Effectiveness Initiative and familiarize the committee with the issues to be discussed. They centered on Medicare data files, randomized controlled trials conducted by the National Cancer Institute, and recent reports of the findings of studies relating to use of services and efficacy of various treatment regimens (see the Bibliography, this volume).


Medicare/Medicaid Decision Support System

The description of the Medicare decision support systems included a simplified version of the flow of data into the Medicare systems. That flow starts with entitlement and demographic data for about 33 million Medicare beneficiaries that are obtained initially by the Social Security Administration (SSA). Health care providers and contractors are the primary source of Medicare utilization data. Providers (e.g., institutional providers, home care agencies, suppliers, and physicians) submit bills to fiscal intermediaries (FIs, for Medicare Part A) and carriers (for Medicare Part B); they in turn adjudicate and then pay the bills and pass them into the system. These utilization data are merged with the SSA demographic information. From these main sources, several basic record groups are developed.

Basic Record Groups

The first record group is the Health Insurance Master (HIM) Enrollment record, developed from the SSA file; these data, which are updated daily, include dates of birth and death, sex, race, residence, dates of entitlement, and dates of enrollment into health maintenance organizations. This is a rich source of data for and identifying beneficiaries and drawing samples for follow-up research studies. The second file, the Provider of Service (POS) Record, contains considerable information on hospitals, skilled nursing facilities, home health agencies, independent laboratories, ambulatory surgical centers, and similar providers for Medicare. The third and fourth files are the Utilization Records for Medicare Parts A and B billing information, including hospital days of care, diagnoses, surgical procedures, physician visits, charges, and payments. The fifth main record group is the Provider Cost Report Record, which has cost, accounting, and other data from participating institutional providers.

For effectiveness research, other “derivative” files may be important sources of information: MEDPAR (Medicare Provider Analysis and Review file), MADRS (Medicare Automated Data Retrieval System), and BMAD (Medicare Annual Data System for Part B). The SSA-based HIM file provides the beneficiary identification number and demographic information;

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