Stanford-led study points to ways to cut U.S. health care billing costs

Stanford researchers and colleagues find ways to lower health care administration costs within the U.S. multipayer system by analyzing other countries’ approaches.

- By Laurie Flynn

The vast number of codes used for various medical conditions ratchet up the cost of health care in the United States, according to researchers at Stanford and other institutions.

A new Stanford Medicine-led study has found that borrowing certain billing- and insurance-related procedures from other countries could lead to policies that drastically lower health care costs in the United States.

The new study, published in the August edition of Health Affairs, compares costs of health care administrative processes in the U.S. with those of five other high-income countries. In the U.S., administrative processes account for about 30% of health care costs — the highest in the world.

Topping the list of practices that drive excessive costs in the U.S. is a process called coding, which is the assigning of a numeric code for each service a patient receives. The code is used by insurers to determine reimbursement. Coding costs in the U.S. run more than $172 per bill, compared with $50 per bill in Australia, the second highest in the study, and about $16 per bill in the Netherlands, said Kevin Schulman, MD, professor of medicine and faculty at Stanford’s Clinical Excellence Research Center.  

Earlier studies, including a Stanford-led one published in Health Services Research last year, have tried to quantify the drivers of high administrative costs in the U.S. health care system. “This new study provides validation of this analysis using real data from several different markets,” said Schulman, the paper’s senior author.

“In the U.S., the high administrative and billing costs have led for calls to change the financing system from a multipayer market to a single-payer public system,” Schulman added. “These new data show that the financing model is not the sole driver of high billing costs, since other markets with private insurance have lower billing costs than the U.S. Rather than debate a hypothetical single-payer model as a solution, we can focus on how to improve our current market so that it is as low cost per transaction as other private markets.”

The most effective way for the U.S. to reduce billing costs would be to make insurance contracts with providers simpler and more standardized, Schulman said. Germany and the Netherlands, for example, have much simpler administrative strategies for payment, even as private multipayer markets. The U.S. has an overemphasis on coding for incremental features of clinical care that drives up coding costs. 

A look at diverse systems

In 2018, the researchers recruited an international team to analyze administrative costs per bill for inpatient stays at six health care systems in five high-income nations — one in Australia, Canada, Germany and the Netherlands; and two in Singapore — and compared these with estimated costs per bill at a U.S. academic health system based on data from 2016 and 2017. The countries were selected to represent a diversity of size, medical specialty and national payment systems. The health care systems of Germany and the Netherlands include multiple private insurers, making them the most similar to the U.S. system.

Kevin Schulman

“Germany and the Netherlands have competitive insurance markets with multiple private insurers, yet they manage systems with far lower administrative costs,” said Barak Richman, JD, PhD, lead author of the study and a professor of law at Duke University and senior scholar at CERC. “That suggests they have lessons we can readily apply in the U.S.”

Besides coding, other opportunities for cost savings include eligibility, which refers to verifying insurance for the visit; submission, referring to invoice preparation; and rework, correcting billing errors and resolving disputes between the payer and a provider.

Schulman said that the research also highlights the burden of an outdated U.S. administrative system, a legacy of the paper-based system that was in place before adoption of electronic health records. “What we’ve done in health care billing in the U.S. is taken the analog process and digitized it, whereas other countries have created fully digital processes and optimized them, leading to enormous savings,” he said. “The savings have been identified in the literature on the order of $250 billion annually but are likely even greater.”

More possibilities for cutting costs

For some countries, savings also come from assigning tasks to workers in lower-skill job categories. “What we find is an over-reliance on medical coding in the U.S. system, requiring significant input by clinicians in the process. Other countries don’t have clinicians involved at all and have drastically limited the complexity of the coding process,” Schulman said.

Some countries, most notably Singapore, reduce costs by offering pretreatment financial counseling, in which a patient services team meets with patients to explain expected charges, what their insurance covers and what their out-of-pocket cost will be. This lowers costs downstream in the billing process, primarily by reducing rework.

The researchers noted that other health systems have their own unique trade-offs. But learning from successful processes in other countries, Schulman said, could lead to dramatic improvements in efficiency without requiring an overhaul of the entire U.S. health care system.

The investigation was a collaboration between faculty at Stanford Medicine, Harvard Business School, Duke University, the University of Toronto Rotman School of Management, Erasmus University Rotterdam in the Netherlands, GenisisCare in Australia and St. Andrews Hospital in Australia.

The study was funded by Stanford CERC and Harvard Business School.

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit

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