I. Finding and Using Healthcare Data

15. How can I collect cost data from non-VA providers?

Cost-effectiveness analyses require information on patients’ use of health care in all settings. Some researchers collect actual billing records from non-VA providers in order to calculate the total cost of care. Below we present a protocol for collecting billing records and additional recommendations based on our experiences in several clinical trials.

Definitions

Coordinating center: The study site where copies of all completed study forms are kept.

Economist: The person who will be collecting the non-VA cost data.

Site coordinator: A staff person at each study site where data are collected from patients.

ROI: An IRB-approved Release of Information form that gives the non-VA facility permission to send you information on a patient’s stay

Procotol in Brief

• The site coordinator obtains a separate ROI for each non-VA inpatient encounter reported by the patient.
• The site coordinator keeps the original ROI. She transmits a copy to the coordinating center and a copy to the economist.
• The economist prepares two letters to the non-VA provider. A cover letter and a copy of the ROI are sent to the provider's billing department, and a similar cover letter and a copy of the ROI are sent to the provider's medical records department.These are sent at least 30 days after the patient was discharged from the stay.
• The economist follows up on non-responses or partial responses with telephone calls to the non-VA provider.
• At several points during the study, the economist requests from the coordinating center a list of all patients who have indicated that they had a non-VA inpatient stay. These are checked against the list of ROIs received from the sites. Follow-up calls are made to sites as needed.

Release of Information (ROI) form

HIPAA and VA policy mandate several elements for a disclosure of protected health information:

• Patient name and date of birth (DOB)
• Recipient (to whom the information will be disclosed)
• Information requested
• Patient signature

Some providers require the following information as well. We recommend including them on the ROI form.

• An expiration date for the authorization. This is the length of time that the veteran’s authorization to disclose information is valid. Due to difficulties following up with some sites, I recommend at least 12 months following the signature date.
• A statement noting that once the protected information is disclosed, there is a potential that VA will redisclose the information and that it will no longer be protected under federal law. A statement noting that the authorization covers care relating to HIV/AIDS, substance abuse, mental health, and sickle cell anemia. [A VA training document states the following: “Unless it is specifically covered in the authorization, information regarding drug/alcohol and HIV treatment cannot be disclosed” (emphases in original). The Privacy Officer at one VA site, however, indicated that one could request data from an AIDS hospice without special language.]

A few providers require the patient’s social security number. We do not regularly put those on the forms because they are highly confidential. If a provider asks for it, you can request it from the CSPCC and then call them with it.

Follow-up

Telephone follow-up is essential to obtaining complete records. Someone must be assigned to call the medical records department and/or billing department of the provider if sufficient information has not been sent. We recommend calling soon after a partial response or no more than three months after a non-response to a letter.

Check for missing ROIs

The coordinating center should store data collection forms. Ask them to provide a list of the patients (including patient ID and site number) meeting the following criteria:

• Had a follow-up visit in which non-VA inpatient stays were queried
• Indicated that a non-VA inpatient stay occurred

You should have a ROI for every one of those people except for patients who (a) refused consent or (b) were unable to consent. (If a patient reports multiple non-VA inpatient stays, then the number of ROIs will exceed the number of people.) If you have missing ROIs, contact the site coordinator to ask about them. Note that some site coordinators will save all ROIs collected over a given period (e.g., one month) and then will send them in a batch.

How often should you make the request? We would do it at least four times, after 25% of people have passed the first follow-up at which non-VA stays are queried, after 50%, after 75%, and about 1-2 months before the last follow-up. Study coordinators will lose their funding once the data collection is over.

Training site coordinators

We recommend using the study kick-off meeting and every annual meeting as opportunities to train the site coordinators. Here are the elements:

• Give a PowerPoint presentation that explains each step of the process
• Explain how to handle problem situations such as patients who cannot give consent, proxy/surrogates, and multiple non-VA stays in a single episode of care
• Hold a Q&A session for problems that have arisen
• Name the programmer/RA on the project; introduce him/her if present
• Thank them warmly for their efforts; remind them that they can call or write anytime
• Hand out my business cards to people requesting information
• Back at the office, respond promptly to requests for assistance made at the meeting

Solutions to Common Problems

The provider never sends information. Focus your effort on finding someone helpful. We find that 90% of the time we can get the necessary information by talking with the right person.

The provider rejects the ROI form. Sometimes the provider insists that the patient complete a different ROI form. We recommend sending the new form to the site coordinator and calling her to explain that the patient needs to sign the new form as well. If this cannot be done for some reason – such as death of the patient – call the provider’s privacy officer and ask why the study form is insufficient. You are free to try convincing the provider to accept the study ROI, but be aware that they rarely relent.

The information received is hard to interpret. There is no cure for this, but there is a moderately effective vaccine: be specific about what is requested. For example, the cover letter can specify that you are requesting a discharge summary but not the entire medical record; a UB-92 but not an itemized bill (unless you wish to see a detailed bill). We recommend using the term “UB-92” when writing to the billing department, as this term is well known.

Copying charges. A few providers send a bill for copy charges along with the requested documents. If you ignore a bill, the provider may refuse to send information on later patients. We recommend calling to ask for a waiver. Explain that the study is federally funded and has no budget for photocopy charges. If you do make a payment, it can be treated like a regular invoice. Payment will take 4-6 weeks after the invoice enters the purchasing system. The check will be sent directly by VA to the provider.