Sources of VA Care C

and Providers

P l G B tt Ph D Paul G. Barnett, Ph.D.

Ciaran S. Phibbs, Ph.D.

Todd H. Wagner, Ph.D.

Jean Yoon, Ph.D.

October 26, 2011
Topics for today’s talk

 HERC person-level costs file Non-VA cost questionnaire

– Estimating non-VA costs 

 Wage index file

–Geographic Variation in Costs Geographic Variation in Costs
Topics for today’s talk (co

 VA provider data guidebook

– VA data on health care provider

 VA personnel data guidebook

–VA PAID system VA PAID system
HERC Person-Level Co

Jean Yoon Ph D Jean Yoon, Ph.D.
HERC Person-Level Co

 Reports total annual costs and utilization of 

for each patient 

 Annual person-level file FY98-FY10 Costs reported for five categories of inpatie

Costs reported for five categories of inpatie

and four categories of outpatient care

 C t i l d t t l h t dt t l

Costs include total pharmacy costs and total 

Basis costs

 Utilization measured by inpatient length of 

category and total outpatient visits 
HERC Person-Level Co

 Inpatient stays beginning in one fiscal year 

e d g a ot e ave costs a ocated betw

n

din

g in 

a

not

h

er have costs

allocated betw

fiscal years based on the proportion of days each fiscal 

yea

r

 Inpatient categories of care

– Medical/surgical behavioral long term care Medical/surgical, behavioral, long term care, 

residential/domiciliary, all other

 Outpatient categories of care Outpatient categories of care

– Medical/surgical, behavioral, diagnostic , all oth
HERC Person HERC Person

-Level Co

Level Co

 For each inpatient stay and outpatient visit HERC 

For each inpatient stay and outpatient visit, HERC 

two costs: national and local. National costs were such that the

y p sum to the total national ex

penditure

care (divided by care category) reported in DSS. 

 Local costs were estimated similarly, but reconcile 

VA expenditures by care category at the medical cas reported in DSS. 



Ph b i df i ld harmacy costs o

bta

ine

d

from DSS nat

iona

l

data e

(NDE) 

 F B i t bt i d f f F B i (FEN

Fee 

Bas

is cos

ts obt

a

ine

d

from 

four 

Fee 

Bas

is (FEN

Inpatient (FENINPT), Ancillary (FENANCIL), Ou

(FENMED) and Pharmacy (FENPHR ) (FENMED), and Pharmacy (FENPHR

)
HERC Person-L lC 

evel Co

 Inpatient and outpatient costs from HERC Average  HERC method of distributing costs to hospital stay

outpatient visits outpatient visits

 Costs identical for all encounters with same charac

1)Acute medical surgical stays 

– Estimate of what stay would have cost in a Med

hospital, based on a regression model

2) Other inpatient care 2) Other inpatient care

– Length of stay

3) p Out atient care

– Hypothetical Medicare payment based on proce

assigned to visit
HERC Person-Level Co

 The person-level cost datasets are named 

PLCOSTXX 

– XX refers to the fiscal year of dataset

 SAS fil d A i A i C 

SAS files store

d at 

Aust

in 

Automat

ion 

Cent

RMTPRD.HERC.SAS 

 Guidebook for the HERC Person-Level Cost Data

FY1998 – FY2010 available on HERC intranet site
Estimating Non Estimating Non

-VA

Costs

Todd H Wagner Todd

H. Wagner
Learning Objective

 It is common for veterans to use n

providers. 

 At the end of the class, you will kn

At the end of the class, you will kn

pros and cons of different method

id tif en y non-VA tili ti d VA utilization an

d

estimatin

g non-VA costs
Non-VA Use is Commo

 Among Medicare enrollees, 80% of V

underage 65 relied on VA, while 53% underage 65 relied on VA, while 53% 

over age 65 relied on VA*

 Lower differential distance to the VA 

Lower differential distance to the VA, 

higher VA-determined priority for hea

predicted higher VA reliance

 Reliance varied by medical need Reliance varied by medical need

– high

reliance on VA for SUD and MH treat

*Petersen L, et al (2010) Relationship between clinical conditions and use of Veterans Affairs he

Medicare enrolled Veterans. HSR.
Non-VA Utilization

 How do you identify 

the universe? d the universe?

 If you use different 

Me

d

Med

Paid by methods, how do you 

prevent double 

Paid by

VA: Fee Basis / 

p Contractcounting?

Third party cov

uni 

nsure
Self-Report

 Perhaps the best way to 

measure all non-VA 

d 

easu e a o

care

Med

Med

Paid by

 Exception: everyone in 

sample is Medicare

Paid by

VA: Fee Basis / 

Contract sample is Medicare

eligible (over 65 years 

of age or disabled) Third party cov

i 

Contract

of age or disabled) uninsure
Consider...

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

Responses

01234567+ 

Do you have any concerns about this question?
Whiteboard

During the past 12 months, how many times have you seen a doc
Better Specificity

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

care professional about your own health at a doctor's office, a clinicp ce? o o c ude es you we e osp ed ove g , v s s 

lace? D

o n

ot in

c

lude times you we

r

e hospitalized overni

ght, v

i

sit

s 

emergency rooms, home visits, or telephone calls.
What is Self-Report

 Cognitive 

process of

Modifia

process of

recalling 

i f ti

Tu

RT

Fixed attributes information

QD 

Sample demographics

UFr(# E

Self-reportutilization

Fixed attributes

DMcom

Cognitively impaired Predisposing factors (age, gender, language, culture etc.)

A. Bhandari and T. Wagner, "Self-reported utilization of health care services: improvinaccuracy," Medical Care Research and Review 63, no. 2 (2006): 217-235.
Fixed Attributes

 Process influenced by illnesses or 

di biliti ( d ti disabilities 

(e.g., 

dementia or men

retardation

)

 Older age is consistently correlate

poorer recall accuracy (spurious correlation)

– Older adults more likely to under-re
Recommendations

 Are respondents able to self-repor

– Consider age and cognitive capacity– 14 is lower limit– Use cognitive screening tool, such a

MMSE
Recall Timeframe and Freq

 Time Frame

– Longer recall times result in worse accur

recall times result in worse accur

– Longer timeframes lead to telescoping an

memory decay memory decay

 Frequency

– U dn

d

e

r-reporti i b t d ith i 

ting 

is exacer

b

a

t

e

d with

incr

utilization

– A th b f i it i l 

As the num

ber o

f v

i

sits 

increase, peop

le 

some
Recommendations

 Avoid recall timeframes greater 

12 th mon s

 Shorter recall may be necessary f

Shorter recall may be necessary f

– Office visits (low salience)– Frequent users

 Consider two Consider two-timeframe method timeframe method

(i.e., 6-2)
Data Collection

 Modes: mail, telephone, Internet, 

in-person d t a

t

a

– No stud

y p has com

pared all fou

r

– Probing with memory aids can help 

accuracy

– Stigma is important
Recommendations

 No standards exist and standards m

b ibl e possibl

e

 Pretest: Dillman (2000) Pretest: Dillman (2000) Placement in questionnaire might  Phone, in person and some Interne

surveys allow for memory aids surveys allow for memory aids

– For example, landmark events
Response Scale

 Use counts

– Include “your best estimate is fine” 

 Avoid cate

g (, ories 

(

0

, 1-2

, 3-5

, ), 6+ whi

introduce biases and error in the statistanalysis
Costs

 Self-reported costs are unreliable M t i t t f lf Must impute costs from self-repor Limitations

– can introduce biases– N t i ti d t Not as precise as accounting data

 Consider seeking g( billing data (disc

next)
Cost parameters

 Recent bypass trial

– Inpatient per day $2,553 Inpatient per day $2,553– Emergency Dept visit $536– Ambulatory surgery $475 Ambulatory surgery $475– Medicine visit $280– Psychiatry visit $249 Psychiatry visit $249– Psychology visit $199– Home health nurse visit $462 Home health nurse visit $462– Physical therapy $182
Collecting Data from Collecting Data from

Non-VA Providers

 Self-re

p y ort ma

y not be 

sufficiently precise Med

Med

 With permission, you 

can collect the grey area

Paid by VA: Fee Basis 

/ can collect the grey area

by collecting billing 

data from providers Third party cov

/

Contract

data from providers Third party cov

uninsure
O i f M th d Overv

iew o

f

M

eth

o

d

 For each non-VA inpatient stay, ask for the 

following:

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

 Obtain a signed release if you want informa

Obtain

a signed release if you want informa

the non-VA provider.

 Can collect inpatient and outpatient, or focu

inpatient and outpatient surgery
Release of Information (R

 The ROI authorizes the provider to release (

info at o about t e e cou te to you. rmat

i

on about

t

h

e

e

ncou

nter to you.

 Key points about a ROI:

– It is separate from the Informed Consent form It is separate from the Informed Consent form.

– It must be approved by the IRB. 

– It has many required elements See VHA Hand

It has many required elements. See VHA Hand

1605.1, section 14.

– A patient/representative cannot be forced or caj

A patient/representative cannot be forced or caj

signing it. 
Necessary Elements: Highl

 The ROI must contain the following:

– Patient’s name (a few providers require the SSN as well) Patient’s name (a few providers require the SSN as well)– Description of information requested– Name of 

p g gq erson/or

ganization makin

g the re

quest

– Name of person/organization to whom data will be disclo– Description of purpose for disclosure/use– Expiration date for disclosure/use (can be “none” in cert– Signature of patient or authorized representative– Statements about revocation VA benefits being unrelated 

Statements about revocation, VA benefits being unrelated 

and possibility of re-disclosure
After Obtaining the RO

 Find fax and telephone numbers of n

provider.

 Call to find the person to whom info 

Call to find the person to whom info 

be faxed.

 Fax cover letter and ROI. If it doesn’t come within a week, try 
Costs vs. Charges

 Billing records usually report char Charges are fictitious Need to deflate charges using hosp

level cost to charge ratio or level cost to charge ratio, or

 Use the information on the bill to 

estimate Medicare payment or VA 
Inflation

 Costs vary over time Should adjust using the general co

price index or the producer price iprice index or the producer price i

 The medical care consumer price 

The medical care consumer price 

overstates inflation (does not suffi

control f h i li ) * l for changes in quality).*

Frank, R. G., Berndt, E. R., & Busch, S. H. (Eds.). (1999). Price Indexes for the Treatment of Depression. Wash

Brookings Institution Press.
Geographic Variation in C

 Labor represents a large compone

medi l t ca

l care cos

ts.

 Wages vary considerably by geog

Wages vary considerably by geog

market

 Must normalize the costs HERC has developed a Wage Inde
Wage Index

 Medicare creates a Wage Index file W h li k d VA h i l ( h 

We have linked VA hospitals (at the s

level) to the Medicare Wage Index file

 Data are available from 2000-2010 Adjust for wages in the multivariate an More info:

www.herc.research.va.gov/publications/guidebook
Guide to VA Data on Health Care Providers

Dina Roumiantseva, Patricia L. Sinnott, Paul G. BarnettJune 2011

VA Data on Health CaVA Data on Health Ca

Providers

Paul G Barnett Ph D Paul G. Barnett, Ph.D.
Use of provider data

 Evaluate interventions directed at providers Study how provider characteristic

Study how provider characteristic

to efficiency or quality

 Control for correlation of patients th id e same provider
Provider is identified in m

Provider is identified in m

VA datasets 

 Outpatient visits Inpatient encounters Primary care assignments H it l di h e Hospit

a

l disc

harg

e

s

 Prescription fills Prescription fills Laboratory and radiology orders
National Health Care National Health Care

Practitioner Database 

( 

NH

 C i id onta

ins provider name

 Medical center Medical center ID number Real and scrambled Social SecuritNumber
Provi i ifi i ider 

identificat

ion num

 Used in all datasets Id ifi ifi id Identifies a specific provider One number at each site where pro

One number at each site where pro

practices

 Formatted differently in DSS Different variable name in differedatasets
P id t rovider type

 Provider Classification System Developed by CMMS and ANSI Developed by CMMS and ANSI 6-character code  Type of id d f f provider and area ofspec a at o ialization Different variable name in differedt t a ase s Not in the NHCPD
Other provider characteri

 Personnel and Accounting IntegraD S (PAID) Data 

System (PAID)

 Gd d en

der an

d age

 Education and certification Education and certification Hire date and rate of pay Hire date and rate of pay
More information

Guide to VA Data on Health Care Providers Dina Roumiantseva, PatrSinnott Paul G Barnett June 2011 Sinnott, Paul

G. Barnett, June 2011

See www.herc.research.va.gov Æ publications

Æ guidebooks
PAID Data

Ciaran S Phibbs Ph D Ciaran

S. Phibbs, Ph.D.
PAID

 VA’s payroll data system PAID has many different types of  2 parts to PAID 2 parts to PAID

–History file, data from each pay 

History file, data from each pay 

– Master file, annual file with hum

resources data 
PAID, cont.

 PAID History file

– Data on hours worked, including ho

shift differentials

– Data on pay, including all deduction

adj t t us ments

– Essentially g

 all of the detail for gene

paychecks
PAID, cont.

 PAID Master file

– Education/qualifications, including 

dates

– Demographics– Hire date– Job description/title Job description/title
Lii A nk ng to PAID

 Individual identifiers 

– SSN, name, birthdate, etc.

 Workplace identifiers

– TLU, facility, BOC (type of employ
Li ki t PAID t Li

nking 

to PAID, con

t

 Providers

– DSS, PTF, NPCD all have a provide– There is a crosswalk between provid

There is

a crosswalk between provid

and SSN

– Use SSN to pull PAID data and link 

providers
Lii A nk ng to PAID, cont

 Nurses

– Nurse manager of each unit has own – All nurses working for that unit assi

All nurses working for that unit assi

that TLU

– From DSS, can get mapping of TLU

ALBCCs

– This only works for nurses
Next HERC Cyber Cour

November 30, 2011

C i D ii MdCreat

ing a 

Dec

i

s

ion 

M

o

d

e

Abra Jeffers

, M.Phil.