Payer_plan_period - new fields to allow standardized health economic analysis

[gowthamrao]

Use case:

• Allows for standardized health economic analysis about contractual relationship between a person and their health care experience
• Using the constructs of payer, plan and sponsor allows the use of standard OHDSI tools like Atlas and R-packages for cohort-build and cohort charcterization.
• Addresses a key concern among OHDSI community around limited representation from health-plan, health-economics and actuarial science.
• Address forum discussions: here and here

Proposal overview

Introduces, clarifies and standardizes the representation of four new constructs using _source_concept_id, _type_concept_id and _concept_id
sponsor: who finances the transaction
payer: who administers the transaction
plan: the actual contract being administered by the payer and agreed by the sponsor
stop reason: reason for termination of the contract

Changes are only additions of fields. Additions are in bold
Backward compatibility = Yes

Proposed table

Field	Required	Type	Description
payer_plan_period_id	Yes	integer	A identifier for each unique combination of payer, plan, family code and time span.
person_id	Yes	integer	A foreign key identifier to the Person covered by the payer. The demographic details of that Person are stored in the PERSON table.
payer_plan_period_start_date	Yes	date	The start date of the payer plan period.
payer_plan_period_end_date	Yes	date	The end date of the payer plan period.
payer_concept_id	No	integer	A foreign key that refers to a Standard Payer concept identifiers in the Standardized Vocabularies
payer_source_value	No	varchar(50)	The source code for the payer as it appears in the source data.
payer_source_concept_id	No	integer	A foreign key to a payer concept that refers to the code used in the source.
plan_concept_id	No	integer	A foreign key that refers to a Standard plan that represents the health benefit plan in the Standardized Vocabularies
plan_source_value	No	varchar(50)	The source code for the Person's health benefit plan as it appears in the source data.
plan_source_concept_id	No	integer	A foreign key to a plan concept that refers to the code used in the source.
sponsor_concept_id	No	integer	A foreign key that refers to a Standard plan that represents the sponsor in the Standardized Vocabularies
sponsor_source_value	No	varchar(50)	The source code for the Person's sponsor of the health plan as it appears in the source data.
sponsor_source_concept_id	No	integer	A foreign key to a sponsor concept that refers to the code used in the source.
family_source_value	No	varchar(50)	The source code for the Person's family as it appears in the source data.
stop_reason_concept_id	No	integer	A foreign key that refers to a Standard termination reason that represents the reason for the termination in the Standardized Vocabularies.
stop_reason_source_value	No	varchar(50)	The reason for stop-coverage of the record.
stop_reason_source_concept_id	No	integer	A foreign key to a stop-coverage concept that refers to the code used in the source.

---

Proposed vocabulary

To help with standardized analysis, we will need to introduce into the OMOP CDM vocabulary, new concepts. Only omop standard concepts may be used in plan_concept_id, payer_concept_id, sponsor_concept_id and stop_reason_concept_id.

plan_concept_id

• Bronze
• Silver
• Gold
• Platinum
• Catastrophic
  Reference:
• Individual health plan metal level

plan_source_concept_id

• depends on the vocabulary used by source data, not designed/useful for standardized analysis

sponsor_concept_id

• self-insured

• fully-insured

• individual

• small group

• large group

sponsor_source_concept_id

• depends on the vocabulary used by source data, not designed/useful for standardized analysis

payer_concept_id

http://www.phdsc.org/standards/pdfs/SourceofPaymentTypologyVersion7FINALJune27_2016.pdf
Reference: payer types

payer_source_concept_id

• depends on the vocabulary used by source data, not designed/useful for standardized analysis. One option for non-standard vocabulary is [payer list] (https://www.officeally.com/payerList.aspx)

stop_reason_concept_id

• Termination of the employee's employment for any reason other than gross misconduct;
• Reduction in the number of hours of employment.
• Termination of the covered employee's employment for any reason other than gross misconduct;
• Reduction in the hours worked by the covered employee;
• Covered employee becomes entitled to Medicare;
• Divorce or legal separation of the spouse from the covered employee; or
• Death of the covered employee.
  Reference: group coverage termination vocabulary
• Termination of all group health plans by sponsor
• Failure to pay premiums
• Coverage under another plan
• Loss of Social Security disability status
• Entitlement to Medicare
  Reference: opm
• termed by person
• termed by subscriber
• termed by payer
• termed by sponsor

---

Related proposal

The proposal is related to but not dependent on #107 .

[cgreich]

@gowthamrao:

This is a good start. But I think we need to bring it to the Forum to do a couple things:

1. Generally get folks' feedback, including use cases
2. Ask the international folks what they think, and how we can create a nomenclature that is generally applicable. "Platinum" as a concept is not very interoperable.

Thoughts?