A subsidiary of 1 AEA Health Evaluation TIG

A subsidiary of 1 AEA Health Evaluation TIG Roundtable Discussion Brainstorming the Use of Large Data to Assess the Impact of the Affordable Care Act Timothy F. Champney October 17, 2013 Washington, DC This document is for IMS use only. Any unauthorized review, use, disclosure or distribution is prohibited.

Abstract 2 Discussion will consider the possibilities for using large existing data sets such as repositories of health care insurance claims and encounter data and national surveys such as the Medical Expenditure Panel Survey to assess the overall impact of the Affordable Care Act (ACA) on access, outcomes, and costs of health care. Repositories of claims and encounter data may include commercially available data sources such IMS Pharmetrics™ or Truven Market Scan™ and government sources such as the Medicaid Statistical Information System (MSIS). The presentation and discussion will include the logical framework (application of logic models), study design issues and options, data sources and availability, analytic techniques, key evaluation questions, and study limitations, validity threats, and caveats. Copyright © 2013

Relevance 3 The Affordable Care Act represents the largest change in the US health care system at least since the inception of Medicare and Medicaid in 1965. Thus far, most of the literature evaluating the ACA has consisted of policy analysis, speculation, critique, or simulations and projections. However, there already demonstrable increases in the insured population evident from the Current Population Survey (2005 -2011) that can be attributed to the ACA, particularly for adult children between and ages of 18 and 26 (see Cantor JC, Monheit AC, De. Lia D, Lloyd K (2012). Early impact of the Affordable Care Act on health insurance coverage of young adults, Health Services Research. 47(5): 1773 -90. ). Professional evaluators and the AEA will benefit by recognizing the opportunities to evaluate the ACA using objective data and cost effective methods that leverage existing large data sources. Well reasoned, informative studies of the ACA, designed by evaluators can help guide ACA implementation, provide useful feedback to decision makers, and assure the availability of resources along with continued and expanded collection of essential data. Copyright © 2013

Framework -- Andersen’s Behavioral Model 4 Source: Andersen, Ronald (1995). "Revisiting the behavioral model and access to medical care: does it matter? ". J Health Soc Behav 36 (1): 1– 10. Copyright © 2013

Relevant Large Data Sources 5 Complex National Surveys Current Population Survey American Community Survey National Health Interview Survey Medical Expenditure Panel Survey Government Databases MSIS and T-MSIS All Payer Commercial Data IMS Health – Pharmetrics (not same IMS) Truven Market. Scan Optum. Insight Ingenix Many states have established their own all-payer claims databases Copyright © 2013

IMS-Health Pharmetrics. Plus 6 Key Information Types Diagnoses and Procedures Retail and Mail Order Prescriptions Inpatient details—Admitting Diagnosis, Admission Source & Type Provider/Pharmacy ID Pharmacy Benefit Design—Co-pay/ Coinsurance Amount; Deductible Amount Costs of Services and Prescriptions Place of Service Plan Type and Time Enrolled Copyright © 2013

Truven Market. Scan Sample Data Elements 7 Copyright © 2013

Truven Market. Scan Health Plan Characteristics 8 Copyright © 2013

Medicaid Statistical Information System (MSIS) 9 Copyright © 2013

MSIS 10 MSIS Record Types Eligibility (ELIGIBLE) Inpatient (CLAIMIP) Long-term Care (CLAIMLT) Other (CLAIMOT) Pharmacy (CLAIMRX) Data Dictionary http: //www. cms. gov/Research-Statistics-Data-and-Systems/Computer-Data -and-Systems/MSIS/downloads/msisdd 2010. pdf Copyright © 2013

MSIS Payment Record Types (Type-of-Claim) 11 1. Fee-for-service 2. Managed care encounter 3. Capitated payment records 4. Gross payment records 5. Supplemental payment Note: There also some special CHIP payment types (A-E) Copyright © 2013

MSIS Service Types (Type-of-Service) 12 01 Inpatient Hospital 02 Mental Hospital Services for the Aged 04 Inpatient Psychiatric Facility Services for Individuals Age 21 Years and Under 05 ICF Services for the Mentally Retarded 07 NF'S - All Other 08 Physicians 09 Dental 10 Other Practitioners 11 Outpatient Hospital 12 Clinic 13 Home Health 15 Lab and X-Ray 16 Prescribed Drugs 19 Other Services 20 Capitated Payment s to HMO, HIO or PACE Plan 21 Capitated Payments to Prepaid Health Plans (PHPs) 22 Capitated Payments for Primary Care Case Management (PCCM) 23 Capitated Premium Payments to Private Health Insurance 24 Sterilizations 25 Abortions 26 Transportation Services 30 Personal Care Services 31 Targeted Case Management 33 Rehabilitation Services 34 PT, OT, Speech, Hearing Language 35 Hospice Benefits 36 Nurse Midwife Services 37 Nurse Practitioner Services 38 Private Duty Nursing 39 Religious Non-Medical Health Care Institutions 40+ Invalid codes - included in error tolerance 99 Unknown - included in error tolerance Copyright © 2013

MSIS Service, Proc, Revenue, and NDC Codes 13 Service, and procedure codes conform to CPT, HCPCS, and ICD 9 code standards. A code flag for each code indicates which of the above code types applies to each code. Revenue codes conform to CMS revenue code standards. NDC codes conform to FDA NDC standards for drug codes. Note: Descriptors for these codes must be obtained from other sources and are not included in the MSIS Data Dictionary. Copyright © 2013

More Information Regarding MSIS 14 MSIS Data Mart (FY 1999 through 2011) http: //www. cms. gov/Research-Statistics-Data-and. Systems/Computer-Data-and. Systems/Medicaid. Data. Sources. Gen. Info/MSIS-Mart-Home. html Data anomalies listings http: //www. cms. gov/Research-Statistics-Data-and. Systems/Computer-Data-and. Systems/Medicaid. Data. Sources. Gen. Info/downloads/anomalies 1. pdf Copyright © 2013

T-MSIS 15 Three new record types Third Party Liability File Provider File Managed Care Plan File Additional fields Starting January 14, 2014 Maps back to MSIS T-MSIS Data Dictionary http: //www. reginfo. gov/public/do/PRAView. IC? ref_nbr=201301 -0938002&ic. ID=205266 Copyright © 2013

Other Federal Data 16 CDC Vital Statistics http: //www. cdc. gov/nchs/data_access/vitalstatsonline. htm HRSA Areas Resource Files http: //arf. hrsa. gov/ Census Data http: //www. census. gov/ Medicare Data https: //data. medicare. gov/ And http: //www. resdac. org/cms-data/file-family/Medicare-Claims Data from these sources may be linked with Medicaid data. Copyright © 2013

Other State Data 17 All payer claims databases Since 2010 in Kansas, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, Utah, and Vermont. See http: //www. commonwealthfund. org/~/media/Files/Publications/Issue%20 Brief/2010/Sep/14 39_Love_allpayer_claims_databases_ib_v 2. pdf All payer hospital discharge data Example http: //www. healthdatastore. com/ahca-florida-hospital-discharge-data. aspx Controlled substances prescription data Example http: //www. doh. state. fl. us/mqa/pdmp/home. html Mental health services data Example http: //www. mh. state. oh. us/what-we-do/protect-and-monitor/macsis/ Note: availability of these other data sources varies from state to state Copyright © 2013

Third Party Data Enhancements 18 Benchmarking data Groupers and coders CPT/HCPCS and ICD 9 descriptor tables Pharmacy reference files Example http: //www. medi-span. com/medi-span-electronic-drug-file. aspx Copyright © 2013

Researching Medicare & Medicaid Data Issues 19 http: //www. resdac. org/cms-data Copyright © 2013

Early Findings 20 Impact of Medicaid expansion, young adult, and pre- existing condition provisions

Sources of Insurance Coverage, 1999 -2012 21 Source: ASPE calculations from Carmen De. Navas-Walt, Bernadette D. Proctor, and Jessica C. Smith, U. S. Census Bureau, Current Population Reports, P 60 -245, Income, Poverty, and Health Insurance Coverage in the United States: 2012, U. S. Government Printing Office, Washington, DC, 2013 (http: //www. census. gov/prod/2013 pubs/p 60 -245. pdf), accessed September 17, 2013. Copyright © 2013

Discussion Topics 22 Study Design Options Important Evaluation Questions Process and outcome Analysis Methods

Study Design Issues and Options 23 Hypothesis-driven or emergent analysis Outcome measures Quality, cost, and health outcomes Access Care coordination Reduced disparities Populations Low and middle income Employed or unemployed State-specific or national Copyright © 2013

Important Evaluation Questions 24 Do insurance coverage rates increase? Are premiums lower? Are health care costs lower? Does quality improve? Do health, quality of life, and productivity improve? Are disparities reduced? Copyright © 2013

Analysis Methods 25 Multimethod, multistate, multiple populations Longitudinal, nonequivalent groups designs Adjustment for selection effects Time-varying covariates Network and geographic analysis Quantitative and qualitative outcomes Process monitoring Copyright © 2013

Caveats and Threats to Validity 26 Uncontrolled study Data variable quality Data incomparable across states and study populations Data collection methods and availability change over time Missing data Time lag in data Copyright © 2013

One-page Area 365 Tip-a-day 27 What have we learned and what is worth sharing

References 28 Andersen, R. (1995). "Revisiting the behavioral model and access to medical care: does it matter? “ J. Health and Social Behavior, 36 (1): 1– 10. Cantor J. C. , Monheit A. C. , De. Lia D. , & Lloyd K. (2012). Early impact of the Affordable Care Act on health insurance coverage of young adults. Health Services Research, 47(5): 1773 -90. CMS Medicaid Statistical Information System (MSIS) State Summary Datamarts. Available on the Internet at http: //www. cms. gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/Medicaid. Data. Sources. Gen. Info/MSISMart-Home. html Love, D. , Custer, W. , & Miller, P. (2010). All-Payer Claims Databases: State Initiatives to Improve Health Care Transparency, Commonwealth Fund Issue Brief. Available on the Internet at http: //www. commonwealthfund. org/Publications/Issue. Briefs/2010/Sep/All-Payer-Claims-Databases. aspx Finegold, K. (2013). New Census Estimates Show 3 Million More Americans Had Health Insurance Coverage in 2012, ASPE Issue Brief. Available on the Internet at http: //aspe. hhs. gov/health/reports/2013/CPSIssue. Brief/ib_cps. cfm IMS Health (2013). IMS Life. Link Phar. Metrics Plus™ – U. S. Real World Evidence. Real World Impact. Available on the Internet at http: //www. imshealth. com/deployedfiles/imshealth/Global/Content/Home%20 Page%20 Content/Real. World%20 insights/IMS_Lifelink_pharmetrics_Plus. pdf Robert Wood Johnson Foundation and State Health Access Data Assistance Center (2013). Comparing Federal Government Surveys that Count the Uninsured. Available on the Internet at http: //www. shadac. org/publications/comparing-federalgovernment-surveys-count-uninsured Truven (2012). Health Research Data for the Real World: The Market. Scan® Databases. Available on the Internet at http: //www. truvenhealth. com/assets/2012_Truven_Market. Scan_white_paper. pdf Copyright © 2013