Author
Properly analyzed, data on hospitals, physicians, and other healthcare providers can help litigators understand the economics and market dynamics of health plans and providers in litigation. The data can establish causation and damages in many types of litigation, including personal injury, medical fee disputes, False Claims Act, hospital/physician disputes, and others. Once the legal and factual issues are framed, the next step is often identifying the right data sources. Some data will come from clients or through discovery. However, attorneys also should be aware of valuable public healthcare data sets.
This blog is a guide to eight data sets. For six of the data sources, RPC has the most current releases for each file and data for past years. Hyperlinks will direct the reader to webpages with additional descriptions of each data source. We will discuss federal data and Texas data. Several other states publish similar public use files, but these states vary in what data are publicly available. RPC either has or can obtain many of these files for specific projects. In some states, the state hospital association controls the data, and availability varies.
1) Medicare Cost Reports[1]
Medicare cost reports contain financial, descriptive, and operational data that hospitals, skilled nursing facilities (SNFs), home health agencies, and hospices must file annually. Each provider must electronically file a cost report within five months of the end of its fiscal year. The Centers for Medicare and Medicaid Services (CMS) publishes new and updated reports quarterly through the Hospital Cost Report Information System (HCRIS). Reports are available for the past 20+ years for over 6,000 hospitals. The data elements include:
- Balance sheets
- Revenues and expenses
- Charges, expenses, and volume by cost center
- Inpatient and observation days
- Staffing and labor costs
2) Medicare Standard Analytical Files[2]
CMS publishes Standard Analytical Files (SAFs) that contain all final-action fee-for-service Medicare claims for services rendered during a calendar year. The files do not include records from Medicare beneficiaries enrolled in Medicare Advantage plans. Data are organized at the claim level and include most of the information about the beneficiary and services 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 SNFs. 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. The files are available on a calendar-year basis through 2020. 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
3) Medicare Physician and Other Supplier File[3]
The Physician and Other Supplier File (POSF) summarizes data on procedures physicians and other non-facility providers deliver to Medicare patients. The data include physicians’ National Provider Identifiers (NPIs), the average charges, counts of beneficiaries and utilization, and Medicare payment for each CPT code. The data in this file are summarized at the code and provider level. POSF data 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
The comparable SAF is the Carrier 5% Sample File. This file takes a 5% sample of Medicare beneficiaries who filed claims 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 POSF. Which file is best to use depends on the question being addressed.
4) MedPAR File[4]
The Medicare Provider Analysis and Review (MedPAR) file has data from inpatient hospitals and SNFs. Annual MedPAR files are based on year of discharge and contain data for all US hospital inpatient stays and/or SNF stays by Medicare beneficiaries. This file 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 but not necessarily a complete stay. The MedPAR file is prepared on a federal fiscal year basis and is available through fiscal year . MedPAR records include these data elements:
- Hospital provider number
- Procedure (ICD-10 Procedure Code)
- Diagnosis (ICD-10 Diagnosis)
- Diagnosis-related group (DRG Code)
- Reimbursement amount
- Length of stay
- Patient demographic information (state of residence, age group, sex, and race)
5) Form 990, Schedule H, and GuideStar[5]
Form 990 and Schedule H provide additional information about not-for-profit hospitals. Form 990 is an annual reporting return that certain federally tax-exempt organizations, such as not-for-profit hospitals, must file with the IRS. Government-owned hospitals do not have to file this form.
Form 990 provides information the IRS can use to evaluate whether a tax-exempt organization complies with the Internal Revenue Code. The IRS can use a tax-exempt organization’s Form 990 to determine whether it is using its funding in a way that would cause it to lose its tax-exempt status. In Form 990, tax-exempt organizations provide detailed information about their activities, governance, and finances. Information reported on Form 990 includes a detailed income statement and balance sheet; compensation of officers, directors, and the highest-compensated employees; transactions with related parties; information about tax-exempt bonds; and political campaign and lobbying activities.
Tax-exempt hospitals must show they provide community benefits and promote the health of financially disadvantaged people in the community.[6] They do so by filing Schedule H of Form 990. In Schedule H, tax-exempt hospitals must provide information such as their financial assistance policy; net community benefit expense (cost of financial assistance); bad debt expense, including bad debt expense attributable to patients eligible under the hospital’s financial assistance policy; Medicare revenue versus allowable costs; cost of Medicaid and other means-test government health programs; discounts given to self-pay patients; community building activities; ownership interests in companies and joint ventures; community health-improvement services and community-benefit operations; and the net cost of subsidized care.[7]
One source for obtaining a hospital’s Form 990 and Schedule H is GuideStar.[8] The Form 990s available through GuideStar’s website come from the IRS and not-for-profit organizations themselves. The IRS sends Form 990s to GuideStar as TIFF images, which GuideStar converts to PDFs and posts on its website. GuideStar’s database contains over 5 million Form 990 images from the IRS. There is no charge for viewing the Form 990s GuideStar has received from the IRS, but you must create an account and sign in to access them.[9]
6) Hospital Disclosure of Negotiated Rates[10]
On November 15, 2019, CMS issued its final rule (CMS-1717-F2) implementing President Trump’s Executive Order “Improving Price and Quality Transparency in American Healthcare to Put Patients First.” Starting January 1, 2021, the rule requires all healthcare facilities licensed as hospitals[11] to disclose their standard charges for all hospital items and services. Hospitals must provide a machine-readable file online with their gross charges, discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges. “Machine readable” means a “digital representation of data or information in a file that can be imported or read into a computer system for further processing.”[12] Examples of machine-readable formats include .XML, .JSON and .CSV files. For 300 “shoppable” services (70 services specified by CMS and 230 selected by the hospital), the same information about charges must be “displayed and packaged in a consumer-friendly manner.”[13]
A recent survey of 100 of the largest US hospitals, however, found considerable variation in the types and quality of documents posted. By March 2021, roughly two-thirds of the hospitals surveyed had not complied with the new price transparency regulations. Over 50 of these hospitals “either did not include the payer-specific negotiated rates with the name of the payer and plan, or were noncompliant in some other way,”[14] while a dozen others either posted no files or provided links to databases that were not downloadable. Some hospitals posted empty or password-protected files inaccessible to the average consumer. Only “about 22 hospitals seemed to be compliant, with 13 clearly exceeding the regulations.”[15] The Biden administration is expected to enforce the transparency rule.
7) Texas Health Care Information Collection[16]
The Texas Department of State Health Services (DSHS) 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 through the second quarter of 2021. Each record has most of the data elements on the CMS 1450 (a standard facility claim), 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 Code)
- Reimbursement amount
- Length of stay
- Patient demographic information (age group, sex, and race)
8) Texas Annual Hospital Survey Data[17]
The Texas DSHS, with the American Hospital Association and the Texas Hospital Association, collects survey data from all Texas hospitals and publishes the results annually. Data are available from 1990 through 2020. All Texas hospitals must submit the survey data each year. These data contain information on uncompensated care, payor mix, utilization, financial performance, staffing, and many other metrics.
Conclusion
The US healthcare sector is complex, and these eight data sources reflect that complexity. Effectively using the available public data in litigation requires experience with the data and expertise in analyzing it. RPC can help litigators effectively use healthcare data.
[1] “Cost Reports,” CMS, https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/Cost-Reports.
[2] “Standard Analytical Files (Medicare Claims) – LDS,” CMS, https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/LimitedDataSets/StandardAnalyticalFiles.
[3] “Medicare Provider Utilization and Payment Data: Physician and Other Practitioners,” CMS, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.
[4] “MEDPAR Limited Data Set (LDS) – Hospital (National),” CMS, https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/LimitedDataSets/MEDPARLDSHospitalNational.
[5] GuideStar website, https://www.guidestar.org/.
[6] “Opportunities Exist to Improve Oversight of Hospitals’ Tax-Exempt Status,” United States Government Accountability Office Report to Congressional Requesters, GAO-20-679, September 2020, https://www.gao.gov/assets/gao-20-679.pdf, accessed March 15, 2021.
[7] This information is based on a review of a Schedule H filed by a not-for-profit hospital.
[8] GuideStar’s homepage is https://www.guidestar.org/.
[9] The link for creating an account is https://www.guidestar.org/Account/Register?returnUrl=https%3A%2F%2Fwww.guidestar.org%2F.
[10] “Medicare and Medicaid Programs: CY 2020 Hospital Outpatient PPS Policy Changes and Payment Rates and Ambulatory Surgical Center Payment System Policy Changes and Payment Rates. Price Transparency Requirements for Hospitals To Make Standard Charges Public,” 84 FR 65524–65606, https://www.federalregister.gov/documents/2019/11/27/2019-24931/medicare-and-medicaid-programs-cy-2020-hospital-outpatient-pps-policy-changes-and-payment-rates-and.
[11] Except those that are federally owned.
[12] “8 Steps to a Machine-Readable File of All Items & Services,” https://www.cms.gov/files/document/steps-machine-readable-file.pdf, accessed March 14, 2021.
[13] “CY 2020 Hospital Outpatient Prospective Payment System (OPPS) Policy Changes: Hospital Price Transparency Requirements (CMS-1717-F2),” https://www.cms.gov/newsroom/fact-sheets/cy-2020-hospital-outpatient-prospective-payment-system-opps-policy-changes-hospital-price, accessed March 14, 2021.
[14] Alex Kacik, “Two-thirds of the Largest Hospitals Aren’t Complying with Price Transparency Rule,” March 16, 2021, http://www.modernhealthcare.com.
[15] Ibid.
[16] “Texas Health Care Information Collection Center for Health Statistics,” Texas Health and Human Services, https://www.dshs.texas.gov/thcic/hospitals/Inpatientpudf.shtm
[17] “Annual Survey of Hospitals,” Texas Health and Human Services, https://www.dshs.texas.gov/chs/hosp/hosp2.aspx
To learn more about our data files, available reports, and how you can leverage our data for your projects, visit RPC’s Health Data Store here or contact our Health Data Store staff at 512-371-8015, or data@healthdatastore.com