2011

VIR Ce 

Database and Methods 

Cb S i S i Cyber Seminar Series

RESEARCHERS’ GUIDE TO VA DATA
2011 VIReC Database and Methods C 0 a aba a d od yb 

er Semin

Measuring Veterans Health Se

Use in VA and Medicare

(Part 1)

December 5, 2011

Presented by:

Denise M Hynes PhD MPH RN Denise M. Hynes, PhD, MPH, RN 

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

O i f th M di Cl i Overview

of th

e M

edicare Cl

aims

datasetsLocati if i i 

ing in

formation on Inpatient 

Outpatient services

Measurement strategies for evaluaMedicare healthcare useExamples of VA studies that have the Medicare Claims datasets to evhealthcare useWhere to go for more help
Audience Poll

(Heidi convert to poll function

Have you ever used any of the Mediclaims datasets

– Yes– No

How would you rate your overall knoof the Medicare claims datasets?

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

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

O i f th M di Cl i Overview

of th

e M

edicare Cl

aims

datasetsLocati if i i 

ing in

formation on Inpatient 

Outpatient services

Measurement strategies for evaluaMedicare healthcare useExamples of VA studies that have the Medicare Claims datasets to evhealthcare useWhere 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 to the Centers Medicare and Medicaid Services (CMS) reimbursement for services and produClaims are collected by CMS and enterdatasets for analysis based on:

– T f billi f d t th th 

Type

of billing form used t

o gather th

e o

information

– T f id 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
Medicare Claims Files

Institutional Files

– Outpatient– Home Health Agency (HHA)– Hospice– Inpatient– Skill d N i F ilit (SNF) Skill

ed Nursing Facilit

y (SNF)

Non-institutional Files

– Carrier (Physician/Supplier)– Durable Medical Equipment (DME)

I tit ti l St L l Fil Instit

utional Stay Level Fil

e

– Medicare Provider Analysis and Review (
Our focus today

Institutional Files

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

Non-institutional Files

– C i (Ph i i /S li ) Carrier (Physician/Supplier

)

– Durable Medical Equipment (DME)

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

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

RESEARCHERS’ GUIDE TO VA DATA
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

RESEARCHERS’ GUIDE TO VA DATA

-process.htm 
Session Objectives

O i f th M di Cl i Overview

of th

e M

edicare Cl

aims

datasetsLocati if i i 

ing in

formation on Inpatient 

Outpatient services

Measurement strategies for evaluaMedicare healthcare useExamples of VA studies that have the Medicare Claims datasets to evhealthcare useWhere to go for more help

RESEARCHERS’ GUIDE TO VA DATA
Identifying Outpatient Serv

Settin

g Billin

g form 

Outpatient services may be provided

Within institutions CMS1450/

UB-04

Ou

Withi n non-i tit ti l instit

utional CMS 1500 

settings

CMS 1500

Use both Outpatient and Carrier fileoutpatient procedures and services
Outpatient File

Includes services provided by institutional 

Types of ser

– Laboratory

facilities, such as:

– Hospitals (

~80%)

– Radiology– Physical th

Hospitals ( 80%)

– Dialysis facilities– Rural health 

– Dialysis– Emergency 

clinics

RESEARCHERS’ GUIDE TO VA DATA
Carrier File

Primarily includes physician serviceAlso includes ambulance servicesTypes of services:

– Office visits– Laboratory– Minor procedures– Emergency room– Hospital & nursing home visits

RESEARCHERS’ GUIDE TO VA DATA
Identifying Inpatient Serv

Inpati i bill d b h f ili 

ient services are bill

ed b

y

t

h

e facility 

often physicians too)

S i erv ce Billi f Billing form 

Facility

•Room charges

CMS 1450/

UB-04

In

M

•Staff (employed by facility)

Physician visits

(not em

plo

yed b

y the hos

pital

)

CMS 1500 C

Use both In

patient

/MedPAR and Carrier fi

( py y p )

p /

inpatient services
Inpatient File

Incl d h i l f ili h lu

des 

hospital facility c

harges

During long hospital stays, one claim mathe same as one stay

Stay Claim

Claim 1 From: D

Admit: December 15Discharge: January 15

Claim 1 From: D

Thru: D

Claim 2 From: J

Thru: Ja

Combine claims into stays to avoid overs

tays
MedPAR File

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 vs Inpatient File

Inpatient File

for Studying Inpatient Sta

The MedPAR file is advantageous when studying: 

– Number of stays 

– Days per stay – Cost p y er stay– Total costs

Disadvantages:

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

f d th l t l i f th t found on the last claim of the stay

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

O i f th M di Cl i Overview

of th

e M

edicare Cl

aims

datasetsLocati if i i 

ing in

formation on Inpatient 

Outpatient services

Measurement strategies for evaluaMedicare healthcare useExamples of VA studies that have the Medicare Claims datasets to evhealthcare useWhere to go for more help

RESEARCHERS’ GUIDE TO VA DATA
Measuring Medicare Healthca

Metrics used to study healthcare usinclude:

– Claims– Costs– Stays – Procedures– Dates
Claims

Using claims to measure healthcare 

– Th f t th t l i h b b itt d The fact that a claim has been submitted– The number of claims that have been su

Benefits of measuring use with clai

– Easy to categorize claims by types of ca

RESEARCHERS’ GUIDE TO VA DATA
Cost

Using cost to measure healthcare use: 

– Charges submitted to Medicare– Payments made by

• Medicare • By beneficiaries (deductibles & copayments)

• By primary payers (other insurance)

RESEARCHERS’ GUIDE TO VA DATA
Stays

Stay data used to measure healthcare u

– The fact that there is a hospital stay– Length of the stay– Number of stays– Time between stays

Which dataset should I use to look at s

– MedPAR– Inpatient (claims must be combined)

RESEARCHERS’ GUIDE TO VA DATA
Procedures

ICD-9 Procedure/Surgery codes 

– Inpatient file– Outpatient file– Skilled Nursing Facility File

HCPCS - H l h C P d 

Healthcare Common Procedure 

System

– CPT procedure codes + CMS developed c

– Identifies: procedures, supplies, products 

services

– Most useful in Carrier and Outpatient file

RESEARCHERS’ GUIDE TO VA DATA
Procedures

Procedure data elements used to mhealthcare use:

– The fact that a procedure was done, e.

indicator of a disease or disorder

– The number of occurrences of a proced

as an indicator of prevalence or level o

provided

RESEARCHERS’ GUIDE TO VA DATA
Dates

Data elements containing dates used to measure healthcare use - examples:

– Dates of service– Admission and Discharge dates– Cl i billi d t Claim or billing dates

How are dates used to measure healthcuse? Examples:

– Time between diagnosis and treatment– Frequency with which care is provided

RESEARCHERS’ GUIDE TO VA DATA
Dates

Benefits of using dates

– Easy to calculate

Disadvantages of Using Dates

– Different meanings in VA vs. Medicare

• VA – often multiple “events” in one da• Medicare – often different days for ea

“event”

– Claim “from” and “thru” dates are not alw

same as admission and discharge dates of service

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

O i f th M di Cl i Overview

of th

e M

edicare Cl

aims

datasetsLocati if i i 

ing in

formation on Inpatient 

Outpatient services

Measurement strategies for evaluaMedicare healthcare useExamples of VA studies that have the Medicare Claims datasets to evhealthcare useWhere to go for more help

RESEARCHERS’ GUIDE TO VA DATA
Measuring Medicare Healthcar

E l f Th R h SExamples from Three Research S

Measuring outpatient utilization using cla

– Liu

C

‐

F et al. Use of outpatient care in Veterans H

Administration and Medicare among Veterans re

primary care in community

‐based and hospital ou

clinics. Health Services Research. 2010;45(5 Pt 1):

Measuring outpatient utilization using cos

– Hynes D, et al. Veterans’ access to and use of Me

VA health care. Medical Care. 2007;45(3):214

‐23

Measuring healthcare utilization using pro

– Halanych JH et al. Racial/ethnic differences in dia

for older Veterans: Veterans: Accounting Accounting for dual health sys

changes conclusions. Medical Care. 2006;44(5):43

RESEARCHERS’ GUIDE TO VA DATA
Measuring outpatient utiliz

using claims 

Liu C-F et al, F et al, Health Services Research, 

Goal

– To examine differences in use of VA and 

outpatient services by VA primary care pafrom VA community-based vs. VA hospitaprimary care clinics

Cohort

– From VA community clinics and affiliated 

hospitals included in a previous study, 15

primary care users in 2000 who were also in Medicare Fee for Service

RESEARCHERS’ GUIDE TO VA DATA
Measuring outpatient utiliz

using claims 

Liu C-F et al, F et al, Health Services Research, 

Methods

– Data sources: Medicare claims data, VA 

ad i i i d d US d d

ministrative data, and US census dat

– Comparison between VA and Medicare: 

Algo ithm based on p o ide specialt aAlgo

rithm based on p

r

o

vide

r specialt

y a

codes present in both systems

– Dependent variable: Number of outpat

visits assigned to primary care, specialtand mental health over 4 consecutive y

– Independent variable: Primary care rec

from VA community vs. hospital-based 
Measuring outpatient utiliz

using claims 

Liu C-F et al, F et al, Health Services Research, 

Selected Results

– Use of Medicare-reimbursed care (% of e

cohort): primary care >30%; specialty ca

mentalh lh ea

t

h care 3-4%

– Community-based VA primary care patien

d t t d d d VA d i demons

tra

t

ed decreased VA use and incr

Medicare use compared to hospital-based py p rimar

y care 

patients
Measuring outpatient utiliz

using cost

Hynes et al, Medical Care, 2007

Goals

– To measure VA and Medicare reliance am

eligible Veterans

Cohort

– 2.6 million Veterans in VHA cohort enrolle

Medicare Fee

-for

-Service in 1999
Measuring outpatient utiliz

using cost 

Hynes et al, Medical Care, 2007

Meth do

d

s

–

MeasuriO i C ng Outpatient Cost

– Claims files: Outpatient, Carrier, Home Health

– Calculated percent reliance on VA health care 

percentage of total VA and Medicare costs

– Outpatient categories were defined based on 

of costs attributable to VA and Medicare:

• Medicare-onl

y( ) users 

(100% Medicare

)

• Mostly Medicare users (75-99% Medicare)• Equally dual users (26

-76% Medicare)

• Mostly VA users (1-25% Medicare)• VA

-only users (0% Medicare)
Measuring outpatient utilization u

Hynes et al, Medical Care, 2007

VA Only Mostly VA VA Only Mostly VA VA Only and Mostly VA 

Adjusted Odds Ratios of Using VA or Medicare Outpatient Services

VA Only, Mostly VA,

Equally Dual, and 

Mostly Medicare vs. 

Medicare Only

VA Only, Mostly VA,

and Equally Dual, vs. 

Mostly Medicare 

and Medicare Only

VA Only and Mostly VA 

vs. Equally Dual, 

Mostly Medicare, and 

Medicare Only

M

A

g

e

66-74 Ref Ref Ref 75-84 0.71 0.70 0.67 85+ 0.40 0.49 0.50 RaceNonblack Ref Ref Ref Black 1.85 2.09 2.22 Distance to Nearest VA Hospital0-4.9 miles Ref Ref Ref 5-9.9 miles 0.73 0.73 0.73 10-19.9 miles 0.62 0.59 0.57 20-39.9 miles 0.61 0.54 0.48 40+ miles 0.54 0.44 0.34 

RESEARCHERS’ GUIDE TO VA DATA
Measuring Procedure

Halanych et al, Medical Care, 2006

Goal

– Compare racial/ethnic disparities in qualit

for VHA patients with diabetes

Cohort

– National sample of non-institutionalized V

patients, 65 years and over, with diabete

– Diabetes determined from VHA prescripti

ICD-9 codes and from Medicare ICD-9 dia

codes for FY 1997

-1998

RESEARCHERS’ GUIDE TO VA DATA
Measuring Procedure

Halanych et al, Medical Care, 2006

Methods

– Race/ethnicity obtained from both VHA and M

data

– Claims files – Inpatient, Outpatient, Carrier– Care measurements

• VHA data-- Laboratory result files and CPT cod• Medicare data – CPT/HCPCS codes used (outpa

carrier)

• ICD-9 procedure codes (inpatient)

– Three quality of care measures used 

• Annual hemoglobin A1c (HbA1c) test• Annual Low Density Lipoprotein (LDL) test• Annual Dilated eye examination

RESEARCHERS’ GUIDE TO VA DATA
Measuring Procedure

Halanych et al, Medical Care, 2006

Results

– VHA only data 

- Rates of receiving three 

procedures were equal to or higher for BlHispanics than for White patients (except testing in Black patients)

– VHA + Medicare data – Results were reve

R t f i i d l R

a

tes

of receiving proce

dures were lower 

and Hispanics compared to Whites

– More care captured in Medicare for White

compared to Blacks and Hispanics

RESEARCHERS’ GUIDE TO VA DATA
Session Objectives

Overview of the Medicare Claims datasetsLocat g o at o o pat e t 

in

g inf

ormation 

on Inpatie

n

t

Outpatient servicesMeasurement strategies for evaluaMedicare healthcare useExamples of VA studies that have the Medicare Claims datasets to evhealthcare useWhere to go for more help
VIReC Help

VIReC Webpage

– Information on VA data sources and how to acces– http://www.virec.research.va.gov

VIReC Help Desk

– VIReC staff will answer your question and/or dire

avail bl i ilable resources on topics

– VIReC@va.gov or (708) 202-2413

HSRData Listserv

– Join at the VIReC Web site– Discussion among , g

 >400 data stewards, manager

users

– Past messages in archive (on intranet)

RESEARCHERS’ GUIDE TO VA DATA
VIReC’s VA/CMS Web Pag

Complete list and description of files availaLinks to Medicare Files Data dictionariesSAS Proc Contents Frequencies for Medicare variableshttp://www.virec.research.va.gov/DataSoume/VA

-CMS/VACMS il CMS/VACMSavail

-d ht oc.

m
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
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
Questions?

RESEARCHERS’ GUIDE TO VA DATA
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

RESEARCHERS’ GUIDE TO VA DATA
Upcoming Seminars

February 6, 2012

– Measuring Veterans Health Services Use 

and Medicare (Part 2)

– Denise M. Hynes, PhD, MPH, RN

RESEARCHERS’ GUIDE TO VA DATA