Challenges in merging Medicaid and Medicare databases to obtain healthcare costs for dual-eligible beneficiaries: using diabetes as an example

Linking Medicare-Medicaid Claims for Patient-Centered Outcomes Research Among Dual-Eligible Beneficiaries

BACKGROUND

Evaluation of Medicare-Medicaid integration models' effects on patient-centered outcomes and costs requires multiple data sources and validated processes for linkage and reconciliation.

OBJECTIVE

To describe the opportunities and limitations of linking state-specific Medicaid and Centers for Medicare & Medicaid Services administrative claims data to measure patient-centered outcomes for North Carolina dual-eligible beneficiaries.

RESEARCH DESIGN

We developed systematic processes to (1) validate the beneficiary ID linkage using sex and date of birth in a beneficiary ID crosswalk, (2) verify dates of dual enrollment, and (3) reconcile Medicare-Medicaid claims data to support the development and use of patient-centered outcomes in linked data.

PARTICIPANTS

North Carolina Medicaid beneficiaries with full Medicaid benefits and concurrent Medicare enrollment (FBDE) between 2014 and 2017.

MEASURES

We identified need-based subgroups based on service use and eligibility program requirements. We calculated utilization and costs for Medicaid and Medicare, matched Medicaid claims to Medicare service categories where possible, and reported outcomes by the payer. Some services were covered only by Medicaid or Medicare, including Medicaid-only covered home and community-based services (HCBS).

RESULTS

Of 498,030 potential dual enrollees, we verified the linkage and FBDE eligibility of 425,664 (85.5%) beneficiaries, including 281,174 adults enrolled in Medicaid and Medicare fee-for-service. The most common need-based subgroups were intensive behavioral health service users (26.2%) and HCBS users (10.8%) for adults under age 65, and HCBS users (20.6%) and nursing home residents (12.4%) for adults age 65 and over. Medicaid funded 42% and 49% of spending for adults under 65 and adults 65 and older, respectively. Adults under 65 had greater behavioral health service utilization but less skilled nursing facility, HCBS, and home health utilization compared with adults 65 and older.

CONCLUSIONS

Linkage of Medicare-Medicaid data improves understanding of patient-centered outcomes among FBDE by combining Medicare-funded acute and ambulatory services with Medicaid-funded HCBS. Using linked Medicare-Medicaid data illustrates the diverse patient experience within FBDE beneficiaries, which is key to informing patient-centered outcomes, developing and evaluating integrated Medicare and Medicaid programs, and promoting health equity.

Novel Data Linkages to Characterize Palliative and End-Of-Life Care: Challenges and Considerations

CONTEXT

Working groups have called for linkages of existing and diverse databases to improve quality measurement in palliative and end-of-life (EOL) care, but limited data are available on the challenges of using different data sources to measure such care.

OBJECTIVES

To assess concordance of data obtained from different sources in a novel linkage of death certificates, electronic health records (EHRs), cancer registry data, and insurance claims for patients who died with cancer.

METHODS

We joined a database of Washington State death certificates and EHR to a data repository of commercial health plan enrollment and claims files linked to registry records from Puget Sound Cancer Surveillance System. We assessed care in the last month including hospitalizations, intensive care unit (ICU) admissions, emergency department visits, imaging scans, radiation, and hospice, plus chemotherapy in the last 14 days. We used a Chi-squared test to compare differences between health care in EHR and claims.

RESULTS

Records of hospitalization, ICU use, and emergency department use were 33%, 15%, and 33% lower in EHR versus claims, respectively. Radiation, hospice, and imaging were 6%, 14%, and 28% lower, respectively, in EHR, but chemotherapy was 4% higher than that in claims. These differences were statistically different for hospice (P < 0.02), hospitalization, ICU, ER, and imaging (all P < 0.01) but not radiation (P = 0.12) or chemotherapy (P = 0.29).

CONCLUSION

We found substantial variation between EHR and claims for EOL health-care use. Reliance on EHR will miss some health-care use, while claims will not capture the complex clinical details in EHR that can help define the quality of palliative care and EOL health-care utilization.

A natural language processing program effectively extracts key pathologic findings from radical prostatectomy reports

INTRODUCTION AND OBJECTIVE

Natural language processing (NLP) software programs have been widely developed to transform complex free text into simplified organized data. Potential applications in the field of medicine include automated report summaries, physician alerts, patient repositories, electronic medical record (EMR) billing, and quality metric reports. Despite these prospects and the recent widespread adoption of EMR, NLP has been relatively underutilized. The objective of this study was to evaluate the performance of an internally developed NLP program in extracting select pathologic findings from radical prostatectomy specimen reports in the EMR.

METHODS

An NLP program was generated by a software engineer to extract key variables from prostatectomy reports in the EMR within our healthcare system, which included the TNM stage, Gleason grade, presence of a tertiary Gleason pattern, histologic subtype, size of dominant tumor nodule, seminal vesicle invasion (SVI), perineural invasion (PNI), angiolymphatic invasion (ALI), extracapsular extension (ECE), and surgical margin status (SMS). The program was validated by comparing NLP results to a gold standard compiled by two blinded manual reviewers for 100 random pathology reports.

RESULTS

NLP demonstrated 100% accuracy for identifying the Gleason grade, presence of a tertiary Gleason pattern, SVI, ALI, and ECE. It also demonstrated near-perfect accuracy for extracting histologic subtype (99.0%), PNI (98.9%), TNM stage (98.0%), SMS (97.0%), and dominant tumor size (95.7%). The overall accuracy of NLP was 98.7%. NLP generated a result in <1 second, whereas the manual reviewers averaged 3.2 minutes per report.

CONCLUSIONS

This novel program demonstrated high accuracy and efficiency identifying key pathologic details from the prostatectomy report within an EMR system. NLP has the potential to assist urologists by summarizing and highlighting relevant information from verbose pathology reports. It may also facilitate future urologic research through the rapid and automated creation of large databases.

Integrating databases for research on health and performance in small animals and horses in the Nordic countries

In a world of limited resources, using existing databases in research is a potentially cost-effective way to increase knowledge, given that correct and meaningful results are gained.Nordic examples of the use of secondary small animal and equine databases include studies based on data from tumour registries, breeding registries, young horse quality contest results, competition data, insurance databases, clinic data, prescription data and hunting ability tests. In spite of this extensive use of secondary databases, integration between databases is less common. The aim of this presentation is to briefly review key papers that exemplify different ways of utilizing data from multiple sources, to highlight the benefits and limitations of the approaches, to discuss key issues/challenges that must be addressed when integrating data and to suggest future directions. Data from pedigree databases have been individually merged with competition data and young horse quality contest data, and true integration has also been done with canine insurance data and with equine clinical data. Data have also been merged on postal code level; i.e. insurance data were merged to a digitized map of Sweden and additional meteorological information added. In addition to all the data quality and validity issues inherent in the use of a single database, additional obstacles arise when combining information from several databases. Loss of individuals due to incorrect or mismatched identifying information can be considerable. If there are any possible biases affecting whether or not individuals can be properly linked, misinformation may result in a further reduction in power. Issues of confidentiality may be more difficult to address across multiple databases. For example, human identity information must be protected, but may be required to ensure valid merging of data. There is a great potential to better address complex issues of health and disease in companion animals and horses by integrating information across existing databases. The challenges outlined in this article should not preclude the ongoing pursuit of this approach.

Health services research and data linkages: issues, methods, and directions for the future

BACKGROUND

Research on pressing health services and policy issues requires access to complete, accurate, and timely patient and organizational data.

AIM

This paper describes how administrative and health records (including electronic medical records) can be linked for comparative effectiveness and health services research.

MATERIALS AND METHODS

We categorize the major agents (i.e., who owns and controls data and who carries out the data linkage) into three areas: (1) individual investigators; (2) government sponsored linked data bases; and (3) public-private partnerships that facilitate linkage of data owned by private organizations. We describe challenges that may be encountered in the linkage process, and the benefits of combining secondary databases with primary qualitative and quantitative sources. We use cancer care research to illustrate our points.

RESULTS

To fill the gaps in the existing data infrastructure, additional steps are required to foster collaboration among institutions, researchers, and public and private components of the health care sector. Without such effort, independent researchers, governmental agencies, and nonprofit organizations are likely to continue building upon a fragmented and costly system with limited access. Discussion. Without the development and support for emerging information technologies across multiple health care settings, the potential for data collected for clinical and transactional purposes to benefit the research community and, ultimately, the patient population may go unrealized.

CONCLUSION

The current environment is characterized by budget and technical challenges, but investments in data infrastructure are arguably cost-effective given the need to reform our health care system and to monitor the impact of health reform initiatives.