Centers for Medicare and Medicaid Services: Market Saturation and Utilization Data Tool

WASHINGTON, Aug. 30 -- The U.S. Department of Health and Human Services' Centers for Medicare and Medicaid Services issued the following news release:

Market Saturation and Utilization Data Tool

Market Saturation and Utilization Data Tool was developed to allow the Centers for Medicare & Medicaid Services (CMS) to monitor market saturation as a means to help prevent potential fraud, waste, and abuse (FWA). Market saturation, in the present context, refers to the density of providers of a particular service within a defined geographic area relative to the number of beneficiaries receiving that service in the area. The data can be used to reveal the degree to which use of a service is related to the number of providers servicing a geographic region. There are also a number of secondary research uses for these data, but one objective of making these data public is to assist health care providers in making informed decisions about their service locations and the beneficiary population they serve.

The tool includes interactive maps and datasets that show national-, state-, county-, and Core-Based Statistical Area (CBSA)-level provider services and utilization data for selected health service areas. Provider services and utilization data by these geographic regions are easily compared using the interactive maps above. The tool is available through the CMS website at: https://data.cms.gov/market-saturation. Future releases may include comparable information on additional health service areas.

Release 9 introduces two additional service areas and contains eleven, twelve-month reference periods and nineteen health service areas: Home Health, Ambulance (Emergency, Non-Emergency, Emergency & Non-Emergency), Independent Diagnostic Testing Facilities (Part A and Part B), Skilled Nursing Facilities, Hospice, Physical and Occupational Therapy, Clinical Laboratory (Billing Independently), Long-Term Care Hospitals, Chiropractic Services, Cardiac Rehabilitation Programs, Psychotherapy, Federally Qualified Health Centers, Ophthalmology, Preventive Health Services, Dialysis, and Telemedicine.

Release 9 also introduces an additional geographic division of Core-Based Statistical Area (CBSA). CBSAs are geographical delineations that encompass both metropolitan statistical areas and micropolitan statistical areas. A micropolitan statistical area is an urban cluster of at least 10,000 people but less than 50,000 people, while a metropolitan statistical area is an urban cluster of at least 50,000 people. CBSAs are Census Bureau-defined urban clusters of at least 10,000 people. In order to better provide appropriate data and services, CMS defines additional custom CBSAs beyond those defined by the US Census Bureau. At this time CBSA-level trend data is not calculated since only one reference period is currently available. CMS defined CBSAs are not currently included in the shapefile needed to create the CBSA interactive map. The CMS defined CBSAs are included in the interactive data set and contribute to the Nation + Territories level totals.

Methodology

The analysis is based on paid Medicare Fee-for-Service (FFS) claims data from the CMS Integrated Data Repository (IDR). The IDR contains Medicare FFS claims, beneficiary data, provider data, and plan data. FFS claims data are analyzed for a 12-month reference period, and state- and county-level results are updated quarterly to reflect a more recent 12-month reference period. CBSA data are also analyzed for a 12-month reference period and results will be updated annually to reflect a more recent calendar year.

The Market Saturation and Utilization methodology is different from other public use data with respect to determining the geographic location of a provider. In this analysis, claims are used to define the geographic area(s) served by a provider rather than the provider's practice address. Further, a provider is defined as "serving a county" if, during the 12-month reference period, the provider had paid claims for more than ten beneficiaries located in a county. A provider is defined as "serving a state" if that provider serves any county in the state. Similar to the county-level definition, a provider is defined as "serving a CBSA" if, during the one-year reference period, the provider had paid claims for more than ten beneficiaries located in that CBSA. The CBSA location is an aggregation of county level data.

The Market Saturation and Utilization methodology is also different from other public use data with respect to determining the number of Medicare beneficiaries who are enrolled in a fee-for-service (FFS) program. In this analysis, a FFS beneficiary is defined as being enrolled in Part A and/or Part B with a coverage type code equal to "9" (FFS coverage) for at least one month of the 12-month reference period. There must not be a death date for that month or a missing zip code for the beneficiary so that the beneficiary can be assigned to a county. Other public use data may define a FFS beneficiary using different criteria, such as requiring the beneficiary to be enrolled in the FFS program every month during the reference period.

Starting with Release 7 (April 2018), the interactive data set for state- and county-level data includes all reference periods for the following United States territories, commonwealths, and freely associated states: American Samoa (AS); Micronesia (FM); Guam (GU); Northern Mariana Islands (MP); Puerto Rico (PR); and the U.S. Virgin Islands (VI). The national-level data in the interactive data set for all previous reference periods reflects the U.S. plus the aforementioned territories. With Release 9, the interactive data set for CBSA-level data includes one reference period and data for United States territories, commonwealths, and freely associated states that have defined CBSAs.

The Market Saturation and Utilization Tool does not include information on market saturation and utilization for Medicaid or private insurance. Dual eligible metrics are produced from Medicare claims data only and therefore do not incorporate Medicaid claims data.

The Market Saturation and Utilization Data Tool includes an interactive map that is color-coded based on an analysis that separates the distribution into the following categories of states/counties/CBSAs for the selected metric: lowest 25 percent, second lowest 25 percent, third lowest 25 percent, top 25 percent excluding extreme values, and extreme values. An extreme value is one that greatly differs from other values in its field (e.g., Number of Providers). Counties and CBSAs that are excluded from the analysis are colored gray in the interactive maps. The CBSA map is generated using the 2017 shapefile, which contains the same CBSAs as the 2018 file.

For those interested in states and counties affected by CMS' temporary provider enrollment moratoria during the reference periods for which data are available, the interactive map permits a visualization that identifies those states and counties. On January 30, 2019, the CMS temporary provider enrollment moratoria was lifted. The tool currently reflects the status of an active moratoria during the reference periods available. In this visualization, Ambulance and Home Health service areas for moratoria versus non-moratoria states/counties are identified based on color scheme.

The State/County-level examples below utilize the Home Health service area data (selected for illustration purposes only). Similar maps can be created through the Data Tool for all of the health service areas included in this release and for the following State/County-level twelve-month reference periods:

* October 1, 2014 through September 30, 2015

* January 1, 2015 through December 31, 2015

* April 1, 2015 through March 31, 2016

* July 1, 2015 through June 30, 2016

* October 1, 2015 through September 30, 2016

* January 1, 2016 through December 31, 2016

* April 1, 2016 through March 31, 2017

* July 1, 2016 through June 30, 2017

* October 1, 2016 through September 30, 2017

* January 1, 2017 through December 31, 2017

* April 1, 2017 through March 31, 2018

The CBSA example below utilizes the Ophthalmology service area data (selected for illustration purposes only). Similar maps can be created through the Data tool for all of the health service areas included in this release. CBSA data is refreshed annually and currently includes one reference period (January 1, 2017 - December 31. 2017). Additional reference periods will be included in future releases.

Map 1 displays the distribution of providers by state for the October 1, 2016 through September 30, 2017 reference period. The dual color scale distinguishes between moratoria (blue) and non-moratoria states (green).

Click here (https://www.cms.gov/newsroom/fact-sheets/market-saturation-and-utilization-data-tool-5)

Similar maps can be created at the national- and state-level for the other metrics included in the Data Tool: Number of FFS Beneficiaries, Average Number of Users per Provider, Percentage of Users out of FFS Beneficiaries, Number of Users, Average Number of Providers per County, Number of Dual Eligible Users, Percentage of Dual Eligible Users out of Total Users, Percentage of Dual Eligible Users out of Dual Eligible FFS Beneficiaries, and Total Payment.

Map 3 shows the distribution of Fee-for-Service Beneficiaries by CBSA for the January 1, 2017 through December 31, 2017 reference period. Future releases will include additional reference periods and trend data. The CBSA interactive map uses a single color scale. The map does not include moratoria information as the moratoria were enacted statewide. CBSAs can cross state lines and extend into non-moratoria states.