Download Topical Session 3-1974

ROUGH EDITED COPY
EDHI CONFERENCE
DETERMINING AVERAGE COSTS REIMBURSEMENT FOR
NEWBORN HEARING SCREENING USING MARKETSCAN
MARCH 14, 2016
CART CAPTIONING PROVIDED BY:
ALTERNATIVE COMMUNICATION SERVICES, LLC
PO BOX 278
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This is being provided in a rough draft format.
Communication Access Realtime Translation (CART)
is provided in order to facilitate communication
accessibility and may not be a totally verbatim
record of the proceedings.
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>> QUYNH:
me?
Okay.
Okay.
Can everyone hear
Going to go ahead and get started.
Sorry to be a couple of minutes late.
My name is
Quynh Do a fellow for the national center for birth
defects on the early hearing detection and
intervention team.
And today, I'll be talking to
you about determining average cost reimbursement
for newborn hearing screening using a Truven health
databases it's a commercial database that actually
includes insurance claims from private insurers,
Medicaid and a Medicare supplemental, I have a days
claimer, the find or for myself and do not represent
the Centers for Disease Control and prevention
before today I'm going to summarize use all
insurance claims data to identify deaf and hard of
hearing children, assess reimbursement nor newborn
screening with private or Medicaids in and compare
how much parents are paying when they're billed
separately.
I'm going to give you an overview of
my presentation, I'm going to get into the
background, cover the EHDI 360 plan, if you don't
know what that is, talk about current efforts and
newborn hearing screening, give a quick overview
of cost, discuss my key finding than a go into the
method, and how I calculated these numbers and a
discussion of what my next steps are going to be.
First we all flow babies develop
speech and land from when they're born and it can
affect from 1 to 3 babies of every 1,000 live
infants specifically 1 out of 1,000 are profoundly
death and 2 out of the 3 of 1,000 have partial
hearing loss.
According to the 1-3-6 plan we want
to make sure infants have hearing screening no
later than one month of age and if they do fail the
hearing test and they need to have a hearing
evaluation it occurs no later than 3 months of
administering and have an audiological early
intervention no later than 6 months we know
children who are deaf or hard of hearing don't have
any developmental delays later.
So according to the CDC's 2013 EHDI,
about 97.2% of newborns were screened for hearing
loss.
Because a lot of -- 97.2 because a lot of
commercial claims abandoned all lab and delivery,
theirs not much information for newborn screenings
but past research has shown that it depends on the
setting whether it's an inpatient or outpatient
set, the provider or provider type and screening
technologies that are specifically used.
I'm going to go over some terms of
what cost is.
You can define as the value of
resource people, equipment, supplies, vehicles
used to provide a specific service and the value
implies it's worth something not necessarily of
money is actually being exchanged or not and cost
can either be explicit or implicit.
Flow there are
three different speak types of costs, theirs direct
cost, which is the monetary costs directly related
to prevention, treatment, diagnosis of a specific
disease and this study I'll actually cover the
insurance reimbursement.
Indirect costs monetary
costs not directly related to a disease
specifically loss of production -- productivity or
the time and cost to get to the your doctor's
appointment.
Intangible costs are the social
emotional and human costs that can't really be
calculated they're not really related to money, it
more that's do with loss of quality of life,
participation in social events and self-esteem, so
to be a child who is deaf and hard of hearing these
are the intangible costs we also have to think
about.
And one caveat, even though I'm looking at
insurance reimbursement, I'm looking at just what
is being billed and paid to the provider, I'm not
specifically looking at how much the technology
itself costs because that's a whole other cost in
itself.
So my key findings are I'm finding
that babies even in an in-patient setting right
after they're delivered are receiving multiple
hearing screenings, not just one screening that
they're actually they ever referred for additional
rescreening, they're receiving multiple hearing
screenings in then and out patient setting there's
a higher reimbursement for privilege insurance
versus Medicaid even though according to CMS4% of
babies are paid by Medicaid.
There's a higher
reimbursement for an inpatient cell set knowledge
an outpatient setting.
So I did a retrospective analysis of
2014 data from the commercial encounters database
both includes inpatient and outpatient services
specifically the commercial cram claims encounters
database contains claims from self insured
employers and 30 different health plans.
The
Medicaid multistate database is not inclusive of
all the state in the United States it has just
pulled claims from 11 geographically pulled states
and Truven does not provide where they are.
The advantage of using an
administrative database is it's already been
collected, you only have to extract and clean the
data for your purposes.
It definitely provides
historical information and allows time series to
be built up, say for example sense lime okay looking
at babies being screened right after delivery, I
can follow them through the outpatient records and
see how many additional screenings they had,
another slang of using an administrative dataset
it's a large sample sized and it definitely has the
complete episodes of care at every single point.
The limitations is it is a large
convenience sample like process I will large
employer data so it doesn't include small firms
they are not letted in the data.
Also, it's not
a random sample so you're to have some biases and
so issues in trying generalize them to other
populations but despite the limitations it does
compliment other data and in this trader can be used
as a benchmark in determining what the cost
reimburse S. for newborn hearing screening so
looking at the commercial claims data which I
actually started out with babies under a year old
it was were 229,000 enrollees that I liked at.
Next, I looked at newborn DRGs so we're talking
about just babies right who have a specific
diagnostic related groups and codes that I actually
used are in the back of your handout.
Then I looked at hearing screening
current procedure technology codes and what unique
about this is in the different hospitals, they're
using codes that are not just newborn hearing
screening they're also coding them for screening
codes that are done during a well-child checkup so
I had to do both in order to capture all of them.
Then next I looked at those had it hat
an unique ID because if they were missing an ID I
couldn't follow them through to the outpatient and
then in doing that I then matched them up with their
delivery codes to kind of estimate an age of when
the screening was done and that gave me the coast
information of the inpatient sample.
Now the cost information Truven
health actually to see what variables that I used
specifically, page which is defined on your handout
which describes the total amount they can bill
someone for that specific purpose and I looked at
net payment, which is the amount received by the
provider after you exclude out of packet costs and
their coordination and benefits.
Truven data does include into
negative costs and the outpatient data they do
adjust it, however, in the inpatient specific
service file they don't.
So what I did was I summed
it up by enroll re, and if there were negative
numbers I dropped they and I removed any 0 payments
or net payments because that basically indicated
it was a bundled service, they weren't being
charged separately for the newborn screening and
then I included any payments net payments that were
over $1, it didn't make any sense to include those
that were like in the cents.
So after getting my inpatient claims
data I then looked at the outpatient babies.
And
then I matched the enrollee IDs with the inpatient
and outpatient data and then I limited it to those
that actually had a hearing screening performed,
and then I wanted to make sure that that hearing
screening was done within 89 days.
I set it at 89
days because we want them have a full evaluation
by 90 days, there were several babies in -- 90 days
that were in the 6-month range that I didn't
include.
And then yet again, I always looked
at that and determined the specific costs.
So
here's a descriptor table of the enrollees that I
did include, so I started out with 50,591 enrollees
that's the babies that were in the inpatient
admissions that have a newborn screening code.
And on average, they had 1.23 claims per -- that
to the ranged anywhere from 1 to 15 claims and this
is with hearing claims.
So as I said earlier there were some
adjustments made because sometimes they were coded
more than once but they had anywhere from 1 to 15.
95% of those inpatient enrollees had at least one
claim.
is.
So anything 95% had a weird number before
It was equally distributed between male and
female babies and the mean age of screening was
about 1.58 days but it ranged anywhere in the
inpatient setting from 0 days to 167 days.
95% were done in a day.
Looking at
the outpatient data and linking the inpatients with
outpatient there were only 148 babies I found, they
had about -- 148 babies and their claims averaged
between 1 to 5 and equal distribution of male and
female.
On average they were screened about 25
days and it ranged from 0 to 89.
So here are the
different costs that you found specifically to the
reimbursements.
So for the commercial claims
inpatient, they were allotted a charge of on
average $183.50.
And the outpatient setting, it
was about $150.67.
Now when you're comparing the
payment and net payment, the difference between
those two amounts is actually what their out of
pocket cost is or their discount cost.
So out of
the total amount that was billed to the employer,
$169.28 was paid by the insurance, and the
inpatient setting and $136 was paid in the
outpatient setting.
Again, working with the Medicaid
data I went through the same sequence looking at
those under a year old had a newborn DRG, had a
hearing screening, a procedure technology code,
looked at those that had unique ID numbers had
specific delivery codes and when I was looking at
the delivery codes I limited to those with the
normal deliveries I did not include people are me,
so a low birth way and again, I looked at the cost
enumeration after doing that I then at the medicate
state patient, matched the enrollee IDs to
determine how many had a hearing screening and then
look the add how many had it done within 89 days
and the cost information99999 there.
There were
131,000 babies in the Medicaid patient file and
they had a little higher average at the 1.56 and
95% had their -- 95 perfected had one to two claims,
equal distribution of fail and employee mail and
the screening age was similar to the
inpatient -- the commercial claims data and that
1.63 days when they were screened.
Looking at the
outpatient file, I was able to match up 429 babies.
We had similar number of claims.
distribution.
longer.
And gender
But the screening age was a lot
The mean here was 41 days versus 25.
Which is kind of interesting considering I had sat
the limit to be 89 days but they were in the higher
part.
About 95% fell between 25 and 6 days of
having their newborn screening done and when you
look at the Medicaid average cost reimbursement as
you can tell the reimbursements are extremely a lot
lower than the commercial claims, it's about a
third, so for the inpatient setting, the total
amount that they could charge was on average was
$60, the total amount for the outpatient setting
what 37 Dollars.
And the net payment or the
difference between the payment and what was
actually paid by the insurance company, well,
Medicaid in this case, was $1.50, what was
interesting for the net payment is there were some
adjustments made because what you will see is the
outpatient net payment is actually more than what
was the mean for the outpatient payment which is
the total number of charges we can compare all the
inpatient cost reimbursements keen commercial
claims and Medicaid as you can tell it's definitely
a third of how much they can charge.
And with net
payments it's very similar as well.
And the said kind of follows for the
outpatient well, in a commercial claims data they
charged on average $150 versus in the Medicaid
outpatient payment it was $37.
So private
reimbursement is definitely a lot greater than
Medicaid, the results definitely show that.
The
percent paid by the primary insurer and the
inpatient setting for commercial claims was
approximately 92%, so out of $183.50, $169 was paid
by their insurance company, and Medicaid covered
most of the costs, it was almost 98% covered by
Medicaid.
And for the outpatient setting about
90% of the commercial claims was paid by the
insurer, and in Medicaid, there was a weird
adjustment there, check the numbers several
different times not quite sure why the net payment
was higher than the payment.
And there was another paper that was
published in 2006 where it was also using Truven
data but it was using treatment pathways they found
that there was greater reimbursement for
outpatient versus inpatient and here I found the
latter.
The study was of course 10 years ago it
was 2004 data versus me using 2014 data and they
didn't look at Medicaid and another interesting
thing is they didn't take out the bundled service,
they included the 0 cost so think I think notice
a major reason why the reimbursement rates are a
lot lower than they should be.
So the strength of the study is that
it definitely determined the average reimbursement
for newborn hearing screening it's the first one
to compare reimbursement between private and
Medicaid, as I said previously, we've only looked
at private insurance claims we have not looked at
Medicaid and the amount Medicaid pays for 40% of
babies being delivered, it's the first study look
at newborn screening, the actual newborn screening
process at an individual level.
Because a lot of
the data that's reported is at an aggregate level,
here because I have specific babies that I have
identified in the inpatient claims data I can
follow them in the outpatient data.
Some
limitations, this is samples populated from
commercially insured populations and it primarily
represents large self insured employers
concentrated in the south and north value that
regions it does not represent all Medicaid
enrollees across the U.S. and it represents 11
geographically states, and we know it can vary it's
really hard to compare them in because they vary
from state to state.
So my next steps are with the
commercial claims data I actually do geographic
information so I can look at regional differences
and reimbursement and screening.
My next steps
with this data is actually to use these claims and
look at how well they're adhering to the 1-3-6 plan.
How many screen -- how many screens are occurring,
how many rescreens are occurring.
What's the
average age of diagnosis?
Because I know that they
go through multiple screenings, we can actually
determine when they got a diagnosis and perhaps
when an audiological early intervention occurred.
And then look at the average age of the audiological
and early intervention.
And these my references.
And I'd
like to thank John Eichwald, Winnie Chung, Scott
Grosse, Marcus Gaffney, Lijing Ouyang, Steven
Richardson, and Eric Cahill.
Anybody have any
questions?
>> PARTICIPANT:
(Off mic.) is this
the identified data you're looking at?
Do you
actually have names and ->> QUYNH:
It's completely
identified, what's unique in how we use the data
we actually for date of birth, because I'm looking
at ICD9 codes in conjunction with delivery codes
I can kind of estimate the age based on when the
service date of their delivery is and that's how
I estimated identified the age.
>> PARTICIPANT:
>> QUYNH:
(Off mic.)
Correct.
Because it's
completely de-identified all you know is birth
year, so technically, you just ever could to just
a birth co-record if I was just looking at babies
say over 6 months of age and I wasn't looking at
specifically following those that were delivered
in an in-patient setting and followed them to the
outpatient setting then yeah.
It would be
different.
>> PARTICIPANT:
>> QUYNH:
questions.
Thank you.
No problem, any other
In the back?
>> PARTICIPANT:
>> QUYNH:
Right.
>> PARTICIPANT:
>> QUYNH:
question.
(Off mic.)
(Off mic.)
I'm going to repeat the
It would be interesting to look at the
reimbursement by provider type, correct,
especially in the outpatient setting.
And that is
actually on my next steps, the hardest part was just
getting to the cohort and following these babies
from inpatient to outpatient.
To give you an idea
my original sample was in the millions and I was
looking at babies it was about 200,000 and then when
I go down to those that actually were specifically
separately billed for hearing screening I only had
50,000.
So it's like 10% of the larger sample
because a lot of labor and delivery charges, labor
and screening falls under bundled payments and so
when they're not billed separately we don't know
how much it actually costs.
And given that babies
can receive many different screenings over time,
that does add up.
Any other questions?
But what I've included in your
handout, I went over a couple of definitions with
the items much costs, what the different codes
were, because I used four different codes and the
actual codes that I used in determining the EHDI
costs are actually on the back page.
Yes?
>> PARTICIPANT:
>> QUYNH:
(Off mic.)
Yes, so I'm going to
repeat the question, so you said when I was doing
the cost analysis did I look at by DRG or by CBT
code, yes, I did.
Looking at the CPT codes in the
back, the two top ones are usually the
primarily -- are appear I will used for newborn
hearing screening the three latter are usually used
in an outpatient setting but for some reason, some
hospital records include them so to make sure that
they actually fell under the infant health check
I make sure that to the also had the combination
of the IDG9 code in that and it was a very small
percentage probably about 90% was covered by the
top two CPT codes and then an additional maybe 10%
depending on which dataset you're looking at was
followed under the three additional codes.
>> PARTICIPANT:
>> QUYNH:
(Off mic.)
Sure.
>> PARTICIPANT:
(Off mic.)
>> PARTICIPANT:
Did you look at the
pavement variance between those two codes you
mentioned.
>> QUYNH:
look at.
No, I have not but that's
I timed it so we had time for questions.
>> PARTICIPANT:
The providers were
they physicians, audiologists, what type of a
provider.
>> QUYNH:
type and it varied.
I did look by provider
It actually included all, so
if I was -- in my additional analysis, I'll look
at specific provider types, because it will be
interesting to see what the distribution would be.
All right.
If you have any other questions, here's
my contact information.
And I'll be at the front
if you have any other questions.
[Applause]