Medicaid Analytic eXtract (MAX) Karyn Kai Anderson, Ph.D., M.P.H. Social Science Research Analyst Office of Research, Development and Information (ORDI)

What is MAX? Person-level data on… Medicaid Eligibility & Beneficiary Demographics Medicaid Eligibility & Beneficiary Demographics Medicaid Service Utilization Medicaid Service Utilization Medicaid Payment Information Medicaid Payment Information

Who uses MAX? CMS Employees across different components CMS Employees across different components Other Federal agencies Other Federal agencies ASPE, HRSA, AHRQ, NCI, CBO, CRS, Census and Others ASPE, HRSA, AHRQ, NCI, CBO, CRS, Census and Others State agencies State agencies Academics Academics Consultants/Contractors Consultants/Contractors

What for? MAX was created for analytic purposes Research Research Evaluation Evaluation Epidemiology Epidemiology Statistics Statistics Forecasting Forecasting Actuarial analysis Actuarial analysis Policy analysis Policy analysis Disparities in health care Disparities in health care Developing quality indicators Developing quality indicators Modeling/simulation for drug policy Modeling/simulation for drug policy

Where does MAX come from? MMIS MSIS (7 calendar quarters) MSIS (7 calendar quarters) MAX (1 Calendar Year) From States to CMSO From CMSO to ORDI

How, then, is MAX different? Transformed to Calendar Year Transformed to Calendar Year For every service rendered, for every beneficiary, MAX combines ALL claims (initial, interim & actual) voids & adjustments resulting in… For every service rendered, for every beneficiary, MAX combines ALL claims (initial, interim & actual) voids & adjustments resulting in…  “FINAL ACTION EVENT”  “FINAL ACTION EVENT”

History of Medicaid Person-Level Data Medicaid Tape-to-Tape Project Medicaid Tape-to-Tape Project 1980 to early 1990s 1980 to early 1990s Five states Five states Prototype for later data collection Prototype for later data collection Medicaid Statistical Information System (MSIS) Medicaid Statistical Information System (MSIS) From 1987 to 1998 From 1987 to 1998 Voluntary participation by states (5-38 states) Voluntary participation by states (5-38 states)  State Medicaid Research Files (SMRFs)  State Medicaid Research Files (SMRFs) Beginning in 1999 Beginning in 1999 Mandatory participation for all 50 states + D.C. Mandatory participation for all 50 states + D.C.  Medicaid Analytic eXtract (MAX)  Medicaid Analytic eXtract (MAX)

MAX Data Sets 1 Person Summary File (PS) 1 Person Summary File (PS) Eligibility (annual and monthly) and demographics Eligibility (annual and monthly) and demographics Managed care enrollment Managed care enrollment Summary of utilization and Medicaid payment by type of service Summary of utilization and Medicaid payment by type of service 4 Claims Files 4 Claims Files Inpatient hospital (IP) Inpatient hospital (IP) Long-term care (LT) Long-term care (LT) Prescription drug (RX) Prescription drug (RX) Other Services (OT) Other Services (OT) Claims for Claims for Fee-for-service Fee-for-service Prepaid managed care (premium payments only) Prepaid managed care (premium payments only)

Why Do We Need MAX? Eligibility Eligibility Improved identification of unique enrollees Improved identification of unique enrollees Retroactive eligibility in proper chronology Retroactive eligibility in proper chronology Eligibility codes – verified and improved Eligibility codes – verified and improved Eligibility data added to each claim Eligibility data added to each claim Services (Claims) Services (Claims) Final action events (interim claims combined) Final action events (interim claims combined) Organized by dates of service (vs. date of adjudication) Organized by dates of service (vs. date of adjudication) Type of service – verified and regrouped Type of service – verified and regrouped

Medicaid Data Enhancements: Eligibility More detail on Medicaid eligibility More detail on Medicaid eligibility Dual eligibility (Medicare and Medicaid) status Dual eligibility (Medicare and Medicaid) status Qualified Medicare Beneficiaries (QMBs) Qualified Medicare Beneficiaries (QMBs) Specified Low-Income Medicare Beneficiaries (SLMBs) Specified Low-Income Medicare Beneficiaries (SLMBs) Other Other Medicare HIC number Medicare HIC number Medicaid case number Medicaid case number Enrollment in prepaid managed care Enrollment in prepaid managed care Other program eligibility Other program eligibility TANF TANF SCHIP SCHIP

Medicaid Data Enhancements: Services Data on conditions and treatments Data on conditions and treatments ICD-9-CM Diagnosis codes ICD-9-CM Diagnosis codes Procedure codes Procedure codes National Drug Codes (NDCs) National Drug Codes (NDCs) Improved coding for services Improved coding for services Waivers Waivers Cost center data for hospitals Cost center data for hospitals Additional types of service Additional types of service DME and supplies DME and supplies Adult day care Adult day care Other Other Maternal Delivery Indicator Maternal Delivery Indicator

Special MAX Enhancements: Data Linkages Link to Medicare Enrollment Data Base (EDB) Link to Medicare Enrollment Data Base (EDB) Best way to identify dual eligibles Best way to identify dual eligibles Begin and end dates of Medicare eligibility Begin and end dates of Medicare eligibility Other Medicare data (e.g. primary language, date of death) Other Medicare data (e.g. primary language, date of death) Link to First Data Bank (FDB) Data Link to First Data Bank (FDB) Data Prescription drugs Prescription drugs Link on National Drug Code (NDC) Link on National Drug Code (NDC) Therapeutic classes (clinical use) Therapeutic classes (clinical use) Other FDB data (e.g. generic, OTC or prescribed drug) Other FDB data (e.g. generic, OTC or prescribed drug) Infinite Capability for other linkages (e.g. SSA) Infinite Capability for other linkages (e.g. SSA) Social Security Number (SSN) Social Security Number (SSN)

Challenges in Developing Consistent Medicaid Data Medicaid differences… Medicaid differences… Across states (program eligibility and benefits) Across states (program eligibility and benefits) Over time (program eligibility and benefits) Over time (program eligibility and benefits) When Fiscal Agents change (data) When Fiscal Agents change (data) Eligibility Eligibility Review and edit state mapping of state-specific codes Review and edit state mapping of state-specific codes Type of service Type of service Review and edit state mapping of state-specific codes Review and edit state mapping of state-specific codes Add new types of service Add new types of service Create “final action events” Create “final action events” (e.g. stays, visits, etc.) (e.g. stays, visits, etc.)

Who has access? MAX is protected under Privacy Act MAX is protected under Privacy Act Relevant HIPAA regulations apply Relevant HIPAA regulations apply Research protocols must be reviewed Research protocols must be reviewed A Data Use Agreement (DUA) must be filed A Data Use Agreement (DUA) must be filed A CMS processing fee may apply A CMS processing fee may apply

What data are available? Available now Available now MAX All states and D.C. MAX All states and D.C. SMRF – states full data SMRF – states full data SMRF – 5 states, data quality? SMRF – 5 states, data quality? Future availability Future availability 2004 – All states and D.C. – Late – All states and D.C. – Late – All states and D.C. – Mid – All states and D.C. – Mid 2008

MAX Data Limitations Eligibility Eligibility Minimal information on other insurance coverage Minimal information on other insurance coverage No beneficiary name or address No beneficiary name or address Other data unavailable (e.g. income, other programs) Other data unavailable (e.g. income, other programs) Eligibility “Churning” Eligibility “Churning” Services Services Only during spells of eligibility Only during spells of eligibility Only Medicaid-covered services (coverage varies by state) Only Medicaid-covered services (coverage varies by state) Incomplete for duals (residual after Medicare payment) Incomplete for duals (residual after Medicare payment) Incomplete for persons in prepaid plans Incomplete for persons in prepaid plans

Medicaid Data Limitations Payments Payments Missing some payments Missing some payments Aggregate adjustments Aggregate adjustments End-of-year settlements End-of-year settlements Disproportionate Share Hospital (DSH) Disproportionate Share Hospital (DSH) Incomplete for third-party payments Incomplete for third-party payments Drug payment amounts are prior to rebates Drug payment amounts are prior to rebates Completeness Completeness Timeliness Timeliness No provider characteristics No provider characteristics

Strengths: MAX has: All Medicaid fee-for-service (FFS) claims information for all individuals with 1+ Medicaid claim in a given year All Medicaid fee-for-service (FFS) claims information for all individuals with 1+ Medicaid claim in a given year Weaknesses: MAX does not have: Complete service information on Medicaid enrollees enrolled in Medicaid managed care or pre-paid plans Complete service information on Medicaid enrollees enrolled in Medicaid managed care or pre-paid plans Any claims information that is non-Medicaid (private health insurance, VA, other state/federal programs, third party payments, etc.) Any claims information that is non-Medicaid (private health insurance, VA, other state/federal programs, third party payments, etc.) Therefore, MAX provides a complete picture of Medicaid FFS service utilization, but it can be an incomplete picture of total service utilization. Strengths & Weaknesses of MAX

MAX… On the Web The MAX web address is: The MAX web address is: XGeneralInformation.asp#TopOfPage XGeneralInformation.asp#TopOfPage or in Google, just type: CMS MAX DATA or in Google, just type: CMS MAX DATA The web address for detailed MAX prescription drug data is: The web address for detailed MAX prescription drug data is: caidPharmacy.asp#TopOfPage caidPharmacy.asp#TopOfPage

MAX… On the Web General Information General Information Data Dictionaries Data Dictionaries General information General information Better descriptions of data elements Better descriptions of data elements Improved source information Improved source information Addition of user notes Addition of user notes Data Element Lists Data Element Lists Data Validation Reports Data Validation Reports Data Anomaly Reports Data Anomaly Reports Valid data, but unexpected results (e.g. broken time series, new covered service) Valid data, but unexpected results (e.g. broken time series, new covered service) Data inconsistencies (can’t be fix) Data inconsistencies (can’t be fix) SAS Load Statements SAS Load Statements

Thanks to Dave Baugh… “the Grandaddy of MAX” “the Grandaddy of MAX” … for all his hard work in creating MAX over the years and for preparing the majority of these slides!