2012 VIReC Database and Methods C

yber Semina

Measuring Veterans Health Se

Use in VA and Medicare

(Part 2)

February 6, 2012

Presented by:

Denise M. Hynes, PhD, MPH, RN

RESEARCHERS’ GUIDE TO VA DATA
Audience Poll

Did y g ou attend the December session on using Medicadata to study inpatient and outpatient care?

– Yes– No

Have you ever used any Medicare claims data other tOutpatient and Inpatient Standard Analytic Files?

– Yes

– No

How would you rate your overall knowledge of Medicadata?

– 1 (No knowledge)– 2– 3– 4– 5 (Expert-level knowledge)

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

Overview of Medicare claims data (brief rUsing data from selected Medicare files

– Home Health Agency (HHA)– Hospice Services– Skilled Nursing Facility (SNF)– Durable Medical Equipment (DME)

Measurement strate

g g ies for evaluatin

g M

healthcare use and examples of VA studiselected Medicare claims dataWh f hl ere to go 

for more 

h

elp

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

Overview of Medicare claims data (brief rUsing data from selected Medicare files

– Home Health Agency (HHA)– Hospice Services

– Skilled Nursing Facility (SNF)– Durable Medical Equipment (DME)

Measurement strategies for evaluating Mhealthcare use and examples of VA studiselected Medicare claims dataWhere to go for more help

RESEARCHERS’ GUIDE TO VA DATA
Why are Medicare Claims Impo

Many Veterans who use VA health also obtain care outside VAResearchers need full 

picture of he

care use to draw accurate conclusiAlmost half of Veterans enrolled in are also enrolled in Medicare

RESEARCHERS’ GUIDE TO VA DATA
Overview of Medicare Claim

Healthcare providers and health equipsuppliers submit claims, i.e., bills, to tCenters for Medicare and Medicaid Ser(CMS) for reimbursement for services productsClaims are collected by CMS and enterdatasets for anal

ysis based on:

– Type of billing form used to gather the 

information

– Type of provider

RESEARCHERS’ GUIDE TO VA DATA
Sources of Medicare Claims 

Billing Form CMS 1450/ UB-04 CMS 

Provider type Institutional Non-inst

Examples of 

Hospitals

Skilled Nursing Facilities Phys

Providers Home Health Agencies

Hospice

Phys

Supp
Our focus today

Institutional Files

– Outpatient– Home Health Agency (HHA)– Hospice– Inpatient– Skilled Nursing Facility (SNF)

Non-institutional Files

– C i arr

eD bl ura

e M di l E i t (DME) M

edical Equipment (DME)

– r (Physician/Supplier)

Institutional Stay Level File

– Medicare Provider Analysis and Review (

RESEARCHERS’ GUIDE TO VA DATA
Examples: Claims to Care Relat

A single claim may include

– One service,p p roduct or 

procedure such as 

• A physician office visit

– More than one service product or procedure 

More than one service, product or procedure 

• An inpatient hospital stay

M ltiple claims ma be s bmitted for M

ultiple claims ma

y be s

ubmitted fo

r

– A long inpatient stay– A procedure that involved multiple physicians

RESEARCHERS’ GUIDE TO VA DATA
Benefits of Medicare Claims 

Medicare data can be linked with VA dusing Real or Scrambled Social SecuritNumbers (SSNs)Data directly related to billing is likely accurate

– Claim “from” and “thru” dates – Char

g py e and 

p

a

yment amounts 

– Diagnosis codes– Procedure codes– Provider numbers

RESEARCHERS’ GUIDE TO VA DATA
Limitations of Medicare Claim

No/ i i dd /

Limite

d

data on:

– Data not needed for billing

• Demographics (Marital Status, Education

Income)

• Clinical Data (Lab Results Vital Signs Clinical Data (Lab Results, Vital Signs,

Symptoms)

– Services that are not itemized

• Managed Care (HMOs)• Prospective Payment System (PPS)

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Prospective Payment Syste

A Prospecti S ( S) i ive Payment System (PPS) i

s

a 

in which a pre-determined payment amouis expected to cover all operating and capcosts for healthcare services provided durstay or episode of care.A PPS is used by CMS to reimburse: 

– Hospitals

– Home Health Agencies– Hospices– Skill d N i F iliti Skill

ed Nursing Facilities

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Data Access

Eligibility: Medicare and other CMS data are avaVA researchers with VA Research & Development Committee and Institutional Review Board (IRB) aprojects projects.Data Steward: VIReC’s VA/CMS Data for Resp j ro ect

– All use of CMS data for VA research must be a

by VIReC. 

Data Availability: http://www.virec.research.va.gov/DataSourcesNaCMS/VACMSavail-doc.htmRequest Process: http://www.virec.research.va.gov/DataSourcesNaCMS/VACMSrequest process htm

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-process.htm 
Session Objectives

Overview of Medicare claims data (brief rUsing data from selected Medicare files

– Home Health Agency (HHA)– Hospice Services– Sk ll d l ( ) kill

e

d Nursing Facility 

(SNF

)

– Durable Medical Equipment (DME)

Measurement strategies for evaluating Mhealthcare use and examples of VA studiselected Medicare claims dataWhere to go for more help

RESEARCHERS’ GUIDE TO VA DATA
Home Health Agency SA

Incl d i id d b di lu

des services provid

e

d

by Medicare

certified home health agencies:

– Skill d i Skill

ed nursing

– Physical/occupational/speech therapy

– Home health aide– Medical supplies

How is care billed?

– U

p y to 60 da

ys of care on one claim
Home Health Agency SA

How billin

g is reflected in HHA data:

– Each record is a claim, an episode of car

require many claims

– “From” and “thru” dates on claim don’t 

necessarily indicate dates of service

– Some details of types of care provided a

available in revenue center variables
Home Health Agency SA

Measuring healthcare use in HHA d

– Use (any claims)– Length of treatment– Number of treatments– Dia

gnoses

– Charges– Payments

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Hospice SAF

Includes services provided when doctor certified life expectancy of 6 months or 

– Care at home (80-90%) or as inpatient

How i bill d is care billed?

– Single daily rate for each day a beneficiar

enroll d i h i lled in hospice care - regardl f th 

dless of th

or type of services furnished

RESEARCHERS’ GUIDE TO VA DATA
Hospice SAF

How billing p is reflected in Hospice data:

– Claim-level data– An episode of care may require combinin

claims

– Most claims are for less than 30 days of c

y

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Hospice SAF

Measuring healthcare use in Hospice d

– Use (any claims)– Length of hospice use– Diagnoses– Charges– Payments

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Skilled Nursing Facility S

Includes services provided by a skilled nursing facility 

– Inpatient and rehabilitation care 

Does not include:

– Custodial care

How is care billed?

– Facilities are paid a pre-determined dail

for each day of care, up to 100 days. 

RESEARCHERS’ GUIDE TO VA DATA
Skilled Nursing Facility S

How billing is reflected in Skilled NursinFacility (SNF) data:

– When a SNF stay from admission to disc

requi b i i f lti l l i ires su

b

mission

of multi

ple

claims,

researchers must combine claims to meahealth care utilization or cost for a sin

g 

le 

– Frequency of claim submission may be b

facilit

yg y accountin

g or duration of sta

y

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Skilled Nursing Facility S

Measuring healthcare use in SNF data

– Use (any claims)

– Number of stays– Length of stay– Diagnoses– Charges– Payments

RESEARCHERS’ GUIDE TO VA DATA
Durable Medical Equipme

Includes durable medical equipment, prosthorthotics, and suppliesCommon items

– Oxyg pp en and supplies

– Wheelchairs– Hos

pital beds

– Enteral and parenteral nutrition– Drugs administered through DME

RESEARCHERS’ GUIDE TO VA DATA
Durable Medical Equipme

How is care billed?

– Reimbursement based on HCPCS codes– May be purchase or rental– Claim may contain one or multiple prod

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Durable Medical Equipme

Measuring healthcare use in DME d

– Use (any claims)– N b f it Num

ber

of items

– Number of rental months

– Charges– Payments

RESEARCHERS’ GUIDE TO VA DATA
MedPAR File vs SNF SAF 

for Studying SNF Stays

Claims are Claims are rolled up to the stay l

“rolled up

” to the stay l

Contains stays in both inpatient hoand skilled nursing facilities (SNF)

RESEARCHERS’ GUIDE TO VA DATA
MedPAR File vs SNF SAF 

for Studying SNF Stays

The MedPAR file is advantageous when studying: 

– Number of stays – Days per stay – C t t Cost per

s

tay

– Total costs

Disadvantages:

– Sub-category totals for charges not in– Includes only the diagnosis & procedu

found on the last claim of the stay

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

Overview of Medicare claims data (brief rUsin

g data from selected Medicare files

– Home Health Agency (HHA)– Hospice Services– Skilled Nursing Facility (SNF)– Durable Medical Equipment (DME)

Measurement strategies for evaluating Mh l h d l f di healt

hcare use an

d examples o

f VA studi

selected Medicare claims dataWhere to go for more help

RESEARCHERS’ GUIDE TO VA DATA
Measuring Medicare Healthcar

Examples from Two Research S

Van Houtven CH, et al. Home health care ano subseque t a d ed ca e ea t ca e 

f subseque

n

t VA 

a

n

d Medica

r

e health ca

r

e 

for Veterans. The Gerontologist. 2008;48(5)Hubbard Winkler SL, et al. Cost, utilization, provision of assistive technology devices to poststroke by Medicare and VA. Medical Car2010;48(6):558-562.

RESEARCHERS’ GUIDE TO VA DATA
Measuring Measuring Medicare Healthca

Healthca

Van Houtven, et al. (2008) The Geronto

Geronto

Goal

– Describe patterns of healthcare use follow

utilization of VA home health care ( ) HHC

Cohort

– 24,169 VA HHC users and 53,356 non HH

RESEARCHERS’ GUIDE TO VA DATA
Measuring Medicare Healthca

Van Houtven, et al. (2008) The Gerontol

Methods

– VA Fee Basis, Inpatient, Outpatient, and 

files

– M di O i I i Skill d 

M

edicare Outpatient, Inpatient, Skill

ed 

Facility, and Hospice files

– M t h d it l i M

a

t

c

h

ed propensit

y score analysis

RESEARCHERS’ GUIDE TO VA DATA
Selected Results

Van Houtven, et al. (2008) The Gerontol

Table 2 (Modified): Utilization Patterns of HHC 

P it

S M t h d 

VA-Medicare

PropensityScoreM

a

t

c

h

ed 

Cohort Non-mat

Nonusers of 

VA HHC

Users of VA 

HHC Users of VA 

MedicareOutpatient 28.5 28.9 26.8Inpatient 14 9. 17 6. 17 2.Nursing home 4.8 7.7 8.0Hospice 2.7 3.7 4.4VA or MedicareOutpatient 92.7 94.9 94.1I ti t npatien

t 30.2 42.7 51.7

Nursing home 10.3 19.0 24.9Hos

pice 3 0 4 2 5 5

RESEARCHERS’ GUIDE TO VA DATA

p

3.0

4.2

5.5
Measuring Medicare Healthca

Winkler et al. (2010) Medical Care

Goal

– Examine provision of assistive technology 

(ATDs) in 2 systems: Medicare and VA

– A l diff i ATD id d d 

Analyze differences i

n ATD

s provid

ed and 

– Examine potential duplication between sy

Ch t o

hor

t

– 12,046 Veterans post-stroke identified us

Functional Status and Outcome Database Medical SAS datasets

RESEARCHERS’ GUIDE TO VA DATA
Measuring Medicare Healthca

Winkler et al. (2010) Medical Care

Methods

– Retrospective 2

-year study (fiscal year 

2001-2002) of post-stroke Veterans

– Comparative analyses between VA and 

limited to subset of study cohort age 65 at index stroke admission

– Provision of ATDs identified by Health C

Common Procedural Coding System (HC

codes in VA National P osthetic Patient codes in VA National P

rosthetic Patient 

Database and Medicare DME Files

RESEARCHERS’ GUIDE TO VA DATA
Selected Results

Winkler et al. (2010) Medical Care

Table 1 (revised). Characteristics According to Device Provided by M

VA, or VA. Column Percentages Relative to the Number of Unique V

Cohort Are Presented (N = 12,046)

Variable

Device 

provided by 

Medicare Only

Device provided 

by Medicare and 

VA

Device provided 

by VA Only 

y

No. unique 

veterans 139 (1%) 406 (3%) 6798 (56%) 

Age in yr

Mean (SD) 74 (9) 73 (9) 69 (11) 

Service 

Connected

Yes 27 (19%) 106 (26%) 2005 (29%) 

No

( )

112 (81%)

( )

300 (74%)

( )

4793 (71%)

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

Overview of Medicare claims data (brief rUsin

g data from selected Medicare files

– Home Health Agency (HHA)– Hospice Services– Skilled Nursing Facility (SNF)– Durable Medical Equipment (DME)

Measurement strategies for evaluating Mh lh d ea

t

hcare use an

d exampl f di 

les o

f VA studi

selected Medicare claims data

Where to go for more help

RESEARCHERS’ GUIDE TO VA DATA
VIReC Help

VIReC Webpage

http://www.virec.research.va.gov

– Information on VA data sources and how to acces

VIReC Help Desk

– VIReC staff will answer your question and/or dire

available resources on topics

– VIReC@va.gov or (708) 202-2413

HSRData Listserv

– Join at the VIReC Web site– Discussion among >400 data stewards, manage

users

– Past messages in archive (on intranet)

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VIReC’s VA-CMS Web Pag

Compl l d d f f l l 

lete list an

d

description o

f

files availa

Links to Medicare Files Data dictionariesSAS Proc Contents Frequencies for Medicare variableshttp://www.virec.research.va.gov/DataSoume/VA-CMS/VACMSavail-doc.htm

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Research Data Assistance Ce

(ResDAC

)

CMS t t b d t th U i it CMS con

trac

tor based 

at th

e U

niversit

Minnesota Provides free assistance to 

– Researchers– Government agencies– Not-for-profit organizations

Workshops on using Medicare and Meddatawww.resdac.org

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CMS and Medicare Websit

CMS Home Page

– www.cms.gov

CMS Research, Statistics, and Data Sy

– www.cms.gov/home/rsds.asp

For Medicare beneficiaries

– www.medicare.gov

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Questions?

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Requesting VA/CMS data from 

The following documents are required: 

VA/CMS Data for Research Request Forms

– Project Information and Authorization– Data Security Compl h kl iance C

hecklist

– Data Description– Agreement to Provide Secure Data Storage a

Termination of Approved Research

– Rules of Behavior (ROB) Agreement

Initial Research and Development (R & D) Capproval letter I iti l I tit ti l R i B d (IRB) Initi

al Instit

utional Review Board (IRB) appr

Most recent continuing review approval lett

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Upcoming Seminars

March 5, 2012Measuring Outpatient Pharmacy Use in Using VA Pharmacy Data

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