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Estimating non-VA Health Estimating non-VA Health Care CostsCare Costs

Todd H. WagnerTodd H. Wagner

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Learning ObjectivesLearning Objectives

After this talk, you willAfter this talk, you will– Understand whether you need non-VA dataUnderstand whether you need non-VA data

– Know the strengths and weaknesses for Know the strengths and weaknesses for different sources of non-VA datadifferent sources of non-VA data

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Do you need non-VA data?Do you need non-VA data?

Many veterans have a choice in where Many veterans have a choice in where they get carethey get care

Many veterans who get care from VA Many veterans who get care from VA facilities also get care from non-VA facilities also get care from non-VA providers (e.g., Medicare, Medicaid)providers (e.g., Medicare, Medicaid)

Perspective and objectives: these should Perspective and objectives: these should dictate your data needsdictate your data needs

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ExampleExample

Any examples of studies that require non-Any examples of studies that require non-VA data?VA data?

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Sources of non-VA dataSources of non-VA data Medicare dataMedicare data Fee BasisFee Basis Bills from providersBills from providers Self-reportSelf-report

All sources have strengths and All sources have strengths and weaknessesweaknesses

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Medicare DataMedicare Data

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Medicare Data for VeteransMedicare Data for Veterans

Medicare is health insurance for people Medicare is health insurance for people over age 65 or those with a disabilityover age 65 or those with a disability

VIReC maintainsVIReC maintains– Medicare Data for all VA enrollees from Medicare Data for all VA enrollees from

1999 through 20031999 through 2003 Note the delay; this may be critical for Note the delay; this may be critical for

clinical trials.clinical trials.

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Medicare Institutional ClaimsMedicare Institutional Claims

AKA Part A (except outpatient)AKA Part A (except outpatient) Inpatient (short/long)Inpatient (short/long)Outpatient (Part B)Outpatient (Part B)Home Health (Part A & B)Home Health (Part A & B)HospiceHospiceSkilled Nursing FacilitiesSkilled Nursing Facilities

– One file for each type of claimOne file for each type of claim

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Medicare Non-Institutional ClaimsMedicare Non-Institutional Claims AKA Part B:AKA Part B:

– Physician/supplier filePhysician/supplier file Physician, NPs, and other professionalsPhysician, NPs, and other professionals Clinical LaboratoriesClinical Laboratories Ambulance servicesAmbulance services Ambulatory Surgery CentersAmbulatory Surgery Centers

– Durable Medical Equipment (DME) fileDurable Medical Equipment (DME) file

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Medicare File TypesMedicare File Types

Research Identifiable Files (RIFs)Research Identifiable Files (RIFs) Beneficiary Encrypted Files (BEFs)Beneficiary Encrypted Files (BEFs) Limited Data Set (LDS)Limited Data Set (LDS) Downloadable files (PUFs)Downloadable files (PUFs)

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Charges in Medicare DataCharges in Medicare Data

Charges: reflect billed amount. Charges: reflect billed amount. Charges > Costs.Charges > Costs. Adjust charges using cost-to-charge ratio Adjust charges using cost-to-charge ratio

(CCR).(CCR).– Cost to charge ratio is calculated from Cost to charge ratio is calculated from

Medicare Hospital Cost ReportMedicare Hospital Cost Report

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Medicare PaymentsMedicare Payments Payments: reflect amount paid by Medicare. Payments: reflect amount paid by Medicare.

This reflects:This reflects:– Co-payments, deductibles, coinsuranceCo-payments, deductibles, coinsurance– Benefit limitationsBenefit limitations– Wages, disproportionate share, IMEWages, disproportionate share, IME– Direct medical educationDirect medical education– Outlier paymentOutlier payment

Reimbursement Amount = DRG Price + Reimbursement Amount = DRG Price + Outlier Payment – Individual Payment – Other Outlier Payment – Individual Payment – Other Insurance PaymentInsurance Payment

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Fee BasisFee Basis

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Overview of Fee Basis ProgramOverview of Fee Basis Program

Pays for care at Pays for care at non-VA facilitiesnon-VA facilities when when– it is the only source available, or it is the only source available, or – VA could save moneyVA could save money

Full range of services coveredFull range of services covered

Mostly pre-arranged; limited emergent careMostly pre-arranged; limited emergent care

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Fee Basis files Fee Basis files

Subset of all VA contract careSubset of all VA contract care– Non-VA PTF has detail on hospital stays; some overlap Non-VA PTF has detail on hospital stays; some overlap

with Fee Basis fileswith Fee Basis files– Substantial utilization unaccounted forSubstantial utilization unaccounted for

SAS format at AustinSAS format at Austin

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Highlights of Financial DataHighlights of Financial Data Amount claimedAmount claimed Amount paid Amount paid

often much less than amount claimedoften much less than amount claimed

Many variables relating to FMS Many variables relating to FMS record-keeping: invoice date, record-keeping: invoice date, processing date, check number, check processing date, check number, check date, cancel code, etc.date, cancel code, etc.

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User NotesUser Notes

Each Each paidpaid invoice has a separate invoice has a separate record.record.

Invoices may be sent LONG after Invoices may be sent LONG after services are renderedservices are rendered

Search for records in many yearsSearch for records in many years

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Using Fee Basis Files: CautionsUsing Fee Basis Files: Cautions

Beware of missing decimal placesBeware of missing decimal places– ICD diagnosis codesICD diagnosis codes– Payment amountsPayment amounts

Care in community nursing homes, state veterans homes, and Care in community nursing homes, state veterans homes, and some non-VA hospitals may also be recorded in other filessome non-VA hospitals may also be recorded in other files– e.g., contract nursing home care appears in DSS outpatient filese.g., contract nursing home care appears in DSS outpatient files

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Bills from ProvidersBills from Providers

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Collecting Billing DataCollecting Billing Data

With consent, you can attempt to collect With consent, you can attempt to collect hospital billshospital bills

We are doing this for a few clinical trialsWe are doing this for a few clinical trials Mixed success; typically only done for Mixed success; typically only done for

inpatient costsinpatient costs

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MethodMethod

1.1. Use self-report to identify utilizationUse self-report to identify utilization2.2. Ask patient for name of hospital and Ask patient for name of hospital and

approximate dateapproximate date3.3. Have patient sign HIPAA releaseHave patient sign HIPAA release4.4. Contact hospital for UB92Contact hospital for UB925.5. Cost adjust the charges reported on the Cost adjust the charges reported on the

billbill

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Self-ReportSelf-Report

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Limits with Administrative DataLimits with Administrative Data

Obtaining and analyzing claims data can Obtaining and analyzing claims data can be costly and time consumingbe costly and time consuming

Administrative data can be incomplete or Administrative data can be incomplete or inaccurate inaccurate– Limited benefitsLimited benefits

– Out-of-plan or out-of-pocket utilizationOut-of-plan or out-of-pocket utilization

– Capitated health plansCapitated health plans

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What is Self Report?What is Self Report?

Cognitive process of recalling Cognitive process of recalling informationinformation

Ample opportunity for distortion and Ample opportunity for distortion and error (Khilstrom et. al 2000) error (Khilstrom et. al 2000)

Self-report not valid when people lack the Self-report not valid when people lack the cognitive capabilitiescognitive capabilities

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Modifiable ComponentsModifiable Components

1.1. Recall timeframeRecall timeframe

2.2. Type of utilizationType of utilization

3.3. Utilization frequencyUtilization frequency

4.4. Questionnaire designQuestionnaire design

5.5. Mode of data collection Mode of data collection

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Questionnaire DesignQuestionnaire Design

No standards existNo standards exist Pretest: Dillman (2000)Pretest: Dillman (2000) Use counts for responses (not categories)Use counts for responses (not categories)

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Self-Reported CostsSelf-Reported Costs

Self-reported costs are assumed poorSelf-reported costs are assumed poor

Imputing costs from self-reported Imputing costs from self-reported utilization can introduce biasesutilization can introduce biases

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Additional ReadingsAdditional Readings

Fee Basis Technical Report #18Fee Basis Technical Report #18

Bhandari and Wagner. Self-Reported Bhandari and Wagner. Self-Reported Utilization of Health Care Services: Utilization of Health Care Services: Improving Measurement and Accuracy Improving Measurement and Accuracy (2006, MCRR). Available upon request.(2006, MCRR). Available upon request.

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Additional LinksAdditional Links

VIReC– Manages the VA Medicare DataVIReC– Manages the VA Medicare Datawww.virec.research.med.va.govwww.virec.research.med.va.gov

ResDAC (Research Data Assistance ResDAC (Research Data Assistance Center) for Medicare data Center) for Medicare data www.resdac.umn.eduwww.resdac.umn.edu

Medicare and MedicaidMedicare and Medicaidwww.cms.hhs.govwww.cms.hhs.gov

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Additional ViewingsAdditional Viewings

2005 HERC Courses2005 HERC Courses– Talk on Medicare Data (Yu)Talk on Medicare Data (Yu)

– Talk on the Fee Basis (Smith)Talk on the Fee Basis (Smith)

http://www.herc.research.med.va.gov/resouhttp://www.herc.research.med.va.gov/resources/training_course_archives.asprces/training_course_archives.asp