An Introduction to Medicare Claims
Public Use Files (PUFs): Part I
Samuel “Chris” Haffer, Ph.D., Centers for Medicare & Medicaid Services
Craig Coelen, Ph.D., IMPAQ International, LLC
Claudia González Martínez, Ph.D., IMPAQ International, LLC
Sergio Prada, Ph.D., IMPAQ International, LLC
Geena Kim, Ph.D., IMPAQ International, LLC
Betty Tao Fout, Ph.D., IMPAQ International, LLC
July 12, 2011
Welcome
Erin Holve, PhD
Director
AcademyHealth
AcademyHealth
Improving Health and Health Care
As the professional society for health
services researchers and health policy
analysts, our mission is three-fold:
1.
2.
3.
Support the development of health
services research
Facilitate the use of the best
available research and information
Assist health policy and practice
leaders in addressing major health
challenges
We work to both “push” the production
of research and promote the “pull” by
decision makers
CMS and IMPAQ International



Centers for Medicare and Medicaid Services (CMS) administers
Medicare, Medicaid, and the Children's Health Insurance
Program. It provides information for health professionals,
regional governments, and consumers. http://www.cms.gov/
IMPAQ specializes in providing research and consulting
services to domestic and international clients in the areas of
impact evaluation studies, applied research, policy analysis,
quantitative and qualitative data analysis, and technical
assistance. http://www.impaqint.com/
CMS contracted IMPAQ for the CER PUF Pilot Project.
Series Learning Objectives
The objectives of this series are to:
 Provide an overview of the Public Use Files (PUFs)
 Offer analytic examples to highlight potential uses
 Discuss privacy and confidentiality issues that are
important to understanding the opportunities and
challenges of PUFs
Learning Objectives
Part one of the series provides an overview of the CMS
CER Public Use Data Pilot Project to create Medicare
Claims PUFs. The focus of this session is to:
 Provide an overview of the project
 Describe the methodology to produce the public
datasets
 Present the Inpatient, Outpatient, DME, and SNF
PUFs; and
 Provide analytic utility examples for this set of PUFs
Faculty
Samuel “Chris” Haffer,
Ph.D.
Program Manager
Centers for Medicare and
Medicaid Services
Faculty
Craig Coelen, Ph.D.
President
IMPAQ International, LLC.
Faculty
Claudia González Martínez,
Ph.D.
Research Associate
IMPAQ International, LLC.
Faculty
Sergio Prada, Ph.D.
Research Associate
IMPAQ International, LLC.
Faculty
Geena Kim, Ph.D.
Research Associate
IMPAQ International, LLC.
Faculty
Betty Tao Fout, Ph.D.
Research Associate
IMPAQ International, LLC.
An Introduction to Medicare Claims Public Use Files (PUFs) Session 1
Samuel C. “Chris” Haffer, Ph.D.
Data Development & Services Group
Center for Strategic Planning - CMS
Baltimore, Maryland
What is Medicare?
Medicare is health insurance for the following: People 65 or older
People under 65 with certain disabilities
People of any age with End‐Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)
14
What are the Parts of Medicare?
Medicare Part A (Hospital Insurance)
Part A is hospital insurance that helps cover inpatient care in hospitals, skilled nursing facility, hospice, and home health care. Medicare Part B (Medical Insurance)
Part B helps cover medically‐necessary services like doctors' services, outpatient care, home health services, and other medical services. Part B also covers some preventive services. Medicare Advantage (Part C)
A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. Medicare Prescription Drug Coverage (Part D)
Medicare prescription drug coverage is insurance run by an insurance company or other private company approved by Medicare. 15
Sources of Medicare Data
 Enrollment & Entitlement
 FFS
Part A [Hospital Insurance] – Claims, CAHPS
Part B [Medical Insurance] – Claims, CAHPS
 Medicare Managed Care
Part C [Medicare Advantage] – HEDIS, HOS, CAHPS, Risk
Part D [Prescription Drug Plans] – Claims, CAHPS
 Provider Characteristics
16
Context for PUF Project




CMS Data are a National Resource
Access has been limited
Transparency/Open Government
Innovation: CER, Data Entrepreneurs,
Information Intermediaries
Pilot Project Goals
While strictly protecting beneficiary
confidentiality….
Increase access to CMS claims data through
the creation of de-identified data sets and a
public access solution…
While strictly protecting beneficiary
confidentiality!!!!
Team
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IMPAQ International
National Opinion Research Center Buccaneer Computer Systems & Service, Inc.
New Wave Telecom & Technologies, Inc.
George Washington University
Drinker, Biddle & Reath, LLP
Expert Consultants: Beth Virnig, Marshall McBean
Announcing…
20
Webinar Series

Session 1: TODAY
 Describe the methodology to produce the public datasets;
 Present the Inpatient, SNF, Outpatient, and DME PUFs; and
 Provide analytic utility examples for this set of PUFs

Session 2: Tuesday, July 26, 2011 1:00 p.m.-2:30 p.m. (EDT)
 Present the Part D Events, Carrier, Hospice, and Home
Health PUFs

Session 3: Tuesday, August 9, 2011 1:00 p.m.-2:30 p.m. (EDT)
 Process and the lessons learned from trying to create an
"enhanced" PUF;
 Need for alterative access mechanisms for confidential data that
maintain data security and confidentiality, while increasing data
utility; and
 Proposed Data Enclave Pilot Study
We want you!!
•Download and Explore
•Offer Constructive
Feedback
•Encourage Others
•Use as a Teaching Resource
Comparative Effectiveness Research (CER)
Public Use File (PUF) Pilot Project
Methodology to produce BSA PUFs
Craig Coelen, PhD
President
23
Basic Stand Alone (BSA) PUFs
One Basic Stand Alone PUF for each type of care
Available for download at http://www.cms.gov/BSAPUFS/
24
Privacy vs Utility
BSA PUFs aim to achieve a balance between
analytic utility
privacy protection
25
BSA PUFs are…


De‐identified (both beneficiaries and providers)
Tested rigorously to assure confidentiality
Certified by expert statisticians to comply with HIPAA Privacy Rule
26
BSA PUF Source Data

Disjoint 5% sample of Medicare beneficiaries for each PUF defined by type of care from 2008 Beneficiary Summary File

2.4 million Medicare beneficiaries for each PUF

All claims for the sample of beneficiaries selected
27
BSA PUF Content and Structure
28
BSA PUFs Creation Steps
1.
2.
3.
4.
5.
6.
Choice of fields to be included in each PUF with priority given to clinical information such as diagnosis and procedures
De‐identification Creation of candidate PUF
Re‐identification testing and statistical certification
Preparation of documentation, codebook, etc.
Dissemination
29
De-identification of BSA PUFs
1.
2.
3.
4.
5.
Use Disjoint Samples
Choose unit that will be records in the table
(Beneficiaries vs visits/stays vs procedures)
Choose and prioritize data fields (variables)
Coarsen data (e.g., age in 5‐year intervals)
Suppress (drop) records that are extremely rare
30
Dissemination of BSA PUFs
Available at http://www.cms.gov/BSAPUFS/
31
How to get the data?
32
Medicare Claims Data Developer Challenge
The Challenge: Create an online analysis tool that will feature two or more of these new BSA PUFs
Prizes:
$10,000 in cash prizes and passes to
Health 2.0 Conference in SF
Judges:
Todd Park, CTO, HHS
Anthony Rodgers, Director, CMS
Barbara Frank, Director, ResDAC
Craig Coelen, President, IMPAQ
Daniel Gaylin, Executive VP, NORC
Join the challenge and get recognition by key government decision makers and peers
33
Inpatient BSA PUF
Total Medicare expenditures from 2008 PUFs
Claudia Gonzalez
Claudia Gonzalez Martinez, PhD
Martinez, PhD
Research
Research Associate
Associate
cmartinez@impaqint.com
cmartinez@impaqint.com
34
What are Inpatient Services?
 Medically‐necessary services for patients admitted to a hospital
Institutional providers such as critical access hospitals, inpatient rehabilitation facilities, and long‐term care hospitals
 At least one overnight stay, and a doctor must formally admit the patient with an order

35
What Inpatient Coverage is provided by
Medicare?
 Inpatient services covered by Part A Most beneficiaries do not pay a premium if they paid Medicare taxes while working for at least 40 quarters
 Beneficiaries pay a deductible.  A coinsurance is required after 60 days of an illness encounter

36
What data were used to build the Inpatient
PUF?


5% disjoint sample of 2008 Medicare beneficiaries (2.4 M).
All inpatient claims incurred by beneficiaries selected
37
What is an inpatient claim?
 Inpatient (IP) Claims data


Each record is a claim
Information contained in each claim:
• Demographic information.
• Diagnosis, (ICD‐9‐CM diagnosis)
• Procedure (ICD‐9‐CM procedure code)
• Diagnosis Related Group (DRG)
• Dates of service
• Reimbursement amount
• Provider
38
What does an inpatient claim look like?
A hypothetical example…
The highlighted variables are taken from the beneficiary summary file, while the remaining variables are found in the inpatient claims file.
39
What does the final IP Claims PUF look like?
40
How was the Inpatient PUF built?
From IP claims file to IP claims PUF
41
Were any claims excluded or suppressed?


6,332 claims were excluded initially because of negative payment amounts or unknown diagnosis information
52,869 claims were suppressed from the PUF to protect the identities of beneficiaries
42
How did suppression affect the data?
Claims are distributed similarly despite suppression
43
What Information is Available Regarding
Suppression Rates?
Documentation provides suppression rates ranges by Base DRG
code and ICD 9 primary procedure codes
Base DRG codes with suppression rates of less than 10% comprise 74.7% of the Initial 5% file.
 ICD 9 Procedure codes with suppression rates of less than 10% comprise 69.5% of the Initial 5% file
44

WHAT TYPE OF ANALYSIS CAN BE DONE WITH THE INPATIENT PUF?
Analytic Utility of the Inpatient PUF
45
Which are the most common DRGs in
the Inpatient Medicare Population?
46
What is the distribution of Inpatient
claims by Age and Gender?
47
Do male or female beneficiaries have
more individual inpatient claims?
48
Two websites we would like you to visit…
 Online Inpatient claims PUF
Dashboard:
http://public.tableausoftware.com/views/BSAPUFS/InpatientSummary
 Medicare Claims data
developer challenge:
http://www.health2challenge.org/2011/06/01/medicare‐claims‐data/
49
Skilled Nursing Facility BSA PUF
Total Medicare expenditures from 2008 PUFs
Sergio Prada, PhD
Sergio Prada, PhD
Research
Research Associate
Associate
sprada@impaqint.com
sprada@impaqint.com
50
What is the Skilled Nursing Facility (SNF)
Benefit?
 Post-acute care
 Available after a qualifying
hospital stay
 Skilled care

Intravenous injections
Physical therapy

Up to 100 days

Copayment required after
first 20 days

51
Medicare Coverage of SNF
 For more details on
coverage and eligibility
visit
 www.cms.gov/SNFPPS/
 www.medicare.gov
52
What data were used to build the PUF?
5% sample of Medicare beneficiaries with at least one
month of Part A or Part B coverage in 2008
53
What data were used to build the PUF?

31,300 beneficiaries were excluded

Aprox 6,500 because denied claims
 Aprox 24,800 because HMO coverage or partial enrollment

6,080 beneficiaries were suppressed to protect the
identities of beneficiaries.
54
Types of care in SNF Claims
(HIPPS Codes)
55
Distribution of SNF Days by Type of
Care
90% of covered days are Rehabilitation or Rehab + Extensive Services (Out of 2.6 million covered days in PUF)
56
What does the final SNF PUF look like?
57
From claims to PUF
Hypothetical example: Claims for a 82 years old male beneficiary
1st Admission
2nd Admission
Claim Claim From CLM ID Admission Date
Date
Claim Thru Date HIPPS Code Days Count
Payment Amount
XXZ8P
31‐Aug‐08 RUC05
11
4127.09
14‐Nov‐08 RUX01
12
4610.38
21‐Aug‐08 21‐Aug‐08
WLAP3
3‐Nov‐08
3‐Nov‐08
Beneficiary level record in PUF
ID
SEX
AGE
Male 80‐84
Covered Admissions
Covered days Rehabilitation
Two or more
9 to 20 days
Cov Days Rehab + Extensive Services
1 to 20 days
Payment Amount
9,000
58
WHAT TYPE OF ANALYSIS CAN BE DONE WITH THE SNF PUF?
Analytic Utility of the Skilled Nursing Facility PUF
59
Is there a demographic group that accounts
for a large share of SNF Medicare Payments?
60
Do average SNF payments differ by
demographic group?
61
Outpatient BSA PUF
Total Medicare expenditures from 2008 PUFs
Geena Kim, PhD
Geena Kim, PhD
Research
Research Associate
Associate
gkim@impaqint.com
gkim@impaqint.com
62
What Outpatient Coverage is provided
by Medicare?
Institutional outpatient providers
•Hospital outpatient departments, Rural health clinics, Renal dialysis facilities, Outpatient rehabilitation facilities, Comprehensive outpatient rehabilitation facilities, Community mental health centers
Outpatient services covered by Part B
•Beneficiaries pay premium, deductible and copayment
63
What are Outpatient Services?
 Some preventive services 



Mammograms
Cardiovascular Screening
Colon Cancer Screening
Flu Shots  Medically‐necessary services
 Emergency department services
 Outpatient surgery
 Lab tests
64
What data were used to build the
Outpatient PUF?


5% sample of Medicare beneficiaries with at least one month of Part A or Part B coverage in 2008
All outpatient claims incurred by the beneficiaries chosen 65
What does Outpatient Claims File look like?
Outpatient (OP) Claims Data File

Each record is a claim
 Diagnosis Code
• Multiple (up to 10) ICD-9-CM diagnosis codes per claim, with the first
designated as the Primary Diagnosis

Procedures
• Healthcare Common Procedure Coding System (HCPCS) code is
used to report procedures.
• Multiple procedures (up to 450) per claim

Payment
• Medicare claim payment
• Medicare payment per procedure

Count of services is reported per procedure
66
How was the Outpatient PUF built?
From OP Claims to OP Procedures PUF
Outpatient Claims File – Claim level file
PUF ID
Claim ID
Bene1 Claim1
Bene1 Claim2
Primary ICD‐9‐CM diagnosis code
2395
496
HCPCS code on the 1st
procedure
36415
71020
Count of Services on the 1st
procedure
1
1
Medicare Payment on the 1st
procedure
3
32.78
HCPCS code on the 2nd
procedure
84153
Count of Services on the 2nd
procedure
1
Medicare Payment on the 2nd
procedure
29.8
Outpatient Procedures PUF – Procedure level file
Procedure ID
Procedure1
Procedure2
Procedure3
Primary ICD‐9 Diagnosis Code
239
239
496
HCPCS Code
36415
84153
71020
Count of Medicare Payment Services
on Procedure
1
0
1
30
1
30
67
What does the OP Procedures PUF look like?
68
What procedures were excluded or
suppressed?

3,467,153 procedures excluded initially because of invalid HCPCS codes or denied services
File Number of Number of Number of Procedures
Claims
Beneficiaries
Medicare Payments
Initial 5% sample
33,303,358
6,689,521
1,176,616
$1,971,996,200
OP PUF
31,701,499
6,502,007
1,168,574
$1,694,421,310
 1,601,859 procedures suppressed to protect the identities of beneficiaries
69
WHAT TYPE OF ANALYSIS CAN BE DONE WITH THE OUTPATIENT PUF?
Analytic Utility of the Outpatient PUF
70
How much did Medicare pay on average
per beneficiary by gender and age?
71
Which procedures have the highest
average payment per unit of service?
Count of Services
666
68
922
2
26
HCPCS Code
1. 33249 (BETOS classification: Major Procedure, Cardiovascular‐Pacemaker Insertion)
2. 69930 (BETOS classification: Major Procedure – Other)
3. 33240 (BETOS classification: Major Procedure, Cardiovascular‐Pacemaker Insertion)
4. J7311 (Fluocinolone Acetonide, Intravitreal Implant)
5. 27446 (BETOS classification: Major Procedure, Orthopedic ‐ Knee Replacement)
Note: Average Medicare payment per unit of service is calculated by dividing total Medicare payment by total count of services for each HCPCS.
72
What are the procedures associated with
chronic renal failure diagnosis?
Chronic Renal Failure (ICD-9-CM Code 585)
$53.2
$29.3
$0.4
$16.6
HCPCS Code
1. 90999 (BETOS classification: Dialysis services ‐Medicare Fee Schedule)
2. Q4081 (Injection, epoetin alfa,100 units for ESRD on dialysis)
3. A4657 (Syringe, with or without needle, each)
4. J2501 (Injection, paricalcitol, 1 mcg)
73
Durable Medical Equipment BSA PUF
Total Medicare expenditures from 2008 PUFs
Betty Tao Fout, PhD
Betty Tao Fout, PhD
Research
Research Associate
Associate
bfout@impaqint.com
bfout@impaqint.com
74
Durable Medical Equipment (DME)
 Durable medical equipment, prosthetics, orthotics and supplies


Blood glucose monitors, hospital beds, crutches, wheelchairs, home oxygen equipment
Back braces, artificial limbs, breast prostheses, ostomy supplies, therapeutic shoes
75
DME Coverage by Medicare
 DME is covered by Part B, so a beneficiary must pay the deductible and 20 percent of DME cost
 DME must be prescribed by medical provider
 Provided by specific suppliers that are approved by Medicare
 DME suppliers are reimbursed though the HCPCS codes
76
Data Used to Build the DME PUF
 5% sample of Medicare beneficiaries with at least 1 month of Part A or B coverage in 2008

A line item is one item/supply on a DME claim. Each claim can consist of up to 13 line items
77
From DME Claims File to DME Line Items PUF
Medicare DME Claims File
DME Line Items PUF
Medicare’s Beneficiary Summary File
78
Variables in the DME Line Items PUF
79
Exclusions and Suppressions from the DME
Line Items PUF

750,115 line items were suppressed because of missing or invalid HCPCS codes, denied services or the protection of solo practitioners
 292,969 line items were suppressed from the PUF to protect the identities of beneficiaries
80
WHAT TYPE OF ANALYSIS CAN BE DONE WITH THE DME PUF?
Analytic Utility of the Durable Medical Equipment PUF
81
Top HCPCS Codes by Medicare Payment
Total Medicare DME Payments in 2008 (5% Sample)
$431 Million
82
How much does Medicare pay
per HCPCS code?
Quantity
7,156
628,953
346,334
1,950,481
2,821,623
69,559,240
Note: Medicare payment per supply is calculated by dividing total
Medicare payment by quantity (service count) for each HCPCS.
83
Beneficiary-Level Distribution of
Medicare Payment and Line Items
Average Payment Per Beneficiary
Average Number of Line Items Per Beneficiary
Source: DME Line Items BSA PUF and DME General Documentation Tables 4 to 7.
84
Total Medicare Payment for Top HCPCS
Codes Patients Under Age 65
Immunosuppressive drugs
 Medicare covers beneficiaries under 65 with End‐stage renal disease

85
Additional Information and Resources
 Download the files: http://www.cms.gov/BSAPUFS
 Read the Documentation
 Need help? Contact ResDAC


resdac@umn.edu
1-888-9RESDAC
Take the Medicare Claims Challenge
http://www.health2challenge.org/2011/06/01/medicare‐claims‐data/
http://www.health2challenge.org/2011/06/01/medicare‐claims‐data/
86
Thank you!
Next Webinar on July 26 will cover Part D, Carrier, Home Health, and Hospice PUFs
…AND will provide a sneak peak into PUFs
that are currently under development!
87
Resources

AcademyHealth
– www.academyhealth.org/training
• PDF of slides and recommended reading
available with this presentation
• Research Resources: HSRProj, HSRR,
PubMed HSR Search Filters

HSRMethods.org
– www.hsrmethods.org
Methods Updates
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Receive updates on:
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