MILI 6990 : Using Insurance Claims Data for Health Market Opportunity Analysis - PowerPoint Presentation

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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

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AgendaOur Background and CDRGIntroduction to Claims Data

Utilization of Claims Data Market OpportunitiesMILI Program – Students and Affiliates

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I. Background: CDRG Mission

The Chronic Disease Research Group pursues its commitment to public health by advancing knowledge about chronic disease to improve patient care and outcomes.

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I. Background: CDRG Organizational Hierarchy

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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

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I. Background: Knowledge Factory

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II. Intro to Claims Data: OverviewClaims – billable interactions between:

covered patients and the healthcare deliveryhealth care or service provider and the payer

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II. Intro to Claims: EMR vs. Claims

ClaimsEMRScope of DataInformation from all doctors/providers caring for a patientOnly the portion of care provided by doctors/providers using the EMRScope of PatientsInsured onlyUninsured and insuredData ElementsDiagnosis, procedures as codedLab results, vital signs, free text, habits, problem listOther Limitations of EMRs – Lack of standardization – “If you’ve seen one EMR, you’ve seen one…”Inconsistent data entrySingle

site of patient care

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II. Intro to Claims: Source of Claims DataCommercial Claims (i.e. United Health, MarketScan)

Medicare Limited (LDS) Research Identifiable (RIF)USRDS (ESRD)MedicaidLinked Datasets (i.e. SEER-Medicare)

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II. Intro to Claims: Commercial vs. Medicare

FeatureMedicareCommercialEnrollmentElderly and disabled (Compulsory at age 65 and ESRD)Coverage is until deathTraditionally employer based, insurance exchanges emerging (ACA)Coverage may change with employment (affects follow-up)Data ElementsMedical services, prescription drug, laboratory billing (no results)Medical services, prescription drug, laboratory billing and results provided through limited contracts with laboratoriesDemographicRace, gender, and region well represented. Age is >65 years (unless ESRD)Limitations to region depending on dataset. Greater range for age (including pediatric)

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II. Intro to Claims Data: MedicarePart A – hospital care, skilled nursing facility care, nursing home care, hospice, and home health servicesPart B – physician visits, ambulance services, durable medical equipment, mental health, preventative services

Part D – prescription drug coverage (70%)

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II. Intro to Claims: Medicare

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HEALTH INSURANCE CLAIM FORM

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II. Intro to Claims Data: CodingICD 9

– International Classification of Diseases, Version 9 (diagnoses)XXX.XX – AMI 410.X, PTCA 00.66X mattersCPT 4 – Current Procedural Terminology, Version 4 (procedures) 5 digits, 0 mattersi.e. PTCA 92982NDC - Food and Drug Administration’s Nation Drug Code directory (Drugs) 10 digit number with 3 segments

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II. Intro to Claims: DRGsPart A Hospital ClaimsICD-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.

The position of codes matters for payment. That is, not all diagnosis and procedure code are created equal.

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II. Intro to Claims: ICD 9 to ICD 10

ICD-9 (Procedure Codes)ICD-10-PCS (Procedure Codes)Number of Characters3-4 Numeric7 AlphanumericNumber of Codes~4,000 ~90,000Example 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)

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II. Intro to Claims: Health Data Representation

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II. Intro to Claims: Strengths and Limitations

StrengthsLimitationsClinical validity – information about covered servicesDemographic information (if available)Population Coverage (different strengths for different datasets)Cost effective in comparison to chart reviews or clinical trialsUnderdiagnosed diseases (diabetes, depression, hypertension)Incomprehensive disease and severity information Incidence vs. prevalenceLimited clinical informationLimit to reimbursed servicesLimit to number of codes reportedPrimary 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)

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II. Intro to Claims: Access to DataMedicare & Medicaid:Research Data Assistance Center (

ResDAC)Aggregate-level data through private research groups that use CMS with approval (i.e. CDRG and University of Minnesota)Direct for federally funded contractsData lag: 9 months for Part A/Part B and 15 for Part DCommercially-insured claims data:OptumInsights, MarketScan, Medco, PharMetricsData updated quarterly

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III. Utilization of Claims DataMarket ResearchQuality Improvement- QIPFraud DetectionDrug Safety Signal Detection (FDA Sentinel

)Post-market Safety and SurveillanceHealth Economics and Outcome Research (CDRG’s Core)Comparative EffectivenessClinicalEconomicValueClinical Trial Supplement

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III. Utilization of Claims DataPopulation MonitoringPolitical, 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 HSASource: 2012 USRDS Annual Data Report: Figure 1.3 (Volume 2)

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Source: 2012

USRDS Annual Data Report, Figure 11.5 (Volume 2)III. Utilization of Claims Data

Total Medicare dollars

spent on

ESRD, by type of service

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Prevalence of Recognized Bone Metastases in the US Adult PopulationMethods: 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). 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. BM prevalence was extrapolated to the national commercially insured population aged 18-64 years and to the traditional Medicare population aged ≥65 years. 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, 2009III. Utilization of Claims

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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 breastProstateLungMultiple 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

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III. Utilization of ClaimsLong-Term

Survival and Repeat Revascularization in US Dialysis Patients after Surgical versus Percutaneous Coronary Intervention (ASN Renal Week 2009)MethodsSearched 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.

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Results: Event Free Survival (%)

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.

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Zzzzzz?!

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III. Utilization of Claims DataBenchmarkingQuality of care: ESRD Quality Incentive Program (QIP), Hospital Readmission PenaltyPerformance measurement: State-specific, Agency-specific, Facility-specific measures (Transplant Program-specific Reports, Dialysis Facility Compare,

etc)Accountable Care Organization – performance monitoring and payment/penalty systemEvaluating PolicyCBO, GAO – Cost assessment of ESRD BundleDiffering findings on including Oral Drugs in Bundle

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IV. Market OpportunitiesData Linkages:US CensusCancer Registries (SEER)

Other Providers (VA, Medicaid)National death index/vital statisticsSurveys (MCBS, NHANES, Health and Retirement Study)Provider InformationEHRClinical Trial Data

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IV. Market OpportunitiesBusiness Opportunities with Claims:

Users: Insurance/PayersProvidersPharma/Device/BiotechPolicy-makersQuality User/PurposeProject TypeMarketingMarket sizing, medical service process or flow, sales estimatesFinanceRevenue projections, baseline opportunityRegulatorySafety monitoring, risk assessment

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V. MILI Students and AffiliatesMILISAMILI SpecializationMILI Affiliates/AlumniMILI Valuation Lab

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Tying It Together: MILI DC Field Trip

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