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Medicare Claims Analysis with HSI

Top Ten Medicare Claims Myths

Myth #1: Medicare claims analysis is a mainframe-only analysis.

CMS Fact: The entire Medicare claims database for one year is stored on approximately 2,000 data tapes. While the Centers for Medicare and Mediciad Services (CMS) never release a 100% sample of their data, they will provide a 5% sample of the claims for under $5,000. The problem is that CMS WILL ONLY - with rate exception - PROVIDE THE DATA ON MAINFRAME TAPE OR CARTRIDGE.

HSI Fact: We offer a service to convert a year of 5% sample to Medicare Claims History File to DVD for approximately $3,500 to $7,000 depending upon the value-added elements of the database the analyses would like to see included. This means that for under $15,000 (including cost of purchasing source data from DVD), an analyst can have complete access to the largest claims database in the world, including the cost of the computer to complete the analysis (from beginning to end). Sometimes, the cost be under $10,000 depending upon the needs of the analyst. Please read on for the additional value-added services HSI can offer as we tackle the Myths of Medicare claims data analysis.

HSI Fact: We've made the cost Medicare claims analysis at least 10% of what it has been. There are two big costs to using Medicare claims data: loading the data and cleaning/preparing it for analysis. Even if you have access to a mainframe, the task of loading and preparing in excess of 80 tapes per year for a year is time-consuming task. Since HSI staff know the structure of Medicare claims, we can easily generate a core set of analytic files from mainframes tapes using our 3480 and 3490E tape readers. We also save you significant programmer/analyst labor costs by 'cleaning' the data of unwanted data elements for analysis. Finally, the databases we produce from CMS data are on PC-based media CD-ROM, DVD.

HSI Fact: We've made Medicare claims analysis as convenient as working with any other relational database. We have developed a common file claims file structure that can be applied to any data using Medicare claims as a template. With this technology we built a episode of care client-server application for use on a stand-alone windows based machine.

CMS Fact:ALL Medicare claims data requests must be approved by CMS. Over the last few years, CMS has significantly increased the security of its data systems to prevent the release of "individually identifiable information". To acquire Medicare claims data you must request it through the Office of Healthcare Information at CMS. In your request, you must provide a research protocol defending how your analysis will provide a public health benefit. HSI staff have contacted CMS personnel regarding this process and help stream-line the application process by acting as the agent for the organization requesting data. After successfully navigating through CMS's data proposal review process. we would then pre-process the claims data and provide analytic files under the terms outlined in CMS's data release agreement to be signed by HSI staff and any prospective client.

Painful HSI Fact: In 1996, we made a formal request to CMS allow purchase of the Medicare 5% claims file to HSI for re-packing as a commercial HSI product. Our plan was to market an analysis ready version of the 5% sample at roughly half the CMS purchase price on a multi-volume DVD set designed to be used by SAS and relational database packages. We and another inquiring organization were turned down by CMS early this year on account of heightened security procedures and CMS's desire to review every use of line-item Medicare claims data. HSI will continue to engage CMS in a discussion on the best method to promote ease of use of the data and safeguard the inappropriate release of individually identifiable information.

HSI Fact: Other organizations, such as HSI, can be approved by CMS to act as custodians of the data to create databases and perform analyses by signing the data release agreement between CMS and the organization that purchased the data from CMS. All organizations using CMS data must return the data following the completion of an analysis and NOT use in for any other analysis that was not approved by CMS (See Myth #9).

HSI Fact: From the Medicare National Claims History file, one can purchase:

• Part B physician and outpatient claims
• Part B institutional records
• Part A institutional records
• Skilled nursing facility claims
• Home health service claims
• Hospice claims

The total cost of the 5% sample for a year is currently running at about $5,000 to $9,000.

CMS Fact: To date, CMS has not established a web based client-server system to allow access to Medicare claims data from the WWW. Based on our experience with the Web and Medicare claims, we believe this technology is possible, provided CMS either runs or contracts out a subscription service to potential analysts.

CMS Fact: CMS is especially not fond of organizations that use Medicare claims for purposes other than those approved when the data was provided. CMS clearly states that any new use of the data must by cleared through another review of research protocol. HSI seeks to operate under the rules laid out by CMS and would work with an organization to modify their original data approval from CMS as necessary if the purchase of Medicare claims was facilitated through HSI.

HSI Fact:We've worked with both, so we should know. While the data elements are similar, there are significant disparities between Medicaid and Medicare claims because of each state's 'custom' Medicaid claims database. Suffice it to say that CMS is working or developing a standard database for more recent years that can be applied as easily as the Medicare National Claims File for analysis. The one key advantage of Medicaid claims data over Medicare claims is the inclusion of pharmacy claims. The one clear disadvantage of Medicaid data (other than a lack of uniformity) over Medicare data is that a person may spend only a few months out of year in the Medicaid program and not provide adequate information for research and analysis purposes. Because of the design of the program, Medicare beneficiaries generally provide continuous information unless they just entered or left the program due to age, death or entry into a managed care plan.