Introduction to Medicare Utilization Data Created by Sarah Brunsberg

About ResDAC

Centers for Medicare and Medicaid (CMS) contractor

Offer free assistance to researchers interested in using Medicare and Medicaid data for research

Staffed by a team of public health and health services research specialists

Provide a range of services related to CMS data ˗ Assistance Desk ˗ Workshops and Outreach

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Overview of Medicare Utilization Data

Goals for today ˗ Define claims data or utilization data ˗ Define the claims types ˗ Discuss the types of claims files that CMS has

available

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What are claims data?

Claims data is derived from reimbursement or payment of bills

Claims are bills for services provided to the Medicare enrollees

The information in the claims data that is necessary to pay the bill will be of higher quality than other information ˗ The enrollment data are the basis for determining

whose bills are qualified to be paid ˗ Demographic information is largely reliable and valid

because it comes from the SSA and the states

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Claims Data: A rich data source

It is estimated that 98% of adults age 65 and over are enrollment in Medicare

Over 99% of deaths in the US for persons age 65 and older are accounted for in the Medicare program

Information contained in claims data include diagnosis information, procedure information, dates of service and payment and reimbursement information

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Information on a Claim

Basic information regarding the service provided: dates of service, beneficiary information

Procedure and diagnosis codes Payment amounts Provider information Fee for service utilization

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Claim Types

Institutional: ˗ Inpatient ˗ Outpatient ˗ Skilled Nursing Facility ˗ Home Health Agency ˗ Hospice ˗ MedPAR file (combines Inpatient and Skilled Nursing)

Non-Institutional: ˗ Physician/Supplier (AKA Carrier) ˗ Durable Medical Equipment Suppliers

Prescription Drug Events: ˗ Part D Event Data

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Claims Forms

CMS collects data on two different forms: Uniform Bill-04 (AKA UB-04 or historically CMS-1450)

˗ Institutional providers provide services covered under Part A benefit. But, not necessarily exclusively » Providers or Part A services only: Skilled nursing facilities and

hospices » Providers of Part A and Part B services: Hospitals and home

health agencies

CMS 1500 ˗ Only used by non-institutional providers which includes:

physicians, nurse practitioners, clinical laboratories, ambulance services, durable medical equipment suppliers, stand-alone ambulatory surgical centers

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Claims Processing

The claims research files contain more variables than those found on the claim form ˗ Additional fields are added during claims processing ˗ Likewise, not all fields on the claims form are found in

the research files

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Standard Analytical Files (SAFs)

SAFs contain final action claims Each SAF contains claims for services rendered in

one calendar year (based on claim-through date) Each July, CMS SAFs are created and finalized for

the prior years claims, capturing 98% of that year’s claims

There is a SAF for each type of service (institutional and non-institutional): Inpatient, Outpatient, SNF, Home Health, Hospice, Carrier, DME

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Medicare Provider Analysis and Review (MedPAR)

The MedPAR file was created from the SAF files and contains information on hospital inpatient stays and skilled nursing facility stays

Each observation contains aggregated data of all facility claims related to one episode of care (either a hospital or skilled nursing facility stay)

The MedPAR is available as a fiscal or calendar year based on the discharge date for the Inpatient MedPAR or the admission date for the SNF MedPAR

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Part D Event Data

Part D prescription drug data are considered different than claims, they are considered “events”

A Part D Event Data record is not the same as a pharmacy claim and so it differs from point-of-service ˗ There can be post-transaction adjustments between

the plan and pharmacy ˗ There can be plan-to-plan adjustments for misenrollees ˗ There can be plan-to-CMS adjustments for some

demonstration projects

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Information on a Part D Event

Product Service Identifier (NDC) Prescription Service Date Days supply Gross Drug Cost

˗ Note: researchers cannot determine “true” cost to Medicare or the plan for prescription drugs, but can determine “point of sale” cost to beneficiary

Benefit Phase Low Income Subsidy Amount Patient Pay Amount Third party payments

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Part D Files

In addition to the drug event file, researchers can request characteristics files: ˗ Drug Characteristics ˗ Pharmacy Characteristics ˗ Prescriber Characteristics ˗ Plan Characteristics ˗ Formulary File (only available from 2010 forward)

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RIF versus LDS Data

Research Identifiable Data (RIF) contain beneficiary level protected health Information

Requests for RIF data require a DUA and are reviewed by the CMS privacy board to ensure that the beneficiary’s privacy is protected and the need for RIF data is justified

Limited Data Sets (LDS) contain beneficiary level protected health information; however, selected variables are encrypted, blanked or ranged

LDS requests require a DUA but do not require a privacy board review

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Research Identifiable Files

Limited Data Sets

Requires privacy board review

Yes No

Requires DUA Yes Yes

File includes beneficiary level data

Yes Yes

Data file can be customized to only include a specific cohort

Yes No (only available as 100% or 5% national sample)

Data can be linked to non-CMS data using a beneficiary identifier (such as SSN_

Yes No

Variable Differences between RIF and LDS Data

Variable File Research Identifiable File

Limited Data Set

Beneficiary Identifier

Claims & Enrollment Files

Encrypted Identifier

Encrypted Identifier

Health Insurance Claim (HIC) or SSN

Claims & Enrollment Files

Not included in file Not included in file

Dates (MM/DD/YYYY)

Claims Files Included Included as of calendar year 2010

Beneficiary Zip Code

Enrollment File Included Not included, only county or state

Beneficiary Date of Birth

Enrollment File Included Not included, either age year or 5-year age range

Date of Death Enrollment File Included Included, only for validated dates of death

UPIN/NPI of performing provider

Claims Files Included Included but encrypted

Institutional Provider Number

Claims Files Included Included 17

RIF versus LDS

The Standard Analytical Files (SAFs) are available as an LDS or a RIF

The MedPAR file is available as an LDS or a RIF ˗ MedPAR LDS is a stand-alone file that cannot be linked to

other files, MedPAR RIF can be linked to other files The Part D files are only available as a RIF Both LDS and RIF files have a Medicare enrollment file

which provides information about a beneficiaries Medicare enrollment and demographics ˗ LDS Denominator ˗ RIF Master Beneficiary Summary file (base/enrollment

segment)

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Structure of CMS Medicare Data Files

Available as annual calendar year files, most files available back to 1999 (Part D 2006)

RIF data can be requested as a standard national sample (5% or sometimes 20%) or a as a customized cohort (based on researcher’s criteria)

LDS data can be requested as a 5% sample or for most files as a 100% file

Organized by beneficiary

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Resources for Help

ResDAC Assistance Desk ˗ Email: resdac@umn.edu ˗ Phone: 1-888-973-7322 ˗ Web: http://www.resdac.org

ResDAC Website ˗ CMS Data ˗ ResConnect (Resource Library)

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Webinar Series

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02/28 – Introduction to CMS Data 03/19 – Non-Identifiable Data 04/04 –Cost Reports 04/09 - DE-SynPUFs 04/10 –Limited Data Sets 04/25 –Research Identifiable Data 05/02 – Utilization Data View past webinars and register for upcoming webinars at the ResDAC website (www.resdac.org/training/media/webinars)