Market Scoping
Where we stand on stoploss coverage across US inpatient markets — measured by the share of payer-provider combinations where we've identified a stoploss provision from MRF data.
How We Track Coverage
Three metrics measure stoploss coverage, each answering a different question:
| Metric | What It Measures | Denominator | National Coverage |
|---|---|---|---|
| Unweighted | Found / expected provider×payer combos | 4,114 providers × 138 payers per state (by market share) = 45,941 combos | 4.1% (1,880 / 45,941) |
| Top Combos — Unweighted | Found / expected, filtered to top 50 NPR providers per state × payers with >10% state market share | 2,012 providers × 55 payers = 5,776 combos | 13.7% (790 / 5,776) |
| NPR × Market Share Weighted | Share of NPR covered, weighted by hospital NPR × payer market share | $133.2B total net patient revenue | 10.6% ($19.9B covered) |
| Encounter Volume Weighted | Share of actual claims covered, weighted by Komodo encounter volume | 306K total inpatient claims with charges above $200K | 14.2% (43.5K covered) |
The gap between unweighted (4.1%) and weighted (10.6–14.2%) tells us we tend to have stoploss terms for payer-provider combinations that have more stoploss volume.
What We're Using
The rest of this page uses NPR charge-weighted coverage as the primary metric. Why:
- Full market view — covers all 50 states + territories and every qualifying hospital, even those with zero claims in Komodo. The encounter approach is capped at the top 500 combos nationally, and Komodo volume is skewed — we know data gaps exist for certain payers but don't know the full extent.
- Revenue-weighted — weighting by NPR × payer market share prioritizes the combinations most likely to have stoploss activity. Unweighted treats every combo equally regardless of volume.
- Trackable over time — as we add Phase 2 (CC Validation) and Phase 3 (Inference) data, this denominator stays fixed, so coverage % is directly comparable across releases.
Example: How NPR × Market Share Weighting Works
Say Hospital A has $500 million in NPR and sits in a state with three qualifying payers:
| Payer | State Market Share | Weight (NPR × Share) | MRF Stoploss Found? |
|---|---|---|---|
| Aetna | 40% | $500M × 0.40 = $200M | Yes |
| BCBS | 35% | $500M × 0.35 = $175M | No |
| United | 25% | $500M × 0.25 = $125M | Yes |
Denominator (total expected weight): $200M + $175M + $125M = $500M
Numerator (covered weight): $200M + $125M = $325M (the two combos where we found MRF stoploss terms)
Weighted coverage for this hospital: $325M / $500M = 65%
The unweighted coverage would be 2/3 = 67% — similar here, but across the full market, weighted coverage diverges because large-share payer gaps at high-NPR hospitals count more than small-share payer gaps at small hospitals.
This calculation is repeated for every hospital in every state, then summed nationally to get the 10.6% weighted figure.
- $133.2 billion total net patient revenue scoped across 50 states + territories
- $19.9 billion covered by direct MRF stoploss terms (14.9%)
- 1,031 unique providers · 121 unique payers · 1,880 combos found
Coverage Map
Darker teal = higher NPR charge-weighted coverage. Gray = zero coverage.
Coverage by Charge Tier
| Tier | NPR | % of Total | Description |
|---|---|---|---|
| Direct MRF Coverage | $19.9 billion | 14.9% | Provider×payer combos where we have MRF stoploss terms |
| System Extrapolation | $13.9 billion | 10.4% | Same health system as a covered combo — terms likely exist but aren't in MRF yet |
| Coverage Gap | $99.4 billion | 74.6% | No MRF data and no system-level inference |
The system extrapolation layer is significant: if a health system has stoploss terms with Payer A, they likely also have terms with Payer B at the same facility. This adds 10.4pp of "likely covered" NPR on top of the 14.9% we have directly.
State Tier Analysis
Tier 1 — Strong Coverage (>40%)
States where our MRF data covers a significant share of the inpatient market.
- TX — $13.1 billion NPR, 44.1% covered. Largest well-covered market with $5.8 billion in MRF coverage.
- NY — $8.0 billion NPR, 39.0% covered. Second-strongest major market.
- TN — $2.2 billion NPR, 42.0% covered. Encounter-weighted coverage even higher at 60.5%.
- CO — $1.6 billion NPR, 73.2% covered. Near-saturated.
- NV — $738 million NPR, 62.0% covered. Strong coverage in a mid-size market.
- AR — $225 million, 70.6% | KS — $356 million, 73.6% | VT — $94 million, 83.2%
- WI — $325 million, 54.5% | LA — $478 million, 50.0% | ID — $74 million, 48.8% | WY — $22 million, 46.8%
Tier 2 — Moderate Coverage (10–40%)
Partial coverage with room to grow. Biggest expansion opportunities here.
- FL — $9.3 billion NPR, 24.9% covered. Second-largest market. $7.0 billion uncovered.
- NJ — $4.5 billion NPR, 9.5% covered. Large market, low but present foothold.
- AZ — $3.9 billion NPR, 14.3% covered. Good base to expand from.
- DC — $2.2 billion, 8.5% | MN — $1.8 billion, 26.7% | VA — $1.1 billion, 26.0%
- SC — $816 million, 15.5% | NC — $754 million, 37.3% | NH — $547 million, 33.3%
- OK — $472 million, 30.6% | UT — $418 million, 9.0% | MO — $375 million, 35.3% | IA — $105 million, 32.2%
Tier 3 — Low/No Coverage (<10%)
States where MRF data is sparse or absent. The largest gaps represent the biggest opportunities.
- CA — $36.6 billion NPR, 5.2% covered. Largest single gap.
- MI — $8.8 billion, 0% covered. Entirely greenfield.
- OH — $5.4 billion, 1.0% | GA — $5.4 billion, 2.0% — near-zero coverage.
- IN — $4.4 billion, 0% | PA — $4.3 billion, 0.7% | WA — $4.2 billion, 1.6%
- MA — $3.1 billion, 0% | KY — $1.2 billion, 0.5% | IL — $992 million, 1.6%
- Plus 16 additional states with under $750 million in NPR and zero or near-zero coverage.
Full State-by-State Table
Methodology Notes
Two Scoping Approaches
We evaluate MRF stoploss coverage using two complementary methodologies:
NPR × Payer Market Share ("Supply-Side") — For every hospital (ranked by Net Patient Revenue) crossed with every qualifying payer (filtered by market share of covered lives), does our MRF data contain an inpatient stoploss term? This captures the entire addressable universe including hospitals with zero claims in our data. Best for total market sizing.
Encounter Volume ("Demand-Side") — For provider×payer combinations that have actual inpatient claims in Komodo data, does our MRF data contain a stoploss term? Only includes combos with real activity. Best for operational coverage and pricing impact.
Why NPR Coverage % is the Primary Metric
The map and tier analysis above use NPR charge-weighted coverage because:
- It covers all 50 states + territories (encounter data is more limited in scope)
- It represents the full addressable market, not just observed claims
- NPR × payer market share weighting correctly prioritizes high-revenue hospitals with large-share payers
Key Assumptions
- Inpatient only — All MRF data filtered to inpatient setting. Outpatient stoploss terms excluded.
- Hospital types — Short Term Acute Care Hospitals and Children's Hospitals only.
- MRF matching — A provider×payer combo is "covered" if any inpatient MRF stoploss term exists for that pair, regardless of review status.
- Encounter top-500 — Encounter columns reflect top 500 combos nationally by claims volume (~64% of total claims).
- NPR expected combos — Upper bound: every qualifying hospital × qualifying payer per state. Not every pair will actually have a stoploss provision.
Data Sources
- MRF data: 6,522 inpatient stoploss records from hospital Machine-Readable Files
- Komodo claims: Provider×payer×year combinations with total claims and charges
- Hospital metadata: NPR, beds, state, subtype, health system affiliation (CMS/hospital filings)
- Payer data: Covered lives by state for market share computation