Data for the Health Care Digest™ were gathered from the following sources:
Inpatient and Outpatient Data
Definitive Healthcare Medicare Standard Analytics Files (SAFs) are part of the Limited Data Set (LDS)
files released on a yearly and quarterly basis by the Centers for Medicare & Medicaid Services. The SAFs
capture adjudicated claims and are 100% Medicare fee-for-service claims (Medicare Advantage not included).
Claims adjudication refers to the determination of the insurer’s payment or financial responsibility
after the member’s insurance benefits are applied to a medical claim to yield “final action” claims.
The SAFs are available for all claim settings (e.g., inpatient, outpatient, home health, skilled nursing
facility, and hospice).
The Definitive Healthcare commercial data set, which includes Medicaid, is sourced from some of the
largest medical claim clearinghouses in the United States and includes a mixture of professional and
institutional claims processed through those clearinghouses. Professional claims are generated for work
performed by physicians, suppliers, and other non-institutional providers for both inpatient and
outpatient services. Institutional claims are generated for work performed by hospitals, skilled nursing
facilities, and other institutions for inpatient and outpatient services (e.g., use of
equipment/supplies, laboratory, radiology). Definitive Healthcare aggregates claims data and reports as
cases.
Patient Claims Data
Patient-level, chronic disease–specific claims data derive from the
Managed Care Digest Series®
Local Trends Summary™ database. These data come from health care professional
and institutional insurance claims, including all physician specialties and all hospital types. IQVIA
gathers prescription activity from the National Council for Prescription Drug Programs (NCPDP). These data
account for some 4 billion prescription claims annually, or more than 92% of the retail prescription
universe and 72% of the traditional and specialty mail order universe.
Proprietary lab data derive from one of the largest independent commercial lab companies in the U.S.
Patient information is de-identified, matched, and linked with other patient data assets
(e.g., medical claims data). The most common attributes used are the de-identified patient ID,
observation date, diagnosis, test name, test code, and test result.
Claims undergo a careful de-duplication process to ensure that when multiple, voided, or adjusted claims
are assigned to a patient encounter, they are applied to the database, but only for a single, unique
patient. Through its patient encryption methods, IQVIA creates a unique, random numerical identifier for
every patient, and then strips away all patient-specific health information that is protected under the
Health Insurance Portability and Accountability Act (HIPAA). The identifier allows IQVIA to track
disease-specific diagnosis and procedure activity across the various settings where patient care is
provided (hospital inpatient, hospital outpatient, emergency rooms, clinics, doctors’ offices, and
pharmacies), while protecting the privacy of each patient.
Medicare, Medicaid, and Health Insurance Exchanges (HIXs)
The Centers for Medicare & Medicaid Services (CMS) provided data on the following: Medicare Advantage
enrollment and Star Ratings, Medicare costs, accountable care organization (ACO) payments, readmission
rate penalties, and Medicaid enrollment. In June 2024, CMS announced that, in light of court decisions, it
would recalculate the 2024 Star Ratings for 2025 Bonus Payment purposes. This digest includes analysis of
only the original release of the 2024 Star Ratings (CMS. [2024]. Update to 2025 Quality Bonus Payment
Determinations.
https://www.cms.gov/files/document/updateto2025qualitybonuspaymentdeterminations.pdf).
Medicare readmission rate penalty data for fiscal year (FY) 2024 are from the CMS Hospital Readmissions
Reduction Program. For FY 2024, CMS calculates excess readmission ratios (the ratio of predicted
readmissions to expected readmissions), dual proportions, and hospitals’ payments for each
condition/procedure and overall using discharges that occurred during a non-contiguous 29-month period,
including portions of 2019–2022. Medicare Shared Savings Program (MSSP) ACO performance data are for
performance year 2022 and are current as of April 2024.
Data on Medicare fee-for-service (FFS) actual costs by setting are derived from CMS’s Geographic
Variation Public Use Files (PUFs), which are current as of May 2024. Overall Medicaid enrollment data are
from state Medicaid and Children’s Health Insurance Program (CHIP) applications, eligibility,
determinations, and enrollment data, and are current as of December 2023. Information on these and other
public sources listed can be found on their respective websites.
Data on HIXs are provided by PUFs from CMS. State-level HIX enrollment data come from the state-level PUF
that includes total health plan selections in all 50 states plus the District of Columbia. The PUF
provides state-level data on metrics such as average monthly premium, financial assistance, age, gender,
metal level, self-reported race and ethnicity, rural location, household income as a percentage of the
federal poverty level (FPL), and plan switching behavior among consumers with a plan selection. In
addition, the state-level PUF includes data on dental plan selections and Basic Health Plan (BHP)
enrollments.
Emerging Topics
CMS provided historical and projected data for the National Health Expenditure Accounts, as well as
information on Medicaid enrollment trends. IQVIA served as the source of social determinants of health
(SDoH) data for Type 2 diabetes patients at the county level. Cancer incidence rates are from the National
Cancer Institute; CMS provided data on the location of the participants in the Enhancing Oncology Model.
Maps in this digest were generated using R (R Core Team [2021]. R: A language and environment for
statistical computing. R Foundation for Statistical Computing, Vienna, Austria.
https://www.R-project.org/).
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