Others titles

  • Medicare Drug Spending Data
  • Medicare Drug Cost and Drug Spending
  • Medicare Part B Drug Cost and Utilization

Keywords

  • Medicare
  • CMS Drugs
  • CMS Drug Costs
  • Drug Utilization
  • Medicare Spending
  • Part B Drugs Cost

Medicare Part B Drug Cost and Utilization Data 2016-2020

Medicare Part B Drug Cost and Utilization Data 2016-2020

The Medicare Part B Drug Cost and Utilization Dataset presents drug spending and utilization information on Medicare Part B drugs (drugs administered in doctors’ offices and other outpatient settings) and includes annual data for 2016 to 2020.

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Description

Medicare Part B claims (e.g. physician and other suppliers, durable medical equipment and other supplies, hospital outpatient data) contain information on drugs administered and billed directly by providers. Analyses of Part B drugs are possible for all Part B fee-for-service Medicare beneficiaries, but exclude any beneficiaries in the Medicare Advantage program. Drug spending metrics for Part B drugs are based on total spending, which is derived from summing the three revenue center payment fields on the claim referring to Medicare payment, deductible, and coinsurance. This represents the full value of the product, including the Medicare payment and beneficiary liability.

Part B claims were summarized by Healthcare Common Procedure Coding System (HCPCS) codes and limited to HCPCS codes listed in the publicly available Medicare Average Sales Price (ASP) quarterly files at any point in the prior 5 years. In addition to the HCPCS listed in the ASP drug lists, oral anti-cancer drugs identified by HCPCS beginning with ‘WW’ were included. Part B claims were excluded if Medicare was not the primary payer or if the drugs were billed using “Not Otherwise Classified” (NOC) codes (e.g. J3490, J3590, or J9999), since identification of NOC drugs are not specified on the claim. In addition, Part B institutional claims submitted by critical access hospitals (CAHs), Maryland hospitals, as well as claims with total spending amounts of zero associated with the drug, which is due to bundling in Ambulatory Payment Classification groups, were excluded.

Claims data were averaged across any applicable modifiers or place of service indicators associated with a single HCPCS. Drugs with multiple strengths (e.g. 20mg, 40mg, 80mg) were not combined when individual HCPCS codes exist for different strengths (e.g., methylprednisolone has different HCPCS codes for 20mg, 40mg, and 80mg).

**OUTLIER FLAGS**

Average Spending per Dosage Unit is a key measure in the Medicare Part B Spending by Drug dataset. Incorrect dosage unit values reported on a small percentage of records may result in a misrepresentation of the overall “Average Spending per Dosage Unit” and “Change in Average Spending per Dosage Unit”. To address this concern, potentially anomalous drugs are identified as outliers so that users can exercise caution when interpreting results.

In the full underlying data file, potentially anomalous drugs are identified using a yearly outlier flag variable, which is set to “1” when a drug’s Average Spending per Dosage Unit is substantially impacted by outlier records in a given year.

There are three methods by which drugs are identified as outliers within the Medicare Part B Spending by Drug dataset:

**1.5 IQR Outlier Identification**
– For each Medicare Part B Drug (HCPCS), lower and upper bounds for average cost per dosage unit are defined as:
– Lower Bound: 25th percentile – 1.5*Interquartile Range
– Upper Bound: 75th percentile + 1.5*Interquartile Range
– Claim lines that fall outside of these bounds are flagged. Additionally, claim lines associated with HCPCSs for which there are fewer than 30 claim lines in total are flagged.
– Average Spend per dosage unit are calculated with and without flagged claim lines; if these values differ by over 10% and $1, the drug is identified as an outlier.

**Physician vs. Outpatient Outlier Identification**
– Medicare Part B Drugs are comprised of both physician and outpatient claims. In some cases, billing units may differ between settings.
– If both the average physician spend per dosage unit and average outpatient spend per dosage unit differ from the overall average spend per dosage unit by > 10% and $1, the drug is identified as an outlier.

**Low Record Count Identification**
– Methods 1 and 2 require robust distributions of data to identify outliers (i.e. observations outside of an established norm). In cases where a drug has fewer than 30 observations, it is flagged since there is not enough data to identify outliers.

About this Dataset

Data Info

Date Created

2020
Last Modified

2022-01-27
Version

2022-01-27
Update Frequency

Annual
Temporal Coverage

2016-2020
Spatial Coverage

United States
Source

John Snow Labs; Centers for Medicare and Medicaid Services;

Source License URL

Source License Requirements

N/A
Source Citation

N/A
Keywords

Medicare, CMS Drugs, CMS Drug Costs, Drug Utilization, Medicare Spending, Part B Drugs Cost

Other Titles

Medicare Drug Spending Data, Medicare Drug Cost and Drug Spending, Medicare Part B Drug Cost and Utilization

Data Fields

Name Description Type Constraints
HCPCS_CodeHealthcare Common Procedure Coding System (HCPCS) code for the drugstringrequired : 1
HCPCS_DescriptionHCPCS Description of the drugstringrequired : 1
Brand_NameName of the drug furnished by the provider. This includes both brand names (drugs that have a trademarked name) and generic names (drugs that do not have a trademarked name).stringrequired : 1
Generic_NameA term referring to the chemical ingredient of a drug rather than the trademarked brand name under which the drug is sold.string-
Total_Spending_2016Aggregate drug spending for the Part B program for 2016numberlevel : Ratio
Total_Dosage_Units_2016The sum of the dosage units of medication dispensed across the calendar year 2016 (e.g. number of tablets, grams, milliliters or other units). For Part B, the quantity of a drug in a dosage unit is the same as the quantity of the drug in a HCPCS billing unit.integerlevel : Ratio
Total_Claims_2016Number of Medicare Part B claims for the year 2016 for each drug.integerlevel : Ratio
Total_Beneficiaries_2016Number of Medicare Part B fee-for-service beneficiaries utilizing the drug in the year 2016.integerlevel : Ratio
Average_Spending_Per_Dosage_Unit_2016Part B drug spending divided by the number of dosage units during the year 2016.numberlevel : Ratio
Average_Spending_Per_Claim_2016Part B drug spending divided by the number of claims during the year 2016.numberlevel : Ratio
Average_Spending_Per_Beneficiary_2016Total Part B drug costs divided by the number of unique beneficiaries utilizing the drug during the benefit year 2016.numberlevel : Ratio
Outlier_Flag_2016Set to 1 when outliers in data cause Average Spending per Dosage Unit to change by at least 10% and $1, or there are not enough records to identify outliers during the year 2016. The description of dataset contains additional details.integerlevel : Nominal
Total_Spending_2017Aggregate drug spending for the Part B program for 2017numberlevel : Ratio
Total_Dosage_Units_2017The sum of the dosage units of medication dispensed across the calendar year 2017 (e.g. number of tablets, grams, milliliters or other units). For Part B, the quantity of a drug in a dosage unit is the same as the quantity of the drug in a HCPCS billing unit.integerlevel : Ratio
Total_Claims_2017Number of Medicare Part B claims for the year 2017 for each drug.integerlevel : Ratio
Total_Beneficiaries_2017Number of Medicare Part B fee-for-service beneficiaries utilizing the drug in the year 2017.integerlevel : Ratio
Average_Spending_Per_Dosage_Unit_2017Part B drug spending divided by the number of dosage units during the year 2017.numberlevel : Ratio
Average_Spending_Per_Claim_2017Part B drug spending divided by the number of claims during the year 2017.numberlevel : Ratio
Average_Spending_Per_Beneficiary_2017Total Part B drug costs divided by the number of unique beneficiaries utilizing the drug during the benefit year 2017.numberlevel : Ratio
Outlier_Flag_2017Set to 1 when outliers in data cause Average Spending per Dosage Unit to change by at least 10% and $1, or there are not enough records to identify outliers during the year 2017. The description of dataset contains additional details.integerlevel : Nominal
Total_Spending_2018Aggregate drug spending for the Part B program for 2018.numberlevel : Ratio
Total_Dosage_Units_2018The sum of the dosage units of medication dispensed across the calendar year 2018 (e.g. number of tablets, grams, milliliters or other units). For Part B, the quantity of a drug in a dosage unit is the same as the quantity of the drug in a HCPCS billing unit.integerlevel : Ratio
Total_Claims_2018Number of Medicare Part B claims for the year 2018 for each drug.integerlevel : Ratio
Total_Beneficiaries_2018Number of Medicare Part B fee-for-service beneficiaries utilizing the drug in the year 2018.integerlevel : Ratio
Average_Spending_Per_Dosage_Unit_2018Part B drug spending divided by the number of dosage units during the year 2018.numberlevel : Ratio
Average_Spending_Per_Claim_2018Part B drug spending divided by the number of claims during the year 2018.numberlevel : Ratio
Average_Spending_Per_Beneficiary_2018Total Part B drug costs divided by the number of unique beneficiaries utilizing the drug during the benefit year 2018.numberlevel : Ratio
Outlier_Flag_2018Set to 1 when outliers in data cause Average Spending per Dosage Unit to change by at least 10% and $1, or there are not enough records to identify outliers during the year 2018. The description of dataset contains additional details.integerlevel : Nominal
Total_Spending_2019Aggregate drug spending for the Part B program for 2019.numberlevel : Ratio
Total_Dosage_Units_2019The sum of the dosage units of medication dispensed across the calendar year 2019 (e.g. number of tablets, grams, milliliters or other units). For Part B, the quantity of a drug in a dosage unit is the same as the quantity of the drug in a HCPCS billing unit.integerlevel : Ratio
Total_Claims_2019Number of Medicare Part B claims for the year 2019 for each drug.integerlevel : Ratio
Total_Beneficiaries_2019Number of Medicare Part B fee-for-service beneficiaries utilizing the drug in the year 2019.integerlevel : Ratio
Average_Spending_Per_Dosage_Unit_2019Part B drug spending divided by the number of dosage units during the year 2019.numberlevel : Ratio
Average_Spending_Per_Claim_2019Part B drug spending divided by the number of claims during the year 2019.numberlevel : Ratio
Average_Spending_Per_Beneficiary_2019Total Part B drug costs divided by the number of unique beneficiaries utilizing the drug during the benefit year 2019.numberlevel : Ratio
Outlier_Flag_2019Set to 1 when outliers in data cause Average Spending per Dosage Unit to change by at least 10% and $1, or there are not enough records to identify outliers during the year 2019. The description of dataset contains additional details.integerlevel : Nominal
Total_Spending_2020Aggregate drug spending for the Part B program for 2020.numberlevel : Ratio
Total_Dosage_Units_2020The sum of the dosage units of medication dispensed across the calendar year 2020 (e.g. number of tablets, grams, milliliters or other units). For Part B, the quantity of a drug in a dosage unit is the same as the quantity of the drug in a HCPCS billing unit.integerlevel : Ratio
Total_Claims_2020Number of Medicare Part B claims for the year 2020 for each drug.integerlevel : Ratio
Total_Beneficiaries_2020Number of Medicare Part B fee-for-service beneficiaries utilizing the drug in the year 2020.integerlevel : Ratio
Average_Spending_Per_Dosage_Unit_2020Part B drug spending divided by the number of dosage units during the year 2020.numberlevel : Ratio
Average_Spending_Per_Claim_2020Part B drug spending divided by the number of claims during the year 2020.numberlevel : Ratio
Average_Spending_Per_Beneficiary_2020Total Part B drug costs divided by the number of unique beneficiaries utilizing the drug during the benefit year 2020.numberlevel : Ratio
Outlier_Flag_2020Set to 1 when outliers in data cause Average Spending per Dosage Unit to change by at least 10% and $1, or there are not enough records to identify outliers during the year 2020. The description of dataset contains additional details.integerlevel : Nominal
Percent_Change_In_Average_Spending_Per_Dosage_Unit_2020The percentage change in average spending per dosage unit for the year 2020 from the year 2019.numberlevel : Ratio
Percent_Annual_Growth_Rate_In_Avg_Spending_Per_Dosage_Unit_2016_2020The constant average change in spending per unit over the most recent five years (2016-2020) of data availability, calculated using the compound annual growth rate (CAGR).numberlevel : Ratio

Data Preview

HCPCS CodeHCPCS DescriptionBrand NameGeneric NameTotal Spending 2016Total Dosage Units 2016Total Claims 2016Total Beneficiaries 2016Average Spending Per Dosage Unit 2016Average Spending Per Claim 2016Average Spending Per Beneficiary 2016Outlier Flag 2016Total Spending 2017Total Dosage Units 2017Total Claims 2017Total Beneficiaries 2017Average Spending Per Dosage Unit 2017Average Spending Per Claim 2017Average Spending Per Beneficiary 2017Outlier Flag 2017Total Spending 2018Total Dosage Units 2018Total Claims 2018Total Beneficiaries 2018Average Spending Per Dosage Unit 2018Average Spending Per Claim 2018Average Spending Per Beneficiary 2018Outlier Flag 2018Total Spending 2019Total Dosage Units 2019Total Claims 2019Total Beneficiaries 2019Average Spending Per Dosage Unit 2019Average Spending Per Claim 2019Average Spending Per Beneficiary 2019Outlier Flag 2019Total Spending 2020Total Dosage Units 2020Total Claims 2020Total Beneficiaries 2020Average Spending Per Dosage Unit 2020Average Spending Per Claim 2020Average Spending Per Beneficiary 2020Outlier Flag 2020Percent Change In Average Spending Per Dosage Unit 2020Percent Annual Growth Rate In Avg Spending Per Dosage Unit 2016 2020
90371Hepatitis B immune globulin for injection into muscleHyperHEP B S-DHepatitis B Immune Globulin2365772143506160110.4467.541478.602611322408405167108.44644.771563.670137212.261365301139100.52455.85987.1401338401253312161106.82428.97831.308220385614783.096.03559.2990.40-10.1-3.42
90375Rabies immune globulin for injection beneath the skin and/or into muscleHyperRABRabies Immune Globulin/PF57153552033225862534281.12210.112255.47069319412418127572732286.672514.312537.3107722116.192777331083070278.042484.592515.35093879923396133953366276.432765.242789.06082504913150130693021.0261.912688.332731.050-5.25-1.75
90376Rabies immune globulin for injection beneath the skin and/or into muscleImogam Rabies-HTRabies Immune Globulin/PF16451036085796786270.352066.712093.01020129496795779775296.242584.022597.3501874211.256252704696299.782662.232692.83012584034708498491267.292526.912562.9408883303303348348.0268.952552.672552.6700.62-0.13
90586Vaccine for bladder cancer injection into urinary bladderBCG (Tice Strain) (90586)BCG Live2599121420454121.45127.41481.3106871606018114.52114.52381.7216141.06535311115.87115.87558.2817824605927130.41132.62289.79030462222138.46138.4616.183.33
90632Vaccine for Hepatitis A injection into muscle, adult dosageHavrixHepatitis A Virus Vaccine/PF1185323023021651.5351.5354.8802134643043040949.6449.6452.19098033.419011901176551.5751.5755.5408036514081408131857.0857.0860.98038404657657649.058.4558.4559.1702.413.2
90653Vaccine for influenza for injection into muscleFluad 2017-2018Flu Vacc TS2017(65up)/Mf59c/PF1367266737746537742737732736.2236.2336.2406800509315095411509532150319245.0545.0545.240122198204.824260312426033240221350.3750.3750.87015920695129348312934809291510254.2554.2554.61026328827464569464550461237.056.6756.6857.0804.4711.84
90662Vaccine for influenza for injection into muscleFluzone High-Dose 2017-2018Flu Vacc TS2017-18(65yr Up)/PF33257940884807688470237838075439.2239.2639.68039514571989469138929660878826744.1744.2544.960461229753.793415929341367915406449.3749.3750.39042814218082740408263719814972451.7551.8152.530473362244828021682700498111879.057.1757.2458.35010.489.88
90670Pneumococcal vaccine for injection into musclePrevnar 13Pneumococcal 13-Valent Vaccine667483118400644939538613925000166.6168.82170.060477149945267911026788762660076178.1178.12179.370432793749.8228273722826572267575189.59189.6190.860389175951194766619475801931368199.82199.83201.50282415079129279912927621284782.0218.45218.46219.8209.337.01
90672Vaccine for influenza for nasal administrationFlumist Quad 2018-2019Flu Vacc Qv Live 2018(2-49yrs)2116411421142112318.5318.5318.851858150850850516.8916.8916.9917756.9936736736621.1421.1421.1911040839139138826.6226.6226.82012967396396394.032.7432.7432.91123.0115.29
90674Influenza virus vaccine, quadrivalent (ccIIV4)Flucelvax Quad 2017-2018 (90674)Flu Vac QS 17-18(4yr Up)cel/PF200458489883899378990022.322.2922.302098520390962190958890665023.0723.0723.15016619925.8570768970766570030823.4823.4923.7302131522081096081101780464126.2826.2826.49018665831675086674818668057.027.6527.6627.9405.25.52
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