Table of Contents Introduction 1 Definitions of Injury and Expenses 1 Population Characteristics 2 Total Expenses for Injury-Related Conditions 2 Ambulatory Care Expenses 3 Inpatient Hospital Expenses 4 Source of Payment 4 Summary 5 References 6 Figures showing percent distributions of expenses: 1. For injury-related conditions by type of care 3 2. For non-injury-related conditions by type of care 3 3. For injury-related conditions by source of payment 4 4. For non-injury-related conditions by source of payment 5 Tables showing information on injury-related conditions: 1. Percent with conditions and percent incurring expenses 7 2. Total medical expenses 8 3. Ambulatory medical expenses 9 4. Inpatient medical expenses 10 Technical Appendix Survey Design 11 Definitions of Terms 12 Significance Testing 14 Rounding 14 Standard Error Tables 15 Health Care Expenses for Injuries: Estimates from the 1997 MEPS by Nancy A. Krauss, M.S., Steven R. Machlin, M.S., Agency for Healthcare Research and Quality; Gregory A. Adams, M.A., Doctoral Candidate, University of Massachusetts Introduction Injuries are the fifth leading cause of death in the United States (Hoyert, Arias, Smith, et al., 2001) and the leading cause of death for people ages 1-44 (Department of Health and Human Services (U.S.), 2000). The risk of injury is so great that most people sustain a significant injury at some time during their lives (Department of Health and Human Services (U.S.), 2000). It is not surprising that injuries impose a large burden on national health care costs, exceeded only by heart disease and cancer (Cohen and Krauss, 2003). This report presents estimates from the 1997 Medical Expenditure Panel Survey Household Component (MEPS HC) of spending for direct medical care provided for conditions caused by injuries among the U.S. civilian noninstitutionalized population. Because direct medical costs do not include reduced or lost productivity in the working-age population or the nonmonetary cost of the disability and emotional stress caused by injuries, this report does not analyze the total economic burden attributable to injuries. Emphasis is placed on injury-related expenses for ambulatory care and inpatient hospital care. Specific comparisons are made by age, sex, race/ethnicity, health insurance status, and poverty status. The overall distribution of expenses is shown by type of care and source of payment for injury- and non-injury-related conditions. The estimates are representative of the civilian noninstitutionalized population of the United States during calendar year 1997. A technical appendix at the end of this report provides definitions of the variables used in this report. It also gives a detailed description of the MEPS HC, including data collection methods, sample size, variable construction, and statistical procedures used to derive estimates. The standard errors for the tables and figures discussed in the text of this report are also shown in the appendix. Only differences between estimates that are statistically significant at the 0.05 level are discussed in this report. Definitions of Injury and Expenses The standard definition of injury is the occurrence of sudden external forces resulting in trauma. Furthermore an injury may be unintentional (an accident) or intentional (violence or abuse). A single injury episode may result in several injuries or conditions. For example, a person may fall (the injury episode) and receive a concussion and a broken hip (the conditions related to the injury episode). This report examines 1997 expenses for medical treatment of conditions resulting from an injury episode regardless of whether the episode occurred in 1997 or prior to 1997. Approximately 41 percent of the injuries for which households reported receiving treatment during 1997 actually occurred in a prior year (data not shown). The household respondent identified the date of the injury and the resulting conditions in the Condition Enumeration section of the MEPS HC Questionnaire and identified the number and type of provider visits in the Medical Event Sections. (See www.meps.ahrq.gov for details regarding the questionnaire.) This report contains estimates of the percent of the population reported to have an injury-related condition, not the percent with an injury per se. If a person did not have a medical provider visit and did not miss work or school because of an injury, such as a pulled muscle, the injury may not have been reported during the MEPS interview. This report focuses on overall expenses in 1997 associated with injuries, as well as on expenses for ambulatory care and for inpatient hospital care, and estimates injury-related expenses as a proportion of total expenses for all care provided in these settings. Ambulatory visits to medical providers in office and hospital settings, hospital inpatient care, home health care, and prescribed medicines are included in total expenses, but payments for over-the-counter-drugs, alternative care services, and telephone contacts with medical providers are not included. In contrast to other reports containing MEPS expenditure estimates (e.g., Thorpe and Machlin, 2000), this report excludes expenses for durable medical equipment and other miscellaneous items (eyeglasses, contact lenses, ambulance services, orthopedic items, hearing devices, prostheses, bathroom aids, medical equipment, disposable supplies, and other miscellaneous items or services) because it was not possible to determine from the survey questions which of these expenses were associated with injuries. Population Characteristics Approximately 23 percent of the population (about 62 million persons) had a medical condition in 1997 that resulted from an injury (Table 1), and approximately 70 percent of those people (about 43 million) had some medical expense for that condition. About 16 percent of children under age 16 had at least one injury-related condition, compared to about one-quarter of people 16 years of age and over. People ages 16-24 were less likely to have an expense associated with an injury-related condition than those under 16 or 45 and over. Females (21.2 percent) were less likely than males (25.0 percent) to have had an injury-related condition. Males and females who had an injury-related condition were equally likely to have a related medical expense. Whites (25.4 percent) were more likely than blacks (17.3 percent), Hispanics (17.5 percent), and others (14.6 percent) to have an injury-related condition. The probability of having an injury-related condition did not vary by either insurance status or poverty status. However, the uninsured population under age 65 were the least likely to report an injury-related expense. Total Expenses for Injury-Related Conditions An estimated $57.9 billion was spent on injury-related conditions for the U.S. civilian noninstitutionalized population in 1997 (Table 2). This was 10.8 percent of all health care spending during that year. For people with an injury-related expense, the mean expense for injury-related conditions was $1,330 but the median expense was only $241. As a proportion of total expenses for all health care in 1997, injuries presented a greater burden for people ages 16-24 (25.6 percent) than for those under 16 or 45 and over. The mean expense for injury-related conditions was lowest for children under age 16 ($467). An estimated $35.3 billion was spent on health care for injury-related conditions for males, higher than the $22.6 billion spent for women. The proportion of total expenses associated with injuries was about twice as high for males (14.9 percent) as for females (7.5 percent). Per capita expenses were about 62 percent higher for males ($266) than for females ($163), and mean expenses for people with injury-related conditions also were higher for males ($1,536) than for females ($1,101). Per capita injury-related expenses for whites were $246 in 1997, higher than for blacks ($122) or Hispanics ($137). Among those under age 65, the proportion of total medical expenses attributable to injuries was approximately twice as high for the uninsured (24.3 percent) as for people with private coverage (12.4 percent) and people with public insurance (11.0 percent). There were no statistically significant differences among poverty status groups in the proportion of total expenses attributable to injuries, per capita expenses, or the mean or median expenses for injury-related conditions. Figures 1 and 2 summarize the distribution of expenses for injury- and non-injury-related conditions, respectively, by type of care received. Ambulatory care accounted for a higher proportion of expenditures for injuries (51.3 percent) than noninjury conditions (31.7 percent). The proportion of total expenses that went for inpatient hospital care was similar for injury- and non-injury-related conditions (36.9 percent and 39.3 percent, respectively). Dental care and prescribed medicines made up a smaller proportion of expenses for injury-related conditions: dental care, 2.2 vs. 9.0 percent; prescribed medicines, 4.4 vs. 14.6 percent. Ambulatory Care Expenses In 1997 expenses for injury-related care received by the U.S. civilian noninstitutionalized population in office-based settings and clinics, hospital outpatient departments, emergency rooms, and clinics owned and operated by hospitals amounted to approximately $29.7 billion, representing 16.4 percent of the ambulatory care expenses for all conditions (Table 3). The per capita expense for ambulatory care for injury-related conditions was $109. For those with an injury-related expense, the mean cost of ambulatory care for injury-related conditions was $787 and the median expense was $234. Injury-related expenses for ambulatory visits accounted for about one-quarter of all ambulatory expenses for people ages 16-24 (26.4 percent) and 25-44 (24.5 percent), a higher proportion than for the other age groups. Per capita expenses for ambulatory care were highest for people ages 25-44 ($146) and 45-64 ($152). For persons with injury-related expenses, mean injury-related ambulatory care expenses also were highest for people ages 25-44 ($968) and 45-64 ($991). Expenses for injury-related ambulatory care were higher for males ($17.0 billion) than for females ($12.7 billion). The proportion of total ambulatory care expenses associated with injuries was about 9 percentage points higher for males than for females (21.6 vs. 12.3 percent). However, differences in mean ambulatory care expenses for males and females were not statistically significant. There were no statistically significant differences in the proportion of total ambulatory expenses associated with injuries by race/ethnicity. The mean injury-related expense was not statistically significantly different for blacks ($689) than for either whites or Hispanics, but it was significantly higher for whites ($813) than for Hispanics ($594). For the population under 65 years old, the proportion of total ambulatory expenses attributed to injuries was higher for uninsured people (29.7 percent) than for those with private insurance (19.3 percent) or public insurance (16.1 percent). Differences in mean expenses by insurance status for this age group were not statistically significant. For people age 65 and over, the proportion of total ambulatory care expenses attributed to injuries was more than twice as high for those covered by Medicare only (9.5 percent) as for people covered by Medicare and other public insurance (4.3 percent). There were no statistically significant differences in mean ambulatory care expenses for injury-related conditions by poverty status. Inpatient Hospital Expenses The inpatient expense estimates shown in Table 4 include room and board charges, all hospital diagnostic and laboratory expenses associated with the basic facility charge, payments for separately billed physician inpatient services, and emergency room expenses incurred immediately prior to inpatient stays for injury-related conditions. Estimated expenses for inpatient services for injury-related conditions in 1997 were about $21.4 billion, which constituted 10.2 percent of expenditures for all inpatient care. The mean inpatient expense per person for people with an injury-related inpatient expense was $9,510, while the median expense was $5,473. The amount spent on injury-related conditions for people ages 16-24 ($4.6 billion) amounted to an estimated 39.6 percent of all inpatient expenses for that age group.1 This proportion is substantially higher than the estimated proportions of total inpatient expenses for any other age group (ranging from 6.7 to 12.5 percent). Males incurred about 72 percent of the total expenses for injury-related inpatient care in 1997Ñ$15.3 billion, compared to only $6.1 billion for females. The proportion of inpatient expenses spent on injury-related care was approximately three times as high for males (15.4 percent) as for females (5.5 percent). Per capita expenses for injury-related inpatient care were nearly three times as high for males ($115) as for females ($44). The mean injury-related expense for those with an injury-related inpatient expense was about $4,300 higher for males than for females ($11,194 compared to $6,891). 1 Relative standard errors of 30 percent or more. The proportion of total inpatient expenses for injury-related care did not vary by race/ethnicity. However, per capita expenses for injury-related inpatient care for the white population ($93) were more than double expenses for the black population ($42), and the mean cost for inpatient care for injury-related conditions was substantially higher for whites than for blacks ($10,084 vs. $5,936). There were no statistically significant differences in either the proportion of inpatient medical expenses attributable to injuries or the mean inpatient care expenses for injury-related conditions by either insurance status or poverty status. Source of Payment Figures 3 and 4 summarize the percent distribution of expenses by source of payment for injury- and non-injury-related conditions in 1997. WorkersÕ Compensation covered 14.4 percent of injury-related expenses. The proportion paid out of pocket was smaller for injury-related conditions than for non-injury-related conditions (11.5 percent vs. 19.1 percent). In contrast, the proportion of expenses paid by private insurance was similar for both injuries (45.2 percent) and noninjuries (44.0 percent), despite the noteworthy proportion of expenses for injuries paid by WorkersÕ Compensation. Summary Approximately $57.9 billion was spent on injury-related care in 1997, constituting 10.8 percent of all health care spending during that year. This amount does not include payments for over-the-counter-drugs, alternative care services, telephone contacts with medical providers, or expenses for durable medical equipment or other miscellaneous items such as eyeglasses or ambulance services. The average total expense for injury-related conditions was lowest for children under 16 ($467 per person with expense). However, as a proportion of total health care expenditures in 1997, injuries imposed a relatively high burden on people ages 16-24 years; about one-quarter of their total health care costs were attributed to injury-related conditions, a significantly higher share than for most other age groups. Furthermore, injury-related health care for this age group accounted for about 40 percent of all inpatient care expenses (about $4.6 billion),2 higher than for any other age group. Injury prevention strategies targeted toward this group of older teenagers and young adults may well be cost effective. The proportion of total medical expenses associated with injuries was about twice as high for males (14.9 percent) as for females (7.5 percent). Males also incurred approximately 72 percent of all inpatient health care expenses for injury-related conditions ($15.3 billion). About 15.4 percent of all inpatient expenses for males were for injury-related conditions, approximately three times the proportion for females (5.5 percent). Injury-related conditions also accounted for approximately one-fifth (21.6 percent) of ambulatory care expenses for males compared to only 12.3 percent for females. The impact of injuries on national health care expenditures raises important public policy issues. The extent of expenses for injury-related care is particularly significant when one considers that, unlike many major conditions, injuries often can be prevented or avoided by relatively inexpensive intervention programs (Bernstein and Schur, 1990). In Healthy People 2010 (Department of Health and Human Services (U.S.), 2000), the reduction of unintentional injuries, as well as violence and abuse, was identified as a priority area. Achievement of these national goals requires timely and accurate measures of the incidence of injury and expenses, including data on cause of injury and type of injury sustained, to form the basis for planning, analysis, and evaluation of injury control efforts (Miller and Lestine, 1996). 2Relative standard errors of 30 percent or more. References Bernstein AB, Schur CL. Expenditures for unintentional injuries among the elderly. J Aging Health 1990; 2:157-78. Cohen JW, Krauss NA. Spending and service use among people with the fifteen most costly medical conditions, 1997. Health Aff 2003 Mar./Apr.; 22(2):129-38. Cohen SB. Sample design of the 1996 Medical Expenditure Panel Survey Household Component. Rockville (MD): Agency for Health Care Policy and Research; 1997. MEPS Methodology Report No. 2. AHCPR Pub. No. 97-0027. Cohen SB. Sample design of the 1997 Medical Expenditure Panel Survey Household Component. Rockville (MD): Agency for Healthcare Research and Quality; 2000. MEPS Methodology Report No.11. AHRQ Pub. No. 01-0001. Department of Health and Human Services (U.S.). Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington: U.S. Government Printing Office; Nov. 2000. Hoyert DL, Arias E, Smith BL, et al. Deaths: final data for 1999. Hyattsville (MD): National Center for Health Statistics; 2001. National Vital Statistics Reports; Vol. 49, No. 8. Miller TR, Lestine DC. Patterns of U.S. medical expenditures and utilization for injury, 1987. Am J Public Health 1996; 86:89-93. Thorpe JM, Machlin SR. Health care expenses in the U.S. civilian noninstitutionalized population, 1997. Rockville (MD): Agency for Healthcare Research and Quality; 2000. AHRQ Pub. No. 01-R086.