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Patient Claims Databases

Patient Claims Databases. Physician Office and Hospital Outpatient Settings

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Patient Claims Databases

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  1. PatientClaims Databases • Physician Office and Hospital Outpatient Settings • The IMS Health analysis of claims data focuses specifically on patients diagnosed with multiple myeloma. These data are obtained from CMS-1500 medical forms and include patient-level diagnoses and procedures for visits to U.S. office-based physicians, ambulatory, general health care sites, and hospitals. The CMS-1500 form is the standard reimbursement form for all non-cash claims. This includes all third-party payers, Medicare, and Medicaid. • The reporting period is for calendar year 2010 through calendar year 2012, with a look back through the patient’s medical history to assign cancer diagnoses. Patients diagnosed and treated for multiple myeloma were tracked if they received chemotherapy. Patients diagnosed with multiple myeloma but not receiving chemotherapy were included if they visited practitioners in the reporting year who potentially could administer chemotherapy (Oncologists or Hematologists). All patients receiving therapy were included regardless of the specialty of the physician providing the therapy. • Physician office charges include only those drug charges administered in that setting (i.e., chemotherapy, supportive care, steroids). If there is a lab component, this would also be captured, along with administrative service charges. Medication charges incurred in a physician office are usually paid at contracted rates, which can be lower than billed charges. With more than two-thirds of myeloma patients treated in the physician office setting covered by Medicare, physician offices are also disproportionately affected by corresponding Medicare reimbursement rates. As of April 2013, separately paid drugs in physician offices were reimbursed at ASP + 4.3%, reduced from 6.0% in 2012. • In addition to drug charges, hospital outpatient charges incorporate other aspects of care (i.e., pharmacy, imaging, provider services). Although hospitals and physician offices use the same billing codes, rates still differ. Due to economies of scale and stronger relationships with group purchasing organizations, hospitals generally pay less for chemotherapy drugs and are reimbursed at lower rates.

  2. Hospital Procedure/Diagnosis (HPD) Discharge Data • Inpatient Setting: • This database contains an extensive set of hospital inpatient and outpatient discharge records, including actual diagnoses and procedures data for about 75% of all hospital discharges nationwide (including 100% of Medicare-reimbursed discharges). • IMS uses Medicare procedure counts and additional hospital-level information to estimate procedure counts for the remaining 25% of discharges—the non-Medicare hospital discharge information in non-reporting states. • The hospital inpatient data will include three years of data and will be current as of calendar year 2011.

  3. Physician Office and Hospital Outpatient Multiple Myeloma Patients: Age

  4. Physician Office 1 Includes HMOs, PPOs, point-of-service plans and exclusive provider organizations. Note: Physician office charges include only those drug charges administered in that setting (i.e., chemotherapy, supportive care, steroids). If there is a lab component, this would also be captured, along with administrative service charges. Medication charges incurred in a physician office are usually paid at contracted rates, which can be lower than billed charges. With more than two-thirds of myeloma patients treated in the physician office setting covered by Medicare, physician offices are also disproportionately affected by corresponding Medicare reimbursement rates. As of April 2013, separately paid drugs in physician offices were reimbursed at ASP + 4.3%, reduced from 6.0% in 2012. In addition to drug charges, hospital outpatient charges incorporate other aspects of care (i.e., pharmacy, imaging, provider services). Although hospitals and physician offices use the same billing codes, rates still differ. Due to economies of scale and stronger relationships with group purchasing organizations, hospitals generally pay less for chemotherapy drugs and are reimbursed at lower rates.

  5. Physician Office

  6. Physician Office Treatment Patterns: Cycles 1 Includes HMOs, PPOs, point-of-service plans and exclusive provider organizations.

  7. Physician Office Multiple Myeloma Patients: Complications 1 A complication is defined as a patient condition caused by the multiple myeloma of the patient. These conditions are a direct result of having multiple myeloma.

  8. Physician Office Financial Impact: Complications 1 A complication is defined as a patient condition caused by the multiple myeloma of the patient. These conditions are a direct result of having multiple myeloma. Note: Physician office charges include only those drug charges administered in that setting (i.e., chemotherapy, supportive care, steroids). If there is a lab component, this would also be captured, along with administrative service charges. Medication charges incurred in a physician office are usually paid at contracted rates, which can be lower than billed charges. With more than two-thirds of myeloma patients treated in the physician office setting covered by Medicare, physician offices are also disproportionately affected by corresponding Medicare reimbursement rates. As of April 2013, separately paid drugs in physician offices were reimbursed at ASP + 4.3%, reduced from 6.0% in 2012. In addition to drug charges, hospital outpatient charges incorporate other aspects of care (i.e., pharmacy, imaging, provider services). Although hospitals and physician offices use the same billing codes, rates still differ. Due to economies of scale and stronger relationships with group purchasing organizations, hospitals generally pay less for chemotherapy drugs and are reimbursed at lower rates. Some physician office charge data were unavailable for the selected markets.

  9. Hospital Outpatient Note: Hospital outpatient data on this slide are based on all short-term, acute-care, nonfederal hospitals and are effective as of end-of-year 2011. Psychiatric, rehabilitation, and children’s hospitals are excluded.

  10. Hospital Outpatient Multiple Myeloma Patients: Case Counts Note: Hospital data are based on all short-term, acute-care, nonfederal hospitals and are effective as of end-of-year 2011. Psychiatric, rehabilitation, and children’s hospitals are excluded.

  11. Hospital Outpatient

  12. Hospital Inpatient Treatment Patterns: Average Length of Stay Note: Hospital data are based on all short-term, acute-care, nonfederal hospitals and are effective as of end-of-year 2011. Psychiatric, rehabilitation, and children’s hospitals are excluded.

  13. Hospital Inpatient Financial Impact: Charges 1 Charge data are per-case averages for inpatients with a particular diagnosis of interest. Charges may be for treatment related to other diagnoses.

  14. Hospital Inpatient Secondary Diagnoses and Procedures

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