**Transcript of Cyberseminar**

**ViREC Database and Methods Seminar**

**Measuring Veteran’s Health Services Used in VA and Medicare, Part I**

**Presenter: Denise Hynes, Ph.D.**

**December 3, 2012**

**Measuring Veteran’s Health Services Used in VA and Medicare, Part I**

**December 3, 2012**

17:50  top of page 5

Margaret:Welcome to VIReC Database and Method Cyber Seminar entitled, “Measuring Veteran’s Health Services Used in VA and Medicare, Part I.” Thank you to CIDER for providing technical and promotional support for this series. Today’s speaker is Denise Hynes, Director of VIReC and Research Career Scientist with the HSR&D Center of Excellence here at Hynes VA Hospital. Dr. Hynes holds a joint position at the University of Illinois at Chicago as Professor of Public Health and as Director of the Biomedical Informatics Core of the university’s Center for Clinical and Translational Sciences. Questions will be monitored during the talk in the Q&A portion of Go-to-Webinar, and will be presented to Dr. Hynes after each section of her talk. 

A brief evaluation questionnaire will pop up when you close, Go-to-Webinar. We would appreciate if you would take a few moments to complete it. I am pleased to welcome today’s speaker Dr. Denise Hynes. 

Dr. Denise Hynes:Good morning everybody! Margaret, if you could just give me some feedback to make sure that the volume and everything is okay, we will go ahead and get started. 

Margaret:Sorry, the volume is fine Denise. 

Dr. Denise Hynes:Okay good, so, good morning to some and good afternoon to others. We kind of think of this as our lunchtime seminar series. Today we are going to begin a two part lecture on using Medicare data with VA data. Most of my comments today are going to focus on specific elements of data within Medicare claims datasets. I will be talking about the topics on slide two here. I will talk today mostly about inpatient and outpatient services. Our next lecture in January, I believe, will be focused on other data sets that Medicare provides to the VA. I will be talking a bit about some of the measurement strategies researchers have used for evaluating Medicare beneficiary healthcare use, among Veterans in particular, and then some specific examples of VA studies that have used these data, and then close with where to go for more help. 

So, let’s get a sense first, I like to know our audience. I know we have a lot of people on. I would like to first know in this quick poll, how many of you have ever used any of the Medicare claims datasets in your research. This will give me a sense of how familiar you are with some of the terms and types of data that we will be talking about. These polls take a few minutes to collect the information. 

I will also be asking about how you rate your knowledge. So it looks like about three quarters of our group have no experience working with the Medicare claims datasets themselves. Twenty five percent of you have had some. So, the next question is exactly how would you rate your overall knowledge about working with these datasets? One would be no knowledge at all, meaning you have never had any experience. Three would be, maybe you are familiar with it, but you know maybe it is your staff who are really working with the Medicare data. And five means, expert knowledge, so you have actually had some experience doing some analysis with these Medicare claims data, have published a paper with Medicare claims data. And in particular if you have used Medicare data plus VA data that would put you in the five-category. 

Let’s see how everybody fans out on this one. Okay so we have nobody who considers themselves an expert. Darn! I was looking for someone to help us do this lecture next year. We have a lot of novices, 51%. About 25% rank themselves as a two on the Likert scale. Thirteen percent in the middle and eleven percent at the four-level. Great, so we have lots to learn today, and I hope that the information that I am going to describe will be helpful to you. Next year, I would like to – I hope that this will help you write some papers using Medicare claims data. I should caution, today’s lecture and next month’s lecture will be introductory only. I am afraid that by listening to these two lectures it will not move you to a five, but I hope that those of you who said that you had no experience at all, it can at least move you up the scale and to consider using Medicare with VA data in some of your research, and at least to appreciate the importance of understanding why Medicare data might be important, even if you are focused on a VA cohort. 

So, let’s just talk first about sort of why they are important. I am also going to mention our assistant on the call today; Margaret Browning is going to help me with questions. I would encourage you to use the chat mechanism for submitting questions as we are going along. And we will have pauses at a couple of places in today’s lecture, so that we can see what questions we can answer online today. Any questions that we might not be able to address due to either substance or time, we will answer offline. So please do not hesitate to ask questions today. 

So, why are Medicare claims important? First of all, many Veterans who use VA healthcare also obtain some of their healthcare outside of the VA. Notably in particular those who are 65 and older are likely to be eligible for Medicare. So, it is very common for Veterans to use both the VA and to use resources outside VA healthcare. So, if you are someone who needs a full picture of healthcare to draw you know conclusions about various types of care, whether it be about a chronic disease or we will get into some examples of the types of outcome measures that researchers are using. You might want to consider using Medicare claims as part of your data sources. In fact, almost half of Veterans enrolled in the VA are also enrolled in Medicare. And there are also some special populations who might be eligible because of various forms of disability or particular disease entities. 

Healthcare providers and health equipment suppliers, they submit claims to centers for Medicare and Medicaid services. They are reimbursed for services and products. So a physician at a university medical center, a physician in a non-university community entity, a health clinic, urgent care, suppliers of medical equipment, they all submit claims to CMS. The claims are then collected by CMS and entered into the datasets for analysis based on the type of billing form that they used to gather the original information, and then the type of provider. So, a supplier vendor would be different than a physician delivering healthcare services. Outpatient services would have a different billing form than inpatient services. These are critical components to keep in mind, because these two dimensions are in part – a large part how the datasets themselves are organized. It is shown here on this slide. I will give you just a table to kind of sort that out. The billing forms, the provider type, and just some examples of providers. The names of the forms, you know, the government likes to use numbers and these are the most up-to-date forms that are used. So you will hear CMS providers refer to CMS1500, and that has a particular meaning. It is non-institutional provider type and the types of providers that submit their claims to CMS for reimbursement are physicians and suppliers, and the same with the CMS 1450, also known as “the Uniform Billing 04.”

It is also interesting to note that most of the major health insurers use these forms as well in just collecting information for their own information. So, it makes information gathering – if you are doing a study that involves yet another dimension, a private health insurance and you are lucky enough to be able to get access to that information, there are some standards that are used, and CMS is basically setting that standard. 

So, types of information about the claims files that Medicare produces, there are institutional files. There are non-institutional files. Then there is what is called, institutional stay files. So the institutional files include the five that are listed here, outpatient, home health agency, hospice, inpatient, SNF. We like to pronounce our acronyms sometimes when we can, Skill Nursing Facility. Non-institutional files are the Carrier, is what is referred to, and it can include physician services that are outside the actual hospital setting. It can include consults that are provided in a hospital stay. But whenever a physician can separately bill outside of what the hospital bills for, that is not in an outpatient setting or part of the inpatient admission that might be in the Carrier file or suppliers, medical equipment, IV medications, etcetera, durable medical equipment as well. 

Institutional stay file, this one is more of a compiled file, if you will. Medicare Provider Analysis and Review, you have probably heard of it known as MedPAR. And it collapses information about an inpatient stay or a skilled nursing facility stay and includes information about a particular stay as opposed to breaking it out into individual records by a particular person. You can identify a person, but it is organized by the particular stay. 

Today, we will focus on the items highlighted here in red, outpatient and inpatient for the institutional files. I will talk a little bit about the Carrier file and I’ll talk about the MedPAR file is one that is very commonly used. It sort of compiles information in a useful way and depending up on your research question, might save you some programing time, because often times you might have to construct something that is similar to the MedPAR file if you are looking at inpatient care. 

So, let’s just talk a little bit about some examples so that you can understand, especially since we have a little bit more than half of our audience today not familiar with the Medicare data to understand a little bit about how the claims relate to clinical care. You have to keep in mind and it is sort of a simplistic view, but think of Medicare as a large insurance provider which it is. It is just the largest in the world, frankly. You have to think of these as filings for reimbursements. So, things are driven by services and costs. So a provider, a single claim or a claim for reimbursements for actual payments of a service, there is one service or product or procedure. So, a physician office visit would be a service. 

If you have more than one service, product, or procedures, such as an inpatient hospital stay, in the inpatient file that would be potentially a service. Sometime there are services that can be provided that require multiple claims like a long inpatient stay, for example one that goes over multiple years, or that has multiple aspects to it, different entities within the same institution. There might be multiple claims submitted for an inpatient stay, or for a procedure that involved multiple physicians. If somebody is having either a diagnostic or therapeutic procedure that involves multiple specialists, the specialists might bill separately for their services. 

So what you really need to think about is what kind of care are you interested in using the Medicare claims for, and you really need to hone in on understanding how the claims for that particular service, or product, or procedure that you want to study are represented in the claims data. It is really imperative that you understand the questions that you have and how it is organized in the claims data. No one from Medicare of VIReC can help with – you understand your research best. We can help you understand how the data are organized, but you really – it is an area that would be good for you to really understand for the particular aspects of your particular project. 

Some things to think about how the Medicare data can be beneficial, in the VA, we have spent something on the order of ten plus years to ensure that we have some good agreements between CMS and VHA. So that we can link data with VA data using social security numbers and the VA scrambling algorithm for social security numbers. So that gives you some options if you are conducting a study using VA data and you want to bring information in about subjects that you are studying and to be able to link VA data with Medicare data, so that you can have information that is coordinated by patients. 

The data are directly related to billing. So the items that are collected related to billing are going to be the most accurate, again these are claims data. So, information about from and through dates, some services last a period of time. So it is maybe important aspects depending on the service that you are looking at, for example home health care. They might deliver a service over many weeks or over many months. Those would be particular aspects to pay attention to. 

Charge and payment amounts are usually pretty accurate. Diagnosis codes are a condition of payment. Procedure codes are conditions of payments, and certainly provider numbers are conditions of payments. Less accurate, may be sociodemographic information about either providers or patients. There are some exceptions to that, but the billing data are the most accurate. Some things to think about too, some limits of the Medicare claims data is that you know information that is as I mentioned the demographic data is not essential for billing. So, you know it is not the best place we would recommend for looking for marital status, while there might be a field there, there may be better sources for this. 

Similarly for clinical data, there really is extremely limited information in Medicare claims data on lab results and it is really a very select few bits of information that are directly tied to reimbursement. Vital signs are fairly absent. Symptoms are absent in Medicare claims data. Then there are some services that are not itemized. Keep in mind that Medicare, for the most part, reimburses on a fee-for-service system for outpatients and some services. Inpatient, they provide reimbursements on a prospective payment system, so information about the details of an inpatient event may not be very complete or reliable since inpatient is reimbursed basically on the fact that the stay happened, not so much on the aspects of the stay or the number of procedures that occurred during that stay. 

Similarly managed care is even more challenging, because managed care does not provide detailed billing at all. Those are separately maintained and there is no information in a claims database at Medicare for populations in managed care organization. 

17:50

Let’s just talk a little about data access so that you understand right up front how you might be able to avail yourselves of these data for a VA research project. So keep in mind that Medicare makes data available to researchers across the country and you can make a special request to Medicare for your non-VA funded research. Within the VA, we have arranged a special situation where you can under a VA authorized research project, you can request access to Medicare data as long as you have VA Research and Development committee and institutional review board approved projects. The data steward for this is the VA Information Resource Center, VIReC. 

In red there, we have a special project that we maintain. We are the data steward for all the CMS data for research within the VA. Therefore, all of the requests for VA research need to go through VIReC. If you have additional questions about this, we have tried to put a lot of information on our website and the URL is there. It is not a live link, but it is something that you can refer to offline. Just to clarify, if you have a non-VA research project, for example based at a university, you can go directly to CMS and request this similar information that I will be describing today, same type of dataset organization. We are describing the standard files that Medicare maintains. The fork in the road here is that if you go as a university-based researcher, you will have to maintain some kind of budget in your request and go through your university process. 

Within the VA, for the most part, the costs are already covered by the Assistant Deputy under Secretary for Health. Policy and Planning, VIReC has basically curated these data. There are some special requests that can cost a little extra for data that we don’t already have onsite. I will leave it at that for introductory remarks about how to access the data. We can certainly entertain more questions and again, I would refer you to the website. 

So that sort of concludes our overview, and as you can tell, I am giving you very introductory information to give you a sense of the kind of data and information that we can make available through VIReC. I am going to pause here and see if we have any questions so far, and then we will continue. Margaret, do you have any questions that you want to pass along? So, I’m going to take that as a no. 

We have one question here, are Veterans eligible for Medicare only when they are over 65? So, in general, most people are eligible for Medicare when they become 65; however there are some special populations, especially people who might have qualified earlier than 65 because of some disability, which some of our Veteran population might be. There is a particular carve out, meaning a special program for people with endstage renal disease. They can apply for Medicare benefits when they become dialysis dependent at any age. So there are those sorts of special circumstances. 

There are people who might not be eligible for Medicare until later, because it does depend on payments into the Social Security Administration over time. So, it is not available to everyone just because they are 65. You would have to have paid into the system. So, I am going to keep going and we will talk a little bit about locating some specific information, and we will see if we have more questions when we get to the next section. 

Margaret: Denise, this is Margaret. I am sorry I didn’t respond. I lost my mute control. There are some ...

Dr. Denise Hynes: Okay, we will do some more questions in the next section. Thanks Margaret. 

Margaret: Okay sorry. 

Dr. Denise Hynes: So let’s just talk about identifying outpatient services. First outpatient services might be provided in sort of the following places. I had mentioned this before. They are either within institutions or they might be within non-institutional settings. I talked a little bit about how this information is basically communicated to CMS, and then organized into a particular file or dataset. I am going to use this term file interchangeably with dataset today. So there is the outpatient file and the carrier file. Usually when researchers are trying to identify outpatient services, we strongly recommend that you consider using both the outpatient file and the carrier file for outpatient procedures and services. 

I am going to tell you a little bit about why. The outpatient file includes services provided by institutional facilities. So again, reminding you, institutional facility is a hospital. They tend to be the majority of those institutions that are represented. Hospitals can deliver outpatient services as well as inpatient services. So any kind of outpatient based clinics that are at a hospital would be separately billed in the outpatient file, and therefore show up in the outpatient database. Dialysis facilities also provide outpatient services; therefore in the outpatient file. Rural health clinics for example can be considered an institutional facility. The types of services that are reported in the outpatient file can be laboratory, radiology, physical therapy, dialysis, emergency room. 

The carrier file, on the other hand, it primarily includes physician services, but it also includes ambulance services and other types of services. So it can include some office visits, for example, care that might be provided in a private doctor’s office, not attached to a hospital. It can include laboratory services, again, in a laboratory, exclusively or a laboratory that is part of a physician office. Again, not connected with a hospital for example, or minor procedures, emergency room, and then also hospital and nursing home visits. 

When you are looking for inpatient services, these inpatient services are billed by the facility and they can often be billed by physicians too. So a facility could be for you know room charges for a hospital stay. There could be staff people who are employed by the facility. These are recorded on the UV04 and they would show up in either the inpatient or the MedPAR file. But for physician visits, you know for physicians who are seeing patients outside of the hospital setting or physicians who are not necessarily billing as an employee of the hospital, they would be submitting information on the CMS1500. That data would be represented in the carrier file. 

We recommend that both the inpatient or the MedPAR and the carrier file be used for all inpatient services. If you think about it, if a patient has an inpatient event, and supposed an infectious disease consult is required, some of those services might be “provided by employees” of the hospital, staff physicians. But there also might be an outside consultant who comes in or the physician might be able to bill as a hospital employee; then might be also providing some services that are not directly due to his or her employment by the hospital. So that aspect of it that is not due to their employment by the hospital could be separately billed on the carrier file. 

If you are interested in the whole picture of the infectious disease consult, you would want both the inpatient file and the carrier file. So again, it comes back to what your research questions are, and being sure that you understand how this information is transmitted into from care into the claims files. The inpatient file includes hospital facility charges. So just keep that in mind. During long hospital stays, one claim might not be the same as one stay. An example that we show here is that supposed somebody is admitted on December 15th, keep in mind the CMS data operate on a calendar year. I know in the VA we use fiscal year. Although we are both government agencies, CMS organizes all their datasets along calender years. 

So if an, inpatient stay rolls over into the next year, in this example January 15th, they may split up the claims. So it is really important for stays to look especially at the beginning and end of year, to make sure that you are capturing the full complement of claims to represent inpatient stays. So if I have not made it clear so far, using Medicare claims data are not for the faint of heart. You really have to be making a commitment to understand these data. I have talked so far about the inpatient and outpatient institutional files.

 Let me talk a little bit about the MedPAR file. The MedPAR file takes the data sort of to another level if you will, and it rolls these claims – rolls them up if you will, combines them, compiles them, and organizes them to the level of a hospital stay. So instead of having multiple records, multiple claims for a hospital stay, it would roll it all up into one. So for example, the example that I showed on the previous slide, that MedPAR file would represent both of those claims in MedPAR. I would suggest; however I would as someone who has used Medicare data and always likes to do a double check, I would always check the previous MedPAR file just to make sure that they were rolled up properly. The MedPAR file includes both inpatient hospital stay and scaled nursing facilities. So, information about both of those pieces are in the MedPAR file. 

So, just some things to think about, when should I use the MedPAR file versus using inpatient files for studying inpatient-stays? The MedPAR file is particularly useful when you are studying the number of stays, the days per stay, the cost per stay, or total cost for an inpatient stay. That information is already compiled. You don’t have to roll up a bunch of claims and sort that out. However, if you wanted to look at subcategories or totals for charges that are not included in MedPAR, you might have to go back to the claims data to reconstruct it. It includes only the diagnosis and procedure codes found on the last claim of the say. So if this inpatient event on the MedPAR file included information from multiple claims, the diagnosis and procedures codes would only be there for the last claim., although, the cost might be there for the full. So again, some nuances to think about. I've talked briefly, about locating information on inpatient and outpatient services, and before I go onto the next section of measurement strategies. I want to pause here, and see if we have accumulated any questions. Margaret you have any questions on this section.

Margaret: I do have questions. One question is what if you are a contractor working for the VA, or you're a WOC in the VA, are you eligible to get Medicare data from VIReC. 

Dr. Denise Hynes: VIReC Services research projects that are VA research that have VA R&D, and IRB approval. If a contractor is working in research capacity with a researcher, then by all means, they would be within the service scope that VIReC services, same with a WOC. Somebody who has Without Compensation, appointment who is working with a VA researcher, and has the same criteria, can also request through VIReC. We have out partner office, known as, the Medicare and Medicaid Analysis Center, based in Boston which is an entity within the Office of the Assistant Deputy under Secretary for Health. Within their scope, they service all non-research requests. 

So, the broad answer is, Medicare data are available in the VA, to any affiliated with the VA, and doing work under VA auspices. Research goes to VIReC, non-research goes to MAC. 

Margaret:One more question now, how about for each Medicare service that is billed, is there a specific provider identified for the service?

Dr. Denise Hynes:Yes. That's an easy one. 

Margaret:Okay. You want to go on?

Dr. Denise Hynes:Let's keep going, and we can have more questions later. the provider ID is a unique ID that Medicare has as part of their system. the things to keep in mind, some services are provided by entities, a hospital, a home-health agency, a physician. There's certainly institution IDs. There's also, individual provider IDs. I’m not sure that the provider ID's are provided for individuals on the claims data, but there is a separate database that is publically available, that provides information describing providers.

So, let's talk a little bit about measurement strategies, and this will kind of transition us to talking about some of the topics that get us into examples of research questions.  Now, I'm just going to give you a heads up. We're a little bit behind on where I'd like to be, but that said, we have three examples of research projects. I probably will have time to go through one of them today depending on how fast we go through this next section. The citation for the specific research examples are in published papers, so we have some information to summarize today. So by all means the citations are there, and you can get additional information, but let me move on, and just talk about some of the measurement strategies, so you can get a flavor of what researchers tend to do, and then, we can get into as many examples as we have time for. It's always a balance to try, and provide information, and also, be responsive to questions. Especially, when we have this, everybody's muted, and we have the chat box, so please, continue to put your questions into the chat box, and I'll go back to Margaret when we're done with the section. 

So, remember, most often, we talked a little bit about some of these aspects, already, and just to summarize, the metrics that are most commonly used to study healthcare use with the claims data are those for which the claims data are most reliable, so the claims themselves, i.e. how many, the events the types, the costs. Charges and payment amounts are in there, and they're very reliable. Stay, so how inpatient stays, or nursing-home stays are there, procedures, because there are billing codes attached to those, and then, dates. And, that's very important, because dates are also tied to reimbursement rates. Remember the reimbursement rates change every year. They're congressionally mandated. There's a fee file that's put out in the congressional record every January, so submissions for claims in 2012 would be reimbursed at a rate that would be different than 2013, so dates are very important in the Medicare Claims Data. Therefore, those domains are commonly used as metrics in research projects. Claims to measure healthcare are used, you know, this is the fact that a claim has been submitted, or the number of claims that have been submitted. 

It's easy to categorize claims by types of care inpatient, outpatient, home-health, whether it's durable medical, and you'll often see summary information that CMS actually produces organized along these lines, and you can do the same with our Veteran population. You could do a broad description, and describe Veteran's use along these major claims areas, for example. Cost is another common one. You can look at charges submitted to Medicare. You can also look at payments made by a different entities, whether it's paid by Medicare, paid by the beneficiary, there are fields in the data set for deductibles, and copayments. So, if you're interested in looking at patients out-of-pocket cost, that would be a place to look, also, for example, by primary payers. Perhaps other insurers are also contributing to the overall healthcare bill. All of this information is recorded as part of the claim data set. Who's the first payer, who's the second payer, etc? What it doesn't say that is worth mentioning is whether the VA is paying anything, and the reason for that is, because the VA is not allowed to submit claims to Medicare. I don't know if that's a question that anybody's put out there. I suppose I could have done it as a pole, but VA does not submit claims to Medicare, so you cannot rely on Medicare to report back VA's for example, co-payments on prescriptions, or any kind of co-pays a patient might have. You would have to get that separately from the VA. 

Okay, stays. Stay data inpatient or SNF stays are used to measure healthcare use, the fact that there is a hospital stay, or a SNF stay, the length of stay, number of stays, time between stays. You might want to look at it by particular disease area. We might have an example of that today, I think, in our research papers, and it could be looked at over time. You could look at it for particular cohorts, and see how often particular cohorts are being readmitted during the course of some particular episode, time, years, etc. Another question is which data set should I look at for stays. We talked a little bit about the tradeoffs between looking at MedPAR versus looking at inpatient claims, and the tradeoff really is how much detail you're interested in for your research project, and whether you have the wherewithal to combine the claims within the inpatient data sets to construct the stay information that you're interested in. 

Procedures, keep in mind there's two types of procedure codes that are important to mention. ICD 9 Procedure and Surgery Codes are used. They're in the inpatient file, and the outpatient file, and they're also in the skilled nursing facility file. CPT Codes are also referred to as HCPCS. We like to pronounce that one and call it, "hick picks." It stands for Healthcare Common Procedure Coding System. So, in your mind equate CPT Procedure Codes with HCPCS. It also, they sometimes have some developed codes that are unique to CMS, but the HCPCS Codes, the CPT codes are what used for billing. Those are really important, and those are reliable. ICD 9 procedure codes, surgery codes are descriptive, and they are not used for billing. The HCPCS Codes, they identify procedures, supplies, products, and they're really useful when you're using the carrier and the outpatient files, and these are unique codes, so a specific radiology procedure, is it within a certain bank of numbers, I believe it's in the seven-thousands. An x-ray is an x-ray, and they do change from year-to-year, so there might be some more detail, some codes may be added in. Some codes may drop out. 

So, if you're doing any research that goes across years, you do need to be mindful of the type of coding data sets that are used by providers to bill, and what are accepted by CMS. Again, this information is available, in the updates that Medicare provides, as well. Procedure data elements that are often used, just a fact that procedures are done, that's a common one that you see in manuscripts. It could be an indicator of a disease, or particular disorder, some sort of screening exam, a mammography, colonoscopy, or some particular type of surgery. Number of occurrences of a procedure could be an indicator of a prevalence or level of care that's provided. 

Let's talk a little bit about dates. Example of dates; elements that contain dates are listed here. There could be a specific data service, admission, and discharge dates. Again, those could be indicative of whether a claim falls over multiple years, and there's also dates for specific when the claim was submitted, and for when it was billed, so you could have multiple date fields in a particular record, depending upon what your research question is, it could be very specific looking at the date services were provided. You may not really care when the service was actually billed. That may be irrelevant. Others may actually be interested in the billing date, so be careful when you're choosing which dates to use in your study. The dates can be useful, if you're looking at, for example, time between diagnosis and treatments, the frequency with which care is provided, and be careful, if you're looking at events, or healthcare use that requires multiple dates, and determining episodes of care, for example, dialysis. That could go over a long period of time, or chemotherapy, anything that lasts a period of time. 

This is where the art of science comes in, and trying to determine time between events may require more than simply looking at a date of service. It could be coming in the future, or there could be gaps in between. Understanding of information that you want to study, again, can't be overemphasized. Dates are useful, because they're easy to calculate. We do use the same calendaring system, so that makes it a little bit easier. Unlike some of the other code sets where we have to do a lot of cross-walking between information, dates are standard dates. There are some disadvantages of using dates. If you're trying to combine VA and Medicare, it's not so much that the dates mean something, but it has to do with the way, the differences in the two systems, and how we record events. In the VA often times, there might be multiple events that happen in one day, where in Medicare, often, different days for each event. 

So, for example, those of you who are clinicians probably realize that a patient in the VA might schedule an outpatient visit, a time with podiatrist, and maybe some group therapy on the same day for convenience sake. In Medicare, that’s just much more difficult to coordinate. So, often time, those events might be split up over different days, and sometimes weeks. So it's just the nature of care. It's not that we really record it differently. Just be mindful of those kinds of things. Some information is best looked at from claim from and through dates. They're not always the same as admission and discharge dates, or dates of service, so be careful if there's types of information that you're looking at that have both a date of service, as well as, claim from and through dates. Depending on what that service is, the choice about which date you use, could be important. So, I raced through that a bit, so that I could get you to some examples of VA studies, but let me pause here, and see if any questions have come in, because I want to make sure that you understand some of the measurement strategies. Margaret do we have any questions? 

Margaret:Here's a general question asking, or stating Medicare is complicated data, and the attendee is wondering whether there will be more sessions to help figure out how to use these Medicare data. 

Dr. Denise Hynes:So, that's a good question. Of course, all these questions are good. We have one other lecture, and again, it will be very introductory. What I'll introduce you to at the end is CMS has a training program, and they host a series of detailed courses on using specific types of data in research. They're not necessarily specific to VA. It's been some time since we've coordinated any special VA sessions with the Research Data Assistance Center. They're based at the University of Minnesota, and they do the training programs for CMS for researchers, and I can highlight that at the end of our lecture today. Thanks Margaret. 

Margaret:Okay. 

Dr. Denise Hynes:So, let me dive into some research example, and like I said, I'll pause probably after the second one today, to give time for some more questions, because we have just ten minutes in today's lecture. There are three research papers, and I wanted to just give you a flavor of research using claims data. Chuan Liu [Chuan-Fen Liu] and colleagues published this paper in 2010. We also have one looking at cost as an outcome measure that is a paper from our group that we published in Medical Care in 2007. And then, another paper that used procedures, and that's from 2006, Halanych and colleagues, and they also, focus on a particular disease entity, as well. So I want to really call your attention to these papers. I believe in our, at the end today, we have, or at least, we have available a bibliography that we maintain and update on VA researchers in the published literature. So if you're interested in access to that kind of literature we can make that available. I don't see it on our slides, but it's some information that we have at our fingertips. 

Let me tell you a little bit about Chuan Liu and colleagues paper in Health Services Research. They looked at measuring outpatient utilization using claims, and their goal was to examine differences in the use of VA and Medicare outpatient services by VA primary care patients, from VA community bases versus VA hospital based primary care clinics. So, they had a very specific question in mind looking at primary care, and they wanted to look at those in a previous study, and they looked at about 15,520 primary-care users. They had already defined who these people were, in 2000. And then, they were also enrolled in Medicare fee-for-service. So, these are VA enrollees, VA users who use primary care beginning in 2000, who were also Medicare beneficiaries. So, that's an important dimension. They're known to have Medicare coverage. 

For their data sources, they used Medicare claims data. They also used VA administrative data, and they used U.S. Census data for some of the demographic, geographic information. The VA administrative data is our generic term for data sets that we've talked about in past lectures, for example, the MedSAS data sets inpatient and outpatient, and some of the administrative data repository information, as well as, the discharge, and outpatient data sets. They compared VA and Medicare. They used an algorithm, based on provider’s speciality, and then, CPT codes that were present in both systems, and they looked at the number of outpatient visits assigned to primary care, specialty care, mental health, over four consecutive years. And they also looked at an independent variable, covariate, primary care received from VA community, versus hospital-based clinics. They found that the use of Medicare reimbursed care that is a percent of the entire cohort of those who received primary care with more than 30%. Specialty care was greater than 60%, and mental health care was down near the bottom at 3% to 4%. Community-based VA primary-care patients showed decreased use of the VA, an increased Medicare use, compared to hospital-based VA primary-care patients. 

Let me tell you, I'm going to skip our paper, and I’m going to go to the one that gets at issues in a particular disease entity, and I'll refer you to our manuscript online for the costs, but I just want to introduce you to using procedures. Again, you can obviously, drill down pretty deep into these Medicare data. This is a group that looked at racial and ethnic disparities in quality of care for a diabetes cohort of VA patients, and they looked at a national sample of non-institutionalized VA patients 65 and over with diabetes, and they had this cohort, and they used this information from both VHA, prescription, and IFCD 9 codes, and Medicare ICD 9 diagnostic codes for the years here. So, they used the descriptive coding information in both VA, and Medicare to define their cohort. Then, they looked at some race and ethnicity information that are available in VA and Medicare data. 

Medicare does have a vital status data set that does, sorry, it does have race information that Medicare data collects, so there is race information in both VA and Medicare, but the claims data that they used that I want to emphasize today, is the inpatient, outpatient, and carrier data. They're interested in procedures, yet, they used all three of these data sets. They looked at CPT codes for laboratory result files in the VA, and in the Medicare data, they used CPT codes or the HCPC codes used in outpatient, and carrier file, and then, they looked at ICD 9 procedure codes in the inpatient. Those of you who have been in some of our previous lecture remember that ICD 9 codes are used in VA's inpatient data, but they looked at three quality of care measures, hemoglobin A1C, LDLs, and then, eye exams for ophthalmology. Important clinical-care measures in diabetes management. They obviously relied on whether the fact of these events took place. 

The results are not available in the Medicare data, but they could look at whether these particular procedures actually occurred. They could look at results within the VA data, and within VA and Medicare data, they could look at whether together these events were occurring. They found that the rates of receiving these procedures were equal to or higher for blacks and hispanics compared to whites, and they found that results were reversed when they looked at receiving procedures in the VHA plus the Medicare data. They found that more care data was captured in Medicare for whites as compared to blacks and hispanics. I'm going to just stop there for examples, and I want to make sure that I highlight information that's available for additional help. I mentioned some of this as we're going through. One is VIReC web page. We do have information on the internet site, and it's pretty detailed. 

You can find some more information about VA data sources on the intranet site as well, but there's a pretty full range of information on the internet site, so those of you outside the VA can still see a lot of information that we provide. If you’re restricted to the internet site, and you still have more questions, please feel free to send us a question on the VIReC Help Desk, and even you can get past, and within the intranet, you're always welcome to use our help desk. We have a team of staff who worked exclusively, are very knowledgeable, and worked especially with the Medicare data in VA, and can help with questions. HSR data list server, I would encourage you to join, if you're interested, and are not familiar with using VA, and Medicare data. It is a discussion group. 

We now have over four hundred data stewards, managers, users, researchers, policy people, it's within the VIReC Website to register, and you do have to have, it's within the intranet. So unfortunately if you're outside of the VA, you can't really join that, but it is information that sometimes can be, you know, sometimes some peer supports, and that could supplement asking questions of VIReC. As I mentioned we have some detailed information on our website, and it includes this kind of information, so for example, if you're planning a study, and you may not have the wherewithal to query the data set in advance of a proposal being funded, some of the information we try to make available, frequencies for example, about common variables used. 

The kind of information most people use these data in SAS, so we put SAS proc contents up there, and this is where the information is on VIReC's website. We also, have links to the Research Data Assistance Center known as ResDAC. They're the CMS contractor based at the University of Minnesota, and they've been around, I don't know exactly how long, but longer that VIReC, and their assistance is free. They provide assistance to researchers, government agencies, not for profits, about working with Medicare data, and have a host of information for training to give you some context. I have our VIReC staff check this website for training opportunities. 

When we hear about, or when ResDEC hears about a quorum of VA researchers, we might coordinate with ResDAC to do a special session that's a little more tailored to VA. So please, be sure if you're interested in some linkages with VA data, or you're really trying to do VA research with Medicare data, let ResDAC know when you contact them, or you contact us. And that will give us some information upon which we can think of coordinating some special sessions with ResDAC.

And of course, CMS. If you want to have more information about you know, sort of overall issues with CMS, coverage issues, I would strongly recommend orienting yourself through the CMS homepage. There's also a lot of information for Medicare beneficiaries, and that's also a good place to start, especially if you're a novice at this. They again, it's geared toward patients, so it's easy to understand, and the CMS home page also has a lot of information at different levels as you become acclimated to it. 

So, I'm going to stop there, and see if we have any other questions, that we can answer in our three minutes that we have left. Margaret? Do we have anything else?

Margaret:We do. One question is, where can you obtain information about medications in Medicare data? 

Dr. Denise Hynes:Medicare has, there are two answers to that questions. There is some information about limited medications that are provided, and that Medicare currently reimburses for under either Part A or Part B, those tend to be parenteral medications IV this, injectable that and those would be in the carrier file, and sometime in the durable medical. For medications that are covered under Part D, Medicare does have a separate set of data under Part D claims. We didn't talk about those today. If you have a VA research project that requires Medicare Part D, let VIReC know. Right now, we have a process with CMS where these are made available on a request-by-request basis, and Medicare, right now, is charging us for those requests, but there are medications in both the Part D for oral meds., covered under Part D, and then, currently available in the carrier and the DME for anything that already is covered outside Part D under A and B. 

Margaret:Okay, an earlier question was about the quality of the race and ethnicity data in Medicare. 

Dr. Denise Hynes:I’m going to refer you to some information that we have both on the VIReC website, and I believe there might even be some new information on the VHA equality Program site. I can tell you that in the VA, we rely on both the VA's race data, as well as Medicare's race data, and there has been some comparisons. And we have a couple publications out there that talk about the quality, and the best choices in different situations for using either the VA data, or going, and obtaining the information from Medicare. As you may, or may not know, how race data are collected has changed, and hopefully improved a bit over time. There is now more information that gets into ethnicity issue, more than just race, so it is highly regarded, but I can't give you a quantitative number on whether it is better than other data. 

Margaret:Denise, maybe one last question. What is Medicare Fee-for-service?

Dr. Denise Hynes:Medicare Fee-for-service, providers deliver care, and they bill Medicare on a piece-by-piece basis for every service, and Medicare has rates developed for every CPT code, every billing code, and every service that is billed. That's fee-for-service, prospective payments, on the other hand, is Medicare has a pre-negotiated rate for events such as inpatient stay. So, every diagnostic related group, every stay is classified according to DRG, and it does not matter how long the stay is, but Medicare has a pre-negotiated rate for stays that are for coronary, artery, by-pass, graft with complications. The patient stays for five days, or if the patient stays for you know, three weeks, there is a pre-negotiated fee for diagnostic related group. So, the distinction is that fee-for-service, Medicare reimburses on a service basis. There are also negotiated rates for each service, but fee-for-service means they're if you will, "unbundled." It's not a package, it is separate items.

Margaret:Okay. We're at the top of the hour. I want to thank everybody for attending. Thank you, Denise. Our next scheduled session, is Monday, January 7th, same time, and it will be again, Measuring Veterans Health Service in VA, and Medicare. It will be Part Two, and Dr. Hynes will be presenting that as well. Thank you all. Happy Holidays! 

Dr. Denise Hynes:Thank you. 

[End of Audio]

Page 1 of 14

14 of 14