Claims, Payers, and Insurance

This page provides a brief overview of the "health economics" built into Synthea, covering claims, costs, payers, insurance, and related details.

Costs

Let's start with costs. Dollars and cents.

Every piece of care provided to our synthetic patients costs some synthetic money.

If you are using default settings, this synthetic money is USD. If you are running with synthea-international configuration files, the synthetic money can be Canadian Dollars, British Pounds Sterling, Euros, or whatever synthetic money you want. We don't care.

The base prices can be found in src/main/resources/costs, where there are CSV files for encounters, immunizations, medications, and procedures.

Each of these CSV files contains a code with associated min, mode, and max costs. Whenever care is provided that matches the code, the price is randomly drawn from a Triangular Distribution using the min, mode, and max costs.

If no code was a match, then default costs are used, which are defined in synthea.properties:

# Default Costs, to be used for pricing something that we don't have a specific price for
# -- $500 for procedures is completely invented
generate.costs.default_procedure_cost = 500.00
# -- $255 for medications - also invented
generate.costs.default_medication_cost = 255.00
# -- Encounters billed using avg prices from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096340/
# -- Adjustments for initial or subsequent hospital visit and level/complexity/time of encounter
# -- not included. Assume initial, low complexity encounter (Tables 4 & 6)
generate.costs.default_encounter_cost = 125.00
# -- https://www.nytimes.com/2014/07/03/health/Vaccine-Costs-Soaring-Paying-Till-It-Hurts.html
# -- currently all vaccines cost $136.
generate.costs.default_immunization_cost = 136.00

The randomly drawn (or default) cost is then adjusted, using geographic adjustment factors (by State) that are located in the adjustmentFactors.csv file.

Costs may be paid by insurance or out of pocket, depending on the situation.

Payers

In order for the costs to be covered, they need to be paid. This can be out of pocket expenses, but typically they are covered by a payer. Synthetic patients can purchase private insurance, or be covered by government/public insurance. The available payers are configurable in the src/main/resources/payers/insurance_companies.csv file.