November 2015

MyMedicalShopper, Inc. 75 Congress Street, L05 Portsmouth, NH 03801

Contact: Christopher Matrumalo – Chris@mymedicalshopper.com – 603 292-3043

New Hampshire Healthcare Savings Potential

An Analysis of Price Disparities between Provider Types, Emergency Department Overuse, and Healthcare

Consumption by Age, Sex, and Cost

New Hampshire Healthcare Savings Potential – MyMedicalShopper Quarterly Report

New Hampshire Healthcare Savings Potential – MyMedicalShopper Quarterly Report

NEW HAMPSHIRE AT A GLANCE In New Hampshire, annual healthcare costs1 have grown from $7,839 per person in 2009, to $10,500 per person in 2015.i MyMedicalShopper preliminary reports estimate that NH residents could have saved nearly $346M in 2014 on the top 100 most common procedures by choosing low-cost, high-quality providers. The average insurer discount in New Hampshire was higher than two bordering states (Maine and Vermont), but lower than the average discount rate in Massachusetts. Despite NH having the second highest average insurer discount among the four states compared—NH, ME, VT, and MA—care is oftentimes cheaper in both Maine and Massachusetts, which is due to varying charged amounts among various providers in each state.ii MyMedicalShopper found that nearly 22% of care for New Hampshire privately insured residents was received out-of-state. Most of the out-of-state care was in Massachusetts, partly due to often-lower prices as well as the availability of medical facilities. A significant finding is that MyMedicalShopper concerns emergency department overuse. Many procedures performed at emergency rooms are not true emergences and could be done at a walk-in clinic or urgent care facility instead. We estimate emergency room overuse at 43.7% of all ER visits. Changing patient attitudes towards emergency care and urgent care can help save significant dollars in the future. Our analysis shows that the greatest savings potential for consumers can be found when comparing medical procedure pricing at non-hospital facilities (NHFs) to hospitals. As expected, hospitals tend to charge more than other providers for many procedures. It is important to note however, that different types of facilities have varying capabilities and equipment, therefore it may not always be appropriate or safe to go to an NHF for treatment of a complex condition. PURPOSE The purpose of this study is to demonstrate the savings potential for New Hampshire residents concerning healthcare costs through the following:

highlighting price disparities for common medical procedures between different provider types

quantifying emergency department overuse

analyzing healthcare consumption by age.

This study will further show that the use of healthcare comparison shopping tools by consumers in the new age of healthcare consumerism can result in significant savings,

1 Premiums, out-of-pocket costs, and care not received through insurance

New Hampshire Healthcare Savings Potential – MyMedicalShopper Quarterly Report

especially for individuals with high out-of-pocket exposure. In fact, as we educate a new generation of empowered healthcare consumers, we expect even greater savings, as our analyses show the potential for saving more than 60% on total healthcare spending in NH.

More background information on our nationwide healthcare crisis can be found at the end of this report. ABOUT THE STUDY’S AUTHOR MyMedicalShopper shines a light on the secretive world of healthcare pricing. Our unique pricing tool enables true comparison shopping for medical procedures. We can save small and midsize employers more than 33% on health insurance premiums while improving employee health benefits.

Our end users are leveraging the MyMedicalShopper platform to access extensive information on price and quality of more than 8,800 medical tests and procedures across more than 700 medical care providers in NH, MA, ME, and VT. MMS Members are expected to reduce their out-of-pocket healthcare spending by over 32% on average.

DATA SOURCES AND METHODOLOGY The primary data source for the study is the NH all-payer claims data (APCD) from 2014 and the first quarter of 2015. MMS experts analyze the source data with our proprietary algorithms, removing outliers and statistical anomalies. KEY FINDINGS Pricing of Common Surgical and Endoscopic Procedures More diagnostic colonoscopies, upper GI endoscopies, arthroscopic knee surgeries, and arthroscopic shoulder surgeries are performed at hospitals vs. non-hospital facilities (NHFs). Hospitals also have higher average costs for these procedures compared to NHFs.

New Hampshire Healthcare Savings Potential – MyMedicalShopper Quarterly Report

Endoscopy Consumers can save 18.5% on a diagnostic colonoscopy and 30.8% on an upper GI endoscopy by going to an NHF instead of a hospital. Despite these relatively low price differences between hospitals and NHFs for diagnostic colonoscopies and upper GI endoscopies, consumers collectively wasted $2.1M and $3.1M respectively over the amount they would have paid at an NHF, by having these procedures performed at a hospital. Surgery For an arthroscopic knee surgery consumers can save 21.7%, and for an arthroscopic shoulder surgery consumers can save 14.0% by going to an NHF that performs these surgeries, instead of a hospital. Consumers wasted nearly $670,000 on arthroscopic knee surgeries and $215,000 on arthroscopic shoulder surgeries by having these surgeries performed at a hospital instead of an NHF.

New Hampshire Healthcare Savings Potential – MyMedicalShopper Quarterly Report

Pricing of Common Imaging Procedures All three of these common imaging procedures are performed more often at hospitals than NHFs, such as imaging centers. Non-hospital facilities, for these three common procedures have lower procedures prices compared to hospitals. Consumers wasted $4.6M collectively on all three imaging procedures by having them performed at a hospital instead of an NHF.

Ankle X-ray The savings potential by going to an NHF for an ankle X-ray was the highest among all imaging procedures in this graph at 56.8%. Consumers wasted $680,000 on ankle X-rays performed at hospitals. Chest X-ray Like an ankle X-ray, a chest X-ray is another common imaging procedure with significant savings potential and the second highest savings potential out of the three imaging procedures compared above at 40.9%. Out of all three imaging procedures, consumers wasted the most money on chest X-rays, wasting nearly $2.7M by going to a hospital to have this procedure performed. However, some of these may have been performed during an emergency or hospital stay, and therefore not all chest X-rays can be avoided at a hospital.

New Hampshire Healthcare Savings Potential – MyMedicalShopper Quarterly Report

Mammography The savings potential for consumers who went to an NHF instead of hospital for a mammography is less than a chest or ankle X-ray at 8%. The lower savings potential for a mammography is less than that of a chest or ankle X-ray because hospitals are only slightly more expensive than NHFs for this procedure. Regardless, consumers still wasted $1.3M by having their mammography performed at a hospital, instead of an NHF. Pricing of Diagnostic Labs and Physical Therapy Diagnostic labs and physical therapy comprise some of the most common procedures performed in NH on an annual basis, and they also vary wildly in price.

Diagnostic Labs Between all three diagnostic lab procedures, consumers collectively wasted $6.1M by going to a hospital instead of NHF for these common lab procedures. More of these diagnostic lab procedures were performed at hospitals than NHFs. The savings potential for a comprehensive metabolic lab is 81.3% by going to an NHF. On this diagnostic lab alone, consumers wasted $3.4M by having the procedure performed at a hospital.

New Hampshire Healthcare Savings Potential – MyMedicalShopper Quarterly Report

Lipid panel had the second most significant savings potential out of the three diagnostic labs included in the graph at 78%. While consumers wasted less on lipid panels than comprehensive metabolic panels performed at hospitals, they still wasted $2.7M. The savings potential for a strep test performed at an NHF versus a hospital is less significant than for a comprehensive metabolic panel or lipid panel, as hospitals and NHFs have comparable pricing for strep tests. However, consumers can still save 19.4% by going to an NHF for a strep test. Physical Therapy Out of all three physical therapy procedures compared, the only one performed more frequently at an NHF was manual therapy. Collectively, consumers wasted $6.7M on all three physical therapy procedures. Hospitals were higher priced than NHFs for these physical therapy procedures. Chiropractic manipulation had the least savings potential out of all three procedures, however it is significant (56.1% by going to an NHF). Consumers wasted $150,000 on chiropractic manipulation performed at hospitals. Manual therapy had the greatest savings potential for consumers who go to an NHF for treatment instead of a hospital at 86.3%. Price differences between hospitals and NHFs for manual therapy are dramatically different and therefore show a significant amount of waste ($1.7M) by having the procedure performed at a hospital. Therapeutic exercises also had a significant savings potential at 83.9%. This procedure also had the most amount of waste out of all three physical therapy procedures ($4.8M) by consumers having this procedure performed at a hospital. Medical Procedure Consumption by Age, Sex, and Cost Newborns and both sexes from ages 40–65 have relatively higher healthcare costs and claims than other age groups. The apparent drop-off in number of claims at age 65 for both sexes indicated in the graph below is due to individuals switching from private insurance to Medicare. A noticeable drop-off for both sexes at 26 is likely due to individuals who become ineligible to be on parental insurance. Year 50 is expensive for both sexes, which is likely due to the increase in recommended preventive care, such as colonoscopy screenings at that age. Females overall, have higher claims and costs of claims compared to males. Some of this can be attributed to childbearing years, which is shown as the "bulge" in claims in years 26-38. Men are most costly between the ages of 18-28 and 40-65.

New Hampshire Healthcare Savings Potential – MyMedicalShopper Quarterly Report

New Hampshire Healthcare Savings Potential – MyMedicalShopper Quarterly Report

Emergency Department Overuse Emergency department visits are billed in terms of severity. Many walk-in clinics and urgent care facilities are equipped to deal with non-life threatening emergencies, such as broken bones, sore throats, and kidney infections, typically with shorter wait times and cheaper prices. MyMedicalShopper estimates emergency department overuse comprises 43.7% of all ER visits, when consumers could have instead gone to a walk-in clinic or urgent care facility. The chart on the following page illustrates the breakdown of ER visits in terms of severity.

New Hampshire Healthcare Savings Potential – MyMedicalShopper Quarterly Report

CONCLUSIONS Conclusions gathered from this data strongly suggest that consumers should go to non-hospital facilities—surgery, imaging, lab, and urgent care centers—for commonly performed procedures when appropriate, to save the most money. Consumers are also strongly encouraged to comparison shop for their healthcare through use of a price transparency tool like MyMedicalShopper, in order for them to choose which provider is the best fit based on price, quality, and convenience. Currently, consumers have little access to comprehensive cost and quality information for providers and procedures. With provider pricing varying wildly, this information is vital in order for consumers to cut healthcare costs. When consumers do have the right tool and are actively engaged in shopping for care, they can realize significant savings. MyMedicalShopper members are currently on track to save more than 32% on out-of-pocket costs in 2015. Likewise, employers that arm employees with this tool could save more than 33% in health insurance premiums. ADDITIONAL BACKGROUND Healthcare costs are continuing to rise in the United States at an alarming rate. In 1970, healthcare costs were 7.2% of America's GDP.iii As of 2013, healthcare costs represent 18% of the GDP (or $3.1T), and are projected to be 20% of the GDP by 2022.iv The chart below shows healthcare expenditures as a percentage of GDP since 1965.v Since the 1970's, healthcare costs have outpaced wage increases, signaling a crisis decades in the making.vi From 1999-2015, healthcare costs have grown by an average of 7.6% annually, while wages have only grown 2.8% annually.vii If this trend is not resolved

New Hampshire Healthcare Savings Potential – MyMedicalShopper Quarterly Report

in the coming years, it is clear that businesses, consumers, and our government will face an even bigger economic crisis. As it stands today, businesses—big and small—are being crippled by healthcare costs. To compensate for high costs, employers are shifting healthcare costs to their workforce in the form of higher deductibles and out-of-pocket exposure. While this is an unfortunate reality, it has sparked an unprecedented age of consumerism in the healthcare industry. Though still in its infancy, healthcare consumerism offers significant potential for dramatically decreasing healthcare costs nationwide, not only through increased engagement because of high deductibles, but through price and quality transparency with healthcare comparison shopping tools. However, most healthcare consumers currently have little access to provider quality and pricing data. When consumers have access to this data, they can make educated consumer decisions, comparable to online or grocery shopping, where quality and price can be readily compared between products. Price is often used as a proxy for quality in industries where consumers have limited knowledge. In the world of healthcare however, the opposite is true. For example, a surgery center specializing in knee arthroscopy procedures will have surgeons equally or more experienced in performing the procedure than those of a higher-priced, lower-volume hospital across the street. In fact, risks are higher at low-volume hospitals, and procedure performance frequency has been cited as an accurate indicator of quality.viii Armed with the knowledge that cost and quality are not related, in addition to incentives ignited by high deductibles, the savings potential for individuals and the general public when it comes to healthcare is astronomical. ABOUT MYMEDICALSHOPPER MyMedicalShopper enables true comparison shopping for medical procedures by shining a light on the secretive world of healthcare pricing. We can save small and midsize employers more than 33% on health insurance premiums while improving employee health benefits. Now anyone can become an empowered consumer and never overpay for healthcare again. At MyMedicalShopper, our mission is to empower healthcare consumers by providing access to provider pricing and quality data for virtually every medical procedure, so consumers can take control of their physical and financial health.

New Hampshire Healthcare Savings Potential – MyMedicalShopper Quarterly Report

Our website and mobile apps make it possible for medical consumers to choose their care based on price, quality, and convenience. MyMedicalShopper is addressing a huge need in the market by integrating actual medical procedure cost data with real-time consumer insurance information in order to create an unparalleled, personalized tool. The driving vision is to reverse the trend of rising healthcare costs and to develop technology to interpret, create, and display the symmetric data needed to transform the healthcare industry into a fair market for consumers.

Our end users are leveraging the MyMedicalShopper platform to access extensive information on price and quality of more than 8,800 medical tests and procedures across virtually every medical care provider, and reduce their out-of-pocket healthcare spending by over 32% on average. In fact, as we educate a new generation of empowered healthcare consumers, we expect even greater savings, as our analyses show the potential for saving more than 60% on total healthcare spending in NH.

In addition to the personal savings that each user can realize (even with the “freemium” version of our app), employers are licensing our platform to take a proactive approach to reducing their health benefits costs. Businesses are benefiting from MyMedicalShopper in a number of important ways: providing the MMS app to their employees as a new benefit; reducing health insurance premiums as a direct result of reducing their total medical claims; and saving the time, money, and frustration associated with administering health savings accounts (HSAs), health reimbursement arrangements (HRAs), and flexible spending accounts (FSAs) through MyMedicalShopper’s robust employer dashboard.

MyMedicalShopper has also recently added the benefit of automated EOB monitoring for fraud and overbilling detection. The error rate for medical bills (which derive from EOBs), is estimated at up to 80%. Fraud is estimated at nearly $300 billion, according to one noted Harvard expert. MyMedicalShopper can help individuals recover money by identifying overbilling and taking remedial action. Lowering payments made to providers helps employers reduce their healthcare costs.

MyMedicalShopper is empowering informed decision-making by providing instant access to our expansive data through our cutting-edge technology platform, which is accessible through our iOS and Android mobile apps, as well as our website.

New Hampshire Healthcare Savings Potential – MyMedicalShopper Quarterly Report

Endnotes

i" The Kaiser Family Foundation State Health Facts." Data Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. National Health Expenditure Data: Health Expenditures by State of Residence, December 2011. ii MyMedicalShopper Data Analysis, Fall 2015. Data Source: NH All-Payer Claims Database, 2014 & Q1 2015. iii "Health Care Costs: A Primer." The Kaiser Family Foundation. May 01, 2015. http://kff.org/health-costs/issue-brief/health-care-costs-a-primer/. iv "Health Expenditures." Centers for Disease Control and Prevention. April 29, 2015. http://www.cdc.gov/nchs/fastats/health-expenditures.htm. "National Health Expenditure Projections 20 2 - 2022." Centers for Medicare & Medicaid Services. 2012. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/downloads/proj2012.pdf. Radnofsky, Louise. "U.S. Health-Spending Growth Jumped to 5.5% in 2014." The Wall Street Journal. July 25, 2015. http://www.wsj.com/articles/u-s-health-spending-growth-jumped-to-5-5-in-2014-1438114020?alg=y. v "Reforming Health Care for the 21st Century." National Economic Council. February 2006. http://georgewbush-whitehouse.archives.gov/stateoftheunion/2006/healthcare/. vi Hall, Katy, and Jan Diedhm. "Why U.S. Health Care Is Obscenely Expensive, In 12 Charts." The Huffington Post. October 3, 2013. http://www.huffingtonpost.com/2013/10/03/health-care-costs-_n_3998425.html. vii Sarasohn-Kahn, Jane. "Health Consumers' Cost Increases Far Outpace Wage Growth "- Health Populi." Health Populi. September 23, 2015. http://healthpopuli.com/2015/09/23/health-consumers-cost-increases-far-outpace-wage-growth/. viii Gantz, Sarah. "Johns Hopkins Wants Surgeons to Stop Performing Procedures They Do Infrequently." Baltimore Business Journal. May 20, 2015. http://www.bizjournals.com/baltimore/news/2015/05/20/johns-hopkins-wants-surgeons-to-stop-performing.html

MyMedicalShopper, Inc. 75 Congress Street, L05 Portsmouth, NH 03801

New Hampshire Healthcare Savings Potential – MyMedicalShopper Quarterly Report

Contact: Christopher Matrumalo – Chris@mymedicalshopper.com – 603 292-3043