Use Case 40: Patient demographics for provider utilization datasets
Use case summary
- Title: Patient demographics for provider utilization datasets
- Work item: https://github.com/demand-driven-open-data/ddod-intake/issues/40
There's a need to better understand the data in provider utilization datasets by incorporating patient demographics. That's because Medicare patients do not all look alike.
- A provider who sees a majority of patients with disabilities who are under the age of 65 should have their other data points interpreted completely differently.)
- Similarly, a doctor whose average patient age is 95 should be evaluated differently then one whose patient age is 67.
- Tranches of ages and gender should be considered for this report. To avoid the risk re-identification for these general cases, it would be fine to provide no patient counts under 50.
- Value to industry/public:
- This information enables industry analysts and media more effectively interpret the previously published provider utilization data. Utilization data has sometimes been used incorrectly to imply waste, fraud and abuse.
- Consumers benefit from having more accurate information when choosing their healthcare provider.
- Additionally, the potential misinterpretation of utilization data could have an adverse effect on the decisions healthcare providers make when treating patients.
Current data and limitation
- Data source: Provider utilization dataset.
- Limitations: Doesn't give sufficient insight into demographics to distinguish populations.
- Original fields: NPI, HCPCS (CPT), number of services, number of beneficiaries, average submitted charge
- Beneficiary demographic fields: Age, sex, race, Medicare / Medicaid entitlement, chronic conditions, risk scores
- Joins between datasets: Demographic fields should be consistent and joinable with other datasets for analytics
- Update frequency: Same as provider utilization datasets
- Lag time: Same as provider utilization datasets
- History: Same as provider utilization datasets
- Delivery mechanism: Same as provider utilization datasets
An update has been made on 10/5/2015 to the relevant tables of CY 2012 and CY 2013 "Medicare Provider Utilization and Payment Data: Physician and Other Supplier" datasets that includes the items asked for.
- Provider-level summary tables now include aggregated information on the following beneficiary attributes:
- "Average Age of Beneficiaries
- "Number of Beneficiaries Age...": Less than 65, 65 to 74, 75 to 84, Greater than 84
- "Number of Female Beneficiaries", "Number of Male Beneficiaries"
- "Number of Beneficiaries" who are... Black or African American, Asian Pacific Islander, Hispanic, American Indian/Alaska Native, Race Not Elsewhere Classified
- Medicare and Medicaid entitlement:
- "Number of Beneficiaries With Medicare Only Entitlement"
- "Number of Beneficiaries With Medicare & Medicaid Entitlement"
- 16 chronic conditions:
- "Percent (%) of Beneficiaries Identified With..." Alzheimer’s Disease or Dementia, Asthma, Atrial Fibrillation, Cancer, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Depression, Diabetes, Heart Failure, Hyperlipidemia, Hypertension, Ischemic Heart Disease, Osteoporosis, Rheumatoid Arthritis / Osteoarthritis, Schizophrenia / Other Psychotic Disorders, Stroke
- Risk scores:
- "Average HCC Risk Score of Beneficiaries"
- File locations
- CY 2012: "Medicare Physician and Other Supplier Aggregate table, CY2012, Microsoft Excel (.xlsx)"
- CY 2013: "Medicare Physician and Other Supplier Aggregate table, CY2013, Microsoft Excel (.xlsx)"
Limitations and challenges
- Users should keep in mind the limits of these datasets:
- The data includes only care delivered to Medicare beneficiaries in the fee-for-service (Medicare Part B) program. So it may not represent a provider's entire patient population. (It doesn't capture patients who are uninsured or enrolled in Medicare Advantage, Medicaid coverage or private health insurance.)
- For services provided in a facility setting (i.e., in outside a physician's office), typically only the payment to the provider is included, but not to the facility.
- There's an associated "Lookup Tool" at https://data.cms.gov/use-agreement/data-limitations/provider-explorer that's populated from the same data. But as of 11/3/2015, it lacked the new demographic data.