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Inpatient, Outpatient, and Pharmacy Costs from the
Decision Support System (DSS)
Jean YoonOctober 3, 2012
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Outline HERC Average Cost vs Decision Support System
(DSS) cost data How DSS gets costs DSS National Data Extracts
– Inpatient data– Outpatient data– Intermediate product department data– Pharmacy data
Using DSS data for research – HERC-created files (Station Level, Discharge with Subtotals)– Comparison with Medicare costs– Advantages of using DSS– Merging with clinical records, outliers, other issues
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Overview of VA Cost Data Sets Two possible sources:
– DSS cost Activity-based, managerial cost accounting system Implemented on a local level
– HERC average cost Assigns costs for each VA encounter based on
diagnoses, length of stay, procedures Directly comparable to Medicare and other payers
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Q&A Panel
What do you want to use DSS data for?
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HERC Average Costs Datasets
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HERC Average Cost Datasets HERC method of distributing costs to hospital stays
and outpatient visits Created to merge easily with clinical files
1)Acute medical surgical stays – Estimate of what stay would have cost in a Medicare
hospital, based on a regression model2) Other inpatient care– Length of stay
3) Outpatient care– Hypothetical Medicare payment based on procedure codes
assigned to visit
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Directly comparable to non-VA providers (Medicare)
Costs identical for all encounters with same characteristics
HERC has file with average cost for each person in each fiscal year
HERC Average Cost Datasets
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DSS National Data Extracts
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How Does DSS Provide VHA Cost Data?
VISTA workload, clinical, & financial data (FMS, PAID)
National Data Extracts of DSS
Time allocation Relative valuesDSS VISN Level Production Databases
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DSS Determines Costs of Products
Products are components of encounter Cost assigned to cost center (corresponding
department)– Staff labor mapping and financial data
Cost of overhead distributed to direct care departments
Products in each department tabulated Relative values assigned to products Unit cost of each product determined
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DSS Assigns Cost to Encounters
= Total cost of
encounter
X IP Cost ∑Intermediate Product (IP)
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DSS National Data Extracts
Inpatient (Treating Specialty, Discharge) Outpatient Encounter Intermediate Product Department Pharmacy Account Level Budget Cost Center Clinical
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DSS Cost File: Inpatient Discharge File
Care of patients discharged in each fiscal year One record per discharge May include cost incurred in prior fiscal years
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DSS Data Only in Discharge File Discharge day Total days of stay Discharge bedsection
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Discharge example
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Patient ADMITDAY DISDAY FP LOS DBEDSECT TOT
A 24SEP05 01OCT05 1 7 Gen Acute Med
9824.24
A 31OCT05 11NOV05 2 11 Gen Acute Med
4673.01
A 04AUG06 21SEP06 12 48 Rehab 81868.77
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DSS Cost File: Inpatient Treating Specialty File
Treating specialty One record per treating specialty per month
– More than one record in a month if more than one treating specialty in a month
– All care provided during fiscal year
– Include stays not yet over
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DSS Data Only in Treating Specialty File
Treating specialty Census indicator Date of entry and exit from treating specialty
– No discharge date Treating specialty length of stay
– No total length of stay
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DSS Treating Specialty File Example
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Patient TRTIN TRTOUT TR SP
TR SP LOS
FP TCST_TOT
A 01OCT05 01OCT05 15 1 1 350.01
A 31OCT05 11NOV05 15 1 1 544.24
A 31OCT05 11NOV05 15 10 2 23787.22
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DSS Data in Both Inpatient Files
Admit day Admitting diagnosis related group (DRG) Principal diagnosis Admitting diagnosis
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Comparison of Record Structure
ADMITDAY 3/15/04TRTIN 3/22/04
TRTOUT 4/12/04FP 6
ADMITDAY 3/15/04TRTIN 3/22/04
TRTOUT 4/12/04FP 7
MarchRehabilitation
AprilRehabilitation
ADMITDAY 3/15/04 DISDAY 4/12/04
MarchGeneral Medicine
ADMITDAY 3/15/04TRTIN 3/15/04
TRTOUT 3/22/04FP 6
Treating Specialty- 3 records
Discharge– 1 record in FY 04
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Comparison of Record Structure(Overlapping fiscal year)
SeptemberGeneral Medicine
OctoberGeneral Medicine
ADMITDAY 9/22/03 DISDAY 10/8/03
ADMITDAY 9/22/03TRTIN 9/22/03TRTOUT 9/30/03FP 12 CENSUS=YIn FY03 File
ADMITDAY 9/22/03TRTIN 9/22/03TRTOUT 10/8/03FP 1 CENSUS=NIn FY04 File
Treating Specialty- 2 records
Discharge– 1 record in FY 04 file
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DSS Cost Files: Outpatient Files One record per patient per day per clinic
stop– National Patient Care Database (NPCD)
events file allows more than 1 record per clinic stop per day
– DSS includes care not in NPCD events file, e.g., prosthetics
Primary DX and CPT codes
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DSS Data Only in Outpatient Files
Date of encounter DSS identifier (clinic stop)
– DSS uses “pseudo stop” code for prosthetics, pharmacy, etc.
Flag variables identifying data source
– NPCD, pharmacy, prosthetics, Vast CBOC, etc
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DSS Outpatient Example
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Patient VIZDAY CLSTOP OCST_TOT
A 20051018 411 34.10
A 20051018 108 24.33
A 20051018 306 25.20
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DSS Cost Variables in All Files
Fixed direct Fixed indirect Variable direct Variable supply Total Variable labor category 4 & 5
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Additional Cost Variables in Inpatient Files
Separate costs for lab, nursing, pharmacy, radiology, surgery, all other– Variable, fixed direct, fixed indirect, supply
(where applicable)
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DSS Intermediate Product Department Files
IPD inpatient and outpatient files released 2005 Multiple product departments per encounter Cost incurred in each product department Inpatient: monthly record per patient per inpatient
product department Outpatient: one record per patient per outpatient
product department
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Inpatient (TRT) IPD Example
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Patient TRTIN TRTOUT
IPD_NUM IPD_TOT
A 06-07-22 06-07-27 psychiatry MD bedday 471.11
A 06-07-22 06-07-27 psychology & neuropsychology lab
1.08
A 06-07-22 06-07-27 occupational therapy 1985.01
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DSS Pharmacy
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In the DSS Pharmacy Extract file
– For outpatient records, there is one record Per prescription or supply per person per day
– For inpatient records, there is one record Per person per day
DSS sometimes groups two prescriptions into one record if they are for the same NDC and the same person on the same day
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DSS Pharmacy Variables
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Medication: drug name, NDC, formulary indicators, VA drug class
Dispensing: fill date, quantity dispensed, days supplied Patient: SCRSSN, date of birth, gender, age Ordering provider: provider ID, provider treating specialty Note: Clinical information on related visits/stays can be
linked to Rx data using SCRSSN. Cost: VA cost including direct labor, indirect costs of the
pharmacy department, and supplies Total VA cost prescription = ACT_COST + DISPCOST Costs can be negative, ex: return to pharmacy
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Pharmacy Copayments
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VA charges some copayments.
– Depends on income, disability percentage
– Rules & eligibility levels change year to year
– Rules available on VA internet DSS does not show copayments; they show VA’s
expense. Medical Care Cost Recovery (MCRR) files could
show reimbursement from private insurance, if collected
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Using DSS for Research
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HERC-Created DSS Files
DSS Station Level Cost Data Set beginning 2002 Annual costs and total utilization (inpatient days or outpatient visits)
in HERC-designated service categories (13 inpatient categories, 12 outpatient categories)
One record per service per station (STA3N) per fiscal year
HERC DSS Discharge Dataset with Subtotals DSS Discharge NDE only discharge bed section but not other
treating specialties HERC DISCH file beginning FY 2007 functionally identical to the
DSS DISCH NDE with additional fields for cost and length of stay subtotals for each inpatient category of care, e.g., acute medicine, psychiatry, nursing home, etc.
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Comparing DSS to Medicare Costs
Cost Type DSS Medicare
Physician Services Included in hospital costs (VL-4 & VL-5)
Excluded from hospital costs
Indirect costs Includes VA central office and national operation costs plus hospital admin costs
Only hospital admin costs
Capital costs Financing costs excluded
Financing costs included
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Advantages of Using DSS DSS costs estimate reflect facility differences in
productivity, efficiencies, economies of scale, etc DSS has pharmacy data DSS has community and state nursing home stays. DSS is an activity-based method and is the official
cost managerial accounting system for the entire Department of VA
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Costing Methods
Direct measurem
ent
Pseudo-bill
Clinical cost function
Average cost per visit
More precise Less precise
InpatientHERCMed/Surg
OutpatientHERC AC Costs
Inpt. Rehab, HERC MH, LTC
DSS
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Treating specialtyPTF Bed section filesmore difficult
DischargePTF Main fileseasy
OutpatientNPCD Outpatient Filesmoderate
VA Utilization Data DSS Cost Data
Ease of Merging DSS Cost Files with Utilization Files
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Cost Outliers in DSS
Users should look for cost estimates that are unexpectedly high given characteristics of care
Mismatch of cost and utilization can result in unit costs that are very high cost, or negative
DSS quality assurance efforts– Audit that costs in DSS agree with general ledger – Extreme high outliers are identified and corrected
when DSS national data extracts (NDE) are built
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DSS Resources
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DSS Data Access See HERC guide on DSS DSS Program Office Web Site (VA Intranet DSS web site) SAS and SQL files available at Corporate Data Warehouse
with FY05 and beyond FY12 DSS data will be posted to Austin Center (AITC) but
expected that all DSS files removed from AITC in January 2013
DSS Reports Web Site (VA Intranet VSSC web site)
– Summaries of DSS data
– Documentation of DSS and new DSS datasets
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HERC DSS Guidebooks
Research Guide to Decision Support System National Cost Extracts (updated 2010)
HERC's Station Level Cost Dataset FY2000 - FY2010 HERC's DSS Discharge Dataset with Subtotals for
Inpatient Categories of Care, Fiscal Year 2010 Research Guide to the DSS Intermediate Product
Department Files
http://www.herc.research.va.gov/publications/guidebooks.asp
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DSS Pharmacy Resources
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VIReC’s Pharmacy Prescription Data Guide– VIReC research user guide on DSS and PBM pharmacy prescription
data
http://www.virec.research.va.gov
HERC Technical Report: – Comparing Outpatient Cost Data in the DSS National Pharmacy
Extract and the Pharmacy Benefits Management V3.0 Database http://www.herc.research.va.gov/data/dss.asp
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HERC Average Cost Guidebooks
HERC’s Average Cost Datasets for VA Inpatient Care 1998 - 2011
HERC's outpatient average cost dataset for VA care: fiscal year 2010 update
HERC's Annual Person Level Cost Dataset User Guide: Fiscal Years 1998-2010
http://www.herc.research.va.gov/publications/guidebooks.asp
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Next ClassesOctober 10, 2012
Sources of VA Care Costs and Providers
HERC staff
October 24, 2012Medical Decision Making
and Decision Analysis
Jeremy Goldhaber-Fiebert