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RESEARCH DATA ASSISTANCE CENTER (RESDAC) Barbara Frank, MS, MPH October 17, 2011 CMS SAS Day RESDAC The Research Data Assistance Center (ResDAC) is a CMS contractor that provides free assistance to academic, government and non-profit researchers interested in using Medicare and/or Medicaid data for their research. ResDAC is staffed by a epidemiologists, public health specialists, health services researchers, biostatisticians, and health informatics specialists from the University of Minnesota. RESDAC ROLE To help CMS increase the number of researchers skilled in accessing and using CMS databases for studies of the Medicare and Medicaid programs and beneficiaries. To provide education for researchers interested in using and obtaining CMS data for Comparative Effectiveness Research (CER). RESDAC ASSISTANCE ResDAC web site, www.resdac.org - Information specific to CMS data files and data requests What’s new-updates on CMS data release policies Available Data Data Documentation Requesting Data FAQs Workshops/Education Outreach presentations ResDAC Technical Register for assistance RESDAC ASSISTANCE ResDAC web site, www.resdac.org - Tools to support health services research Statistical links Health services links Education – Workshops - Introduction to the Use of Medicare data for Research Conducting Research with Medicaid Claims Data Intro to the Use of Medicare Part D Data for Research Using Medicare Data in Comparative Effectiveness Research (CER) - Using Cost Report Data for Research CONTACTING RESDAC ASSISTANCE DESK Phone - Toll free: 888-9ResDAC (888-973-7322 ) email - [email protected] WEB - www.resdac.org (information) - resdac.oit.umn.edu (request assistance) RESDAC ASSISTANCE ResDAC Assistance Desk functions: - Answer questions regarding Medicare and Medicaid data: data access and availability, record layouts, individual variables, location of Medicare and Medicaid program information, CMS SAS Input Statements - Work with researchers from first inquiry to submission of a complete request to CMS for data - Support ResDAC website - Tour of ResDAC website www.resdac.org AVAILABLE CMS DATA Types of Data for use in Comparative Effectiveness studies 3 Types of CMS Data - Non-Identifiable (Public Use Files) - Limited Data Sets (LDS) - Research Identifiable AVAILABLE CMS DATA Research Identifiable Medicare Utilization and Enrollment Data - Enrollment File – Denominator/Part D Denominator or CCW Beneficiary Summary File - Utilization – Institutional Inpatient Outpatient Skilled Nursing Facilities (SNF) Home Health Agencies Hospice MedPAR – Stay record file containing Inpatient and SNF stays AVAILABLE CMS DATA Medicare Utilization Data - Utilization – Non-Institutional Carrier Durable Medical Equipment (DME) - Utilization – Part D Event Data Available 2006 to current Additional CCW Characteristic Files Drug, Plan, Pharmacy, Provider - Beneficiary Annual Summary File Contains CCW Chronic Condition flags, summary utilization variables, demographic information AVAILABLE CMS DATA Assessment Data - Outcome and Assessment Information Set (OASIS) Available July 1999 to current - Long Term Care Minimum Dataset (MDS) Available 1999 to current - Inpatient Rehab Facility Patient Assessment Instrument (IRF-PAI) Available January 2002 to current Medicaid Utilization & Enrollment (MAX) - Personal Summary , Inpatient, Other Therapy, Long Term Care, and Prescription Drug - Available for all 50 States plus DC AVAILABLE CMS DATA Limited Data Sets Medicare Current Beneficiary Survey (MCBS) - Rolling Panel Survey of approximately 16,000 per year Includes: Aged, Disabled, and Institutionalized Medicare beneficiaries Source of information on socioeconomic and demographic characteristics, health status and functioning, health care use and expenditures, and health insurance coverage. - Access to Care module available 1991 – 2009 With accompanying Part A & B Claims data - Cost and Use module available 1992 – 2008 With accompanying Part A & B Claims data Part D data has been integrated into MCBS CMS DATA TYPE Non-Identifiable Basic Stand-alone Public Use Files Provider of Services File NPI File Physician/Supplier Procedure Summary File Cost Reports Some files are downloadable or low cost GOAL FOR REST OF THIS PRESENTATION Review key data variables in the Medicare administrative data available for Comparative Effectiveness Research BASIC ELEMENTS OF A CE STUDY Basic elements of CER include: - Cohort identification A “treatment” Treatment An outcome Patient demographics Measures of patient comorbidity and severity of illness - Potential observed confounders - Potential unobserved confounders - Methods to deal with confounding/selection bias Demographics Outcome Observed Co-morbid Conditions and Other Observed Potential Confounders Potential Unobserved Confounders COHORT IDENTIFICATION Numerator and Denominator Two general rules are: - all persons in the denominator must be eligible to have events - all persons in the numerator (events) must be eligible to be in the denominator Issues in the Medicare files - HMO Enrollees in Part A/B and D - Part D Enrollment DENOMINATOR INFORMATION A patient ID number – may be HIC - If linking across various types of files be sure how to identify patient across all files and time Date of birth Gender Race/ethnicity Place of residence: state, county and zip code KEY POINTS All demographic information in the Medicare claims data comes from the Enrollment Database (EDB) maintained at CMS Data Center As claims are processed, the demographic information known to CMS overwrites any demographic information in the claim with current information RACE – ONE COLUMN VARIABLE; HISPANIC ETHNICITY NOT ASKED NOR CODED SEPARATELY Originally, race coded as: - white, black, other, unknown Effective 1994, race codes were expanded to: - white, black, Asian, Hispanic, Native American, other, unknown New “RTI Race Code” variable is available in the Part D Denominator/Beneficiary Summary File PERCENTAGE DISTRIBUTION OF MEDICARE ENROLLEES BY RACE, 2008 ORIGINAL RACE CODE 1.86% Asian 1.84% Other 10.12% Black 2.49% Hispanic 0.43% N American Native RTI RACE CODE 0.42% American 7.80% Hispanic Indian/Alaska Native 2.43% Asian/Pl 1.19% Other 9.77% Black 83.11% White 77.64% NonHispanic White SOCIOECONOMIC INFORMATION Denominator - “State buy-in” variable: lumped all Medicare Savings Plan beneficiaries (Medicaid, QMB, SLMB, QDWI, and QI) into one variable New Part D variables - State Reported Dual Eligible Status: indicates which of the Medicare Savings Plans the beneficiary is enrolled in, if any; by month - Low Income Subsidy (LIS) recipient: Premium and/or copayment assistance depending on income and assets; includes persons with higher incomes and/or assets than those in Medicate Savings Plans BASIC ELEMENTS OF A CE STUDY Basic elements of CER include Demographics - A “treatment” βG Treatment Outcome - An outcome - Patient demographics - Measures of patient coObserved Co-morbid Conditions morbidity and Other Observed Potential and severity of illness Confounders - Potential observed confounders Potential Unobserved - Potential unobserved Confounders confounders - Methods to deal with confounding/selection bias ELEMENTS OF CER AND HOW TO FIND THEM IN MEDICARE ADMINISTRATIVE DATA Why all 3 in RED? One researcher’s treatment may be another researcher’s covariate One researcher’s outcome may be another researcher’s covariate So, where do you find this information in the Medicare data files? WHERE TO FIND TREATMENT INFORMATION IN MEDICARE DATA Data file Prescription drug event (PDE) Medications Procedures Devices DRG codes ICD-9 Procedure codes DRG codes ICD-9 Procedure codes Product Service ID MedPAR or Inpatient Carrier HCPCS codes Outpatient hospital APC codes HCPCS codes DME Home health Agency HCPCS codes APC codes HCPCS codes HCPCS codes Revenue Center codes HCPCS codes NDC: National Drug Code HCPCS: Healthcare Common Procedure Coding System APC: Ambulatory Payment Classification MEDICATION INFORMATION Prescription Drug Event (PDE) data file - Product Service ID is the variable that = NDC code Generic name Brand name Strength and Drug dosage form Days supplied NO therapeutic drug class – need help Medi-Span – Master Drug Database First DataBank Multum MEDICATIONS – MAY ALSO BE PAID FOR AS A PART B SERVICE Medicare has paid for specific drugs under Part B - Generally, drugs that are administered in physician or other offices, used as part of infusion devices - Some oral drugs used following organ transplant. - Most (40% in 2001) are oncology drugs Identified by HCPCS codes starting with “J” in DME claims file Drug name Erythropoietin (anemia) Lupron (prostate cancer Ipratropium bromide (Asthma) Zolodex (prostate cancer) Albuterol (Asthma) % of Part B drug costs in 2001 12.1% 10.4% 7.3% 6.8% 5.5% PROCEDURES – IN-PATIENT Procedures performed in hospital are incorporated into an institutional claim that becomes an In-patient file record or MedPAR stay record Identified by ICD-9 Procedure codes - Up to 6 per claim. First listed is the “primary” procedure - Four digits of the form XX.XX with leading zero BACK-UP FOR INDENTIFYING IN-PATIENT PROCEDURES Physician claims in Carrier file Surgeon will submit a clam for the procedure that will appear in the Carrier file with “place of service” = hospital PROCEDURES – “OUTPATIENT” Services provided in an outpatient clinic or in a physician’s office Defined by HCPCS – next slide - (Outpatient and Carrier files) or ICD-9 procedure codes (Outpatient file) When billed by physicians or other “noninstitutional” providers, appear in non-institutional (i.e., Carrier) claims file Also, like an in-patient procedure, a physician claim for work done in an outpatient facility appears in a Carrier file line item with “place of service” = hospital outpatient HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) CODES Appear in Outpatient, Home Health Agency, Carrier (physician claims, ambulatory care center, health departments, etc.) and Durable Medical Equipment (DME) claims files - CMS pays these payment requests (claims or line items) based on the HCPCS code and its modifiers - HIGHEST QUALITY DATA HCPCS: HEALTHCARE PROCEDURE CODING SYSTEM CODES – 3 “LEVELS” Level 1 - 5 position numeric codes – They are CPT (Current Procedural Terminology) codes of American Medical Association - 52630 Transurethral resection of the prostate - 99201 Office or other outpatient visit for the evaluation and management of new patient Level 2 - 5 position alpha-numeric codes; national codes - J0540 Injection, penicillin G benzathine and penicillin G procaine, up to 1,200,000 units Level 3 - 5 position alpha-numeric codes beginning with W, X, Y or Z; local codes OUTCOMES Mortality Hospital-related - hospitalization, re-hospitalization Diagnoses Procedures – see prior slides on locating and describing treatments and procedures and information OUTCOMES - MORTALITY Two important fields in Denominator File/BSF - date of death, and - death date validation field Death dates are missing if the beneficiary is alive and non-missing if they are deceased 100% of DEATHS are validated 96% of death DATES are validated Validated death dates are noted with ‘V’ All files linkable at the beneficiary-level, so can do survival analysis, 30-day, etc. post-admission mortality OUTCOMES - HOSPITAL-RELATED Hospitalization - Yes/no - Principal diagnosis gives the reason for hospitalization Readmission to hospital - Dates of admission and discharge are in MedPAR and In-patient files OUTCOMES - DIAGNOSES All Part A and Part B claims -- ICD-9-CM diagnoses - Institutional claims up to 10 codes - Non-institutional claims up to 8 codes Inpatient, Outpatient and Skilled Nursing Facilities also have admission diagnosis code OUTCOME - COSTS (IF ALLOWED IN CER) Amount reimbursed by Medicare for each service is in each file MEASURES OF CO-MORBIDITY AND OTHER OBSERVED CONFOUNDERS Charlson Co-morbidity Score, as well as other co-morbidity scores Provider-related confounders - High versus low volume hospitals Teaching versus non-teaching hospitals Number of physician visits Treatment by physician specialists WHERE TO FIND PROVIDER-RELATED CONFOUNDERS Teaching hospital - Payment adjustment variable in MedPAR or Inpatient file: Indirect Medical Education Amount Physician specialty - Line CMS Provider Specialty code variable in Carrier file ADDITIONAL INFORMATION ABOUT PROVIDERS Institutional - Provider ID – link to Provider of Services file for additional information Non-institutional - National Provider Identification Number (NPI) link to NPI registry for location of provider and not much else ADDITIONAL INFORMATION ABOUT PROVIDERS Part D PDE File variables - Provider ID/Pharmacy ID/CCW Encrypted Pharmacy ID – link to Pharmacy Characteristics file to obtain additional information about the pharmacy - Prescriber ID/CCW Encrypted Prescriber ID – link to Prescriber Characteristics file to obtain additional information about the prescriber INFORMATION ON OTHER POSSIBLE CONFOUNDERS IN THE BENEFICIARY ANNUAL SUMMARY FILE (BASF) BASF - by calendar year; one record for each beneficiary Number of events and Medicare payments by Standard Analytic File type Information on 21 chronic conditions - Based on algorithms supported by literature During current year of file By July 1 of current year of file First ever date of meeting the criteria in the algorithm OTHER DATA SETS TO CONSIDER SEER-Medicare Linked Data Health & Retirement Survey – Medicare Linked Dataset NCHS Surveys linked with Medicare Data CAHPS and HOS linked with Medicare Data CONTACTING RESDAC ASSISTANCE DESK Phone - Toll free: 888-9ResDAC (888-973-7322 ) email - [email protected] WEB - www.resdac.org (information) - resdac.oit.umn.edu (request assistance)