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On May 1, 2009, Susan Haber and Diane Orenstein presented the
CDC Chronic Disease Cost Calculator on a Web conference. This tool
is supported by AHRQ's Medical Expenditure Panel Survey (MEPS)
data. These are the questions asked by participants during the event,
with the associated answers.
Question: Included in the calculator are outpatient,
inpatient, medication, long-term care, etc., but not indirect costs,
Diane Orenstein: In the current calculator, we are
not. In version two, we are doing indirect costs but only by defining them by
data on absenteeism. Indirect costs can include so many different
costs, and after looking at the literature, we believe this is the best
way to capture indirect costs for lost productivity. So in the
user guide will clearly explain what absenteeism is, what that represents,
and what the data source is.
Question: How can the code for the cost calculations
Susan Haber: T he calculations in this are based
on the MEPS data, but we also wrote parallel code where you can do
the same type of calculation using your Medicaid claims data. We've
written sample SAS code that you can use, and we've got instructions
about what you need to do. Basically, we describe what variables
you need to create in your data to do these analyses, what you should
call the variable, how to set up the file to do the analysis. You
can run the data against the SAS code that we provided using your
own State Medicaid data. It means you are going to have to be
able to manipulate your Medicaid data. For example, the basic
variable that you need is a variable for what the total Medicaid expenditures
are for a person during the year. You need information on what
diseases the person has. So basically, you need to go through
your claims data for a person to find claims that have different diagnoses
on them. We have written code that will do that calculation
for you, but you have to have the Medicaid data set up in the right
way to run through it in that way. We have provided that sample
SAS code. So you've got to have SAS and you have to have
some ability to manipulate your own Medicaid data.
Diane Orenstein: It's not anywhere in the format
where the tool is, but it has all been for you using the MEPS data. You
have to have that information and manipulate it and do all that yourself. We
just provide how to do it--the codes to do it or the program to do
Question: Where can the information
and the sample code be downloaded. Is there a link on the Web
site? How do you access that information?
Susan Haber: It's on the CDC Web site. There's
a link to the code and to some documentation how to use the code.
Question: Is this is cost data and not charges
Susan Haber: Right. This is cost data.
Diane Orenstein: This is what Medicaid pays out.
Question: How exactly does one go about saving the
outputs in a text and in an MCC file?
Susan Haber: It's quite simple. Let's
say you wanted to save it to the text file. Click on the button
that says save and it's going to ask you where you
want to save it to, what folder in your computer you want to save
it to. Then it's going to ask you to give a name to
it. Once you do that, it will save the information for you. The
output is going to be saved in something called a CSV file. It
looks like an Excel spreadsheet. It basically has that type
of format. Same thing, if you want to save the input, again
you just click on the button and it will ask you where you want
to save it to and give the file a name and you're done.
Question: I don't have MCC software and so
I don't know how it would go into an MCC file. Also, I
don't know how to do manipulations on text file. I can
do manipulations on an Excel spread sheet but what kind of files are
the data going to go into? Are they in my computer and how can
I manipulate the data if it's in text rather than actual data?
Susan Haber: I don't believe you need
any special software to do this because I don't have MCC software on
my computer either. You don't need anything special when you save the data.
If you want to manipulate the output file, it will be saved as a CSV file,
so you can open that up in Excel. It will go into Excel perfectly and you
can manipulate in Excel.
Question: Can site-specific cancer estimates,
e.g., colorectal cancer be selected?
Susan Haber: We did not do that for this project
because the sample size in MEPS just wasn't large enough to
support site-specific cancer estimates. So we don't have that
in this, unfortunately. This is just an average across all cancers
and it reflects the mix of cancers in your State Medicaid program.
Diane Orenstein: That's actually listed
in the technical user guides, which cancers.
Question: Is there any way to use the tool to see changes and
cost over time.
Susan Haber: Version 2.
Diane Orenstein: Yes, version 2. That's not something we could
Question: Are the cost estimates the calculator provides
Susan Haber: Yes. These are annual costs.
Question: Has risk adjustment been incorporated
in the estimates and is it applicable?
Susan Haber: No. There's no risk adjustment
here. I guess I don't think that's applicable in
this case because we're just reflecting on what is the cost
for this population in your Medicaid program. I'm not
sure how risk adjustment would apply here. We're not trying
to make people with hypertension more comparable to somebody else. We're
trying to reflect what the people with hypertension cost. There's
no risk adjustment here.
I guess in a sense, our numbers reflect the different risk associated with
these populations, or at least a piece of the risk. So, this is how much more
a person with hypertension costs than a person without hypertension. So in that
sense, it's reflecting the different risks.
Question: What data do you have from private payers
that would provide expenditure data included the cost calculator?
Susan Haber: The MEPS dataset includes everybody,
not just people in Medicaid. It includes privately insured people,
people in Medicare; it's everyone. What the MEPS people
do is ask everyone: What's your source of insurance? So
we use that to identify whether a person is a Medicaid beneficiary
versus a Medicare recipient versus someone who's privately insured.
Question: How do you know which expenditures go
along with which coverage? Is it what is reported to be paid
on their behalf by the payer?
Susan Haber: Exactly, MEPS is a very impressive
dataset. They start out by asking people that question, but
then they go out and they do a lot of validation of the information
that's reported by the respondents in the survey. AHRQ
goes out and validates for example, by going out to their insurer
and their physician's office to make sure they check the accuracy
of what people are reporting.
Question: You've mentioned the sample
size being a factor. I'm assuming that also applies to
county-specific information, that it's not projected to be available
in version two?
Susan Haber: That's right.
Diane Orenstein: If you have some of your
own data about the prevalence within your county, I wouldn't
say this is an accurate estimate, but it can be probably a better
guesstimate for you.
Susan Haber: Absolutely. I would agree with
that. If you've got some information on county-level
prevalence, for example, you could use that to get an estimate. You
would be assuming that the per-person costs aren't different
at the county level. But at least you could reflect differences
in the prevalence across different counties.
Question: Are the cost estimates limited by any age
groups? Are children included?
Susan Haber: Since these conditions
basically don't occur among children or the prevalence is extremely
low, the cost estimates are based on adults. As you see in the
calculator itself, you can look at cost estimates by different age
groups; that's only adult age groups. However, when we
look at what the prevalence is in the Medicaid population, we include
the total Medicaid population. So the cost estimates are based
on adults but it's within the entire Medicaid population.
Diane Orenstein: When we add asthma, that will include
a younger population.
Question: Can the calculator be used
to identify cases of excess cost?
Susan Haber: Yeah. I don't think you could use a calculator
in exactly that way, but you'll see that. What we do is provide you with
the average cost of a person with this condition in your State and the
prevalence of the condition in your State. We also provide information
on national averages, so you could compare those to the national average to
see whether you are high or low. That's the best information,
the closest information we have to what is excess. Obviously, there are so
many factors that drive the State variation in costs for these different
diseases: the cost of medical care in your State, practice patterns.
Prevalence is going to be driven by the population characteristics. There's
a lot that goes into it. Even in making the judgment of how you stand next to
a national average, you certainly want to think about all of those, deciding
whether your costs are excessive or not.
Question: Any possibility to gauge the effects
and cost of obesity?
Susan Haber: The tool as it is currently set up
does not really look at a risk factor like obesity.
Question: Is there any inflation factor that can
be used to project expenditures based on today's costs?
Diane Orenstein: These costs are inflated to 2007
dollars. Even though the data are from 2001 to 2005, they
have been inflated. So what you're seeing is the costs
inflated to 2007 dollars, and version two will be inflated to 2008
dollars. When the MEPS data become available, there's
a lag time. So version two will be 2006. That's
the latest, so we will inflate that to 2008 dollars.
Susan Haber: The reason data are only inflated
to 2007 is that basically we were using estimates of the Medical
Care Consumer Price Index [CPI] to inflate the data from 2001 to
2005 up to 2007. 2007 was the most current Medical CPI estimate
that was available at the time. If you've got some estimates
of how costs in your Medicaid program have been increasing between
2007 and currently and you wanted to apply that inflator, you certainly
could, although I caution you to make sure it's being used
appropriately. That's the only reason we go up to 2007.
Diane Orenstein: One point of clarification--how
can someone look at the regional costs to get the costs for services?
Susan Haber: The costs are adjusted for many States,
and the adjustment represents differences in medical costs between
your State and other States in the country, or between that and
the national average. There are some States where the sample
isn't large enough in the MEPS data to actually get a good
State-level estimate. So for some States, we're using
regional estimates of what that region's costs are to adjust
the medical spending. But basically, these are all being adjusted
to reflect variation and costs within the States or within regions
of the country. Is that what you were referring to Diane?
Diane Orenstein:Yes. You don't want to
use the cost for New York to represent all the States or the cost
for South Carolina to represent all the States.
Question: When seniors can't access health
care due to a lack of providers who accept Medicare, how will their
health costs be calculated? Would they be included in the tool?
Diane Orenstein: In version one, I think the answer
is no. Susan, please correct me. In version two, I don't
know if that goes under "other payers."
Susan Haber: I'm assuming that the person
means that they've actually paid out of pocket for the services,
so they've actually accessed the services, they are just not
being paid through Medicare/Medicaid. Version two, the way it's
broken down is we have Medicare estimates, Medicaid, private insurance,
and then we have total, which would include everything, other types
of insurers as well as individual out-of-pocket payments.
Question: How many States are currently doing this work?
Diane Orenstein: I can answer that from about
a month ago. We've looked at how many hits we've
had and how many downloads we've had. It wouldn't
be fair to say how many States. We've had over 400 hits
and over 70 downloads, so that's more than 50 States. I
think it's being used very broadly, but we have not conducted
any type of evaluation to find out who's using it other than
the feedback that we've been given when we are having any kind
of interactions with the States. So that doesn't break
down whether it's a State health department or Medicaid department. We
don't know that difference at this point.
Question: Has there been any dialog between
people that developed this calculator and those who developed the
ROI [return on investment] calculator at the Center for Health Care
Strategies? How does this calculator tool vary from others that
are out on the market?
Susan Haber: When we started this project, no,
there wasn't dialog. But probably about a year or so
ago, we were contacted by the people from the Center for Health
Care Strategies. I did make a presentation to a group of people
through them. Basically, they serve kind of different purposes. Ours
is not an ROI calculator, but when I spoke with the people there,
they viewed this as something that could feed into their ROI calculator. For
their calculator, you need to know what a disease is costing you. Then
it goes from that to estimate what the potential savings are from
a particular intervention. So I guess, in our discussions,
it seemed like it could potentially provide an input that someone
might use in their ROI calculator.
Diane Orenstein: I think these complement. They're
for two different purposes but our data can be used in theirs.
Questions about Version Two:
Question: When will version two would be ready?
Diane Orenstein: I'm comfortable saying
in a year.
Question: Will version two allow grouping
by year of data?
Susan Haber: The way version two will work is
there will be a base estimate, which will be, maybe, 2008, and then
we're going to show for the next 10 years. I don't
know if it's going to be year by year or if it's just
going to be 10 years out, what the costs will be. It's
going to drive off of changes in population demographics and the prevalence
of these different conditions within different population groups.
Question: Will calculations be available by
race and ethnicity in version 2?
Susan Haber: Unfortunately, that's a
MEPS sample size limitation and the sample wasn't large enough
to support estimates by race.
Question: Since you are going to be including
cost estimates for children with asthma in version two, what are you
going to be using for absenteeism if that's going be included?
Susan Haber: In terms of absenteeism for children
with asthma, it's going be based on children missing time
from school and then it's assuming a parent has to miss time
from work when a child is absent from school. So the absenteeism
will be the parent's lost time from work due to the child's
Question: Are you looking to break down the
costs by buckets, including pharmacy costs or inpatient costs associated
with a given disease? That would be a powerful feature if you
Susan Haber: The current plans for version
two do not include that. In theory, it's possible. It's
just not in our current plans for it.
Diane Orenstein: I think that when we hear
these questions, just as we said, they have certainly had input
in how we have been designing version two. It's something
that we do go back as a team and work on, and discuss. Even
though it's not in there now, it's certainly a question
that will be up for discussion. That doesn't mean we
can do it. It means we can debate it, look at whether it's
something that can or cannot be done in this version, and what it
would entail to do that. I'm not trying to be difficult
about this, but every change is a cost to us. We really do
appreciate this type of input so we can make sure we create a tool
that addresses the issues for our audience.
Specific questions from Kansas Medicaid:
Susan Haber performed a tool demonstration on the event. Since
she used Kansas as an example, the Kansas Medicaid Medical Director,
Dr. Margaret Smith was invited to comment about the results and given
an opportunity to ask questions. Below are the questions and
answers to Dr. Smith's questions.
Dr. Margaret Smith: Does this data
include both the managed care population as well as the fee-for-service
population in the State in the estimates?
Susan Haber: Yes. That's because we
are using the MEPS data rather than the Medicaid claims data for
the main source of our cost estimates. So MEPS, they go out
and survey everybody or a sample of the population regardless of
whether they are in managed care or fee-for-service Medicaid. And
then they ask people to keep track of what services they're
using and then they also go out and validate that against medical
records and provider offices and things like that. They're
not relying on claims data for getting their estimates. That's
one of the advantages of using the MEPS data rather than Medicaid
claims data. More and more Medicaid beneficiaries are enrolled
in managed care, which is a great thing, but then we lose their
claims data, and you can't do these types of analyses in something
like the MAX data or the MSIS data that States report to CMS. That's
the great advantage of using the MEPS data. Obviously, certain
populations are enrolled in managed care rather than fee-for-service
Medicaid. So if you only look for Medicaid at the fee-for-service
population, you get a very biased picture of what Medicaid is spending
and what the prevalence is and things.
Diane Orenstein: If I could just shortly add to
that, one of the reasons why we wanted to use the MEPS data is to
make it easy for States that don't have access to the data
or don't have clean data or have the resources (staff and
financial), to actually do their own calculations. This allows
every State to have the ability to use this calculator and use a
consistent methodology as well as data source across all States.
Dr. Margaret Smith: Is the cost per beneficiary
attributable just to that disease? That's not going to
be our total cost for that beneficiary, correct?
Susan Haber: That's correct. That's
one of the ways that our cost estimates differ from other estimates
that you may see out there in the world. They may look at
who are the people that have these diseases and what's the
total amount that Medicaid is spending for them. Whereas we're
looking at just the amount that's attributable to that disease. There
are reasons for doing each way, there are pros and cons of each. But
obviously even if you control hypertension or you find less costly
ways of strokes--for example, keeping people out of the nursing
home--that's not going to get rid of all of the medical costs
that people have. So that's why we wanted to focus specifically
on the costs attributable to these diseases.
Dr. Margaret Smith: Do we know if those people that
have the chronic diseases have higher costs--say, for their preventive
care or whatever--beyond the cost that is attributable to the disease?
Susan Haber: Well, we didn't look at that
in this. I couldn't speak to preventive care in particular,
but certainly lots of other people have looked at the costs of people
with chronic diseases--the Center for Health Care Strategies has
done this, there's some work from people out of John Hopkins--and
all of that shows that the overall costs for people with chronic
diseases are much higher than costs for people without chronic diseases. But
we didn't address that in this calculator.
Dr. Margaret Smith: The other thing I thought was
interesting is that if you just look at the cost per beneficiary,
you would tend to focus on, say, congestive heart failure or diabetes. Obviously,
diabetes is one that is very big and it still has one of the higher
prevalences of these diseases. But something like hypertension,
which has an attributable cost that isn't as high as those other
things, certainly not as high as stroke, has the total overall greatest
amount of costs because of the high prevalence.
Susan Haber: Absolutely.
Dr. Margaret Smith: Just a technical question--how
small a population can I introduce into the calculator before I start
getting lots of insufficient boxes in my estimates?
Diane Orenstein: The insufficient boxes are based
on our analysis of the MEPS data. We were analyzing the MEPS
data--the prevalence of these conditions that was surveyed in MEPS
was not large enough. If you have your own data, if you have
some estimates of prevalence conditions at the county level or something
similar that you want to use, you can always enter those in. You
won't get any insufficient. You just need to use your
own judgment that your sources of data are adequate to support analyses
at that level. We're just saying that based on the data
we use to create our default estimates, we couldn't do it
any finer than what we show.
Dr. Margaret Smith: If I'm trying to develop
a care management program that focuses on diabetes and I've
got a pilot and I only have 200 people in that pilot, could I still
get some estimates even though I only have a small number of people?
Susan Haber: Sure. First of all you've
got what the per-person cost is. You know what the per-person
cost is. So you could just take that number there and say, "Here
is the per-person cost, I have 200 people in this pilot, I think
I can reduce per person costs by 10%." You can use that
number and the 200 people you've got in your pilot, reduce
that per-person cost by 10%, multiply by your 200 people and see
what your savings are.
Diane Orenstein: You can look at this as,
if you feel that you have a program that would reduce the prevalences,
what would the costs look like? You can enter it the other
way as—if you can reduce the cost by X amount, what would that
Once you download the tool and use it, you can play with that and say--if
disease management programs or other programs through our health departments,
etc. were able to reduce the prevalence, what change would we see in
those costs? When you mentioned about hypertension, this is a
wonderful way to look at this. If you are going to use this in
aiding you in having discussions about disease management, you can see
that the focus of hypertension is so high, if you can reduce it, then
you know that you probably are going to be able to reduce stroke and
heart failure in the future. Even though this is a burden as well
as a cost, it still gives you some of the information when you are thinking
about how to focus your programs or which programs you would like to
create and hopefully reduce those burdens.
Current as of May 2009
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