{
  "alt": "Three views. The first is a set of five horizontal stacked bars of payments per beneficiary by service line, one for each fifth of counties from the least to the most deprived, with total bars of similar length and a thinner procedures, tests and imaging segment toward the deprived end. The second is a scatter plot of county life expectancy against payments with two lines of markers for tenths of counties: one weighted by beneficiaries that stays level and one counting each county once that falls. The third is a bar chart of emergency department visits per thousand beneficiaries rising from {fact:er_q1} to {fact:er_q5}.",
  "caption": "The five totals are close and the difference between the ends is not distinguishable from zero, but the fifths are different kinds of counties: {fact:small_ben_q5} of the most deprived fifth's beneficiaries live in counties with fewer than {fact:small_cut} fee-for-service beneficiaries, against {fact:small_ben_q1} in the least deprived fifth. The first view splits each total by service line, the second plots county life expectancy against payments, and the third plots emergency department visits. Medicare Advantage enrollees are not in these figures, and {fact:n_outside_le} counties fall outside the plotted range of the second view.",
  "data": [],
  "id": "medicare_spending",
  "notes": [
    "Payments are CMS price-standardized Part A and Part B payments per capita for beneficiaries enrolled in Original Medicare with both parts, so Medicare Advantage enrollees, who are {fact:ma_share} of beneficiaries with both parts in these counties, are not in them. Standardization removes local price differences and does not adjust for how sick beneficiaries are. The file counts beneficiaries of all ages, including those under {fact:medicare_age} who qualify through disability.",
    "A fifth holds equal numbers of counties, ranked on the county Area Deprivation Index (the mean of its tracts' ranks, weighted by population). Intervals resample whole states. Connecticut is by planning region. The service lines view leaves out counties for which CMS blanks a line, and its last segment is the total minus the lines shown. Evaluation and management visits are CMS's category for visits to physicians and other clinicians in many settings, among them offices, hospitals, nursing facilities, homes and emergency departments.",
    "Life expectancy is the County Health Rankings 2024 estimate computed from NCHS death counts. Connecticut is left out of the second view because that file uses its legacy counties.",
    "Across all the counties in the comparison, there are {fact:us_ed_visits} emergency department visits per thousand fee-for-service beneficiaries per year."
  ],
  "source": "CMS Medicare Geographic Variation, county, 2024, and Area Deprivation Index 2023; price-standardized payments per fee-for-service beneficiary, weighted by fee-for-service beneficiaries, full counts (life expectancy from County Health Rankings 2024, deaths 2019-2021, full counts)",
  "spec": {
    "panels": [
      {
        "figure": {
          "alt": "Five horizontal stacked bars of payments per beneficiary, one for each fifth of counties from the least to the most deprived. The bars are about the same length. The segment for procedures, tests, imaging and treatments shrinks from {fact:proc_q1} to {fact:proc_q5}, and the skilled nursing facility segment grows from {fact:snf_q1} to {fact:snf_q5}.",
          "caption": "The totals are close. Differences between the most and the least deprived fifth, in dollars per beneficiary, are {fact:proc_diff} for procedures, tests, imaging and treatments, {fact:em_diff} for evaluation and management visits, {fact:snf_diff} for skilled nursing facilities, {fact:op_diff} for hospital outpatient departments and surgery centers and {fact:oth_diff} for all other services; the intervals for inpatient hospital stays ({fact:ip_diff}) and for home health and hospice ({fact:hh_diff}) include zero. Each segment is a mean of county payments weighted by fee-for-service beneficiaries.",
          "data": [
            {
              "ci_high": 3001,
              "ci_low": 2712,
              "counties": 605,
              "dollars": 2871,
              "fifth": "1 (least deprived)",
              "service": "Inpatient hospital stays"
            },
            {
              "ci_high": 2963,
              "ci_low": 2765,
              "counties": 585,
              "dollars": 2869,
              "fifth": "2",
              "service": "Inpatient hospital stays"
            },
            {
              "ci_high": 2993,
              "ci_low": 2812,
              "counties": 571,
              "dollars": 2913,
              "fifth": "3",
              "service": "Inpatient hospital stays"
            },
            {
              "ci_high": 3036,
              "ci_low": 2858,
              "counties": 565,
              "dollars": 2955,
              "fifth": "4",
              "service": "Inpatient hospital stays"
            },
            {
              "ci_high": 3073,
              "ci_low": 2919,
              "counties": 541,
              "dollars": 3005,
              "fifth": "5 (most deprived)",
              "service": "Inpatient hospital stays"
            },
            {
              "ci_high": 2684,
              "ci_low": 2401,
              "counties": 605,
              "dollars": 2516,
              "fifth": "1 (least deprived)",
              "service": "Hospital outpatient and surgery centers"
            },
            {
              "ci_high": 2953,
              "ci_low": 2618,
              "counties": 585,
              "dollars": 2780,
              "fifth": "2",
              "service": "Hospital outpatient and surgery centers"
            },
            {
              "ci_high": 3035,
              "ci_low": 2708,
              "counties": 571,
              "dollars": 2864,
              "fifth": "3",
              "service": "Hospital outpatient and surgery centers"
            },
            {
              "ci_high": 3201,
              "ci_low": 2793,
              "counties": 565,
              "dollars": 3002,
              "fifth": "4",
              "service": "Hospital outpatient and surgery centers"
            },
            {
              "ci_high": 3098,
              "ci_low": 2768,
              "counties": 541,
              "dollars": 2926,
              "fifth": "5 (most deprived)",
              "service": "Hospital outpatient and surgery centers"
            },
            {
              "ci_high": 986,
              "ci_low": 712,
              "counties": 605,
              "dollars": 865,
              "fifth": "1 (least deprived)",
              "service": "Skilled nursing facilities"
            },
            {
              "ci_high": 829,
              "ci_low": 721,
              "counties": 585,
              "dollars": 771,
              "fifth": "2",
              "service": "Skilled nursing facilities"
            },
            {
              "ci_high": 928,
              "ci_low": 831,
              "counties": 571,
              "dollars": 879,
              "fifth": "3",
              "service": "Skilled nursing facilities"
            },
            {
              "ci_high": 1081,
              "ci_low": 925,
              "counties": 565,
              "dollars": 1004,
              "fifth": "4",
              "service": "Skilled nursing facilities"
            },
            {
              "ci_high": 1462,
              "ci_low": 1122,
              "counties": 541,
              "dollars": 1302,
              "fifth": "5 (most deprived)",
              "service": "Skilled nursing facilities"
            },
            {
              "ci_high": 1148,
              "ci_low": 839,
              "counties": 605,
              "dollars": 1010,
              "fifth": "1 (least deprived)",
              "service": "Home health and hospice"
            },
            {
              "ci_high": 1066,
              "ci_low": 853,
              "counties": 585,
              "dollars": 962,
              "fifth": "2",
              "service": "Home health and hospice"
            },
            {
              "ci_high": 1187,
              "ci_low": 864,
              "counties": 571,
              "dollars": 1018,
              "fifth": "3",
              "service": "Home health and hospice"
            },
            {
              "ci_high": 1228,
              "ci_low": 896,
              "counties": 565,
              "dollars": 1060,
              "fifth": "4",
              "service": "Home health and hospice"
            },
            {
              "ci_high": 1460,
              "ci_low": 975,
              "counties": 541,
              "dollars": 1234,
              "fifth": "5 (most deprived)",
              "service": "Home health and hospice"
            },
            {
              "ci_high": 1426,
              "ci_low": 1218,
              "counties": 605,
              "dollars": 1333,
              "fifth": "1 (least deprived)",
              "service": "Evaluation and management visits"
            },
            {
              "ci_high": 1219,
              "ci_low": 1062,
              "counties": 585,
              "dollars": 1146,
              "fifth": "2",
              "service": "Evaluation and management visits"
            },
            {
              "ci_high": 1102,
              "ci_low": 992,
              "counties": 571,
              "dollars": 1054,
              "fifth": "3",
              "service": "Evaluation and management visits"
            },
            {
              "ci_high": 1028,
              "ci_low": 902,
              "counties": 565,
              "dollars": 967,
              "fifth": "4",
              "service": "Evaluation and management visits"
            },
            {
              "ci_high": 967,
              "ci_low": 831,
              "counties": 541,
              "dollars": 903,
              "fifth": "5 (most deprived)",
              "service": "Evaluation and management visits"
            },
            {
              "ci_high": 2723,
              "ci_low": 2275,
              "counties": 605,
              "dollars": 2508,
              "fifth": "1 (least deprived)",
              "service": "Procedures, tests, imaging and treatments"
            },
            {
              "ci_high": 2399,
              "ci_low": 2011,
              "counties": 585,
              "dollars": 2204,
              "fifth": "2",
              "service": "Procedures, tests, imaging and treatments"
            },
            {
              "ci_high": 2073,
              "ci_low": 1808,
              "counties": 571,
              "dollars": 1938,
              "fifth": "3",
              "service": "Procedures, tests, imaging and treatments"
            },
            {
              "ci_high": 1936,
              "ci_low": 1655,
              "counties": 565,
              "dollars": 1786,
              "fifth": "4",
              "service": "Procedures, tests, imaging and treatments"
            },
            {
              "ci_high": 1884,
              "ci_low": 1635,
              "counties": 541,
              "dollars": 1770,
              "fifth": "5 (most deprived)",
              "service": "Procedures, tests, imaging and treatments"
            },
            {
              "ci_high": 1745,
              "ci_low": 1375,
              "counties": 605,
              "dollars": 1578,
              "fifth": "1 (least deprived)",
              "service": "All other services"
            },
            {
              "ci_high": 1830,
              "ci_low": 1456,
              "counties": 585,
              "dollars": 1639,
              "fifth": "2",
              "service": "All other services"
            },
            {
              "ci_high": 1922,
              "ci_low": 1544,
              "counties": 571,
              "dollars": 1724,
              "fifth": "3",
              "service": "All other services"
            },
            {
              "ci_high": 1931,
              "ci_low": 1622,
              "counties": 565,
              "dollars": 1776,
              "fifth": "4",
              "service": "All other services"
            },
            {
              "ci_high": 2226,
              "ci_low": 1863,
              "counties": 541,
              "dollars": 2058,
              "fifth": "5 (most deprived)",
              "service": "All other services"
            }
          ],
          "id": "medicare_service_lines",
          "spec": {
            "category": "fifth",
            "categoryLabel": "Fifth of counties by ADI",
            "colors": {
              "All other services": "cat7",
              "Evaluation and management visits": "cat5",
              "Home health and hospice": "cat4",
              "Hospital outpatient and surgery centers": "cat2",
              "Inpatient hospital stays": "cat1",
              "Procedures, tests, imaging and treatments": "cat6",
              "Skilled nursing facilities": "cat3"
            },
            "format": {
              "digits": 0,
              "prefix": "$",
              "thousands": true
            },
            "group": "service",
            "orientation": "h",
            "sort": "data",
            "stack": true,
            "value": "dollars",
            "valueLabel": "Dollars per fee-for-service beneficiary per year"
          },
          "subtitle": "Price-standardized payments per fee-for-service beneficiary by service line, dollars per year, fifths of counties by the county Area Deprivation Index",
          "table": {
            "columns": [
              {
                "key": "fifth",
                "label": "Fifth of counties by ADI"
              },
              {
                "key": "service",
                "label": "Service line"
              },
              {
                "format": {
                  "thousands": true
                },
                "key": "dollars",
                "label": "Dollars per beneficiary"
              },
              {
                "format": {
                  "thousands": true
                },
                "key": "ci_low",
                "label": "Lower limit of the 95% interval"
              },
              {
                "format": {
                  "thousands": true
                },
                "key": "ci_high",
                "label": "Upper limit of the 95% interval"
              },
              {
                "format": {
                  "thousands": true
                },
                "key": "counties",
                "label": "Counties"
              }
            ]
          },
          "title": "Payments for procedures, tests, imaging and treatments fall from {fact:proc_q1} to {fact:proc_q5} across fifths of counties while payments for skilled nursing facilities rise from {fact:snf_q1} to {fact:snf_q5}",
          "type": "bar"
        },
        "label": "Service lines"
      },
      {
        "figure": {
          "alt": "Scatter plot of county life expectancy against Medicare payments per beneficiary: a wide cloud of dots of different sizes, a line of ten markers for tenths of counties weighted by beneficiaries that stays within a narrow band of life expectancy, and a second line counting each county once that falls as payments rise.",
          "caption": "The beneficiary-weighted correlation is {fact:le_r_spend}, with a slope of {fact:le_slope_1k} years per thousand dollars and an interval that includes zero, and holding the county ADI fixed the weighted slope is {fact:le_slope_ctrl}. Counting each county once, the correlation is {fact:le_r_spend_unw} and the slope holding the ADI fixed is {fact:le_slope_ctrl_unw}. The first line of markers is weighted by beneficiaries and the second counts each county once, each with 95% intervals from a bootstrap over states. The county ADI correlates {fact:le_r_adi} with life expectancy. No line is fitted.",
          "data": [],
          "id": "spend_vs_life_expectancy",
          "spec": {
            "overlays": [
              {
                "hi": "hi",
                "kind": "line",
                "label": "Tenths of counties by payments, weighted by beneficiaries",
                "lo": "lo",
                "rows": [
                  {
                    "hi": 79.13,
                    "lo": 78.11,
                    "n_units": 305,
                    "x": 9374,
                    "y": 78.6
                  },
                  {
                    "hi": 79.23,
                    "lo": 77.46,
                    "n_units": 306,
                    "x": 10455,
                    "y": 78.45
                  },
                  {
                    "hi": 78.75,
                    "lo": 76.77,
                    "n_units": 306,
                    "x": 11043,
                    "y": 77.8
                  },
                  {
                    "hi": 79.42,
                    "lo": 76.75,
                    "n_units": 305,
                    "x": 11446,
                    "y": 78.21
                  },
                  {
                    "hi": 77.68,
                    "lo": 76.26,
                    "n_units": 306,
                    "x": 11848,
                    "y": 77
                  },
                  {
                    "hi": 77.87,
                    "lo": 75.94,
                    "n_units": 306,
                    "x": 12258,
                    "y": 76.87
                  },
                  {
                    "hi": 78.21,
                    "lo": 76.22,
                    "n_units": 305,
                    "x": 12707,
                    "y": 77.33
                  },
                  {
                    "hi": 78.12,
                    "lo": 76.19,
                    "n_units": 306,
                    "x": 13284,
                    "y": 77.27
                  },
                  {
                    "hi": 78.76,
                    "lo": 75.56,
                    "n_units": 306,
                    "x": 14093,
                    "y": 77.41
                  },
                  {
                    "hi": 78.83,
                    "lo": 75.25,
                    "n_units": 306,
                    "x": 15775,
                    "y": 77.62
                  }
                ],
                "x": "x",
                "y": "y"
              },
              {
                "hi": "hi",
                "kind": "line",
                "label": "Tenths of counties by payments, each county once",
                "lo": "lo",
                "rows": [
                  {
                    "hi": 78.59,
                    "lo": 77.53,
                    "n_units": 305,
                    "x": 9230,
                    "y": 78.07
                  },
                  {
                    "hi": 77.61,
                    "lo": 76.37,
                    "n_units": 306,
                    "x": 10467,
                    "y": 77.04
                  },
                  {
                    "hi": 77.07,
                    "lo": 75.67,
                    "n_units": 306,
                    "x": 11025,
                    "y": 76.39
                  },
                  {
                    "hi": 76.91,
                    "lo": 75.44,
                    "n_units": 305,
                    "x": 11452,
                    "y": 76.19
                  },
                  {
                    "hi": 76.65,
                    "lo": 74.95,
                    "n_units": 306,
                    "x": 11852,
                    "y": 75.75
                  },
                  {
                    "hi": 76.25,
                    "lo": 74.86,
                    "n_units": 306,
                    "x": 12258,
                    "y": 75.51
                  },
                  {
                    "hi": 76.19,
                    "lo": 74.53,
                    "n_units": 305,
                    "x": 12714,
                    "y": 75.27
                  },
                  {
                    "hi": 75.79,
                    "lo": 74.01,
                    "n_units": 306,
                    "x": 13263,
                    "y": 74.87
                  },
                  {
                    "hi": 75.57,
                    "lo": 73.94,
                    "n_units": 306,
                    "x": 14087,
                    "y": 74.69
                  },
                  {
                    "hi": 74.74,
                    "lo": 72.54,
                    "n_units": 306,
                    "x": 16160,
                    "y": 73.66
                  }
                ],
                "x": "x",
                "y": "y"
              }
            ],
            "payload": "spend_vs_life_expectancy.json",
            "size": "ffs",
            "sizeFormat": {
              "digits": 0,
              "thousands": true
            },
            "sizeLabel": "Fee-for-service beneficiaries",
            "x": "spend",
            "xDomain": [
              6000,
              22000
            ],
            "xFormat": {
              "digits": 0,
              "prefix": "$",
              "thousands": true
            },
            "xLabel": "Price-standardized payments per fee-for-service beneficiary, 2024 (dollars)",
            "y": "le",
            "yDomain": [
              66,
              88
            ],
            "yFormat": {
              "digits": 0
            },
            "yLabel": "County life expectancy at birth, deaths in 2019 to 2021 (years)"
          },
          "subtitle": "County life expectancy at birth in years against price-standardized Medicare payments per fee-for-service beneficiary in dollars, one dot per county, dot area is beneficiaries, with means for tenths of counties by payments",
          "title": "Weighted by beneficiaries, county life expectancy has no clear relation to payments per beneficiary, a correlation of {fact:le_r_spend}, but counting each county once the correlation is {fact:le_r_spend_unw}",
          "type": "scatter"
        },
        "label": "Life expectancy"
      },
      {
        "figure": {
          "alt": "Five vertical bars of emergency department visits per thousand beneficiaries, one for each fifth of counties from the least to the most deprived, rising from {fact:er_q1} to {fact:er_q5}, each with an interval.",
          "caption": "The means rise at every step toward the most deprived fifth, though the intervals of neighboring fifths overlap, and the county correlation with the ADI is {fact:er_r}. Each bar is a mean of county rates weighted by fee-for-service beneficiaries, with a 95% interval from a bootstrap over states.",
          "data": [
            {
              "conf_high": 584,
              "conf_low": 555.5,
              "fifth": "1 (least deprived)",
              "n": 625,
              "visits": 570.5
            },
            {
              "conf_high": 617.4,
              "conf_low": 582.1,
              "fifth": "2",
              "n": 625,
              "visits": 598.9
            },
            {
              "conf_high": 635.5,
              "conf_low": 603,
              "fifth": "3",
              "n": 626,
              "visits": 620.1
            },
            {
              "conf_high": 655.4,
              "conf_low": 627.3,
              "fifth": "4",
              "n": 628,
              "visits": 642.1
            },
            {
              "conf_high": 693.6,
              "conf_low": 656.4,
              "fifth": "5 (most deprived)",
              "n": 624,
              "visits": 676.7
            }
          ],
          "id": "emergency_visits",
          "spec": {
            "category": "fifth",
            "categoryLabel": "Fifth of counties by ADI",
            "domain": [
              0,
              800
            ],
            "format": {
              "digits": 0
            },
            "hi": "conf_high",
            "lo": "conf_low",
            "n": "n",
            "orientation": "v",
            "value": "visits",
            "valueLabel": "Visits per thousand beneficiaries per year"
          },
          "subtitle": "Emergency department visits per thousand fee-for-service beneficiaries per year, fifths of counties by the county Area Deprivation Index",
          "title": "Emergency department visits are higher in the more deprived fifths of counties, from {fact:er_q1} in the least deprived to {fact:er_q5} in the most deprived per thousand fee-for-service beneficiaries",
          "type": "bar"
        },
        "label": "Emergency visits"
      }
    ]
  },
  "subtitle": "Medicare Part A and Part B payments per Original Medicare beneficiary with local prices removed, by fifth of the county Area Deprivation Index, service lines, emergency department visits and county life expectancy, 2024",
  "title": "Price-standardized Medicare payments are {fact:spend_q1} per fee-for-service beneficiary in the least deprived fifth of counties and {fact:spend_q5} in the most deprived, a difference whose interval includes zero",
  "type": "tabs",
  "width": "wide"
}