Building the Data Infrastructure to Improve Health Care for Dual Eligibles: The Role of Health Reform and a New Comparative Effectiveness Research Initiative Rosaly Correa-de-Araujo, MD, MSc, PhD Deputy Director Office on Disability/Office of the Secretary U.S. Department of Health and Human Services 2010 SNP Alliance Annual Meeting Washington, D.C., October 28, 2010

Dual Eligibles 9 million, costly segment of beneficiaries for both Medicare and Medicaid ($250M/year) Most severely disabling: chronic physical and/or mental, multiple co-morbidities Co-morbidity common, more likely in older duals Service use high, Medicare & Medicaid care coordination challenging Per capita spending of Medicare and Medicaid higher w/ multiple chronic conditions (mental/cognitive) With multiple co-morbidity, more heavily reliance on Medicare for hospital services and Medicaid for LTSS Source: KFF Report, July 2010

Dual Eligibles Challenge Poor understanding on how spending distributes across both Medicare and Medicaid Poor Coordination Increased cost Decreased quality Challenge Program incentives encourage avoiding cost rather than coordinating care.

Policy Implications Coordination of both Medicare and Medicaid funding is a major problem in access to and delivery of quality care for duals eligibles. Nevertheless, both Medicare and Medicaid programs contribute to meeting the needs for acute and supportive services for this population.

Policy Implications Opportunities under Health Reform Reauthorization of Medicare Special Needs Plans (SNPs) through 2013 Expanded Medicaid HCBS New Medical Home Grant Program CMS Federal Coordinated Health Care Office CMS Centers for Innovation Section 4302 – Health Disparities and Disability Standards for Data Collection

Special Needs Plans (SNPs) Valuable partnership w/ State Medicaid Full array of Medicare, Medicaid, supplemental benefits in a single plan Diverse population, opportunity for high-quality person-centered care Accountable integrated care organizations: cost control improved outcomes and enhanced quality of life data gathering and sharing implementation site for models of care development and implementation of quality indicators

FY 2011 - Person Centered Health Research American Recovery and Reinvestment Act Comparative Effectiveness Research $7 million (May FY2010-2012) FY 2011 - Person Centered Health Research CORE ACTIVITIES Identify and review existent evidence Build a data warehouse Establish criteria and standards Develop and prioritize research questions Disseminate findings

Person-Centered Care Providers’ Experience Clinical , Functional Status & Circumstances Scientific Evidence Persons with Disabilities Preferences Providers’ Experience Providers’ Experience

Disability Data Infrastructure Federal costs with programs - $226 billion/year Data inconsistent, program specific, no accurate analysis Who and how many are benefiting? To what extent people draw on multiple programs? What specific services are provided and to whom? How effective are they? What are the outcomes? Are there state variations over time? How are services integrated?

CMS-ResDAC Medicare Data Research Identifiable Files (RIFs) Part D Denominator Files Standard Analytical Files (SAFs) Denominator Files Part D drug Event (PDE) Files Medicare Provider Analysis & Review Files (MedPAR) Research identifiable files allow a state to match Medicare and Medicaid utilization data for individual dual eligible beneficiaries to get a full picture of the services that a particular person may have used over a period of time. Specific identifiers are also available such as date of birth, age, race, sex, residence information. Because these identifiers are regulated by federal laws, rules, and regulations, research identifiable files can be difficult to access. Research identifiable files can serve as rich sources of information on Medicare utilization and costs for dual eligibles. However, states should be aware that these data do not include claims paid by sources other than fee-for-service Medicare. As a result, dual eligibles receiving care through managed care organizations (e.g., Medicare Advantage) and actual Part D claims information are not included in these files. Beneficiary Annual Summary Files (BASF) Chronic Conditions Summary Files

CMS-ResDAC Medicare Data Limited Dataset LDS MEDPAR Files LDS Standard Analytical Files (SAF) LDS Denominator Files The limited data set files also contain individual-level health information, but exclude the specific identifiers found in the research identifiables files. However, LDS data are still considered identifiable data sets even though specific identifiers are not included. The limited datasets are much easier to obtain but a number of variables (e.g., age, service dates, zip codes, etc) are either encrypted, grouped into ranges, or left blank, making it difficult to use for individual-level analysis.

Linking Medicare to Medicaid Data to Improve Dual Eligibles Care Beneficiaries ID number Unduplication of services Utilization & cost analysis: Medicare Claims to Medicaid crossover data Medicare only information Medicaid only information Medicare & Medicaid service use & costs Future Outcomes data?

Disability Data Infrastructure The Center of Excellence will: Work with CMS Chronic Conditions Warehouse database Identify and link existing sources of disability related datasets Medicare Current Beneficiary Survey (MCBS) and Medicare’s National Claims History File Examining screening and preventive services , satisfaction with care, access to care and out-of-pocket expenditures according to ability to perform routine daily activities for people with Disabilities

CMS CCW Upcoming Upgrades 100% of Medicare claims data back to 1999 Medicaid data for dual eligible beneficiaries back to 1999 Cause of death from death certificates back to 1999 Provider characteristics data Medicare risk scores Census track information to help estimate income Gooding data to address access issues More chronic conditions flags Enhanced race codes Enhanced analytical capabilities Enhanced ability to extract data by diagnoses and procedures

Final Thoughts on CER – Center of Excellence Plenty of opportunities to increase data availability to support health services research – effectiveness & CER studies Better understanding of access to, quality, effectiveness of care Conduct research that will tell us what treatments, intervention, and models of care work best. SNPs as great setting to study care coordination. Collection, sharing, merging, integration of Medicare and Medicaid data to support better coordination Identify, implement quality indicators that better reflect HCBS, care coordination, and measure what is important for dual eligibles Not a short-term effort, long-term partnerships among Federal, State, and private sector.

THANK YOU! Rosaly.correa@hhs.gov (202) 205-1104 http://www.hhs.gov/disabilityresearch/index.html Rosaly.correa@hhs.gov (202) 205-1104 THANK YOU!