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documentation:cdm:cost
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COST table
The COST table captures records containing the cost of any medical entity recorded in one of the DRUG_EXPOSURE, PROCEDURE_OCCURRENCE, VISIT_OCCURRENCE or DEVICE_OCCURRENCE tables. It replaces the corresponding DRUG_COST, PROCEDURE_COST, VISIT_COST or DEVICE_COST tables that were initially defined for the OMOP CDM V5. However, it also allows to capture cost information for records of the OBSERVATION AND MEASUREMENT tables.
The information about the cost is defined by the amount of money paid by the Person and Payer, or as the charged cost by the healthcare provider. So, the COST table defines both cost and revenue, irrespective of the perspective. The cost_type_concept_id field will use concepts in the Vocabulary to designate the source of the cost data. A reference to the health plan information in the PAYER_PLAN_PERIOD table is stored in the record that is responsible for the determination of the cost as well as some of the Payments.
| Field | Required | Type | Description |
|---|---|---|---|
| cost_id | Yes | integer | A unique identifier for each COST record. |
| cost_event_id | Yes | integer | A foreign key identifier to the event (e.g. Measurement, Procedure, Visit, Drug Exposure, etc) record for which cost data are recorded. |
| cost_domain_id | Yes | string(20) | The concept representing the domain of the cost event, from which the corresponding table can be inferred. |
| currency_concept_id | No | integer | A concept representing the 3-letter code used to delineate international currencies, such as USD for US Dollar. |
| total_charged | No | float | The total amount charged by the provider of the good/service (e.g. hospital, physician pharmacy, dme provider) billed to a payer. This information is usually provided in claims data. |
| total_cost | No | float | Cost of service/device/drug incurred by provider/pharmacy. This field is more commonly derived from charge information. Use case: The resulting amount after the hospital charges are multiplied by the cost-to-charge ratio. This data is currently available for NIS datasets, or any other HCUP datasets. See cost calculation explanation from AHRQ here. |
| total_cost_type_concept_id | Yes | integer | Shows the provenance or the source of the total_cost data: Calculated from provider revenue, calculated from cost-to-charge ratio, reported from accounting database, etc. |
| total_paid | No | float | The total amount paid from all payers for the expenses of the service/device/drug. This field is calculated using the following formula: paid_by_payer + paid_by_patient + paid_by_primary. In claims data, this field is considered the calculated field the payer expects the provider to get reimbursed for the service/device/drug from the payer and from the patient, based on the payer's contractual obligations. |
| paid_by_payer | No | float | The amount paid by the Payer for the service/device/drug. In claims data, generally there is one field representing the total payment from the payer for the service/device/drug. However, this field could be a calculated field if the source data provides separate payment information for the ingredient cost and the dispensing fee. If the paid_ingredient_cost or paid_dispensing_fee fields are populated with nonzero values, the paid_by_payer field is calculated using the following formula: paid_ingredient_cost + paid_dispensing_fee. If there is more than one Payer in the source data, several cost records indicate that fact. The Payer reporting this reimbursement should be indicated under the payer_plan_id field. |
| paid_by_patient | No | float | The total amount paid by the Person as a share of the expenses. This field is most often used in claims data to report the contracted amount the patient is responsible for reimbursing the provider for said service/device/drug. This is a calculated field using the following formula: paid_patient_copay + paid_patient_coinsurance + paid_patient_deductible. If the source data has actual patient payments (e.g. the patient payment is not a derivative of the payer claim and there is verification the patient paid an amount to the provider), then the patient payment should have it's own cost record with a payer_plan_id set to 0 to indicate the the payer is actually the patient, and the actual patient payment should be noted under the total_paid field. The paid_by_patient field is only used for reporting a patient's responsibility reported on an insurance claim. |
| paid_patient_copay | No | float | The amount paid by the Person as a fixed contribution to the expenses. paid_patient_copay does contribute to the paid_by_patient variable. The paid_patient_copay field is only used for reporting a patient's copay amount reported on an insurance claim. |
| paid_patient_coinsurance | No | float | The amount paid by the Person as a joint assumption of risk. Typically, this is a percentage of the expenses defined by the Payer Plan after the Person's deductible is exceeded. paid_patient_coinsurance does contribute to the paid_by_patient variable. The paid_patient_coinsurance field is only used for reporting a patient's coinsurance amount reported on an insurance claim. |
| paid_patient_deductible | No | float | The amount paid by the Person that is counted toward the deductible defined by the Payer Plan. paid_patient_deductible does contribute to the paid_by_patient variable. The paid_patient_deductible field is only used for reporting a patient's deductible amount reported on an insurance claim. |
| paid_by_primary | No | float | The amount paid by a primary Payer through the coordination of benefits. paid_by_primary does contribute to the total_paid variable. The paid_by_primary field is only used for reporting a patient's primary insurance payment amount reported on the secondary payer insurance claim. If the source data has actual primary insurance payments (e.g. the primary insurance payment is not a derivative of the payer claim and there is verification another insurance company paid an amount to the provider), then the primary insurance payment should have it's own cost record with a payer_plan_id set to the applicable payer, and the actual primary insurance payment should be noted under the paid_by_payer field. |
| paid_ingredient_cost | No | float | The amount paid by the Payer to a pharmacy for the drug, excluding the amount paid for dispensing the drug. paid_ingredient_cost contributes to the paid_by_payer field if this field is populated with a nonzero value. |
| paid_dispensing_fee | No | float | The amount paid by the Payer to a pharmacy for dispensing a drug, excluding the amount paid for the drug ingredient. paid_dispensing_fee contributes to the paid_by_payer field if this field is populated with a nonzero value. |
| payer_plan_period_id | No | integer | A foreign key to the PAYER_PLAN_PERIOD table, where the details of the Payer, Plan and Family are stored. Record the payer_plan_id that relates to the payer who contributed to the paid_by_payer field. |
| amount_allowed | No | float | The contracted amount agreed between the payer and provider. This information is generally available in claims data. This is similar to the total_paid amount in that it shows what the payer expects the provider to be reimbursed after the payer and patient pay. This differs from the total_paid amount in that it is not a calculated field, but a field available directly in claims data. Use case: This will capture non-covered services. Noncovered services are indicated by an amount allowed and patient responsibility variables (copay, coinsurance, deductible) will be equal $0 in the source data. This means the patient is responsible for the total_charged value. The amount_allowed field is payer specific and the payer should be indicated by the payer_plan_id field. |
| revenue_code_concept_id | No | integer | A foreign key referring to a Standard Concept ID in the Standardized Vocabularies for Revenue codes. |
| revenue_code_source_value | No | string(50) | The source code for the Revenue code as it appears in the source data, stored here for reference. |
Conventions
- Each Drug Exposure may have any number of corresponding records in the DRUG_COST table, but usually it is none (no cost data recorded) or one. They are linked directly through the drug_exposure_id field.
- The amounts paid are:
- Copay – a fixed amount to be paid by the Person
- Coinsurance – a relative amount of the total paid by the Person
- Deductible – an amount of money paid by the Person before the Payer starts contributing
- Primary Payer – the amount the primary Payer pays towards the total
- Coordination of Benefits – the amount a secondary Payer or Family Plan pays towards the total
- Out of Pocket = Copay + Coinsurance + Deductible
- Total – the total amount paid for the Drug Exposure
- Drug costs are:
- Ingredient Cost – the amount charged by the wholesale distributor or manufacturer
- Dispensing Fee – the amount charged by the pharmacy
- Sales Tax. This is usually very small and typically not provided by most source data, and therefore not included in the CDM
- The amount paid should equal the cost, so Copay + Coinsurance + Deductible + Primary Payer + Coordination of Benefits = Total Paid = Ingredient Cost + Dispensing Fee. In reality, this is not always reflected in the source data. It is up to the ETL to determine how to deal with quality problems in the data.
- The Average Wholesale Price is the list price of the drug, but not the price actually charged or paid.
documentation/cdm/cost.1460422875.txt.gz · Last modified: 2016/04/12 01:01 by cgreich
