The accuracy of medicare claims data in identifying Alzheimer's disease

We linked Medicare claims data to information on 417 patients with a clinical diagnosis of Alzheimer's disease in the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) to determine what proportion of them were identified as having Alzheimer's disease (AD) in Medicare claims records. Seventy-nine percent of these patients were identified as having AD using 5 years of claims data; 87% were identified as demented when a broader set of ICD-9-CM codes was used. An Anderson-Gill counting process approach was used to model the "hazard" of patients being identified as having AD in Medicare claims data. CERAD patients with mild dementia were less likely to be identified in the claims data as having AD. Once identified in Medicare claims as having AD, patients were more likely to be so identified again. When using only the physician supplier and institutional outpatient files, approximately 75% of CERAD patients were identified as having AD; hospital files used alone identified less than one-third (29%) of the CERAD patients as having AD. The data indicate that at least 3 consecutive years of physician supplier and physician outpatient claim files should be used to identify Medicare beneficiaries with AD using Medicare claims.     

Impact of influenza immunization on medical expenditures among Medicare elderly, 1999-2003

BACKGROUND: The impact of influenza immunization on expenditures for inpatient, outpatient, and professional services among elderly Medicare beneficiaries between 1999 and 2003 was examined. METHODS: Data were from independent annual survey samples of 175,000 beneficiaries. Response rates ranged from 64% to 71%. Survey data included beneficiaries' demographics, education, supplemental insurance, perceived health, and influenza vaccination. Baseline measures, derived from Medicare claims for the year prior to influenza season, included service utilization, comorbidities, influenza immunization, and health status. The outcome measure was medical expenditures for acute and chronic respiratory conditions (ACRCs) for each 33-week annual influenza season. RESULTS: Total expenditures for ACRCs were lower among the immunized population during all four seasons. The amount and statistical significance of the savings varied with the severity of the virus and the vaccine match to the prevalent influenza strains. During the 1999-2000 influenza season, which had the most severe virus and a close vaccine match, average costs for ACRCs were $88 lower among immunized beneficiaries than among nonimmunized beneficiaries (equivalent to a 3.06% savings). During the 2002-2003 season, which had a less severe virus but the highest vaccine match rate, average costs for ACRCs were $103 lower for immunized beneficiaries than for nonvaccinated beneficiaries (equivalent to a 3.12% savings). The relative reduction in ACRC expenditures among vaccinated beneficiaries is attributable to less frequent use of inpatient services. CONCLUSIONS: In addition to improving the health of older Americans, meeting the Healthy People 2010 influenza immunization goal of 90% among the elderly should also result in lower Medicare expenditures.     

The importance of coding

Medicare is very serious about claims being correctly coded. For those physicians participating with Medicare, claims will be denied if the ICD-9-CM code is not submitted with all the necessary digits. For those physicians who are non-participating physicians with Medicare, they will first be notified if ICD-9-CM codes are not coded to the greatest level of specificity. After notification, if codes still lack the required digits for specificity, the physician can be fined up to $2,000 per incorrect code.     

Medical expenditures during the last year of life: findings from the 1992-1996 Medicare current beneficiary survey

OBJECTIVE: To compare medical expenditures for the elderly (65 years old) over the last year of life with those for nonterminal years. DATA SOURCE: From the 1992-1996 Medicare Current Beneficiary Survey (MCBS) data from about ten thousand elderly persons each year. STUDY DESIGN: Medical expenditures for the last year of life and nonterminal years by source of payment and type of care were estimated using robust covariance linear model approaches applied to MCBS data. DATA COLLECTION: The MCBS is a panel survey of a complex weighted multilevel random sample of Medicare beneficiaries. A structured questionnaire is administered at four-month intervals to collect all medical costs by payer and service. Medicare costs are validated by claims records. PRINCIPAL FINDINGS: From 1992 to 1996, mean annual medical expenditures (1996 dollars) for persons aged 65 and older were $37,581 during the last year of life versus $7,365 for nonterminal years. Mean total last-year-of-life expenditures did not differ greatly by age at death. However, non-Medicare last-year-of-life expenditures were higher and Medicare last-year-of-life expenditures were lower for those dying at older ages. Last-year-of-life expenses constituted 22 percent of all medical, 26 percent of Medicare, 18 percent of all non-Medicare expenditures, and 25 percent of Medicaid expenditures. CONCLUSIONS: While health services delivered near the end of life will continue to consume large portions of medical dollars, the portion paid by non-Medicare sources will likely rise as the population ages. Policies promoting improved allocation of resources for end-of-life care may not affect non-Medicare expenditures, which disproportionately support chronic and custodial care.     

The Composition of Home Health Care Expenditure Growth

During the period 1980 to 1985, growth in the number of persons served by Medicare home health was the largest source of growth in Medicare home health expenditures. Population growth was in part responsible for the increase in beneficiaries using Medicare home health, but more important was growth in the number of persons served per 1000 elderly population. Cost per person served increased only moderately once input price changes are accounted for. Nevertheless, we recommend that cost-containment efforts focus on cost per visit and per case, because restrictions on persons served are likely to limit Medicare beneficiaries' access to needed, covered care.     

Beneficiary selection, use, and charges in two Medicare capitation demonstrations.

Findings with regard to health status, service use, and charges are presented for Medicare beneficiaries who received care under Medicare risk contracts with two health maintenance organizations from 1980 through 1982 and for fee-for-service comparison groups. Health status of plan enrollees and fee-for-service beneficiaries were compared using mortality data, preenrollment claims, and self-reported health measures. Patterns of use and expenditures during preenrollment and postenrollment periods were examined using Medicare records and data supplied by the plans.     

The composition of home health care expenditure growth.

During the period 1980 to 1985, growth in the number of persons served by Medicare home health was the largest source of growth in Medicare home health expenditures. Population growth was in part responsible for the increase in beneficiaries using Medicare home health, but more important was growth in the number of persons served per 1000 elderly population. Cost per person served increased only moderately once input price changes are accounted for. Nevertheless, we recommend that cost-containment efforts focus on cost per visit and per case, because restrictions on persons served are likely to limit Medicare beneficiaries' access to needed, covered care.     

Medical expenditures for major diseases, 1995

This article distributes the Health Care Financing Administration's (HCFA) estimates of 1995 personal health care expenditures (PHCE) according to sex, age, and diagnosis for each type of health care service. Aggregate and per capita expenditures are reported for 18 broad categories of disease classified according to the International Classification of Diseases (ICD-9-CM). Special emphasis is given to expenditures for persons age 65 or over, the segment of the population with the highest expenditures. These results show how the relative importance of medical conditions and type of health services differs between the sexes and changes with increasing age.     

National and state trends in enrollment and spending for dual eligibles under age 65 in Medicaid managed care

BackgroundTo reduce costs and improve care, states are increasingly enrolling individuals with disabilities in Medicaid managed care. Many states allow or require adults who are dually eligible for Medicaid and Medicare to enroll in these plans.ObjectiveThis study (1) quantifies changes in enrollment by managed care arrangement for duals under age 65, between 2005 and 2008 and (2) compares enrollment and spending between dual eligibles and Medicaid-only beneficiaries.MethodsWe used Medicaid Analytic eXtract data to compare the Medicaid enrollment and spending for all-year, full-benefit dual eligibles ages 21–64 with that of Medicaid-only Supplemental Security Income (SSI) and disabled beneficiaries. The study population was classified into 9 types of managed care to quantify enrollment and calculate expenditures by year.ResultsNationwide, the proportion of adult duals in managed care increased from 2005 to 2008, with the expansion of prepaid health plans (PHPs) (31.0%–46.6%), particularly behavioral health PHPs, driving the increase. In 2008, Medicaid-only disabled adults were three times as likely as dual adults to enroll in comprehensive managed care (CMC) (35.1% versus 11.7%). Average Medicaid expenditures per enrollee differed markedly by managed care arrangement and state.ConclusionsFrom 2005 to 2008, there was little expansion of CMC among adult duals, while the use of PHPs to cover carved out services increased greatly. New federal initiatives aim to reduce barriers to enrolling duals into comprehensive, integrated managed care. With expanded enrollment, it will be important to monitor enrollment and evaluate whether integration improves care.     

The costs of decedents in the Medicare program: implications for payments to Medicare + Choice plans

OBJECTIVE: To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life-a group that accounts for more than one-quarter of Medicare's annual expenditures. DATA SOURCE: Medicare administrative claims for 1994 and 1995. STUDY DESIGN: We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters. DATA EXTRACTION METHODS: The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors. PRINCIPAL FINDINGS: Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments. CONCLUSIONS: More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries.     

Long-Term Trends in Medicare Payments in the Last Year of Life

Objective. To update research on Medicare payments in the last year of life. Data Sources. Continuous Medicare History Sample, containing annual summaries of claims data on a 5 percent sample from 1978 to 2006. Study Design. Analyses were based on elderly beneficiaries in fee for service. For each year, Medicare payments were assigned either to decedents (persons in their last year) or to survivors (all others). Results. The share of Medicare payments going to persons in their last year of life declined slightly from 28.3 percent in 1978 to 25.1 percent in 2006. After adjustment for age, sex, and death rates, there was no significant trend. Conclusions. Despite changes in the delivery of medical care over the last generation, the share of Medicare expenditures going to beneficiaries in their last year has not changed substantially.     

Failure of ICD-9-CM codes to identify patients with comorbid chronic kidney disease in diabetes

OBJECTIVE: To determine prevalence of chronic kidney disease (CKD) in patients with diabetes, and accuracy of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify such patients. DATA SOURCES/STUDY SETTING: Secondary data from 1999 to 2000. We linked all inpatient and outpatient administrative and clinical records of U.S. veterans with diabetes dually enrolled in Medicare and the Veterans Administration (VA) health care systems. STUDY DESIGN: We used a cross-sectional, observational design to determine the sensitivity and specificity of renal-related ICD-9-CM diagnosis codes in identifying individuals with chronic kidney disease. DATA COLLECTION/EXTRACTION METHODS: We estimated glomerular filtration rate (eGFR) from serum creatinine and defined CKD as Stage 3, 4, or 5 CKD by eGFR criterion according to the Kidney Disease Outcomes Quality Initiative guidelines. Renal-related ICD-9-CM codes were grouped by algorithm. PRINCIPAL FINDINGS: Prevalence of CKD was 31.6 percent in the veteran sample with diabetes. Depending on the detail of the algorithm, only 20.2 to 42.4 percent of individuals with CKD received a renal-related diagnosis code in either VA or Medicare records over 1 year. Specificity of renal codes for CKD ranged from 93.2 to 99.4 percent. Patients hospitalized in VA facilities were slightly more likely to be correctly coded for CKD than patients hospitalized in facilities reimbursed by Medicare (OR 5.4 versus 4.1, p=.0330) CONCLUSIONS: CKD is a common comorbidity for patients with diabetes in the VA system. Diagnosis codes in administrative records from Medicare and VA systems are insensitive, but specific markers for patients with CKD.     

Identifying types of nursing facility stays using medicare claims data: an algorithm and validation

Nursing facilities provide skilled nursing and rehabilitative care to patients for short stays and custodial care to patients for long stays. The type of nursing facility stay (short- or long-term) is a potentially important risk factor and health outcome in health services research and is informative from both medical and fiscal perspectives. The purpose of this study was to develop and validate an algorithm to identify the use of nursing facility services and differentiate short- from long-term care using Medicare claims data. We used claims data for a 5% sample of Medicare beneficiaries to develop an algorithm to detect the use of nursing facility services and to distinguish between short- and long-term stays. We tested this algorithm using residency status from Medicaid long-term care claims for dually eligible beneficiaries and using residency status from the Medicare Current Beneficiary Survey (MCBS). Among 1,694,051 beneficiaries included in the baseline cohort, 25.6% had some indication of nursing facility residency. Using our algorithm, 59.8% of beneficiaries using any nursing facility care were classified as long-term residents. Validation of the algorithm against Medicaid long-term care claims and MCBS yielded high sensitivity and specificity. To our knowledge, this is the first paper to present a validated algorithm for identification of use of nursing facility services among Medicare beneficiaries that differentiates between short- and long-term care residency status.     

Identifying comorbidities in home health care patients: does the Outcome and Assessment Information Set have incremental value to Medicare claims data?

We compare the proportion of patients presenting with comorbid conditions among fee-for-service Medicare beneficiaries with heart failure obtained by using (a) home health care claims data, (b) data from the Medicare Provider Analysis and Review (MedPAR), and (c) the Outcome and Assessment Information Set (OASIS), using a unique database developed by linking the records of Medicare administrative data and the OASIS. Data from the MedPAR yielded a higher proportion of patients with comorbid conditions compared to the OASIS or home health care claims data (77%, 51%, and 51%, respectively), leading us to conclude that non-home health care claims data must be used for risk adjustment in studies involving home health care patients.     

Racial differences in health care use among medicare only and dual eligibles

It has been an important financial issue in the U.S. Medicare expenditures that health care expenses of Medicaid-Medicare dual eligibles (MMDE) are much higher than those of Medicare only beneficiaries (MOB). This paper compares health care use and health status of MMDEs and MOBs who are either Afro-American or white recipients. Using total health care use information from the Medical Expenditure Panel Survey (MEPS) 2000, we find that the proportion of dual eligibles with chronic health conditions is higher by 4% than that of the Medicare only beneficiaries and that dual eligibles make more frequent uses of various health care services. The number of office-based physician visits and outpatient physician visits are higher for Afro-American dual eligibles than white dual eligibles. This finding seems to be contributed to by relatively high medical needs among dual eligibles. Higher utilization of agency-related home health services among Afro-American dual eligibles than among white dual eligibles is considered as a consequence of different ethnicity-specific responses to insurance coverage.     

Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life

OBJECTIVE: Although an increasing fraction of Medicare beneficiaries die outside the hospital, the proportion of total Medicare expenditures attributable to care in the last year of life has not dropped. We sought to determine whether disproportionate increases in hospital treatment intensity over time among decedents are responsible for the persistent growth in end-of-life expenditures. DATA SOURCE: The 1985-1999 Medicare Medical Provider Analysis and Review (MedPAR) and Denominator files. STUDY DESIGN: We sampled inpatient claims for 20 percent of all elderly fee-for-service Medicare decedents and 5 percent of all survivors between 1985 and 1999 and calculated age-, race-, and gender-adjusted per-capita inpatient expenditures and rates of intensive care unit (ICU) and intensive procedure use. We used the decedent-to-survivor expenditure ratio to determine whether growth rates among decedents outpaced growth relative to survivors, using the growth rate among survivors to control for secular trends in treatment intensity. Data Collection. The data were collected by the Centers for Medicare and Medicaid Services. PRINCIPAL FINDINGS: Real inpatient expenditures for the Medicare fee-for-service population increased by 60 percent, from $58 billion in 1985 to $90 billion in 1999, one-quarter of which were accrued by decedents. Between 1985 and 1999 the proportion of beneficiaries with one or more intensive care unit (ICU) admission increased from 30.5 percent to 35.0 percent among decedents and from 5.0 percent to 7.1 percent among survivors; those undergoing one or more intensive procedure increased from 20.9 percent to 31.0 percent among decedents and from 5.8 percent to 8.5 percent among survivors. The majority of intensive procedures in the United States were performed in the more numerous survivors, although in 1999 50 percent of feeding tube placements, 60 percent of intubations/tracheostomies, and 75 percent of cardiopulmonary resuscitations were in decedents. The proportion of beneficiaries dying in a hospital decreased from 44.4 percent to 39.3 percent, but the likelihood of being admitted to an ICU or undergoing an intensive procedure during the terminal hospitalization increased from 38.0 percent to 39.8 percent and from 17.8 percent to 30.3 percent, respectively. One in five Medicare beneficiaries who died in the hospital in 1999 received mechanical ventilation during their terminal admission. CONCLUSIONS: Inpatient treatment intensity for all fee-for-service beneficiaries increased between 1985 and 1999 regardless of survivorship status. Absolute changes in per-capita hospital expenditures, ICU admissions, and intensive inpatient procedure use were much higher among decedents. Relative changes were similar except for ICU admissions, which grew faster among survivors. The secular decline in in-hospital deaths has not resulted in decreased per capita utilization of expensive inpatient services in the last year of life. This could imply that net hospital expenditures for the dying might have been even higher over this time period if the shift toward hospice had not occurred.     

There are important reasons for delaying implementation of the new ICD-10 coding system

Federal authorities have recently signaled that they would consider delaying some aspects of implementation of the newest version of the International Classification of Diseases, known as ICD-10-CM, a coding system used to define health care charges and diagnoses. Some industry groups have reacted with dismay, and many providers with relief. We are concerned that adopting this new classification system for reimbursement will be disruptive and costly and will offer no material improvement over the current system. Because the health care community is also working to integrate health information technology and federal meaningful-use specifications that require the adoption of other complex coding standardization systems (such as the system called SNOMED CT), we recommend that the Centers for Medicare and Medicaid Services consider delaying the adoption of ICD-10-CM. Policy makers should also begin planning now for ways to make the coming transition to ICD-11 as tolerable as possible for the health care and payment community.     

TRICARE Extended Care Health Option Program: Prevalence of pediatric ECHO enrollees and healthcare service utilization in the Military Health System

BackgroundThe Extended Care Health Option (ECHO) Program is a TRICARE program aimed at reducing the disabling effects of chronic medical conditions for beneficiaries of the Department of Defense (DoD) healthcare program. However, little is known about military-connected children enrolled in the program.Objective/HypothesisThe aim of this study was to examine the demographic makeup of pediatric ECHO beneficiaries and their healthcare claims data. This is the first study to evaluate healthcare utilization of this subset of military dependents.MethodsA cross-sectional study was performed evaluating ECHO enrolled pediatric beneficiaries and their health service utilization during 2017–2019. TRICARE claims and military treatment facility (MTF) encounter data were utilized to evaluate health service utilization and identify the most frequently reported ICD-10-CM and CPT codes associated with care for this population.ResultsOf the 2,001,619 dependents aged 0–26 years who received medical care in the Military Health System (MHS) during 2017–2019, 21,588 individuals (1.1%) were enrolled in ECHO. The majority of encounters (65.4%) were provided in the MTFs. Inpatient visits, therapeutic services, and in-home nursing care were the top utilized private sector care services. Outpatient visits encompassed 94.8% of healthcare encounters, and neurodevelopmental disorders were the top principal diagnoses among ECHO beneficiaries.ConclusionsWith the increasing prevalence of children with medical complexity and developmental delay, the pediatric TRICARE beneficiaries eligible for ECHO will likely continue to rise. Improving services and supports for military children with special healthcare needs is needed to maximize their developmental trajectory.     

ICD-10 anaphylaxis algorithm and the estimate of vaccine-attributable anaphylaxis incidence in Medicare

BackgroundAnaphylaxis is a rare, serious allergic reaction. Its identification in large healthcare databases can help better characterize this risk.ObjectiveTo create an ICD-10 anaphylaxis algorithm, estimate its positive predictive values (PPVs) in a post-vaccination risk window, and estimate vaccination-attributable anaphylaxis rates in the Medicare Fee For Service (FFS) population.MethodsAn anaphylaxis algorithm with core and extended portions was constructed analyzing ICD-10 anaphylaxis claims data in Medicare FFS from 2015 to 2017. Cases of post-vaccination anaphylaxis among Medicare FFS beneficiaries were then identified from October 1, 2015 to February 28, 2019 utilizing vaccine relevant anaphylaxis ICD-10 codes. Information from medical records was used to determine true anaphylaxis cases based on the Brighton Collaboration’s anaphylaxis case definition. PPVs were estimated for incident anaphylaxis and the subset of vaccine-attributable anaphylaxis within a 2-day post-vaccination risk window. Vaccine-attributable anaphylaxis rates in Medicare FFS were also estimated.ResultsThe study recorded 66,572,128 vaccinations among 21,685,119 unique Medicare FFS beneficiaries. The algorithm identified a total of 190 suspected anaphylaxis cases within the 2-day post-vaccination window; of these 117 (62%) satisfied the core algorithm, and 73 (38%) additional cases satisfied the extended algorithm. The core algorithm’s PPV was 66% (95% CI [56%, 76%]) for identifying incident anaphylaxis and 44% (95% CI [34%, 56%]) for vaccine-attributable anaphylaxis. The vaccine-attributable anaphylaxis incidence rate after any vaccination was 0.88 per million doses (95% CI [0.67, 1.16]).ConclusionThe ICD-10 claims algorithm for anaphylaxis allows the assessment of anaphylaxis risk in real-world data. The algorithm revealed vaccine-attributable anaphylaxis is rare among vaccinated Medicare FFS beneficiaries.     

Managed care and medical expenditures of Medicare beneficiaries

This paper investigates the impact of Medicare HMO penetration on the medical care expenditures incurred by Medicare fee-for-service (FFS) enrollees. We find that increasing penetration leads to reduced spending on FFS beneficiaries. In particular, our estimates suggest that the increase in HMO penetration during our study period led to approximately a 7% decline in spending per FFS beneficiary. Similar models for various measures of health care utilization find penetration-induced reductions consistent with our spending estimates. Finally, we present evidence that suggests our estimated spending reductions are driven by beneficiaries who have at least one chronic condition.