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

>> We will get through questions at the end. If you'd like to download  today's presentation you can do so at this time and you can go to the upper right-hand corner of your screen and click on the handout icon for the PDF version.  Today's recording will be available and you can access it by going to the website and you may click on it on the cyber seminar catalog. Melissa, are you on the line?  

>> Yes.  

>> Do you have your Q&A tab open? It will not capture the questions written in.  

>> It is open.  

>> Thank you.  I’d like to welcome everyone to today's seminar and it's a Database and Methods session and today's topic is Measuring Veterans Health Services Use in Medicare (Part 2) and today we have Denise Hynes presenting.  There will be live captioning for today's session and if you want to access that you may go to the URL at the bottom of your page now.  I also want to let you know that because of the high number of registrants for today's session we will run the call in lecture mode which means your line is muted.  We do encourage participation so please submit any questions or comments you have using the Q&A function of Live Meeting.  You may open Q&A now by going to the upper left-hand corner of the screen and click on the Q&A tab and simply type your question or comment into the top and press Ask.  A friendly reminder, do not use the hand raising function in the Q&A tab as your line is muted and I cannot call on you.  If you would like to download a version of today's slide you may do so at this time by going to the handout section which is in the upper right-hand corner of your screen and you may click on the icon that looks like three pieces of paper stacked on one another and you may download a PDF version of today's slide.  

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We are actually experiencing technical difficulties with uploading the handouts right now so please bear with us and we'll try to get the downloading function fixed momentarily.  

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If you do want a version of the slides immediately, you can email it to cyber seminar and we will send over a PDF version to you immediately.  You may email to cyberseminar@va.gov .  Denise do I have you on the line with me?  

>> Yes I am getting feedback.  

>> You will want to mute your line.  

>> I've never had that happen before.  

>> We are feeding the audio.  How are you today?  

>> Good.  Did I hear that we are having technical difficulty?  

>> Just the handouts, people are having a hard time downloading them so we're trying to troubleshoot them now.  

>> But the Live Meeting is working OK?  

>> Yes, everything is up and running.  

>> OK.  

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>> Welcome to the cyber seminar and today's session is a VIReC Database and  Methods seminar.  Today we do have Denise Hynes presenting for us and as I mentioned if you would like a copy of today's slides please send an email request to cyberseminar@va.gov .  I would like to introduce today's speaker, Dr. Denise Hynes.  She's the director of the VA Information Resource Center and research career scientist with the Center for Management of Complex Chronic Care based at Edward Hines Junior VA Hospital.  I would like to turn the presentation over to Dr. Hynes for today's session.  

>> Thank you Melissa.  I'm just seeing the slides come up on Live Meeting now and they are just taking longer to load today I guess.  Thank you everybody.  As I mentioned earlier, this is sort of a second in a two-part lecture.  What I will try to do today is highlight a few aspects that will be relevant for those of you who were not on the November call but also, try not to dwell on it since this is information that you can locate in other places.  I am sort of stalling here in the hope that the polling option will come up.  Is that visible elsewhere?  There we go.  

To get our conversation started today, we would like to start out with a poll to see who is able to be on session one of the Medicare data.  It's still about 40%, maybe one third of people who were not on the call.  I will not go through that set of slides that quickly, but, I will try not to take too long on them.  

A second question concerns have you ever used Medicare data to study long-term care yourself?  [pause]  And those answers are coming in.  This is important as today's topic will focus on some of the datasets that are most relevant for looking at long-term care populations.  The majority of people have not so far.  Or our yeses are just slow polling.  So far I have 89% of those who have responded, so not used to carry data to study long-term care.  That is interesting.  It's very well-suited for that so hopefully everyone will learn something today.  

Our third question, how would you rate your overall knowledge of the Medicare claims dataset, with one being no knowledge at all and five the expert level?  If you could rate your level of expertise that would give us a sense of the expertise of our audience today.  [pause]  I am not seeing anybody who is claiming they are experts but I bet there are some out there.  So we are seeing approximately 1/3 of our audience so far that has responded saying that they have no experience.  Another 38% are in the number two category and one person is an expert, or one response I should say as we never know how many people they represent.  I will look at these numbers and consider that we probably have a relatively inexperienced group as far as Medicare data and I will speak to that level today.  

Thank you for participating in that.  Our objective, which is on slide number three, will be to accomplish four things today.  First of all, to provide an overview of the Medicare claims data and give you a bit of background in light of the fact that not as many people were on the November call and highlight some of the basic information about understanding what Medicare means.  A second objective is to focus on using data, specifically the Medicare data on services provided for home health care agencies, skilled nursing facilities, and hospice services and on durable medical equipment and supplies.  Last month's session we focused on inpatient and outpatient claims data and today we are focusing on these specific aspects of what you might call long-term-care.  We'll also talk about measurement strategies for evaluating Medicare health care use with some specific examples from VA research and we have tried to identify as the most recent research as possible.  We'll also highlight aspects of where to go for help.  

I am still not seeing the object of the slide.  Are we okay and should I continue? 

>> I am having it come up in both of my screens but there is a delay that is happening.  Lois, are you seeing it OK?  

>> I am not seeing it OK.  

>> Please email cyberseminar@va.gov so we can email you a set of slides and you can follow along if you are having difficulties.  

>> I will just continue.  Right now we are on slide number four for those of you who have the slides and perhaps can see it on the screen.  I just highlighted some of the objectives and we will first start with an overview of the Medicare claims data.  For those of you who are experienced, I apologize, but, let's touch base on some of the high-level aspects of Medicare data so we're all on the same page here.  Claims data for Medicare are submitted to the centers for Medicare and Medicaid services, CMS, by health care providers and health equipment suppliers to request reimbursement for services and products.  When processing is complete, final adjudicated claims are included in analytic datasets based on the types of billing forms used, together with the original information and the type of provider or supplier providing the service or product.  This is important because of the type of form, the billing form indicates whether it's an inpatient or outpatient service and what kind of institutional affiliation it is.  

Slide number six describes how the Medicare payment system has a predetermined payment amount that is expected to cover all operating capital costs for healthcare services provided during his stay, an inpatient stay or an episode of care.  PBS's are used to reimburse home health care agencies, skilled nursing facilities and hospice services so you need to keep this in mind in particular where using these long-term-care data as we are describing them today.  Claims for reimbursement can include individual or multiple services, products, or supplies so you really need to keep that in mind when you're looking at specific records as to whether they indicate an individual service, multiple service and or whether it's a service, product, or supply.  There are specific codes in the data but these are caveats to keep in mind.  We will talk about some examples of talk about specific dataset.  Some healthcare services generate no claim at all and you need to keep that in mind especially if care was provided under a health maintenance organization plan specifically.  

Slide number seven describes examples of the relationship of claims to care so a single claim might include one service product or procedure such as a wheelchair.  That is a product supplied by durable medical equipment suppliers.  It also could include more than one service, product, or procedure and an example is care provided to a patient during a skilled nursing  -- nursing facility stay and then also possible are claims submitted during a long, skilled nursing facility or an extended home healthcare episode.  

Slide number eight.  This is a table summarizing the sources of Medicare claims data and it is particularly important when looking at long-term-care data.  This indicates what is known as a HCFA 1450 and UB is a Universal Billing form provides a 1992 and recently revised in 2004 in this describes institutional claims provided in an inpatient setting.  This could be hospitals, skilled nursing facilities, home health agencies, and hospice services.  It's not always an inpatient facility, it's institutional.  And then there is the HCFA 1501 which describes non-institutional providers or claims.  These could include physicians and other individual healthcare providers, as well as suppliers such as those who provide wheelchairs and other durable medical equipment and those who provide independent labs for example, or other sources of care outside of institutional care, such as flu vaccines that are provided at retail pharmacies like Walgreens and CVS -- and these are claims that would include only part B benefits.  

For those of you who are joining, if you're having trouble with the video, Live Meeting and the slides might not be there and I am trying to just annotate the slides as I go through.  

Right now we are on slide number nine which describes a process from bills to claims to data.  I think we are one slide behind so we should be on slide number nine.  This process begins when one of Medicare beneficiary receives the services and the physician or provider said it’s an actual bill to request reimbursement whether they are an institutional or non-institutional provider, they fill out the requisite form that is processed by a CMS contractor.  CMS contracts finalizes the claim and adjudicates the claim and the final claims are converted into datasets and that is usually as researchers what we know and those are known as the standard analytic files.  That is the summary information that we have available to us so you must keep in mind that it begins with a bill or a request for reimbursement and that is an important aspect to keep in mind when you are considering the wealth of information that is included in claims data.  Keep in mind that the incentive here is for billing.  

Slide number 10 summarizes what is contained in the Medicare claims data that we all have available as an important research tool.  There are institutional standard analytic files, outpatient home health agencies, hospice in-school nursing facilities and there is also the non-institutional carriers which includes any physician or supplier provided data, I am sorry, invited resources.  Product for supplies and then durable medical equipment.  And there is also institutional summary files, the Medicare analysis and review.  

Today, we will focus on slide number 11, the institutional standard analytic files for home health, hospice skilled nursing facility, and the durable medical equipment.  

Let's just talk a little bit about what is contained in a standard analytic file.  Slide number 12.  These include data elements that are common across basically all of the standard analytic files, regardless of whether it's an institutional or non-institutional SAF and that includes the clay model data estimated by the specific provider and it includes diagnosis codes, claims from entry dates which become really important for services for claims provided over a timeframe.  Also from and through dates can be the same day for services provided on the same day.  It includes charges and payment amounts and also provider numbers so you can uniquely identify providers.  

Slide number 13, I just want to highlight a little bit on how you can get access to these data from new processes that have been in place over the last couple of years for researchers.  I want to emphasize that what I am about to describe is for VA research and you should be aware that CMS data are available for the broad range of research that is conducted in our country, and it can be requested directly for non-VA research such as information or research funded by a foundation.  I'm not aware of whether or not they would consider research that is underfunded.  CMS likes to be reassured that you have the requisite resource to conduct research that is fairly compensated using these data, so they usually look for some sort of assurance that there are adequate resources to conduct the research.  

In the next two slides I will highlight some of the procedures that have been put into place and policies for VA researchers to utilize CMS data.  In 2009, we established a central interagency group agreement which is formally known as the Permission Exchange Agreement.  Basically agreements between BHA -- between VHA and CMS, the VHA data is housed at VIReC and they have been doing this at some capacity for about 11 years now and the agreements have been revised in the last year.  Essentially, VHA researchers who have IRB projects, they can go through VIReC for approved research.  [Indiscernible-low volume]  Also, VA researchers should contact VIReC if you're interested in using any of the CMS data for your research.  

Slide number 14 covers the request process and I will not go over this in great detail.  It mirrors our research process which relies heavily on rules of behavior, approval from the R and D committee and also the VA facility review boards and the process for ensuring data security and authorizations locally to protect the data.  We have provided some guidance on the VIReC website specific to this process and a few have specific questions about what is required.  We have provided our email in the slide so you can contact us and get some more information about the specifics of the request packet.  

So, so seeing no slides on Live Meeting today.  I will keep moving ahead and hope we are not losing our audience today.  

>> If I may interject really quick, you can also just type your email address into the Q&A and I can send slides that way.  

>> I can see slide 15 so I don't have to guess which one I am highlighting. We'll move to some specific discussion about the datasets for home healthcare agency, nursing facilities, and hospital services -- and hospice services and durable medical supplies.  

Slide number 16 summarizes the kind of information that is in the home health agency SAF and I mentioned previously that there are some common elements so to give you some flavor of the kind of information is represented in the home health agency services and products.  We have given you a breakout of one of the most recent years of the kind of services that are included in the home health agency SAF.  About 50% are in skilled nursing, 22% are in physical therapy, 19% are in home health services him a good 5% are in medical supplies and 4% are occupational  therapy.  This kind gives you the services included to distinguish it from some of the others and that is not to say that if you were interested in skilled nursing facility care that this would be the only place that you should focus.  You will see why in a few moments.  And then how care is billed.  It can be up to 60 days of care on one claim.  

Slide number 17 highlights how the billing is reflected in the home health agency data.  You should note that each record is a claim representing an episode of care and it may require many claims.  There are from and through dates on the claim and they don't necessarily indicate dates of service, but it could indicate when service was ordered if a patient has a prescription if you will for home health services for say one month, the beginning of the month until the end of the month, that is when services are authorized and authorized for billing.  You should look at actual service dates for details of the actual services provided.  Are some details of types of care provided they are available in a revenue center.  Walls revenue center variables.  This gives additional information about the types of care provided.  

Slide number 18.  Information in the home health agency data that could be useful in measuring healthcare use include whether there are, the number of claims that exist, you might use some of the date fields to identify number of days for use for particular types of services and again, you have to utilize information in the claim through date and the from date as well as the service dates.  You may also utilize a diagnosis field which is common across the SAF end and charges and payments.  If you're in novice category number one or number two, at the end of today's lecture, you'll by no means be a category expert.  The purpose of today's lecture is to give you a sense of the incredible resource that is available to us to conduct research for this data but also give you pause about the complexity of using it.  I would strongly recommend additional educational resources offered by both VIReC in the research data systems center which we will talk about it in today's lecture.  I say that because I am going to already move onto the next SAF so we have only covered a couple of slides for the home health agency SAF but it least it gives you a sense of the kind of information that is available in the home health agency standard and would file.  

The slide number 19 highlights what is in the skilled nursing facility. It includes services provided by a skilled nursing facility.  It includes inpatient and rehabilitation care.  What it does not include is custodial care and you should know that the care is billed as facilities are paid on a predetermined, daily rate for each day of care, up to 100 days.  You need to keep this in mind when you're utilizing the claims data from the SAF because it is billed in a different way than the home health agency information which might include information with a skilled nursing facility on the home health basis.  

Slide number 20 highlights more about how billing is reflected in a SAF period of stay -- a stay from admission to discharge requires submission of multiple claims, claims must be combined to measure healthcare utilization or cost for a civil stay. [Indiscernible-low volume]  You want to include the entire information about a single stay so there might be a time limit to the admission and discharge so that you might have to combine some claims.  It probably seems a little abstract for those of you who haven't looked at this kind of data or not as familiar with how long-term care is provided.  But for the SNF files it might be that multiple records need to be combined to represent a full SNF day. Frequency of claims submission may also be based on facility accounting  or duration of stay so you also need to be aware of, for example, an individual beneficiary moved from facility to facility, how the claims are recorded may change a little bit, the date fields may be different,  the amount of time that is recorded in an when he -- in any one particular record may be different so you may have to adjust some of your programming if you are also combining records when you're looking at care across different institutional providers as well.  

Slide 21 talks about how the information in the SNF dataset might be used in measuring healthcare use.  As we described previously, this slide summarizes some of the information in the records to account for stays. You can also look at specific types of use and whether there are any claims for specific types of use, you can look at number of days of use you can summarize using charges of payments as well.  

Okay, fast-paced.  That gives you a flavor of what is in the dataset and how it might be used and will have some examples at the end of today's lecture as well.  

Slide number 22 highlights the kind of information that is in the MedPar dataset and it provides sort of a summary of some of the information that is included in some of the examples we described previously for the SNF dataset and the MedPar does that for you, and it does it for both inpatient and SNF data so if you're interested in both types of data, you might want to consider the MedPar file which does come item of information and it might save you some programming time.  

Slide number 23.  So the MedPar file might be more efficient because it does provide some summary data about number of stays, days per stay, cost per stay, total cost which is rolled up into a single record.  Some of the disadvantages of using this file is that some of the subcategory totals for charges may not be included so you want to review the contents so you know what information is summarized and what is not so as to assess whether it would be useful for your specific research project.  Another disadvantage is that it includes only the diagnosis codes found on the last day of the stay.  If it's a diagnosis code that is in the initial part of the stay, and that is important to you to have all the diagnosis code data, you might want to think about using the SNF data rather than this file.  

OK.  Moving on to the hospice SAF which is slide number 24. This includes services provided one doctor has certified life expectancy of six months or less and the care at home is usually in the category of about 80% or 90% and it can also be on an inpatient basis.  It only includes information on those who have been determined to be terminal. Care is billed on a single daily rate for each day so the beneficiary is enrolled in hospice care.  This is regardless of the amount or type of service is furnished.  

Slide number 25.  This talks about how billing is reflected in hospice data. There are claim level data, an episode of care which may require combining many claims similar to the home health agency and the SNF data and most plans are for less than 30 days of care.  A time dimension which is different from some of the other files and you can understand that in the hospice file, you would normally expect individuals to be receiving claims for long periods of time given that they are terminal.  

And then, slide number 26, measuring healthcare use in hospice data. You will see a similar pattern here to some of the other datasets. Again, you can look at whether there are any claims, you can look at counts of days of use, diagnoses, charges, and payments, similar to some of the other files as well.  

We will go to slide number 27 and talk about durable medical equipment and after that we will review questions.  Now that it looks like our slides are showing up.  The durable medical equipment file includes purchase or rental of supplies and equipment.  Some examples.  There is a variable, a BETOS code and look at the distribution of the types of services provided in the 2006 data and you can see that 23% of the claims are for oxygen and a company supplies.  11% were for orthotic devices, 6% were for wheelchairs, 2% were for hospital beds and enteral and parenteral.  Bills may be submitted for single or multiple products or supplies on one claim they need to be aware of products were supplies for one claim.  Especially if you are going to do any kind of counting.  We did include a slide about measurements, but I would suggest the same thing applies here.  The event is what you might have with using a DME file is that you could correspond some of the dates of service with data service in hospice or home health agency and determine concurrency services.  Some oxygen and supplies, for example, could be provided also during the home health service, but separately billed as a result to be provided during the same event, but accounted for industry claims it is the -- for -- accounted for in different claims datasets. 

I will stop now and go over any questions.  We've gone over a lot of material on the content of datasets and I wonder if we have any questions that have come through Live Meeting.  

>> We have no questions at this time.  You can submit questions through Live Meeting and we can answer that through our lecture today and you have that available to you through your Q&A button and we will keep our eye on that and address questions at the end.  We'll pause again after the next session as well.  I am going to do some examples to give you some concreteness for what we have discussed for all these various datasets. 

>> Slide number 29 provides you with specific citations for the two research studies we will highlight today.  This will give you a different sense of how our colleagues in the research community have used these various datasets in long-term care.  The first example is by Zhu and colleagues and it's an article published in 2009 in the Journal of the American Geriatric Society.  It was the use of Medicare and Department of Veteran’s Affairs for healthcare by veterans with dementia.  And then the next study was through Van Houtven and partners looking at home healthcare use for veterans.  We will start with the more recent publication in 2009. 

>> Slide number 30. We want to highlight some aspects about how researchers are using these data in different ways and we can certainly make these publications available, at least through the citation here, and I'm not sure that we can actually provide you with a PDF copy but it's certainly available to you through the Journal and the probably through the authors directly.  This particular article from 2009 sought to identify veterans with dementia over a four-year timeframe.  They looked at the timeframe from 1998 until 2001 and they were interested in looking at the predictors of healthcare use for the population that met their criteria for dementia.  Their cohort included over 2000 male veterans and they chose those who were 65 and older.  Keep in mind that if you are looking at a Medicare population, Medicare benefits are conferred by age, and although there are some exceptions to this if you are looking at a population that is equally available, or has Medicare data -- Medicare services equally available to them, you have to focus on those who are at least 65 and older.  They specifically focused on a cohort that had a diagnosis of Alzheimer's disease or vascular dementia in the VA dataset.  

Slide number 31 describes the datasets that they used to identify their cohort and also to look at healthcare use.  They relied on information from the national longitudinal caregiver study which we will not talk about today, just so you know that that is a dimension to their research that makes it a little bit unique.  And they specifically focused on the datasets that they used to identify both their cohort and healthcare use. They looked at VA data, specifically inpatient and outpatient MedSAS datasets. [Indiscernible-low volume]  We will focus on the Medicare claims data they used to identify both their cohort and their healthcare use, they looked at inpatient, skilled  nursing facility, outpatient, hospice, home health, carrier, DMA, and MedPAR so they basically look at a full range of datasets to identify healthcare use in this population of dementia patients.  What I should point out from what I have gleaned from the article, is that this will nursing facility data, the home healthcare data, the carrier data, and the DME data appear to have been used to identify their cohort and not specifically to categorize patients according to their  healthcare use.  I would welcome a correction on this if I am reading the article from -- if I am reading the article wrong. 

If you move to slide number 32, our colleagues described, this is an extract of one of the tables in their article.  In the outcome data, the outcome measure that they used in their study was to basically determine the present alliance -- percent per alliance and they focus on inpatient and outpatient use.  From my reading of the article, it appears that outpatient use did not include some of these other healthcare aspects such as home health agency, SNF care and DME. Instead, they use those data to define a period -- to define a cohort. What you see in this table is how a patient fared on their reliance on Medicare and call number one, versus the VA only, another perspective and a different slice of that trilevel variable if you will. [Indiscernible-muffled speaker]  They have a pretty extensive table about some of the various characteristics that they looked at that were predictive of whether patients utilized exclusively VA or more likely to use exclusively Medicare.  Apostolate that probably looking at some of the more detailed levels of specific care might reveal some different patterns.  They did not for example look at only weather home health agency care was provided in some of these cares or skilled nursing facility, so this is a combination of those inpatient and outpatient uses.  

Let's move onto the next study, slide number 33.  This is a study by Van Houtven published in 2008 in the Gerontologist.  The goal was to describe VA home healthcare utilization.  The cohort was approximately 24,000 users and approximately 53,000 non-home healthcare users.  

Slide number 34 highlights the types of datasets they used in particular.  They looked at VA fee basis data, inpatient, outpatient, and veterans benefits information, BIRLS which gives you the information about the degree of compensation and pensions that veterans obtained.  Medicare data included home health agency, inpatient, hospice, outpatient, skilled nursing facility, and hospice filed data.  They also used a propensity score analysis similar to the Zhu study.  

Slide number 35 summarizes information from one of the tables in their article.  They specifically describe how patients and their cohort used specific elements of Medicare care, outpatient, inpatient, or single, and hospice, and whether they also used VA or Medicare for the same aspects of care.  In this study, they utilized these data to identify patients who are receiving VA home healthcare services are not, and then actually use the various datasets to describe how that cohort used or did not use various types of VA and Medicare services including the nursing home and hospice care as well.  As you can see from these examples, you can utilize these datasets for Medicare with the VA data in a variety of ways to summarize your cohorts.  We have seen the information used to identify cohorts, to identify the type of healthcare use, to characterize the types of healthcare used, not only whether it's VA or Medicare, but also the types of care that are provided as well.  

At VIReC we tried to stay up on the literature being produced, especially from VA researchers that have requested it from us and we try to keep this information up to date and we are pleased to see that studies are actually beginning to be able to publish some of this information as well so that we can all learn from it. I can pause here and check again to see if we have any questions.  

>> There is one question, actually, two questions.  The first is regarding whether Medicare data is available for research and the second is for, along similar lines, is MDF data available for research?  

>> The answer to the first question is Medicare data available for research and that is a big whopping yes.  Hopefully, if you missed the beginning or middle part of our lecture, you will see that we have established some prophecies with these data.  All of the data I describe today and in our previous lecture are available for VA researchers to use.  There is also Medicare data available for research use that are not included in our lecture.  And MDF data is one.  There is also data available on a request by request basis for part D. data which is the prescription data Medicare now keeps.  And also data for non-veteran cohorts.  For example, if you are conducting a study you want to compare information for veteran population that VIReC may not have the claims data for -- we can and will facilitate a request to CMS for comparable information for one of the non-veteran cohort is that as part of your study as well.  The answer is yes, Medicare data is available for researchers and the other, MDF is available as well.  Contact that it is in the slides and also the VIReC website as well. Any other questions?  

>> Not at this time.  

>> This is a good segue into slide number 36. We have listed here were some of this information, now that you have lots of ideas for how Medicare might be using your study or maybe some new ideas for how to use data that you have or would like to acquire.  There are three key resources here.  What is our webpage.  We tried to put as much information out on the public web as possible.  You may run into roadblocks in information that we had to put behind the VA firewall, but I would say that most of the information about the Medicare data available for VA research and processes are out on the public internet.  In part, that is because CMS put most of their permission out on the Internet because they can make that information or data available directly available to researchers outside the VA as well so we are mirroring that process.  If you are venturing into a project that requires examination of health services used in your looking at both VA health service use and Medicare or Medicaid health services used information about those datasets are available on the VIReC webpage with appropriate links to CMS pages as well.  

There is also our VIReC help desk and we provide an email and a phone number here.  If your question is specifically using Medicare or Medicaid data, you will be put in touch with our staff who are experts at understanding both the process and the data. Or possibly connecting you with some colleagues with experience in it as well.  There is also the HSR data listserv and it's very interesting and it's been around for about 10 years plus.  It includes discussion among more than 400 data stewards, badgers, end-users and I guarantee you that if you put a question to this, you will get responses.  It is behind a VA firewall and although not encrypted, it does give you more freedom to ask questions that you might feel are a little more sensitive.  Messages are also maintained in an archive.  You can actually query the archive if you become a member of the HSR data listserv.  

Slide number 38, I should highlight some specific aspects of the VIReC VA-CMS webpage.  Specific webpages are dedicated to this and it includes links to Medicare files, data dictionaries, meaning CMS data dictionaries.  It also includes summary information that we at VIReC produced including frequencies for selected Medicare variables over a long time frame you want to get a sense of what is in the data before you actually make the request, and I should get a sense of specific aspects.  I would highly recommend consulting what is on our public internet site for VIReC to give you an idea of what is there before you put a request together.  Also, a list of information about the VHA cohort so if you want to get a sense of how large that cohort is, if you're concerned about conducting a trial or developing a particular cohort, whether your study population might be included in the data that VIREC is already required -- already acquired.  It might add time to get -- it might add time to delay but you can have the appropriate insurance that the majority of the studies we have encountered so far are included in the cohort we have already built.  We already do have some non-not -- not better and data as well so the assured that just because you are not better in comparison cohort is part of your study does not necessarily mean that we do not have at it already.  We encourage technical consultations with our staff before you submit a formal data request so you can get a little more information if you haven't become an expert just by consulting our materials online. 

Slide number 39 also talks about the incredible resources available through the research data assistance Center.  The ResDAC, we have collaborated with them for a long time. They are based at the University of Minnesota and they are the city of mass contractor -- they are the CMS contractor. They provide free assistance to researchers.  We send our staff and encourage you as researchers to take advantage of some of their opportunities.  They develop modules specific to the VA depending upon demand.  We encourage you to consider some other courses such as CMS 101: Introduction to the Use of Medicare Data for Research.  The 101 course provides a nice overview without having to feel like you have to know all of the data already.  We provide the website.  

And then slide number 40, it is a closing slide of additional resources. If you'd like to become more familiar with the benefit package that CMS beneficiaries have available to them, I would highly recommend consulting the CMS website.  You should also take a look at some of the statistics and data system summaries they provide on the CMS website as well.  And sometimes it's important to get the beneficiary perspective on some of these things and that type of information is also available on the CMS website as well.  It might give you another perspective when you're thinking about how to use these data.  I am going to close at this point and see if we have any other questions.  

>> There are a few questions.  The first is: “I am trying to map some of the medical dataset services to Medicare claims services at the finance level of detail.  A finer level of detail than inpatient and outpatient etc.  Is there any mapping scheme that VIReC has developed?”  

>> That would definitely require an individual conversation.  We have done a lot of work and others have with using the revenue center codes, and provider codes, but we can at least get a better understanding of your question and perhaps a callout that is more specific to what your needs are as far as mapping services.  I will just leave it at that.  

>> Next question is regarding Medicare part D and whether the data for that is available to researchers?  

>> Yes, Medicare part D is available to researchers generally.  It is a very new product that CMS is making available.  I cannot speak to how widely available it is outside of VA that I have seen presentations at professional meetings.  As far as research is concerned, it's available on a request by request basis.  If you are interested, I would highly recommend writing a research protocol that includes use of the Medicare part D data and when you get your protocol approved, please talk to us about how that, how the next steps go and I would strongly encourage you to have research funding to support any request that would include part  D data.  It will be individually reviewed by Medicare as well as the VA processes and there will be additional requirements and we do not at VIReC currently housed in a Medicare part D data.  We require that on a case-by-case basis and it passes through VIReC for the specific researcher.  It is new territory, but I would encourage you to develop this research proposals, get them funded, and we will help you with that process.  

>> There is one final question.  The researcher is looking for codes and they find that some codes do not have a cost associated with them.  Assuming that the cost is getting rolled up, they are wondering how to without getting funding for the cost?  

>> Yes.  We can consult on that and that would probably be a question that is specific to the types of codes you are looking at.  We did not talk about HCPC codes but they are similar to what you would find a current procedure terminology codes.  It depends on what years of data you're looking at.  These are sort of dictionaries or codes that the change from year to year if you well.  There are some collapsing that could be done. Would have to know more information about the specific types of codes were dealing with and what kinds of categories of data and we would be more than happy to either provide some information or to give advice. Please send us a more detailed email and we would be happy to help.  

>> Great.  Thank you.  That concludes the questions and also the time that we have left for the session.  I do encourage everyone to fill out the feedback form that is now being posted regarding this session.  We do take that into account, this feedback as we plan our next sessions.  

>> I apologize to everyone, I hope that you have the slides available to you.  We went through the beginning part pretty intensively and quickly so if you have other questions please feel free to send them to our VIReC helpdesk so we can help you move from a one to at least a number two or a three on the scale of expertise.  

>> Excellent.  I would like to point our remaining attendees to the next VIReC seminar which will be on January 3 at 1 PM.  You can access and register for this by going to the cyber seminar catalog via the homepage. Thank you all for joining us today and you will be receiving the archive link in just a day or two so that hopefully will fill in some of the missing pieces from the technical difficulties this morning.  A big thank you to Dr. Hynes.  

>> You're welcome.  

>> Thank you. That does conclude today's session.