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Program Overview MAX Data Data Integrity Resources
Using Medicaid Data, or:How I Learned to Stop Worrying and Love MedMAX
Becky StaigerTDI Data Analytics Seminar
Research Assistant, The Dartmouth InstitutePh.D. Candidate, Yale Health Policy & Management
May 31, 2018
MedMAX Data Becky Staiger [email protected] 1
Program Overview MAX Data Data Integrity Resources
Thank You’s
HUGE thank you to Jon Skinner and everyone at the DAC!!
MedMAX Data Becky Staiger [email protected] 2
Program Overview MAX Data Data Integrity Resources
Goals
1 Understand concerns about MAX data
2 Understand where these concerns come from
3 Understand how to use resources
4 Use the data!
MedMAX Data Becky Staiger [email protected] 3
Program Overview MAX Data Data Integrity Resources
Goals
1 Understand concerns about MAX data
2 Understand where these concerns come from
3 Understand how to use resources
4 Use the data!
MedMAX Data Becky Staiger [email protected] 4
Program Overview MAX Data Data Integrity Resources
Goals
1 Understand concerns about MAX data
2 Understand where these concerns come from
3 Understand how to use resources
4 Use the data!
MedMAX Data Becky Staiger [email protected] 5
Program Overview MAX Data Data Integrity Resources
Goals
1 Understand concerns about MAX data
2 Understand where these concerns come from
3 Understand how to use resources
4 Use the data!
MedMAX Data Becky Staiger [email protected] 6
Program Overview MAX Data Data Integrity Resources
Agenda
1 Program Overview
2 MAX Data
3 Data Integrity
4 Resources
MedMAX Data Becky Staiger [email protected] 7
Program Overview MAX Data Data Integrity Resources
Agenda
1 Program Overview
2 MAX Data
3 Data Integrity
4 Resources
MedMAX Data Becky Staiger [email protected] 8
Program Overview MAX Data Data Integrity Resources
History
Source: Office of the Actuary, Centers for Medicare & Medicaid Services, 2015
MedMAX Data Becky Staiger [email protected] 9
Program Overview MAX Data Data Integrity Resources
Medicaid Coverage
Source: Kaiser Family Foundation. “Medicaid in the United States.” June 2017.
MedMAX Data Becky Staiger [email protected] 10
Program Overview MAX Data Data Integrity Resources
Medicaid Organization
Federal Government
State
FMAP ($%)
TraditionalMedicaid
FFS ($)
Managed CareOrganization
Capitated Pmt ($)
(Not) For ProfitMedicaid-Only v.Commercial
FMAP = Federal Medical Assistance Percentage
FFS = Fee-for-service
MedMAX Data Becky Staiger [email protected] 11
Program Overview MAX Data Data Integrity Resources
Medicaid Organization
Federal Government
State
FMAP ($%)
TraditionalMedicaid
FFS ($)
Managed CareOrganization
Capitated Pmt ($)
(Not) For ProfitMedicaid-Only v.Commercial
FMAP = Federal Medical Assistance PercentageFFS = Fee-for-service
MedMAX Data Becky Staiger [email protected] 12
Program Overview MAX Data Data Integrity Resources
History
Source: Office of the Actuary, Centers for Medicare & Medicaid Services, 2015
MedMAX Data Becky Staiger [email protected] 13
Program Overview MAX Data Data Integrity Resources
Medicaid Organization
Federal Government
State
FMAP ($%)
TraditionalMedicaid
FFS ($)
Managed CareOrganization
Capitated Pmt ($)
(Not) For ProfitMedicaid-Only v.Commercial
FMAP = Federal Medical Assistance PercentageFFS = Fee-for-service
MedMAX Data Becky Staiger [email protected] 14
Program Overview MAX Data Data Integrity Resources
Increase in Managed Care Enrollment, 2002–2016
2002 2004 2006 2008 2010 2012 2014 20160
20
40
60
80
Year
En
rolle
es(M
illio
ns)
TotalMCO
Source: Medicaid Managed Care Enrollment Reports (missing: 2012)
MedMAX Data Becky Staiger [email protected] 15
Program Overview MAX Data Data Integrity Resources
Agenda
1 Program Overview
2 MAX Data
3 Data Integrity
4 Resources
MedMAX Data Becky Staiger [email protected] 16
Program Overview MAX Data Data Integrity Resources
“Eras” of Data Development
Source: Baugh et al. “Federal Stewardship of the Medicaid Program: Strengthening Data Systems for EffectiveDecision Making.” Mathematica. July 2017.
MedMAX Data Becky Staiger [email protected] 17
Program Overview MAX Data Data Integrity Resources
“Eras” of Data Development
Source: Baugh et al. “Federal Stewardship of the Medicaid Program: Strengthening Data Systems for EffectiveDecision Making.” Mathematica. July 2017.
MedMAX Data Becky Staiger [email protected] 18
Program Overview MAX Data Data Integrity Resources
MAX Records Files
Inpatient(IP)
Drug (RX)
Long-TermCare (LT)
Other Services (OT)
Person Summary (PS)
MedMAX Data Becky Staiger [email protected] 19
Program Overview MAX Data Data Integrity Resources
MAX Records Files
1 IP: services provided in an inpatient setting• At a “stay” level• Information available: diagnosis codes, procedure codes,
services performed in the facility
2 RX: service provided by a pharmacy• Any claim with an NDC code (e.g. drugs, durable medical
equipment)
3 LT: services provided in long-term care institutions (e.g.,nursing facilities, intermediate care facilities, psychiatrichospitals)
4 OT: everything else (e.g. office visits, ED admissions)
5 PS: summary files about utilization, expenditures at thebeneficiary × year level
MedMAX Data Becky Staiger [email protected] 20
Program Overview MAX Data Data Integrity Resources
MAX Records Files
Inpatient(IP)
Drug (RX)
Long-TermCare (LT)
Other Services (OT)
Person Summary (PS)
MedMAX Data Becky Staiger [email protected] 21
Program Overview MAX Data Data Integrity Resources
MAX Records Files
1 IP: services provided in an inpatient setting• At a “stay” level• Information available: diagnosis codes, procedure codes,
services performed in the facility
2 RX: service provided by a pharmacy• Any claim with an NDC code (e.g. drugs, durable medical
equipment)
3 LT: services provided in long-term care institutions (e.g.,nursing facilities, intermediate care facilities, psychiatrichospitals)
4 OT: everything else (e.g. office visits, ED admissions)
5 PS: summary files about utilization, expenditures at thebeneficiary × year level
MedMAX Data Becky Staiger [email protected] 22
Program Overview MAX Data Data Integrity Resources
MAX Records Files
Inpatient(IP)
Drug (RX)Long-TermCare (LT)
Other Services (OT)
Person Summary (PS)
MedMAX Data Becky Staiger [email protected] 23
Program Overview MAX Data Data Integrity Resources
MAX Records Files
1 IP: services provided in an inpatient setting• At a “stay” level• Information available: diagnosis codes, procedure codes,
services performed in the facility
2 RX: service provided by a pharmacy• Any claim with an NDC code (e.g. drugs, durable medical
equipment)
3 LT: services provided in long-term care institutions (e.g.,nursing facilities, intermediate care facilities, psychiatrichospitals)
4 OT: everything else (e.g. office visits, ED admissions)
5 PS: summary files about utilization, expenditures at thebeneficiary × year level
MedMAX Data Becky Staiger [email protected] 24
Program Overview MAX Data Data Integrity Resources
MAX Records Files
Inpatient(IP)
Drug (RX)Long-TermCare (LT)
Other Services (OT)
Person Summary (PS)
MedMAX Data Becky Staiger [email protected] 25
Program Overview MAX Data Data Integrity Resources
MAX Records Files
1 IP: services provided in an inpatient setting• At a “stay” level• Information available: diagnosis codes, procedure codes,
services performed in the facility
2 RX: service provided by a pharmacy• Any claim with an NDC code (e.g. drugs, durable medical
equipment)
3 LT: services provided in long-term care institutions (e.g.,nursing facilities, intermediate care facilities, psychiatrichospitals)
4 OT: everything else (e.g. office visits, ED admissions)
5 PS: summary files about utilization, expenditures at thebeneficiary × year level
MedMAX Data Becky Staiger [email protected] 26
Program Overview MAX Data Data Integrity Resources
MAX Records Files
Inpatient(IP)
Drug (RX)Long-TermCare (LT)
Other Services (OT)
Person Summary (PS)
MedMAX Data Becky Staiger [email protected] 27
Program Overview MAX Data Data Integrity Resources
MAX Records Files
1 IP: services provided in an inpatient setting• At a “stay” level• Information available: diagnosis codes, procedure codes,
services performed in the facility
2 RX: service provided by a pharmacy• Any claim with an NDC code (e.g. drugs, durable medical
equipment)
3 LT: services provided in long-term care institutions (e.g.,nursing facilities, intermediate care facilities, psychiatrichospitals)
4 OT: everything else (e.g. office visits, ED admissions)
5 PS: summary files about utilization, expenditures at thebeneficiary × year level
MedMAX Data Becky Staiger [email protected] 28
Program Overview MAX Data Data Integrity Resources
Record Layout and Description Documents
CMS: File layout and description documents (for each file)
MedMAX Data Becky Staiger [email protected] 29
Program Overview MAX Data Data Integrity Resources
Example: PS 2014
MedMAX Data Becky Staiger [email protected] 30
Program Overview MAX Data Data Integrity Resources
Example: PS 2014
MedMAX Data Becky Staiger [email protected] 31
Program Overview MAX Data Data Integrity Resources
Example: PS 2014
MedMAX Data Becky Staiger [email protected] 32
Program Overview MAX Data Data Integrity Resources
Example: PS 2014
MedMAX Data Becky Staiger [email protected] 33
Program Overview MAX Data Data Integrity Resources
Example: PS 2014
MedMAX Data Becky Staiger [email protected] 34
Program Overview MAX Data Data Integrity Resources
File Details
Additional information:
• Years available: 2008–2014
• States available: depends
• Beneficiary identifiers: MSIS ID (state), BENE ID (national)
• Provider identifiers: NPI (national)1
• Incomplete information when beneficiary has other coverage(e.g. third-party payers or Medicare)
1Caveat: This is a little tricky in earlier years—use MAXPC as thecrosswalk between between state-specific i.d. and NPI
MedMAX Data Becky Staiger [email protected] 35
Program Overview MAX Data Data Integrity Resources
Agenda
1 Program Overview
2 MAX Data
3 Data Integrity
4 Resources
MedMAX Data Becky Staiger [email protected] 36
Program Overview MAX Data Data Integrity Resources
Data Concerns
“What keeps MedMAX users up at night?”
1 Encounter data2 Certain variables, e.g.
• Race/ethnicity reporting• Payment amounts for third-party payers• Procedure coding differences
3 State-specific concerns
MedMAX Data Becky Staiger [email protected] 37
Program Overview MAX Data Data Integrity Resources
Data Concerns
“What keeps MedMAX users up at night?”
1 Encounter data
2 Certain variables, e.g.• Race/ethnicity reporting• Payment amounts for third-party payers• Procedure coding differences
3 State-specific concerns
MedMAX Data Becky Staiger [email protected] 38
Program Overview MAX Data Data Integrity Resources
Data Reporting Structure (MAX)
CMS
State
MSIS
TraditionalMedicaid
Managed CareOrganization
Capitated Pmt ($)
ServicesUsed
Cost ofCare
ServicesUsed
Cost ofCare
“FFS Claims”
“CapitatedClaims”
“EncounterClaims”
MedMAX Data Becky Staiger [email protected] 39
Program Overview MAX Data Data Integrity Resources
Data Reporting Structure (MAX)
CMS
State
MSIS
TraditionalMedicaid
Managed CareOrganization
Capitated Pmt ($)
ServicesUsed
Cost ofCare
ServicesUsed
Cost ofCare
“FFS Claims”
“CapitatedClaims”
“EncounterClaims”
MedMAX Data Becky Staiger [email protected] 40
Program Overview MAX Data Data Integrity Resources
Data Reporting Structure (MAX)
CMS
State
MSIS
TraditionalMedicaid
Managed CareOrganization
Capitated Pmt ($)
ServicesUsed
Cost ofCare
ServicesUsed
Cost ofCare
“FFS Claims”
“CapitatedClaims”
“EncounterClaims”
MedMAX Data Becky Staiger [email protected] 41
Program Overview MAX Data Data Integrity Resources
Data Reporting Structure (MAX)
In summary:
The state reports:
1 FFS claims (all files)
2 Capitated claims (OT files)
The managed care plans report:
1 Encounter claims, i.e. servicesprovided to an enrollee by the MCO
CMS creates MAX
Problem: encounter claims don’t undergo the same quality andvalidation checks
MedMAX Data Becky Staiger [email protected] 42
Program Overview MAX Data Data Integrity Resources
Data Reporting Structure (MAX)
In summary:
The state reports:
1 FFS claims (all files)
2 Capitated claims (OT files)
The managed care plans report:
1 Encounter claims, i.e. servicesprovided to an enrollee by the MCO
CMS creates MAX
Problem: encounter claims don’t undergo the same quality andvalidation checks
MedMAX Data Becky Staiger [email protected] 43
Program Overview MAX Data Data Integrity Resources
Data Reporting Structure (MAX)
In summary:
The state reports:
1 FFS claims (all files)
2 Capitated claims (OT files)
The managed care plans report:
1 Encounter claims, i.e. servicesprovided to an enrollee by the MCO
CMS creates MAX
Problem: encounter claims don’t undergo the same quality andvalidation checks
MedMAX Data Becky Staiger [email protected] 44
Program Overview MAX Data Data Integrity Resources
Claim Types
Sample: OT 2010
22 %
Encounter
50 %
FFS
28 %
Capitation
MedMAX Data Becky Staiger [email protected] 45
Program Overview MAX Data Data Integrity Resources
Data Concerns
But, don’t despair!
1 “Assessing the Usability of Encounter Data for Enrollees inComprehensive Managed Care Across MAX 2007–2009.”
2 “Assessing the Usability of Encounter Data for Enrollees inComprehensive Managed Care 2010–2011.”
Further:
• Differences within files
• Differences within eligibility categories
MedMAX Data Becky Staiger [email protected] 46
Program Overview MAX Data Data Integrity Resources
Data Concerns
But, don’t despair!
1 “Assessing the Usability of Encounter Data for Enrollees inComprehensive Managed Care Across MAX 2007–2009.”
2 “Assessing the Usability of Encounter Data for Enrollees inComprehensive Managed Care 2010–2011.”
Further:
• Differences within files
• Differences within eligibility categories
MedMAX Data Becky Staiger [email protected] 47
Program Overview MAX Data Data Integrity Resources
Sample: OT Encounter Data, 2010–2011
NR = fields not available in MAX
MedMAX Data Becky Staiger [email protected] 48
Program Overview MAX Data Data Integrity Resources
Sample: OT Encounter Data, 2010–2011
NR = fields not available in MAX
MedMAX Data Becky Staiger [email protected] 49
Program Overview MAX Data Data Integrity Resources
Sample: OT Encounter Data, 2010–2011
NR = fields not available in MAX
MedMAX Data Becky Staiger [email protected] 50
Program Overview MAX Data Data Integrity Resources
Sample: OT Encounter Data, 2010–2011
NR = fields not available in MAX
MedMAX Data Becky Staiger [email protected] 51
Program Overview MAX Data Data Integrity Resources
Sample: OT Encounter Data, 2010–2011
NR = fields not available in MAX
MedMAX Data Becky Staiger [email protected] 52
Program Overview MAX Data Data Integrity Resources
Data Concerns
“What keeps MedMAX users up at night?”
1 Encounter data
2 Certain variables, e.g.• Race/ethnicity reporting• Payment amounts for third-party payers• Procedure coding differences
3 State-specific concerns
MedMAX Data Becky Staiger [email protected] 53
Program Overview MAX Data Data Integrity Resources
Data Concerns
“What keeps MedMAX users up at night?”
1 Encounter data2 Certain variables, e.g.
• Race/ethnicity reporting• Payment amounts for third-party payers• Procedure coding differences
3 State-specific concerns
MedMAX Data Becky Staiger [email protected] 54
Program Overview MAX Data Data Integrity Resources
Data Concerns
“What keeps MedMAX users up at night?”
1 Encounter data2 Certain variables, e.g.
• Race/ethnicity reporting• Payment amounts for third-party payers• Procedure coding differences
3 State-specific concerns
MedMAX Data Becky Staiger [email protected] 55
Program Overview MAX Data Data Integrity Resources
Data Concerns
But, don’t despair!1 Validation tables
• One report per state × year• Includes measures for each file• Compares measures to two previous years
2 Anomaly tables• Flag “weird” data (outside normal ranges);• Provide explanation for observed value• Claims anomaly tables• Eligibility anomaly tables
All available online (CMS.gov)
MedMAX Data Becky Staiger [email protected] 56
Program Overview MAX Data Data Integrity Resources
Example: Validation Table, DC
MedMAX Data Becky Staiger [email protected] 57
Program Overview MAX Data Data Integrity Resources
Data Concerns
But, don’t despair!1 Validation tables
• One report per state × year• Includes measures for each file• Compares measures to two previous years
2 Anomaly tables• Flag “weird” data (outside normal ranges);• Provide explanation for observed value• Claims anomaly tables• Eligibility anomaly tables
All available online (CMS.gov)
MedMAX Data Becky Staiger [email protected] 58
Program Overview MAX Data Data Integrity Resources
Example: Claims Anomaly Tables
MedMAX Data Becky Staiger [email protected] 59
Program Overview MAX Data Data Integrity Resources
Example: Eligibility Anomaly Tables
MedMAX Data Becky Staiger [email protected] 60
Program Overview MAX Data Data Integrity Resources
Agenda
1 Program Overview
2 MAX Data
3 Data Integrity
4 Resources
MedMAX Data Becky Staiger [email protected] 61
Program Overview MAX Data Data Integrity Resources
Resources
• “Assessing the Usability of Encounter Data for Enrollees inComprehensive Managed Care Across MAX 2007–2009.” Byrdand Dodd. Mathematica Policy Research. December 2012.
• “Assessing the Usability of Encounter Data for Enrollees inComprehensive Managed Care 2010–2011.” Byrd and Dodd.Mathematica Policy Research. August 2015.
• “Guide to MAX Data.” Ruttner, Borck, Nysenbaum, andWilliams. Mathematic Policy Research. August 2015.
• Medicaid Managed Care Enrollment Reports.
• Kaiser Family Foundation (references)
• CMS’ Record Layout and Description Annual Files
• Much more!
MedMAX Data Becky Staiger [email protected] 62
Program Overview MAX Data Data Integrity Resources
Questions/Comments
Questions/comments?
Thanks for coming!
MedMAX Data Becky Staiger [email protected] 63