This is lesson 2.2.3, the Sources of Claims Data. In this lesson, we'll discuss where claims data may be obtained in order to use it for technology assessments. Commercial claims data, which would cover mostly the under 65 population with employer sponsored insurance or individual insurance is available from some commercial companies such as Optum or Truven MarketScan. These can be purchased by commercial companies, such as pharmaceutical companies or device companies, to use for technologies assessments. Medicare, which tends to cover the over 65 population, as well as the disabled in many cases, has numerous types of datasets. One is a limited dataset, which has a limited amount of beneficiary information in order to protect identities of the beneficiaries, as well as the providers is one source of data. There's also research identifiable files, which are available to researchers which have more detailed data. And there's a separate set of data from the US Renal Data System that covers only the ESRD population, or the end stage renal disease population. Which is paid for by Medicare, and is included in some of the other Medicare files, but has it's own separate data set for surveillance and research purposes. Medicaid claims data are available and this is for potentially the over 65 or under 65 population, but it's based on income requirements and is available on a state by state basis although some data is available through the centers for Medicare and Medicaid for research purposes known as the Medicaid Analytic Extract File. Additionally, the health care costs and utilization project is discharge data, which is inpatient claims data rolled up to a single stay for each patient and, that's available from HRQ through to H-CUP system. In terms of accessing the data, Medicare and Medicaid data has a limited amount of access for commercial purposes. RIF files are only available for research institutions. An application needs to go through ResDAC. Aggregate-level data through private research groups can be used with CMS approval. And additionally, limited data sets are available to commercial entities to perform some research and policy evaluations. But they're not usually available for specific technology assessments for commercial purposes. On the other hand, commercially-insured claims data can be purchased and the data is updated monthly to annually depending on the source, but it does not include the full commercial claims population. So, it may include a subset of the population and may or may not be applicable to the purposes of a particular technology assessment. Additionally, it tends to cover as I mentioned the under 65 population. Another emerging source of claims data are state all paid or claims data bases which aggregate medicare, Medicaid and commercially insured claims data into a single source. These would be available on a state by state basis, and the use of the data would depend on what's allowed by each state. Quickly summarizing the difference between Commercial vs Medicare data, Medicare is again the over 65 and disabled population. And once an individual is enrolled in Medicare they continue to be covered until death. However, in the commercial population, which is traditionally employer based, and the individual market it includes under 65 and coverage may change with employment. So If a person changes jobs every few years, their insurer will change. Alternatively if the employer changes insurers, the insurer will also change. Other differences between Medicare and commercial insurance include demographic information. Most importantly, race and ethnicity is included in the Medicare data, but it's not included in commercial data. Overall, the strengths and limitations of, there are strengths and limitations of claims data. There is clinical validity in that there's information about all covered services and claims data and all types of claims data include demographic information. Additionally, claims data covers the large populations, so there's large sample sizes for technology assessment. And, compared to chart reviews or clinical data collection, claims data is cost effective. It's important to remember the limitations of claims data too. It's not comprehensive in the disease and severity information collected. Only the information about, that's recorded in the claims data is available. So, there's limited clinical information, no lab results, no test results, and it's only services that are reimbursed or that needed to be coded are listed in the claims data. Additionally, if it's not recorded, it's not reported and not available in claims data. This leads to, tends to lead to under diagnosis of diseases. It's also not in the claims data, if people don't take care for it. So, if people with diabetes aren't going to their physicians, it's not recorded in their claims. And finally it's not representative of the general population. Medicare claims don't represent the under 65 population. Commercial health claims don't represent the over 65 population. So although there's large samples, it's still not representative of all patients seeking care at all times.
