**Transcript of Cyberseminar**

**VIReC Database and Methods Seminar**

**Measuring Veterans Health Services Use in VA and Medicare (Part 2)**

**Presenter: Denise M. Hynes, MPH, PhD, RN**

**January 7, 2013**

**Measuring Veterans Health Services Use in VA and Medicare (Part 2)**

**January 7, 2013**

Moderator:  This is Arika Owens, and I'd like to welcome everyone to VIReC's Database and Methods Cyber Seminar entitled “Measuring Veterans Health Services Use in VA and Medicare (Part 2).”  Thank you to CIDER for providing technical and promotional support for this series.

Today's speaker is Denise Hynes, Director of VIReC, and research career scientist at the HSR&D Center of Excellence here at Hines VA Hospital.  Dr. Hynes holds a joint position at the University of Illinois/Chicago, as Professor of Public Health and as Director of the Biomedical Informatics Core of the University's Center for Clinical and Translational Sciences.  

Questions will be monitored during the talk in the Q & A portion of GoToWebinar and will be presented to Dr. Hynes after each section of her talk.  A brief evaluation questionnaire will pop up when you close GoToWebinar.  We would appreciate it if you would take a few moments to complete it.  

I am pleased to welcome today's speaker, Dr. Denise Hynes.

Denise Hynes:  Thank you Arika.  Thanks Heidi.  So I just want to make sure that the audio is working well today?    

Heidi:  Audio is working well and we can see your slides.

Denise Hynes:  Great, thank you.  So good morning or good afternoon, everybody.  Hopefully you can see all the slides and if you have questions, as Arika mentioned, please post them in the chat box so that we can see them as we go along and I will try to pause and look for some questions that we can answer online.  For questions that we don't get to answer online today, we will definitely respond to through our VIReC Help Desk.  

Let me just get started here, we have an audience poll, it would help me a little bit, especially since today is our second in a part talking about measuring veterans' health services use in VA and Medicare.  We did a previous lecture that was more introductory.  There's a poll on the screen; "Did you attend the December session on using Medicare claims data to study inpatient and outpatient care?"  It gives me a better sense of how much time to spend on some of the introductory remarks, as opposed to going into some of the other details.  And then we also have a second question —   

Heidi:  Hold on.  Wait.  Just give me a second.  I'm going to put the results up and then we'll move to the next one.

Denise Hynes:  Okay.

Heidi:  I can only do one at a time here.   

Denise Hynes:  Okay, thanks Heidi.   

Heidi:  And there's your results.   

Denise Hynes:  Okay, very good.  So we have about 55 percent of people who were on the previous session and about half that are also new in this lecture.  And then we have a second question that asks specifically if you, as an investigator, or if you're not an investigator, have had some experience, "used Medicare claims data other than the Outpatient and Inpatient Standard Analytic Files?"  And the reason is because today's focus will be on other files that Medicare provides.  So do you have any experience other than using the Inpatient and Outpatient Standard Analytic Files, please answer yes or no.  

Today's lecture will be focusing on some of the other files; Home Health, the MedPAR Files.  And it looks like only about 17 percent have had some experience outside using the Inpatient and Outpatient Standard Analytic Files.  So the majority is new to this.  So that's great.  So, hopefully, we'll give you some introductory information to think about.  And then, just, if you would rate your overall knowledge of Medicare claims data is our third question.  One-to-five Likert scale; no knowledge being one, and five being expert knowledge.  It would be good to know how you rate yourself in this domain.  

Today's lecture is introductory, so you don't have to be an expert to be on this.  But it's also helpful, as a lecturer, to know how everybody falls.  So we have a lot of novices today; 43 percent report they have no experience and it trickles off.  So we don't have any experts, so I can't ask anybody to help with questions today.  And that's quite all right, we'll handle the questions in VIReC.  So you're among good company if you're new to using Medicare data.  

So let's begin, and we're on slide three for those of you who have the handouts, and I'll go back to my screen here.  Thank you, Heidi, for doing that.  So today I'll do a brief introduction since there's a little less than half were not on the December call, and I'll remind you that if you weren't on the call in December, the slides are archived so you can refer to those.  And they do provide a good overview of the inpatient and outpatient data sets in some level of detail.  I will remind everyone, though, that these two lectures will, by no means, move you from a one to a five in terms of expertise.  It may, you know, make you a little feeling like you want to even rate yourself as a two.  I would suggest, though, that until you have some hands-on experience working with any of these Medicare data, I'd keep yourself in the one category because they can be quite complicated.  So these two lectures will basically give you some introduction to the data, some caveats, how they've been used.  

Today's lecture will focus in a little bit more detail on some of the data sets listed here; Home Health, Hospice Services, Skilled Nursing Facility, Durable Medical Equipment.  We'll also talk a little bit about the MedPAR File, which is a roll-up of some of the inpatient data.  We'll give you some examples from two papers, some measurement strategies they used, and talk a little bit about it in terms of the context of their study results.  And, in particular, where to go for more help.  So let's just start with an overview of the Medicare claims data, and I'll just kind of do a check here to make sure that I can see questions that come in and also talk with you a little bit about what we're going to do here today.  

So we're on slide five, for those of you who have the slide set.  Why are Medicare Claims important?  It's just generally speaking, you need to keep in mind that many veterans who use the VA health care are also obtaining their health care outside the VA.  So they may not be getting 100 percent of their health care from the VA, especially those who are 65 and older who are eligible to get benefits from the Medicare Program.  There's often a high percentage that are going to non-VA health care facilities.  VA and Medicare do not generally exchange information about health care use between the agencies.  And there is no, if you will, reimbursement from one program to another.  They're definitely separate and distinct.  

However, if you're conducting research trying to get a sense of veterans' complete health care use, and you want to look at how veterans are using health care across the health care systems, adding Medicare claims data to your research portfolio would certainly make that picture more complete.  I'll remind you, however, that it may not make it totally complete because there's still public entities where veterans and other citizens can get their health care.  For example, county hospitals, public hospitals that are outside VA and outside Medicare.  But, certainly, putting VA and Medicare data together will give you a more complete picture of health care use.  We found in previous research that almost half of veterans enrolled in the VA are also enrolled in Medicare.  

Sorry, it's always a little tricky just getting our system to just forward the slide.  Sometimes I'm slow with the page up and page down, and it seems like the mouse works better, so we'll try that for now.  

I also want to just give you a sense of, for those of you who are novice here and that seems to be most, remember that the claims data are really a report of bills.  So the health care providers and health equipment suppliers, when they provide services to patients, beneficiaries if you will, they submit claims to Medicare, or bills.  And they submit these to CMS, the agency responsible for administering Medicare and Medicaid, and they provide reimbursement for services to the providers and reimbursement for products.  This is really important to keep in mind because billing data is what drives claims data.  So if reporting a particular variable is important to being reimbursed, it's most likely to be complete.  Information that's less important to being reimbursed may be less complete.  So just kind of keep that in the back of your mind as we go through some of the slides today and I'll try to point that out in places where it's relevant.   

Claims data or billing data are collected by CMS and entered into data sets for analysis based on the type of billing form used to gather the original information and the type of provider.  So it's important to keep in mind what the original purpose of these data are for.   

And this just gives you an overview.  Again, this is a review, for those of you who were in our lecture the last time.  The billing form; there's one that's more institutional oriented, and one that's more non-institutional.  And when we say "institutional", generally speaking, non-institutional corresponds to suppliers or independent providers, so you see physicians and supplier data there, whereas institutional tends to refer to larger organizations, if you will.  That's not necessarily complete, but Hospitals, Skilled Nursing Facilities, Home Health Agencies, Hospice Providers would complete their services provided on institutional forms.  It's a little bit different; basically, the institutional form has a component that's more akin to allowing for an inpatient event, and outpatient events, whereas the non-institutional providers generally don't provide anything that would look like an institutional stay, or an inpatient stay.

Okay so our focus today, as I listed previously, are those items highlighted here in red.  So our previous lecture highlighted the outpatient, the inpatient, and the carrier, or the physician's supplier claims data.  Today we'll be focusing on the Home Health Agency, the Hospice, Skilled Nursing Facility (you can sort of think about that as long-term care,) and Durable Medical Equipment (they tend to be non-institutional providers providing some equipment,) and then the Medicare Provider Analysis and Review, also, you'll see in here that we often refer to acronyms and pronounce them like others that we do in the VA, in CMS as well, and MedPAR.  

So some things to think a little bit about, some examples so that you can just, sort of, think about the relationship between claims and health care.  So a single claim, or bill, can sometimes include one service, or product, or procedure, for example, a physician office visit.  But it can also include more than one service, product, or procedure.  So, for example, an inpatient hospital stay could include lots of services or products within it.  You could also think about multiple claims being submitted for some types of events; a long inpatient stay, especially those that might carry over from one year to the next.  For example, from December into January, they may be split up as if they are two separate events — you have to be mindful of dates — or a procedure that involved multiple physicians.  Some type of surgical procedure that's done on an outpatient basis that might involve different specialists or different consultants that could be involved.  So you need to be mindful of how claims might be split or merged.

And as you get into your particular domain of study, you may find some routines, not to get into too much of a concern about whether specific procedures are always done a particular way.  You really need to be mindful of this from year-to-year; there could be routines that are different and how one procedure is done from one year to the next could be different across time.  So you really need to be mindful of this that there are situations in which a claim might be split, or claims may be merged.  

Benefits of using Medicare claims data are just highlighted here in our next couple of slides.  What's particularly advantageous is the way that information is coordinated in Medicare and in VA is that these data can be linked with real or scrambled Social Security Numbers.  Scrambled Social Security Numbers in the VA are unique to VA, but we have set up some procedures so that they can be linked to real Social Security Numbers and, therefore, because the Medicare claims data uses real Social Security Numbers, the VA data and the Medicare data can be linked.  

These data are directly related to billing and they tend to be pretty accurate as far as claims' beginning and end dates, if you will, they're called "from" and "through" dates.  There's information about charge amounts and payment amounts, so what a provider will be charged for a service, and when is actually paid.  Both pieces of information are in the claims data.  The data also include different types of coding for diagnosis procedures, and there are also unique provider numbers.  This information is important when you're trying to utilize these data.  It's also important to realize that there are limitations to these data.  The data, again, as we mentioned earlier, that the data are primarily originating from purposes for billing.  So those data that are generally not needed, if you will, for billing, may not be as reliable to use, or you might find higher rates of missing in the variable field.

So, for example, demographic data may not be — such as marital status, or education, or income — may not be dependent, in terms of billing so, therefore, the rate of missing data there might be a little bit higher.  The same with clinical data; laboratory results, vital sign symptoms, generally are not fields in Medicare claims data.  There are some very limited select components that do have some laboratory results, for example, for particular medications, but generally speaking, Medicare data do not have clinical data.  

Also to keep in mind that services that are billed, of course they're included in the claims data, but services that are not billed are not included here.  And understanding how Medicare is organized, organizations that are covered under Prospective Payment Systems or Managed Care that do not generate bills, are not part of the claims data.  So the claims data are limited to that service that is provided under the "Fee for Service System."  So, for example, care that might be offered by a particular HMO, not to call any particular one out, those services would not be included in the Medicare claims fee for service data.  Similarly, you're not going to see itemized services within an inpatient stay for hospital services.  They're provided under the diagnosis related grouping system, under PPS, and there's limit to how much detail is actually provided.  

And just a high-level overview prospective payment system is a system in which a predetermined payment amount or rate is expected to cover all the operating and capital expenses for health care services provided during an episode or a stay in the case of inpatient stay or a long-term care stay. And it’s used by CMS to reimburse these entities and with the HMOs there’s a predetermined rate and a predetermined agreement not to provide specific individual claims.  So that’s why that information is not provided.  

Let me also just give you some introductory remarks about data access to that you're clear on how you can get access to these data, should you be so inclined.  So if you're wearing your VA hat, you’re a VA researcher or you're doing your research under VA auspices, Medicare and other CMS data are available to VA researchers through VA Research & Development Service and through, specifically, VIReC.  You would need to have VA R&D Committee and institutional IRB‐approved research projects. 

The data can then be requested through the VA Information Resource Center, VIReC, and VIReC provides all the CMS data for your research that's been approved.  And there's a lot of detail, I'll touch on it at the very end today, but we provide information about the data that are available in the request process.  And I should also mention that we also can provide the data through VIReC, even for information that is not generally available, especially when you're doing clinical trials and you might need some specialized data.  VIReC brokers those requests so that you can get those data through VIReC.  

So let's just focus today on the sections that we have colored in red here, using data from selected Medicare files, and this is slide number 14.  And this is the section that we're going to go through next and before I jump into that I just want to see if there's any questions.  Arika, I don't know if you want to give me any questions that we might have. 

Arika Owens:  Yes. There's a couple so far.  The first question is, "Do institutions capture charges in other ways in addition to the UB04?" 

Denise Hynes:  Well, it is possible that they do.  Generally speaking, we found that institutions that use the UB04, so that is the inpatient, or the institutional form.  Institutions will use that even for reimbursement through other insurers besides Medicare.  So they tend to take this on pretty whole-heartedly.  I suppose it is possible that they use something other than UB04, but I couldn't speak to what that is.  Every institution may also have some internal billing system that they may track some information in other ways.  So if you don't like using the UB04, I'm sure that you could request other information.  But the UB04 is required and used by Medicare, and also by Blue Cross and Blue Shield, and large health care insurers as well. 

Arika Owens:  Okay.  And what is the MedPAR State Level File?   

Denise Hynes:  Well, we'll get into that in a few moments, so I'll hold off on that question.   

Arika Owens:  Okay.   

Denise Hynes:  Great.  Thanks Arika.  Okay, so let's go into this next section.  Like I said, the ones we're going to highlight are these files here, and we're also going to talk a little bit about the MedPAR File.  At least I think it's in today's.  And if I don't have it in today, I'll make sure I answer that question, so you can hold me to it.  

So first let's talk about the Home Health Agency.  SAF stands for "Standard Analytic File."  And the Home Health Agency File is an important part of Medicare coverage.  It includes a range of services provided in the home, including provision of medical supplies.  It's important to understand how care is captured on claims data in order to know what's available to researchers in the data sets that Medicare builds based on these claims.  So it does include information that is acquired through Home Health Agencies for skilled nursing care; physical therapy/occupational therapy/speech therapy; home health aide, medical supplies.  And it's also up to 60 days of care on one claim.

The billing data reflected in the HHA, or the Home Health Agency SAF, it's not necessarily a simple one-to-one correspondence between care and claims.  Each record is a claim, an episode of care may require many claims.  There's "from" and "through" dates on the claim.  But they don't necessarily indicate dates of service.  So you may have to string together many records.  There are revenue center codes that indicate particular revenue-producing units within an institution; for example, an emergency room or pathology.  

Measuring health care use in the Home Health Agency, you know, it gives you opportunities to look at different dimensions, very similar to some of the other kinds of data that you might use.  You could look at count of claims, you know, what types of use it was.  You can look at the length of treatment.  You'd have to be careful what date fields that you use.  If you're going to use dates of service as opposed to the claim from or through dates, you could look at number of treatments.  You could look at the specific type of treatments.  You could look at it by diagnoses, charges, and payments as well.  

You're going to see some similarities with some of these files and how you use these files really depends upon the particular research question that you have in mind.  But I just wanted to introduce you a little bit to the structure of these files today, and we'll highlight a couple of examples as I mentioned.  

The Hospice Standard Analytic File also includes services claims data.  They tend to be for care that's provided in a home or in a hospice institution.  And this can get a little bit tricky because, as you saw in one of our earlier slides, hospice care could be provided in an institutional setting, or hospice care could be provided in a home.  So the information could be submitted either on the UB04, or it could submitted on the outpatient claim file.  

But in the hospice SAF, it includes information that is provided in the home, and that's 80 to 90 percent of it, or as an inpatient, so it combines those two sources.  And the care is billed at a daily rate so, unlike inpatient care which is billed on a prospective payment system, hospice care is provided on a daily rate, so those claims will look a little bit different than inpatient care.

Billing's reflected on a claim level.  It's an episode of care, so it might require combining many claims.  You have to be very careful to be mindful of dates when you're working with hospice data.  Most claims are for less than 30 days of care.  But oftentimes hospice care, as you can imagine for some patients, could go on for months.  So you need to consider carefully, depending upon the type of questions, perhaps the type of conditions that you're looking at, it can go on for some period of time.

Measuring health care use in hospice, again, very similar to what I described in the home health agency.  You can also look at use, you could look at the length of hospice care, you can look at diagnosis, charges, and payments.  Again, it depends on the type of questions that you have, but these same fields are available in the hospice file.  

Some of the similar structures of the data sets makes it useful if you want to combine information across data sets or files for a cohort of patients.  And, again, it depends on what your research question is, but you could look at diagnosis and procedures that occur across different domains of care, if you will; Home Health Agency, Hospice, Skilled Nursing, if you have patients that have events across these different files.  

Skilled Nursing Facilities' Standard Analytic File; it includes services provided under a Skilled Nursing Facility care.  So this can include custodial care, provides, for example, assistance in activities of daily living.  It's typically needed for a very long period of time, if not for the rest of a person's life.  So you can see this care go on for a long period of time.  It's also inpatient and rehabilitation care that Medicare reimburses, is generally only available for a short time following hospitalization.  So there's a difference between those types.  

And you should also keep in mind that Skilled Nursing Facility care is another type, like hospice care, that is a, kind of bundled program.  So you need to be mindful of the different date fields that are used in the claims data, and how the information is, maybe, across different claims when you're looking at some of the information that's used.  So it includes services provided, both inpatient and rehab.

 The SNF file itself does not include the custodial care.  So it’s really the Skilled Nursing Care that’s part of the SAF file.  The facilities are paid on a predetermined daily rate for each day of care and it’s up to 100 days.  So you’re going to be looking at rates, billing data, and charge and payment data that account for either daily rates or up to 100 days. 

The Skilled Nursing Facility data, some things to keep in mind with regard to how this information, how these services are billed.  When an SNF stay from admission to discharge, requires submission of multiple claims, researchers need to think about combining claims to measure health care use or cost for a single stay.  So a stay can go over multiple records, if you will, or multiple claims.  

It's also important to note that the frequency of claim submission might be based on facility accounting or duration of stay.   So you might need to look at patterns by facilities.  Some facilities may record their information a little bit in similar ways, but different from each other.  And you also need to look at duration of stay.  So that there are some patterns that Skilled Nursing Facility A might use all the time and it might be different that Facility B uses.  So they have an option of either recording their claim separately or together.  

Again, you're going to see some similarities here.  How you measure health care use or examine health care use in your research study.  You could look at, again, use, stays, the length of stay and, again, similarly, there are diagnoses, charges, and payments in these data so you can examine information at that level.  

Durable Medical Equipment includes durable medical supplies, orthotics, prosthetics, equipment, some typical items, oxygen and the supplies that go with it, wheelchairs, hospital beds, parenteral or enteral nutrition. There are some medications administered through DME, parenteral medications could be recorded in DME.  How this care is billed, you should keep in mind that there are specific coding systems that correspond to procedures and equipment.  The HCPCS codes, this is a procedure coding system.  It does account for medical equipment and supplies and it's included in this data set and every piece of equipment or supply has an HCPCS code in this data set.  

Some of the information that you'll see in this could be a purchased item, or it could be rental.  And the claims, again, may contain one or multiple products, so that's another aspect that you have to be mindful of.  And that kind of goes for all of these files, you really have to get a sense of what type of information might be including multiple and what type of information might be one at a time.  And I'll illustrate some of these examples when I'm talking about the medical supplies in one of our research examples in a little bit. 

Here you can see some examples of how one might measure use of DME services.  You could look at use, number of items, number of rental months, charges, and payments.  You're not seeing diagnosis and procedures so much in the DME.  

And to our question about MedPAR:  The MedPAR File, this is the file that basically rolls up the inpatient and the SNF inpatient stay, if you will.  So what the MedPAR File does is it rolls up to a stay level, and it includes information both on the inpatient hospital stay, and the Skilled Nursing Facility stay for patients.  So if a patient has both of those components, it would be rolled up into one stay.  You can see the information about both the inpatient stay and the SNF stay, what you won't see is a lot of detail that happens and that would be otherwise available in the Standard Analytic File.  

So it's an alternative.  It sort of makes some choices for you.  The thing to keep in mind is that the MedPAR File will have less detail about each of the components that make up a stay for a patient.  It will have less detail about the inpatient hospital stay.  It will have less detail about the Skilled Nursing Facility.  But it might be just what you need and might offer some efficiency in terms of data processing.  If you don't need all the detail, by all means, request the MedPAR File as opposed to the Standard Analytic File for inpatients and the Standard Analytic File for SNF.

The MedPAR File is advantageous, for example, when you're studying number of stays, the days per stay, total cost.  But if you need detailed information about sub category of charges, you may really need to go to the Standard Analytic File.  If it's sufficient for your research project to have the diagnosis and procedure codes from the last claim of the stay; so if you have a long stay and the diagnosis and procedure codes towards the end of the stay are sufficient for your research, then, by all means, use the MedPAR File.  If you need diagnosis and procedure codes from each of the claims within a stay, then you might want to go for the Standard Analytic File; it will provide more of that detail.  It will be a lot more data for you to process, so keep that in mind.  

So that's the highlights of the data sets themselves.  The next section we're going to be getting into two research examples so let's pause for a moment and see if we have any questions.  As I've sort of warned you, this is going to be high-level introductory.  You'll by no means be an expert after today's lecture and I will highlight at the very end where you can get some more training about how to use these files.  So let's see if Arika's got any questions that we can address here today.

Arika Owens: Yes.  "Generally speaking, how hard is it to get a project approved through VIReC and the IRB?  Can the project be rather ambiguously defined?” 

Denise Hynes:  Well, thank you for that softball question.  You really need to have your research project well defined.  Ambiguity is not something that the R&D Committee or the IRB Committee will really take.  And it really needs to be through that process before you submit your requests through VIReC.  What we highly recommend at VIReC is that you have what we call a technical consultation.  So perhaps while you're brainstorming your project and you're trying to think about what data sets you really need to use, that would be a good time to contact VIReC.  It's much better for us at VIReC to have an abstract, some research questions, goals, aims, how long you wanted to do your project for, what disease area.  The more information you can provide, the more useful the technical consultation will be.  

We recommend technical consultations before you fill out all the forms for VIReC, but if you're familiar with those forms, it will make the technical consultation much easier and much more useful.  It's also possible that you might need more that one technical consultation.  It's much better, though, if you've thought through your project in pretty much detail for the technical consultation to be useful.  

And when you do get to formally submitting your forms through VIReC, we'll even do a preview of your forms, if you'd like, and give you some advice about where there's still some holes.  We generally can't fill in the blanks for you because so much depends on what your research question is.  But I would definitely recommend taking advantage of technical consultations before you get too far down the line.

Arika Owens:  Great, and one other.

Denise Hynes:  Okay.

Arika Owens:  "Is it possible that a veteran uses VA services but is also dual eligible for Medicare and Medicaid?  And how is the billing processed in such cases?"

Denise Hynes:  Thank you.  It's possible that a veteran could be eligible and using VA, Medicare, and Medicaid.  Now what I don't have in today's lecture is any kind of highlights about Medicaid data.  But, in fact, at VIReC we do have Medicaid data available and I should also mention we also have some other data that are indirectly available through cooperation with CMS and United States Renal Data System for sub cohorts of patients who have renal disease and are getting dialysis through Medicare.  

But if you have a cohort that is triple or quadruply eligible, if you will, you can request information or claims data for all of those purposes.  The tricky part is that you have keep in mind with claims data, these are not available in real time.  In fact, it's far less satisfying.  Medicare claims data are generally about a year and a half lag.  Medicaid data, because these have to also process through individual states, Medicaid programs, and through CMS, they tend to be three or four years lagged.  And then that's about how the renal data are as well.  That said, you can request those data through VIReC and VIReC will help broker obtaining those data.  

We have on our website what is currently available in-house in the VA now, so you know what the lag is.  So, for example, if you're doing a study in 2013, and you're enrolling patients in a prospective observational study, or an intervention study, you will have to wait two years for the claims data to come into VIReC.  So those data will become available in 2015, maybe at the tail end of 2014.  But those are things you have to keep in mind when you're using claims data.  They're really not available any faster through CMS.  We get them as fast as they're available.  We may actually get them in the VA sooner than some entities.  So these are just things you have to keep in mind if you're going to be a user of these data.

Okay.  So we'll go on to this next section and if there's other questions, we'll take those later or offline.  So let's talk a little bit about some examples from colleagues.  Might have skipped one here, okay, here we go.  

So there's two papers, these are published and generally available and they may even be generally available through public sources now because these are published.  The first one is by Van Houtven and colleagues, published in 2008.  And we'll give you some examples there of how they looked at some health care use patterns and what they measured.  And a paper by Winkler and colleagues published in *Medical Care* in 2010 that will get at some of the issues around HCPCS codes and assistive devices.

So let's just go with the first paper.  And I believe that these might not have been available for download, but they are ones that you can easily obtain.  And generally speaking, I'm just going to highlight some of the components of the measures that they use, keeping with our theme of measuring Medicare health care use.  And you'll see that both of these studies looked at both a combination of VA and Medicare because they're cohorts of VHA health care users.  

So the goal of this particular paper — we're on slide 31 from Van Houtven and colleagues — looked at patterns of health care use following use of VA home health care.  So these patients included VA home health care users, about 24,169.  And then they also looked at patients who did not use home health care.  They looked at a combination of data sets, some that we've talked about today, some that we've talked about in our previous lectures.  They looked at VA data sets that includes the fee-basis data set, inpatient, outpatient, and then the VBA's Beneficiary Information Record Locater System files, data sets; the BIRLS files.  This is why we pronounce our acronyms.  And in the Medicare data they used outpatient data, inpatient data, skilled nursing facility data, and hospice files.  So they used the Standard Analytic Files.  They did not use MedPAR.  And they also, just by way of mentioning, did a propensity score analysis so that they could match their cohorts.  

This table just, sort of, summarizes some of the information they have in their manuscript.  And what it shows is it's broken down into two categories and if you just focus on this section here that I'm going to highlight, or try to highlight, let's see if I can do this.  So this section in the middle here, and it's broken down into, basically, the non-users of the VA home health care and the users of VA home health care.  So there's non-users and there's users.  

And what you can see here is just generally, you know, then there's broken down by the Medicare, and then the VA or Medicare.  And they tried to look at different components of the different aspects of outpatient care, inpatient care, nursing home, and Hospice, and then they also looked at whether they used VA or Medicare here.  And, I mean, generally speaking, what you can see if you look at this third column that, in general, a greater percentage of VA home health care users utilize different types of care, both in Medicare covered facilities alone, and in the VA and Medicare combined.  

So in this first section they basically looked at Medicare only.  And you can see that, you know, one-for-one here, users of VA home health care were more likely to use care for outpatient Medicare services, 28.9 percent, versus 28.5 percent.  Similarly for inpatient care; users of VA home health care had a higher rate of inpatient care use than non-users of VA home health care.  And right on down the line.  So generally speaking, users of VA home health care had higher rates of Medicare outpatient, inpatient, nursing home, and Hospice use.  They also had higher rates of VA or Medicare combined outpatient, inpatient, nursing home, or Hospice use than the non-users of VA home health care.  

Then let's go to the second paper. Winkler and colleagues looked at the goal of examining use of assistive technology devices in the two systems.  And we particularly chose this paper so that you can see how some of the supplier data are used in research studies.  They looked at differences in assistive devices and their cost.  And they examined the potential duplication between systems, so between the VA and Medicare.  

They looked at a cohort of veterans post-stroke, about 12,000 veterans, and they identified them using the VA and functional status and outcomes database, and they looked at the VA medical SAS data sets.  

They looked at a retrospective cohort.  They looked back at patients from 2001 to 2002 who had post-stroke.  They looked at VA and Medicare.  They limited their cohorts to 65 and older.  Again, the reason the limit there is because then you're looking at patients who are dually eligible in VA and Medicare.  And they looked at those who were 65 or older at the time of the index stroke admission.  They looked at the provision of assistive devices, identified by the HCPCS codes in both the VA National Prosthetic Patient database, and the Medicare DMEs.  Generally speaking, the VA National Prosthetic database gives you information about equipment, as does the Medicare DME.  It also gives you information about other aspects as well.  But they both use HCPCS.  

So here's a table, again we abstracted some information from Winkler [inaudible] Medical Care.  And it presents information about their cohort.  It looks at the devices provided by Medicare only.  It looks at the device provided by Medicare and VA.  And then it looks at the device provided by VA only.  And then those that had no device at all.

And as you can see, less than 1 percent of patients had duplicative assistive devices.  Most patients had some kind of separation along where the information was, so there wasn't like there was double billing in Medicare and VA, and that's important for all kinds of reasons.  And then they were able to characterize the patients using information from the combination of the VA and the Medicare files.  They were also looked at whether they were service-connected or not.  And they were able to look at and characterize whether patterns were different for patients whose devices were provided in Medicare only, whether the devices were provided in both, or in VA only.  And you can see that VA provides a broader variety of assistive devices at a lower cost than at Medicare.  

So this just gives you a flavor of the kind of research that colleagues have used these Medicare claims data for.  And to introduce you to some of the ways that it really is pretty critical when you are looking at Medicare data, unless your question is exclusively looking at Medicare use by veterans, you'll probably need to look at some of the VA data as well.  If it's not for defining your cohort, it may be for characterizing some of the health care that's used.

Just in the interest of time, let me just tell you about the help that's available, and then we'll circle back to questions.  I'm highlighting here on this slide 38 the VIReC webpage.  This is the Internet URL.  We also have an Intranet URL.  On this talk we don't provide the Intranet URL, but for those of you who are within the VA, you can see that there's generally more detailed information provided, so if you are interested in some of the more sensitive information in the VA, by all means, you should go to the VA Intranet site.  

Our Help Desk is available.  There's both an e-mail here and a phone number, and we try to respond to questions within two days and get you hooked up with somebody, if needed.  If you need to get more advice or, specifically, if you need a technical consultation, immediately get you in touch with the VIReC VA CMS team.  We also have a Listserv highlighted here.  If you're not a member of this, this may be something you consider.  You can join on the VIReC website.  It's a discussion group.  It tends to be, I've noticed, very busy on Fridays, sort of the end-of-the-week discussion, I guess, if you want to call it a happy hour.  There tends to be more discussion on Fridays, but there's discussion all the time.  There's more than 400 data stewards, managers, and users; it might be even higher than that now.  And the messages are also archived so if you want to look back at discussion threads, those are part of what's made available.  Specifically, on the VA CMS web page, for those of you interested in Medicare data, there is components within our website that specifically addresses the Medicare data, and it also gives you some information about the Medicare files, gives you some direct links to CMS.  We try not to duplicate the good information that CMS provides, but we also do provide some frequencies on the Medicare variables that are unique to veterans as well.  

I want to definitely point out educational opportunities.  The Research Data Assistance Center is a contractor based at the University of Minnesota for CMS.  They provide free, let me emphasize free, assistance to researchers, government agencies, not-for-profit organizations in how to use the Medicare data, in particular for research use.  Of course these data can be used for other purposes, but specifically for research use, there is a lot of help out there, including workshops that are offered.  Occasionally, we do try to coordinate some workshops with ResDAC specific for VA users.  If there's a lot of registrants for some of their workshops who are affiliated with VA, we might have some special topics.  So, by all means, let them know that you're particularly interested in some of the VA connections if you're going to sign up for a workshop so that we might be more in tune to that.  

But, again, these workshops are available, even if you're not affiliated with the VA there's resources available, both VA and non-VA.  And I would strongly encourage you to take advantage of these.  

Also, if you're completely novice to using CMS, or need more information about CMS, Medicare, Medicaid, I would highly recommend taking a look at even some of the consumer sites so you get a better sense of what the scope of Medicare and Medicaid are.  

And now, let's go back to some questions, Arika?

Arika Owens:  Yes.  "When working with observational data, as in HSR&D database research, is it usual for IRBs to expedite review?"

Denise Hynes:  It's hard to give you a general answer.  Sometimes they do and sometimes they don't.  IRBs, really, are local entities so, generally speaking, for any request that VIReC processes for data requests for research, there must be IRB approval.  It doesn't really matter if it's expedited or not, but it does need to be IRB approved. 

Arika Owens:  Okay, great.  "Does the VA have or host a session with comparable coverage as the ResDAC workshops?"

Denise Hynes:  Say that again.  So is it pertaining to VA data?

Arika Owens:  Yeah.

Denise Hynes:  Or just Medicare data, do you think?

Arika Owens:  VA data. 

Denise Hynes:  Well, so one of the things that we try to do in this database and methods series is cover the scope of VA data sets with a research context.  And that's probably — I mean, there are some other cyber seminar series that are available.  We are going to be launching a new series in the next year that's a more intensive one that's focused on just general good data practices.  You can, certainly, consult some of the archived sessions on the various specific VA databases that are commonly used.  And I would encourage you to look at some of the other lectures as part of this series.  But if you're interested in any particular types of databases, let us know and we can give you some more specific information.

Arika Owens:  Okay.  "Can anyone sign up for the Listserv?"

Denise Hynes:  Right now, the Listserv is behind the VA firewall.  So you have to have a VA e-mail.  We've done some experiments over time and because the discussions sometimes include discussions about information that is probably best being behind the VA firewall, it's there.  So you do need to have a VA e-mail to sign up.

Arika Owens:  Okay.  And another one, "I understand that data on race is better collected through CMS than VA.  Is this correct and, if so, what is the best CMS resource for race information on veterans?"

Denise Hynes:  So that is an interesting question.  A couple remarks I should make.  One, we recommend a combination of data sources when you're ascertaining race.  And we actually have an upcoming lecture on race and ethnicity data and, Arika, you're going to have to help me, it's either April or May, I think we have it slated for in this particular series.

Arika Owens:  May.

Denise Hynes:  May? 

Arika Owens:  Yes. 

Denise Hynes:  And if you can't wait until May, I would strongly encourage you to look at some of our archived sessions from last year.  And there is a data set in the VA that includes some information on race and it's called the vital status data set which, surprisingly, it focuses on vital status, you know, date-of-death.  But it also includes a combination of information that we have available on race.

I would also encourage you to consult with, I think we just put out in our newsletter, The Data Issues Brief, if it hasn't gone out today, it'll go out tomorrow, highlighting some information that the VHA data quality office put out on some of the information that's in the corporate data warehouse, information on race data as well. 

Arika Owens:  Okay.

Denise Hynes:  Thank you everyone.  Do you want to highlight our next session?   

Arika Owens:  Yes.  Our next session is scheduled for Monday, February 4, from 1:00 to 2:00 p.m. Eastern, and is entitled, "Research Access to VA Data" presented by Linda Kok.

Heidi:  Great.  Thank you so much to Denise and Arika.  Denise, we really appreciate you putting all the time and effort into presenting today.  And, Arika, congratulations making it through your first Database and Methods session on your own there.

Arika Owens:  Thank you.

Heidi:  For our audience, thank you so much for joining us for today's session.  As Arika mentioned at the beginning, you will get a pop-up feedback survey when you leave the session, please take a moment and fill that out.  We love to hear your feedback.  We definitely read through all of it and use it for our current and upcoming sessions.  Thank you, everyone, for joining us today and we hope to see you at a future HSR&D cyber seminar.  Thank you.

**[End of Recording]**

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