Update on Using Medicare Data to Integrate Care for ...€¦ · Integrate Care for...

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The Integrated Care Resource Center, a joint initiative of the Centers for Medicare & Medicaid Services Medicare-Medicaid Coordination Office and the Center for Medicaid and CHIP Services, provides technical assistance for states coordinated by Mathematica Policy Research and the Center for Health Care Strategies. ICRC Extended Study Hall Call Series: An Update on Using Medicare Data to Integrate Care for Medicare-Medicaid Enrollees December 3, 2012 For audio, dial: 1-800-273-7043; Passcode 596413

Transcript of Update on Using Medicare Data to Integrate Care for ...€¦ · Integrate Care for...

The Integrated Care Resource Center, a joint initiative of the Centers for Medicare & Medicaid Services Medicare-Medicaid Coordination Office and the Center for Medicaid and CHIP Services, provides technical assistance for states coordinated by Mathematica Policy Research and the Center for Health Care Strategies.

ICRC Extended Study Hall Call Series:An Update on Using Medicare Data to Integrate Care for Medicare-Medicaid Enrollees

December 3, 2012

For audio, dial: 1-800-273-7043; Passcode 596413

• Welcome and Roll Call

• MMCO/CMS Update

• New York State Update

• Washington State Update

• Questions from States

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Agenda

Wendy Alexander, Program Alignment Group, MMCO, CMS

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MMCO/CMS Update

New York State’s Experience in Accessing and Using Medicare DataPatrick J. Roohan, DirectorOffice of Quality and Patient SafetyNew York State Department of Health

December 3, 2012

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New York’s Data Use Agreement• Data is being used for program design and analysis.

• New York State does not re-release Part A and B claims data for care coordination and other quality improvement activities.

• New York was recently granted approval by CMS to share with an outside Vendor for purposes of data analysis (that work has not yet begun).

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Program Design and Analysis• New York Medicaid Redesign

Fully Integrated Duals Advantage Programhttp://www.health.ny.gov/facilities/long_term_care/docs/2012-05-25_final_proposal.pdf

• New York State Data Request for the Full Benefit Dual Enrollee Population • Actuarial analysis on membership and

expenditures.• Fully Integrated Dual Advantage (FIDA) Health

Homes for Community Well

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New York’s Dual Eligible Data Files

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Medicare Data File YearsIdentifier Crosswalk Buccaneer BENE ID to HIC 2007-2011Identifier Crosswalk Buccaneer BENE ID to SSN 2007-2011Master Beneficiary Summary Files (Base, Chronic Conditions, Cost and Utilization) 2011Beneficiary Annual Summary Files (Demographics/Enrollment) 2007-2010Part A Inpatient 2007-2011Part A Outpatient 2007-2011Part A SNF 2007-2011Part A Hospice 2007-2011Part A Home Health 2007-2011Part B Carrier 2007-2011Part B DME 2007-2011Part D Drug Data 2007 forwardCOBA Claim Files (Part A, Part B and NCPDP) 2011 forward

Difficult Issues in Using Data: Beneficiary Identification

• Not all Beneficiary IDs present on Parts A/B claims data (BENE_CLM_ACNT_NUM) are listed on the Crosswalk File (HIC).

• A Medicare HIC when matched to Medicaid enrollment and eligibility information, may be a one to many, or many to many match (NY 1-2%).

• Medicare HICs may be more susceptible to change over time than Medicaid identification numbers (NY ~30%).

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• Linkages with Medicaid payment data is critical to understand the relationship between payers. • Without claims linkages in place, utilization patterns

cannot be fully analyzed.• Understanding payment dynamics on an episode of

care. ▫ For example, the relationship of the

Medicaid/Medicare dynamic on home health care coverage;

▫ Complex interplay for nursing facility stays and inpatient admissions: both short term and long term.

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Difficult Issues in Using Data: Claim Level Linkages

• Creating comparable categories of service across Medicaid and Medicare. • State’s should prepare their own “Metadata” for

interpreting the data elements received. • ResDAC has a Medicare Data Documentation

link: http://www.resdac.org/ddvh/index.asp• The Annual Summary Files received from

Buccaneer come with documentation, code reference sets and tips on getting started with the data.

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Difficult Issues in Using Data: Mapping / Interpreting Data Elements

• COBA Claim Data Need to be “Translated”

• Transmitted in an X12 837I (Institutional) and 837P (Professional) data format.

• New York is still pending translation to usable data formats. • Needed to procure software vendor.

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Difficult Issues in Using Data: Format Conversions

• Part C Expenditure Data is Not Available▫ To estimate, NY used a CY 2011 weighted benchmark

PMPM on the Kaiser Family Foundation statehealthfacts.org; applied a 2% reduction for 2010 calculations; and then multiplied by MA member months (e.g., $983.86 - 2% = $964.18 for CY 2010; $964.18 * 2,210,580 MM = $2.1 billion).

• Part D: Financial and health plan information are not made available as part of the data feed. ▫ To estimate, NY had a 2013 estimated PMPM from

actuarial analyses and multiplied by FBDE member months ($480.15 * 7,458,022 MM= $3.6 billion).

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Difficult Issues in Using Data: Expenditures: Part C and Part D

• A significant investment of program management, information technology and analytical staff is needed for converting, storing interrogating, linking and analyzing Part A and B claim data.

• Part D data feeds are received monthly.• COBA Claim data is sent bi-weekly. • Data Use Agreement monitoring.

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Difficult Issues in Using Data: Devoted Resources

Risk Profile• New York State uses 3M Clinical Risk Groups

(CRGs) to assess the severity of illness of its Medicaid enrollees. The CRG software is currently used for risk-adjusted payment for managed care enrollees, to determine thresholds for utilization review and to stratify the Medicaid population for potential programs including care management and health homes.

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Base Health Status and Severity of Illness(Unique Beneficiaries and Percent of Total Community Based LTC and DD Cohort, CY2010)

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Severity of Illness Level

Base Health Status 0 1 2 3 4 5 6 Grand Total Pct

Healthy/Acute 2,888 2,888 2% 100% 100%

Minor Condition 854 389 270 178 1,691 1%51% 23% 16% 11% 100%

Single Chronic 7,660 3,112 1,300 288 521 25 12,906 7%59% 24% 10% 2% 4% 0% 100%

Pairs Chronic 18,824 18,263 19,832 21,043 18,492 2,657 99,111 52%19% 18% 20% 21% 19% 3% 100%

Triples Chronic 2,644 5,270 19,155 9,624 11,209 4,727 52,629 28%5% 10% 36% 18% 21% 9% 100%

Malignancies 50 433 1,612 4,082 1,833 8,010 4%1% 5% 20% 51% 23% 100%

Catastrophic 218 1,978 2,223 1,905 940 3,831 11,095 6%2% 18% 20% 17% 8% 35% 100%

HIV / AIDS 410 531 865 549 2,355 1%17% 23% 37% 23% 100%

Grand Total 2,888 30,250 29,855 44,923 37,985 33,544 11,240 190,685 100%Pct 2% 16% 16% 24% 20% 18% 6% 100%

Note: Medicaid, Medicare and Part D claims included in classification.

Prevalence of Chronic Health Conditions (Top 20): Community Based LTC and DD Cohort

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Episode Disease ConditionUnique

Beneficiary

Percent Total

Cohort Hypertension 144,862 76.0 Hyperlipidemia 116,310 61.0 Chronic Joint and Musculoskeletal Diagnoses - Minor 78,980 41.4 Diabetes 71,735 37.6 Osteoarthritis 62,439 32.7 Depression 57,945 30.4 Coronary Atherosclerosis 50,565 26.5 Chronic Gastrointestinal Diagnoses - Minor 42,090 22.1 Angina and Ischemic Heart Disease 41,158 21.6 Congestive Heart Failure 40,218 21.1 Peripheral Vascular Disease 39,185 20.5 Chronic Thyroid Disease 38,267 20.1 Osteoporosis 38,154 20.0 Schizophrenia 38,127 20.0 Chronic Endocrine, Nutritional, Fluid, Electrolyte and Immune Diagnoses - Moderate 35,310 18.5 Alzheimer's Disease and Other Dementias 35,217 18.5 Chronic Stress and Anxiety Diagnoses 33,725 17.7 Mild / Moderate Mental Retardation 33,569 17.6 Asthma 33,174 17.4 Chronic Genitourinary Diagnoses 32,206 16.9

Chronic Behavioral & Physical,

52%

Chronic Behavioral Only <1%

ChronicPhysical

Only, 48%

Top 20 Co-Occurring Chronic Health Conditions: Community Based Developmentally Disabled

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Episode Disease ConditionUnique

Beneficiary

Percent DD

Cohort Hyperlipidemia 17,229 39.0%Hypertension 16,981 38.4%Schizophrenia 15,699 35.5%Chronic Joint and Musculoskeletal Diagnoses - Minor 15,347 34.7%Epilepsy 15,278 34.6%Depression 14,294 32.3%Chronic Thyroid Disease 9,920 22.4%Chronic Stress and Anxiety Diagnoses 8,634 19.5%Chronic Gastrointestinal Diagnoses - Minor 6,971 15.8%Osteoporosis 6,669 15.1%Chronic Endocrine, Nutritional, Fluid, Electrolyte and Immune Diagnoses - Moderate 5,876 13.3%Diabetes 5,574 12.6%Conduct, Impulse Control, and Other Disruptive Behavior Disorders 4,996 11.3%Depressive and Other Psychoses 4,989 11.3%

Chronic Genitourinary Diagnoses 4,564 10.3%Asthma 4,161 9.4%Chronic Mental Health Diagnoses - Minor 3,986 9.0%Chronic Hearing Loss 3,792 8.6%Obesity 3,556 8.0%Extrapyramidal Diagnoses 3,530 8.0%

Chronic Behavioral & Physical,

52%

Chronic Behavioral Only <1%

ChronicPhysical

Only, 48%

n =44,190

Full-Benefit Dual Eligible RecipientsPopulation Cohort (700,000 approx.)*

Population MemberMonths Medicaid $ Medicare $ Total Total

PMPM

Institutional – NH 1,006,147 $5,695,115,759 $1,835,235,425 $7,530,351,185 $7,484

Community –BasedLTC

1,639,374 $5,683,607,363 $2,661,299,331 $8,344,906,694 $5,090

OPWDD 517,506 $4,521,383,716 $272,818,618 $4,794,202,335 $9,264

Community Well 4,141,923 $1,104,714,346 $2,919,032,042 $4,023,746,388 $972

Total 7,304,923 $17,004,821,184 $7,688,385,416 $24,693,206,602 $3,380

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*Reflects Medicare Part A and B only.

Dual Eligible Recipients by Category of Service

19Community-Based LTC Cohort

COS Recipients Medicaid $ Medicare $ Total $ PMPM $Inpatient 57,833 115,070,134 1,243,565,704 1,358,635,837 829

SNF 13,850 43,925,162 180,617,594 224,542,756 137

Hospice 2,731 4,274,284 26,146,362 30,420,646 19

Non-ER HOPD 74,817 51,354,093 112,836,819 164,190,912 100

ER (HOPD) 39,515 2,963,721 21,899,290 24,863,011 15

FS Clinic 22,867 45,976,937 88,482,912 134,459,848 82

Home Health Care 71,739 1,777,985,127 220,648,732 1,998,633,859 1,219

Physician/Specialist 126,325 42,298,233 497,808,014 540,106,247 329

DME 96,675 66,211,854 82,380,069 148,591,923 91

Pharmacy 116,302 56,594,189 --- 56,594,189 35

Capitation 41,425 1,182,771,609 --- 1,182,771,609 721

Personal Care 54,350 1,682,541,484 --- 1,682,541,484 1,026

Waiver Services 2,645 94,165,270 --- 94,165,270 57

ALP/Adult Day Care 15,180 294,780,308 --- 294,780,308 180

Case Mgmt. 2,084 8,637,716 --- 8,637,716 5

Other Services 125,856 214,057,243 186,913,836 400,971,079 244

Total 146,287 $ 5,683,607,363 $ 2,661,299,331 $ 8,344,906,694 $ 5,090

Technical Assistance• Buccaneer: Beneficiary ID Crosswalk;

interpreting Annual Summary files.

• Mathematica: Estimating Part C costs; Understanding netting Part D data; Understanding HIC numbers are issued, etc.

• Acumen: Help with linking questions and understanding payment dynamics.

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• Patrick Roohan: [email protected]• Mary Beth Conroy: [email protected]

Office of Quality and Patient SafetyNew York State Department of HealthAlbany, New York

Phone: 518-486-9012Fax: 518-486-6098

Contact Information

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22DSHS | Planning, Performance and Accountability ● Research and Data Analysis Division ● DECEMBER 2012

Patterns of Hospital Readmissions and Nursing Facility Utilization among Washington State Dual Eligibles

David Mancuso, PhD

December 3, 2012

23DSHS | Planning, Performance and Accountability ● Research and Data Analysis Division ● DECEMBER 2012

Medicaid Paid Nursing Facility Stay HOSPITAL STAY

ADMISSION

Medicare Paid Nursing Facility

Medicaid Paid Nursing Facility

Other (home, other facility, death)

Hospital Discharge Status Analysis Timeline

Hospitalizations frequently restart Medicare payments for nursing facility stays

Discharge Status of Dual Eligibles Admitted to a Hospital from a Medicaid-Paid Nursing Facility Stay

Directly discharged to

NF paid by Medicaid

34%

Directly discharged to NF paid by Medicare43%

Discharged to other setting

23%

Dual Eligible Elders Dual Eligible Disabled

Number of discharges in SFY 2010 = 3,135

Average age = 80.5

Discharged to other setting24%

Directly discharged to

NF paid by Medicaid

45%

Directly discharged to NF paid by Medicare

31%

Number of discharges in SFY 2010 = 957

Average age = 54.3

Discharged to . . .

24DSHS | Planning, Performance and Accountability ● Research and Data Analysis Division ● DECEMBER 2012

Dual eligibles admitted to the hospital from nursing facility stays have relatively high rates of subsequent hospital

readmissionsReadmission within 90 Days of Discharge

0%

. . . paid by Medicare38%

. . . paid by Medicaid26%

. . . paid by Medicare54%. . . paid by

Medicaid47%

0

Admitted to hospital from nursing facility . . .

Number of discharges in SFY 2010 = 3,135

Average age = 80.5

Number of discharges in SFY 2010 = 957

Average age = 54.3

2,13878.0

93454.4

Medicare Or Medicaid Paid Nursing Facility Stay

HOSPITAL STAY

HOSPITAL ADMISSIO

N

HOSPITAL DISCHARG

E

90-Day Readmission Rate Analysis

Readmission Analysis Timeline

Dual Eligible Elders Dual Eligible Disabled

25DSHS | Planning, Performance and Accountability ● Research and Data Analysis Division ● DECEMBER 2012

Case-mix adjusted measurement of rehospitalization risk appears feasible

Facility average readmission rates by average patient PRISM risk score for dual eligible patients,

by nursing facility receiving the patient following initial dischargeNOTE: Unit of observation is a nursing facility receiving at least 25 dual eligible hospital discharges in SFY 2010

0%

10%

20%

30%

40%

50%

60%

70%

2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00

LOWER RISK HIGHER RISKPRISM Risk Score

LOW

ERH

HIG

HER

90-D

ay In

patie

nt R

eadm

issi

on R

ate

SOURCE: Washington State Department of Social and Health Services, Research and Data Analysis Division, Integrated Client Database, May 2012.

26DSHS | Planning, Performance and Accountability ● Research and Data Analysis Division ● DECEMBER 2012

Policy Implications

• Many nursing facilities serve relative low acuity patients who may be appropriate to consider for transition to community-based care

• Identifying clients with high risk of hospital readmission and nursing facilities with persistently high case-mix adjusted hospital readmission rates appears feasible

• Case-mix adjustment of hospital readmission rates is essential to accurately measure facility performance

• The performance payment terms of our Duals Demonstration MOU with CMS provides the state with an incentive to invest in strategies to reduce the rate of hospitalization of dual eligibles emanating from nursing facilities

27DSHS | Planning, Performance and Accountability ● Research and Data Analysis Division ● DECEMBER 2012

Using Risk Models To Identify Patients Most at Risk of Potentially Avoidable Adverse Health Outcomes

0

Inpatient $809

Medicare $ PMPM...

Elders Disabled

SFY 2010 Medicare Costs Per Member Per Month (PMPM)Excludes Medicaid Expenditures

ELDERS DISABLEDLow Risk

PRISM Score < 1.5High Risk

PRISM Score > 1.5Low Risk

PRISM Score < 1.5High Risk

PRISM Score > 1.5

Total PMPM $334 $2,023 $357 $2,371Inpatient PMPM $59 $809 $70 $960SNF PMPM $27 $339 $7 $153Covered Lives 46,241 28,703 39,560 20,117

SNF $339

Other $875

HIGH RISKPRISM Score >

1.5

LOW RISKPRISM Score <

1.5

HIGH RISKPRISM Score >

1.5

LOW RISKPRISM Score <

1.5

Inpatient $960SNF $153

Other $1,258

TOTAL = $334 TOTAL = $2,023

TOTAL = $357 TOTAL = $2,371

28DSHS | Planning, Performance and Accountability ● Research and Data Analysis Division ● DECEMBER 2012

Acknowledgements

• Chad and Summer “cracked” mainframe Medicare historical data files and built a 5-year Medicare claims analytical data repository, in addition to integrating Medicare data into PRISM

• Dan calibrated the PRISM risk model used to illustrate the potential for case-mix adjustment of hospital readmission rates

• Elizabeth developed the multidimensional “day array” analytical programming processes that these analyses required

• Barb designed the layout and presentation of complex information

• Bev co-authored the paper and made essential contributions to improve the narrative and better capture the policy environment

• Thanks!

Questions?

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About ICRC• Established by CMS to advance integrated care models for Medicaid

beneficiaries with high costs and high needs

• Provides technical assistance (TA) to help states integrate care for: (1) individuals who are dually eligible for Medicare and Medicaid; and (2) high-need, high-cost Medicaid populations via health homes as well as other emerging models

• TA coordinated by Mathematica Policy Research and the Center for Health Care Strategies

• Visit www.integratedcareresourcecenter.com to submit a TA request and/or download resources, including briefs and practical tools to help address implementation, design, and policy challenges