2.2.3 Sources of Claims Data

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En provenance du cours de University of Minnesota

Medical Technology and Evaluation

112 notes

University of Minnesota

Medical Technology and Evaluation

112 notes

Cours 4 sur 5 dans Specialization Healthcare Marketplace

Innovations in medical technologies are one of the leading areas of economic growth in the world. Whether new technologies take the form of pharmaceutical, medical device, biotechnology, information technology of some combination of these innovations, the opportunities for both private enterprise and social welfare are substantial. However, these innovations are not without cost, and require reimbursement from either a privately or publicly financed health care delivery system to enter the marketplace. This course aims to provide knowledge of the concepts, data, and methodology required to critically evaluate new medical technologies in order to secure financial investment, reimbursement, and regulatory compliance objectives, such as FDA approval. The course is designed to provide understanding of the analytic tools needed to evaluate medical technologies. After completing this course, students will have the skills needed to: - Understand the reimbursement systems financing medical technology use. - Understand the role of government and regulatory agencies in the development and use of new medical technologies. - Identify a population to be served by a medical technology. - Use health care data to evaluate a medical technology. - Perform cost/benefit and cost/effectiveness analysis of a new technology.

À partir de la leçon

Clinical Trials and Insurance Claims Data

This module discusses the two most common types of data used in medical technology evaluations: clinical trial data and health insurance claims data. The discussion of clinical trial data covers the basic elements of trial design that help ensure the results will be reliable inputs to technology evaluations. The discussion of claims data covers what types of information is available in claims and how it differs from clinical data. It also covers potential sources of data. The module concludes with a few lessons that discuss general considerations and precautions when using data to ensure the validity of a technology evaluation.

2.2.1 Introduction to Administrative Data6:13

2.2.2 Elements of Claims Data12:17

2.2.3 Sources of Claims Data6:58

Rencontrer les enseignants

Eric Barrette
Director of Research
Health Care Cost Institute

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.

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