Two new benchmarking data sources available
Provide discharge, fraud and abuse data
Data useful for health care research and market analysis are available from a central coordinator and distributor sponsored by the U.S. Agency for Health Care Policy and Research (AHCPR). And soon, a new data bank will be an effective quality tool in fighting health care fraud and abuse.
The State Inpatient Databases (SID) are a powerful set of hospital databases from 22 states that participate in AHCPR’s Healthcare Cost and Utilization Project (HCUP).
The databases contain the universe of each state’s inpatient discharge abstracts, translated into a uniform format to facilitate multistate analyses. Overall, the databases contain more than half of all U.S. community hospital discharges, spanning diverse local markets and geographic regions.
The SID contain a core set of more than 100 patient-level clinical and nonclinical variables included in a hospital discharge abstract for all patients — regardless of payer, including persons covered by Medicare, Medicaid, and private insurance, and the uninsured. In addition to the core set of uniform data elements, some of the databases are enhanced with additional variables, such as patient race. There are 11 states whose data may now be obtained from the centralized service: California, Colorado, Iowa, Maryland, Massachusetts, New Jersey, New York, Oregon, South Carolina, Washington, and Wisconsin.
SID is a resource to researchers and policy-makers investigating questions that require a complete listing of hospitals and discharges within market areas or states, or across states. SID can be used to identify state or market-specific trends in inpatient utilization, access, charges, and outcomes, as well as to investigate questions involving more than one state. The data files do not contain direct personal information about patients, nor characteristics that might lead to the identification of patients.
This AHCPR-contracted service can provide inquirers with application kits for purchasing data from the 11 participating state data organizations, as well as information on obtaining files from the remaining 11 state data organizations in the SID project.
Starting early next year, there will be a new tool available that works in tandem with the National Practitioner Data Bank (NPDB) in efforts to discourage health care fraud and abuse while encouraging quality.
Established by the U.S. Department of Health and Human Services (DHH), the Healthcare Integrity and Protection Data Bank (HIPDB) will allow federal and state agencies and private health plans to access the following types of information:
• civil judgments (with the exception of malpractice judgments) against health care providers, suppliers, and practitioners in federal or state courts related to the delivery of a health care item or service;
• actions by federal or state agencies responsible for the licensing and certification of health care providers, suppliers, and practitioners;
• exclusion of health care providers, suppliers, and practitioners from participation in federal or state health care programs.
A complementary focus
"For example, health plans with access to the data bank will be able to more thoroughly check the qualifications of those with whom they seek to contract, affiliate, hire, or credential," according to a statement issued by DHH Inspector General June Gibbs Brown. "This will help identify health care practitioners, providers, and suppliers who are unsuitable to participate in patient care."
Mandated by provisions of the Health Insurance Portability and Accountability Act of 1996, HIPDB complements information contained in, and the service provided by, the 10-year-old NPDB in a number of aspects, according to Alwyn Cassil, spokeswoman for the Office of Inspector General at DHH.
"NPDB serves as more of a credentialing data bank that is used largely by hospitals, peer review organizations, and accreditation agencies," says Cassil.
"Its focus is on events such as medical malpractice payments, adverse licensing actions, adverse clinical privileges actions, and adverse professional society membership actions," she explains, "and its scope is largely limited to physicians, dentists, and in some cases, other health care practitioners."
With a wider focus that encompasses civil judgments, criminal convictions, negative licensing/certification actions, and program exclusions for all kinds of health care providers and suppliers — including practitioners — "HIPDB is much more aimed at being an anti-fraud and abuse tool," says Cassil. "It essentially serves as a flagging system, so that government, federal and state agencies, and health plans can look more deeply into the backgrounds of those they contract with, credential, or do business with in any way."
Entities mandated by law to report to the HIPDB data bank include state and federal law enforcement organizations; state and federal agencies responsible for licensing or certifying any type of health care practitioner, provider, or supplier; and federal agencies that administer or provide payment for health care, according to a statement from DHH. Additionally, private health plans, which DHH defines as "any group, organization or company providing health benefits whether directly or indirectly through insurance, reimbursements or otherwise," and is comprised primarily of insurance agents, brokers, solicitors, consultants, and reinsurance intermediaries, insurance companies, self-insured employers, and health care purchasing groups, must also report.
Day-to-day operation of HIPDB will be managed by the DHH’s Health Resources and Services Administration (HRSA), which is also charged with operating the NPDB.
Given that there are some areas of overlap in focus, reporting requirements, and querying privileges between HIPDB and NPDB, a single NPDB-HIPDB integrated Querying and Reporting Service (IQRS) will be used to report to and query both data banks over the World Wide Web, according to Cassil. Based on the action being reported and the applicable laws, the IQRS will automatically submit the report to the NPDB, the HIPDB, or both, as appropriate. Users must first register and certify eligibility to report or submit queries to the data banks before access will be authorized.
Earlier this year, HIPDB began accepting voluntarily submitted reports, and began taking in required reports this past November. Requests for information disclosure, however, will not be accepted until early in 2000, says Cassil.
During HIPDB’s start-up period, entities required to report to HIPDB — i.e., government agencies and private health plans — must provide information on all reportable final adverse actions taken since Aug. 21, 1996, the date of enactment of the Health Insurance Portability and Accountability Act of 1996.
As has always been the case with NPDB, access to HIPDB reports is strictly limited by law, with the general public not having access to data bank information. Only entities required to report to the data bank will be authorized to obtain data bank information, although subjects of reports may obtain access to their own reports.
Information reported to the data bank is confidential, "and must be provided and used in a manner consistent with protecting confidentiality," according to a statement from DHH. People and organizations receiving data bank information, either directly or indirectly, must use it solely for the purpose for which it was disclosed. Permissible uses of HIPDB information include those for privileging and employment, professional review, licensing, certification or registration, fraud and abuse investigation, certification to participate in a government program, and civil and administrative sanctions.
As required by law, the operating cost of the data bank will be covered by a fee for each information search requested by a non-federal entity authorized to use the data bank. Initially, the fee will be $4 per query. Individual practitioners, providers, and suppliers making self-queries initially will be charged $10 per request, with any fee changes to be announced through a notice in the Federal Register.
[More information on the HIPDB and NPDB data banks is available from HRSA at (800) 767-6732. You can visit their Web site at http://www.npdb-hipdb.com.
To request data or to inquire about SID, contact the HCUP SID Coordinator, the MEDSTAT Group, by phone at (805) 681-5876; by fax at (805) 681-5888; or via e-mail to [email protected].]
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