsboro, OR-WA[A]; 
Average adjusted spending: 
Episode: $14,337; 
Professional services: $2,644; 
Average for professional services: 
Volume (number of services): 4.63; 
Intensity: 5.68; 
Price per unit of Intensity: 100.45. 

Rank: 17; 
MSA: Nashville-Davidson-Murfreesboro-Franklin, TN; 
Average adjusted spending: 
Episode: $14,335; 
Professional services: $2,831; 
Average for professional services: 
Volume (number of services): 4.87; 
Intensity: 5.75; 
Price per unit of Intensity: 100.97. 

Rank: 18; 
MSA: Cape Coral-Fort Myers, FL; 
Average adjusted spending: 
Episode: $14,327; 
Professional services: $2,445; 
Average for professional services: 
Volume (number of services): 5.55; 
Intensity: 5.88; 
Price per unit of Intensity: 74.89. 

Rank: 19; 
MSA: [B]; 
Average adjusted spending: 
Episode: $14,115; 
Professional services: $2,196; 
Average for professional services: 
Volume (number of services): 3.45; 
Intensity: 6.44; 
Price per unit of Intensity: 99.00. 

Rank: 20; 
MSA: [B]; 
Average adjusted spending: 
Episode: $14,042; 
Professional services: $2,273; 
Average for professional services: 
Volume (number of services): 5.08; 
Intensity: 5.40; 
Price per unit of Intensity: 82.86. 

Rank: 21; 
MSA: Ann Arbor, MI; 
Average adjusted spending: 
Episode: $13,986; 
Professional services: $1,969; 
Average for professional services: 
Volume (number of services): 5.05; 
Intensity: 5.67; 
Price per unit of Intensity: 68.82. 

Rank: 22; 
MSA: [B]; 
Average adjusted spending: 
Episode: $13,933; 
Professional services: $2,508; 
Average for professional services: 
Volume (number of services): 4.40; 
Intensity: 6.16; 
Price per unit of Intensity: 92.51. 

Rank: 23; 
MSA: Akron, OH; 
Average adjusted spending: 
Episode: $13,788; 
Professional services: $2,177; 
Average for professional services: 
Volume (number of services): 5.66; 
Intensity: 5.21; 
Price per unit of Intensity: 73.83. 

Rank: 24; 
MSA: Allentown-Bethlehem-Easton, PA-NJ; 
Average adjusted spending: 
Episode: $13,634; 
Professional services: $2,095; 
Average for professional services: 
Volume (number of services): 6.16; 
Intensity: 4.76; 
Price per unit of Intensity: 71.40. 

Rank: 25; 
MSA: Tampa-St. Petersburg-Clearwater, FL; 
Average adjusted spending: 
Episode: $13,374; 
Professional services: $2,761; 
Average for professional services: 
Volume (number of services): 6.23; 
Intensity: 5.19; 
Price per unit of Intensity: 85.26. 

Rank: 26; 
MSA: Dayton, OH; 
Average adjusted spending: 
Episode: $12,973; 
Professional services: $2,449; 
Average for professional services: 
Volume (number of services): 5.40; 
Intensity: 5.55; 
Price per unit of Intensity: 81.69. 

Rank: 27; 
MSA: Huntington-Ashland, WV-KY-OH; 
Average adjusted spending: 
Episode: $12,897; 
Professional services: $2,229; 
Average for professional services: 
Volume (number of services): 4.72; 
Intensity: 5.95; 
Price per unit of Intensity: 79.30. 

Rank: 28; 
MSA: Detroit-Warren-Livonia, MI; 
Average adjusted spending: 
Episode: $12,879; 
Professional services: $1,801; 
Average for professional services: 
Volume (number of services): 5.07; 
Intensity: 5.40; 
Price per unit of Intensity: 65.82. 

Rank: 29; 
MSA: Sacramento-Arden-Arcade-Roseville, CA; 
Average adjusted spending: 
Episode: $12,862; 
Professional services: $3,257; 
Average for professional services: 
Volume (number of services): 5.09; 
Intensity: 5.56; 
Price per unit of Intensity: 115.17. 

Rank: 30; 
MSA: Chicago-Joliet-Naperville, IL-IN-WI; 
Average adjusted spending: 
Episode: $12,800; 
Professional services: $2,377; 
Average for professional services: 
Volume (number of services): 5.44; 
Intensity: 5.53; 
Price per unit of Intensity: 79.13. 

Rank: 31; 
MSA: Kansas City, MO-KS; 
Average adjusted spending: 
Episode: $12,596; 
Professional services: $2,436; 
Average for professional services: 
Volume (number of services): 5.92; 
Intensity: 5.34; 
Price per unit of Intensity: 77.04. 

Rank: 32; 
MSA: Cincinnati-Middletown, OH-KY-IN; 
Average adjusted spending: 
Episode: $12,571; 
Professional services: $2,365; 
Average for professional services: 
Volume (number of services): 4.85; 
Intensity: 5.77; 
Price per unit of Intensity: 84.40. 

Rank: 33; 
MSA: Minneapolis-St. Paul-Bloomington, MN-WI; 
Average adjusted spending: 
Episode: $12,477; 
Professional services: $2,951; 
Average for professional services: 
Volume (number of services): 5.50; 
Intensity: 5.20; 
Price per unit of Intensity: 103.29. 

Rank: 34; 
MSA: Dallas-Fort Worth-Arlington, TX; 
Average adjusted spending: 
Episode: $12,413; 
Professional services: $2,854; 
Average for professional services: 
Volume (number of services): 4.69; 
Intensity: 5.86; 
Price per unit of Intensity: 103.99. 

Rank: 35; 
MSA: Raleigh-Cary, NC; 
Average adjusted spending: 
Episode: $12,403; 
Professional services: $2,803; 
Average for professional services: 
Volume (number of services): 4.56; 
Intensity: 6.07; 
Price per unit of Intensity: 101.15. 

Rank: 36; 
MSA: Providence-New Bedford-Fall River, RI-MA; 
Average adjusted spending: 
Episode: $12,394; 
Professional services: $2,309; 
Average for professional services: 
Volume (number of services): 5.01; 
Intensity: 5.43; 
Price per unit of Intensity: 84.84. 

Rank: 37; 
MSA: [B]; 
Average adjusted spending: 
Episode: $12,358; 
Professional services: $2,107; 
Average for professional services: 
Volume (number of services): 3.41; 
Intensity: 6.92; 
Price per unit of Intensity: 89.23. 

Rank: 38; 
MSA: [B]; 
Average adjusted spending: 
Episode: $12,336; 
Professional services: $2,379; 
Average for professional services: 
Volume (number of services): 4.20; 
Intensity: 6.29; 
Price per unit of Intensity: 90.21. 

Rank: 39; 
MSA: New York-Northern New Jersey-Long Island, NY-NJ-PA; 
Average adjusted spending: 
Episode: $12,252; 
Professional services: $4,250; 
Average for professional services: 
Volume (number of services): 5.77; 
Intensity: 5.22; 
Price per unit of Intensity: 141.25. 

Rank: 40; 
MSA: Shreveport-Bossier City, LA; 
Average adjusted spending: 
Episode: $12,011; 
Professional services: $3,008; 
Average for professional services: 
Volume (number of services): 5.09; 
Intensity: 5.49; 
Price per unit of Intensity: 107.60. 

Rank: 41; 
MSA: Birmingham-Hoover, AL; 
Average adjusted spending: 
Episode: $11,960; 
Professional services: $2,835; 
Average for professional services: 
Volume (number of services): 4.29; 
Intensity: 6.05; 
Price per unit of Intensity: 109.22. 

Rank: 42; 
MSA: [B]; 
Average adjusted spending: 
Episode: $11,851; 
Professional services: $2,172; 
Average for professional services: 
Volume (number of services): 6.21; 
Intensity: 4.97; 
Price per unit of Intensity: 70.38. 

Rank: 43; 
MSA: Houston-Sugar Land-Baytown, TX; 
Average adjusted spending: 
Episode: $11,496; 
Professional services: $2,492; 
Average for professional services: 
Volume (number of services): 4.93; 
Intensity: 5.68; 
Price per unit of Intensity: 88.96. 

Rank: 44; 
MSA: Boston-Cambridge-Quincy, MA-NH; 
Average adjusted spending: 
Episode: $11,417; 
Professional services: $2,777; 
Average for professional services: 
Volume (number of services): 4.67; 
Intensity: 5.76; 
Price per unit of Intensity: 103.22. 

Rank: 45; 
MSA: Phoenix-Mesa-Glendale, AZ; 
Average adjusted spending: 
Episode: $11,403; 
Professional services: $3,194; 
Average for professional services: 
Volume (number of services): 6.37; 
Intensity: 5.14; 
Price per unit of Intensity: 97.47. 

Rank: 46; 
MSA: Philadelphia-Camden-Wilmington, PA-NJ-DE-MD; 
Average adjusted spending: 
Episode: $11,351; 
Professional services: $2,266; 
Average for professional services: 
Volume (number of services): 5.08; 
Intensity: 5.54; 
Price per unit of Intensity: 80.53. 

Rank: 47; 
MSA: Tulsa, OK; 
Average adjusted spending: 
Episode: $11,314; 
Professional services: $2,050; 
Average for professional services: 
Volume (number of services): 3.51; 
Intensity: 7.21; 
Price per unit of Intensity: 81.08. 

Rank: 48; 
MSA: Rochester, NY; 
Average adjusted spending: 
Episode: $11,144; 
Professional services: $2,456; 
Average for professional services: 
Volume (number of services): 4.13; 
Intensity: 6.32; 
Price per unit of Intensity: 94.11. 

Rank: 49; 
MSA: Cleveland-Elyria-Mentor, OH; 
Average adjusted spending: 
Episode: $11,078; 
Professional services: $2,300; 
Average for professional services: 
Volume (number of services): 4.54; 
Intensity: 5.95; 
Price per unit of Intensity: 85.17. 

Rank: 50; 
MSA: [B]; 
Average adjusted spending: 
Episode: $11,037; 
Professional services: $1,975; 
Average for professional services: 
Volume (number of services): 5.44; 
Intensity: 5.31; 
Price per unit of Intensity: 68.36. 

Rank: 51; 
MSA: Springfield, MA; 
Average adjusted spending: 
Episode: $10,958; 
Professional services: $2,660; 
Average for professional services: 
Volume (number of services): 4.73; 
Intensity: 5.82; 
Price per unit of Intensity: 96.57. 

Rank: 52; 
MSA: Lexington-Fayette, KY; 
Average adjusted spending: 
Episode: $10,831; 
Professional services: $1,910; 
Average for professional services: 
Volume (number of services): 4.64; 
Intensity: 5.86; 
Price per unit of Intensity: 70.23. 

Rank: 53; 
MSA: Bridgeport-Stamford-Norwalk, CT; 
Average adjusted spending: 
Episode: $10,821; 
Professional services: $2,941; 
Average for professional services: 
Volume (number of services): 5.16; 
Intensity: 5.30; 
Price per unit of Intensity: 107.53. 

Rank: 54; 
MSA: [B]; 
Average adjusted spending: 
Episode: $10,775; 
Professional services: $1,613; 
Average for professional services: 
Volume (number of services): 3.72; 
Intensity: 5.99; 
Price per unit of Intensity: 72.42. 

Rank: 55; 
MSA: Louisville-Jefferson County, KY-IN; 
Average adjusted spending: 
Episode: $10,771; 
Professional services: $1,929; 
Average for professional services: 
Volume (number of services): 4.88; 
Intensity: 5.90; 
Price per unit of Intensity: 67.05. 

Rank: 56; 
MSA: [B]; 
Average adjusted spending: 
Episode: $10,766; 
Professional services: $2,139; 
Average for professional services: 
Volume (number of services): 6.44; 
Intensity: 8.49; 
Price per unit of Intensity: 39.14. 

Rank: 57; 
MSA: New Orleans-Metairie-Kenner, LA; 
Average adjusted spending: 
Episode: $10,695; 
Professional services: $2,563; 
Average for professional services: 
Volume (number of services): 5.16; 
Intensity: 5.44; 
Price per unit of Intensity: 91.40. 

Rank: 58; 
MSA: Toledo, OH; 
Average adjusted spending: 
Episode: $10,693; 
Professional services: $2,285; 
Average for professional services: 
Volume (number of services): 6.37; 
Intensity: 4.87; 
Price per unit of Intensity: 73.61. 

Rank: 59; 
MSA: [B]; 
Average adjusted spending: 
Episode: $10,470; 
Professional services: $3,041; 
Average for professional services: 
Volume (number of services): 5.08; 
Intensity: 5.53; 
Price per unit of Intensity: 108.20. 

Rank: 60; 
MSA: Denver-Aurora-Broomfield, CO; 
Average adjusted spending: 
Episode: $10,372; 
Professional services: $3,043; 
Average for professional services: 
Volume (number of services): 4.96; 
Intensity: 5.46; 
Price per unit of Intensity: 112.29. 

Rank: 61; 
MSA: Los Angeles-Long Beach-Santa Ana, CA; 
Average adjusted spending: 
Episode: $10,351; 
Professional services: $3,020; 
Average for professional services: 
Volume (number of services): 6.21; 
Intensity: 5.03; 
Price per unit of Intensity: 96.65. 

Rank: 62; 
MSA: Memphis, TN-MS-AR; 
Average adjusted spending: 
Episode: $10,191; 
Professional services: $3,122; 
Average for professional services: 
Volume (number of services): 4.86; 
Intensity: 5.95; 
Price per unit of Intensity: 107.95. 

Rank: 63; 
MSA: San Antonio-New Braunfels, TX[C]; 
Average adjusted spending: 
Episode: $10,163; 
Professional services: $2,364; 
Average for professional services: 
Volume (number of services): 5.27; 
Intensity: 5.41; 
Price per unit of Intensity: 82.85. 

Rank: 64; 
MSA: [B,C]; 
Average adjusted spending: 
Episode: $10,116; 
Professional services: $2,828; 
Average for professional services: 
Volume (number of services): 3.91; 
Intensity: 6.10; 
Price per unit of Intensity: 118.54. 

Rank: 65; 
MSA: Riverside-San Bernardino-Ontario, CA[C]; 
Average adjusted spending: 
Episode: $10,108; 
Professional services: $2,907; 
Average for professional services: 
Volume (number of services): 5.48; 
Intensity: 5.26; 
Price per unit of Intensity: 100.73. 

Rank: 66; 
MSA: Knoxville, TN[C]; 
Average adjusted spending: 
Episode: $9,887; 
Professional services: $2,820; 
Average for professional services: 
Volume (number of services): 5.30; 
Intensity: 5.21; 
Price per unit of Intensity: 102.16. 

Rank: 67; 
MSA: Hartford-West Hartford-East Hartford, CT[C]; 
Average adjusted spending: 
Episode: $9,304; 
Professional services: $2,726; 
Average for professional services: 
Volume (number of services): 4.59; 
Intensity: 5.83; 
Price per unit of Intensity: 101.79. 

Rank: 68; 
MSA: Savannah, GA[C]; 
Average adjusted spending: 
Episode: $9,281; 
Professional services: $2,388; 
Average for professional services: 
Volume (number of services): 4.33; 
Intensity: 6.13; 
Price per unit of Intensity: 90.02. 

Rank: 69; 
MSA: Albany-Schenectady-Troy, NY[C]; 
Average adjusted spending: 
Episode: $8,922; 
Professional services: $2,338; 
Average for professional services: 
Volume (number of services): 4.90; 
Intensity: 5.96; 
Price per unit of Intensity: 80.11. 

Rank: 70; 
MSA: [B,C]; 
Average adjusted spending: 
Episode: $8,880; 
Professional services: $1,924; 
Average for professional services: 
Volume (number of services): 6.14; 
Intensity: 5.14; 
Price per unit of Intensity: 60.98. 

Rank: 71; 
MSA: San Jose-Sunnyvale-Santa Clara, CA[C]; 
Average adjusted spending: 
Episode: $8,848; 
Professional services: $3,273; 
Average for professional services: 
Volume (number of services): 5.54; 
Intensity: 5.19; 
Price per unit of Intensity: 113.79. 

Rank: 72; 
MSA: Youngstown-Warren-Boardman, OH-PA[C]; 
Average adjusted spending: 
Episode: $8,747; 
Professional services: $1,765; 
Average for professional services: 
Volume (number of services): 5.33; 
Intensity: 5.34; 
Price per unit of Intensity: 62.06. 

Rank: 73; 
MSA: Santa Rosa-Petaluma, CA[C]; 
Average adjusted spending: 
Episode: $8,618; 
Professional services: $2,780; 
Average for professional services: 
Volume (number of services): 5.38; 
Intensity: 5.43; 
Price per unit of Intensity: 95.23. 

Rank: 74; 
MSA: Oxnard-Thousand Oaks-Ventura, CA[C]; 
Average adjusted spending: 
Episode: $7,993; 
Professional services: $2,449; 
Average for professional services: 
Volume (number of services): 6.21; 
Intensity: 4.96; 
Price per unit of Intensity: 79.43. 

Rank: 75; 
MSA: Albuquerque, NM[C]; 
Average adjusted spending: 
Episode: $7,989; 
Professional services: $2,631; 
Average for professional services: 
Volume (number of services): 4.73; 
Intensity: 5.68; 
Price per unit of Intensity: 98.04. 

Rank: 76; 
MSA: Las Vegas-Paradise, NV[C]; 
Average adjusted spending: 
Episode: $7,773; 
Professional services: $2,982; 
Average for professional services: 
Volume (number of services): 6.54; 
Intensity: 5.09; 
Price per unit of Intensity: 89.66. 

Rank: 77; 
MSA: St. Louis, MO-IL[C]; 
Average adjusted spending: 
Episode: $7,698; 
Professional services: $2,448; 
Average for professional services: 
Volume (number of services): 4.97; 
Intensity: 5.58; 
Price per unit of Intensity: 88.14. 

Rank: 78; 
MSA: Fresno, CA[C]; 
Average adjusted spending: 
Episode: $7,096; 
Professional services: $1,935; 
Average for professional services: 
Volume (number of services): 5.01; 
Intensity: 5.65; 
Price per unit of Intensity: 68.30. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 78 MSAs. We included all MSAs with a sufficient 
number of episodes to support our analyses for all three procedures. 
Spending, volume, and intensity were adjusted to control for 
differences in demographics and health status of enrollees in each 
MSA; spending was also adjusted for geographic differences in the cost 
of doing business. Intensity was measured by the relative value unit 
(RVU) assigned to each service. 

[A] MSA was in the highest-spending quintile. The 16 MSAs in the 
highest-spending quintile had an average of $2,726 in spending on 
professional services. For those professional services, the 16 MSAs 
had an average of 4.57 services, average intensity of 5.90, and 
average price per unit of intensity of $102.39. 

[B] MSA name withheld to protect the confidentiality of entities that 
contributed private data. 

[C] MSA was in the lowest-spending quintile. The 16 MSAs in the lowest-
spending quintile had an average of $2,535 in spending on professional 
services. For those professional services, the 16 MSAs had an average 
of 5.23 services, average intensity of 5.50, and average price per 
unit of intensity of $89.49. 

[End of table] 

Table 14: Professional Services Spending, Number of Services, 
Intensity, and Price, by Metropolitan Statistical Area (MSA), for 
Total Hip Replacement Episodes: 

Rank: 1; 
MSA: Salinas, CA[A]; 
Average adjusted spending: 
Episode: $57,990; 
Professional services: $4,048; 
Average for professional services: 
Volume (number of services): 8.30; 
Intensity: 6.52; 
Price per unit of intensity: $74.72. 

Rank: 2; 
MSA: Dallas-Fort Worth-Arlington, TX[A]; 
Average adjusted spending: 
Episode: $41,129; 
Professional services: $4,181; 
Average for professional services: 
Volume (number of services): 8.35; 
Intensity: 6.68; 
Price per unit of intensity: $74.91. 

Rank: 3; 
MSA: San Diego-Carlsbad-San Marcos, CA[A]; 
Average adjusted spending: 
Episode: $37,906; 
Professional services: $5,450; 
Average for professional services: 
Volume (number of services): 8.74; 
Intensity: 6.38; 
Price per unit of intensity: $97.81. 

Rank: 4; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $37,669; 
Professional services: $4,792; 
Average for professional services: 
Volume (number of services): 13.05; 
Intensity: 4.89; 
Price per unit of intensity: $75.05. 

Rank: 5; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $36,936; 
Professional services: $4,450; 
Average for professional services: 
Volume (number of services): 6.78; 
Intensity: 7.49; 
Price per unit of intensity: $87.72. 

Rank: 6; 
MSA: Madison, WI[A]; 
Average adjusted spending: 
Episode: $36,258; 
Professional services: $9,794; 
Average for professional services: 
Volume (number of services): 5.11; 
Intensity: 9.47; 
Price per unit of intensity: $202.36. 

Rank: 7; 
MSA: Milwaukee-Waukesha-West Allis, WI[A]; 
Average adjusted spending: 
Episode: $35,963; 
Professional services: $6,774; 
Average for professional services: 
Volume (number of services): 6.67; 
Intensity: 7.78; 
Price per unit of intensity: $130.68. 

Rank: 8; 
MSA: New York-Northern New Jersey-Long Island, NY-NJ-PA[A]; 
Average adjusted spending: 
Episode: $35,682; 
Professional services: $7,839; 
Average for professional services: 
Volume (number of services): 14.23; 
Intensity: 4.46; 
Price per unit of intensity: $123.44. 

Rank: 9; 
MSA: Houston-Sugar Land-Baytown, TX[A]; 
Average adjusted spending: 
Episode: $35,332; 
Professional services: $5,003; 
Average for professional services: 
Volume (number of services): 10.08; 
Intensity: 5.92; 
Price per unit of intensity: $83.92. 

Rank: 10; 
MSA: San Antonio-New Braunfels, TX[A]; 
Average adjusted spending: 
Episode: $35,319; 
Professional services: $4,099; 
Average for professional services: 
Volume (number of services): 15.03; 
Intensity: 4.03; 
Price per unit of intensity: $67.62. 

Rank: 11; 
MSA: Fort Wayne, IN[A]; 
Average adjusted spending: 
Episode: $34,711; 
Professional services: $3,978; 
Average for professional services: 
Volume (number of services): 4.84; 
Intensity: 10.07; 
Price per unit of intensity: $81.70. 

Rank: 12; 
MSA: Sacramento-Arden-Arcade-Roseville, CA[A]; 
Average adjusted spending: 
Episode: $34,420; 
Professional services: $4,741; 
Average for professional services: 
Volume (number of services): 7.12; 
Intensity: 7.76; 
Price per unit of intensity: $85.80. 

Rank: 13; 
MSA: Nashville-Davidson-Murfreesboro-Franklin, TN[A]; 
Average adjusted spending: 
Episode: $34,311; 
Professional services: $5,103; 
Average for professional services: 
Volume (number of services): 13.31; 
Intensity: 4.27; 
Price per unit of intensity: $89.68. 

Rank: 14; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $33,899; 
Professional services: $4,306; 
Average for professional services: 
Volume (number of services): 7.91; 
Intensity: 6.33; 
Price per unit of intensity: $86.03. 

Rank: 15; 
MSA: Albany-Schenectady-Troy, NY[A]; 
Average adjusted spending: 
Episode: $32,246; 
Professional services: $4,335; 
Average for professional services: 
Volume (number of services): 9.42; 
Intensity: 5.82; 
Price per unit of intensity: $79.01. 

Rank: 16; 
MSA: [A,B]; 
Average adjusted spending: 
Episode: $31,726; 
Professional services: $4,642; 
Average for professional services: 
Volume (number of services): 6.64; 
Intensity: 7.47; 
Price per unit of intensity: $93.58. 

Rank: 17; 
MSA: Colorado Springs, CO; 
Average adjusted spending: 
Episode: $31,648; 
Professional services: $4,383; 
Average for professional services: 
Volume (number of services): 11.30; 
Intensity: 4.91; 
Price per unit of intensity: $79.01. 

Rank: 18; 
MSA: [B]; 
Average adjusted spending: 
Episode: $31,550; 
Professional services: $4,792; 
Average for professional services: 
Volume (number of services): 6.42; 
Intensity: 7.98; 
Price per unit of intensity: $93.59. 

Rank: 19; 
MSA: Charleston, WV; 
Average adjusted spending: 
Episode: $31,376; 
Professional services: $5,079; 
Average for professional services: 
Volume (number of services): 8.33; 
Intensity: 5.83; 
Price per unit of intensity: $104.53. 

Rank: 20; 
MSA: [B]; 
Average adjusted spending: 
Episode: $31,371; 
Professional services: $5,052; 
Average for professional services: 
Volume (number of services): 11.08; 
Intensity: 5.22; 
Price per unit of intensity: $87.39. 

Rank: 21; 
MSA: Portland-Vancouver-Hillsboro, OR-WA; 
Average adjusted spending: 
Episode: $30,535; 
Professional services: $4,882; 
Average for professional services: 
Volume (number of services): 6.66; 
Intensity: 8.12; 
Price per unit of intensity: $90.19. 

Rank: 22; 
MSA: Orlando-Kissimmee-Sanford, FL; 
Average adjusted spending: 
Episode: $30,473; 
Professional services: $3,857; 
Average for professional services: 
Volume (number of services): 9.66; 
Intensity: 6.32; 
Price per unit of intensity: $63.16. 

Rank: 23; 
MSA: Cape Coral-Fort Myers, FL; 
Average adjusted spending: 
Episode: $30,422; 
Professional services: $3,797; 
Average for professional services: 
Volume (number of services): 7.40; 
Intensity: 7.18; 
Price per unit of intensity: $71.40. 

Rank: 24; 
MSA: Seattle-Tacoma-Bellevue, WA; 
Average adjusted spending: 
Episode: $30,398; 
Professional services: $4,961; 
Average for professional services: 
Volume (number of services): 5.53; 
Intensity: 6.68; 
Price per unit of intensity: $134.30. 

Rank: 25; 
MSA: Tampa-St. Petersburg-Clearwater, FL; 
Average adjusted spending: 
Episode: $30,380; 
Professional services: $4,225; 
Average for professional services: 
Volume (number of services): 9.92; 
Intensity: 5.99; 
Price per unit of intensity: $71.16. 

Rank: 26; 
MSA: [B]; 
Average adjusted spending: 
Episode: $30,205; 
Professional services: $5,688; 
Average for professional services: 
Volume (number of services): 7.78; 
Intensity: 6.99; 
Price per unit of intensity: $104.61. 

Rank: 27; 
MSA: [B]; 
Average adjusted spending: 
Episode: $30,072; 
Professional services: $4,345; 
Average for professional services: 
Volume (number of services): 11.73; 
Intensity: 15.45; 
Price per unit of intensity: $23.97. 

Rank: 28; 
MSA: [B]; 
Average adjusted spending: 
Episode: $29,817; 
Professional services: $4,335; 
Average for professional services: 
Volume (number of services): 9.61; 
Intensity: 5.76; 
Price per unit of intensity: $78.39. 

Rank: 29; 
MSA: Lakeland-Winter Haven, FL; 
Average adjusted spending: 
Episode: $29,480; 
Professional services: $4,029; 
Average for professional services: 
Volume (number of services): 7.85; 
Intensity: 10.46; 
Price per unit of intensity: $49.05. 

Rank: 30; 
MSA: Knoxville, TN; 
Average adjusted spending: 
Episode: $29,470; 
Professional services: $4,664; 
Average for professional services: 
Volume (number of services): 8.44; 
Intensity: 6.22; 
Price per unit of intensity: $88.93. 

Rank: 31; 
MSA: Memphis, TN-MS-AR; 
Average adjusted spending: 
Episode: $29,073; 
Professional services: $5,566; 
Average for professional services: 
Volume (number of services): 12.28; 
Intensity: 4.51; 
Price per unit of intensity: $100.39. 

Rank: 32; 
MSA: New Orleans-Metairie-Kenner, LA; 
Average adjusted spending: 
Episode: $29,035; 
Professional services: $4,022; 
Average for professional services: 
Volume (number of services): 8.16; 
Intensity: 6.87; 
Price per unit of intensity: $71.68. 

Rank: 33; 
MSA: San Jose-Sunnyvale-Santa Clara, CA; 
Average adjusted spending: 
Episode: $28,626; 
Professional services: $5,681; 
Average for professional services: 
Volume (number of services): 8.47; 
Intensity: 6.55; 
Price per unit of intensity: $102.36. 

Rank: 34; 
MSA: Raleigh-Cary, NC; 
Average adjusted spending: 
Episode: $28,162; 
Professional services: $4,623; 
Average for professional services: 
Volume (number of services): 7.64; 
Intensity: 7.73; 
Price per unit of intensity: $78.27. 

Rank: 35; 
MSA: [B]; 
Average adjusted spending: 
Episode: $28,090; 
Professional services: $4,487; 
Average for professional services: 
Volume (number of services): 9.52; 
Intensity: 5.94; 
Price per unit of intensity: $79.35. 

Rank: 36; 
MSA: Huntington-Ashland, WV-KY-OH; 
Average adjusted spending: 
Episode: $28,065; 
Professional services: $4,212; 
Average for professional services: 
Volume (number of services): 7.51; 
Intensity: 8.44; 
Price per unit of intensity: $66.41. 

Rank: 37; 
MSA: Denver-Aurora-Broomfield, CO; 
Average adjusted spending: 
Episode: $28,042; 
Professional services: $4,663; 
Average for professional services: 
Volume (number of services): 10.83; 
Intensity: 6.02; 
Price per unit of intensity: $71.46. 

Rank: 38; 
MSA: Providence-New Bedford-Fall River, RI-MA; 
Average adjusted spending: 
Episode: $27,936; 
Professional services: $4,667; 
Average for professional services: 
Volume (number of services): 8.28; 
Intensity: 6.58; 
Price per unit of intensity: $85.70. 

Rank: 39; 
MSA: Chicago-Joliet-Naperville, IL-IN-WI; 
Average adjusted spending: 
Episode: $27,774; 
Professional services: $5,042; 
Average for professional services: 
Volume (number of services): 12.56; 
Intensity: 4.91; 
Price per unit of intensity: $81.76. 

Rank: 40; 
MSA: Kansas City, MO-KS; 
Average adjusted spending: 
Episode: $27,770; 
Professional services: $4,197; 
Average for professional services: 
Volume (number of services): 9.48; 
Intensity: 6.71; 
Price per unit of intensity: $65.92. 

Rank: 41; 
MSA: Ann Arbor, MI; 
Average adjusted spending: 
Episode: $27,709; 
Professional services: $3,784; 
Average for professional services: 
Volume (number of services): 7.13; 
Intensity: 7.40; 
Price per unit of intensity: $71.76. 

Rank: 42; 
MSA: Philadelphia-Camden-Wilmington, PA-NJ-DE-MD; 
Average adjusted spending: 
Episode: $27,354; 
Professional services: $4,452; 
Average for professional services: 
Volume (number of services): 12.18; 
Intensity: 4.72; 
Price per unit of intensity: $77.41. 

Rank: 43; 
MSA: Detroit-Warren-Livonia, MI; 
Average adjusted spending: 
Episode: $26,945; 
Professional services: $3,704; 
Average for professional services: 
Volume (number of services): 9.97; 
Intensity: 5.57; 
Price per unit of intensity: $66.73. 

Rank: 44; 
MSA: Savannah, GA; 
Average adjusted spending: 
Episode: $26,937; 
Professional services: $4,590; 
Average for professional services: 
Volume (number of services): 6.17; 
Intensity: 8.57; 
Price per unit of intensity: $86.71. 

Rank: 45; 
MSA: Cincinnati-Middletown, OH-KY-IN; 
Average adjusted spending: 
Episode: $26,868; 
Professional services: $4,231; 
Average for professional services: 
Volume (number of services): 10.85; 
Intensity: 5.09; 
Price per unit of intensity: $76.59. 

Rank: 46; 
MSA: Bridgeport-Stamford-Norwalk, CT; 
Average adjusted spending: 
Episode: $26,858; 
Professional services: $6,051; 
Average for professional services: 
Volume (number of services): 12.67; 
Intensity: 4.58; 
Price per unit of intensity: $104.35. 

Rank: 47; 
MSA: Phoenix-Mesa-Glendale, AZ; 
Average adjusted spending: 
Episode: $26,856; 
Professional services: $5,394; 
Average for professional services: 
Volume (number of services): 11.21; 
Intensity: 6.10; 
Price per unit of intensity: $78.87. 

Rank: 48; 
MSA: Tulsa, OK; 
Average adjusted spending: 
Episode: $26,651; 
Professional services: $4,136; 
Average for professional services: 
Volume (number of services): 7.14; 
Intensity: 8.15; 
Price per unit of intensity: $71.06. 

Rank: 49; 
MSA: Minneapolis-St. Paul-Bloomington, MN-WI; 
Average adjusted spending: 
Episode: $26,628; 
Professional services: $6,107; 
Average for professional services: 
Volume (number of services): 7.82; 
Intensity: 6.78; 
Price per unit of intensity: $115.13. 

Rank: 50; 
MSA: Boston-Cambridge-Quincy, MA-NH; 
Average adjusted spending: 
Episode: $26,618; 
Professional services: $4,353; 
Average for professional services: 
Volume (number of services): 7.39; 
Intensity: 6.96; 
Price per unit of intensity: $84.64. 

Rank: 51; 
MSA: Shreveport-Bossier City, LA; 
Average adjusted spending: 
Episode: $26,580; 
Professional services: $5,292; 
Average for professional services: 
Volume (number of services): 8.00; 
Intensity: 6.74; 
Price per unit of intensity: $98.06. 

Rank: 52; 
MSA: [B]; 
Average adjusted spending: 
Episode: $26,557; 
Professional services: $5,229; 
Average for professional services: 
Volume (number of services): 10.76; 
Intensity: 5.33; 
Price per unit of intensity: $91.20. 

Rank: 53; 
MSA: Albuquerque, NM; 
Average adjusted spending: 
Episode: $26,481; 
Professional services: $5,099; 
Average for professional services: 
Volume (number of services): 6.91; 
Intensity: 7.88; 
Price per unit of intensity: $93.65. 

Rank: 54; 
MSA: Cleveland-Elyria-Mentor, OH; 
Average adjusted spending: 
Episode: $25,683; 
Professional services: $4,037; 
Average for professional services: 
Volume (number of services): 9.23; 
Intensity: 6.09; 
Price per unit of intensity: $71.73. 

Rank: 55; 
MSA: Columbus, OH; 
Average adjusted spending: 
Episode: $25,627; 
Professional services: $3,717; 
Average for professional services: 
Volume (number of services): 9.15; 
Intensity: 6.05; 
Price per unit of intensity: $67.19. 

Rank: 56; 
MSA: [B]; 
Average adjusted spending: 
Episode: $25,409; 
Professional services: $5,168; 
Average for professional services: 
Volume (number of services): 4.46; 
Intensity: 11.04; 
Price per unit of intensity: $104.92. 

Rank: 57; 
MSA: Los Angeles-Long Beach-Santa Ana, CA; 
Average adjusted spending: 
Episode: $24,972; 
Professional services: $4,432; 
Average for professional services: 
Volume (number of services): 10.00; 
Intensity: 5.86; 
Price per unit of intensity: $75.59. 

Rank: 58; 
MSA: Springfield, MA; 
Average adjusted spending: 
Episode: $24,914; 
Professional services: $4,570; 
Average for professional services: 
Volume (number of services): 7.71; 
Intensity: 7.14; 
Price per unit of intensity: $83.01. 

Rank: 59; 
MSA: Oxnard-Thousand Oaks-Ventura, CA; 
Average adjusted spending: 
Episode: $24,908; 
Professional services: $4,160; 
Average for professional services: 
Volume (number of services): 11.05; 
Intensity: 5.03; 
Price per unit of intensity: $74.76. 

Rank: 60; 
MSA: Santa Rosa-Petaluma, CA; 
Average adjusted spending: 
Episode: $24,548; 
Professional services: $5,962; 
Average for professional services: 
Volume (number of services): 11.09; 
Intensity: 4.99; 
Price per unit of intensity: $107.64. 

Rank: 61; 
MSA: Las Vegas-Paradise, NV; 
Average adjusted spending: 
Episode: $24,490; 
Professional services: $4,815; 
Average for professional services: 
Volume (number of services): 16.18; 
Intensity: 4.51; 
Price per unit of intensity: $65.98. 

Rank: 62; 
MSA: Grand Rapids-Wyoming, MI; 
Average adjusted spending: 
Episode: $24,475; 
Professional services: $4,178; 
Average for professional services: 
Volume (number of services): 6.55; 
Intensity: 7.76; 
Price per unit of intensity: $82.26. 

Rank: 63; 
MSA: Rochester, NY[C]; 
Average adjusted spending: 
Episode: $24,365; 
Professional services: $3,340; 
Average for professional services: 
Volume (number of services): 5.95; 
Intensity: 9.18; 
Price per unit of intensity: $61.17. 

Rank: 64; 
MSA: Louisville-Jefferson County, KY-IN[C]; 
Average adjusted spending: 
Episode: $24,199; 
Professional services: $3,816; 
Average for professional services: 
Volume (number of services): 8.89; 
Intensity: 6.52; 
Price per unit of intensity: $65.87. 

Rank: 65; 
MSA: Allentown-Bethlehem-Easton, PA-NJ[C]; 
Average adjusted spending: 
Episode: $24,117; 
Professional services: $4,530; 
Average for professional services: 
Volume (number of services): 14.13; 
Intensity: 4.47; 
Price per unit of intensity: $71.81. 

Rank: 66; 
MSA: [B,C]; 
Average adjusted spending: 
Episode: $23,894; 
Professional services: $5,745; 
Average for professional services: 
Volume (number of services): 8.00; 
Intensity: 6.98; 
Price per unit of intensity: $102.79. 

Rank: 67; 
MSA: St. Louis, MO-IL[C]; 
Average adjusted spending: 
Episode: $23,816; 
Professional services: $3,804; 
Average for professional services: 
Volume (number of services): 7.37; 
Intensity: 7.14; 
Price per unit of intensity: $72.26. 

Rank: 68; 
MSA: Dayton, OH[C]; 
Average adjusted spending: 
Episode: $23,614; 
Professional services: $3,925; 
Average for professional services: 
Volume (number of services): 7.33; 
Intensity: 8.49; 
Price per unit of intensity: $63.08. 

Rank: 69; 
MSA: Riverside-San Bernardino-Ontario, CA[C]; 
Average adjusted spending: 
Episode: $23,361; 
Professional services: $3,855; 
Average for professional services: 
Volume (number of services): 9.15; 
Intensity: 5.97; 
Price per unit of intensity: $70.55. 

Rank: 70; 
MSA: [B,C]; 
Average adjusted spending: 
Episode: $23,314; 
Professional services: $3,880; 
Average for professional services: 
Volume (number of services): 12.93; 
Intensity: 4.19; 
Price per unit of intensity: $71.67. 

Rank: 71; 
MSA: Akron, OH[C]; 
Average adjusted spending: 
Episode: $23,100; 
Professional services: $3,110; 
Average for professional services: 
Volume (number of services): 9.33; 
Intensity: 5.58; 
Price per unit of intensity: $59.78. 

Rank: 72; 
MSA: Hartford-West Hartford-East Hartford, CT[C]; 
Average adjusted spending: 
Episode: $22,478; 
Professional services: $4,924; 
Average for professional services: 
Volume (number of services): 8.33; 
Intensity: 7.10; 
Price per unit of intensity: $83.32. 

Rank: 73; 
MSA: Lexington-Fayette, KY[C]; 
Average adjusted spending: 
Episode: $22,274; 
Professional services: $3,817; 
Average for professional services: 
Volume (number of services): 10.77; 
Intensity: 5.44; 
Price per unit of intensity: $65.19. 

Rank: 74; 
MSA: Toledo, OH[C]; 
Average adjusted spending: 
Episode: $22,242; 
Professional services: $4,286; 
Average for professional services: 
Volume (number of services): 14.92; 
Intensity: 4.08; 
Price per unit of intensity: $70.34. 

Rank: 75; 
MSA: Fresno, CA[C]; 
Average adjusted spending: 
Episode: $20,508; 
Professional services: $3,732; 
Average for professional services: 
Volume (number of services): 13.05; 
Intensity: 4.64; 
Price per unit of intensity: $61.66. 

Rank: 76; 
MSA: [B,C]; 
Average adjusted spending: 
Episode: $19,794; 
Professional services: $4,018; 
Average for professional services: 
Volume (number of services): 15.52; 
Intensity: 3.90; 
Price per unit of intensity: $66.41. 

Rank: 77; 
MSA: Birmingham-Hoover, AL[C]; 
Average adjusted spending: 
Episode: $19,166; 
Professional services: $5,827; 
Average for professional services: 
Volume (number of services): 9.56; 
Intensity: 6.06; 
Price per unit of intensity: $100.68. 

Rank: 78; 
MSA: Youngstown-Warren-Boardman, OH-PA[C]; 
Average adjusted spending: 
Episode: $19,164; 
Professional services: $3,893; 
Average for professional services: 
Volume (number of services): 15.72; 
Intensity: 3.91; 
Price per unit of intensity: $63.28. 

Source: GAO analysis of 2009 and 2010 claims data from Truven Health 
Analytics. GAO-15-214. 

Note: Data were from 78 MSAs. We included all MSAs with a sufficient 
number of episodes to support our analyses for all three procedures. 
Spending, volume, and intensity were adjusted to control for 
differences in demographics and health status of enrollees in each 
MSA; spending was also adjusted for geographic differences in the cost 
of doing business. Intensity was measured by the relative value unit 
(RVU) assigned to each service. 

[A] MSA was in the highest-spending quintile. The 16 MSAs in the 
highest-spending quintile had an average of $5,221 in spending on 
professional services. For those professional services, the 16 MSAs 
had an average of 9.10 services, average intensity of 6.58, and 
average price per unit of intensity of $95.88. 

[B] MSA name withheld to protect the confidentiality of entities that 
contributed private data. 

[C] MSA was in the lowest-spending quintile. The 16 MSAs in the lowest-
spending quintile had an average of $4,157 in spending on professional 
services. For those professional services, the 16 MSAs had an average 
of 10.68 services, average intensity of 5.85, and average price per 
unit of intensity of $71.86. 

[End of table] 

[End of section] 

Appendix VII: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

James Cosgrove, (202) 512-7114 or cosgrovej@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Christine Brudevold, Assistant 
Director; Ramsey Asaly; Greg Giusto; Andy Johnson; Corissa Kiyan; 
Elizabeth T. Morrison; Vikki Porter; and Dan Ries made key 
contributions to this report. 

[End of section] 

Footnotes: 

[1] See Centers for Medicare & Medicaid Services, Table 1: National 
Health Expenditures and Selected Economic Indicators, Levels and 
Annual Percent Change: Calendar Years 2007-2023, accessed October 28, 
2014, [hyperlink, http://www.cms.gov/Research-Statistics-Data-and-
Systems/Statistics-Trends-and-
Reports/NationalHealthExpendData/Downloads/Proj2013tables.zip]. 

[2] See, for example, E. Fisher et al., "The Implications of Regional 
Variations in Medicare Spending. Part 1: The Content, Quality, and 
Accessibility of Care," Annals of Internal Medicine, vol. 138, no.4 
(2003). 

[3] Medicare is the federally financed health insurance program for 
persons aged 65 and over, certain individuals with disabilities, and 
individuals with end-stage renal disease. 

[4] In 2012, private sector spending accounted for $917 billion of the 
$2.8 trillion in overall national health expenditures. 

[5] Volume is the number of services used, and intensity is the 
resources needed to provide a service--for example, a 30-minute office 
visit has greater intensity than a 15-minute office visit. 

[6] The Office of Management and Budget defines MSAs as having at 
least one urbanized area with a population of 50,000 or more, plus 
adjacent territory that has a high degree of social and economic 
integration with the core. Office of Management and Budget, Executive 
Office of the President, OMB Bulletin No. 13-01, Revised Delineations 
of Metropolitan Statistical Areas, Micropolitan Statistical Areas, and 
Combined Statistical Areas, and Guidance on Uses of the Delineations 
of These Areas (Washington, D.C.: Feb. 28, 2013). 

[7] Coronary stent placement, also known as percutaneous transluminal 
coronary angioplasty, is a surgical cardiology procedure to open a 
blocked coronary artery and insert a stent (an expandable metal coil) 
into the newly opened artery to help prevent renarrowing or reclosure. 
Laparoscopic appendectomy is a general surgical procedure to remove an 
infected appendix using instruments placed into small abdominal 
incisions. Total hip replacement, also known as Total hip 
arthroplasty, is a surgical orthopedic procedure where cartilage and 
bone from the hip joint are replaced with prosthetic components. 

[8] These procedures also have high levels of volume among all 
patients in the United States. For example, according to the 
Healthcare Cost and Utilization Project, which includes data for all 
privately insured, Medicare, Medicaid, uninsured, and all other 
patients, these 3 procedures were among the 20 procedures with the 
most discharges in 2009. During that year, there were approximately 
614,000 discharges for coronary stent placement, approximately 200,000 
discharges for Laparoscopic appendectomy, and approximately 274,000 
discharges for Total hip replacement. 

[9] In 2012, about one-third of all health care spending in the United 
States was for hospital services. Spending for professional services 
represented over one-quarter of spending, and the remainder of 
spending included services such as prescription drugs, nursing home 
care, and home health care, as well as administrative costs. See 
Centers for Medicare & Medicaid Services, Table 2: National Health 
Expenditures; Aggregate and Per Capita Amounts, Annual Percent Change 
and Percent Distribution, by Type of Expenditure: Selected Calendar 
Years 1960-2012, accessed October 28, 2014, [hyperlink, 
http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-
Trends-and-Reports/NationalHealthExpendData/Downloads/tables.pdf]. 

[10] Specifically, we included any outpatient services received by an 
enrollee in the 3 days prior to admission at the same hospital where 
the inpatient admission occurred, because those services may be 
related to the admission. 

[11] We excluded MSAs that had fewer than 24 coronary stent placement 
episodes, fewer than 17 Laparoscopic appendectomy episodes, or fewer 
than 24 Total hip replacement episodes. We had a sufficient number of 
episodes to support our analyses of coronary stent placement in 155 
MSAs, Laparoscopic appendectomy in 139 MSAs, and Total hip replacement 
in 141 MSAs. For some analyses where we drew comparisons across 
procedures, we reported data on only those MSAs that had a sufficient 
number of episodes for all three procedures, and 78 MSAs fell into 
this category. We took steps to remove and limit the effect of 
atypical episodes. For example, we excluded enrollees who received the 
procedure more than one time during the episode, enrollees whose 
overall initial hospital admission was coded as being for a reason 
unrelated to the procedure analyzed, enrollees with diagnoses of end-
stage renal disease, enrollees who were pregnant, and enrollees with a 
hospice stay. 

[12] "Enrollee" also refers to any dependents, unless otherwise 
specified. To control for geographic differences in the cost of doing 
business, we applied Medicare's payment-adjustment methodology--the 
Geographic Practice Cost Index or the Hospital Wage Index, as 
appropriate--to the unadjusted spending for services within each 
episode. To control for differences in the demographics and health 
status of enrollees in each MSA, we used a regression-based approach 
with enrollee-level variables such as age, gender, number of 
readmissions, and certain comorbidities. See appendix I for a 
description of our approach. 

[13] Examples of postdischarge services are services at a skilled 
nursing facility and home health services. Professional services 
include office visits, hospital consultations, surgeries, and other 
services provided by a physician or other health professional, such as 
a physician assistant. Examples of ancillary services are lab tests 
and ambulance services. 

[14] We calculated volume, intensity, and price for hospital 
outpatient services but did not report them because we found that 
hospital outpatient spending constituted only 1 to 2 percent of 
episode spending. We could not calculate consistent measures of 
volume, intensity, and price for postdischarge care and ancillary 
services because of the variability of services within these 
categories and the absence of a measure of intensity for these 
services. 

[15] Medicare bases its payment rates for physician services on RVUs, 
which reflect estimates of the resources needed to provide a given 
service relative to other services--including physician time and 
intensity; other clinical labor, equipment, and supplies; and premiums 
paid for malpractice. 

[16] We did not report the names of certain MSAs to protect the 
confidentiality of entities contributing private data to the 
MarketScan database. 

[17] See Institute of Medicine, Variation in Health Care Spending: 
Target Decision Making, Not Geography (Washington, D.C.: The National 
Academies Press, July 24, 2013). Health status was accounted for by 
IOM using diagnosis information recorded on claims; insurance plan 
factors included measures such as benefit generosity and plan type; 
and market-level factors included measures such as hospital 
competition, payer mix, and percentage of population uninsured. 

[18] To do this work, IOM commissioned original analyses of public and 
private payer databases, and focused on describing and accounting for 
geographic variation in health care spending, utilization, and quality 
for the overall population, as well as for populations with specific 
diseases or conditions. IOM contractors quantified geographic 
variation in spending, utilization, and quality across various 
populations, payers, and geographic units; identified types of health 
care services with disproportionately high rates of variation; and 
identified factors that drove variation, such as enrollee health 
status and demographic characteristics, health plan, and price and 
market factors, among other things. 

[19] Medicare Payment Advisory Commission, "Chapter 7, Variation in 
private-sector payment rates," in Report to the Congress: Medicare and 
the Health Care Delivery System (June 15, 2011). 

[20] GAO, Federal Employees Health Benefits Program: Competition and 
Other Factors Linked to Wide Variation in Health Care Prices, 
[hyperlink, http://www.gao.gov/products/GAO-05-856] (Washington, D.C.: 
Aug. 15, 2005). 

[21] These findings appear in a subcontractor report commissioned by 
IOM. See Michael McKellar et al., Geographic Variation in Health Care 
Spending, Utilization, and Quality among the Privately Insured, a 
special report prepared at the request of The Institute of Medicine 
Committee on Geographic Variation in Health Care Spending and 
Promotion of High-Value Care (Boston, Mass.: Harvard Medical School 
Department of Health Care Policy, Aug. 29, 2012). 

[22] Chapin White, James D. Reschovsky, and Amelia M. Bond, Inpatient 
Hospital Prices Drive Spending Variation for Episodes of Care for 
Privately Insured Patients, Brief No. 14 (Washington, D.C.: National 
Institute for Health Care Reform, February 2014). 

[23] The markets in this analysis included Louisville, Kentucky; 
Cleveland, Ohio; Lansing, Michigan; Flint, Michigan; Warren, Michigan; 
Detroit, Michigan; Kansas City, Missouri; Indianapolis, Indiana; and 
Buffalo, New York. 

[24] The National Institute for Health Care Reform study included nine 
areas. IOM also reported less geographic variation in private sector 
spending per enrollee compared to our episode spending. Our study, 
with its focus on three hospital-based, surgical episodes of care, 
likely had a different composition of utilization of services (mix, 
quantity, and intensity) and prices, compared to the IOM's measure of 
Total spending since not all services provided in medical practices 
are associated with inpatient admissions or surgical procedures. 

[25] The correlation coefficient captures the relationship between two 
variables of interest and takes a value between negative 1 and 1. A 
correlation coefficient of 0 would indicate that there was no 
relationship between the variables. A correlation coefficient close to 
1 would indicate a strong positive relationship, while a correlation 
coefficient close to negative 1 would indicate a strong negative 
relationship. 

[26] Researchers at the National Institute for Health Care Reform 
found a correlation of 0.68 when comparing hospitals' spending on knee 
and hip replacements to spending across all types of episodes, and 
found a correlation of 0.80 when comparing cardiology episodes to all 
episodes. They concluded that a high-spending hospital for one episode 
type is also likely to have high spending for other episode types. IOM 
also studied this issue by conducting an episode-based analysis on a 
subset of conditions and, although finding correlation, the extent of 
the correlation depended on conditions examined. For example, the 
correlation between episode spending for diabetes and coronary heart 
disease was 0.79, but the correlation between spending on stroke and 
prostate cancer was 0.29. 

[27] In addition, we examined whether the number of episodes in an MSA 
had an effect on average episode spending for that MSA, and did not 
find evidence of an effect. 

[28] We identified price as the amount spent on the initial hospital 
inpatient admission (which excluded spending on any subsequent 
readmissions), because hospitals are generally paid one amount per 
admission regardless of the patient's length of stay or the services 
delivered. 

[29] There was little or no difference across MSAs in the number of 
days in the initial admission. The average number of days was 2.32 in 
the lowest-spending quintile and 2.31 in the highest-spending quintile 
for coronary stent placement, 1.71 and 1.53 for Laparoscopic 
appendectomy, and 2.87 and 2.91 for Total hip replacement. Hospital 
inpatient prices generally cover all hospital services during an 
inpatient admission regardless of the length of stay or the services 
delivered, so there is no financial incentive for hospitals to keep 
patients for additional days in an inpatient setting. 

[30] MSAs in the lowest-or highest-spending quintiles did not 
necessarily have spending on professional services that coincided with 
these quintiles. For example, for each of the three procedures, San 
Jose, California, had a level of spending on professional services 
that was among the 10 highest-spending MSAs, even though it was not in 
the highest-spending quintile for episode spending for any procedure. 
In contrast, Madison, Wisconsin, had the highest or second-highest 
level of spending on professional services for all three procedures 
and was also in the highest-spending quintile for episode spending for 
all three procedures. 

[31] Coronary stent placement, also known as percutaneous transluminal 
coronary angioplasty, is a surgical cardiology procedure to open a 
blocked coronary artery and insert a stent (an expandable metal coil) 
into the newly opened artery to help prevent renarrowing or reclosure. 
Laparoscopic appendectomy is a general surgical procedure to remove an 
infected appendix using instruments placed into small abdominal 
incisions. Total hip replacement, also known as Total hip 
arthroplasty, is a surgical orthopedic procedure where cartilage and 
bone from the hip joint are replaced with prosthetic components. 

[32] The MarketScan database contains claims for over 50 million 
enrollees paid by over 100 private insurers across 50 states and the 
District of Columbia in 2009 and 2010. 

[33] For coronary stent placement, we identified enrollees with claims 
with a principal hospital procedure code for percutaneous transluminal 
coronary angioplasty or for coronary atherectomy and a professional 
procedure code for inserting an intracoronary stent, and we excluded 
enrollees with claims that indicated placement of a stent in more than 
one artery. For Laparoscopic appendectomy, we identified enrollees 
with a principal hospital procedure code and a professional procedure 
code for Laparoscopic appendectomy, and we excluded enrollees with 
claims that indicated extra work or additional procedures. For Total 
hip replacement, we identified enrollees with claims with a principal 
hospital procedure code for Total hip replacement and a professional 
procedure code for Total hip arthroplasty, and we excluded enrollees 
with claims that indicated bilateral procedures. 

[34] These procedures also have high levels of volume among all 
patients. For example, according to the Healthcare Cost and 
Utilization Project, which includes data for all privately insured, 
Medicare, Medicaid, uninsured, and all other patients, these 3 
procedures were among the 20 procedures with the most discharges in 
2009. During that year, there were approximately 614,000 discharges 
for coronary stent placement, approximately 200,000 discharges for 
Laparoscopic appendectomy, and approximately 274,000 discharges for 
Total hip replacement. 

[35] In 2012, about one-third of all health care spending in the 
United States was for hospital services. Spending for professional 
services represented over one-quarter of spending, and the remainder 
of spending included services such as prescription drugs, nursing home 
care, and home health care, as well as administrative costs. See 
Centers for Medicare & Medicaid Services, Table 2: National Health 
Expenditures; Aggregate and Per Capita Amounts, Annual Percent Change 
and Percent Distribution, by Type of Expenditure: Selected Calendar 
Years 1960-2012, accessed October 28, 2014, [hyperlink, 
http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-
Trends-and-Reports/NationalHealthExpendData/Downloads/tables.pdf]. 

[36] We excluded enrollees who had secondary insurance or were 
enrolled in a managed care or other capitated care plan because the 
claims data may not provide a complete record of all the services and 
spending associated with an episode of care. 

[37] The Office of Management and Budget defines MSAs as having at 
least one urbanized area with a population of 50,000 or more, plus 
adjacent territory that has a high degree of social and economic 
integration with the core. Office of Management and Budget, Executive 
Office of the President, OMB Bulletin No. 13-01, Revised Delineations 
of Metropolitan Statistical Areas, Micropolitan Statistical Areas, and 
Combined Statistical Areas, and Guidance on Uses of the Delineations 
of These Areas (Washington, D.C.: Feb. 28, 2013). 

[38] Before assigning episodes to MSAs, we excluded episodes with 
Total spending that was three standard deviations above or below the 
national average of the lognormal distribution. After assigning 
episodes to MSAs, we excluded MSAs with less than 40 percent of 
episodes in either 2009 or 2010. We also excluded MSAs that had fewer 
than 24 coronary stent placement episodes, fewer than 17 Laparoscopic 
appendectomy episodes, or fewer than 24 Total hip replacement 
episodes. We established these thresholds by sequentially dropping the 
MSA with the fewest episodes and analyzing the change in the national 
coefficient of variation of average episode spending for the remaining 
MSAs. The threshold for each procedure was based on the point at which 
the change in national coefficient of variation stabilized. 

[39] We included any out-of-network claims because these claims are 
part of Total spending by both the insurer and the enrollee on the 
episode. Therefore, to the extent that an insurer paid a higher rate 
to a non-network provider, we included those higher payments in our 
data. However, we did not include any balance billing because the 
MarketScan database does not include information on the billed charges. 

[40] The correlation coefficient captures the relationship between two 
variables of interest and takes a value between negative 1 and 1. A 
correlation coefficient of 0 would indicate that there was no 
relationship between the variables. A correlation coefficient close to 
1 would indicate a strong positive relationship, while a correlation 
coefficient close to negative 1 would indicate a strong negative 
relationship. 

[41] Examples of postdischarge services are services at a skilled 
nursing facility and home health services. Professional services 
include office visits; hospital consultations; surgeries; and other 
services provided by a physician or other health professional, such as 
a physician assistant. Examples of ancillary services are lab tests 
and ambulance services. 

[42] Although we compared MSAs in the lowest-and highest-spending 
quintiles for each procedure, we determined that our overall results 
would be similar if we compared MSAs based on the bottom and top 10th, 
15th, or 25th percentile. 

[43] We calculated volume, intensity, and price for hospital 
outpatient services but did not report them because we found that 
hospital outpatient spending constituted only 1 to 2 percent of 
episode spending. We could not calculate consistent measures of 
volume, intensity, and price for postdischarge care and ancillary 
services because of the variability of services within these 
categories and the absence of a measure of intensity for these 
services. 

[44] Medicare bases its payment rates for physician services on RVUs, 
which reflect estimates of the resources needed to provide a given 
service relative to other services--including physician time and 
intensity; other clinical labor, rent, equipment, and supplies; and 
premiums paid for malpractice. 

[45] We did not include volume for anesthesia services, which are 
measured in units of time and not the number of services. We also did 
not include intensity for anesthesia services, which are not assigned 
RVUs. 

[End of section] 

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