A Study of Cancer in the Military Beneficiary Population

Transcription

1 MILITARY MEDICINE, 172, 10:1084, 2007 A Study of Cancer in the Military Beneficiary Population Guarantor: Raymond Shelton Crawford III, MD MBA Contributors: Raymond Shelton Crawford III, MD MBA*; Julian Wu, MD MPH ; Dae Park, MS ; Galen Lane Barbour, MD This study s objective was to describe: (1) patterns of cancer prevalence and type, (2) patient demographics, and (3) the sources, and cost, of medical care in the military beneficiary population using the Military Health System administrative databases. Calendar year 2002 patient enrollment, inpatient and outpatient encounter, and cost data from the 50 United States were analyzed to determine beneficiary cancer prevalence, demographics, source of care, cost of care, and cancer type. A total of 355,442 military beneficiaries were identified to have a cancer diagnosis (excluding nonmelanoma skin cancers) in More than two-thirds of these beneficiaries were over the age of 65, 55% were male, and 44% lived in three geographic areas of the country. Cancer of the prostate, breast, lung, and colon were most common. Almost 90% received their care outside of military medical treatment facilities and the overall cost of their care for 2002 was over $1 billion. Introduction he United States spending for cancer is increasing rapidly T because of the aging society, greater use of screening services, and new treatments that come with very high price tags. 1 In 2002, for example, the care provided to the 9.6 million Americans with cancer yielded substantial national cost and quality consequences. 2 The National Institutes of Health (using national surveys and administrative claims data) estimated that, in 2002, the costs to care for Americans with cancer throughout the United States were $171.6 billion, 3 or almost 10% of the total 2002 $1.6 trillion in health care expenditures. 4 Additionally, in that same year, the American Cancer Society estimated over 1.2 million new cancer cases, with over 500,000 deaths from cancer, 5 and the Agency for Health Care Research and Quality announced that 4 of the top 10 health conditions with the highest in-hospital mortality in 2002 were related to cancer. 6 This substantial societal impact has prompted discussion of the best approaches to studying cancer:... rather than focusing on the cost (of cancer research), the research and policy communities should consider a value-based approach toward *Assistant Professor and Medical Director, Division of Health Services Administration, Center for Population Health, Uniformed Services University of the Health Sciences, Bethesda, MD Senior Analyst, Division of Health Services Administration, Center for Population Health, Uniformed Services University of the Health Sciences, Bethesda, MD Current address: U.S. Military Cancer Institute, Walter Reed Army Medical Center, Washington, DC Senior Mathematical Statistician, Division of Health Services Administration, Center for Population Health, Uniformed Services University of the Health Sciences, Bethesda, MD Professor and Director, Division of Health Services Administration, Center for Population Health, Uniformed Services University of the Health Sciences, Bethesda, MD This manuscript was received for review in June The revised manuscript was accepted for publication in May developing and adopting cancer therapies, whereby innovations in cancer are viewed by gains in survival and reduced morbidity relative to their price. 1 One such approach to the study of cancer is the use of electronic, administrative claims data to analyze care provided to large, national populations. It has been suggested (keeping in mind limitations in clinical data and data quality issues) that administrative data offer substantial practical advantages for widespread quality assessment and can be useful as a screening tool for identifying quality problems and targeting areas that might require in-depth investigation. 7 Administrative data have been used to study large national populations such as in Medicare 8 10 and Veterans Health Administration (VHA) 11 patients. Another potential population for a large national cancer study is that population served by the Military Health System (MHS). The MHS population is large, currently 9.3 million, and is more diverse than either of the two other databases cited above. This population composed of active duty and retired military personnel and their family members includes all ages, socioeconomic levels, and different ethnic and educational backgrounds and receives care in many different public and private institutions across the country. 15 Studies of this national, heterogeneous population to assess (1) patterns of cancer prevalence and type, (2) patient demographics, and (3) their sources, and cost, of medical care can facilitate the discovery of best clinical practice using a data-driven approach focused on the best patient outcomes and the most effective use of resources. 16 Although a recent report has supported the risk adjustment of MHS data, 17 available published studies, to date, using MHS administrative databases have focused primarily on specific cancer types or specific health care institutions In this study, the Center for Population Health (CPH) at the Uniformed Services University of the Health Sciences used MHS administrative databases to study all cancer diagnoses in the overall military beneficiary population. Background The MHS is a large, complex, multi-institutional system that pays for, and provides care to, 9 million beneficiaries around the world. These beneficiaries have predominately been active duty personnel and retirees, and their family members, while more recently, military reservists and their family members have been extended coverage. The MHS makes health care available to its beneficiaries in two ways. First, it provides care directly through its 131,000 uniformed and civilian employee provider staffs working within its 536 military medical treatment facilities (MTF) worldwide called Direct Care. Second, it pays for care by contracting with thousands of providers through its network of civilian health care providers called TRICARE. These providers are private 1084

2 Cancer in the Military Beneficiary Population practitioners and facilities that may or may not be located in the same geographic area as the beneficiaries local MTFs. During 2002, TRICARE consisted of 12 civilian health services support regions within the 50 United States. In 2002, the MHS supported more than 30 million direct care outpatient visits and over 280,000 inpatient admissions in its 536 military hospitals and outpatient clinics. Also during that year, the system provided over 22 million TRICARE outpatient visits and over 290,000 inpatient admissions, processing over 44 million TRICARE health care claims. The MHS operates several large databases that capture beneficiary enrollment data and patient administrative data from both the Direct Care system and TRICARE. The enrollment database (the Defense Eligibility and Enrollment System) is the equivalent of managed care plan enrollment databases and contains complete sociodemographic data about all enrolled beneficiaries. MHS direct care inpatient and outpatient administrative data are captured in the Composite Health Care System (CHCS). Similarly, TRICARE administrative inpatient and outpatient data are captured in the Health Care Service Record (HCSR). Data from these databases are organized into inpatient and outpatient medical records. The inpatient records in CHCS are called the Standard Inpatient Data Record (SIDR), and in HCSR are called HCSR institutional (HCSRi). Both of these records, like the Centers for Medicare and Medicaid Services Form UB-92, contain all relevant diagnostic codes (International Classification of Disease, Clinical Modification, Version 9 (ICD-9-CM)) and procedural codes (Current Procedural Terminology Codes, Fourth Edition (CPT-4)). The outpatient records in CHCS are the Standard Ambulatory Data Record (SADR) and in HCSR are the HCSR noninstitutional (HCSRn). These records, like the Centers for Medicare and Medicaid Services Form 1500, contain all ICD-9-CM and CPT-4 codes from all outpatient encounters. Data related to cost of care were obtained from the Expense Assignment System IV, which is a standard Department of Defense cost accounting/assignment system consisting of a costassignment application and a data repository. These administrative databases are all aggregated into a central repository called the Medical Data Repository; from this repository, an extract named the MHS Analysis and Reporting Tool (M2), serves as an addressable source for patient sociodemographic and administrative data from both the direct and purchased inpatient and outpatient encounters. The M2 infrastructure provides an opportunity to assess the utility of these administrative data in the study of a large population of patients with cancer. Study Sample and Analysis Methods Creation of Complete Study Data Set Using the statistical software SAS (version 8.02; Cary, North Carolina), the CPH created a complete study data set through the following steps: Patient Identification From the records in the M2, all patients living within the 50 United States, who had received care in any MHS care venue during fiscal year (FY) 2002 (October 1, 2001 through September 30, 2002) were identified. From that population, 355,422 beneficiaries with a primary or secondary diagnosis of cancer (except for nonmelanoma skin cancer) were identified by querying for ICD-9-CM codes 140 to 208. The unit of measure was a patient, not a cancers type; records on patients with more than a single cancer were consolidated and a final composite record was created for each unique patient, allowing up to four cancer diagnoses per patient. Extraction of Patient Sociodemographic Information Using preapplied unique patient identifiers, the CPH extracted from Defense Eligibility and Enrollment System patient sociodemographic data, including sponsor identification (ID), family member prefix (a numerical prefix applied to the military member s Social Security number that designates the family member s relationship to the member: spouse, child, dependant parent, etc.); gender, birth date, and date of the health care encounter. Extraction of Patient Administrative Data Using the same unique identifier, the CPH extracted all other administrative data (additional diagnostic codes, procedural codes) from SIDR and SADR inpatient and outpatient encounters, and HCSRi and HCSRn inpatient and outpatient encounters. This process, to this point, created four unique beneficiary data sets for patients with cancer: patients receiving direct inpatient care, direct outpatient care, purchased inpatient care, and/or purchased outpatient care. Creation of the Final Data Set The SIDR and SADR data set were then merged using the combination of sponsor ID and family member prefix; similar actions were taken for the HCSRi and HCSRn databases. The final study data set of 355,422 individuals with at least one MHS encounter for cancer was created by merging the direct and TRICARE data sets. At each step, records were compared using several variables (patient ID, date of encounter, MTF identification code, or provider tax ID, admission and discharge dates, service provider code, and procedure codes) to identify and remove duplicate encounters. Data Analysis The descriptive analysis focused on the following elements: date of birth, gender, race/ethnicity, beneficiary home zip code, TRICARE region, inpatient admission date, inpatient discharge date, outpatient encounter date, primary ICD-9-CM code, secondary ICD-9-CM codes (up to 4), and CPT-4 codes (up to 4). This study s focus was on point prevalence and was limited to collecting a single year s data. Therefore, the CPH did not attempt to determine new diagnoses or the incidence rates for individual cancers. Results 1085 A total of 355,442 military beneficiaries with a diagnosis of an invasive malignancy (excluding nonmelanoma skin cancers) who received care from the MHS in FY 2002 were identified. This number represents an overall cancer prevalence of 4.1% in the

3 1086 Cancer in the Military Beneficiary Population TABLE I AGE AND GENDER DISTRIBUTION OF BENEFICIARIES WITH CANCER No. of Cancer Percentage Age group , , , , Gender Female 156, Male 198, Unspecified military beneficiary population, although beneficiaries who obtained their health care from sources completely external to the MHS (VHA, Medicare, or other outside insurance) were included in this analysis. Of the beneficiaries in the study, more than two-thirds were over age 65. Most were males (55%). Incomplete data precluded an analysis of race or ethnicity, since 80% of the records were blank. The age and gender distribution of the study population is shown in Table I. Forty-four percent of the study population lived clustered in 3 of the 12 TRICARE regions: (1) the southeast region centered in Florida with 61,591 individuals (17.33% of the total patient population), (2) the northeast region located mostly in the mid- Atlantic seaboard with 50,734 patients (14.27%), and (3) the southwest region centered in Arizona containing 46,751 individuals (13.15%). The complete geographic distribution in the 50 states is displayed in Table II. We also determined that of these patients who received MHS care for their cancer, only 8.81% received all of their MHS care from the Direct Care system. Most of the patients (89.35%) TABLE II REGIONAL DISTRIBUTION OF TRICARE BENEFICIARIES WITH CANCER Region a Description No. of Cancer Percentage 1 Northeast 50, Mid-Atlantic 29, Southeast 61, Gulf South 32, Heartland 30, Southwest 46, TRICARE central 19, TRICARE central 27, Southern 22, California 10 Golden Gate 14, Northwest 14, TRICARE Pacific 4, (Hawaii) 16 Alaska and Puerto 1, Rico Total 355, a Regions 13 to 15 are overseas locations and were not included in this study. obtained their MHS care solely through TRICARE, and a very small segment (1.85%) through both (see Table III). In addition, using the MHS financial database (using direct care fields Full Cost, Direct and Full Cost, Variable ; and TRICARE field Amount Paid, Raw ) the global cost to the federal government for these patients care during 2002 was found to be more than $1 billion. Of this amount, $188,469,724 (17.2%) occurred in the Direct Care sector and $905,347,605 (82.8%) in TRICARE. The degree of specificity and variations in accounting techniques in the financial systems did not allow determination of either per-case costs or any comparison of costs between Direct Care and TRICARE. More than 60 different types of cancer diagnoses were found in the study population (Table IV). Prostate cancer in men and breast cancer in women were the most common malignancies found, followed closely by lung cancer and colorectal cancer; these four accounted for 73% of all of the cancer diagnoses. Discussion The primary purpose of this study was to evaluate the utility of studying cancer patterns or trends in beneficiaries of the MHS through the use of the MHS administrative databases. The only other currently available national database that can be used to answer these types of questions is the Surveillance, Epidemiology, and End Results (SEER) Cancer Statistics Review that is published annually by the Cancer Statistics Branch of the National Cancer Institute. Geographic areas within the United States submit data from the tumor registry data into the SEER; data from the geographic areas used in this report represent 9 to 14% of the U.S. population. This database includes incidence, mortality, survival, and prevalence statistics on those cases reported from 1975 through 2001, the most recent years for which data are available. 2 The SEER database is not nationally representative, but has been reported to compare adequately with the Medicare database in some aspects of cancer care, 21,22 although clearly there are inherent limitations. One obvious limitation of the SEER database is the fact that it is comprised of manual inputs of a nonrandom sample of less than all cases treated. Manual input allows the inclusion of some clinical material, but requires time and effort to complete and introduces other possible causes to doubt the completeness and veracity of the data. Nonetheless, as this is the only reasonably comparable database for such a heterogeneous population, we compared our data with the latest SEER results. This study identified a fiscal year 2002 overall invasive cancer prevalence rate in the MHS of 4.1% (excluding nonmelanoma skin cancer), while the SEER data (calendar year 2000) showed a 2.1% prevalence of all invasive cancers. It is not known whether this difference in cancer prevalence is a real difference between the two calendar periods or possibly due to underreporting in the SEER system. Actual incidence rates depend upon patients coming into contact with the health care system. Since SEER data may represent a significant number of uninsured individuals, it is possible that any lack of access to care would result in an underestimation of cancer prevalence. On the other hand, the MHS database not only represents a population with universal access to health care but also contains automated input concerning every encounter in the system.

4 Cancer in the Military Beneficiary Population 1087 Source of Care TABLE III SOURCE OF CARE FOR TRICARE BENEFICIARIES WITH CANCER All 65 Years 65 Years Direct Care Only 48, , , Purchase Care Only 293, , , Both 12, , , Total 355, , , TABLE IV CANCER DIAGNOSES OF TRICARE BENEFICIARIES ICD-9-CM Code Description 185 Malign prostate 174 Malig neo female breast a 162 Mal trachea/ lung 153 Malignant colon Cancer Percentage 67, , , , All other 80, Most cancer patients in this study were older than 65 years of age. Additionally, 55% of them were male. This gender breakout is in contrast to the SEER database in which 55.6% of patients are female. This said, although males dominate in the active duty military population, the MHS beneficiary from which this study population was drawn is a good representation of the national population as it includes all ages and a proportionate mix of genders. Documentation of ethnicity in the MHS database was absent in a high proportion of instances, therefore no conclusions can be drawn from ethnicity regarding any impact on various aspects of care. Although the four most common cancers in this study are the same as those in the SEER database, the order of their frequency is different. In SEER, the most common cancer involved breast, while in the MHS prostate cancer was more common. The frequency of these cancers may reflect simply the predominance of females in the national population (55.6%) and of males (51.8%) in the MHS. Most beneficiaries were clustered in three geographic areas of the United States: the southeast, the northeast, and the southwest (consistent with the distribution of the general MHS population in that year). The cost of cancer care in FY 2002 was more than $1 billion. Furthermore, evaluation of the pattern of spending is of interest, because MHS health care costs have doubled from 2001 to Most of this cost for cancer care was incurred through TRI- CARE because most of the care to these patients was delivered in the private sector. Before the present study, little had been published about cancer patients relative use of Direct Care and TRICARE. Whether such variation in care location occurs with other major illnesses is also not known. Any number of questions that flow from identifying such disparity in sites of care for a costly and complex set of diagnoses could have significant policy implications. Issues such as whether care should be recaptured into the Direct Care System and whether the readiness of the medical force might be improved by additional case volume may have much more powerful cost implications. Additionally, any concern about the type and capability of specialty care needed within the MHS raises questions about the training for such specialists and whether the MHS has the volume for best quality educational programs. Thus, the identification of the imbalance in the sites of care for cancer in the MHS would imply that additional studies are needed to: (1) determine the underlying reasons for the pattern of care noted; (2) further assess other clinical patterns of care in the MHS population; and (3) ascertain the impact of such patterns on the cost, quality, military readiness, and graduate medical education aspects of military health care. Another consideration that needs to be studied is the degree to which military retirees are also VHA-eligible beneficiaries and receive some portion of care in Veterans Affairs treatment facilities. Conclusions The MHS administrative databases provide a powerful mechanism through which to study cancer at the national level by leveraging this heterogeneous population and the existence of a thorough administrative database in the federal sector. The data elements available for analysis within the MHS are comparable to those found in other systems such as the Medicare and VHA databases and should allow for direct comparisons between the various systems. The current study demonstrates the lack of historical information on race/ethnicity in many MHS records, possibly as a result of past policy decisions not to require such information. As evidence grows that race and ethnicity are important determinants for some common diseases, the MHS is putting more attention toward collecting and verifying this variable. The MHS has a unique attribute in that it contains within the single system, data from a federal (capitated) health care system and data from care delivered in nonfederal, managed care, and fee-for-service environments. Moreover, given the span of ages of the beneficiaries of the MHS, it is plausible to consider the military population a microcosm of the total national population. As a representative sample of the national population, studies involving MHS beneficiaries and their cancer care can

5 1088 Cancer in the Military Beneficiary Population provide worthwhile input to national health care decisions. Further study into reasons for geographic distribution of MHS patients with cancer, patterns of care, or clinical outcome and cost of care for common cancer diagnoses is warranted. Acknowledgment This project was supported, in part, by Grant USMCI-HSA 01/03 from the U.S. Military Cancer Institute (Washington, DC; References 1. Ramsey S: What do we want from our investment in cancer research. Health Affairs, September 26, Available at content/full/hlthaff.w5.r101/dc1; accessed October 28, SEER Cancer Statistics Review , National Cancer Institute. Available at accessed October 21, Chang S, et al: Estimating the cost of cancer: results on the basis of claims data analyses for cancer patients diagnosed with seven types of cancer during 1999 to J Cancer Oncol 2004; 22: Cowan C, Catlin A, Smith C, Sensenig A: National health expenditures, Health Care Financ Rev 2004; 25: American Cancer Society: Cancer Facts and Figures Available at accessed April 16, HCUP Fact Book No. 6: Hospitalization in the United States, Available at accessed April 17, Iezzoni LI: Assessing quality using administrative data. Ann Intern Med 1997; 127: Freeman JL, et al: Measuring breast, colorectal, and prostate cancer screening with Medicare claims data. Med Care 2002; 40(Suppl 8): IV Rao S, Kubisiak J, Gilden D: Cost of illness associated with metastatic breast cancer. Breast Cancer Res Treat 2004; 83: Cooper GS, Yuan Z, Jethva RN, Rimm AA: Use of Medicare claims data to measure county-level variation in breast carcinoma incidence and mammography rates. Cancer Detect Prev 2002; 26: Billingsley K, Maynard C, Schwartz DL, Dominitz JA: The use of trimodality therapy for the treatment of operable esophageal carcinoma in the veteran population: patient survival and outcome analysis. Cancer 2001; 92: Office of the Undersecretary of Defense, Personnel and Readiness: Executive Summary of the 2003 Population Representation in the Military Services. Available at accessed October 15, Military Family Resource Center/Office of the Deputy Undersecretary of Defense (Military Community and Family Policy): 2003 Demographics Profile of the Military Community. Available at LSN/BINARY_RESOURCE/BINARY_CONTENT/ swf; accessed October 15, TRICARE For Life. Available at accessed October 15, TRICARE Provider Directory. Available at providerdirectory; accessed October 15, Krakauer H, et al: Best Clinical Practice : assessment of processes of care and of outcomes in the U.S. Military Health Services System. J Eval Clin Pract 1998; 4: Ruben M, Mihara T, Hill M, Fristoe K: The potential for risk adjustment for the Military Health System TRICARE Program. Milit Med 2005; 170: Yamane GK, Johnson R: Testicular carcinoma in U.S. Air Force aviators: a case-control study. Aviat Space Environ Med 2003; 74: Wade TP, Halaby IA, Stapleton DR, Virgo KS, Johnson FE: Population-based analysis of treatment of pancreatic cancer and Whipple resection: Department of Defense hospitals, Surgery 1996; 120: 680 5, discussion Grayson JK, Lyons TJ: Cancer incidence in United States Air force aircrew, Aviat Space Environ Med 1996; 67: Cooper GS, Virnig B, Klabunde CN, Schussler N, Freeman J, Warren JL: Use of SEER-Medicare data for measuring cancer surgery. Med Care 2002; 40(Suppl 8): IV Cooper GS, Yuan Z, Stange KC, Dennis LK, Amini SB, Rimm AA: Agreement of Medicare claims and tumor registry data for assessment of cancer-related treatment. Med Care 2000; 38: American Forces Information Service News Articles: DoD Healthcare Spending Doubled in Past Four Years. January 25, Available at denselink.mil/news/jan2005/n _ html; accessed October 23, 2006.