Health Care Cost Transparency
Board
Annual Report
Second Substitute House Bill 2457; Section 7(2); Chapter 340; Laws of 2020
Substitute Senate Bill 5589; Section 1(3); Chapter 155; Section 1(3); Laws of 2022
August 1, 2023
Policy Division
P.O. Box 45502
Olympia, WA, 98504-5502
Phone: (360) 725-0491
Fax: (360) 586-9551
www.hca.wa.gov
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 2
Table of contents
Executive summary ............................................................................................................................................................... 3
Background ............................................................................................................................................................................ 6
Advisory committees to the Board ............................................................................................................................. 8
Cost growth benchmark ................................................................................................................................................ 8
Cost drivers analysis ........................................................................................................................................................ 9
Progress toward improving health care affordability ............................................................................................... 10
Ensuring flexibility within Washington’s cost growth benchmark ................................................................... 10
Inflation and the benchmark ................................................................................................................................. 111
Reporting on benchmark performance ................................................................................................................. 144
Updates to the benchmark data call and technical manual ......................................................................... 144
Publishing results of the cost driver analysis ....................................................................................................... 144
Key findings .............................................................................................................................................................. 177
Moving forward with the cost driver analysis ................................................................................................ 244
Other cost driver analyses.................................................................................................................................... 244
Advisory committee on primary care ...................................................................................................................... 311
Background ................................................................................................................................................................ 311
Objective 1: Defining primary care..................................................................................................................... 322
Objective 2: Detailing how to achieve Washington’s target to increase primary care expenditures to
12 percent of total health care expenditures .................................................................................................. 344
Objective 3: Effectively measuring primary care, including identifying any barriers to access and use
of data ....................................................................................................................................................................... 366
Next steps ................................................................................................................................................................ 366
Conclusion ......................................................................................................................................................................... 377
Additional information ................................................................................................................................................... 388
Appendix A – County level PMPM data .................................................................................................................... 399
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 3
Executive summary
House Bill (HB) 2457 (2020) established the Health Care Cost Transparency Board (Board) under the
Washington State Health Care Authority (HCA) because increasing health care costs have a significant impact
throughout the state. Rising health care costs in Washington make health care unaffordable to working families
across the state.
About half of U.S. adults say they have difficulty affording health care costs:
• About four in ten adults reports that they have delayed or gone without medical care in the last year
due to cost.
1
• Substantial shares of adults 65 or older report difficulty paying for various aspects of health care.
2
• Approximately, a quarter of adults say they or a family member in their household have not filled a
prescription, cut pills in half, or skipped doses of medicine in the last year because of the cost of
prescriptions.
3
These costs also strain the budgets of businesses and government agencies which attempt to cover needed
health care services.
The Board is responsible for analyzing total health care expenditures in Washington, identifying trends in
health care cost growth, and establishing a health care cost growth benchmark to assist in Washington’s
efforts to better control increasing health care costs. The goal of the benchmark is to gain a better
understanding of and respond to growing health care costs. As a part of its responsibilities, the Board also
provides an annual report to the Legislature on developments over the past year.
The Board made significant progress in its work since the 2022 legislative report:
• Conducted cost driver analysis covering 2017 through 2021
4
and began to identify potential
additional focus areas.
5
Some of the key findings from the initial analysis were:
o All other markets except Medicare FFS experienced high growth in total expenditures.
1
KFF https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/
2
Ibid.
3
Ibid.
4
Note: The cost driver analysis does not include an in-depth examination of the effects of the COVID-19
pandemic on outlier impacts.
5
In February 2023, the Board discussed options for a second cost driver analysis. Finalization of phase two
analysis is still under development. OnPoint plans to present potential phase two analysis options to the
Advisory Committee on Data Issues, and the board, in fall of 2023. The second level analysis is estimated to
be completed before the end of 2023.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 4
o For total spending by categories of care, inpatient services were the highest category of
spending in 2018 and continued to be the highest in 2021, with outpatient services also
rising.
o There was greater overall growth in outpatient spending compared to inpatient. Outpatient
PMPM growth was driven by a utilization increase of 32 percent despite no pricing increases.
Prices increased for inpatient services, including both the plan paid and member
responsibility, however, there was a decrease in utilization.
o For pharmacy spending, individuals had the same number of prescriptions, but prices
increased by almost 25 percent.
o Medical Per Member Per Month (PMPMs) across Washington counties ranged from $150 to
$1,200. These variations could be due to outlier patients, or differences in care delivery.
o Spending growth occurred across all age categories for both men and women.
• Initiated a two-year grant extending from 2023 to 2025 with the Institute for Health Metrics and
Evaluation (IHME) to create a new Analytic Support Initiative. The Analytic Support Initiative will
provide additional data and evidence to guide the Board’s recommendations in addressing health
care costs.
• Continued to analyze Washington hospital cost and profit through a contract with independent
consultants.
6
• Established the Advisory Committee on Primary Care to develop recommendations to increase
primary care spending to 12 percent of total health care expenditures.
• Continued the benchmark analysis including:
o Collected data for the cost benchmark data call with a comprehensive initial report expected
in fall 2023.
7
o Engaged with a variety of stakeholders and consultants, including the Washington State
Hospital Association (WSHA), the Washington State Medical Association (WSMA), Bailit
Health, and Bartholomew-Nash & Associates, to gather additional data on costs affecting the
benchmark.
o Completed the 2023 data call technical manual and submission template for the second
benchmark data call.
With the information collected from the benchmark and cost driver analyses, the Board can continue
ongoing conversations with all stakeholders in Washington’s health system. This next phase of discussions
6
In April 2023, the Board approved plans with Bartholomew-Nash & Associates for a phase two analysis of
Washington hospital costs, price, and profit analysis.
7
Results from the first benchmark report published in 2023 will be used to define large provider entities for
future reports (to be published in 2024 and beyond). No cost growth analysis will occur at the provider and
payer levels until 2024.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 5
will include identifying the best ways to curb health care spending and take meaningful action to increase
health care affordability for all Washingtonians.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 6
Background
Nationally, health care spending continues to increase. Over the past 20 years in Washington, health care
costs have increased faster than inflation
8
and premiums have increased faster than wages.
9
The Board’s
primary objective is to set a target for future cost growth and collect Washington-specific data on total
health care expenditures. The Board is also tasked with analyzing growth trends in the state and by insurance
market, and in future years by health insurance carrier and large provider. The board will utilize benchmark
data and cost driver analysis to make informed recommendations and develop statewide health care policy to
lower spending and curb health care cost growth.
To better understand and respond to growing health care costs, the Board organized its work into four
different data projects:
1. Cost growth benchmark
2. Performance against the benchmark
3. Cost driver analysis
4. Primary care spending
Table 1: Health Care Cost Transparency Board data projects overview (not including
specific cost driver analyses, e.g., hospital cost analysis)
Cost growth
benchmark
Performance
against
benchmark
Cost driver
analysis / cost
experience
Primary care spend
measurement
What it is
The goal for the
growth of
spending on
health care year
over year.
Assessment of cost
growth against the
benchmark.
Assessment of key
drivers of cost
growth.
Measurement of
expenditure on
primary care in
relation to overall
health care
expenditure.
8
From 2000 to 2020, annual growth in health care costs averaged 5.14 percent. Health care cost growth has
slowed since 2010 but remains higher than inflation. Washington Office of Financial Management, “Change
in Medical Costs.”
9
AHRG’s Medical Expenditure Survey, Tables D.1 and D.2 for 2001-2019 and Bureau of Economic Analysis
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 7
Cost growth
benchmark
Performance
against
benchmark
Cost driver
analysis / cost
experience
Primary care spend
measurement
What it represents
Reflects
affordability
for health care
consumers and
purchasers.
Reflects
performance of
payers and
providers against
the cost growth
benchmark at an
aggregate level.
Reflects a first-level
drill down analysis
of factors that are
contributing to
health care cost
growth.
Reflects the emphasis
on primary care and
preventive care as
measured through
proportion of total
health care
expenditure spent on
primary and
preventive care
activities.
Analytic basis
Macro-
economic
indicators such
as median wage,
potential gross
state product
(PGSP).
Aggregate
expenditure data,
direct from all
payers (carriers).
Includes claims-
based and non-
claims-based
expenditures.
Claims-based
payment data that
Carriers submit to
WA- APCD.
Includes Individual
claims data –
enables
stratification by
geography, risk, etc.
WA-APCD claims
based payments; plus,
not-yet-developed
measurement of non-
claims payments.
Risk-adjustment
consideration
Does not apply.
Based on
macro-economic
indicators.
Age and sex
adjustment is being
used for the
analysis of
performance
against the
benchmark.
Severity-of-illness-
based risk
adjustment is not
applicable as data
are submitted by
payers at an
aggregate level and
not at a client level.
Risk-adjustment
based on severity-
of-illness may be
applied to WA-
APCD data to
better assess the
impact of cost
drivers for certain
analyses where the
adjustment would
be prudent. An
example might be
person-oriented
measures.
Yet to be discussed
and developed.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 8
Cost growth
benchmark
Performance
against
benchmark
Cost driver
analysis / cost
experience
Primary care spend
measurement
Other
considerations
WA-APCD only
includes voluntarily
reported data from
PEBB/SEBB which
offers an
incomplete picture
for self-funded plan
data. For this
reason, this data
cannot be used for
assessing provider
performance
against the
benchmark.
For the purposes of
cost-driver
analyses, risk-
adjustment
methodology will
need to be
developed in
collaboration with
Data Advisory
Committee and
applied consistently
to relevant
analyses.
Risk adjustment
typically focuses on all
aspects of care for an
individual. How to
appropriately focus on
a single category of
care will need to be
investigated.
Advisory committees to the Board
Since the last report in August 2022, the Board continued its work analyzing Washington health care
expenditures and the Board’s advisory committees have assisted with each of the board’s data projects,
including the Advisory Committee for Health Care Providers and Carriers and the Advisory Committee on
Data Issues. The Advisory Committee for Health Care Providers and Carriers continues to provide expert
advice from the provider and carrier perspective to support the development and analysis of the cost growth
benchmark through the data call. The Advisory Committee on Data Issues is comprised of members across a
broad range of stakeholders, such as the Washington Office of Financial Management, the Health Benefit
Exchange, the Washington Health Alliance, and several health plans, among others. This committee provides
expertise on many aspects of the benchmark data call, as well as the analysis of existing data sources to
determine cost drivers.
The Board also established the Advisory Committee on Primary Care, as directed by SSB 5589 (2022), to focus
on measurement of primary care spending and developing recommendations for increasing primary care
spending while reducing total health care expenditures. The goal of this legislative assignment is to
recommend steps to increase primary care expenditures to 12 percent of total health care expenditures by
measuring and incentivizing reimbursement of primary care spending.
Cost growth benchmark
Washington is one of nine states in the nation to adopt a cost growth benchmark. It is also a participant in
the Peterson-Milbank Program for Sustainable Health Care Costs. The Board established the benchmark
target in 2022 for the subsequent five years and will evaluate the benchmark annually moving forward. The
cost growth benchmark represents a common goal for payers, purchasers, regulators, and consumers to
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 9
increase health care affordability. It serves as a starting point from which to align health care spending to
ensure that spending growth does not increase at a faster rate than the economy, state revenue, or wages.
Performance against the benchmark, also referred to as the data call, is assessed by measuring annual cost
growth against each annual benchmark target. Benchmark performance data will reflect the performance of
payers and providers against the cost growth benchmark at an aggregate level, for each insurance market
(e.g., commercial, Medicare, Medicaid). The benchmark data comes from aggregate expenditure data from all
payers (carriers) and include claims-based and non-claims-based expenditures.
Cost drivers analysis
In addition to developing a cost growth benchmark, the Legislature directed the Board to analyze cost drivers
in the health care delivery system. The cost driver analysis examines paid claims to assess where services have
been provided, e.g., hospital inpatient, outpatient, pharmacy, etc. Unlike the work on the cost growth
benchmark, cost driver analysis requires disaggregated data that is not currently captured as part of the data
call.
To develop the cost driver analysis, the board contracted with OnPoint, the data vendor for the Washington
State All Payer Claims Database (WA-APCD) for review of APCD data. OnPoint provided the board with the
preliminary findings of its cost growth drivers study, or the cost driver analysis findings, in December 2022.
The Board also worked with OnPoint to develop an interactive cost driver analysis dashboard using WA-
APCD data that will be posted on the APCD website as it is completed.
The first-year cost driver analysis included a high-level review of:
• Trends in price and utilization
• Spend and trend by geography
• Spend and trend by demographics
In February 2023, the Board discussed options for a second cost driver analysis. Finalization of phase two
analysis is still under development. OnPoint plans to present potential phase two analysis options to the
Advisory Committee on Data Issues, and the board, in fall of 2023.
In 2022, the Board also contracted with Tom Nash and John Bartholomew, independent consultants, to
perform an initial analysis of Washington hospital costs, price, and profit. This year, the Board continued its
contract with Bartholomew-Nash & Associates to analyze Washington hospital costs and margins. The Board
approved the framework for the secondary analysis in April 2023 with findings to be presented in fall of 2023.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 10
Progress toward improving health care affordability
The Board achieved several significant milestones to assist with Washington’s efforts to reduce health care
cost growth and increase transparency. These include:
• Furthering the work related to performance against the benchmark such as:
o Deciding how to account for inflation’s possible effects on the benchmark.
o Continuing to process submissions for the initial benchmark data call.
o Preparing to issue the second benchmark data call.
• Completing the cost driver analysis for Washington and preparing for a second cost driver analysis to
analyze health care price trends.
• Initiating specific analysis on health care drivers in Washington, such as hospital costs, and engaging
with a variety of stakeholders and board consultants to gather additional data.
• Establishing the Advisory Committee on Primary Care to provide recommendations to the board on
increasing primary care spending to 12 percent of total health care expenditures.
Ensuring flexibility within Washington’s cost growth
benchmark
The benchmark target is a specific rate that carriers’ and providers’ expenditure performance will be measured
against. The goal of the benchmark is to influence slower health care cost growth to ensure access to
affordable health care. The Board’s benchmark target covers a five-year period, granting providers and
policymakers the ability to plan for future years when calculating total expenditures. In September 2021, the
Board approved Washington’s cost growth benchmark from 2022–2026 (see Figure 1, below). This benchmark
is based on a hybrid of median wage and potential gross state product (PGSP) at a 70:30 ratio. Median wage
was selected to link the measure to consumer affordability, and PGSP as a reflection of business cost and
inflation.
In establishing the benchmark, the Board reviewed how other states created their benchmarks and
considered many different factors that might influence their choice of benchmark. One of these factors
included current economic indicators, such as wages and inflation. In designing Washington’s benchmark
methodology, the board examined rates of health care inflation in other states with cost growth benchmarks,
as well as those states’ benchmark methodologies.
Figure 1: Cost growth benchmark for Washington State
Years
Target
2022
3.2%
2023
3.2%
2024
3.0%
2025
3.0%
2026
2.8%
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 11
Figure 2: Reporting schedule
Year of Release of Report
Includes Data from Specified
years
Data included
Fall 2023
2017-2019
State and market data only –
the board will not publicly
report insurance carrier* or
provider cost growth for this
period
Summer 2024
2020-2022
For large provider entities and
carriers** - with growth target
of 3.2%
Summer 2025
2022-2023
For large provider entities and
carriers – with growth target of
3.2%
Summer 2026
2023-2024
For large provider entities and
carriers – with growth target of
3.0%
Summer 2027
2024-2025
For large provider entities and
carriers – with growth target of
3.0%
Summer 2028
2025-2026
For large provider entities and
carriers – with growth target of
2.8%
*Alternatively, payers.
**Large provider entities will be determined using 2017-2019 as a historical baseline.
Inflation and the benchmark
During February and March 2022, the Board reviewed the impacts of inflation on spending trends in 2019
and 2020, and in June 2022, invited the WSHA to present on cost challenges, including the impact of COVID-
19 and increasing labor costs. While the Board recognized the significant impacts of the pandemic on the
system, it also considered the impact of increasing cost to residents and the need for a cost growth target to
support affordable access.
The Board consulted with Bailit Health on the impact of inflation on health care spending and the
implications for Washington’s cost growth benchmark. Bailit Health is a consulting firm dedicated to ensuring
insurer and provider performance accountability on behalf of public agencies and employer purchasers and
has worked with several other states in their cost growth benchmark efforts. Bailit Health has been involved
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 12
with the Board since 2021 as part of a grant and participation in the Peterson-Milbank Program for
Sustainable Health Costs.
Inflation’s impact on health care spending lags compared to the prices of goods and services because rising
prices in the general economy don’t impact health prices immediately for several reasons:
• Medicare prices for most services are updated annually based on projected growth in input costs.
• Commercial prices are often defined within multi-year contracts.
• Medicaid prices change infrequently and are not specifically linked to input costs.
During 2021, the price for goods increased significantly, the price for services increased somewhat, and the
price for health care services remained relatively flat in comparison.
10
In 2022, the prices for medical care
increased at a significantly slower rate than other goods and services. Another analysis by Altarum showed
that health care inflation was relatively flat through the end of 2022, despite high and sustained inflation
overall.
11
Figure 3: Inflation by product type, January 2017–January 2022
Year-over-year percent change. Source: Inflation’s Impact on Health Care Spending and Implications for the Cost Growth
Benchmark, Bailit Health. 2023. Bureau of Economic Analysis, personal consumption expenditures price indices.
All five Peterson-Milbank cost growth target states have based target values on economic indicators that are
affected by inflation. For example, the cost growth benchmark established by the Board in Washington
incorporates median wages and income, which are indirectly impacted by inflation. Additionally, household
income tends to grow when inflation grows. As a result, these methodologies were developed under the
assumption that inflation would increase at low levels.
10
Source: Bureau of Economic Analysis, personal consumption expenditure prices indices.
11
Inflation-Adjusted Health Care Spending is Falling for the First Time in Half a Century | Altarum. 2023.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 13
Arguments for adjusting for inflation:
• States could lose support from providers and insurers who feel the benchmark value was set using
inputs that are completely different from actual experience,
• The benchmark could be viewed as unrealistic and unfair, potentially leading to lost credibility with
some as a meaningful state policy and a rejection of the benchmark as a basis for contract
negotiations, such as between carriers and providers.
Arguments against adjustment for inflation:
• The benchmark value purposely utilizes a methodology intended to provide long-term stability.
• It is unlikely that the benchmark value or performance against the benchmark would be adjusted if
providers were posting record profits or if deflation occurred.
• Any adjustment could open the door to future calls for benchmark changes. Benchmarks matter
because payers routinely invoke cost growth benchmark values at the negotiating table.
Key policy considerations:
• How the state should balance protecting consumers who face slower income growth and a potential
recession while acknowledging impacts on provider organizations and insurers from increased costs.
• The precedent that might be set if the state chooses to modify benchmark values.
• The basis on which any modification should be made, and for what duration.
Several states have developed their own responses to the rise in inflation. Massachusetts adjusted their 2023
target up by 0.5 percent, and Rhode Island adjusted their 2023 through 2025 targets up by 2.7, 1.8, and .2
percentage points, respectively
12
. Oregon, and Connecticut made no adjustment to the benchmark. After
considering this information, the Board voted for the benchmark to remain unchanged and to account for
additional inflation, if needed, when there is additional data.
12
Massachusetts’ Health Policy Commission (HPC) reviews and sets a benchmark annually. In 2023, the HPC
voted to revert to the PGSP amount, 3.6 percent, which represented an increase from the prior year, but not a
change in methodology. By contrast, Rhode Island changed the factors used in their benchmark
methodology.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 14
Table 2: States’ responses to the rise in inflation
State
Decision / status of stakeholder body discussions
Connecticut
Committee held initial discussions in October 2022. Committee recommended no
adjustment.
Delaware
Discussed by Economic and Financial Advisory Council in January 2023. No decision yet.
Massachusetts
Adjusted 2023 target up by .5 percentage points
New Jersey
Not yet discussed.
Oregon
Advisory Committee recommended no adjustment and delaying application of accountability
provisions by one year.
Rhode Island
Adjusted 2023-25 targets by 2.7, 1.8, and .2 percentage points, respectively.
Source: Inflation’s Impact on Health Care Spending and Implications for the Cost Growth Benchmark, Bailit Health. 2023.
Reporting on benchmark performance
The Board anticipates reporting on the benchmark performance in fall of 2023 for the data call that was
issued in 2022, with the baseline experience for 2017, 2018, and 2019 calendar years. Like other states,
Washington has been challenged with the start-up process, helping carriers/data submitters to submit,
establishing data validation and review processes, and resubmission processes. Care and attention have been
built in as well with a third-party validation process, which should ensure quality baseline data and a
smoother process in future years.
Updates to the benchmark data call and technical manual
The board completed updates to the 2023 benchmark data call. Changes to the 2023 data call include:
• Inclusion of calendar years 2020, 2021, and 2022 in next submission.
• The performance against the benchmark will be calculated using 2021 and 2022 data.
There also will be a few updates to reference categories to clarify submission data. These updates include:
• An additional insurance category for Federal Employee Health Benefits (FEHB).
• Implementation of a new method to associate non-claims-based spending to providers without
age/sex stratification.
The Board has incorporated these changes into the technical manual for submitters. Like the first benchmark
call, training will be provided to submitters through a webinar.
Publishing results of the cost driver analysis
While the benchmark uses payer-collected aggregate data to identify trends, the cost driver analysis
examines granular claims and encounter data to analyze cost. There is a relationship between the cost
growth benchmark and the cost driver analysis. The benchmark identifies overall spending trends, while the
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 15
cost driver analysis helps determine how spending is allocated across categories of health care services and
potentially what is driving trends in spending. The cost driver analysis also helps to identify opportunities for
reducing cost growth and informs policy decisions.
The Board chose and utilized the WA-APCD as the primary data source for the cost driver analysis, after
assessing the limitations and benefits of available data sources. The Board examined other states’ areas of
focus, such as Connecticut, which focused on trends in price and utilization. This approach allowed
Connecticut to decipher whether increasing costs were due to increased utilization or increased payment per
unit of service (price).
In addition to utilization and price, the Board focused on the importance of better understanding how
Washington’s geographic environment impacts cost and access to care. The Advisory Committee for Health
Care Providers and Carriers and the Advisory Committee on Data Issues provided feedback to the Board on
possible consequences of transparency and cost reduction efforts and recommended areas for monitoring.
Based on the research and information reviewed, the following areas of focus were identified for cost driver
analysis:
• Trends in price and utilization
• Spend and trend by geography
• Spend and trend by health condition
• Spend and trend by demographics
These metrics produce robust data and reporting on cost drivers. These metrics also create a solid foundation
for future areas of focus and recommendations to the Legislature.
In December 2022, the cost diver analysis was complete and the results available. The analysis utilized five
years of data from the WA-APCD, from 2017 through 2021, to align with the initial cost-benchmarking
period. This data set represents approximately 4 million individuals across Medicaid managed care, Medicare
(fee-for-service, or FFS, data only for 2019
13
), commercial
14
, commercial Medicare Advantage (MA),
commercial and MA Public Employees Benefits Board (PEBB), and the commercial Health Benefit Exchange
(HBE) markets out of the state population of approximately seven and a half million.
15
13
Due to lags in publication of Medicare data, data from 2020 and 2021 were not available for inclusion in
this initial analysis.
14
PEBB employees were broken out separately from the rest of commercial. SEBB employees were not
separated out because the SEBB was newly created in 2020 and a flag for the school employee population
was not historically submitted to the APCD. School employees are in the data combined with the rest of the
commercial population, due to a lack of a specific SEBB identifier prior to 2020. A SEBB flag was added in the
APCD in 2020 and it may be possible to separate SEBB for 2020 and future years.
15
Source: United States Census Bureau. Washington’s population in 2021 was 7.739 million.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 16
Between 2017 and 2021, enrollment (as measured in the WA-APCD) increased from 3.5 to 4 million. As a
result of individual changes between insurance types during the year, e.g., from Medicaid to employer
coverage, there is only partial data for the full 12 months for every enrollee. Additionally, enrollees moved in
and out of state, further contributing to inexact enrollment figures. Between 2017 and 2019, enrollment in
Medicaid increased from 1.5 to 1.7 million. Nationwide, MA plans became more popular, in part due to
increased marketing. There was also a significant increase in Exchange enrollees, from .22 million to .35
million. Commercial plans and PEBB plans stayed relatively stable during this time. See Figure 4 below for
enrollment details.
Figure 4: WA-APCD enrollment by market, 2017 and 2021
Source: Cost Driver Analysis Results. December 2022.
The cost driver analysis detailed the changes in Washington’s health care cost landscape. The insured
population has grown and there have been shifts between markets, such as increases in Medicaid, Exchange,
and MA enrollees, driving changes in spending. Both total and per capita expenditures have increased.
Professional spending growth also occurred in most specialties and other provider categories, like physician
assistants (PAs) and nurse practitioners (NPs). There are some differences in how inpatient, outpatient, and
pharmacy spending growth has occurred due to pricing and utilization (See Table 4) and variation by
geography, age, and gender (Figures 11 through 13), detailed in later sections of this report.
The markets analyzed included:
• Commercial (limited data from self-insured plans)
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 17
• Medicaid (managed care only)
• Medicare FFS data (only available through 2019)
• MA (Medicare benefits provided through commercial plans)
• PEBB (commercial and MA)
• Washington HBE (commercial individual health plans)
• Dual-eligibles
16
(not broken out separately due to missing FFS data beyond 2019)
Categories of service for the cost driver analysis were aligned with the benchmarking initiative including:
• Hospital inpatient
• Hospital outpatient
• A narrow definition of primary care providers
• Non-primary care specialty providers
• Other providers like PAs and NPs, etc., long-term care, retail pharmacy
17
, and all other spending
(ambulances, durable medical equipment, etc.)
There were several limitations to the parameters of the analysis, including:
• WA-ACPD does not contain Alternative Payment Model (APM) data.
• No data on self-insured plans, other than voluntarily submitted data from self-funded PEBB/SEBB
Uniform Medical Plan.
• Medicaid FFS data has a longer delay in entry to the APCD.
• Long-term care data for Medicaid was not reported in the APCD.
Key findings
Changes in total expenditures
All other markets except Medicare FFS experienced high growth in total expenditures. Medicare FFS, which
was broken out separately from Medicare, remained stable. For total spending by categories of care,
inpatient was the highest category of spending in 2017 and continued to be the highest in 2021, with
outpatient also rising. There was greater overall growth in outpatient spending compared to inpatient. The
percentage of overall spending on inpatient care decreased relative to other spending, as did specialist, long-
term care, and primary care. Retail pharmacy claim expenditures increased from 4.6 to 6 percent from 2017
to 2021. Pharmacy costs continue to be a key area of investigation for the Board and future analyses will
16
A dual-eligible individual has both Medicare coverage and Medicaid coverage. This includes physical and
behavioral health care coverage.
17
This includes mail order pharmacy. Retail pharmacy includes all pharmacy claims submitted, which is
distinguishable from pharmacy claims submitted through medical insurance claims. Some claims like
injectable drugs would be part of medical spending and not categorized as “retail pharmacy,”
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 18
include collaboration with other efforts underway by the HCA, such as the work of the Prescription Drug
Affordability Board.
Figure 5: Growth in medical claims expenditures, 2017 and 2021
Spending in billions of dollars. Source: Cost Driver Analysis Results. December 2022.
Changes in PMPM expenditures
For this analysis, the PMPM calculation was derived by dividing total expenditures by member months in a
group. Total medical PMPM expenditures increased from $271 to $340 between 2017 and 2021. The
aggregate growth was $69 per month, $800 per year, per person. There was an aggregate change of 25
percent over time – mostly focused in 2021. This includes commercial, Medicaid, MA (as a combined rate
across all markets) and does not include Medicare FFS. Different markets experienced different growth rates,
for medical spending only. MA has the highest PMPMs due to enrollees’ higher health needs compared to
commercial patients. There was growth across all payers, but slightly lower in MA.
The cost driver analysis also examined pharmacy
18
spending by market. Pharmacy PMPMs showed the same
aggregate percent increase of 25 percent over five years with an increase of $21 per month. Spending was
slightly higher under the HBE. All markets increased between 21 and 29 percent.
For PMPM spending by category, most spending was on inpatient and outpatient services. Other professional
services and other medical services, while lower than inpatient and outpatient, still saw significant growth.
The data and analysis revealed that inpatient and outpatient spending constituted the bulk of costs for both
purchasers and consumers when compared to other spending categories.
18
This refers to retail pharmacy and does not include pharmacy captured in medical claims.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 19
Figure 6: Total medical PMPM spending by market, 2017 and 2021
Source: Cost Driver Analysis Results. December 2022.
Figure 7: PMPM by category of medical service, all markets, 2017 and 2021
Source: Cost Driver Analysis Results. December 2022.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 20
Rates of growth across markets
The cost driver analysis also specifically examined inpatient, outpatient, and total pharmacy
19
PMPM
spending growth across markets. These three were selected due to their high impact on cost for insurance
purchasers, such as Washingtonian individual health plan purchasers and employers. For inpatient spending
by market, spending for MA was much higher than other plans. Outpatient spending showed a growth for
MA of almost 50 percent. Individual market outpatient spending was also high, with 47 percent growth.
Commercial outpatient growth remained steady, while Medicaid outpatient growth remained low. Outpatient
PMPM growth was driven by a utilization increase of 32 percent despite no pricing increases.
For retail pharmacy spending, individuals had the same number of prescriptions, but prices increased by
almost 25 percent. The spending increase was higher for pharmacy than for outpatient services. Prices
increased for inpatient services, including both the plan paid and member responsibility, however, there was
a decrease in utilization. Additional analysis was done for the top three components of cost (pharmacy,
inpatient, and outpatient). Of these three cost drivers analyzed, pharmacy costs, followed by outpatient
services, had the highest growth in average price per service for the commercially insured population.
Consumers, employers, and other health care purchasers are experiencing higher costs, reflected by higher
premiums and greater cost-sharing for needed services.
20
In Washington, average premiums for individual
health plans have increased 39 percent since 2014
21
and some Washingtonians have been forced to forego
health care services such as pharmacy prescriptions and inpatient services.
22
19
Retail pharmacy only, not including pharmacy captured in medical claims.
20
An estimated 5 to 6 percent of Washington residents remain uninsured, an issue which disproportionately
affects communities of color. Source: OFM (2021),
https://ofm.wa.gov/sites/default/files/public/dataresearch/healthcare/healthcoverage/COVID-
19_impact_on_uninsured.pdf
21
KFF Marketplace Average Benchmark Premiums, www.kff.org/health-reform/state-indicator/marketplace-
average-benchmark-premium.
22
Altarum’s Consumer Healthcare Experience State Survey (CHESS). 2022.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 21
Figure 8: Changes in commercial cost drivers, 2017–2021
Source: Cost Driver Analysis Results. December 2022.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 22
Regional differences in spending
Medical PMPMs across Washington counties ranged from $150 to $1,200. To view the full range of PMPMs
by county, please refer to Appendix A. This analysis showed a wide range of geographic variation for
Medicaid and MA. In addition to other regional differences, PMPM spending by Accountable Community of
Health (ACH) regions showed a significant increase in spending growth for the southwest ACH region and
significant variation between individual regions. These variations could be due to outlier patients, or
differences in care delivery.
23
Figure 9: County-level variation in medical PMPM spending by market in 2021
Source: Cost Driver Analysis Results. December 2022.
23
ACHs are independent, regional organizations. They work with their communities on specific health care
and social needs-related projects and activities. Health care is measured in the region and is not reflective of
the ACH as an entity.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 23
Figure 10: Commercial medical PMPM spending by accountable community of health
regions, 2017 and 2021
Source: Cost Driver Analysis Results. December 2022.
Spending variation by age and gender
Washingtonian’s health care spending increased in every age category.
24
Spending growth occurred across
the age categories for both men and women. There was higher spending for men in most age categories and
higher spending in comparison for infants as well.
24
This analysis did not include individuals over 65, as most are covered under Medicare.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 24
Figure 11: Age and gender categories (PMPMs), 2021
Source: Cost Driver Analysis Results. December 2022.
Moving forward with the cost driver analysis
Future cost driver analyses will continue evaluating subsequent years’ data to monitor and examine the
various markets for changes in health care costs in Washington including:
• Trends in price and utilization
• Spend and trend by geography
• Spend and trend by health condition
• Spend and trend by demographics
The Board is currently evaluating its resources to determine if it might also include future in-depth cost-
driver analysis on specific topics. These additional topics would supplement the other strategic in-depth
topical analysis the Board is currently working on, such as hospital cost analysis.
Other cost driver analyses
To build on and complement OnPoint’s cost driver analyses, the Board has engaged in further analysis that is
targeted at specific cost drivers that constitute the top areas of health care spending. Hospital costs remain a
high-priority area of investigation for the Board and the Board has continued its work with Bartholomew-
Nash & Associates to examine Washington hospital costs, including workforce trends and administrative
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 25
costs. These additional areas provide key information to develop cost growth mitigation strategies, including
those that reduce the total cost of care.
Hospital costs
Phase one hospital cost analysis by Bartholomew-Nash & Associates
Bartholomew-Nash & Associates have worked with the board since 2022 to examine hospital costs in
Washington. Bartholomew-Nash & Associates developed the Colorado-specific hospital costs analysis. In
June 2022, Bartholomew-Nash & Associates detailed and released the Washington hospital costs, price, and
profit analysis.
25
The research was based on Medicare Cost Reports, submitted annually to the federal
government by hospitals as a condition of participation in Medicare. These reports contain information about
facilities and cost data, including utilization, charges by cost center in total and for Medicare, and financial
statement data.
The first stage of analysis revealed that the price of services versus total costs of patient care in Washington
hospitals is above the national average.
26
Additionally, hospital-only operating expense per patient is much
higher in Washington as compared to the national average. After reviewing the results of the initial study, the
Board has engaged in a second phase of hospital cost analysis from Bartholomew-Nash & Associates.
Phase two hospital cost and margin analysis
In April 2023, the Board approved plans with Bartholomew-Nash & Associates for a phase two analysis of
Washington hospital costs, price, and profit analysis. The second level analysis will include two types of
methodology enhancements and additional financial review, consisting of:
• Calculated adjustments to the first level analysis of costs
• Creation of additional groupings beyond bed size, to allow for comparisons to the national
database
27
• Washington hospital margin analysis
To inform the next phase of analysis, Bartholomew-Nash & Associates formed a workgroup to review the
assumptions to address methodology enhancements for second level hospital financial analysis with a
collection of Washington subject member experts. Workgroup members included representatives from
WSHA, HealthTrends, University of Washington (UW) Medicine, HCA leadership, Tom Nash, and John
25
Washington Hospital Costs, Price, and Profit Analysis. John Bartholomew & Tom Nash Bartholomew-Nash &
Associates. 2022.
26
Ibid.
27
The national database system is the Healthcare Cost Report Information System (HCRIS) as published by
the Centers for Medicare and Medicaid (CMS). The HCRIS database includes the most recent Medicare cost
report filings for nearly every hospital in the nation. The Medicare cost report is the most comprehensive and
standardized reporting mechanism available for hospital financial information. HCRIS data is supplemented
with case mix and wage index information from other CMS public use files and cost of living information
obtained from the Council for Community and Economic Research (C2ER).
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 26
Bartholomew. The workgroup held a series of meetings and conversations in early 2023 and finalized the
recommendations for phase two analysis.
Adjustments to the cost data will include an adjustment to hospital-only operating expense by removing
C2ER as a cost-of-living adjustment. The analysis will utilize the labor wage index information from CMS
wage index files and from the Medicare Cost Report at the hospital level. The labor wage index will be
applied to the salary amount of costs of each hospital, with remaining costs applying the C2ER statistic.
The second analysis will contain additional groupings beyond bed size to create more informed peer
groupings for hospital comparisons, both within Washington, and nationally, using data from the Medicare
Cost Report. In addition to bed size, the secondary analysis will utilize one or a combination of the following
measures to further refine the ability to compare “like” hospitals:
• Teaching intensity measure: A physician-resident-to-bed ratio measure which identifies the level of
teaching at a hospital grouped into percentage ranges.
• Service intensity measure: A measure which calculates intensive care costs as a percentage of total
costs and captures the degree to which a hospital offers intensive care services, grouped into
percentage ranges.
• Medicare case mix index (CMI)
28
: A measure reported in the Medicare final rule public use files
which is an index that captures the level of acuity at a hospital, grouped into ranges.
Finally, the second level analysis will review the payer mix measure. The payer mix measure is a ratio of
hospital charges from Medicare and Medicaid, divided by total charges, and grouped into percentages. The
second level analysis is estimated to be completed before the end of 2023.
WSHA hospital cost analysis
In July 2022, Jonathan Bennett, Vice President of Data and Analytic Services for WSHA and Bruce Deal,
Economic Expert for WSHA, presented their analysis of Washington State hospitals and hospital costs. WSHA
sought to provide a supplementary analysis to Bartholomew-Nash & Associates’ hospital cost analyses.
Two-thirds of patient days in the hospital are provided by 19 larger hospitals in Washington.
29
The
Washington state hospital system is comprised of five large systems and several smaller ones. Compared to
national standards, Washington hospital admissions, utilization, and length of stay are very low.
30
28
The secondary analysis will include Medicare CMI, which is based on inpatient utilization. The dataset will
include a CMI adjustment to total adjusted discharges, as well as a CMI adjustment to only the inpatient
discharges, plus outpatient discharge equivalents. These variables will be labeled ‘CMI-Adjusted Discharges’
and ‘CMI-Adjusted Inpatient Discharges Plus Outpatient Discharge Equivalents.’
29
A larger hospital is one with over 250 beds in the hospital.
30
Bennett, Jonathan, WSHA and Deal, Bruce, WSHA. Washington State Hospitals: A Primer on Washington
Hospital Costs. July 2022.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 27
Table 3: Washington hospitals by size
Source: A Primer on Washington State Hospitals. WSHA. 2022. Note: CAH refers to Critical Access Hospital.
Table 4: Washington hospitals by system affiliation
Source: A Primer on Washington State Hospitals. WSHA. 2022. Note: LTAC refers to long-term acute care hospitals and Psych
refers to psychiatric hospital
.
The costs of running a hospital were also outlined, including employee costs, supply costs, purchased
services (including travelling nurses) and facility/equipment costs. For example, a 300-bed hospital with over
50 departments would cost approximately $500 million annually. Salaries and benefits would represent about
60 percent of total costs, with an average of $125,000 per full-time-employee (FTE) in salary and benefits.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 28
Figure 12: Hospital cost example
Source: WA DOH Hospital Financial Reports
Workforce trends
In August 2022, Dr. Bianca Frogner, Board Member and Director of the Center for Health Workforce Studies
for UW, relayed her findings on workforce trends in Washington to the Board. Dr. Frogner provided details
on the:
• Health workforce and its connection to health care spending.
• Effects of the COVID-19 pandemic on the health care workforce.
• National health care workforce shortage and support strategies.
Health care labor and wage rates have generally grown at a smooth rate, but the contribution of labor to
health care spending is not well understood, especially at the state level. Dr. Frogner also presented research
on:
• Various sectors within the health care industry and how much employment they represent.
• Occupations within the health care industry.
• Average education in each sector.
• Racial and ethnic distribution.
At the peak of the pandemic, in April 2020, 1.4 million health care jobs were lost in the United States. Various
researchers and analyses tracked turnover among health care workers during the pandemic and looked at
turnover rates per COVID phase by sector, occupation, race/ethnicity, and gender/parenthood. COVID has
had the largest effect on long-term care employment. Additionally, since the start of the pandemic, wage
rates have increased nationally and continue to increase at a faster rate in Washington.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 29
Figure 13: Relative number of health care employees by segment, January 2020–July
2022
(January 2020=1.00)
Source: Influence of health workforce trends on health spending growth, Calculations by Bianca Frogner, 2022.
https://www.bls.gov/news.release/empsit.t17.htm.
Currently, there is a low health care labor supply.
31
There are several reasons for this, including lack of
availability to work due to COVID and caregiving responsibilities, or unwillingness to work due to safety
concerns or burnout. There is also a lack of qualified applicants because training is unavailable, slow, and
expensive to complete. The availability of health care workers has fluctuated significantly over the pandemic
and has not yet returned to pre-pandemic levels. As the economy recovers, competition will arise from other
industries and within the health care sector. Labor shortages will continue to hamper access to care, and the
board will continue to monitor the impact of workforce trends on health care costs.
Administrative costs
At the October 2022 board meeting, Dr. Mika Sinanan, M.D., Ph.D., Medical Director for Contracting and
Value-Based Specialty Care, University of Washington Medicine, and Jeb Shepard, director of policy for
WSMA, gave a joint presentation to the board on administrative costs using data from WSMA, the American
Medical Association (AMA) and Health Affairs. In their presentation, WSMA cited a study from the Annals of
Internal Medicine that determined physicians spend only 27 percent of their total time with patients
compared to 49 percent spent completing administrative work, e.g., work with electronic health records
31
Influence of health workforce trends on health spending growth. Frogner, Bianca K. University of
Washington Center for Health Workforce Studies. August 2022.
0.80
0.85
0.90
0.95
1.00
1.05
1.10
Jan-20
Mar-20
May-20
Jul-20
Sep-20
Nov-20
Jan-21
Mar-21
May-21
Jul-21
Sep-21
Nov-21
Jan-22
Mar-22
May-22
Jul-22
Total Private
Offices of Physicians
Other ambulatory care
Home Health
Hospitals
Nursing & Residential Care
Facilities
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 30
(EHRs).
32
The same study found that on average, clinicians spend one to two hours of personal time each day
doing additional clerical work, e.g., responding to patient emails, etc., which has contributed to burnout, both
before and during the pandemic.
WSMA reviewed several examples of administrative burdens in the health care system, including insurance
approvals, prior authorization requests, coding and billing, and practice management. Increased
administrative costs can be associated with several negative consequences, including more complicated
coding systems, variable contractual agreements, and non-standard health care service authorization
processes. Time spent on administrative work has resulted in less time spent with patients, reduced access to
care, poorer clinical outcomes, and increased practice and treatment costs.
33
Data from a 2022 Health Affairs
study that compared billing and insurance-related costs across six countries found that coding costs were
significantly higher in the U.S. compared to the other countries.
34
The same cross-national analysis found that
administrative costs consumed 25 to 31 percent of total health care spending in the U.S. The Board will
continue to monitor administrative costs and their impact on total health care cost growth.
Figure 14: Billing and insurance-related costs in six countries, by activity category,
derived from a time-driven activity-based costing study, 2018–2020
Cost per bill, purchasing power parity adjusted. Source: The Cost of Administrative Burden, WSHA, October 2022
32
The Cost of Administrative Burden. WSMA. 2022. Allocation of Physician Time in Ambulatory Practice: A
Time and Motion Study in 4 Specialties | Annals of Internal Medicine (acpjournals.org)
33
The Cost of Administrative Burden. WSMA. 2022.
34
https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.00241
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 31
IHME analysis
IHME will be partnering with HCA on a two-year, $1.7 million grant, funded jointly by the Peterson Center on
Healthcare and Gates Ventures, to create a new Analytic Support Initiative. The grant runs from 2023 through
2025 and will combine in-house expertise in health care spending, state data, and policy with world-class
analytics capabilities at IHME. This partnership with IHME builds on Washington’s efforts to improve health
care affordability and transparency. The Analytic Support Initiative will provide additional data and evidence
to guide the Board’s recommendations in addressing health care costs. This grant builds on prior research by
IHME on the drivers of health care cost growth, funded by the Peterson Center on Healthcare and Gates
Ventures, as well as the Peterson-Milbank Program for Sustainable Health Care Costs that helps states build
capacity to set and track health cost growth targets.
Advisory committee on primary care
Background
Primary care is a fundamental component of the health care system. Primary care promotes healthier
outcomes through preventive care and addresses a range of issues, including short and long-term health
problems. Over time, expectations related to primary care service delivery have increased, while practitioners
remain understaffed and underpaid in comparison to other medical specialties. This has led to multiple issues
with primary care delivery, including sharp reductions in the primary care workforce, limited access to care,
and inequitable care delivery.
35
Strong evidence supports the value of investing in primary care to deliver
higher quality health outcomes and lower total health care costs.
36
Nationally, primary care spending remains low compared to other medical expenditures, e.g., other
professional services, prescription drugs, and hospital care.
37
Washington primary care spending is also low,
but current reporting could be refined to account for additional data. While Washington tracks claims-based
spending, the state does not yet track non-claims-based primary care spending, unlike Oregon and Rhode
Island.
38
. Non-claims-based payments are payments made for services other than through traditional fee-for-
service payments. Non-claims-based spending includes but is not limited to capitated payments, sub-
capitated payments, bundled payments, quality incentive payments, shared savings/risk arrangement
payments, and infrastructure payments.
35
National Academies of Sciences, Engineering, and Medicine 2021. Implementing High-Quality Primary Care:
Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press.
https://doi.org/10.17226/25983.
36
Mark Friedberg, Peter S. Hussey, and Eric C. Schneider, “Primary Care: A Critical Review of the Evidence on
Quality and Costs of Health Care” Health Affairs 29, no. 5 (2010): 766-772.
37
Centers for Medicare and Medicaid Services, Office of the Actuary, All Payments.
38
Washington State Office of Financial Management, Forecasting and Research, Primary Care Expenditures,
Summary of current primary care expenditures and investment in Washington, Report to the Legislature,
December 2019.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 32
With the passage of SSB 5589 in 2022, the Legislature directed the board to build on previous efforts to
define and measure primary care spending, and to consider work from the Office of Financial Management
(OFM), the Dr. Robert Bree Collaborative (Bree Collaborative), other states, and the HCA in its
recommendations. Washington became one of 19 states with statutory or regulatory actions to measure
primary care spending and one of 11 states publishing annual reports on primary care spending. However,
there is no standard definition of primary care in use at a national level or a universal method for measuring
primary care expenditures, making it difficult to directly compare primary care spending between different
states.
In October 2022, the Board established the Advisory Committee on Primary Care to develop
recommendations for consideration by the Board to define and measure primary care spending. Under the
legislation, the Board is responsible for:
• Defining primary care.
• Detailing how to achieve Washington’s target to increase primary care expenditures to 12 percent of
total health care expenditures.
• Effectively measuring primary care, including identifying any barriers to access and use of data, and
how to overcome them.
In December 2022, the Board released an initial legislative report on primary care spending. The report
detailed the establishment of the primary care committee and the committee’s initial progress reviewing
existing primary care work in Washington. The report also previewed the committee’s work to create a high-
level definition of primary care, based on an amalgamation of the National Academy of Engineering and
Medicine (NASEM) and the Bree Collaborative’s definitions of primary care.
Objective 1: Defining primary care
In February 2023, the board approved the Advisory Committee on Primary Care’s recommended definition of
primary care. The definition was later amended by the Advisory Committee on Primary Care after additional
stakeholdering with WSHA and other members of the public. The final definition of primary care is:
“Team-based care led by an accountable primary care clinician that serves as a person’s
source of primary contact with the larger healthcare system. Primary care includes a
comprehensive array of equitable, evidence-informed services to support patients in
working toward their goals of physical, mental, and social health and the general
wellbeing of each person, through illness prevention, and minimizing disease burden,
through a continuous relationship over time. This array of services is coordinated by the
accountable primary care clinician but may exist in multiple care settings or be delivered
in a variety of modes.”
Recommendation for a claims-based measurement methodology
The Board also recently approved and adopted the Advisory Committee on Primary Care’s recommendations
regarding a claims-based measurement approach to primary care providers, facilities, and services. Providers
were grouped into narrow and broad categories (see tables 5 and 6) for measurement and modeled closely
on the providers selected by OFM in their 2019 primary care expenditures report. The committee’s list of
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 33
primary care facilities was developed with significant input from researchers at UW Medicine (see Figure 16).
Finally, to select the list of service codes, committee members reviewed information compiled by the
California Health Care Foundation, which consolidated code-level primary care service definitions from across
11 states (including Washington), as well as two health care organizations, Milliman and the New England
States Consortium Systems Organization (NESCSO).
Table 5: Primary care service providers – narrow
Primary Care Provider Types and Relevant Subtypes - Narrow
•
Advanced Practice Registered Nurse
o Nurse practitioner
o Nurse midwife
• Family medicine
o Adolescent medicine
o Adult medicine
o Geriatric medicine
• General practice
• Internal medicine
o Internal medicine/pediatrics
o Geriatric medicine
•
Naturopath
• Pediatrics
o Adolescent medicine
• Physician assistant
• Prevention medicine,
Preventive/Occupational environmental
medicine
Table 6: Primary care service providers – broad
Primary Care Provider Types and Relevant Subtypes - Broad
•
Advanced Practice Registered Nurse
o Nurse practitioner
o Nurse midwife
o Psychiatric mental health
• Counselors
o Addiction (substance use
disorder)
o Mental Health
• Family medicine
o Addiction Medicine
o Adolescent medicine
o Adult medicine
o Bariatric Medicine
o Geriatric medicine
o Hospice and Palliative Care
• General practice
• Internal Medicine
o Pediatrics
o Addiction Medicine
o Bariatric Medicine
•
Marriage and Family Therapist
• Naturopath
• OBGYN
• Physician Assistant
o Psychiatric Mental Health
• Psychologist
o Addiction (substance use
disorder)
o Clinical
o Adult Development and Aging
o Etc.
• Prevention medicine,
preventive/occupational environmental
• Registered Nurse
• Social Worker
o Clinical
o School
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 34
o
Geriatric
Note: The broad definition includes all provider types and subtypes from the narrow definition
Table 7: Primary care facilities
Primary Care Facilities
• Ambulatory Health Clinic/Center
• Community Health Clinic/Center
• Critical Access Hospitals (CAHs) with
Method II Billing
• Federally Qualified Health Center (FQHC)
• Indian Health Services Facility
• Long-term Care Facility
• Multi-specialty Clinic/Center
• Primary Care Clinic (including on-site at
hospitals)
• Rural Health Clinic (RHC)
• School-based Health Center
• Urgent Care Clinic with IPCP
• Virtual Care
Recommending a non-claims-based measurement methodology
In May 2023, the Primary Care Committee heard joint presentations from the State of Oregon and Bailit
Health on non-claims-based measurement methodologies. To date, the committee has initiated discussions
of possible non-claims-based approaches for use in Washington.
Objective 2: Detailing how to achieve Washington’s target to increase
primary care expenditures to 12 percent of total health care
expenditures
In April 2023, the committee began a discussion of policies to achieve the 12 percent primary care
expenditure target. The committee used a four-domain framework to begin exploration of different types of
policies that could support the expenditure target goal. The four domains (direct investment, capacity
growth, patient behavior, and reduced expenditure on other services) are shown in Figure 15.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 35
Figure 15: Four-component primary care policy framework
A key observation that emerged from the committee’s discussion was that while direct investment is critically
important, it is insufficient to achieve the primary care expenditure target and the goal of ensuring access to
and appropriate utilization of high-quality primary care services for the population. With that concept in
mind, the committee developed a preliminary list of policies across three of the domains that committee
members were interested in exploring further. Reduced expenditures on other services as a means of
achieving the 12 percent expenditure target was not discussed, as ideally this will occur naturally as a result
of implementation of other policies to support primary care. The preliminary list below was informed by
strategies implemented in other states, strategy recommendations at the national level, and committee
member ideas. The initial list of polices, ordered by level of committee support, included the following:
1. Direct Investment - Increase primary care reimbursement.
2. Capacity Growth - Payer focus on reducing administrative burden/costs for providers.
3. Capacity Growth - Forgiveness for non-compete clause penalties incurred by primary care clinicians
who leave a position to work elsewhere in Washington State.
4. Patient Behavior - Encourage employers to support/incentivize/encourage patients in selecting a
PCP.
5. Capacity Growth - State funded expansion of loan forgiveness opportunity.
6. Capacity Growth - Work with education system to bolster pipeline of healthcare professionals.
•Increase patients’
use of primary care
services
•Reduce utilization
of other services
due to improved
primary care access
•Reduce barriers to
spending time on
patient care
•Workforce
investment
•Pay more for
primary care
services
Direct Investment Capacity Growth
Patient Action
Reduced
Expenditure on
Other Services
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 36
7. Direct Investment - Increasing Medicaid reimbursement for primary care services
8. Capacity Growth - Multipayer collaboration to develop and implement payment models that offer
greater financial flexibility and incentives while growing access and improving quality.
9. Capacity Growth - Provide options for practice teams to have a fully capitated system.
10. Direct Investment - Increase fee-for-service for remote patient monitoring services and chronic care
management.
11. Direct Investment - Increase fee-for-service reimbursement for care team members such as clinical
pharmacists, care coordinators / Community Health Workers, registered nurses, etc.
In addition to the aforementioned policies, the committee also discussed data and information technology
policies that would be important to support effective delivery of primary care, maximize capacity, improve
patient behavior through patient navigation and care coordination, and monitor the delivery system. The
preliminary list of policies the committee members expressed interest in was informed by recommendation
at the national policy level, opportunities related to existing efforts in Washington state, and ideas from
committee members. The initial list of polices, ordered by level of committee support, included the
following:
1. Invest in and support HCA's EHR-as-a-Service initiative which will provide access to certified EHR for
BH, small, and rural providers.
2. Invest in and support HCA's Electronic Consent Management (ECM) initiative to support exchange of
health information.
3. Maximize utility of OneHealthPort through investment and other policy initiatives.
4. Maximize comprehensiveness/utility of APCD by encouraging self-funded plans to contribute data.
5. Support Master Patient Index by promoting use of a uniform patient identifier.
6. Expand the reach of the Clinical Data Repository through investment and other policy initiatives.
The committee will continue to explore policy options and refine policy recommendations that support
achieving the 12 percent expenditure target over the course of the remaining committee meetings in 2023.
Objective 3: Effectively measuring primary care, including identifying
any barriers to access and use of data
Work is currently underway with HCA’s data team to develop a data strategy that addresses primary care
data collection challenges. The data strategy also will clarify who is responsible for measuring and reporting
on primary care data. This work will continue throughout the remainder of 2023.
Next steps
Committee work to-date has largely focused on development of a primary care definition and initial
exploration of policies that will support achieving the 12% primary care expenditure target. Next steps for
the committee include the following:
• Finalize claims/nonclaims-based measurement methodology recommendations,
• Finalize development of a suite of policy recommendations to achieve the 12% expenditure target
and related strategies to incentivize achievement of the target and present these options to the
Board for potential adoption, and
• Identify and recommend strategies to remediate challenges in measuring primary care expenditures.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 37
Conclusion
The Board’s continued efforts on its data projects—the benchmark, performance against the benchmark (the
data call), cost driver analysis, and primary care spending—will support more comprehensive health care cost
reporting and creation of effective recommendations for the Legislature. Thorough research and
understanding of increasing health care costs will facilitate and enhance efforts to improve affordability. The
Board’s evidence-based approach to health care cost data will provide a common understanding of spending
trends for consumers, purchasers, and regulators to help make health care more affordable in Washington.
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 39
Appendix A – County level PMPM data
Note: Medicare Advantage and Medicare FFS do not include pharmacy or total medical and pharmacy values
because Part D missing for 2020 and 2021. Medicare FFS data not available for 2020 and 2021 and Medicare
FFS is not included in the “Total” product. Data for categories with 1-10 services have been omitted due to
privacy concerns.
Year
Product
Category of
Spending
Geography
Type
Region
PMPM
2021
Medicaid
Total Medical
County
Franklin
$ 135
2021
Medicaid
Total Medical
County
San Juan
$ 139
2021
Medicaid
Total Medical
County
Adams
$ 154
2021
Medicaid
Total Medical
County
Walla
Walla
$ 169
2021
Medicaid
Total Medical
County
Grant
$ 169
2021
Medicaid
Total Medical
County
Yakima
$ 169
2021
Medicaid
Total Medical
County
Douglas
$ 173
2021
Medicaid
Total Medical
County
Benton
$ 183
2021
Medicaid
Total Medical
County
Chelan
$ 184
2021
Medicaid
Total Medical
County
Clark
$ 193
2021
Medicaid
Total Medical
County
Whatcom
$ 201
2021
Medicaid
Total Medical
County
Skamania
$ 205
2021
Medicaid
Total Medical
County
King
$ 207
2021
Medicaid
Total Medical
County
Kitsap
$ 215
2021
Medicaid
Total Medical
County
Skagit
$ 216
2021
Medicaid
Total Medical
County
Okanogan
$ 217
2021
Medicaid
Total Medical
County
Snohomish
$ 219
2021
Exchange - Commercial
Total Medical
County
Garfield
$ 220
2021
PEBB - Commercial
Total Medical
County
Columbia
$ 220
2021
Total
Total Medical
County
Franklin
$ 220
2021
Medicaid
Total Medical
County
Whitman
$ 223
2021
Exchange - Commercial
Total Medical
County
Columbia
$ 224
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 40
2021
Medicaid
Total Medical
County
Thurston
$ 226
2021
Medicaid
Total Medical
County
Lincoln
$ 229
2021
Medicaid
Total Medical
County
Spokane
$ 232
2021
Medicaid
Total Medical
County
Pierce
$ 233
2021
Medicaid
Total Medical
County
Stevens
$ 239
2021
Medicaid
Total Medical
County
Pend
Oreille
$ 240
2021
Medicaid
Total Medical
County
Asotin
$ 244
2021
Medicaid
Total Medical
County
Lewis
$ 245
2021
Medicaid
Total Medical
County
Cowlitz
$ 246
2021
Medicaid
Total Medical
County
Island
$ 251
2021
Total
Total Medical
County
Yakima
$ 255
2021
Medicaid
Total Medical
County
Kittitas
$ 255
2021
Medicaid
Total Medical
County
Klickitat
$ 263
2021
Total
Total Medical
County
Adams
$ 265
2021
Medicaid
Total Medical
County
Wahkiakum
$ 267
2021
Medicaid
Total Medical
County
Mason
$ 270
2021
Total
Total Medical
County
Benton
$ 273
2021
Exchange - Commercial
Total Medical
County
Yakima
$ 275
2021
Total
Total Medical
County
Grant
$ 278
2021
PEBB - Commercial
Total Medical
County
Yakima
$ 282
2021
Total
Total Medical
County
Pend
Oreille
$ 284
2021
PEBB - Commercial
Total Medical
County
Franklin
$ 289
2021
Exchange - Commercial
Total Medical
County
Thurston
$ 290
2021
Medicaid
Total Medical
County
Clallam
$ 292
2021
Total
Total Medical
County
Whitman
$ 292
2021
Exchange - Commercial
Total Medical
County
Whitman
$ 294
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 41
2021
Total
Total Medical
County
Walla
Walla
$ 294
2021
Medicaid
Total Medical
County
Jefferson
$ 296
2021
Exchange - Commercial
Total Medical
County
Franklin
$ 296
2021
Exchange - Commercial
Total Medical
County
Pend
Oreille
$ 297
2021
PEBB - Commercial
Total Medical
County
Island
$ 299
2021
Medicaid
Total Medical
County
Columbia
$ 299
2021
Exchange - Commercial
Total Medical
County
Klickitat
$ 299
2021
PEBB - Commercial
Total Medical
County
Whitman
$ 302
2021
Exchange - Commercial
Total Medical
County
Snohomish
$ 302
2021
Medicaid
Total Medical
County
Ferry
$ 303
2021
Medicaid
Total Medical
County
Pacific
$ 304
2021
Exchange - Commercial
Total Medical
County
Spokane
$ 304
2021
PEBB - Commercial
Total Medical
County
Asotin
$ 305
2021
Commercial
Total Medical
County
Pend
Oreille
$ 309
2021
Medicaid
Total Medical
County
Grays
Harbor
$ 309
2021
Exchange - Commercial
Total Medical
County
Pierce
$ 311
2021
PEBB - Commercial
Total Medical
County
Jefferson
$ 312
2021
Medicare Advantage
Total Medical
County
Ferry
$ 314
2021
PEBB - Commercial
Total Medical
County
San Juan
$ 314
2021
Commercial
Total Medical
County
Spokane
$ 316
2021
PEBB - Commercial
Total Medical
County
Benton
$ 317
2021
Exchange - Commercial
Total Medical
County
King
$ 321
2021
Total
Total Medical
County
Asotin
$ 321
2021
Total
Total Medical
County
Klickitat
$ 322
2021
PEBB - Commercial
Total Medical
County
Adams
$ 322
2021
Total
Total Medical
County
Okanogan
$ 323
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 42
2021
Exchange - Commercial
Total Medical
County
Walla
Walla
$ 323
2021
Exchange - Commercial
Total Medical
County
Island
$ 325
2021
Total
Total Medical
County
Lincoln
$ 325
2021
Total
Total Medical
County
Skamania
$ 327
2021
Total
Total Medical
County
San Juan
$ 331
2021
Total
Total Medical
County
Snohomish
$ 331
2021
Total
Total Medical
County
King
$ 332
2021
Exchange - Commercial
Total Medical
County
Asotin
$ 332
2021
Total
Total Medical
County
Stevens
$ 333
2021
Total
Total Medical
County
Spokane
$ 334
2021
PEBB - Commercial
Total Medical
County
Stevens
$ 334
2021
Commercial
Total Medical
County
Asotin
$ 335
2021
Total
Total Medical
County
Columbia
$ 335
2021
Exchange - Commercial
Total Medical
County
Benton
$ 336
2021
Commercial
Total Medical
County
Thurston
$ 336
2021
PEBB - Commercial
Total Medical
County
Spokane
$ 336
2021
Commercial
Total Medical
County
Whitman
$ 338
2021
PEBB - Commercial
Total Medical
County
Whatcom
$ 338
2021
Commercial
Total Medical
County
Benton
$ 339
2021
Total
Total Medical
County
Chelan
$ 339
2021
Total
Total Medical
County
Lewis
$ 340
2021
Total
Total Medical
County
Pierce
$ 341
2021
Total
Total Medical
County
Skagit
$ 344
2021
Commercial
Total Medical
County
Island
$ 345
2021
Total
Total Medical
County
Douglas
$ 346
2021
Total
Total Medical
County
Kitsap
$ 346
2021
Commercial
Total Medical
County
Franklin
$ 346
2021
Total
Total Medical
County
Thurston
$ 347
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 43
2021
Total
Total Medical
County
Whatcom
$ 348
2021
Commercial
Total Medical
County
Grays
Harbor
$ 348
2021
PEBB - Commercial
Total Medical
County
Walla
Walla
$ 349
2021
Exchange - Commercial
Total Medical
County
Skagit
$ 349
2021
Commercial
Total Medical
County
Yakima
$ 349
2021
Exchange - Commercial
Total Medical
County
Skamania
$ 351
2021
PEBB - Commercial
Total Medical
County
Skagit
$ 351
2021
Total
Total Medical
County
Kittitas
$ 353
2021
Commercial
Total Medical
County
King
$ 353
2021
PEBB - Commercial
Total Medical
County
Kitsap
$ 353
2021
Total
Total Medical
County
Jefferson
$ 354
2021
Total
Total Medical
County
Ferry
$ 354
2021
Commercial
Total Medical
County
Walla
Walla
$ 356
2021
Exchange - Commercial
Total Medical
County
Jefferson
$ 357
2021
Total
Total Medical
County
Grays
Harbor
$ 358
2021
Commercial
Total Medical
County
Snohomish
$ 358
2021
PEBB - Commercial
Total Medical
County
Lewis
$ 361
2021
Medicaid
Total Medical
County
Garfield
$ 363
2021
Exchange - Commercial
Total Medical
County
Kitsap
$ 364
2021
Commercial
Total Medical
County
Skagit
$ 365
2021
Total
Total Medical
County
Island
$ 367
2021
Commercial
Total Medical
County
Pierce
$ 368
2021
Commercial
Total Medical
County
Whatcom
$ 369
2021
Exchange - Commercial
Total Medical
County
Mason
$ 370
2021
PEBB - Commercial
Total Medical
County
Pierce
$ 370
2021
Commercial
Total Medical
County
Kitsap
$ 371
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 44
2021
Exchange - Commercial
Total Medical
County
San Juan
$ 372
2021
PEBB - Commercial
Total Medical
County
Snohomish
$ 372
2021
Total
Total Medical
County
Garfield
$ 373
2021
Exchange - Commercial
Total Medical
County
Lewis
$ 373
2021
Commercial
Total Medical
County
Lincoln
$ 374
2021
PEBB - Commercial
Total Medical
County
Thurston
$ 376
2021
Exchange - Commercial
Total Medical
County
Kittitas
$ 376
2021
Total
Total Medical
County
Pacific
$ 378
2021
PEBB - Commercial
Total Medical
County
King
$ 378
2021
Exchange - Commercial
Total Medical
County
Stevens
$ 381
2021
PEBB - Commercial
Total Medical
County
Wahkiakum
$ 382
2021
PEBB - Commercial
Total Medical
County
Kittitas
$ 384
2021
PEBB - Commercial
Total Medical
County
Pend
Oreille
$ 385
2021
Commercial
Total Medical
County
Grant
$ 385
2021
Commercial
Total Medical
County
Garfield
$ 388
2021
PEBB - Commercial
Total Medical
County
Klickitat
$ 391
2021
Commercial
Total Medical
County
Kittitas
$ 391
2021
Total
Total Medical
County
Mason
$ 392
2021
Exchange - Commercial
Total Medical
County
Clark
$ 393
2021
Commercial
Total Medical
County
Columbia
$ 394
2021
Exchange - Commercial
Total Medical
County
Ferry
$ 394
2021
Exchange - Commercial
Total Medical
County
Lincoln
$ 395
2021
Exchange - Commercial
Total Medical
County
Whatcom
$ 395
2021
Commercial
Total Medical
County
Mason
$ 397
2021
Total
Total Medical
County
Clallam
$ 398
2021
Commercial
Total Medical
County
Skamania
$ 400
2021
PEBB - Commercial
Total Medical
County
Clallam
$ 405
2021
PEBB - Commercial
Total Medical
County
Clark
$ 405
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 45
2021
Commercial
Total Medical
County
Stevens
$ 406
2021
PEBB - Commercial
Total Medical
County
Garfield
$ 408
2021
Commercial
Total Medical
County
Lewis
$ 409
2021
PEBB - Commercial
Total Medical
County
Mason
$ 409
2021
PEBB - Commercial
Total Medical
County
Grant
$ 410
2021
Exchange - Commercial
Total Medical
County
Okanogan
$ 411
2021
Exchange - Commercial
Total Medical
County
Adams
$ 412
2021
Commercial
Total Medical
County
Klickitat
$ 412
2021
Commercial
Total Medical
County
Jefferson
$ 413
2021
Commercial
Total Medical
County
Chelan
$ 413
2021
Commercial
Total Medical
County
Ferry
$ 414
2021
PEBB - Commercial
Total Medical
County
Pacific
$ 416
2021
Exchange - Commercial
Total Medical
County
Grant
$ 416
2021
PEBB - Commercial
Total Medical
County
Grays
Harbor
$ 419
2021
Commercial
Total Medical
County
San Juan
$ 419
2021
Exchange - Commercial
Total Medical
County
Chelan
$ 424
2021
Commercial
Total Medical
County
Pacific
$ 425
2021
PEBB - Commercial
Total Medical
County
Lincoln
$ 426
2021
Exchange - Commercial
Total Medical
County
Grays
Harbor
$ 427
2021
PEBB - Commercial
Total Medical
County
Chelan
$ 438
2021
Commercial
Total Medical
County
Okanogan
$ 440
2021
Total
Total Medical
County
Clark
$ 442
2021
Commercial
Total Medical
County
Clark
$ 444
2021
Exchange - Commercial
Total Medical
County
Pacific
$ 445
2021
PEBB - Commercial
Total Medical
County
Douglas
$ 452
2021
PEBB - Commercial
Total Medical
County
Cowlitz
$ 463
2021
Exchange - Commercial
Total Medical
County
Wahkiakum
$ 468
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 46
2021
Commercial
Total Medical
County
Adams
$ 474
2021
Total
Total Medical
County
Cowlitz
$ 477
2021
PEBB - Medicare
Advantage
Total Medical
County
Grays
Harbor
$ 481
2021
Exchange - Commercial
Total Medical
County
Clallam
$ 483
2021
PEBB - Commercial
Total Medical
County
Okanogan
$ 484
2021
Commercial
Total Medical
County
Clallam
$ 488
2021
Total
Total Medical
County
Wahkiakum
$ 503
2021
Exchange - Commercial
Total Medical
County
Douglas
$ 504
2021
Medicare Advantage
Total Medical
County
Lewis
$ 505
2021
Commercial
Total Medical
County
Cowlitz
$ 507
2021
Commercial
Total Medical
County
Douglas
$ 508
2021
PEBB - Medicare
Advantage
Total Medical
County
Wahkiakum
$ 535
2021
PEBB - Commercial
Total Medical
County
Skamania
$ 538
2021
Medicare Advantage
Total Medical
County
Snohomish
$ 551
2021
Exchange - Commercial
Total Medical
County
Cowlitz
$ 589
2021
Medicare Advantage
Total Medical
County
Thurston
$ 592
2021
Medicare Advantage
Total Medical
County
King
$ 592
2021
Commercial
Total Medical
County
Wahkiakum
$ 613
2021
Medicare Advantage
Total Medical
County
Island
$ 631
2021
PEBB - Medicare
Advantage
Total Medical
County
Skagit
$ 634
2021
PEBB - Medicare
Advantage
Total Medical
County
Lewis
$ 642
2021
Medicare Advantage
Total Medical
County
Whatcom
$ 643
2021
Medicare Advantage
Total Medical
County
Yakima
$ 657
2021
Medicare Advantage
Total Medical
County
Skagit
$ 658
2021
Medicare Advantage
Total Medical
County
Pierce
$ 662
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 47
2021
Medicare Advantage
Total Medical
County
Spokane
$ 665
2021
Medicare Advantage
Total Medical
County
Franklin
$ 679
2021
PEBB - Medicare
Advantage
Total Medical
County
Whatcom
$ 681
2021
Medicare Advantage
Total Medical
County
Kitsap
$ 688
2021
Medicare Advantage
Total Medical
County
Stevens
$ 697
2021
PEBB - Medicare
Advantage
Total Medical
County
Kitsap
$ 701
2021
PEBB - Medicare
Advantage
Total Medical
County
Spokane
$ 702
2021
Medicare Advantage
Total Medical
County
Clallam
$ 707
2021
Medicare Advantage
Total Medical
County
Benton
$ 714
2021
Medicare Advantage
Total Medical
County
Jefferson
$ 717
2021
PEBB - Medicare
Advantage
Total Medical
County
Island
$ 718
2021
Medicare Advantage
Total Medical
County
San Juan
$ 719
2021
Medicare Advantage
Total Medical
County
Okanogan
$ 721
2021
PEBB - Medicare
Advantage
Total Medical
County
Thurston
$ 749
2021
PEBB - Medicare
Advantage
Total Medical
County
Snohomish
$ 751
2021
Medicare Advantage
Total Medical
County
Walla
Walla
$ 754
2021
PEBB - Medicare
Advantage
Total Medical
County
Mason
$ 758
2021
Medicare Advantage
Total Medical
County
Douglas
$ 770
2021
Medicare Advantage
Total Medical
County
Mason
$ 778
2021
Medicare Advantage
Total Medical
County
Chelan
$ 778
2021
Medicare Advantage
Total Medical
County
Grays
Harbor
$ 782
2021
PEBB - Medicare
Advantage
Total Medical
County
King
$ 789
Health Care Cost Transparency Board Annual Report
August 1, 2023
Page | 48
2021
PEBB - Medicare
Advantage
Total Medical
County
Pierce
$ 797
2021
Medicare Advantage
Total Medical
County
Asotin
$ 804
2021
Medicare Advantage
Total Medical
County
Garfield
$ 807
2021
Medicare Advantage
Total Medical
County
Kittitas
$ 826
2021
Medicare Advantage
Total Medical
County
Grant
$ 857
2021
Medicare Advantage
Total Medical
County
Columbia
$ 878
2021
PEBB - Commercial
Total Medical
County
Ferry
$ 886
2021
Medicare Advantage
Total Medical
County
Cowlitz
$ 892
2021
Medicare Advantage
Total Medical
County
Adams
$ 918
2021
Medicare Advantage
Total Medical
County
Clark
$ 952
2021
Medicare Advantage
Total Medical
County
Lincoln
$ 952
2021
Medicare Advantage
Total Medical
County
Wahkiakum
$ 953
2021
Medicare Advantage
Total Medical
County
Klickitat
$ 992
2021
Medicare Advantage
Total Medical
County
Whitman
$ 1,040
2021
PEBB - Medicare
Advantage
Total Medical
County
Cowlitz
$ 1,062
2021
Medicare Advantage
Total Medical
County
Skamania
$ 1,070
2021
Medicare Advantage
Total Medical
County
Pend
Oreille
$ 1,088
2021
PEBB - Medicare
Advantage
Total Medical
County
Clark
$ 1,124
2021
PEBB - Medicare
Advantage
Total Medical
County
Skamania
$ 1,176
2021
Medicare Advantage
Total Medical
County
Pacific
$ 1,262
