Author
Robin B. Gage, MBA, MHA
Robin B. Gage, MBA, MHASenior Consultant

Author: Robin B. Gage, MBA, MHA

Data on hospitals, physicians and other providers, properly analyzed, help litigators understand the economics and market dynamics of the healthcare sector and of the parties in litigation. The data can establish causation and damages in many types of cases: personal injury, medical fee disputes, False Claims Act, hospital/physician disputes and many others. Once the issues are framed, the next step is often identifying the right data sources. Some data internal to the parties will come from the client or through discovery. However, to help control for external factors there are valuable public healthcare data sets. Here is a guide to five of them. RPC has the most current releases for each file and data for past years. The hyperlinks are to web pages with additional descriptions of each data source.

Medicare Cost Reports

Medicare cost reports contain financial, descriptive and operational data hospitals, skilled nursing facilities, home health agencies, and hospices must file annually. Each provider must file a cost report electronically by five months after its fiscal year end. CMS publishes new and updated reports quarterly through the Hospital Cost Report Information System (“HCRIS”). There are reports for the past 20+ years for nearly 9,000 hospitals. The data elements include:

  • Balance sheet
  • Revenues and expenses
  • Charges, expenses and volume by cost center
  • Inpatient and observation days
  • Staffing and labor costs

Medicare Standard Analytical Files

Standard Analytical Files (SAFs”) are published by the Centers for Medicare and Medicaid Services (CMS) and contain all final action fee-for-service Medicare claims for services rendered during one calendar year. Data are organized at the claim level and include most of the information about the beneficiary and services performed found on a standard professional (CMS 1500) or facility (CMS 1450, UB-04) claim. CMS publishes separate SAF data sets for inpatient and outpatient hospital services, home health agencies, hospices and skilled nursing facilities. Because SAFs contain a unique patient identifier for each Medicare beneficiary, these data provide a resource for following patients across many types of care. SAF data sets are also available for professional services and durable medical equipment. Depending on the provider type, data elements available in the files include:

  • Unique beneficiary identifier
  • Patient demographic information (county of residence, age group, sex, and race)
  • Place of service and attending physician identification
  • Diagnosis codes
  • Procedure codes
  • Charges
  • Medicare allowed amount
  • Patient discharge status

Medicare Physician and Other Supplier File

The Physician and Other Supplier file provides data on procedures delivered to Medicare patients by physicians and other non-facility providers. The data include the National Provider Identifier (NPI) of the physician, the average charges, counts of beneficiaries and utilization, and Medicare payment for each CPT code. The data in this file are aggregated at the code and provider level instead of the individual claim records in the SAF. It can be used to determine charges at a code level for a variety of physician-provided services, such as anesthesia, imaging, and surgical procedures. The files are available on a calendar year basis from 2012 to 2017.

The comparable SAF is the Carrier 5% Sample File. This file takes a 5% sample of Medicare beneficiaries who received care during a calendar year and includes all physician and therapist claims for that beneficiary for the year. There are more data elements and less data suppression in this file than in the Physician and Other Supplier file. Which file is best to use depends on the question being addressed.

MedPAR File

The Medicare Provider Analysis and Review (MedPAR) file has inpatient hospital data and skilled nursing facility data. Annual MedPAR files are based on year of discharge and contain data for all U.S. hospital inpatient stays and / or skilled nursing facility (SNF) stays by Medicare beneficiaries. This file and has fewer data elements than the SAFs. Each record represents a single stay in an inpatient hospital or SNF and can summarize multiple claims. This distinguishes the MedPAR file from the SAF, where each record represents a claim and not necessarily a complete stay. MedPAR records include:

  • Hospital provider number
  • Procedure (ICD-10 Procedure Code)
  • Diagnosis (ICD-10 Diagnosis)
  • Diagnosis related group (DRG)
  • Reimbursement amount
  • Length of stay
  • Patient demographic information (state of residence, age group, sex, and race)

Texas Health Care Information Collection

The Texas Department of State Health Services collects inpatient and outpatient data for all payors from Texas hospitals, ambulatory surgery centers, and freestanding emergency departments. DSHS publishes public use data files quarterly. The DSHS database has data for over 3 million discharges and 12 million visits annually. Data are available from 1999. Each record has most of the data elements on the CMS 1450 with some data elements modified to protect patient and physician confidentiality.

  • Hospital provider number
  • Procedure (ICD-10 Procedure Code)
  • Diagnosis (ICD-10 Diagnosis)
  • Diagnosis related group (DRG)
  • Reimbursement amount
  • Length of stay
  • Patient demographic information (age group, sex, and race)

Several other states publish similar public use files. RPC either has or can obtain these files for specific projects. In other states, the state hospital association controls the data and availability varies.

The U.S. healthcare sector is complex and these data sources reflect that complexity. Making effective use of the available public data in litigation requires experience with the data and expertise in analyzing the data. RPC can help litigators make effective use of healthcare data.

Visit RPC’S Health Data Store at healthdatastore.com