mili 6990 : using insurance claims data for health market opportunity analysis
DESCRIPTION
MILI 6990 : Using Insurance Claims Data for Health Market Opportunity Analysis. Adrine Chung, MBA and Stephan Dunning, MBA Chronic Disease Research Group, Minneapolis Medical Research Foundation. AKA - Steve called in a favor. Agenda. Our Background and CDRG Introduction to Claims Data - PowerPoint PPT PresentationTRANSCRIPT
MILI 6990: Using Insurance Claims Data for Health
Market Opportunity Analysis
Adrine Chung, MBA and Stephan Dunning, MBAChronic Disease Research Group, Minneapolis
Medical Research Foundation
AKA - Steve called in a favor
AgendaI. Our Background and CDRGII. Introduction to Claims DataIII. Utilization of Claims Data IV. Market OpportunitiesV. MILI Program – Students and Affiliates
I. Background: CDRG Mission
Impacting public policy and clinical careRespected for independence and quality
Multispecialty with a focus on Chronic Diseases
Private non-profit research organization
The Chronic Disease Research Group pursues its commitment to public health by advancing knowledge about chronic disease to improve patient care and outcomes.
I. Background: CDRG Organizational Hierarchy
Hennepin Healthcare System, Inc.: Operating Hennepin County Medical Center in Minneapolis, MN, a nationally recognized academic medical center employing 400+ healthcare providers. The physicians also have faculty appointments at the University of Minnesota.
Minneapolis Medical Research Foundation (MMRF): Private, non-profit research subsidiary of Hennepin Healthcare System, Inc.
Chronic Disease Research Group (CDRG): Operational division within MMRF employing more than 65 staff.
I. Background: CDRG Programs
Scientific Registry of Transplant Recipients
Health Resources and Services Administration
(HRSA) Contract
Analyzes data and simulates for policy
development, creates reports of programs, and
provides data for evaluation of solid organ
transplantation in U.S.
United States Renal Data System
National Institute of Diabetes and Digestive
and Kidney Disease (NIDDK)
Collects, analyzes, and distributes information about end-stage renal disease (ESRD) in the
United States
Chronic Disease Research Group
Various (sponsored, grants, independent)
Public health research in nephrology, cardiology,
oncology, pharmacoepidemiology, and geriatric medicine
I. Background: Knowledge Factory
II. Intro to Claims Data: Overview
• Claims – billable interactions between:• covered patients and the healthcare delivery• health care or service provider and the payer
II. Intro to Claims: EMR vs. Claims
Claims EMR
Scope of Data Information from all doctors/providers caring for a patient
Only the portion of care provided by doctors/providers using the EMR
Scope of Patients Insured only Uninsured and insured
Data Elements Diagnosis, procedures as coded
Lab results, vital signs, free text, habits, problem list
Other Limitations of EMRs – • Lack of standardization – “If you’ve seen one EMR, you’ve seen
one…”• Inconsistent data entry• Single site of patient care
II. Intro to Claims: Source of Claims Data
• Commercial Claims (i.e. United Health, MarketScan)• Medicare
o Limited (LDS) o Research Identifiable (RIF)o USRDS (ESRD)
• Medicaid• Linked Datasets (i.e. SEER-Medicare)
II. Intro to Claims: Commercial vs. Medicare
Feature Medicare CommercialEnrollment Elderly and disabled
(Compulsory at age 65 and ESRD)
Coverage is until death
Traditionally employer based, insurance exchanges emerging (ACA)
Coverage may change with employment (affects follow-up)
Data Elements Medical services, prescription drug, laboratory billing (no results)
Medical services, prescription drug, laboratory billing and results provided through limited contracts with laboratories
Demographic Race, gender, and region well represented. Age is >65 years (unless ESRD)
Limitations to region depending on dataset. Greater range for age (including pediatric)
II. Intro to Claims Data: Medicare
• Part A – hospital care, skilled nursing facility care, nursing home care, hospice, and home health services
• Part B – physician visits, ambulance services, durable medical equipment, mental health, preventative services
• Part D – prescription drug coverage (70%)
II. Intro to Claims: Medicare
HEALTH INSURANCE CLAIM FORM
II. Intro to Claims Data: Coding
• ICD 9 – International Classification of Diseases, Version 9 (diagnoses)• XXX.XX – AMI 410.X, PTCA 00.66• X matters
• CPT 4 – Current Procedural Terminology, Version 4 (procedures) • 5 digits, 0 matters• i.e. PTCA 92982
• NDC - Food and Drug Administration’s Nation Drug Code directory (Drugs) • 10 digit number with 3 segments
II. Intro to Claims: DRGs• Part A Hospital Claims
o ICD-9 and CPT codes associated with the hospitalization episode are processed through “grouping” algorithms to result in a single Diagnosis Related Group (DRG) for payment from CMS.
o The position of codes matters for payment. That is, not all diagnosis and procedure code are created equal.
II. Intro to Claims: ICD 9 to ICD 10
ICD-9 (Procedure Codes)
ICD-10-PCS (Procedure Codes)
Number of Characters 3-4 Numeric 7 Alphanumeric
Number of Codes ~4,000 ~90,000
Example of mapping: “PTCA of two coronary arteries, with insertion of two coronary stents”
00.66 (PTCA), 00.41 (Procedure on two vessels), 00.46 (insertion of two vascular stents), 36.06 (insertion of non-drug-eluting coronary artery stents)
02713DZ (dilation of coronary artery, two sites using intraluminal device, percutaneous approach)
II. Intro to Claims: Health Data Representation
II. Intro to Claims: Strengths and Limitations
Strengths Limitations
• Clinical validity – information about covered services
• Demographic information (if available)
• Population Coverage (different strengths for different datasets)
• Cost effective in comparison to chart reviews or clinical trials
• Underdiagnosed diseases (diabetes, depression, hypertension)
• Incomprehensive disease and severity information
• Incidence vs. prevalence• Limited clinical information• Limit to reimbursed services• Limit to number of codes reported
• Primary source of all clinical insight but codes are at times“ questionable accuracy, completeness, meaningfulness and clinical scope”
• “…codes are not meant to tell stories, rather to generate reimbursement…”
(Iezzoni 2002:348)
II. Intro to Claims: Access to Data
• Medicare & Medicaid:o Research Data Assistance Center (ResDAC)o Aggregate-level data through private research groups that
use CMS with approval (i.e. CDRG and University of Minnesota)
o Direct for federally funded contractso Data lag: 9 months for Part A/Part B and 15 for Part D
• Commercially-insured claims data:o OptumInsights, MarketScan, Medco, PharMetricso Data updated quarterly
III. Utilization of Claims Data• Market Research• Quality Improvement- QIP• Fraud Detection• Drug Safety Signal Detection (FDA Sentinel)• Post-market Safety and Surveillance• Health Economics and Outcome Research (CDRG’s Core)
o Comparative Effectiveness• Clinical• Economic• Value
o Clinical Trial Supplement
III. Utilization of Claims DataPopulation Monitoring• Political, administrative, demographic populations (state based, dual eligible, VA)• Disease monitoring (incidence, prevalence, and medical expenditures)
Adjusted incident rates of ESRD per million population, 2010, by HSA
Source: 2012 USRDS Annual Data Report: Figure 1.3 (Volume 2)
Source: 2012 USRDS Annual Data Report, Figure 11.5 (Volume 2)
III. Utilization of Claims DataTotal Medicare dollars spent on ESRD, by type of service
Prevalence of Recognized Bone Metastases in the US Adult Population
Methods: o All available claims from 2004-2008 were studied in 2 point-prevalent cohorts with
insurance coverage on Dec 31, 2008: • 1) persons aged 18-64 years enrolled in commercial plans (MarketScan) and • 2) persons aged ≥65 years enrolled in traditional Medicare (Medicare 5% sample).
o Presence of BM was defined by 1 inpatient or 2 outpatient claims in any 1-year interval with a diagnosis of BM or 1 claim for zoledronic acid or pamidronate with a qualifying diagnosis for cancer.
o BM prevalence was extrapolated to the national commercially insured population aged 18-64 years and to the traditional Medicare population aged ≥65 years.
o Applying age/sex-specific rates to the 2008 US census population, we estimated BM prevalence in the US adult population overall and for select cancers.
Li et al, presented a the American Society of Clinical Oncology, 2009
III. Utilization of Claims
• In the commercially insured and Medicare cohorts, we identified 9,502 (in 18.2 million) and 6,427 (in 1.3 million) BM cases, respectively.
• We estimated there were 279,679 US adults with recognized BM on Dec 31, 2008. Estimates by cancer type are shown in the table [N (95% CI), in thousands].
Li et al, presented a the American Society of Clinical Oncology, 2009
Female breast Prostate Lung Multiple
Myeloma Other All cancers
Commercially insured
25.6 (24.7, 26.4)
4.8 (4.4, 5.1)
7.8 (7.3, 8.2)
10.8 (10.3, 11.4)
11.5 (10.9, 12.0)
60.4 (59.1, 61.7)
Medicare 35.4 (33.8, 37.0)
36.3 (34.6, 37.9)
15.7 (14.6, 16.8)
22.5 (21.2, 23.8)
18.6 (17.5, 19.8)
128.5 (125.5, 131.6)
US adults 89.8 (87.0, 92.6)
61.1 (58.6, 63.7)
34.8 (33.0, 36.6)
49.2 (47.1, 51.4)
44.7 (42.7, 46.7)
279.7 (274.6, 284.8)
Results
III. Utilization of ClaimsLong-Term Survival and Repeat Revascularization in US Dialysis
Patients after Surgical versus Percutaneous Coronary Intervention (ASN Renal Week 2009)
Methods• Searched United States Renal Data System claims database to
identify 4,351 dialysis pts having coronary artery bypass surgery,(CAB), bare metal stents (BMS), or drug-eluting stents (DES) in 2005.
• Outcomes of Long-term event-free survival for all-cause mortality, repeat revascularization (CAB or PCI), and the combined event of death or repeat revascularization was estimated by Kaplan-Meier method.
Results: Event Free Survival (%)
Month1
Month 6
Month 12
Month 240
102030405060708090
100
All Cause Mortality
CABDESBMSAxis Title
Month1
Month 6
Month 12
Month 240
102030405060708090
100
Repeat Revasc.
CABDESBMSAxis Title
Month1
Month 6
Month 12
Month 240
102030405060708090
100
Death/Repeat Revasc
CABDESBMSAxis Title
Herzog et al, presented at the American Society of Nephrology, 2009.
Conclusion: Data suggest that DES provide the best first year survival in dialysis pts, but CAB patients have better un-adjusted long-term survival and lower risk of repeat coronary revascularization.
Zzzzzz?!
III. Utilization of Claims DataBenchmarking• Quality of care: ESRD Quality Incentive Program (QIP),
Hospital Readmission Penalty• Performance measurement: State-specific, Agency-specific,
Facility-specific measures (Transplant Program-specific Reports, Dialysis Facility Compare, etc)
• Accountable Care Organization – performance monitoring and payment/penalty system
Evaluating Policy• CBO, GAO – Cost assessment of ESRD Bundle
o Differing findings on including Oral Drugs in Bundle
IV. Market Opportunities• Data Linkages:
o US Censuso Cancer Registries (SEER)o Other Providers (VA, Medicaid)o National death index/vital statisticso Surveys (MCBS, NHANES, Health and Retirement Study)o Provider Informationo EHRo Clinical Trial Data
IV. Market Opportunities• Business Opportunities with Claims:
• Users: o Insurance/Payerso Providerso Pharma/Device/Biotecho Policy-makerso Quality
User/Purpose Project Type
Marketing Market sizing, medical service process or flow, sales estimates
Finance Revenue projections, baseline opportunity
Regulatory Safety monitoring, risk assessment
V. MILI Students and Affiliates
• MILISA• MILI Specialization• MILI Affiliates/Alumni• MILI Valuation Lab
Tying It Together: MILI DC Field Trip
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