Methodology

What is the exact process for calculating cost?

The cost data on this site comes from the Human Services Department’s (HSD) Medicaid claims database. The data presented represents claims from procedures completed from January 1, 2016 through December 31, 2016. At this time, this New Mexico Healthcare Compare website only includes information on Medicaid claims; data for commercial payers, Medicare, and the uninsured are not currently available.

The cost estimates on New Mexico Healthcare Compare are average (mean) payments for Medicaid. They are only meant to serve as a reference point for comparison.

The procedure cost is the average cost for a procedure at a certain facility. This average cost is the total allowable amount due to the provider from the payer, inclusive of both the payer’s and patient’s responsibility. We calculated the average using the mean; the sum of all numbers divided by how many numbers there are. For example, the mean of 2, 7, and 9 would be (2+7+9) divided by 3 (total number of observations).

For each procedure (except for vaginal deliveries and cesarean deliveries), the average cost displayed includes facility costs as well as professional costs . For vaginal deliveries and cesarean deliveries, only facility costs were included in the calculation of average cost per facility.

Review of Claims Data

A statistical analysis of data takes place prior to calculating separate rates by payer. Data is grouped by the specific insurance provider. Once grouped by insurance provider, each procedure is analyzed by number of observations, mean, and standard deviation. Any claim amounts that are greater or lower than two standard deviations from the mean are excluded from that cost estimation. These are removed from analysis as they represent “outliers” that could potentially skew the data. Once outliers are removed, the mean is calculated for each procedure by facility.

Medicaid claims where the portion paid by Medicaid totaled $0 were removed from the analysis prior to any calculations for estimating average cost per procedure. By law, Medicaid is the payer-of-last-resort, meaning a patient’s third-party insurance will pay the claim first. Claims that were partially paid by Medicaid were included in the cost estimation.

Depending on the procedure, the total cost can include:

  • Professional Costs:
    The portion of the cost paid to the healthcare provider, such as a doctor, nurse, midwife, who provides direct services or procedures to a patient.

  • Facility Costs:
    The portion of the cost paid to the organization that provides healthcare services and procedures. This includes hospitals, surgical centers, and diagnostic imaging facilities.

Healthcare expenses can be very different in different facilities – even for the same service. There are many reasons for this:

  • The types of patients the facility cares for

  • The doctors and other healthcare providers who work there

  • The equipment they use

  • The agreements they have made with health insurance companies

Review of Quality Data

Patient Recommendation – The Centers for Medicare & Medicaid Services (CMS) along with the Agency for Healthcare Research & Quality (AHRQ) developed the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey to provide a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care. The national survey is sent to a random sample of inpatients, regardless of health plan coverage, and consists of 32 questions that are then transformed in to 11 composite measures. For the NM Healthcare Compare website, the HCAPHS recommendation rating (by facility) is used to capture patient experience and recommendations. The measure is based on a scale of 0-10; 0 indicating the patient does not recommend the facility and a 10 indicating the patient highly recommends the facility. The data collection period presented on this website is for patients discharged between January 1, 2016 and December 31, 2016. For more information about this survey, please visit http://www.hcahpsonline.org/home.aspx

Facility Influenza Vaccination Rate for Eligible Healthcare Personnel – The National Healthcare Safety Network (NHSN) is the national most widely used healthcare-associated infection tracking system. NHSN allows healthcare facilities to track important healthcare process measures like blood safety errors and healthcare personnel influenza vaccine status. The Advisory Committee on Immunization Practices (ACIP) recommends that all healthcare personnel and persons in training for healthcare professions should be vaccinated annually against influenza. [1] Vaccination of healthcare personnel has been associated with reduced work absenteeism and with fewer deaths among nursing home patients and elderly hospitalized patients. The Healthy People 2020 goal for healthcare personnel influenza vaccination is 90%. [2] For more information about healthcare personnel vaccination surveillance, please visit https://www.cdc.gov/nhsn/acute-care-hospital/hcp-vaccination/index.html

The data currently on the website covers vaccination during the 2016-2017 influenza season (October 1, 2016 – March 31, 2017). This vaccination rate only includes healthcare personnel who are eligible for the vaccine, defined as all facility employees, licensed independent practitioners, adult students/trainees, and volunteers regardless of full time/part time status, clinical responsibility, or patient contact who have worked at the facility for at least one day during the flu vaccination reporting period.

1. Centers for Disease Control and Prevention. “Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009.” MMWR 58, no. Early Release (2009): 1-52.

2. Healthy People 2020. Immunization and Infectious Diseases

30-Day Hospital-Wide All-Cause Unplanned Readmission Rates – The National Quality Forum (#1789) evaluated this measure and provides guidance for its calculation. This measure estimates the hospital-level, risk-standardized rate of unplanned, all-cause readmission after admission for any eligible condition within 30 days of hospital discharge for inpatients aged 18 and older. For New Mexico Healthcare Compare, the 30-day readmission rate measure displayed on the website was based on the Centers for Medicaid and Medicare Services (CMS) hospital-wide all-cause unplanned readmission rate calculation. Readmission rates can be calculated following patients across all hospitals or following patients at the same hospital. For the New Mexico Hospital Compare Website, patients were only followed for readmission at the same hospital as the index admission.

New Mexico Hospital Compare Website, Hospital Wide Readmissions

General Information
Data Source Hospital Inpatient Discharge Data (HIDD) from the Department of Health. Collection period: January 1, 2016 – December 31, 2016
Hospitals Included Non-Federal acute care hospitals in New Mexico.
Definition of Index Case (Denominator for Rate)
Qualifying Event Admissions for inpatients discharged alive from the hospital.
Exclusions Admissions for medical treatment of cancer, primary psychiatric disease, and rehabilitations. Admissions where the patient was discharged from the hospital against medical advice.
Definition of Readmission (Numerator for Rate)
Qualifying Event An unplanned inpatient admission for any cause to an acute care facility in New Mexico that occurs within 30 days of the discharge date of an index admission.
Limited to Readmission at the Same Hospital? Yes
Exclusions Planned readmissions are excluded and are defined as either a nonacute readmission in which a planned procedure occurs or a readmission for maintenance chemotherapy and rehabilitation. For a list of ICD-10-CM codes for exclusions, please go here. (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2016-ACR-MIF.pdf)


List of Procedure Codes

The health care services on New Mexico Healthcare Compare are selected using:

  1. Current Procedural Terminology (CPT) codes

  2. Diagnosis Related Group (DRG) codes

  3. Healthcare Common Procedure Coding System (HCPCS) codes

In some cases, multiple codes may be included under a single service. Sometimes this is due to changes in the coding scheme, and in other cases, changes in the technology available or the delivery of care.

Below is a list of procedures on NM Healthcare Compare. When looking up average costs on this website, you may not see every facility. This is because:

  1. The facility may not provide the procedure, and/or

  2. There are too few claims for services. To ensure stability in the estimate, any procedures with 5 or less claims were not published on the website.

Please read the Methodology page for more information.

Diagnostic Procedures
CPT codes DRG codes HCPCS codes Procedure
44388-44392, 44394, 45378, 45379, 45380-45386, 45389, 45391, 45392, 45393   G0104, G0105, G0106, G0120, G0121 Colonoscopy
59510, 59514, 59515, 59525, 59620, 59622 765, 766   Cesarean Delivery (C-section)
77051, 77052, 77053, 77054, 77055, 77056, 77057, 77058, 77059, 77061, 77062, 77063   G0202 Mammogram
73721, 73723     MRI of lower extremity (knee) without dye
72148, 72158     MRI of lower back without dye
95805, 95806, 95807, 95808, 95810, 95811   G0398, G0399, G0400 Sleep Study
43200- 43202, 43204, 43205, 43206, 43215, 43216, 43217, 43220, 43226, 43227, 43229, 43231, 43232, 43235-43255, 43257, 43259     Upper Gastrointestinal Endoscopy
59400, 59409, 59410, 59610, 59612, 59614 767, 768, 774, 775   Vaginal Delivery
55250   G0027 Vasectomy


More Information

For more information about each procedure, please click on the following links: