Use Case 40: Patient demographics for provider utilization datasets

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Requirements

Use case summary

Description

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

  • 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.


Customer

  • DocGraph
  • ProPublica


Current data and limitation

  • Data source: Provider utilization dataset.
  • Limitations: Doesn't give sufficient insight into demographics to distinguish populations.


Specifications

  • Fields:
    • 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



Solution

Datasets provided

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:
    1. Age:
      • "Average Age of Beneficiaries
      • "Number of Beneficiaries Age...": Less than 65, 65 to 74, 75 to 84, Greater than 84
    2. Sex:
      • "Number of Female Beneficiaries", "Number of Male Beneficiaries"
    3. Race:
      • "Number of Beneficiaries" who are... Black or African American, Asian Pacific Islander, Hispanic, American Indian/Alaska Native, Race Not Elsewhere Classified
    4. Medicare and Medicaid entitlement:
      • "Number of Beneficiaries With Medicare Only Entitlement"
      • "Number of Beneficiaries With Medicare & Medicaid Entitlement"
    5. 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
    6. Risk scores:
      • "Average HCC Risk Score of Beneficiaries"


  • File locations
CY 2012: "Medicare Physician and Other Supplier Aggregate table, CY2012, Microsoft Excel (.xlsx)"
http://download.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Downloads/Medicare_Physician_and_Other_Supplier_NPI_Aggregate_CY2012_update.zip
CY 2013: "Medicare Physician and Other Supplier Aggregate table, CY2013, Microsoft Excel (.xlsx)"
http://download.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Downloads/Medicare_Physician_and_Other_Supplier_NPI_Aggregate_CY2013.zip

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.