This report describes methodologies, estimates, and technical considerations related to measuring health care utilization in Medicare Part C encounter data (ED). The primary aim of the report is to provide technical details for researchers on the structure and scope of ED and on the methodological steps and analytical decisions necessary to assess utilization of health care services using ED.

Measuring Health Care Utilization in Medicare Advantage Encounter Data

Methods, Estimates, and Considerations for Research

Andrew W. Mulcahy, Melony E. Sorbero, Ammarah Mahmud, Asa Wilks, Jennifer Gildner, Anne Hornsby, Arthur Pignotti

ResearchPublished Jul 25, 2019

This report describes analytical methodologies, estimates, and technical considerations related to the measurement of health care utilization in Medicare Part C encounter data (ED) submitted by organizations offering Medicare Advantage plans to Medicare beneficiaries. The primary aim of the report is to provide technical details for researchers on the structure and scope of ED and on the methodological steps and analytical decisions necessary to assess utilization of health care services using ED. The authors identify key considerations related to enrollment, differences in ED and Medicare claims data, and decisions that researchers must make about data field selection.

From 2015 to 2016, there was a slight decrease in inpatient hospital stays (from 0.231 to 0.225 per enrollee) and a slight increase in professional visits (from 21.095 to 21.292 per enrollee). Outpatient facility visits, emergency department visits, and other outpatient facility visits increased slightly.

Key Findings

Utilization in 2015

  • There was an average of 0.231 inpatient hospital stays per beneficiary.
  • There was a higher number of outpatient hospital visits than inpatient hospital stays, at 3.397 per beneficiary on average.
  • There was an average of 0.594 emergency department visits per beneficiary.
  • There was an average of 0.609 other outpatient facility visits per beneficiary. This utilization category includes visits to outpatient facility settings other than outpatient hospital or emergency departments, such as ambulatory surgery centers and federally qualified health centers.
  • There was an average of 21.095 professional visits per beneficiary. Professional services include services provided by physicians, other practitioners, and suppliers (e.g., laboratories) across all places of service.

Changes in utilization from 2015 to 2016

  • There was a slight decrease in inpatient hospital stays (from 0.231 to 0.225 per enrollee) and a slight increase in professional visits (from 21.095 to 21.292 per enrollee).
  • Outpatient facility visits, emergency department visits, and other outpatient facility visits increased slightly.
  • While all of the 2015 to 2016 changes were statistically significant, the magnitudes of the changes were very small relative to the standard deviation of each measure.

Topics

Document Details

Citation

RAND Style Manual
Mulcahy, Andrew W., Melony E. Sorbero, Ammarah Mahmud, Asa Wilks, Jennifer Gildner, Anne Hornsby, and Arthur Pignotti, Measuring Health Care Utilization in Medicare Advantage Encounter Data: Methods, Estimates, and Considerations for Research, RAND Corporation, RR-2681-CMS, 2019. As of September 11, 2024: https://www.rand.org/pubs/research_reports/RR2681.html
Chicago Manual of Style
Mulcahy, Andrew W., Melony E. Sorbero, Ammarah Mahmud, Asa Wilks, Jennifer Gildner, Anne Hornsby, and Arthur Pignotti, Measuring Health Care Utilization in Medicare Advantage Encounter Data: Methods, Estimates, and Considerations for Research. Santa Monica, CA: RAND Corporation, 2019. https://www.rand.org/pubs/research_reports/RR2681.html.
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The research described in this report was funded by the Centers for Medicare & Medicaid Services (Centers for Medicare & Medicaid Services, Medicare Plan Payment Group), and conducted by the Payment, Cost, and Coverage Program within RAND Health Care.

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