Measuring Veterans Health Services 

Use in VA and Medicare

(Part 2)

January 7, 2013

 Presented by:

Denise M. Hynes, MPH, PhD, RN 

1 

2012-2013 VIReC Database and Methods Cyber Seminar Series 
Audience Poll

Did you attend the December session on using Medicare claims 

data to study inpatient and outpatient care?

– Yes

– No

Have you ever used any Medicare claims data other than the 

Outpatient and Inpatient Standard Analytic Files?

– Yes

– No

How would you rate your overall knowledge of Medicare claims 

data?

– 1 (No knowledge)

– 2 

– 3 

– 4 

– 5 (Expert-level knowledge)

2 
Session Objectives

Overview of Medicare claims data (brief review)

Using data from selected Medicare files

– Home Health Agency (HHA)

– Hospice Services

– Skilled Nursing Facility (SNF)

– Durable Medical Equipment (DME)

Measurement strategies for evaluating Medicare 

healthcare use and examples of VA studies using 

selected Medicare claims data

Where to go for more help

3 
Session Objectives

Overview of Medicare claims data (brief review)

Using data from selected Medicare files

– Home Health Agency (HHA)

– Hospice Services

– Skilled Nursing Facility (SNF)

– Durable Medical Equipment (DME)

Measurement strategies for evaluating Medicare 

healthcare use and examples of VA studies using 

selected Medicare claims data

Where to go for more help

4 
Why are Medicare Claims Important?

Many Veterans who use VA health care 

also obtain care outside VA

Researchers need full picture of health 

care use to draw accurate conclusions

Almost half of Veterans enrolled in VHA 

are also enrolled in Medicare

5 
Overview of Medicare Claims

Healthcare providers and health equipment 

suppliers submit claims, i.e., bills, to the 

Centers for Medicare and Medicaid Services 

(CMS) for reimbursement for services and 

products 

Claims are collected by CMS and entered into 

datasets for analysis based on:

– Type of billing form used to gather the original 

information 

– Type of provider

6 
Sources of Medicare Claims Data

Billing Form CMS 1450/

UB-04

CMS 1500

Provider type Institutional Non-institutional

Examples of 

Providers

Hospitals

Skilled Nursing Facilities

Home Health Agencies

Hospice

Physicians

Suppliers
Our focus today

Institutional Files

– Outpatient

– Home Health Agency (HHA)

– Hospice

– Inpatient 

– Skilled Nursing Facility (SNF)

Non-institutional Files

– Carrier (Physician/Supplier)

– Durable Medical Equipment (DME)

Institutional Stay Level File

– Medicare Provider Analysis and Review (MedPAR)

8 
Examples: Claims to Care Relationship

A single claim may include

– One service, product or procedure such as 

• A physician office visit

– More than one service, product or procedure such as 

• An inpatient hospital stay

Multiple claims may be submitted for

– A long inpatient stay

– A procedure that involved multiple physicians

9 
Benefits of Medicare Claims Data

Medicare data can be linked with VA data 

using Real or Scrambled Social Security 

Numbers (SSNs)

Data directly related to billing is likely to be 

accurate

– Claim “from” and “thru” dates 

– Charge and payment amounts 

– Diagnosis codes

– Procedure codes

– Provider numbers

10
Limitations of Medicare Claims Data

No/Limited data on:

– Data not needed for billing

• Demographics (Marital Status, Education, 

Income)

• Clinical Data (Lab Results, Vital Signs, 

Symptoms)

– Services that are not itemized

• Managed Care (HMOs)

• Prospective Payment System (PPS)

11
Prospective Payment System

A Prospective Payment System (PPS) is a system 

in which a pre-determined payment amount (rate) 

is expected to cover all operating and capital 

costs for healthcare services provided during a 

stay or episode of care.

A PPS is used by CMS to reimburse: 

– Hospitals

– Home Health Agencies

– Hospices 

– Skilled Nursing Facilities

12
Data Access

Eligibility: Medicare and other CMS data are available to 

VA researchers with VA Research & Development (R&D) 

Committee and Institutional Review Board (IRB) approved 

projects. 

Data Steward: VIReC’s VA/CMS Data for Research 

project

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

by VIReC. 

Information about data available and the request 

process: 

– http://www.virec.research.va.gov/Index-VACMS.htm

13
Session Objectives

Overview of Medicare claims data (brief review)

Using data from selected Medicare files

– Home Health Agency (HHA)

– Hospice Services

– Skilled Nursing Facility (SNF)

– Durable Medical Equipment (DME)

Measurement strategies for evaluating Medicare 

healthcare use and examples of VA studies using 

selected Medicare claims data

Where to go for more help

14
Home Health Agency SAF

Includes services provided by Medicarecertified home health agencies:

– Skilled nursing

– Physical/occupational/speech therapy

– Home health aide

– Medical supplies

How is care billed?

– Up to 60 days of care on one claim

15
Home Health Agency SAF

How billing is reflected in HHA data:

– Each record is a claim, an episode of care may 

require many claims

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

necessarily indicate dates of service

– Some details of types of care provided are 

available in revenue center variables

16
Home Health Agency SAF

Measuring healthcare use in HHA data:

– Use (any claims)

– Length of treatment

– Number of treatments

– Diagnoses

– Charges

– Payments

17
Hospice SAF

Includes services provided when doctor has 

certified life expectancy of 6 months or less

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

How is care billed?

– Single daily rate for each day a beneficiary is 

enrolled in hospice care - regardless of the amount 

or type of services furnished

18
Hospice SAF

How billing is reflected in Hospice data:

– Claim-level data

– An episode of care may require combining many 

claims

– Most claims are for less than 30 days of care

19
Hospice SAF

Measuring healthcare use in Hospice data

– Use (any claims)

– Length of hospice use

– Diagnoses 

– Charges 

– Payments

20
Skilled Nursing Facility SAF

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 daily rate 

for each day of care, up to 100 days. 

21
Skilled Nursing Facility SAF

How billing is reflected in Skilled Nursing 

Facility (SNF) data:

– When a SNF stay from admission to discharge 

requires submission of multiple claims, 

researchers must combine claims to measure 

health care utilization or cost for a single stay

– Frequency of claim submission may be based on 

facility accounting or duration of stay

22
Skilled Nursing Facility SAF

Measuring healthcare use in SNF data

– Use (any claims)

– Number of stays

– Length of stay

– Diagnoses 

– Charges 

– Payments

23
Durable Medical Equipment

Includes durable medical equipment, prosthetics and 

orthotics, and supplies

Common items

– Oxygen and supplies

– Wheelchairs

– Hospital beds

– Enteral and parenteral nutrition

– Drugs administered through DME

24
Durable Medical Equipment

How is care billed?

– Reimbursement based on HCPCS codes

– May be purchase or rental

– Claim may contain one or multiple products

25
Durable Medical Equipment

Measuring healthcare use in DME data

– Use (any claims)

– Number of items

– Number of rental months

– Charges 

– Payments

26
MedPAR File vs SNF SAF 

for Studying SNF Stays

Claims are “rolled up” to the stay level

Contains stays in both inpatient hospitals 

and skilled nursing facilities (SNF)

27
MedPAR File vs SNF SAF 

for Studying SNF Stays

The MedPAR file is advantageous when 

studying: 

– Number of stays 

– Days per stay 

– Cost per stay

– Total costs

Disadvantages:

– Sub-category totals for charges not included

– Includes only the diagnosis & procedure codes 

found on the last claim of the stay

28
Session Objectives

Overview of Medicare claims data (brief review)

Using data from selected Medicare files

– Home Health Agency (HHA)

– Hospice Services

– Skilled Nursing Facility (SNF)

– Durable Medical Equipment (DME)

Measurement strategies for evaluating Medicare 

healthcare use and examples of VA studies using 

selected Medicare claims data

Where to go for more help

29
Measuring Medicare Healthcare Use: 

Examples from Two Research Studies 

 

Van Houtven CH, et al. Home health care and patterns 

of subsequent VA and Medicare health care utilization 

for Veterans. The Gerontologist. 2008;48(5):668-678.

Hubbard Winkler SL, et al. Cost, utilization, and policy 

provision of assistive technology devices to Veterans 

poststroke by Medicare and VA. Medical Care. 

2010;48(6):558-562.

30
Measuring Medicare Healthcare use 

Van Houtven, et al. (2008) The Gerontologist 

Goal

– Describe patterns of healthcare use following 

utilization of VA home health care (HHC)

Cohort

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

31
Measuring Medicare Healthcare use 

Van Houtven, et al. (2008) The Gerontologist

Methods

– VA Fee Basis, Inpatient, Outpatient, and BIRLS 

files

– Medicare Outpatient, Inpatient, Skilled Nursing 

Facility, and Hospice files

– Matched propensity score analysis

32
Selected Results

Van Houtven, et al. (2008) The Gerontologist

Table 2 (Modified): Utilization Patterns of HHC Users (%)

VA-Medicare

Propensity-Score-Matched 

Cohort Non-matched

Nonusers of 

VA HHC

Users of VA 

HHC Users of VA HHC

Medicare

Outpatient 28.5 28.9 26.8

Inpatient 14.9 17.6 17.2

Nursing home 4.8 7.7 8.0

Hospice 2.7 3.7 4.4

VA or Medicare

Outpatient 92.7 94.9 94.1

Inpatient 30.2 42.7 51.7

Nursing home 10.3 19.0 24.9

Hospice 3.0 4.2 5.5

33
Measuring Medicare Healthcare use 

Winkler et al. (2010) Medical Care 

Goal

– Examine provision of assistive technology devices 

(ATDs) in 2 systems: Medicare and VA

– Analyze differences in ATDs provided and their cost

– Examine potential duplication between systems

Cohort

– 12,046 Veterans post-stroke identified using VA 

Functional Status and Outcome Database and VA 

Medical SAS datasets

34
Measuring Medicare Healthcare use 

Winkler et al. (2010) Medical Care

Methods

– Retrospective 2-year study (fiscal year [FY] 

2001-2002) of post-stroke Veterans

– Comparative analyses between VA and Medicare 

limited to subset of study cohort age 65 or older 

at index stroke admission

– Provision of ATDs identified by Health Care 

Common Procedural Coding System (HCPCS) 

codes in VA National Prosthetic Patient 

Database and Medicare DME Files

35
Selected Results

Winkler et al. (2010) Medical Care

Table 1 (revised). Characteristics According to Device Provided by Medicare, Medicare + 

VA, or VA. Column Percentages Relative to the Number of Unique Veterans in Each 

Cohort Are Presented (N = 12,046)

36

Variable

Device 

provided by 

Medicare Only

Device provided 

by Medicare and 

VA

Device provided 

by VA Only No Device

No. unique 

veterans 139 (1%) 406 (3%) 6798 (56%) 4703 (39%)

Age in yr

Mean (SD) 74 (9) 73 (9) 69 (11) 68 (12)

Service 

Connected

Yes

No

27 (19%)

112 (81%)

106 (26%)

300 (74%)

2005 (29%)

4793 (71%)

1191 (25%)

3512 (75%)
Session Objectives

Overview of Medicare claims data (brief review)

Using data from selected Medicare files

– Home Health Agency (HHA)

– Hospice Services

– Skilled Nursing Facility (SNF)

– Durable Medical Equipment (DME)

Measurement strategies for evaluating Medicare 

healthcare use and examples of VA studies using 

selected Medicare claims data

Where to go for more help

37
38

VIReC Help

VIReC Webpage

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

– Information on VA data sources and how to access data

VIReC Help Desk

– VIReC staff will answer your question and/or direct you to 

available resources on topics

– VIReC@va.gov or (708) 202-2413

HSRData Listserv

– Join at the VIReC Web site

– Discussion among >400 data stewards, managers, and 

users

– Past messages in archive (on intranet)
VIReC’s VA-CMS Web Page

Complete list and description of files available

Links to Medicare Files Data dictionaries

SAS Proc Contents 

Frequencies for Medicare variables

http://www.virec.research.va.gov/Index-VACMS.htm

39
Research Data Assistance Center 

(ResDAC) 

CMS contractor based at the University of 

Minnesota 

Provides free assistance to 

– Researchers 

– Government agencies

– Not-for-profit organizations

Workshops on using Medicare and Medicaid 

data

www.resdac.org

40
CMS and Medicare Websites

CMS Home Page

– www.cms.gov

For Medicare beneficiaries

– www.medicare.gov

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Questions?
Requesting VA/CMS data from VIReC

The following documents are required: 

VA/CMS Data for Research Request Forms

– Project Information and Authorization

– Data Security Compliance Checklist

– Data Description

– Agreement to Provide Secure Data Storage at 

Termination of Approved Research

– Rules of Behavior (ROB) Agreement

Initial Research and Development (R & D) Committee 

approval letter 

Initial Institutional Review Board (IRB) approval letter 

Most recent continuing review approval letter

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Upcoming Seminars

February 4, 2013

Research Access to VA Data: Linda Kok, MA