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Research With Medicare Claim Data

Research With Medicare Claim Data

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Research With Medicare Claim Data

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  1. Research With Medicare Claim Data Xinhua Yu, MD PhD Division of Epidemiology and Biostatistics School of Public Health University of Memphis June 22, 2012

  2. Outlines • Medicare program overview • Bill process and claim data • Data structure and important variables • Requesting CMS Medicare data • Data analysis • Research applications • Discussion

  3. 1. Medicare Overview

  4. Medicare Program • National health insurance for age >=65, or people with certain disabilities, or people with ESRD etc. • 1965 - Title XVIII of the Social Security Act • 7/1/1966 - Medicare Program started • 2003, Medicare Prescription Drug, Improvement, and Modernization Act (MMA) • 2006 prescription drug program (Part D) started

  5. Medicare Coverage (Entitlement) • Part A , or Hospital Insurance (HI) • Part B, or Supplemental Medical Insurance (SMI) • Part “C”, or Medicare Advantage Plans (HMO, PPO) • Part D, or Prescription Drug Coverage

  6. Medicare Part A Benefits • Hospital care • Skilled nursing facility (SNF) care • Home health care • skilled nursing and rehabilitation care • patient confined to home • Hospice care (added in 1983) • For terminally ill patients with a life expectancy of 6 months or less

  7. Part A Eligibility • Elderly • Person is eligible if they or their spouse worked 40, or more, quarters in their lifetime and paid Medicare tax while working • For those who did not work 40 quarters, enrollment is possible by paying a monthly premium • Disabled • a person who has received Social Security disability benefits for 24 months • ESRD- persons with end-stage renal disease, ALS - persons with Amyotrophic Lateral Sclerosis (ALS), or Lou Gehrig’s Disease

  8. Part B Benefits • Physician services (including nurse practitioners, physician assistants etc), and services provided by other providers (e.g., health departments) • Facility charges for hospital outpatient services and ambulatory care centers • Note: a person who is seen in a hospital or hospital outpatient setting will generally generate two claims, one from the facility and one from the physician • Durable Medical Equipment • Must pay a premium to be enrolled in part B

  9. Medicare Funding and Payment • Part A: Medicare Hospital Insurance Trust Fund (Medicare tax) • 98% people >=65 are enrolled in part A • Part B and D: Supplementary Medicare Insurance Fund (beneficiary premium and congress appropriation) • 96% elderly part A beneficiaries are enrolled in part B • ~60% elderly enrolled in Part D • Deductable and coinsurance

  10. Types of Medicare Program • Fee-for-service (FFS) or traditional Medicare program • Medicare managed care (now Medicare Advantage plan, Part C) began in 1985 • Risk based: insurance co. receive a capitated money, and plan assumes financial risk • Cost based • 12-16% of beneficiaries are in managed care • Higher in west coast (CA, OR etc.) • Medicare claims are likely incomplete for these managed care enrollees, thus often excluded in the analysis

  11. 2. Bill Processing and Claim Data

  12. Bill and Claims • Claims are bills for services given to the Medicare enrollees • Claims are processed sequentially and through hierarchical system • Help understand the contents of Medicare data and validity of data fields

  13. Type of Services • Institutional • Hospital Inpatient • Hospital Outpatient • Skilled Nursing Care • Home Health Care • Hospice • Non-Institutional • Physician, Laboratory and Other Supplier Services • Durable Medical Equipment

  14. Treatment Medicare Beneficiary Institutional Provider Non-institution Provider Payment/ Denial Claim CWF Host Claim (daily) • Update entitlement data • Check claims for entitlement, deductible, remaining benefit, and duplicates • Authorize full payment, partial payment, denial, or request additional data • Medicare Administrative • Contractor (MAC) • Fiscal Intermediary • Carrier Response • Enter claim into system • Perform consistency and utilization edits • Calculate payment • Deny claims based on • Medicare policy • Return denied claims • to provider Entitlement data (Daily) Claims data (Weekly) CMS • Update EDB with entitlement data • Add claims to National Claims • History Repository (NCHR)

  15. Claim Forms • Uniform bill: UB-92/UB-04, for institutional providers (e.g., hospitals, Skilled Nurse Facilities, home health, hospice) • Facility (institutional) claims • Used to be processed through Fiscal Intermediaries • CMS-1500 form: for non-institutional providers (e.g., physicians, lab, ambulance services, medical equipment bills) • Non-institutional claims • Used to be processed through Carriers • 23 Medicare Administrative Contractors (MACs) process both bills • 15 MACs for part A and B, 4 MACs for DME, and 4 for Home health and hospice • Components are different between these two forms

  16. Research Claim Files • SAF: Standard Analytical Files, i.e., claim based files • Contain “final action” claims • Inpatient, outpatient, physician services etc. • MedPAR: Medicare Provider Analysis and Review • Each observation contains aggregated data of all facility claims related to one episode of care • An episode of care is either a hospital or skilled nursing facility stay.

  17. SAFs and MedPAR • Each SAF contains “final action” claims • All adjustment (partial pay, denial, amendment) are rolled up into one record • SAF is available for each type of services • For inpatient services • SAF is more detailed (e.g., attending physician ID) • But MedPAR is easier to work with • 99% of inpatient SAF contain only one record for each hospital stay, thus essentially the same as MedPAR • Requesting SAF costs more than requesting MedPAR

  18. Example: Emergency Room Visit • ER services are considered outpatient services • But ER is usually attached to a hospital • Billed using facility forms (UB-92/04) • Outpatient SAF • What if ER results in a hospital admission? • Becomes Part A (hospitalization services) • Inpatient SAF/ MedPAR • Physician services are Part B • Carrier files will have them • So you need all files to capture diagnosis, procedures, and discharge destination for an ER visit

  19. 3. Medicare Data Structure http://www.ccwdata.org/data-dictionaries/index.htm

  20. 3.1 Beneficiary Summary File

  21. Beneficiary Summary File (Denominator File) • A calendar year file (cross-sectional file) • All eligible Medicare beneficiaries who ever enrolled (>= 1day) in Medicare • Limited by the criteria you requested • Served as the denominator for calculating rate or prevalence • Contains basic demographic, coverage, HMO, and part D enrollment information (discussed later)

  22. Demographic Variables • Encrypted beneficiary ID • Encrypted from HIC (11 digit unique identifier that is related to SSN) • Can be linked with multiple claim files • Date of birth (age) • There are disabled people with age <65 • Sex • Race • Sources: social security administration (SSA), railroad board (RRB)

  23. Age • It is better to calculate the age variable by yourself based on date of birth • The age variable in the file is calculated as of Dec. 31 in the previous year, thus misclassify those turning 65 during the study year as 64 • Something wrong with really really old people • Medicare had higher percent of people with >100 than the census • There are people with age >120 which is still very unlikely • i.e., some deaths are missed • Could be excluded in the analysis (a very small population)

  24. Race/ethnicity • Since 1994, race codes were: white, black, Asian, Hispanic, Native American, other, unknown • The sensitivity for the Hispanics code is estimated about 35%, i.e., only one third of Hispanics recorded themselves as Hispanics • But specificity is very high, i.e., if they claim themselves Hispanics, they are almost sure Hispanics • Many people claim themselves as other • No penalty for doing that • Research Triangle Institute Race variable • Higher sensitivity (60%+) for identifying Hispanic population

  25. Sex • Sex is coded 1=male 2=female • There are no missing values for this field • Persons with missing information have it filled according to the rule: if age is less than 65 and sex missing then sex=male if age is greater than or equal to 65 and sex is missing then sex=female • Thus there are “female” people with prostate disease

  26. Mortality • Date of death • Date of death validation indicator (“V”) • If date of death is not empty, beneficiary is died • 100% deaths are validated • But about 96% of death dates are validated • Survival time may be over-estimated if unvalidated date of death is recorded as end of month • Source is from SSA and claim info (e.g. hospital discharge status is dead)

  27. Medicare Enrollment Status • Medicare Status Code (MSC) combines current entitlement and ESRD • 10= Aged w/out ESRD • 11= Aged w/ ESRD • 20= Disabled w/out ESRD • 21= Disabled w/ ESRD • 31= ESRD only • Often we excluded those with ESRD as they have different health care utilization patterns • Disabled with age <65 are often excluded as well • Many of them are in Medicaid as well

  28. State Buy-in • Medicaid paying Medicare premiums • All states exercise the option of paying Medicare premiums for at least some people • This can take 3 forms: • State pays premiums only (5%) • State pays premiums and cost sharing (45%) • State provides full Medicaid benefits (50%) • Monthly indicator (buy-in part A, B, or both) • Those with state buy-in can e assumed to have lower income

  29. Benefit Coverage/Enrollment Indicator • Monthly entitlement/buy-in indicator • Not entitled (0) • Part A only (1) • Part B only (2) • Part A and Part B (3) • Part A, State buy-in (A) • Part B, State buy-in (B) • Parts A and B, State buy-in (C) • Also summary month counts for part A,B and buyin • 94% have both Part A and Part B • Often we limited the study to this population • Part A is entitled, while part B is not required

  30. Examples: bene_mdcr_entlmt_buyin_ind • CCCCCCCCCCCC (12 months, A&B SBI) • 333333333333 (12 months A&B) • 111111333333 (5 mon. A, then 7 mon A&B) • 111111111111 (12 months A) • 333300000000 (4 mon A&B,8 mon not elig) • 000000000033 (10 mon not elig,2 mon A&B) • 333333330000 (8 mon A&B, 4 mon not elig)

  31. HMO indicator • Monthly HMO enrollment indicator • Those in the HMO often have incomplete claim history • Claims are not required to be submitted to CMS or not released from CMS • a summary count of Months HMO coverage • No information on the actual managed care types and plans • 12-16% of HMO enrollment

  32. Examples of Monthly HMO Indicators • 000000000000 (never in MCO) • 111111111111 (12 months non-lock-in) • 00000CC00000 (months 6 & 7 in risk MCO) • CCCCCCCCCCCC (12 months in risk MCO) • 00000CCCCCCC (months 6-12 in risk MCO)

  33. Dual Eligible Status • Eligible for both Medicare and Medicaid • Medicaid is means based: i.e., primary for people with income lower than some standard, or needs based • Some dual eligible are in HMO or managed care • Dual eligible variable is better to identify low income patients than state buyin • Dual eligible variable identify more low income patients

  34. Beneficiary Residency • Available in Research Identifiable file (RIF) • State, county and ZIP code of residence are the mailing address for official correspondence • From SSA data • Some persons have their mail sent to another person (e.g., son, daughter, guardian) • Analyses comparing state of treatment with state of residency generally show high concordance • Always use denominator residence information • Residence info on other claims is not validated

  35. 3.2 Institutional Claims

  36. Type of Claims • Institutional (facility) claims: UB-92 /UB-04 forms • Inpatient • Outpatient • Skilled nursing facility • Home health agency • Hospice • Non-institutional claims: CMS 1500 form • Physician (and other providers) services • Lab tests and diagnostic exams • Durable medical equipment (DME) • Standard alone ambulatory services

  37. UB 92 /UB-04 Form • Patient demographics • Provider (hospital) ID and location (zip) • Admission/discharge date • Disease diagnosis and procedure: ICD-9 codes • Detailed services (revenue centers in SAF) • Payment and coinsurance • Discharge destination

  38. Hospitalization/MedPAR • Medicare Provider Analysis and Review • Short-stay/Long stay hospitals • Short stay 85% • Long stay hospital 2% • Skilled Nursing Facility (SNF) 13% • Reimbursement for SNF is different (per diem based) • One record per hospital stay in MedPAR • One stay may consist of several records in Inpatient SAF, but these are small proportion • Categorized payment info in MedPAR • Original revenue center codes in SAF

  39. Finding Provider (Hospitals) • Organization NPI • Intelligence free identifier • HIPPA compliant • PRVDR_NUM variable • 6 columns: SSA state (2)+type of facility(4) • Traditional acute care hospitals: 0001-0879 • critical access hospitals: 1300-1399 • Critical access hospitals may not use PPS • Short stay hosp, long stay hosp, and skilled nursing facility (SS_LS_SNF_IND_CD) • Need to separate them in analysis

  40. Length of Stay/Admission and Discharge Dates • LOS=discharge date – admission date • Plus one if the same day hospitalization • LOS for SNF is different • SNF is paid as per diem based on resource utilization groups (RUGs) and has limit in days of stay

  41. Diagnosis, Procedures and DRGs • Clinical information available in four sources: • Medicare Severity Diagnosis Related Group (MS-DRG) (1 per stay, per record) • ICD-9 diagnoses (up to 10 codes: 1 primary, 8 secondary, 1 injury code) • ICD-9 coded Procedures (up to 6 per claim) • Admission diagnosis code • Diagnoses and procedures are consistent with DRG. However, not all DRGs require specific diagnoses

  42. Example: AMI • Almost all persons with primary discharge diagnosis of 410 have following DRGs: • 231-236: CABG with PTCA • 237-238: Major Cardiovascular Procedure • Diagnosis, procedure and DRGs can be used to define distinct population

  43. ICD-9 V codes • “Supplementary Classification of Factors Influencing Health Status and Contact with Health Services” • 23% of hospitalizations have some V code • 2.8% have a V code as their primary reason for hospitalization • Examples: • V56.0 Renal dialysis • V58.1 Chemotherapy • V58.61 Long-term use of anticoagulants • V59.4 Kidney donor • V67.4 Follow-up examination after treatment of a fracture • V70.2 General psychiatric examination

  44. Hospital Charges& Payments • MedPAR contains 34 fields describing charges • Total charges • Total accommodation charges • Total departmental charges • Specific charges for accommodation sub-types and specific departments or groups of departments • Patient’s payments • Inpatient deductible • coinsurance amount • CMS • total reimbursements • bill total per diem • Primary Payer (other than CMS) amount

  45. Estimating Payments from MedPAR • Total paid by CMS: • total reimbursements + bill total per diem • Total paid by the beneficiary: • inpatient deductible + coinsurance amount+blood deductible • Total paid by all sources: • total reimbursement+ bill total per diem + inpatient deductible + coinsurance amount +blood deductible + primary payer amount • Note: Physician charges/payments are not in the MedPAR

  46. Charge/Reimbursement Ratio • Most hospitals are on Prospective Payment systems (PPS) • per stay payment based on DRG (include labor and non-labor cost, with some geographic and risk adjustment) • Claim PPS_IND_CD • Charge and reimbursement ratio for specific hospitals may not be meaningful • But population wise, we often use this (or derived) ratio to obtain estimated payment in hospital discharge data (e.g., cost/discharge ratio)

  47. Categorized Cost Variables In MedPAR • Cost unit: e.g., • Intensive care unit indicator • Coronary care unit indicator • Diagnostic Radiology • CT/MRI • DME use • Indicators for certain service use: • Pharmacy • Physical therapy • Laboratory • Emergency room

  48. Discharge Destination • Information provided by hospital • Home/self care • Other short-term general hospital • Skilled nursing facility (SNF) • Intermediate care facility • Other institution • Home health service care • Left AMA • Home IV drug therapy • Died

  49. Additional Comments on MedPAR • People admitted to hospitals through ER or outpatient visit (planned or unplanned) will appear in MedPAR/inpatient SAF, often not in the outpatient claims • Check admission type variable • Info in MedPAR is care received, not care needed • Some disease diagnoses may be missing, or some conditions may not be diagnosed or recorded (e.g., hypertension) • Combining with other claims, MedPAR is often a start point (e.g., studying the follow up care for those with CABG surgery)

  50. Outpatient Claim File • Facility claims, use UB-92 /04 forms • Data structure is the same as inpatient SAF • CMS provides data in two files: • Base claim • Revenue centers (detailed info and charge) • Can be linked by bene_id and claim_id • If you request CCW data • Chronic condition files: condition, span and health care cost/values