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Chapter 1 INTRODUCTION This report assesses the reliability of selected information describing the utilization of hospital services by a sample of Medicare beneficia- ries. The information is recorded in a data base of hospital records maintained by the Health Care Financing Administration (HCFA).~1] The analysis was to assist in identifying an existing data base for assessing the effects of Professional Standards Review Organizations (PSROs), since baseline data were not gathered before the PSRO program was implemented.~2] This study is a logical extension of an earlier examination of the reliability of hospital utilization data compiled by private abstracting services and based on abstracts of medical records.~3] The Medicare data and information compiled by private abstracting services constitute two of the few national data bases for monitoring utilization of health services. Both are potentially useful for a variety of health services research, policy, and administrative needs, in addition to the PSRO evaluation, provided they are sufficiently reliable. The Health Care Financing Administration (HCFA) was created in March 1977. Components of the Social Security Administration (SSA) dealing with Medi- care became part of HCFA. The data base of Medicare records referred to in this report is maintained by the Office of Policy, Planning and Re- search, HCFA. 2 The establishment of Po20s was authorized by Congress in 1972 through Public Law 92-603. PSROs are intended to assure that medical services financed by Medicare, Medicaid, and Maternal and Child Health Programs conform to appropriate professional standards, are medically necessary, and in the case of inpatient services, could not have been performed equally effectively on an outpatient basis or in an inpatient facility of a different type. 3 Institute of Medicine, Reliability of Hospital Discharge Abstracts . (Washington, D. C.: National Academy of Sciences, February 1977~. 1

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2 The information examined in this study is accumulated as a by-produc t of the Medicare administrative record-keeping system, which contains three primary data files: the health insurance entitlement master file identifies each person eligible for health insurance benefits and contains basic demographic information; the provider file contains information on each participating facility authorized to receive reimbursement; and the hospital insurance utilization file contains basic hospital admission and discharge information derived from the claim form. For a twenty percent sample of all Medicare beneficiaries who are hos- pitalized, the information on diagnoses and surgical procedures entered on the claim form by the hospital billing office is coded by SSA.~4] For these beneficiaries, a statistical discharge record is created (hereafter referred to as the Medicare record), which consolidates information from all three files mentioned above . Six items from the Medicare records for this twenty percent sample constituted the basis for this analysis . They include date of hospital admission, date of discharge, sex, principal diagnosis, the presence of other diagnoses, and principal procedure. There are several characteristics of this data file that support its potential value for program evaluation. The information has been col- lected for the past ten years . - It could be used, therefore, for before- and-after measures of Medicare utilization in areas with and without active PSROs. The ability to identify both patient's residence and place of treatment allows estimates of patient migration in and out of PSRO areas, so that better comparisons of differential admission rates may be made between PSROs. Finally, the unique and permanent identification of the beneficiaries permits the creation of a person-based data file. This, in turn, facilitates the aggregation of isolated hospital admis- sions and examination of an entire episode of illness, readmission pat- terns, and discharge to lower levels of care. The value of these analy- ses depends, in part, on the reliability of the data on diagnoses and procedures, which had not been examined before this study. SPECIFIC STUDY OBJECTIVES The objectives of this examination of Medicare records were: To determine the frequency of discrepancy between selected data items included in the Medicare record and the corresponding hospital medi- cal record; Where discrepancies were detected, to determine the source of the error (usually, either the hospital or HCFA) and the reasons for which it occurred; Beneficiaries are chosen for inclusion in the sample by the terminal digit of their health insurance claim number assigned by SSA when a beneficiary enrolls.

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3 o To analyze the extent to which discrepancies affect utilization sta- tistics aggregated at varying levels of diagnostic, hospital, and geographic groupings; and To compare the reliability of Medicare records and abstracts pro- cessed by private abstracting services. The extent of agreement between the Medicare data and the hospital med- ical record was determined by comparing the results of an independent abstracting of the hospital record with the Medicare record. Informa- tion was also gathered to describe the hospital's procedures for com- pleting the Medicare claim form and forwarding that information to the fiscal intermediary and, eventually, to HCFA. The multiple, but poorly understood paths through which the data flow suggested that this addi- tional documentation was warranted and might be useful ,~ ~ why errors occur. The study conclusions are dependent on the relia- bility of the field work. Therefore, a sub-sample of the medical records abstracted by the field team was independently re-abstracted to assist in determining the reliability of their work. in explaining The study did not examine the validity of information in the medical re- cord--that is, the extent to which recorded information accurately re- flects the patient's condition. Although this is an important question, it was outside the scope of the study.

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