Ei i st mating Non-VA

Costs

Mark Smith &

Todd H Wagner Todd H. Wagner

March 2010
L i Obj ti Learn

ing Objective

 Ii f t 

is common 

for veterans to use no

providers. 

 At the end of the class, you will kno

pros and cons of different methods pros and cons of different methods 

identify non-VA utilization and 

estimating non estimating non

-VA costs VA costs
Non-VA U i C VA Use is Common

 According to 1999 s r e data 73% of 

According to 1999 survey data, 73% of 

enrollees have alternative coverage

– 53% have Medicare 53% have Medicare– 19% private without Medicare– 1% Medicaid without Medicare or private 1% Medicaid without Medicare or private

 Among VA enrollees 

– Approximately 4 in 10 used VA exclusivel

Approximately 4 in 10 used VA exclusivel

– Two-thirds expect to use VA for primary c

the future

Shen Y et al. (2003) VHA Enrollees’ Health Care Coverage and Use of Care. Medical Care Research 253-267
Methods for Assessing Methods for Assessing

Non-VA Utilization

 Existing datasets

– Fee Bas

i

s

– Sharing Agreements

 Primary data collection Primary data collection

– Self-report
F B i Dt Fee 

Bas

is 

D

a

t

a
O i verv ew

 Pf t ays for care at non-VA f iliti h VA facilities when

– it is the only source available, or – VA could save money

 Full range of services covered Nearly all outpatient care is pre-authoriz

limited emergent care
G th i F B i Growth

in 

Fee 

Bas

i

s

 M t i th i l t 10 M

e

teor

ic 

growth

in 

las

t 10

years:

– $556 million in FY2003, $3.1 billion in FY– 10-20% growth per year

 Examples of major spending areas

– lon

g-term care 

( y) communit

y NHs

)

– kidney dialysis– radiology
8 F B i Fil Fi l Y 8

Fee 

Bas

is Files per Fisca

l

Y

 I ti t npatien

t care

– Hospital stays (facility or facility+physician)– Ancillary physician (if billed separately) Ancillary, physician (if billed separately)

 Outpatient care

– Outpatient non Outpatient non

-pharmacy

– Payments to pharmacies

 Travel expenses Travel expenses Two vendor files (pharmacy, all other) Veterans with Fee Basis ID cards Veterans with Fee Basis ID cards
Hi hli ht f Cli i l D t Hi

ghli

ghts o

f Cli

n

ica

l

D

a

t

 O t ti t O

u

tpatien

t

– Date of service– 1 CPT procedure code

 Inpatient

– Start and end dates of invoiced period (ofte

different from overall admission & dischar

– Up to 5 surgery codes– Up to 5 ICD-9 diagnosis codes (*no decim
Hi hli ht f Fi i l D 

Hi

ghli

ghts o

f Financ

i

a

l

D

a

 A li d mount c

l

a

ime

d

 Amount paid 

– often much less than amount claimed often much less than amount claimed

 M fi i l i i bl Many financ

i

a

l process

ing var

i

able
Hi hli ht f V d D t Hi

ghli

ghts o

f

Ven

dor 

D

a

t

 V d ID en

dor ID



Add ( i i ) ddress 

(

c

i

t

y, state, z

i

p

)

 Related VA station number Payment totals by month
Rd E t ecor

ds vs. 

Encoun

ters

 LINENO f t ti d f th LINENO re

fers 

to consecutive recor

ds 

for the 

person

 Each row of data represents a service provide

particular date (outpatient) or time period (inpparticular date (outpatient) or time period (inp

– TREATDTF: Inpatient start of invoice period– TREATDTO: Inpatient end of invoice period TREATDTO: Inpatient end of invoice period– TREATDT: Outpatient date of service 
Rd E t ecor

ds vs. 

Encoun

ters

 I ti t t Inpatien

t encoun

ters

– Locate all records for the same encounter using S

and treatment dates (TREATDTF, TREATDTO) and treatment dates (TREATDTF, TREATDTO)

– Use vendor ID to distinguish between contiguous 

over two or more locations, such as these:

 transfer from NH to hospital or hospital to NH transfer between hospitals

– Concatenate inpatient records to estimate overall l

Concatenate inpatient records to estimate overall l

stay
Rd E t ecor

ds vs. 

Encoun

ters

 O t ti t i O

u

tpatien

t serv

ices

– Each billable procedure (CPT or HCPCS code) w

its own Fee Basis record its own Fee Basis record

 Outpatient pharmacy

– For 

p p p y, rescri

ptions obtained from a 

pharmacy, Fee 

show only the total VA payment to the pharmacy month 

– M di i i j d i li i h ld h 

M

edicat

ions 

i

njecte

d

in a cli

n

ic s

hould

have a sep

Basis record with a “J code” (HCPCS code begins letter ‘J’

)
O l ith Oth Fil Over

lap with Other File

 A j it f t i th PTF N A majority o

f s

tays 

in the PTF

Non-VA

Hospitalization (NVH) file also appear in the 

Basis data Basis data. 

– The reverse is not true: most Fee Basis records are 

the Non-VA Hospitalization file.

 Monthly community nursing home (CNH) cla

record d t ti t i i DSS ti 

d

e

d as ou

tpatien

t serv

ices 

in DSS nation

extracts (NDEs).
N t o es

 Bl k fi ld Blank fields are common.

– They can mean “not applicable” as well as 

“ii ” m ssing.”

 Each paid invoice has a separate record

– Examp p y yp y le: an inpatient stay typically has o

invoice (and therefore one record) for each calendar month.
N t o es

 R d t i ll d ithi 30 d 

Records are typically processed within 30 day

invoicing, BUT

 Invoices may be sent LONG after services are Invoices may be sent LONG after services are

rendered. THEREFORE

 To find all services in a fiscal year look in th

To find all services in a fiscal year, look in th

Basis files in that year and the following 1-2 y

 Search by Search by

– TREATDTF and TREATDTO for inpatient recor– TREATDT for outpatient records
C ti au ons

 W t h f tli t l l t Watch for outliers: extremely long stays If db a stay appears to end on September 30

check the October records

 Look over a longp ( y ) period (2+ years) to fi

records pertaining to an inpatient stay
Sh i A t Shar

ing 

Agreemen

t

s

 Sh i t t t ith Shar

i

n

g a

greemen

ts are con

trac

ts with n

providers. They represent an alternative 

of hi ir

i

n

g non-VA i serv

ices.

 Some care from sharing agreements is 

recorded in the Fee Basis files.

– e.g., DoD hospitals in Alaska and Hawaii
Resources

 F B i i t t b it Fee Basis intranet web site 

– record of national Fee monthly calls

 HERC intranet web site

– guidebook on Fee Basis data– technical report analyzing FY2003 data technical report analyzing FY2003 data

 HERC t i HERC customer service: h @ erc va.gov
Questions on Fee Basis Fi
S lf e -R t epor
Co ec g e C e llecting Health Care

Utilization

 C l di i Costly and time consuming No gold standard method Administrative data are incomplete 

inaccurate

– Limited benefits– Out-of-plan or out-of-pocket utilizati– Cap tated ea t p a s itated health plans
P ll o

 During the past 12 months, how many times have you seen a do

During the past 12 months, how many times have you seen a do

other health care professional about your own health at a doctorclinic, or some other place? Do not include times you were hosovernight, visits to hospital emergency rooms, home visits, or te

calls.

 Responses

01

234567+ 
Wh t i S lf What is Self-R t epor

 C iti ogn ve 

process of 

lli

Recall Timefra

Modifiable 

reca ng

information

Sample demographics

Type outiliza

UtilizatFrequen(# of VEvent R

Self-reportutilization

Fixed attributes

QuestioDesignMode ocollectimail or 

Cognitively impaired Predisposing factors (age, gender, language, culture

g p utilization

etc.)

A. Bhandari and T. Wagner, "Self-reported utilization of health care services: improving maccuracy," Medical Care Research and Review 63, no. 2 (2006): 217-235.
Fi d Att ib t Fixe

d Att

rib

u

tes

 P i fl d b ill Process 

i

nfluence

d

by illnesses or 

disabilities (e.g., dementia or menta

retardation)

 Older age is consistently correlated 

poorer recall accuracy (spurious poorer recall accuracy (spurious

correlation)

– Older adults more likel

y to under-rep
R d ti ecommen

d

ations

 A d bl lf Are respon

dents able to self-report

?

– Consider age and cognitive capacity– 14 is lower limit 14 is lower limit– Use co

g

nii i l h i

t

ive screen

i

n

g too

l, suc

h as 

MMSE
R ll Ti f d F Recall Time

frame an

d

Frequ

 Time Frame Time Frame

– Longer recall times result in worse accurac– Longer timeframes lead to telescoping and Longer timeframes lead to telescoping and

memory decay

 Frequency

– Under-reporting is exacerbated with increa

utilization

– As the number of visits increase, people fo

some
Recommendations

 Avoid recall timeframes greater th

12 months 12 months

 Shorter recall may be necessary fo

–

Offi i i (l li ) ffice v

i

s

its (low salience

)

– Frequent users

 Consider two-timeframe method (

6

-2)
Q ti i D i Questionna

ire 

Des

ign

“H ti h “How many times 

have you seen a 

physician in the past 6 months?”

– What is a “time?” What about multip

times on same day?

– What is a ph

ysician? Does a nurse co

– Is “seen” literal? What about a phone 

consul i ih i i ltat

ion w

i

t

h prescr

ipt

ion?

– What about care for someone else?
D i di es gn: wording

 Recall order Recall order

– Chronological: go back a year and think fo– Reverse chronological: supposition: later e

Reverse chronological: supposition: later e

are the easiest to recall and helps recall preevents

– Free recall

 Data are inconclusive; unclear whether 

varies by gender or culture
D t C ll ti Data Collection

 M d il l h I 

Modes: mail, telephone, Internet, an

person data

– No study has compared all four– Probing with memory aids can help im

Probing with memory aids can help im

accuracy

– Stigma is important Stigma is important
R d ti ecommen

d

ations

 N dd i d dd No stan

dar

ds ex

ist an

d stan

dar

ds m

be possible

 Pretest: Dillman (2000) Placement in questionnaire might m

Placement in questionnaire might m

 Phone, in person and some Internet 

surveys allow for memory aids

– For example, landmark events For example, landmark events
R Sl esponse Scale

 Use counts

– Include “your best estimate is fine” 

 Avoid categories, which introduce b

and error in the statistical analysis and error in the statistical analysis

– 0, 1-2, 3-5, 6+ 
C t os s

 S lf e -reportd t d e costs are assumed poo Imputing costs from self-reports ca

introduce biases

 Analy ,j ze visits, not just costs Consider seeking billing data (discu

next)
Questions
Collecting Data from 

Non-VA P id VA

Providers
Purpose

 Non-VA d d d d l VA cost data needed to develo

full picture of patient spending.

 Many VA users under age 65 use n

Many VA users under age 65 use n

VA services:

– they have other insurance– they gy have a medical emergency
O i f M th d I t

Overv

iew o

f

M

eth

o

d: 

Inpat

 For each non For each non

-VA inpatient stay ask for the following

VA inpatient stay, ask for the following

– facility type (acute, nursing home, hospice, etc.)– facility name and location (at least city) 

Æ find zip code

– admission and discharge dates– distance from patient’s residence (or use patient’s home zip – acute stays: days spent in ICU, whether surgery occurred acute stays: days spent in ICU, whether surgery occurred

*

– primary cause/condition/purpose (e.g., MI; conva

give birth) 

*optional unless you will not collect a bill

 Obtain a signed release if you want informati

t

he non-VA id prov er.
O i f M th d O t 

Overv

iew o

f

M

eth

o

d: 

O

u

tpa

 Note: not essential for cost but may be needed for cl

Note: not essential for cost, but may be needed for cl

outcomes.

 For each encounter ask the followin

g:

– provider type (physician office; dialysis clinic; dentist; etc)– provider name and location (at least city) 

Æ find zip code

– distance from patient distance from patient s’ residence (or use patient residence (or use patient s’ home zip 

home zip 

– service date

 Obtain a signed release if you want information from 

VA provider.
R l f I f ti (RO

R

e

lease o

f

I

n

formation (RO

 Th ROI th i th id t l (d

The ROI author

izes the provider 

to re

lease (d

information about the encounter to you.

 Key points about a ROI: Key points about

a ROI:

– It is separate from the Informed Consent form.– It must be approved by the IRB It must be approved by the IRB. 

– It has many required elements. See VHA Handbo

1605.1, section 14.

– A patient/representative cannot be forced or cajol

signing it. 
N El t Hi hli 

Necessary Elemen

ts: Hi

ghli

 The ROI must contain the following: The ROI must contain the following:

– Patient’s name (a few providers require the SSN as well)– Description of information requested– Name of person/organization making the request– Name of person/organization to whom data will be disclose– Description of purpose for disclosure/use Description of purpose for disclosure/use– Expiration date for disclosure/use (can be “none” in certain – Signature of patient or authorized representative– St t t b t ti VA b fit b i l t d t 

St

a

temen

ts a

bou

t revocation, VA

benefits 

b

e

ing unre

l

a

t

e

d

to 

and possibility of re-disclosure
Aft Obt i i th RO

After Obt

a

i

n

ing the RO

 Find fax and telephone numbers of non-

provider.

 Call to find the person to whom info sho

faxed.

 Fax cover letter and ROI. If it doesn If it doesn t’ come within a week try aga

come within

a week, try aga
Alt ti S f C t 

Alternative 

Sources o

f

Cos

t

 VA DSS NDE HERC VA: DSS NDEs, HERC average co Medicare-funded sta

ygg s usin

g avera

g

per DRG (MS-DRG since FY08)

 Fee Basis data Fee Basis data Other (published values; state or na

averages)
Resources

 P f th i Process of gathering non-VA t d t VA cost data HERC FAQ response I15 HERC FAQ response I15

http://www.herc.research.va.gov/resources/faq_i15.asp

 Requirements for valid ROI VHA Handb k i oo 1605.1, section 14

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1423

45
Resources

 E ti ti t i t d f fi di t l 

Estimating costs instead of finding actual cos

 See the following guidebooks on the HERC w

– F B i dt Fee Basis data– Microcosting methods (cost regression, other)– DSS National Data Extracts for inpatient and outp

DSS National Data Extracts for inpatient and outp

encounters

 HERC Average Cost data  Go to HERC intranet site Æ Publications Æ

Guidebooks
Q ti ? uestions

?