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					                       Report on the Maryland Medical Assistance Program and the
                       Maryland Children’s Health Program – Reimbursement Rates
                                             January 2012

Contents                                                                                                                               Page

I.         Introduction ....................................................................................................................2 

II.        Background ....................................................................................................................2 

III.       Physician Fee Changes in FY 2010, FY 2011, and FY 2012 ........................................5 

                      FY 2011 Physician Fees.....................................................................................6 

                      Physician Fee Reduction for FY 2012 ...............................................................6 

IV.        Maryland’s Medicaid Fees Compared with Medicare and Other States’ Fees..............6 

           Comparisons of E&M and Specialty Procedures...........................................................7 

V.         Trauma Center Payment Issues....................................................................................25 

VI.        Reimbursement for Oral Health Services ....................................................................25 

VII.       Physician Participation in the Maryland Medicaid Program .......................................26 

VIII.  Plan for Future Fee Increases.......................................................................................29 

Appendix A. Medicare RBRVS and Anesthesia Reimbursement ...........................................30 

Appendix B. Employed Physicians by Specialty Area, 2010 ..................................................32 

Appendix C. Rate of Non-Federal Physicians per 100,000 Civilian Population, 2009 ...........35 

Appendix D. Rate of Dentists per 100,000 Civilian Population, 2009 ....................................37 

References ................................................................................................................................39 




                                                                        1
                 Report on the Maryland Medical Assistance Program and the
                 Maryland Children’s Health Program – Reimbursement Rates
                                       January 2012

I.        Introduction

In 2002, Chapter 464 (SB 481) of the laws of Maryland was enacted, directing the Maryland
Department of Health and Mental Hygiene (the Department) to establish a process whereby the
fee-for-service (FFS) reimbursement rates for the Maryland Medical Assistance (Medicaid)
program and the Maryland Children’s Health Program (MCHP) would be established annually in
a manner that ensures provider participation. The law further stipulated that, in order to develop
the rate-setting process, the Department should take into account community reimbursement
rates and annual medical inflation, or utilize the Resource-Based Relative Value Scale (RBRVS)
methodology and American Dental Association (ADA) Current Dental Terminology (CDT-3)
codes. The RBRVS methodology is used by the federal Medicare program to set the Medicare
fee schedule.

The law also directed the Department to submit an annual report to the Governor and various
House and Senate committees regarding the following:

      •   The progress of the rate-setting process mentioned above
      •   A comparison of Maryland Medicaid’s reimbursement rates with the rates of other states
      •   The schedule for bringing Maryland’s reimbursement rates to a level that would ensure
          provider participation in the Medicaid program
      •   The estimated costs of implementing the above schedule and proposed changes to the
          fee-for-service reimbursement rates

In addition, the Department has incorporated into this report information required by HB 70 from
the 2009 session. Section 15 of this act requires the Department to review the rates paid to
providers under the federal Medicare fee schedule and compare those rates with the FFS rates for
the same services paid to providers under the Maryland Medical Assistance program and
managed care organizations (MCOs). On or before January 1 of every year, the Department is
required to report this information and state whether the FFS rates and MCO provider rates will
exceed the rates paid under the Medicare fee schedule. This report satisfies these requirements.

II.       Background

In September 2001, in response to Chapter 702 (HB 1071) of the 2001 session, the Department
prepared the first annual report, analyzing the physician fees that are paid by the Maryland
Medicaid and MCHP programs. In 2002, SB 481 required the submission of this report on an
annual basis. This is the eleventh annual report.

The Department’s first annual report showed that Maryland’s Medicaid reimbursement rates in
2001 were, on average, approximately 36 percent of Medicare rates. The report also included the
results of a survey conducted by the American Academy of Pediatrics in 1998/1999, which
showed that Maryland’s physician reimbursement rate for a subset of procedures ranked 47th


                                                 2
among all Medicaid programs in the country. Based on the 2001 report, the Governor and the
Legislature allocated $50 million in additional total funds ($25 million state funds) to increase
physician fees in the Medicaid program, beginning July 2002. The increase was targeted to
evaluation and management (E&M) procedure codes that are used by both primary care
physicians and specialty care physicians.

SB 836 of the 2005 General Assembly session, entitled “Maryland Patients’ Access to Quality
Health Care Act of 2004 – Implementation and Corrective Provisions,” created the Maryland
Health Care Provider Rate Stabilization Fund. The main revenues of the fund are from a tax
imposed on MCOs and health maintenance organizations (HMOs). SB 836 allocated funds to the
Maryland Medical Assistance program to increase both FFS physician fees and capitation
payments to MCOs to enable these organizations to similarly raise their provider fees. 1 The
legislation allocated $15 million in additional state funds ($30 million total funds) in fiscal year
(FY) 2006 to be used by the Department to increase fees for procedures that are commonly
performed by obstetricians, neurosurgeons, orthopedic surgeons, and emergency medicine
physicians. The legislation targeted the fee increase to these physician specialties because of the
substantial rise in their malpractice insurance premiums. The bill also allocates additional funds
each year to the Maryland Medical Assistance program for maintaining physician fees.

SB 836 also required the Department to consult with the MCOs, the Maryland Hospital
Association, the Maryland State Medical Society (MedChi), the Maryland Chapter of the
American Academy of Pediatrics, the Maryland Chapter of the American College of Emergency
Physicians, the Maryland State Dental Association, and the Maryland Dental Society to
determine the new payment rates each year. These organizations are collectively referred to as
stakeholders in this report.

The Department used the Medicare physician payment methodology as a benchmark, or point of
reference, when it increased physician fees in FYs 2003, 2006, 2007, 2008, and 2009. Medicare
fees are based on the RBRVS methodology, which relates payments to the resources and skills
that physicians use to provide services. The Centers for Medicare and Medicaid Services (CMS)
annually updates the Medicare fee schedule. (See Appendix A for a description of the RBRVS
methodology).

For FY 2007 and FY 2008, based on the stakeholders’ recommendations, the Department
increased fees for procedures of different specialties, as shown in Table 1. In addition,
procedures with the lowest fees were raised to a minimum of 50 percent of Medicare fees in
FY 2008. Subsequently, the Department implemented other fee changes for FY 2009. In
previous years, fees for many procedures, including orthopedic, gynecology/obstetrics,
neurosurgery, otorhinolaryngology (ENT), and emergency medicine were set at 100 percent of
their corresponding Medicare fee. Medicare fees in general had not increased substantially
during the 2006 to 2008 period. However, updates in relative value units (RVUs) led to Medicare
fee decreases for many procedures, which caused Maryland Medicaid fees for some of these
procedures to exceed Medicare fees. At the same time, Medicaid fees for many procedures were
at 50 percent of Medicare fees. Therefore, based on the stakeholders’ recommendations, the
Department increased the lowest Medicaid fees and re-balanced any Medicaid fees that were
1
    Maryland Medicaid Assistance program includes both Medicaid and MCHP.


                                                      3
higher than their corresponding Medicare fees. In addition, separate fees for different sites of
service were established so that Medicaid fees would have site of service differentials for
facilities (e.g., hospitals) and non-facilities (e.g., offices).

Medicaid fees that were higher than Medicare fees were reduced to their corresponding Medicare
fee levels by site of service, and the lowest fees were raised to 78.6 percent of their
corresponding Medicare fees by site of service. The exceptions to this methodology were that
fees for four obstetric procedures (normal and cesarean delivery procedures) were maintained at
their original FY 2008 levels, which are higher than their corresponding Medicare fees.

SB 836 allocated funds to increase capitation payments to MCOs to enable these organizations to
raise their physician fees. Accordingly, the Department increased MCOs’ capitation rates to
reflect the costs of the physician fee increases. To ensure that the MCOs use these funds to raise
their physician fees, the Department requires MCOs to pay their network physicians at least 100
percent of the Medicaid physician fee schedule. Furthermore, the Department reviews the
physician fee schedule of each MCO to monitor compliance with this requirement.

Table 1 shows the percentage of Medicare fees for targeted groups of procedures at the times of
original fee increases in FYs 2003, 2006, 2007, 2008, and 2009.




                                                 4
                 Table 1. Prior Fee Increases to Percentage of Medicare Fees
                                                                  Percent of Medicare
       Fiscal
                            Procedure Code Group                     Fees at Time of
       Year
                                                                  Original Fee Increase
       2003     Evaluation and management (99201-99499)                    80%
       2006     Four Specialties:
                Orthopedic (20000-29999)                                  100%
                Gynecology/Obstetrics (56405-59899)                       100%
                Neurosurgery (61000-64999)                                100%
                Emergency Medicine (99281-99285)                          100%
       2007     Anesthesia (00100-01999)                                  100%
                General Surgery (10000-19396)                             80%
                Digestive System (40490-49905)                            80%
                ENT (69000-69990, 92502-92700)                            100%
                Radiation Oncology (77261-77799)                          80%
                Allergy/Immunology (95004-95199)                          80%
                Dermatology (96900-96999)                                 80%
       2008     Evaluation and management (99201-99499)                   80%
                Evaluation and management in hospital outpatient          50%
                departments
                Neonatology procedures (99294, 99296, 99299)              90%
                Radiology procedures (70010-79900,                        53%
                excluding 77261-77799)
                Vaccine administration procedures                         66%
                Psychiatry (90801-90911)                                  61%

                Floor for the lowest fees                                      50%
       2009     Set separate fees for facilities and non-facilities

                Floor for the lowest fees                                     78.6%

                Orthopedic (20000-29999),                                      100%
                Gynecology/Obstetrics (56405-59899)                            100%
                Neurosurgery (61000-64999)                                     100%
                Emergency Medicine (99281-99285)                               100%

III.    Physician Fee Changes in FY 2010, FY 2011, and FY 2012

The national economic recession reduced state revenues in FY 2010. Therefore, the Department
implemented a reduction in physician fees for FY 2010. Effective July 1, 2009, physician fees
were reduced to achieve an $11.5 million total reduction in payment for physician services for
FY 2010. Some groups of procedure codes and specialties were excluded from the reduction in
fees. Enrollment growth rates were set consistent with historical trends. Then, fees for remaining
procedures were reduced across the board by 5.8 percent to achieve the required reduction of the
$11.5 million in FY 2010 payments.


                                                  5
FY 2011 Physician Fees

The Medicare program regularly updates RVUs for procedures. This results in fee increases for
some procedures and fee decreases for other procedures. The Department compared the
Maryland Medicaid fee for each procedure with its corresponding Medicare fee and reduced
fees for procedures that exceeded Medicare fees to the Medicare fee levels. Fees for the four
obstetric delivery procedure codes (59409, 59410, 59514, and 59515) remained at their original
levels. Aside from these minor adjustments, the Department kept FY 2011 physician fees at the
same level as FY 2010 fees.

Physician Fee Reduction for FY 2012

The Department implemented a $6.52 million total funds reduction in payments for physician
services for FY 2012. Some groups of procedure codes were excluded from the reduction in
fees.

1.     The four specialties mentioned in SB 836 (Orthopedic, Obstetrics/Gynecology,
       Neurosurgery, and Emergency) are kept at a maximum of 100 percent of Medicare fees,
       without increasing their fees. In other words, if the current Medicaid fee for one of these
       procedures was greater than its corresponding Medicare fee, then it was set equal to the
       Medicare fee. However, if the Medicaid fee for one of these procedures was lower than
       its corresponding Medicare fee, then it was not changed.
2.     There are 4 obstetric (delivery) procedures (59409, 59410, 59514, and 59515), 3
       neonatal intensive care unit (NICU) procedures (99469, 99472, and 99479), and 22
       procedure codes that are used by educational institutions (90801, 90804, 90806, 90808,
       90847, 90853, 92506, 92507, 92508, 92557, 96101, 96152, 97001, 97002, 97003, 97004,
       97110, 97150, 97530, 97802, 97803, and T1000) that were kept at their original FY 2011
       levels.

Consistent with the recent trends in enrollment, we assumed a 10 percent annual increase in total
enrollment, which resulted in an approximate 21 percent increase from the database year (FY
2010) to the implementation year (FY 2012). Then, we applied an across-the-board 1.22 percent
reduction in fees for all remaining procedures to achieve the required reduction in FY 2012
payments. Overall, fees were reduced from an average of 75 percent to an average of 74 percent
of Medicare 2011 fees. Of the $6.52 million total reduction in FY 2012 payments, about $1.06
million will be from the reduction in FFS payments and about $5.46 million will be from the
reduction of HealthChoice MCOs’ capitation payments for physician services.

IV.    Maryland’s Medicaid Fees Compared with Medicare and Other States’ Fees

Maryland’s neighboring states have their own Medicaid fee schedules. For this report, we
collected data on the Medicaid physician fees of Delaware, Pennsylvania, Virginia, West
Virginia, and Washington, D.C. We obtained the current physician fee schedules from the
states’ websites and compiled data on each state’s Medicaid fees for a sample of approximately
200 high-volume procedures in various specialties.




                                                6
Table 2 compares Maryland’s FY 2012 Medicaid fees with the corresponding Medicare and
neighboring states’ Medicaid fees for a sample of high-volume procedures in each specialty
group. In this table, procedure fees are rounded to the nearest dollar amount and the last row of
each section shows each state’s weighted average fees for surveyed procedures as a percentage
of Medicare fees in Maryland. Maryland Medicaid’s numbers of claims and encounters were
used as the weights for fees. The average percentage of Medicare fees reported in this table
corresponds to the appropriate Medicare non-facility and facility fees.

Facilities include inpatient hospitals, nursing homes, and other medical care facilities. Non-
facilities mainly include physician offices. Physician fees include three components: physician’s
work, practice expenses (e.g., costs of maintaining an office), and malpractice insurance
expenses. Practice components of fees are, on average, approximately 40 percent of total fees.
When physicians render services in facilities, they do not incur a practice expense. Hence,
facility fees are usually lower than non-facility fees.

Maryland and West Virginia have separate facility and non-facility fees. Therefore, their facility
and non-facility fees are compared with the corresponding Medicare fees. However, for
Washington, D.C., Delaware, and Pennsylvania, which have one fee for each procedure, fees are
compared with Medicare non-facility fees. Hence, for Washington, D.C., Delaware, and
Pennsylvania, the percentages of Medicare fees reported in the table underestimate the
percentage of Medicare fees for procedures performed in facilities. In 2009, Washington, D.C.
set its Medicaid fees to 100 percent of its Medicare non-facility fees. Therefore, it generally has
the highest physician reimbursement rates in the region. Virginia has separate facility and non-
facility fees for some procedures. However, it did not report facility fees for many procedures
that are included in Table 2. Therefore, we reported only Virginia’s Medicaid non-facility fees.

For this report, we have compared Maryland’s and other states’ Medicaid rates with the
Medicare fee schedule for Maryland. Average Medicare fees in Maryland are approximately 3
percent higher than Medicare fees in Pennsylvania, approximately 4 percent higher than
Medicare fees in Virginia, 5 percent higher than Medicare fees in Delaware, and 7 percent
higher than Medicare fees in West Virginia. Average Medicare fees in Washington, D.C. are
approximately 6 percent higher than average Medicare fees in Maryland.

Comparisons of Evaluation and Management (E&M) and Specialty Procedures

In the following paragraphs, we compare Maryland’s fees with other states’ fees for E&M and
each group of specialty procedures, as shown in Table 2.

E&M Procedures
As an average percentage of Medicare fees in Maryland, Washington, D.C. has the highest fees
in the region for the selected E&M procedures. Delaware ranks second; Maryland facility fees
rank third; Virginia non-facility fees rank forth; Maryland non-facility fees rank fifth; West
Virginia facility fees and non-facility fees rank sixth and seventh, respectively; and
Pennsylvania ranks eight. West Virginia did not report fees for three neonatal procedures, so its
percentage of Medicare fees is lower than it would have been had it covered these procedures.



                                                 7
Surgery:

Integumentary Procedures
For integumentary 2 procedures, Washington, D.C. fees rank first, followed by Delaware fees
(second), Maryland facility fees (third), Virginia non-facility fees (fourth), Maryland non-
facility fees (fifth), West Virginia facility fees (sixth), West Virginia non-facility fees (seventh),
and Pennsylvania fees (eighth).

Musculoskeletal System Procedures
Delaware fees for musculoskeletal system procedures are the highest in the region. Washington,
D.C. fees rank second, Maryland facility fees rank third, Maryland non-facility fees rank fourth,
Virginia non-facility fees rank fifth, West Virginia facility fees rank sixth, West Virginia non-
facility fees rank seventh, and Pennsylvania fees rank last.

Respiratory Procedures
For respiratory procedures, Washington, D.C. fees rank first, followed, in ranking order, by
Delaware fees, Virginia non-facility fees, Maryland facility fees, Maryland non-facility fees,
West Virginia facility fees, West Virginia non-facility fees, and Pennsylvania fees.

Cardiovascular System Surgery Procedures
For selected cardiovascular system surgery procedures, Washington, D.C. has the highest fees.
Virginia non-facility fees rank second, Maryland non-facility fees rank third, Maryland facility
fees rank fourth, West Virginia facility fees rank fifth, West Virginia non-facility fees rank
sixth, Delaware fees rank seventh, and Pennsylvania fees rank eighth. Because Pennsylvania has
missing fees for three surveyed procedures, its percentage of Medicare fees is lower than it
would have been had it covered these procedures.

Hemic, Lymphatic, and Mediastinum Systems Procedures
Washington, D.C. has the highest fees for hemic, lymphatic, and mediastinum systems
procedures in the region, followed by Delaware fees, Virginia non-facility fees, Maryland non-
facility fees, West Virginia facility fees, Maryland facility fees, West Virginia non-facility fees,
and Pennsylvania fees. Pennsylvania has a missing fee for procedure 38792 (identify sentinel
node), so its percentage of Medicare fees is lower than it would have been had it covered this
procedure.

Digestive System Procedures
For selected digestive system procedures, Washington, D.C. fees rank the highest, followed by
Delaware fees (second), Virginia non-facility fees (third), Maryland non-facility fees (fourth),
West Virginia facility fees (fifth), Maryland facility fees (sixth), West Virginia non-facility fees
(seventh), and Pennsylvania fees (eighth).




2
    Integumentary procedures are related to skin.


                                                    8
Urinary and Male Genital Procedures
Washington, D.C. fees for urinary and male genital procedures rank highest in the region.
Maryland non-facility fees rank second, Virginia non-facility fees rank third, Maryland facility
fees rank fourth, West Virginia facility fees rank fifth, West Virginia non-facility fees rank
sixth, and Delaware fees rank seventh. Pennsylvania fees rank last in the region.

Gynecology and Obstetrics Procedures
Pennsylvania has the highest fees for the selected gynecology and obstetrics procedures,
followed, in ranking order, by West Virginia facility fees, West Virginia non-facility fees,
Maryland facility fees, Maryland non-facility fees, Washington, D.C. fees, Virginia non-facility
fees, and Delaware fees.

Endocrine System Procedures
For selected endocrine system procedures, Washington, D.C. fees rank the highest. Delaware
fees rank second, Virginia non-facility fees rank third, West Virginia facility fees rank fourth,
West Virginia non-facility fees rank fifth, Maryland non-facility fees rank sixth, Maryland
facility fees rank seventh, and Pennsylvania fees rank last.

Nervous System Procedures
Washington, D.C. fees for nervous system procedures are the highest in the region, followed, in
ranking order, by Delaware fees, Maryland non-facility fees, Maryland facility fees, Virginia
non-facility fees, West Virginia facility fees, West Virginia non-facility fees, and Pennsylvania
fees.

Eye Surgery Procedures
For selected eye surgery procedures, Delaware fees rank first, Washington, D.C. fees rank
second, Virginia non-facility fees rank third, West Virginia facility fees rank fourth, West
Virginia non-facility fees rank fifth, Pennsylvania fees rank sixth, Maryland non-facility fees
rank seventh, and Maryland facility fees rank last.

Ear Surgery Procedures
Washington, D.C. has the highest fees for ear surgery procedures in the region, followed by
Maryland facility fees (second), Maryland non-facility fees (third), Virginia non-facility fees
(fourth), West Virginia facility fees (fifth), West Virginia non-facility fees (sixth), Delaware
fees (seventh), and Pennsylvania fees (eighth).

Radiology Procedures
For the selected radiology procedures, Washington, D.C. fees rank first, Delaware fees rank
second, Virginia non-facility fees rank third, Maryland facility and non-facility fees rank fourth,
West Virginia facility and non-facility fees rank sixth, and Pennsylvania fees rank last.

Laboratory Procedures
Medicare has one fee for each laboratory procedure, regardless of place of service. Delaware has
the highest fees for the selected laboratory procedures in the region, followed, in ranking order,
by Virginia, West Virginia, Maryland, Pennsylvania, and Washington, D.C.


                                                 9
Medicine:

Psychiatry Procedures
For psychiatry procedures, Delaware fees rank first in the region. Maryland facility fees rank
second, Maryland non-facility fees rank third, Washington, D.C. fees rank fourth, Virginia non-
facility fees rank fifth, West Virginia facility fees rank sixth, and West Virginia non-facility fees
rank seventh. Pennsylvania fees rank last in the region.

Dialysis Procedures
For selected dialysis procedures, Delaware fees rank the highest in the region, followed by
Washington, D.C. fees (second), Virginia non-facility fees (third), West Virginia facility and
non-facility fees (fourth), Maryland facility and non-facility fees (sixth), and Pennsylvania fees
(eighth).

Gastroenterology Procedures
Washington, D.C. fees for gastroenterology procedures are the highest in the region. Delaware
fees rank second, Virginia non-facility fees rank third, Maryland facility and non-facility fees
rank fourth, West Virginia facility and non-facility fees rank sixth, and Pennsylvania fees rank
eighth. Because Pennsylvania has a missing fee for procedure 91110 (GI tract capsule
endoscopy), its ranking is lower than it what it would have been had it covered this procedure.

Ophthalmology and Vision Care Procedures
For the selected ophthalmology and vision care procedures, Washington, D.C. fees rank first in
the region, followed by Delaware fees (second), Virginia non-facility fees (third), West Virginia
facility fees (fourth), Maryland non-facility fees (fifth), West Virginia non-facility fees (sixth),
Maryland facility fees (seventh), and Pennsylvania fees (eighth).

ENT (Otorhinolaryngology) Procedures
For the selected ENT (otorhinolaryngology) procedures, Washington, D.C. fees rank first,
followed, in ranking order, by Delaware fees, Maryland non-facility fees, Maryland facility fees,
Virginia non-facility fees, West Virginia facility fees, West Virginia non-facility fees, and
Pennsylvania fees.

Cardiovascular Medicine Procedures
Washington, D.C. has the highest fees for cardiovascular medicine procedures in the region.
Delaware fees rank second, Maryland facility and non-facility fees rank third, Virginia non-
facility fees rank fifth, Pennsylvania fees rank sixth, and West Virginia facility and non-facility
fees rank seventh. Although Pennsylvania did not report a fee for procedure 93325 (Doppler
color flow add-on), its percentage of Medicare fees is higher than West Virginia’s facility and
non-facility fees.

Non-Invasive Vascular Diagnostic Studies
For the selected non-invasive vascular diagnostic studies procedures, Washington, D.C. fees
rank first, Virginia non-facility fees rank second, Delaware fees rank third, West Virginia


                                                 10
facility and non-facility fees rank fourth, Maryland facility and non-facility fees rank sixth, and
Pennsylvania fees rank last.

Pulmonary Procedures
Washington, D.C. has the highest fees for pulmonary procedures in the region. Delaware fees
rank second, Virginia non-facility fees rank third, Maryland facility and non-facility fees rank
fourth, West Virginia facility and non-facility fees rank sixth, and Pennsylvania fees rank
eighth. Pennsylvania’s fee schedule does not provide a fee for procedure 94640 (airway
inhalation treatment).

Allergy and Immunology Procedures
For selected allergy and immunology procedures, Washington, D.C. fees rank first, followed by
Delaware fees (second), Maryland facility fees (third), Maryland non-facility fees (fourth),
Virginia non-facility fees (fifth), West Virginia non-facility fees (sixth), and West Virginia
facility fees (seventh). Pennsylvania fees rank last.

Neurology and Neuromuscular Procedures
Washington, D.C. fees are the highest in the region for neurology and neuromuscular
procedures, followed, in ranking order, by Delaware fees, Virginia non-facility fees, Maryland
facility fees, Maryland non-facility fees, West Virginia facility and non-facility fees, and
Pennsylvania fees.

Central Nervous System (CNS) Assessment Tests
For the selected CNS assessment procedures, Washington, D.C. fees rank first, Maryland
facility fees rank second, Maryland non-facility fees rank third, Virginia non-facility fees rank
fourth, West Virginia facility fees rank fifth, West Virginia non-facility fees rank sixth,
Pennsylvania fees rank seventh, and Delaware fees rank last. Because Delaware has $0 listed for
procedure 96111 (developmental test, extend), its ranking as a percentage of Medicare fees in
Maryland is the lowest.

Chemotherapy Administration
For chemotherapy administration procedures, Washington, D.C. fees rank first, followed by
Delaware fees (second), Maryland non-facility fees (third), Maryland facility fees (fourth),
Virginia non-facility fees (fifth), Pennsylvania fees (sixth), West Virginia facility fees (seventh),
and West Virginia non-facility fees (eighth).

Dermatology Procedures
Washington, D.C. has the highest fees for the selected dermatology procedures. Delaware fees
rank second, Virginia non-facility fees rank third, West Virginia facility and non-facility fees
rank fourth, Maryland facility and non-facility fees rank sixth, and Pennsylvania fees rank
eighth.

Physical Medicine and Rehabilitation Procedures
For the selected physical medicine and rehabilitation procedures, Washington, D.C. fees rank
first, followed by Delaware fees (second), Maryland facility and non-facility fees (third),


                                                 11
Virginia non-facility fees (fifth), West Virginia facility and non-facility fees (sixth), and
Pennsylvania fees (eighth).

Osteopathy, Chiropractic, and Other Medicine Procedure
Virginia non-facility fees rank highest for osteopathy, chiropractic, and other medicine
procedures, followed, in ranking order, by Pennsylvania fees, Washington, D.C. fees, Delaware
fees, Maryland facility fees, Maryland non-facility fees, West Virginia non-facility fees, and
West Virginia facility fees. The Virginia non-facility fee for procedure code 99173 (visual
acuity screening) is 21 times larger than the Medicare fee for this procedure.




                                                  12
           Table 2. Comparison of Maryland’s and Neighboring States’ Medicaid Fees with Medicare Fees
 Procedure                                   MC MC MD MD                        VA     WV WV
   Code     Procedure Description            NF     FA     NF     FA     DE     NF      NF    FA      PA                   DC
             Evaluation & Management
   99203     Office/outpatient visit, new           $109 $78           $76     $65 $102 $82            $71    $53    $54   $103
   99204     Office/outpatient visit, new           $167 $132 $112 $108 $156 $126 $111                        $89    $90   $158
   99212     Office/outpatient visit, establish      $44      $26      $31     $22     $41     $33     $28    $18    $26    $42
   99213     Office/outpatient visit, establish      $73      $51      $48     $41     $69     $55     $47    $34    $35    $69
   99214     Office/outpatient visit, establish     $108 $79           $72     $65 $102 $81            $71    $53    $54   $103
   99223     Initial hospital care                  $202 $202 $133 $133 $191 $155 $137                       $137    $42   $196
   99232     Subsequent hospital care                $72      $72     $49      $49     $68     $55     $49    $49    $17    $73
   99238     Hospital discharge day                  $72      $72      $51     $51     $68     $55     $48    $48    $17     $0
   99244     Office consultation                    $185 $155 $139 $114                 $0    $141 $124      $105   $121   $205
   99283     Emergency dept visit                    $64      $64     $60      $60     $60     $44     $43    $43    $35    $66
   99284     Emergency dept visit                   $120 $120 $111 $111 $113 $83                       $82    $82    $50   $123
   99285     Emergency dept visit                   $176 $176 $166 $166 $165 $121 $120                       $120    $50   $182
   99291     Critical care, first hour              $277 $226 $197 $159 $261 $211 $185                       $154   $152   $280
   99308     Nursing fac care, subseq                $68      $68      $44     $44     $64     $52     $45    $45    $37    $66
   99381     Init pm e/m, new pat, infant            $99      $63     $85      $56     $94     $84     $65    $42    $20   $103
   99391     Per pm reeval, est pat, infant          $84      $54     $64      $48     $79     $71     $55    $36    $20    $85
   99392     Prev visit, est, age 1-4                $93      $63     $72      $56     $88     $79     $61    $42    $20    $95
   99393     Prev visit, est, age 5-11               $93      $63      $71     $56     $87     $79     $61    $42    $20    $94
   99394     Prev visit, est, age 12-17             $101 $72           $78     $64     $95     $86     $66    $48    $20   $103
   99469     Neonate crit care, subsquent           $408 $408 $325 $325 $387 $312 N/A                        N/A    $240   $411
   99472     Ped critical care, subsequent          $406 $406 $325 $325 $384 $310 N/A                        N/A    $240   $416
   99479     Ic lbw inf 1500-2500 g subsquent $131 $131 $107 $107 $124 $100 N/A                              N/A     $76   $132
             Average % of Medicare Fees                               73% 82% 92% 76% 63%                    63%    43%    97%
MC: Medicare; NF: non-facility (e.g., office); FA: facility (e.g., hospital); N/A: data not available.




                                                                13
     Table 2. Comparison of Maryland’s and Neighboring States’ Medicaid Fees with Medicare Fees (continued)
 Procedure                                MC MC MD MD                         VA    WV WV
   Code       Procedure Description        NF    FA      NF     FA     DE     NF     NF     FA     PA      DC

               Integumentary
   10060       Drainage of skin abscess          $115     $97    $74     $66     $108    $89     $75      $64    $24    $111
   11042       Debride skin/tissue                $92     $50     $54     $35     $86     $71     $60      $33   $33     $77
   11721       Debride nail, 6 or more            $44     $27     $31     $21     $42     $34     $29      $18    $20    $46
   12001       Repair superficial wound(s)       $102     $58    $102     $58     $95     $78     $66      $39   $25    $148
   12011       Repair superficial wound(s)       $122     $69    $113    $69     $113    $94      $79      $47   $32    $158
   17110       Destruct b9 lesion, 1-14          $116     $73    $70     $43     $109    $89      $74      $47   $49    $114
   17250       Chemical cautery, tissue           $80     $38    $54     $26      $75     $61     $51      $25   $26     $77
               Average % of Medicare Fees                        75%     78%     94%     77%     65%      66%    30%    110%
             Musculoskeletal System
  20550      Inj tendon sheath/ligament          $59      $43       $56     $39     $56     $46     $39    $29    $32    $60
  20552      Inj trigger point, 1/2 muscl        $55      $38       $50     $33     $52     $43     $36    $25    $31     $0
  20610      Drain/inject, joint/bursa           $82      $52       $72     $48     $76     $63     $53    $35    $24    $80
  25600      Treat fracture radius/ulna         $296 $269 $259 $232 $275 $228 $194                        $177   $115   $283
  29075      Application of forearm cast         $91      $65       $80     $58     $85     $70     $59    $42   $46     $89
  29125      Apply forearm splint                $71      $45       $61     $39     $66     $54     $45    $30   $26     $68
  29130      Application of finger splint        $41      $30       $37     $27     $39     $32     $27    $20   N/A    $40
  29515      Application lower leg splint        $74      $51       $65     $47     $69     $57     $48    $34   $35     $71
             Average % of Medicare Fees                            88% 89% 93% 77% 65%                    66%    37%    92%
MC: Medicare; NF: non-facility (e.g., office); FA: facility (e.g., hospital); N/A: data not available.




                                                                14
      Table 2. Comparison of Maryland’s and Neighboring States’ Medicaid Fees with Medicare Fees (continued)
 Procedure                                   MC MC MD MD                         VA    WV WV
   Code      Procedure Description           NF     FA     NF     FA     DE      NF    NF     FA      PA     DC
               Respiratory
   30300       Remove nasal foreign body              $242    $132     $161    $88    $227     $185      $153    $85    $23   $233
   31231       Nasal endoscopy, dx                    $204     $82     $134    $57    $191     $156      $129    $54    $59    $199
   31500       Insert emergency airway                $115    $115     $77    $77     $106     $90       $79     $79   $72    $115
   31575       Diagnostic laryngoscopy                $123     $81      $83    $57    $115      $94       $79    $54    $69    $121
   31622       Dx bronchoscope/wash                   $335    $154     $236   $108    $144     $257      $216   $105   $134   $342
   31624       Dx bronchoscope/lavage                 $335    $154     $241   $108    $145     $258      $216   $105   $135   $348
               Average % of Medicare Fees                              68%    69%     78%      77%       65%    67%    42%    100%
               Cardiovascular System Surgery
   36400       Bl draw < 3 yrs fem/jugular            $31     $18      $18     $13     $29     $24        $20    $12   N/A     $28
   36406       Bl draw < 3 yrs other vein             $18     $10      $13     $7      $17     $14        $12    $6    N/A     $19
   36410       Non-routine bl draw > 3 yrs            $20     $10      $14     $7      $18     $15       $12     $6    N/A     $21
   36556       Insert non-tunnel cv cath              $251    $128     $194    $90    $119     $193      $163    $88   $113   $258
   36569       Insert picc cath                       $278     $99     $226    $72     $93     $213      $178    $67    $87    $305
   36620       Insertion catheter, artery              $53     $53      $36    $36     $50      $42       $36    $36    $48     $53
               Average % of Medicare Fees                              77%    70%     53%      77%       65%    68%    39%    104%
             Hemic, Lymphatic, and
             Mediastinum
  38220      Bone marrow aspiration                 $162 $65 $123 $44 $152 $124                          $103    $43    $55    $172
  38221      Bone marrow biopsy                     $174 $79 $136 $56 $164 $134                          $111    $53    $70    $190
  38525      Biopsy/removal, lymph nodes            $448 $448 $281 $281 $410 $347                        $304   $304   $156   $422
  38792      Identify sentinel node                  $43      $43      $30     $30     $40     $33       $28     $28   N/A     $43
             Average % of Medicare Fees                               72% 66% 93% 77%                    65%    67%    36%    103%
MC: Medicare; NF: non-facility (e.g., office); FA: facility (e.g., hospital); N/A: data not available.




                                                                  15
     Table 2. Comparison of Maryland’s and Neighboring States’ Medicaid Fees with Medicare Fees (continued)
 Procedure                                 MC MC MD MD                        VA    WV WV
   Code      Procedure Description         NF     FA     NF     FA     DE     NF     NF     FA      PA      DC

               Digestive System
    42820      Remove tonsils and adenoids        $313    $313    $212    $212    $291    $242    $208     $208   $184   $301
    42830      Removal of adenoids                $224    $224    $151    $151    $209    $173    $147     $147   $134    $214
    43235      Upper GI endoscopy, diagnosis      $319    $156    $229    $104    $297    $244    $205     $105   $125   $324
    43239      Upper GI endoscopy, biopsy         $369    $184    $263    $123    $344    $283    $238     $124   $149   $374
    45378      Diagnostic colonoscopy             $422    $233    $299    $155    $393    $324    $275     $157   $181    $425
    45380      Colonoscopy and biopsy             $504    $279    $357    $186    $470    $387    $328     $188   $225   $510
    45385      Lesion removal colonoscopy         $568    $330    $400    $221    $529    $437    $371     $224   $268    $573
    47562      Laparoscopic cholecystectomy       $772    $772    $502    $502    $705    $599    $526     $526   $589   $727
    49080      Puncture, peritoneal cavity        $174     $73    $141     $52     $68    $134    $112      $49    $64    $188
               Average % of Medicare Fees                         70%     67%     92%     77%     65%      67%    49%    100%

             Urinary and Male Genital
  51600      Injection for bladder x-ray          $211 $48 $162 $34                  $45 $161 $133          $32   $32    $230
  51701      Insert bladder catheter               $64      $30      $53      $21    $60     $49     $41    $20    $25    $69
  51798      Us urine capacity measure             $21      $21      $16      $16    $20     $16     $13    $13    $14     $0
  52000      Cystoscopy                           $227 $137 $163 $94 $128 $175 $148                         $92    $75    $247
  54150      Circumcision w/ regional block $179 $106 $145 $73                       $99 $138 $117          $72    $79    $198
             Average % of Medicare Fees                             80% 69% 54% 77% 65%                    67%    41%    109%
MC: Medicare; NF: non-facility (e.g., office); FA: facility (e.g., hospital); N/A: data not available.




                                                                 16
         Table 2. Comparison of Maryland’s and Neighboring States’ Medicaid Fees with Medicare Fees (continued)
Procedure                                    MC        MC       MD        MD               VA        WV      WV
  Code       Procedure Description           NF        FA       NF        FA       DE      NF        NF      FA       PA       DC

             Gynecology/Obstetric
 57452       Exam of cervix w/ scope         $115       $97     $108       $88    $107     $104      $77      $66      $40     $116
 57454       Colposcopy of the cervix        $163      $144     $152      $133    $151     $147     $109      $98     $106     $163
 58300       Insert intrauterine device       $76       $54      $76       $52      $0      $69      $50      $36      $17      $84
 59025       Fetal non-stress test           $50       $50       $46      $46      $46     $45      $33       $33     $18       $51
 59409       Obstetrical care                $790      $790     $860      $860    $707     $713     $846     $846    $1,200    $817
 59410       Obstetrical care               $1,001    $1,001    $942      $942    $897     $904    $1,071   $1,071   $1,200    $950
 59430       Care after delivery             $167      $136     $139      $125    $151     $150     $174     $145     N/A      $149
 59514       Cesarean delivery only          $897      $897     $993      $993    $707     $809     $960     $960    $1,200    $968
 59515       Cesarean w postpartum          $1,214    $1,214   $1,124    $1,124   $897    $1,095   $1,298   $1,298   $1,200   $1,144
             Average % of Medicare Fees                        100%      100%     85%      90%     105%     105%     118%      99%

             Endocrine System
 60100       Biopsy of thyroid               $118      $84      $82      $57      $111      $92      $78     $57      $66     $123
 60240       Removal of thyroid             $1,022    $1,022    $662     $662     $939     $795     $697    $697     $591     $985
             Average % of Medicare Fees                         66%      65%      92%      78%      68%     68%      57%      98%

             Nervous System
 62270       Spinal fluid tap, diagnostic    $166     $83       $150      $73     $154     $127     $107     $56      $42     $166
 62311       Inject spine l/s (cd)           $211     $89       $183      $79     $199     $162     $135     $60      $75     $204
 64450       N block, other peripheral       $108     $72        $99      $68     $102      $84      $70     $48      $21      $108
 64483       Inj foramen epidural l/s        $257     $108      $257     $101     $242     $197     $169     $76      $95      $288
 64614       Destroy nerve, extrem muscle    $186     $161      $161     $132     $171     $143     $123    $108     $123     $175
             Average % of Medicare Fees                         91%      89%      94%      77%      65%     68%      33%      100%
 MC: Medicare; NF: non-facility (e.g., office); FA: facility (e.g., hospital); N/A: data not available.




                                                                 17
       Table 2. Comparison of Maryland’s and Neighboring States’ Medicaid Fees with Medicare Fees (continued)
 Procedure                                         MC         MC       MD MD                       VA  WV WV
   Code      Procedure Description                 NF         FA        NF      FA        DE       NF   NF   FA   PA     DC
             Eye Surgery
   65855     Laser surgery of eye                 $349       $307      $227 $195         $324     $269 $230 $205 $237    $320
   66984     Cataract surg w/ iol, 1 stage        $785       $785      $494 $494         $727     $608 $524 $524 $603    $712
   67028     Injection eye drug                   $136       $114      $136 $111         $127     $105 $89   $75 $106    $203
   67210     Treatment of retinal lesion          $707       $684      $430 $413         $656     $548 $472 $458 $375    $647
   67228     Treatment of retinal lesion         $1,202 $1,083 $731 $636 $1,117 $928 $794 $720 $491                     $1,126
   67311     Revise eye muscle                    $618       $618      $370 $370         $571     $478 $411 $411 $468    $556
             Average % of Medicare Fees                                63% 62%           93%      77% 67% 67% 63%        93%
             Ear Surgery
   69200     Clear outer ear canal                $131        $60      $113 $49          $123     $100 $83   $39  $30   $128
   69210     Remove impacted ear wax               $53        $34       $44     $29      N/A       $41  $34  $23  $20    $51
   69436     Create eardrum opening               $174       $174      $149 $149         $162     $134 $114 $114 $99    $170
   69990     Microsurgery add-on                  $234       $234      $199 $199         $207     $180 $162 $162 $201   $228
             Average % of Medicare Fees                                85% 85%           55%      77% 65% 66% 47%       97%
             Radiology
   70450     Ct head/brain w/o dye                $212       $212      $177 $177         $200     $162 $133 $133 $117   $259
   71010     Chest x-ray                           $25        $25       $20     $20       $24      $19  $16  $16  $19    $28
   71020     Chest x-ray                           $33        $33       $26     $26       $31      $26  $21  $21  $25    $37
   72193     Ct pelvis w/ dye                     $318       $318      $259 $259         $299     $242 $200 $200 $140   $385
   73610     X-ray exam of ankle                   $35        $35       $24     $24       $33      $27  $22  $22  $27    $36
   73630     X-ray exam of foot                    $34        $34       $24     $24       $32      $26  $21  $21  $19     $35
   74000     X-ray exam of abdomen                 $27        $27       $21     $21       $25      $21  $17  $17  $18     $29
   74160     Ct abdomen w/ dye                    $361       $361      $263 $263         $340     $275 $226 $226 $149   $432
   76805     Ob us >/= 14 wks, sngl fetus         $155       $155      $110 $110         $147     $143 $102 $102 $78     $170
   76815     Ob us, limited, fetus(s)              $98        $98       $70     $70       $93      $88  $62  $62  $64    $106
             Average % of Medicare Fees                                77% 77%           94%      79% 63% 63% 55%       116%
MC: Medicare; NF: non-facility (e.g., office); FA: facility (e.g., hospital); N/A: data not available.


                                                              18
      Table 2. Comparison of Maryland’s and Neighboring States’ Medicaid Fees with Medicare Fees (continued)
  Procedure                                  MC MC MD MD                          VA    WV WV
    Code        Procedure Description        NF    FA      NF     FA      DE      NF    NF     FA      PA    DC

                  Laboratory
     80053        Comprehen metabolic panel         $15     $15        $11    $11     $15    $14    $13       $13   $12    $12
     80061        Lipid panel                       $17     $17         $13    $13    $18     $18   $17       $17   $14    $17
     81002        Urinalysis nonauto w/o scope       $4      $4         $3      $3     $4      $3    $3        $3    $4     $2
     83655        Assay of lead                     $17     $17        $12     $12    $17    $16    $15       $15   $10     $8
     85025        Complete cbc w/ auto diff wbc     $11     $11         $8      $8    $11    $10     $10      $10     $6     $5
     86592        Blood serology, qualitative        $5      $5          $4     $4     $6      $5    $5        $5    $4     $3
     87081        Culture screen only                $9      $9         $7      $7     $9     $9     $8        $8    $5     $4
     87086        Urine culture/colony count        $11     $11         $9      $9    $11     $10    $10      $10     $8     $6
     87491        Chylmd trach, dna, amp probe      $44     $44         $33    $33    $48     $43    $44      $44    $23    $23
     87880        Strep a assay w/ optic            $17     $17         $13    $13    $15     $16    $15      $15    $6     $7
                  Average % of Medicare Fees                           75%    75%    101%    95%    94%      94%    61%    58%

               Psychiatry
     90801     Psy dx interview                     $161 $128 $147 $122 $153 $126 $107                        $87   $26    $169
     90804     Psytx, office, 20-30 min              $69      $55     $48      $43      $66      $52   $44    $36    $26    $70
     90805     Psytx, off, 20-30 min w/ E&M $79               $64     $53      $47      $75      $59   $50    $41   $26     $78
     90806     Psytx, off, 45-50 min                 $93      $85     $88      $82      $88      $70   $60    $55    $39    $97
     90847     Family psytx w/ patient              $109 $100 $92              $87     $104      $86   $73    $68    $13   $118
     90853     Group psychotherapy                   $33      $31      $24     $23      $32      $26   $22    $20     $4     $4
     90862     Medication management                 $61      $47     $41      $34      $58      $47   $40    $31   $15     $61
               Average % of Medicare Fees                             85% 88% 95% 77% 65%                    66%    26%    83%
MC: Medicare; NF: non-facility (e.g., office); FA: facility (e.g., hospital); N/A: data not available.




                                                                  19
     Table 2. Comparison of Maryland’s and Neighboring States’ Medicaid Fees with Medicare Fees (continued)
 Procedure                                MC MC MD MD                         VA    WV WV
   Code      Procedure Description         NF    FA     NF      FA     DE     NF    NF      FA     PA      DC

                Dialysis
    90935       Hemodialysis, one evaluation      $78     $78     $49     $49      $74     $61     $52      $52   $50    $73
    90937       Hemodialysis, repeated eval       $111    $111     $80     $80    $105     $87     $75      $75    $50   $119
    90945       Dialysis, one evaluation          $86     $86     $51     $51      $82     $68     $55      $55   $35    $76
                Average % of Medicare Fees                        64%     64%     95%     79%     67%      67%    62%    95%

                Gastroenterology
    91034       Gastroesophageal reflux test      $212    $212    $167    $167    $200    $162    $134     $134   $172    $230
    91110       Gi tract capsule endoscopy        $990    $990    $733    $733    $933    $754    $621     $621   N/A    $1,044
                Average % of Medicare Fees                        75%     75%     94%     76%     63%      63%    22%    106%
                Ophthalmology/Vision Care

    92004    Eye exam, new patient               $148 $101 $95               $65 $140 $115 $97              $68   $59    $142
    92012    Eye exam established pat             $85      $53       $53     $32    $80      $65     $55    $35   $29     $80
    92014    Eye exam & treatment                $123 $81           $77      $50 $116 $95            $80    $54    $45   $117
    92015    Refraction                           $28      $20      $28      $14    $27      $22     $18    $13    $5    $36
    92060    Special eye evaluation              $64       $64      $40      $40    $61      $50     $41    $41   $34    $61
    92081    Visual field examination(s)          $52      $52       $38     $38    $49      $40     $33    $33   $28     $56
             Average % of Medicare Fees                             66% 64% 94% 77% 65%                    67%    38%    98%
MC: Medicare; NF: non-facility (e.g., office); FA: facility (e.g., hospital); N/A: data not available.




                                                                 20
        Table 2. Comparison of Maryland’s and Neighboring States’ Medicaid Fees with Medicare Fees (continued)
Procedur
    e                                    MC      MC     MD       MD              VA     WV      WV
  Code     Procedure Description          NF     FA      NF       FA     DE      NF      NF      FA       PA                   DC
             ENT (Otorhinolaryngology)
  92551      Pure tone hearing test, air          $13      $13       $8       $8      $12        $9       $8     $8     $8     $13
  92552      Pure tone audiometry, air            $28      $28      $18      $18      $26       $21      $17    $17     $8     $26
  92557      Comprehensive hearing test           $43      $38      $47      $44      $40       $33      $28    $25    $29     $50
  92567      Tympanometry                         $16      $13      $16      $13      $15       $13      $10     $8    $12     $20
  92568      Acoustic refl threshold tst          $17      $17      $16      $16      $17       $14      $11    $11    $10     $20
  92585      Auditory evoked potentials
             (ABR comprehensive)                 $122     $122     $101      $101     $115      $93      $76    $76    $27    $117
             Evoked auditory (otoacoustic
  92587      emission) testing                    $40      $40     $40       $40      $37      $30        $25   $25     $34    $46
             Average % of Medicare Fees                            84%       84%      94%      76%       63%    63%    62%    109%
           Cardiovascular Medicine
 93000     Electrocardiogram, complete           $21       $21       $18       $18     $20      $16       $13    $13    $19     $24
 93010     Electrocardiogram report              $9        $9        $6         $6     $9        $7        $6     $6     $8     $10
 93016     Cardiovascular stress test           $24       $24       $18        $18      $0      $19       $16   $16     $22     $27
 93042     Rhythm ECG, report                    $8        $8        $6         $6     $7        $6        $5    $5      $7      $9
 93303     Echo transthoracic                   $225      $225      $171      $171    $213     $172      $142   $142   $157    $256
 93307     Tte w/o doppler, complete            $159      $159      $148      $148    $150     $121      $100   $100   $140    $208
 93320     Doppler echo exam, heart              $67       $67       $66       $66     $63      $51       $42    $42    $61     $92
 93325     Doppler color flow add-on            $39       $39        $39       $39     $36      $29       $24   $24    N/A      $64
           Average % of Medicare Fees                               89%       89%     93%      77%       63%    63%    74%    131%
MC: Medicare; NF: non-facility (e.g., office); FA: facility (e.g., hospital); N/A: data not available.




                                                                    21
         Table 2. Comparison of Maryland’s and Neighboring States’ Medicaid Fees with Medicare Fees (continued)
Procedure                                        MC       MC         MD        MD                VA     WV   WV
  Code     Procedure Description                 NF        FA        NF        FA       DE       NF     NF   FA    PA      DC
           Non-Invasive Vascular
           Diagnostic Studies
  93880    Extracranial study                   $198     $198       $140      $140    $186     $205    $169 $169 $148     $296
  93970    Extremity study                      $202     $202       $143      $143    $190     $212    $174 $174 $147     $302
  93971    Extremity study                      $128     $128        $91       $91    $121     $139    $114 $114 $100     $200
  93976    Vascular study                       $229     $229       $162      $162    $216     $178    $147 $147 $131     $256
           Average % of Medicare Fees                               71%       71%     94%      96%     79%  79%  68%     137%
           Pulmonary
  94010    Breathing capacity test               $38       $38       $26       $26     $36       $29    $24  $24  $15     $39
  94060    Evaluation of wheezing                $65       $65       $45       $45     $62       $50    $41  $41  $19     $68
           Respiratory flow volume
  94375    loop                                  $41       $41       $28       $28     $39       $31    $26  $26  $31      $43
  94640    Airway inhalation treatment           $17       $17       $11       $11     $16       $13    $10  $10  N/A      $16
  94664    Evaluate pt use of inhaler            $17       $17       $12       $12     $16       $13    $10  $10  $12      $18
  94760    Measure blood oxygen level             $3        $3        $2        $2       $3       $2     $2   $2    $2      $3
  94761    Measure blood oxygen level             $5        $5        $5        $5       $4       $4     $3   $3    $4      $7
           Average % of Medicare Fees                               68%       68%     93%      76%     61%  61%  35%     102%
           Allergy/Immunology
  95004    Percut allergy skin tests              $7        $7        $4        $4       $6       $5     $4   $4    $2     $7
  95024    Id allergy test, drug/bug              $8        $8        $5        $5       $8       $6     $5   $5    $5     $8
           Immunotherapy, one
  95115    injection                             $11       $11       $10       $10     $10        $8     $7   $7    $4     $13
  95117    Immunotherapy injections              $14       $14       $13       $13     $13       $10     $8   $8    $7     $15
  95165    Antigen therapy services              $14        $4        $9        $2     $13       $10     $8   $2    $8     $14
           Average % of Medicare Fees                               86%       88%     93%      76%     60%  60%  45%     110%
MC: Medicare; NF: non-facility (e.g., office); FA: facility (e.g., hospital); N/A: data not available.



                                                              22
   Table 2. Comparison of Maryland’s and Neighboring States’ Medicaid Fees with Medicare Fees (continued)
Procedure                                  MC MC MD MD                         VA    WV WV
  Code       Procedure Description          NF    FA      NF    FA      DE     NF     NF     FA      PA                     DC
            Neurology/Neuromuscular
  95810     Polysomnography, 4 or more             $747 $747 $628 $628 $703 $569 $469                        $469   $347   $909
  95816     Eeg, awake and drowsy                  $314 $314 $165 $165 $296 $239 $197                        $197    $23    $255
  95819     Eeg, awake and asleep                  $351 $351 $167 $167 $330 $267 $219                        $219    $23    $274
  95860     Muscle test, one limb                   $96      $96     $64      $64     $91     $74      $62    $62    $30    $92
  95903     Motor nerve conduction test             $74      $74     $49      $49     $70     $57      $48    $48    $38     $71
  95904     Sense nerve conduction test             $57      $57     $38      $38     $54     $43      $35    $35    $22     $54
  95926     Somatosensory testing                  $164 $164 $78              $78 $154 $124 $102             $102    $58   $135
  95934     H-reflex test                           $60      $60      $33     $33     $56     $46      $38    $38    $30     $54
  95957     EEG digital analysis                   $363 $363 $181 $181 $342 $278 $230                        $230   $138    $298
            Average % of Medicare Fees                               67% 67% 94% 76% 63%                     63%    30%    101%
            CNS Assessment Tests
  96110     Developmental test, lim                 $9       $9       $9       $9     $8      $7       $5     $5     $7     $15
  96111     Developmental test, extend             $131 $125 $96              $94     $0     $103 $88         $85   $50    $141
            Average % of Medicare Fees                               79% 80% 20% 78% 66%                     66%    47%    120%
            Chemotherapy Administration
  96411     Chemo, iv push, addl drug               $68      $68     $53      $53     $64     $52      $42    $42   $53     $76
  96413     Chemo, iv infusion, 1 hr               $158 $158 $126 $126 $149 $120 $99                          $99   $125    $177
  96415     Chemo, iv infusion, addl hr             $33      $33     $28      $28     $32     $26      $21    $21   $28     $39
  96417     Chemo iv infus each addl seq            $78      $78     $62      $62     $73     $59      $49    $49   $62     $88
  96450     Chemotherapy, into CNS                 $212 $90 $212 $75 $200 $163 $136                           $60    $77    $243
  96523     Irrig drug delivery device              $28      $28      $21     $21     $26     $21      $17    $17    $19     $30
            Average % of Medicare Fees                               81% 80% 94% 76% 62%                     62%    76%    112%
MC: Medicare; NF: non-facility (e.g., office); FA: facility (e.g., hospital); N/A: data not available.




                                                                 23
      Table 2. Comparison of Maryland’s and Neighboring States’ Medicaid Fees with Medicare Fees (continued)
 Procedure                                     MC MC MD MD                         VA     WV WV
   Code      Procedure Description             NF    FA      NF     FA     DE      NF     NF      FA     PA                  DC
               Dermatology
   96910       Photochemotherapy with UV-B             $75     $75        $46   $46    $71     $57       $46    $46   $20    $76
   96912       Photochemotherapy with UV-A             $97     $97        $59   $59    $91     $73       $59    $59   $20    $98
               Average % of Medicare Fees                                 61%   61%    94%     76%       62%    62%   23%    101%

             Phys Medicine/Rehab Therapy
  97001      Pt evaluation                             $76      $76      $72     $72     $72     $59     $50    $50   $45    $78
  97010      Hot or cold packs therapy                 $6       $6       $4      $4      $5      $4      $3     $3    $17    $5
  97014      Electric stimulation therapy              $15      $15      $10     $10     $15     $12     $10    $10   $17    $15
  97035      Ultrasound therapy                        $12      $12      $9      $9      $12     $10     $8     $8    $10    $13
  97110      Therapeutic exercises                     $31      $31      $29     $29     $30     $24     $20    $20   $8     $31
  97112      Neuromuscular reeducation                 $33      $33      $21     $21     $31     $25     $21    $21   $17    $32
  97140      Manual therapy                            $29      $29      $19     $19     $28     $23     $19    $19   $21    $29
  97530      Therapeutic activities                    $34      $34      $31     $31     $32     $26     $22    $22   $13    $7
             Average % of Medicare Fees                                  82% 82% 95% 78%                 65%    65%   57%    95%
             Osteopathy, Chiropractic
             and Other Medicine
  98941      Chiropractic manipulation                 $36      $32      $25     $21     $0      $29     $24    $21   $13    $37
  99144      Mod sedation by same phys, 5 yrs + $44             $44      $28     $28     $0      $63     $0     $0    N/A    $0
  99173      Visual acuity screen                      $3       $3       $2      $2      $3      $64     $2     $2    $6     $3
  99183      Hyperbaric oxygen therapy                 $221 $124 $150 $85                $207 $170       $144   $84   $107   $215
             Average % of Medicare Fees                                  69% 69% 74% 892%                52%    49%   99%    83%
MC: Medicare; NF: non-facility (e.g., office); FA: facility (e.g., hospital); N/A: data not available.




                                                                     24
V.     Trauma Center Payment Issues

During the 2003 legislative session, the Maryland General Assembly passed, and the Governor
signed into law, SB 479, which created a Trauma and Emergency Medical Fund that is financed
by motor vehicle registration surcharges. The Maryland Health Care Commission (MHCC) and
the Health Services Cost Review Commission (HSCRC) have oversight responsibility for the
fund. Based on the legislation, Maryland Medicaid is required to pay physicians 100 percent of
the Medicare facility rates for the Baltimore area when they provide trauma care to Medicaid’s
FFS and HealthChoice program enrollees. The enhanced Medicaid fees apply only to services
rendered in trauma centers designated by the Maryland Institute for Emergency Medical Services
Systems (MIEMSS) for patients who are placed on Maryland’s Trauma Registry. Initially, the
enhanced Medicaid fees were limited to trauma surgeons, critical care physicians,
anesthesiologists, orthopedic surgeons, and neurosurgeons. However, HB 1164 of the 2006
legislative session extended the enhanced rate to any physician who provides trauma care to
Medicaid beneficiaries beginning July 1, 2006. MHCC and the HSCRC fully cover the
additional outlay of general funds that the Maryland Medical Assistance program incurs due to
enhanced trauma fees (the state’s share of the difference between current Medicare rates and
Medicaid rates). MHCC pays physicians directly for uncompensated care and on-call services.

VI.    Reimbursement for Oral Health Services

Historically, the Maryland Medical Assistance program has had low dental fees. Unlike fees for
physician service, there is no federal public program (such as Medicare) to serve as a benchmark
for oral health service fees. However, every two years, the ADA publishes a survey reporting the
national and regional average charges for approximately 165 of the most common dental
procedures, offering data for comparison. Also, a book entitled the National Dental Advisory
Service (NDAS) contains the percentile of charges for approximately 520 (of a total of
approximately 580) dental procedures.

During the 2003 session of the Maryland General Assembly, the legislature included budgetary
language in HB 40 that stated, “It is also the intent of the General Assembly that $7.5 million of
the funds included in the CY 2004 Managed Care rates for dental services be restricted to
increasing fees for restorative procedures.” The $7.5 million funding increase was based on a
University of Maryland Dental School analysis of the impact of increasing certain restorative
procedure fees to the 50th percentile levels of the ADA survey. In compliance with the budgetary
language, effective March 1, 2004, MCOs were required to reimburse their contracted providers
at the ADA’s then-current 50th percentile of charges for 12 restorative procedures. At the same
time, Medicaid increased FFS rates to the ADA’s 50th percentile levels for the same restorative
procedures.

In June 2007, the Secretary of the Maryland Department of Health and Mental Hygiene
convened the Dental Action Committee to increase access to dental care services for Maryland
children whose families have low incomes. The Dental Action Committee recommended
increasing the dental reimbursement rates to the 50th percentile of the ADA’s South Atlantic
region charges for all dental procedures. Subsequently, SB 545 of the 2008 session of the
Maryland General Assembly allocated $7 million in state funds ($14 million total funds) for



                                               25
increasing dental fees in FY 2009. The rate increase targeted preventive procedures and went
into effect on July 1, 2008.

Based on the recommendations of the Dental Action Committee, effective July 1, 2009, an
administrative service organization (ASO)—DentaQuest, formerly Doral Dental—coordinates
the provision of dental services for Medicaid beneficiaries in the FFS program. Fees for some of
the dental procedures were streamlined and adjusted effective July 1, 2009, to coincide with the
provision of all Medicaid dental services through the ASO. Fees for dental procedures did not
change in FY 2012 from their FY 2011 levels.

Table 3 shows Maryland Medicaid FY 2009 and FY 2012 weighted average dental fees by
groups of procedures as percentages of the ADA’s 50th percentile of charges in 2009. At the time
this report was written, the ADA had not published the results of its 2011 survey.

                       Table 3. Average of Maryland Medicaid Dental Fees
                 as a Percentage of the ADA's 50th Percentile of Charges in 2009
                                                                                 Medicaid        Medicaid
       Procedure Groups                                                          FY 2009         FY 2012
                                                                                  Fees            Fees
       D0100-D1999 Diagnostic and Preventive Procedures                           41%             68%
       D2000-D2999 Restorative Procedures                                           67%             68%
       D3000-D3999 Endodontic Procedures                                            38%             67%
       D4210-D6999 Periodontics and Prosthodontics                                  55%             56%
       D7000-D7999 Oral and Maxillofacial Surgery                                   28%             67%
       D8000-D9999 Orthodontics and Adjunctive General Services                     32%             33%
       All Procedures Combined                                                     47%             62%

VII.    Physician Participation in the Maryland Medicaid Program

Physicians’ claims and encounter data pertaining to FY 2002 (the year before the July 2002 fee
increase), FY 2008, FY 2009, and FY 2010 were analyzed for the number of physicians who had
either partial or full participation in the Medicaid program. 3 In Tables 4, 5, and 6, physicians
who had fewer than 25 claims during the fiscal year are included in the data for all physicians but
are not shown separately. Physicians who submitted more than 25 claims but had fewer than 50
Medicaid patients were considered partial participants in the Medicaid program. Physicians who
had at least 50 Medicaid patients during the year were considered full participants in the
Medicaid program.

Tables 4, 5, and 6 show the percentage changes in the numbers of participating physicians from
all specialties (including primary care) who participated in FFS programs, MCO networks, and
the total Medicaid program. As the data in Table 4 demonstrate, there were significant increases

3
 The data in these tables pertain to FY 2002 through FY 2010. Therefore, these tables to some extent include the
impact of fee changes in FY 2010 on physician participation in the Medicaid program.



                                                        26
in physician participation in the FFS program, MCO networks, and the total Medicaid program
between FYs 2002 and 2010, compared to the increase between 2002 and 2009 (these figures are
not presented in the table). For example, comparable figures for the 2002 to 2009 period for
physicians with full participation in the FFS program, MCO networks, and total Medicaid
program were 86.2, 83.6, and 88.6 percent, respectively.

                       Table 4. FY 2002-2010 Percentage Change in the
                     Number of Participating Physicians of All Specialties
                                                          MCO            Total
                                            FFS        Networks       Medicaid
            Partial Participation          44.0%         49.7%          102.2%
            Full Participation             93.9%         113.3%         114.6%
            All Physicians                 33.2%          57.8%          92.8%
                      FFS: fee-for-service program; MCO: managed care organization

Because some physicians participate in both FFS and MCO networks, the percentages of total
physicians participating in the Medicaid program are not the sum of FFS and MCO network
physicians.

Similarly, examination of the data in Table 5 shows that, following the FY 2008 and FY 2009
fee increases, physician participation increased significantly between FY 2008 and FY 2010.

                       Table 5. FY 2008-2010 Percentage Change in the
                     Number of Participating Physicians of All Specialties
                                                         MCO             Total
                                            FFS        Networks       Medicaid
            Partial Participation          11.1%         14.1%           14.6%
            Full Participation             39.4%         65.4%           57.8%
            All Physicians                  8.7%          3.8%            7.6%
                      FFS: fee-for-service program; MCO: managed care organization

Data in Table 6 show that despite the 5.8 percent reduction in physician fees in FY 2010, the
increasing trend in physician participation in the Medicaid program continued between FY 2009
and FY 2010.

                       Table 6. FY 2009-2010 Percentage Change in the
                     Number of Participating Physicians of All Specialties
                                                         MCO             Total
                                            FFS        Networks       Medicaid
            Partial Participation           9.2%          2.6%           6.7%
            Full Participation              4.0%         16.0%           13.7%
            All Physicians                  3.8%         -1.7%            2.6%
                      FFS: fee-for-service program; MCO: managed care organization

The increases in physician participation within the FFS program (particularly the increase in full
participation among physicians) likely can be attributed to the increases in the physician fees and


                                                  27
Medicaid enrollment during FY 2009 and FY 2010, when many physicians who were not
participating in the FFS program decided to become partial or full participants. There was a
slight decrease in the overall number of physicians who were participating in MCO networks.
The decrease was mainly caused by a 10.5 percent decline in the number of physicians who had
fewer than 25 claims (figure not presented here). This decline should not be considered a
decrease in access to physician services, though, because most of HealthChoice enrollees are
relying on physicians who fully participate in MCO networks, as shown by the 16.0 percent
increase in the number of physicians who fully participate in the HealthChoice program.

Between FY 2009 and FY 2010, the number of physicians who had fewer than 25 claims
decreased by 3.7 percent (figure not presented here). This decrease, along with an increase of
approximately 14 percent in the total number of fully participating physicians, may indicate that
many of the physicians who had fewer than 25 claims started to fully participate in the Medicaid
program. Additional analysis of data shows that between FY 2009 and FY 2010, the increase in
number of partially and fully participating physicians who had more than 25 claims was larger
than the decrease in the number of physicians who had fewer than 25 claims. After taking into
account this increase and decrease, the data show that 1,100 additional physicians participated in
the Medicaid program in FY 2010. This indicates that some of the partial and full participant
physicians did not previously participate in the Medicaid program.

As mentioned above, the increase in the number of participating physicians is, to some extent,
the result of Medicaid Expansion and increased enrollment. Therefore, to separate the effects of
the increase in physician fees from the effects of the increase in Medicaid enrollment, we
conducted an additional analysis in which we calculated the number of claims per enrollee for
each year, beginning in FY 2002 (see Table 7). For this analysis, we excluded radiology and
laboratory procedures for all years, as they may not be representative of patients’ access to
physician services.

                        Table 7. Number of Claims per Medicaid Enrollee
                                                                                 Increase in
               Average         Number of        Average         Annual %
                                                                                Claims Per
    Fiscal     Monthly          Physician      Number of        Change in
                                                                                  Enrollee
    Year       Medicaid        Claims and      Claims Per       Claims Per
                                                                                From Each
              Enrollment       Encounters       Enrollee         Enrollee 
                                                                                Year to 2010 
     2002       617,929         3,919,805            6.3            N/A             49%
     2003       652,414         4,281,928            6.6           3.5%             44%
     2004       669,021         4,789,248            7.2           9.1%             32%
     2005       687,269         4,891,558            7.1           -0.6%            33%
     2006       690,227         5,253,246            7.6           6.9%             24%
     2007       676,522         5,601,598            8.3           8.8%             14%
     2008       709,239         6,079,365            8.6           3.5%             10%
     2009       771,732         6,933,442            9.0           4.8%              5%
     2010       864,678         8,163,536            9.4           5.1%             N/A
  N/A: Not Applicable




                                                28
The continued increase in the average number of claims per enrollee shows that, as physician
reimbursement rates increased during the FY 2006 to FY 2009 period, Medicaid enrollees’
utilization of physician services increased steadily, from an average of 6.3 claims per enrollee in
FY 2002 to an average of 9.4 claims per enrollee in FY 2010. This is a 49 percent increase in
Medicaid enrollees’ utilization of physician services, which is a proxy for an increase in the
participation of physicians in the Maryland Medicaid program and may be interpreted as an
increase in Medicaid enrollees’ access to physician services.
 
VIII. Plan for Future Fee Increases

In the future, when state funds become available for increasing provider reimbursement rates, the
Department will consult with stakeholders about targeting the fee increases to different
procedures. One of the Department’s goals remains to reimburse physicians at 100 percent of
Medicare reimbursement rates. The Affordable Care Act (ACA) provides temporary funding
for Maryland to achieve this goal. Specifically, the ACA requires states to pay 100 percent of
Medicare rates for certain evaluation and management services provided by primary care
physicians in 2013 and 2014. The federal government will pay 100 percent of the increase in
rates for these two years. Another Department goal is to increase the dental reimbursement rates
to the 50th percentile of the ADA’s South Atlantic region charges for all dental procedures.




                                                29
                                     Appendix A
      Medicare Resource-Based Relative Value Scale and Anesthesia Reimbursement

Medicare payments for physician services are made according to a fee schedule. The Medicare
Resource-Based Relative Value Scale (RBRVS) methodology relates payments to the resources
and skills that physicians use to provide services. Three types of resources determine the relative
weight of each procedure: physician work, malpractice expense, and practice expense. A
geographic cost index and conversion factor are used to convert the weights to fees.

For approximately 13,000 physician procedures, the Centers for Medicare and Medicaid Services
(CMS) determines the associated relative value units (RVUs) and various payment policy
indicators needed for payment adjustment. Medicare fees are adjusted depending on the site in
which each procedure is performed. For example, Medicare fees for some procedures are lower
if they are performed in facilities (such as hospitals and skilled nursing facilities) than if they are
performed in non-facilities (offices), where physicians must pay for practice expenses. The
implementation of RBRVS resulted in increased payments to office-based (non-facility)
procedures and reduced payments for hospital-based procedures.

The RVU weights reflect the resource requirements of each procedure performed by physicians.
The Medicare physician fees are adjusted to reflect the variations in practice costs for different
areas. A geographic practice cost index (GPCI) has been established for every Medicare payment
locality for each of the three components of a procedure’s RVU (i.e., physician work, practice
expense, and malpractice expense). Each locality’s GPCI is used in the calculation of fee
amounts by multiplying the RVU for each component by the GPCI for that component. The
resulting weights are multiplied by a conversion factor to determine the payment for each
procedure.

CMS updates the conversion factor based on the Sustainable Growth Rate (SGR) system, which
ties the updates to growth in the national economy. The SGR system is based on formulas
designed to control overall spending while accounting for factors that affect the costs of
providing care.

Medicare rates are adjusted annually. In 2002, overall Medicare rates actually decreased.
However, following federal legislative mandates, Medicare physician fees increased by small
percentages in subsequent years.

Prior to December 1, 2003, the Medicaid program reimbursed anesthesia services based on a
percentage of the surgical fee. The program in general did not use the anesthesia CPT codes, but
rather the surgical CPT codes with a modifier. The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) required that national standard code sets be used. In late
2003, the Medicaid program complied with the federal standards and started the transition from a
fixed anesthesia rate for each surgical procedure to Medicare’s national methodology.

Medicare payments for anesthesia services represent a departure from the RBRVS methodology.
Medicare’s methodology recognizes anesthesia time as the key element for determining payment
rate. The anesthesia time for any additional procedures during the same operative session is



                                                  30
added to the time for the primary procedure. This time is then converted to units, with 15
minutes equal to 1 unit.

More than 5,000 surgical procedure codes exist, but there are less than 300 anesthesia codes.
Each anesthesia procedure code has a non-variable number of base units. Similar to the RBRVS,
the base units represent the difficulty associated with a given group of procedures. The base units
for the selected anesthesia codes are added to the units related to anesthesia time, and the result is
multiplied by a conversion factor to determine payment amount. The Maryland Medicaid
program calculates the payment slightly differently, but the net result is the same.




                                                 31
                                                         Appendix B
                                          Employed Physicians by Specialty Area, 2010

Table Notes:

Definitions: NA = not available, estimate not released. NSD = not sufficient data.
Employment refers to the number of workers who can be classified as full- or part-time employees, including workers on paid
vacation or other types of paid leave. For further information, please see the Technical Notes.

Sources: Bureau of Labor Statistics, State Occupational Employment Statistics Survey, May 2010. Available at
http://www.bls.gov/data/home.htm.




                                                                32
                                                                                                                             All Other
                                     Family and                  Obstetricians                                               Physicians
                                      General        General         and           General                                      and
                Anesthesiologists   Practitioners   Internists   Gynecologists   Pediatricians   Psychiatrists   Surgeons    Surgeons     Total
United States             34,820           97,820      50,070           19,940          30,100         22,690       43,230     293,740    592,410
Alabama                      520              900         370              200             450            230          350        3,280     6,300
Alaska                       NA               450          50               40              40             40           90          430      NSD
Arizona                      730            1,480       1,200              300             480            280          680        5,310    10,460
Arkansas                     190              880         140              220             150            160          440        2,480     4,660
California                 4,080           10,350       8,820            3,160           5,390          4,260        4,850       24,590    65,500
Colorado                     420            2,150         250              520             280            320          970        3,420     8,330
Connecticut                  550              780       1,040              290             320            520          950        2,430     6,880
Delaware                     110              490         230               80             110             90          250        1,070     2,430
D.C.                          70              410         160             NSD             NSD             250          280        1,790      NSD
Florida                    1,780            4,860       1,950              430           1,180            520        1,280       19,610    31,610
Georgia                      680            2,030       2,030              590           1,160            350        1,890        5,510    14,240
Guam                        NSD                50        NSD              NSD             NSD            NSD         NSD           NSD       NSD
Hawaii                       140              780         310              210             130            170          260          730     2,730
Idaho                         50              340          30              NA             NSD              30          140        1,240      NSD
Illinois                   1,840            5,120       2,290              800           1,040            770        2,370       14,510    28,740
Indiana                      420            2,330       1,070              420             390            310        1,130        5,140    11,210
Iowa                         170            2,080         160               40             120            140          280        1,610     4,600
Kansas                       430            1,120         170              NA              150            120          950        1,970      NSD
Kentucky                     730            1,140         580              180             360            210        1,100        2,700     7,000
Louisiana                    510            1,000         290              240             300            120          440        3,240     6,140
Maine                        290              660         310              120              80            110          210        1,770     3,550
Maryland                     600            3,040         620              150             540            440          550        8,940    14,880
Massachusetts                610            1,190       2,790              650           1,750            710        1,350        8,820    17,870
Michigan                   1,120            2,950       2,500              380             270            390          550       12,800    20,960
Minnesota                    720            3,280       1,120              590             720            370        1,320        4,250    12,370
Mississippi                  170            1,350         380              220             310            140          340          570     3,480




                                                                        33
                                       Family                                                                                All Other
                                         and                      Obstetricians                                              Physicians
                                       General        General         and           General                                     and
                 Anesthesiologists   Practitioners   Internists   Gynecologists   Pediatricians   Psychiatrists   Surgeons   Surgeons     Total
Missouri                      750            3,340         700              340             330            290         510        5,850   12,110
Montana                       NA               430          90              130              80            140         130          870     NSD
Nebraska                      340            1,020         170               90              70            140         220        1,570    3,620
Nevada                        NA             1,030         510              110             NA              70         460        1,530     NSD
New
Hampshire                     NA              360           90               70             50              60         240        1,590    NSD
New Jersey                    930           2,380        2,430              820          1,130             760       1,390        9,760   19,600
New Mexico                    230           1,460          340              190            220              90         220          730    3,480
New York                    3,390           2,280        2,770            1,160          2,570           3,440       2,050       41,620   59,280
North Carolina                860           3,880        1,100              810            730             380       1,260        5,930   14,950
North Dakota                   40             200        NSD              NSD               30              50         100          480    NSD
Ohio                          800           4,400        1,890            1,010          1,540             810       1,860       12,950   25,260
Oklahoma                      130           1,950          950              110            190             270         430        2,420    6,450
Oregon                        330             870          590              440            320             180         630        4,830    8,190
Pennsylvania                1,310           5,410        2,050              400            510           1,110       1,950       13,930   26,670
Puerto Rico                   290             810          130               90            110           NSD         NSD            920    NSD
Rhode Island                 NSD              190          NA                30            140             180         250        1,890    NSD
South Carolina                580           1,830          680              310            270              90         500        2,120    6,380
South Dakota                 NSD              380          160              NA              40           NSD           210          370    NSD
Tennessee                   1,060           1,160          440              290            400             240       1,130        4,120    8,840
Texas                       3,540           5,180        2,140            2,030          3,200           1,550       2,890       18,090   38,620
Utah                          NA              740          NA               NA             NA              120         290        2,440    NSD
Vermont                        90             250          190               40            140             110         160          850    1,830
Virgin Islands               NSD             NSD         NSD              NSD            NSD             NSD         NSD             80    NSD
Virginia                      920           2,240        1,120              560            680             450         950        7,520   14,440
Washington                    590           1,580          780              350            830             530       1,160        4,680   10,500
West Virginia                 NA            1,110          140               70            130             120         260        1,320    NSD
Wisconsin                     750           2,580          780              330            340             380         830        7,810   13,800
Wyoming                        50             420           50               50             60              30         100          250    1,010



                                                                        34
                                Appendix C
    Rate of Non-Federal Physicians per 100,000 Civilian Population, 2009
                                  Number of                      Number of
                                 Non-Federal         2009        Physicians
 Rank       Geographic Area
                                  Physicians,    Population      per 100,000
                                     2009                        Population
Average United States                1,077,683    310,973,838        347
    1     Washington, D.C.               5,432        599,657       906
    2     Massachusetts                 37,284      6,593,587       565
    3     New York                      94,836     19,541,453       485
    4     Maryland                      27,450      5,699,478       482
    5     Vermont                        2,980        621,760       479
    6     Connecticut                   16,568      3,518,288       471
    7     Rhode Island                   4,938      1,053,209       469
    8     Pennsylvania                  53,564     12,604,767       425
    9     New Jersey                    36,036      8,707,739       414
   10     Maine                          5,353      1,318,301       406
   11     Hawaii                         5,028      1,295,178       388
   12     New Hampshire                  4,974      1,324,575       376
   13     Michigan                      36,450      9,969,727       366
   14     Oregon                        13,947      3,825,657       365
   15     Ohio                          41,763     11,542,645       362
   16     Minnesota                     18,979      5,266,214       360
   17     Illinois                      45,705     12,910,409       354
   18     Florida                       65,122     18,537,969       351
   19     California                   126,893     36,961,664       343
   20     Washington                    22,791      6,664,195       342
   21     Virginia                      26,402      7,882,590       335
   22     Colorado                      16,775      5,024,748       334
   23     Wisconsin                     18,703      5,654,774       331
   24     Delaware                       2,912        885,122       329
   25     Missouri                      19,575      5,987,580       327
   26     Tennessee                     20,174      6,296,254       320
   27     Puerto Rico                   12,698      3,967,288       320
   28     West Virginia                  5,813      1,819,777       319
   29     Louisiana                     14,108      4,492,076       314
   30     North Carolina                28,995      9,380,884       309
   31     Nebraska                       5,540      1,796,619       308
   32     Kansas                         8,587      2,818,747       305
   33     New Mexico                     6,064      2,009,671       302
   34     North Dakota                   1,938        646,844       300



                                     35
                                           Number of                       Number of
                                          Non-Federal        2009          Physicians
       Rank         Geographic Area
                                          Physicians,      Population      per 100,000
                                             2009                          Population
         35      Montana                        2,914           974,989        299
         36      Arizona                       19,348         6,595,778        293
         37      Kentucky                      12,408         4,314,113        288
         38      South Carolina                12,910         4,561,242        283
         39      South Dakota                   2,259           812,383        278
         40      Indiana                       17,802         6,423,113        277
         41      Iowa                           8,280         3,007,856        275
         42      Alabama                       12,545         4,708,708        266
         43      Texas                         65,622        24,782,302        265
         44      Oklahoma                       9,626         3,687,050        261
         45      Utah                           7,233         2,784,572        260
         46      Georgia                       25,306         9,829,211        257
         47      Alaska                         1,783           698,473        255
         48      Arkansas                       7,254         2,889,450        251
         49      Wyoming                        1,351           544,270        248
         50      Nevada                         6,524         2,643,085        247
         51      Idaho                          3,522         1,545,801        228
         52      Mississippi                    6,619         2,951,996        224

Maryland ranks fourth among all states.

Note: Nonfederal physicians are members of the U.S. physician population who are employed in
the private sector. They include allopathic physicians (MDs) and osteopathic physicians (DOs),
and represent 97 percent of total physicians. Data include all licensed nonfederal physicians.

Sources: Data for physicians are from the American Medical Association (2009). Data for
civilian population are from the U.S. Census Bureau (November 23, 2010).




                                              36
                               Appendix D
          Rate of Dentists per 100,000 Civilian Population, 2009
                                     Total
                                                                  Dentists
                                  Number of         2009
 Rank      Geographic Area                                       per 100,000
                                   Dentists,      Population
                                                                 Population
                                     2009
Average United States                247,670      310,973,838        80
   1     Washington, D.C.                  817        599,657       136
   2     Massachusetts                   7,560      6,593,587       115
   3     Hawaii                          1,318      1,295,178       102
   4     California                     37,390     36,961,664       101
   5     New Jersey                      8,701      8,707,739       100
   6     Maryland                        5,681      5,699,478       100
   7     New York                       19,207     19,541,453        98
   8     Connecticut                     3,447      3,518,288        98
   9     Nebraska                        1,751      1,796,619        97
  10     Washington                      6,342      6,664,195        95
  11     Colorado                        4,655      5,024,748        93
  12     Alaska                            628        698,473        90
  13     Minnesota                       4,469      5,266,214        85
  14     Utah                            2,359      2,784,572        85
  15     Montana                           821        974,989        84
  16     Pennsylvania                   10,607     12,604,767        84
  17     Michigan                        8,176      9,969,727        82
  18     Florida                        15,021     18,537,969       81
  19     Idaho                           1,228      1,545,801        79
  20     Kentucky                        3,423      4,314,113        79
  21     Vermont                           492        621,760        79
  22     Illinois                       10,156     12,910,409       79
  23     Iowa                            2,360      3,007,856        78
  24     Virginia                        6,175      7,882,590        78
  25     New Hampshire                   1,034      1,324,575        78
  26     Arizona                         5,007      6,595,778        76
  27     Wisconsin                       4,232      5,654,774        75
  28     Nevada                          1,935      2,643,085        73
  29     Ohio                            8,025     11,542,645        70
  30     North Dakota                      443        646,844        68
  31     Rhode Island                      718      1,053,209        68
  32     South Carolina                  3,084      4,561,242        68
  33     Tennessee                       4,240      6,296,254        67
  34     West Virginia                   1,222      1,819,777        67
  35     Wyoming                           363        544,270        67
  36     Kansas                          1,858      2,818,747        66
  37     Oregon                          2,507      3,825,657        66


                                   37
                                               Total
                                                                              Dentists
                                             Number of         2009
        Rank         Geographic Area                                         per 100,000
                                              Dentists,      Population
                                                                             Population
                                               2009
          38      Oklahoma                         2,404        3,687,050        65
          39      Louisiana                        2,867        4,492,076        64
          40      Indiana                          4,090        6,423,113        64
          41      Maine                              836        1,318,301        63
          42      Missouri                         3,754        5,987,580        63
          43      North Carolina                   5,796        9,380,884        62
          44      South Dakota                       500          812,383        62
          45      Texas                          15,132        24,782,302        61
          46      New Mexico                       1,223        2,009,671        61
          47      Alabama                          2,736        4,708,708        58
          48      Delaware                           508          885,122        57
          49      Georgia                          5,525        9,829,211        56
          50      Mississippi                      1,559        2,951,996        53
          51      Arkansas                         1,469        2,889,450        51
          52      Puerto Rico                      1,819        3,967,288        46

The ranking of Maryland among all states is sixth.

Note: Data include all licensed dentists.

Sources: Data for dentists are from the American Dental Association (2009). Data for civilian
population are from the U.S. Census Bureau (November 23, 2010).




                                               38
                                          References

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American Dental Association. (2004, October). State and community models for improving
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American Dental Association. (2008). Dental data. Reported on Kaiser Family Foundation State
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American Medical Association. (2008). Physicians professional data as of 2008. Reported on
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Mofidi, M. (2005). Dentist participation in Medicaid: Key to assuring access for North
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Scheffler, R. M., Foreman, S. E., Feldstein, P. J., & Teh-Wei, H. (1996). A multi-equation model
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                                               39

				
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