Estimating nonVA Health Care Costs

1
Estimating non-VA Health Care Costs

• Todd H. Wagner
• Ciaran Phibbs
• Mark W. Smith

2
Who we are
Mark
Todd
Ciaran
3
Learning Objectives

• After this talk, you will
• Understand whether you need non-VA data
• Know the strengths and weaknesses for different
  sources of non-VA data

4
Do you need non-VA data?

• Many veterans have a choice in where they get
  care
• Many veterans who get care from VA facilities
  also get care from non-VA providers (e.g.,
  Medicare, Medicaid)
• Perspective and objectives these should dictate
  your data needs

5
Example

• Any examples of studies that require non-VA data?

6
Sources of non-VA data

• Medicare data
• Fee Basis
• Bills from providers
• Self-report
• All sources have strengths and weaknesses

7
Medicare Data
8
Medicare Data for Veterans

• Medicare is health insurance for people over age
  65 or those with a disability
• VIReC maintains
• Medicare Data for all VA enrollees from 1999
  through 2003
• Note the delay this may be critical for clinical
  trials.

9
Medicare Institutional Claims

• AKA Part A (except outpatient)
• Inpatient (short/long)
• Outpatient (Part B)
• Home Health (Part A B)
• Hospice
• Skilled Nursing Facilities
• One file for each type of claim

10
Medicare Non-Institutional Claims

• AKA Part B
• Physician/supplier file
• Physician, NPs, and other professionals
• Clinical Laboratories
• Ambulance services
• Ambulatory Surgery Centers
• Durable Medical Equipment (DME) file

11
Medicare File Types

• Research Identifiable Files (RIFs)
• Beneficiary Encrypted Files (BEFs)
• Limited Data Set (LDS)
• Downloadable files (PUFs)

12
Charges in Medicare Data

• Charges reflect billed amount.
• Charges Costs.
• Adjust charges using cost-to-charge ratio (CCR).
• Cost to charge ratio is calculated from Medicare
  Hospital Cost Report

13
Medicare Payments

• Payments reflect amount paid by Medicare. This
  reflects
• Co-payments, deductibles, coinsurance
• Benefit limitations
• Wages, disproportionate share, IME
• Direct medical education
• Outlier payment
• Reimbursement Amount DRG Price Outlier
  Payment Individual Payment Other Insurance
  Payment

14
Fee Basis
15
Overview of Fee Basis Program

• Pays for care at non-VA facilities when
• it is the only source available, or
• VA could save money
• Full range of services covered
• Mostly pre-arranged limited emergent care

16
Fee Basis files

• Subset of all VA contract care
• Non-VA PTF has detail on hospital stays some
  overlap with Fee Basis files
• Substantial utilization unaccounted for
• SAS format at Austin

17
Highlights of Financial Data

• Amount claimed
• Amount paid
• often much less than amount claimed
• Many variables relating to FMS record-keeping
  invoice date, processing date, check number,
  check date, cancel code, etc.

18
User Notes

• Each paid invoice has a separate record.
• Invoices may be sent LONG after services are
  rendered
• Search for records in many years

19
Using Fee Basis Files Cautions

• Beware of missing decimal places
• ICD diagnosis codes
• Payment amounts
• Care in community nursing homes, state veterans
  homes, and some non-VA hospitals may also be
  recorded in other files
• e.g., contract nursing home care appears in DSS
  outpatient files

20
Bills from Providers
21
Collecting Billing Data

• With consent, you can attempt to collect hospital
  bills
• We are doing this for a few clinical trials
• Mixed success typically only done for inpatient
  costs

22
Method

• Use self-report to identify utilization
• Ask patient for name of hospital and approximate
  date
• Have patient sign HIPAA release
• Contact hospital for UB92
• Cost adjust the charges reported on the bill

23
Self-Report
24
Limits with Administrative Data

• Obtaining and analyzing claims data can be costly
  and time consuming
• Administrative data can be incomplete or
  inaccurate
• Limited benefits
• Out-of-plan or out-of-pocket utilization
• Capitated health plans

25
What is Self Report?

• Cognitive process of recalling information
• Ample opportunity for distortion and error
  (Khilstrom et. al 2000)
• Self-report not valid when people lack the
  cognitive capabilities

26
Modifiable Components

• Recall timeframe
• Type of utilization
• Utilization frequency
• Questionnaire design
• Mode of data collection

27
Questionnaire Design

• No standards exist
• Pretest Dillman (2000)
• Use counts for responses (not categories)

28
Self-Reported Costs

• Self-reported costs are assumed poor
• Imputing costs from self-reported utilization can
  introduce biases

29
Additional Readings

• Fee Basis Technical Report 18
• Bhandari and Wagner. Self-Reported Utilization of
  Health Care Services Improving Measurement and
  Accuracy (2006, MCRR). Available upon request.

30
Additional Links

• VIReC Manages the VA Medicare Data
• www.virec.research.med.va.gov
• ResDAC (Research Data Assistance Center) for
  Medicare data
• www.resdac.umn.edu
• Medicare and Medicaid
• www.cms.hhs.gov

31
Additional Viewings

• 2005 HERC Courses
• Talk on Medicare Data (Yu)
• Talk on the Fee Basis (Smith)
• http//www.herc.research.med.va.gov/resources/trai
  ning_course_archives.asp

32
Next Health Economics Course

• May 18, 2006
• Effectiveness, Patient Preferences and Utilities
• Patsi Sinnott, PT, PhD, MPH