2012-2013 VIReC Database and Methods C

yber Se

Measuring Veterans Health Se

Use in VA and Medicare Use in VA and Medicare 

(Part 1) 

December 3, 2012 

Presented by: 

Denise M Hynes MPH PhD RN Denise M. Hynes, MPH, PhD, RN 
E l f VA t di th t h 

To

pics for Toda

y

Overview of the Medicare Claim

datasets 

Locating information on InpatieLocating information on Inpatie

and Outpatient services 

Measurement strategies for 

evaluating Medicare healthcare 

Examples 

of VA 

s

t

udies th

at ha

used the Medicare Claims datas

to evaluate healthcare use 

Where to go for more help 
Audience Poll

(Heidi convert to poll function(Heidi convert to poll function

Have you ever used any of the Mediclaims datasets 

– Yes– No

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

–1 (No knowledge) –2 –3 –4 – 5 (Expert-level knowledge) 
E l f VA t di th t h 

To

pics for Toda

y

Overview of the Medicare Claim

datasets 

Locating information on InpatieLocating information on Inpatie

and Outpatient services 

Measurement strategies for 

evaluating Medicare healthcare 

Examples 

of VA 

s

t

udies th

at ha

used the Medicare Claims datas

to evaluate healthcare use 

Where to go for more help 
Why are Medicare Claims impo

Many Veterans who use VA health also obtain care outside VA Researchers need full 

picture of he

care use to draw accurate conclusiAlmost half of Veterans enrolled in are also enrolled in Medicare 
–

t

Overview of Medicare Claim

Healthcare providers and health equipsuppliers: 

– Submit claims to the Centers for Medica

Medicaid Services (CMS) 

– Are reimbursed for services and produc

Are reimbursed for services and produc

Claims are collected by CMS and enterdatasets fo anal sis based on datasets for analysis based on: 

– Type of billing form used to gather the 

if i n ormation 

– Type of provider 
Sources of Medicare Claims 

Billing Form CMS 1450/ UB-04 CMS 

Provider type Institutional Non-inst

Examples of Examples of 

Providers 

Hospitals 

Skilled Nursing Facilities 

Home Health Agencies 

Hospice 

Phys

Supp
Medicare Claims Files

Institutional 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 File 

– Medicare Provider Analysis and Review (
–

Our focus today

Institutional Files 

– Outpatient – Home Health Agency (HHA)– Hospice– Inpatient 

– Skilled Nursing Facility (SNF) 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 Institutional Stay Level File 

– Medicare Provider Analysis and Review (
–

Examples: Claims to Care Relat

A single claim may include 

– One service, product or procedure such as 

• A physician office visit 

– More than one service, product or procedure 

• An inpatient hospital stay 

Multiple claims may be submitted for Multiple claims may be submitted for 

– A long inpatient stay – A procedure that involved multiple physicians A procedure that involved multiple physicians 
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 accurate 

– Claim “from” and “thru” dates – Char

ge and 

p

a

yment amounts 

– Diagnosis codes – Procedure codes Procedure codes – Provider numbers 
Limitations of Medicare Claim

No/Limited data on: 

– Data not needed for billin

g 

• Demographics (Marital Status, Education, I• Clinical Data 

(Lab Results, Vital Si

gns, S

y

m

– Services that are not itemized 

• Prospective Payment System (PPS) Prospective Payment System (PPS) 

• Managed Care (HMOs)
Data Access

Eligibility: Medicare and other CMS data are ato VA researchers with VA Research & Developm(R&D) Committee and Institutional Review Boaapproved projects. Data Steward: VIReC’s VA/CMS Data for Rproject 

– All use of CMS data for VA research must be 

approved by VIReC. 

Information about data available and the rprocess: http://www.virec.research.va.gov/IndVACMS.htm 
E l f VA t di th t h 

To

pics for Toda

y

Overview of the Medicare Claim

datasets 

Locating information on InpatieLocating information on Inpatie

and Outpatient services 

Measurement strategies for 

evaluating Medicare healthcare 

Examples 

of VA 

s

t

udies th

at ha

used the Medicare Claims datas

to evaluate healthcare use 

Where to go for more help 
Identifying Outpatient Servi

Outpatient services may be provid

Setting Billing Form File 

Within institutions CMS 1450/ 

UB-04 

Outpatient 

File 

Within non 

-

institutional 

settings 

CMS 1500 Carrier File 

Use both Outpatient and Carrierfiles for outpatient procedures and services 
Outpatient File

Includes services provided by institutional institutional facilities, such as: 

– Hospitals ( Hospitals ( 80%) ~– Dialysis facilities – Rural health Rural health 

clinics 

Types of ser

– Laboratory – Radiology – Physical th– Dialysis – Emergency 
Carrier File

Primarily includes physician serviceAlso includes ambulance services Also includes ambulance services Types of services: 

– Office visits Office visits – Laboratory – Minor procedures Minor procedures – Emergency room – Hospit al & nursing hh l & ome visits
t

Identifying Inpatient ServIdentifying Inpatient Serv

Inpatient services are billed by the (and often physicians too)

Service Billing form 

Facility 

•Room charges •Staff (employed by facility) 

CMS 1450/ 

UB-04 

Inp 

Me

Ph i iys c an vi i sts 

(not employed by the hospital) 

CMS 1500 C 

Ca

Use both Inpatient/MedPAR and Cafiles for all inpatient services 
t t

Inpatient File

Includes hospital facility charges D i

 h

During l l l i l ong hospital stays, one claim 

not be the same as one stay 

Stay Claim Admit: December 15 Discharge: January 15 

Claim 1 From: Dec 1

Thru: Dec 3

Claim 2 From: Janua

Thru: Janua

Combine claims into stays to avoid ocounting stays 
MedPAR File

Claims are “rolled up” to the slevel Contains stays in both inpatiehospitals and skilled nursing facilities (SNF) 
MedPAR vs Inpatient File

for Studying Inpatient Sta

The MedPAR file is advantageous wstudying: 

– Number of stays Number of stays – Days per stay – Cost per stay Cost per stay – Total costs 

Disadvantages: Disadvantages: 

– Sub-category totals for charges not in– Includes onl

y the dia

gnosis & 

procedu

found on the last claim of the stay 
E l f VA t di th t h 

To

pics for Toda

y

Overview of the Medicare Claim

datasets 

Locating information on InpatieLocating information on Inpatie

and Outpatient services 

Measurement strategies for 

evaluating Medicare healthcare 

Examples 

of VA 

s

t

udies th

at ha

used the Medicare Claims datas

to evaluate healthcare use 

Where to go for more help 
–

Measuring Medicare Healthca

Metrics used to study healthcare usinclude: 

– Claims– Costs– Stays – Procedures Procedures – Dates 
Claims

Using claims to measure healthcare 

– The ff act thata claim hh as bb een submitt ed– The number of claims that have been su

Benefits of measuring use with clai

– Easy to categorize claims by types of ca
Cost

Using cost to measure healthcare use: 

– Charges submitted to Medicare – Payments made by 

• Medicare • By beneficiaries (deductibles & copayments)

• By primary payers (other insurance) 
e act t at t e e s a os ta sta

–

Stays

Stay data used to measure healthcause: 

– Th

e fact 

t

hat 

t

h

e

r

e is 

a hospital stay 

– Length of the stay – Number of stays Number of stays – Time between stays 

Whi

ch

dataset s

hould I use to look a

stays? 

– MedPAR – Inpatient (claims must be combined) 
t

Procedures

ICD-9 Procedure/Surgery codes 9 Procedure/Surgery codes 

– Inpatient file – Outpatient file

– Skilled Nursing Facility File

HCPCS - Healthcare Common ProcedCoding System 

– CPT procedure codes + CMS d CMS d evelopedcod

– Identifies: procedures, supplies, products a

services services 

– Most useful in Carrier and Outpatient files 
Procedures

Procedure data elements used to mhealthcare use: 

– The fact that a procedure was done 

• e.g., as an indicator of a disease o

– The number of occurrences of a proce

• e.g ,. as an indicator of prevalence 

of care provided
–

t

Dates

Examples of data elements containing dExamples of data elements containing dused to measure healthcare use: 

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

How are dates used to measure healthcuse? Examples: Examples: 

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

Benefits of using 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 
Topics for Today

Overview of the Medicare Claim

datasets 

Locating information on InpatieLocating information on Inpatie

and Outpatient services 

Measurement strategies for 

evaluating Medicare healthcare 

E l f VA t di th t h Examples of VA studies that ha

used the Medicare Claims datas

to evaluate healthcare use 

Where to go for more help 
Measuring Medicare Healthcar

Examples from Th Th ree

R Research S

f 

Measuring outpatient utilization using claim

– Liu

C

‐

F et al. Use of outpatient care in Veterans He

Ad i m

nis

tration an

d M di e care among V t e

terans rece

primary care in community

‐based and hospital out

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

Measuring outpatient utilization using cost 

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

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

‐23

Measuring healthcare utilization using proc

– Halan

ych JH et al. Racial

/ethnic differences in diab

for older Veterans: Accounting for dual health syst

changes conclusions. Medical Care. 2006;44(5):439
–

Measuring outpatient utiliz

using claims using claims 

Liu C-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 
o

Measuring outpatient utiliz

using claims using claims 

Liu C-F et al, Health Services Research, 

Methods 

– Data sources: Medicare claims data, VA 

ad i i i d d US d dministrative data, and US census dat

– Comparison between VA and Medicare: 

Algo ithm based on p ide specialt aAlgorithm based on provider specialty acodes present in both systems 

– Dependent variable: Dependent variable: Number of outpat

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 Measuring outpatient utiliz

using claims using claims 

Liu C-F et al, Health Services Research, 

Selected Results 

– Use of Medicare-reimbursed care (% of e

cohort): primary care >30%; specialty camental h 

healt

h care 3-4% 

– Community-based VA primary care patien

demons

tra

t 

ed decreased VA use and incr

Medicare use compared to hospital-based primar

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 using cost 

Hynes et al, Medical Care, 2007 

Meth do s – Measuring 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 

Outpatient categories were defined based on of costs attributable to VA and Medicare: 

• Medicare Medicare -only users (100% Medicare) 

• Mostly Medicare users (75-99% Medicare) • Equally dual users (26 Equally dual users (26 -76% Medicare) 76% Medicare) • Mostly VA users (1-25% Medicare) • VA -only users (0% Medicare) 
Measuring outpatient utilization u

Hynes et al, Medical Care, 2007

Adjusted Odds Ratios of Using VA or Medicare Outpatie

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

Age 66-74 Ref Ref Ref 

75-84 0.71 0.70 0.67 

85+ 0 40 . 0 49 . 0 50 . Race Nonblack Ref Ref Ref Black 1.85 2.09 2.22 Distance to Nearest VA Hospital 0-4.9 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 
Measuring Procedure

Halanych et al, Medical Care, 2006 

Goal 

– Compare racial/ethnic disparities in qualit

for VHA patients with diabetes 

Cohort 

– National sam

ple of non-institutionalized V

patients, 65 years and over, with diabete

– Diabetes determined from VHA prescripti

ICD

-

9 co

d es and f rom M ICD edicare ICD

-9 dia

codes for FY 1997-1998 
Measuring Procedure

Halanych et al, Medical Care, 2006 

Methods 

– Race

/ethnicit

y obtained from VHA and Medicar

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

• VHA data: Laboratory result files; CPT codes • Medicare data: CPT/HCPCS codes used (Outpati• ICD-9 procedure codes 

(in

patient

) 

– Three quality of care measures used 

• Annual hemoglobin A1c (HbA1c) test • 

Annual low density li li poprotein (LDL) test d (LDL) 

• Annual dilated eye examination 
Measuring Procedure

Halanych et al, Medical Care, 2006 

Results 

– VHA only data 

- Rates of receiving three 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 a

tes 

o

f

f receiving proce

dures were l

l ower 

and Hispanics compared to Whites 

– More care captured in Medicare for White

compared to Blacks and Hispanics
E l f VA t di th t h 

To

pics for Toda

y

Overview of the Medicare Claim

datasets 

Locating information on InpatieLocating information on Inpatie

and Outpatient services 

Measurement strategies for 

evaluating Medicare healthcare 

Examples 

of VA 

s

t

udies th

at ha

used the Medicare Claims datas

to evaluate healthcare use 

Where 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

available resources on topics 

– VIReC@va.gov or (708) 202-2413 

HSRData Listserv HSRData Listserv 

– Join at the VIReC Web site – Discussion among >400 data stewards, manager

users 

– Past messages in archive (on intranet) 
VIReC’s VA/CMS Web Pag

Complete list and description of fileavailable Links to Medicare Files Data dictionSAS Proc Contents Frequencies for

MM

edicare variabl es f di 

http://www.virec.research.va.gov/IndeVACMS.htm 
Research Data Assistance Ce

(ResDAC

)

CMS contractor based at the UniverMinnesota Provides 

free assistance to: 

– Researchers – Government agencies – Not-for-profit organizations 

Workshops on using Medicare and Medicaid datawww.resdac.org 
CMS and Medicare Websit

CMS Home Page

– www.cms.gov 

For Medicare Beneficiaries

– www.medicare.gov 
Questions?
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The following documents are required: 

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heckl ist

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utional Review Board (IRB) appr

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Upcoming Seminars

January 7, 2013 

– Measuring Veterans Health Services 

VA and Medicare (Part 2) 

– Denise M. Hynes, PhD, MPH, RN