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2019 Payor Mix at U.S. Hospitals

April 11, 2019 BY Tory Waldron

2019 Payor Mix at U.S. Hospitals

According to the 2017 U.S. census, private health insurance was the predominant form of insurance (67.2 percent of U.S. citizens), versus government-run insurance programs like Medicare and Medicaid (CMS), which cover 37.7 percent of the U.S. 

Using Definitive Healthcare's proprietary data, we decided to take an even deeper dive into the U.S. payor mix, as of March 2019. Here's what we found:

Payor Mix: Hospital Net Revenue

Medicare and Medicaid currently represent a large portion of hospital net revenue, but it is no surprise that self-pay and private insurance (commercial claims) cover the majority. Definitive Healthcare’s analysis of 6,400 hospitals found that private payors and self-pay cover the greatest portion of hospital net revenue by about $1.4T (67.9%), compared with Medicare’s $398B and Medicaid’s $259B.


Payor Days: Hospital Type

Looking at average payor days by hospital type, we see that rehabilitation, critical access, and long-term acute care hospitals have the highest percentage of Medicare days. Psychiatric hospitals, on the other hand, have the highest percentage of private/self-pay days, which may be because CMS programs only cover up to 190 days of inpatient mental health care over a lifetime.


Payor Days: Hospital Region

Hospitals in the Midwest and South have a slightly higher percentage of Medicare days than the national average, which may be the result of an aging population in those areas. Hospitals in the Northeast and West have a higher percentage of private/self-pay days. This may be partially due to variation in health insurance coverage offered by employers in different regions or the country (among other reasons).


Learn More

If you’re only looking at publicly-facing CMS data to research, target and sell to the healthcare provider market, you’re not seeing the full picture. More than half of the country has private insurance and, currently, there are limited ways to access this private claims data.

In most cases, private claims information exists in the form of flat data files that are difficult to search through, sort, manipulate, correlate, and compare against other sets of data. To solve this market need, Definitive Healthcare amassed billions of private (commercial) claims and seamlessly integrated them into its easy-to-use platform. This platform features a search tool that enables its users to find relevant medical and Rx claims data, as well as the unique ability to view CMS and commercial claims data in aggregate. By combining billions of private medical and Rx claims with CMS and proprietary data, Definitive Healthcare empowers its users to better analyze healthcare market trends, develop comprehensive segmentation strategies, identify industry leaders, and hone sales and marketing strategies.

Definitive Healthcare tracks:

  • 1 billion Medical Claims annually for 7,900 hospitals and nearly 1.3M healthcare professionals
  • 900 million Rx Claims annually, bringing clarity to the prescribing habits of more than 1 million physicians across the U.S.
  • 247 million covered lives total (from 2016 to the present)
  • 150 million covered lives annually (65% of the U.S. population)

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