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. CMS ResDAC is staffed by a epidemiologists, public health specialists, health services researchers, biostatisticians, and health informatics specialists from the University of Minnesota.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, -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, -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 ( )   WEB - (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

AVAILABLE CMS DATA  3 Types of CMS Data -Non-Identifiable (Public Use Files) -Limited Data Sets (LDS) -Research Identifiable Types of Data for use in Comparative Effectiveness studies

AVAILABLE CMS DATA  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 Research Identifiable

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  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 – 2009Access to Care  With accompanying Part A & B Claims data -Cost and Use module available 1992 – 2008Cost and Use  With accompanying Part A & B Claims data  Part D data has been integrated into MCBS Limited Data Sets

CMS DATA TYPE  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 Non-Identifiable

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” -An outcome -Patient demographics -Measures of patient co- morbidity and severity of illness -Potential observed confounders -Potential unobserved confounders -Methods to deal with confounding/selection bias Outcome Potential Unobserved Confounders Observed Co-morbid Conditions and Other Observed Potential Confounders Demographics Treatment

COHORT IDENTIFICATION  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 Numerator and Denominator

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 RTI RACE CODE

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 -A “treatment” -An outcome -Patient demographics -Measures of patient co- morbidity and severity of illness -Potential observed confounders -Potential unobserved confounders -Methods to deal with confounding/selection bias Outcome Treatment Potential Unobserved Confounders Observed Co-morbid Conditions and Other Observed Potential Confounders Demographics βGβG

ELEMENTS OF CER AND HOW TO FIND THEM IN MEDICARE ADMINISTRATIVE DATA  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? Why all 3 in RED?

WHERE TO FIND TREATMENT INFORMATION IN MEDICARE DATA NDC: National Drug Code HCPCS: Healthcare Common Procedure Coding System APC: Ambulatory Payment Classification Data fileMedicationsProceduresDevices Prescription drug event (PDE) Product Service ID MedPAR or Inpatient DRG codes ICD-9 Procedure codes DRG codes ICD-9 Procedure codes CarrierHCPCS codes Outpatient hospitalAPC codes HCPCS codes APC codes HCPCS codes DMEHCPCS codes Home health Agency Revenue Center codes HCPCS codes

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% of Part B drug costs in 2001 Erythropoietin (anemia) 12.1% Lupron (prostate cancer 10.4% Ipratropium bromide (Asthma) 7.3% Zolodex (prostate cancer) 6.8% Albuterol (Asthma) 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  Surgeon will submit a clam for the procedure that will appear in the Carrier file with “place of service” = hospital Physician claims in Carrier file

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 “non- institutional” 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 position numeric codes – They are CPT (Current Procedural Terminology) codes of American Medical Association Transurethral resection of the prostate Office or other outpatient visit for the evaluation and management of new patient  Level position alpha-numeric codes; national codes -J0540 Injection, penicillin G benzathine and penicillin G procaine, up to 1,200,000 units  Level 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  Amount reimbursed by Medicare for each service is in each file (IF ALLOWED IN CER)

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 In- patient 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 ( )   WEB - (information) -resdac.oit.umn.edu (request assistance)