MarketScan
Commercial Insurance Claims at a Glance
| MarketScan® Commercial Claims & Encounters (CCAE) | |
|---|---|
| Data type | Commercial medical insurance claims |
| Sample | Convenience sample of privately insured patients |
| VEHSS Topics Included | Service Utilization Medical Diagnoses |
| Years Analyzed | 2016 |
| Approximate Size | 43.6 million persons |
The MarketScan® Commercial Claims and Encounters Data (CCAE) is produced by IBM Watson Health. The CCEA data contain a convenience sample of insurance claims information from person with employer-sponsored insurance and their dependents, including 43.6 million person years of data in 2016.1 Several types of insurance plans are included in the CCAE including fee-for-service, partial capitation, and full capitation, which use benefit designs including preferred and exclusive provider organizations (PPOs and EPOs), point-of-service (POS) plans, indemnity plans, health maintenance organizations (HMOs), and consumer-directed health plans (CDHPs). Encounter level data include diagnoses and procedures, insurer, and patient paid amounts from outpatient, inpatient, pharmacy, laboratory, and dental claims. These services are linked by unique patient ID to patient characteristics as measured and included in a separate patient enrollment file. Because patient characteristics are dependent on information included in enrollment forms, some variables (in particular race/ethnicity) are limited. MarketScan does not include vision insurance claims. Although the MarketScan® CCAE is very large convenience sample, it is not nationally representative. Additionally, differences in patient characteristics, and representation of plan and benefit type between it and the universe of all privately insured individuals has not been assessed. With those limitations in mind, because of its large sample, information from the MarketScan® CCAE is likely related to what would be found in the full population of those privately insured. However, users of the data should be cautioned that the CCAE information is not representative and results derived from it may differ substantially from what would be found using a representative sample of privately insured persons. Further these differences may be most extreme at the state level.
Analysis Overview
VEHSS analyzed data from the MarketScan® CCAE data for the year 2016. The study population includes all patients enrolled in insurance plans included in the MarketScan CCAE, including carrier and other care files. The VEHSS team analyzed MarketScan data to calculate the proportion of patients with vision and eye health indicators defined below:
Eye Care Services
VEHSS analyzes the proportion of privately insured patients who had at least one commercial insurance claim indicating a specified service group as defined below in Table 1.
| Category | Subgroup |
|---|---|
| AMD treatment, among diagnosed AMD patients | Any AMD procedure |
| Intravitreal injections (including anti-VEGF) | |
| Laser surgery | |
| Photodynamic therapy | |
| Cataract surgery, among diagnosed cataract patients | Any Cataract treatment |
| Cataract surgery | |
| Diabetic retinopathy Treatment, among diagnosed diabetic retinopathy patients | Any DR treatment |
| Intravitreal injections (including anti-VEGF) | |
| Laser/photocoagulation | |
| Retinal detachment repair | |
| Victrectomy | |
| Eye exams | By any provider type |
| By an ophthalmologist or other physician | |
| By an optometrist or optician | |
| Glaucoma treatment, among diagnosed glaucoma patients | Any glaucoma treatment |
| Drain | |
| Glaucoma surgery | |
| Laser surgery | |
| Imaging or diagnostic test | Any diagnostic eye test |
| Flourescein angiography | |
| Gonioscopy | |
| Optical coherence tomography | |
| Stereo fundus exam | |
| Tonometry test | |
| Visual field testing | |
| Screening | Any eye or vision screening |
| Glaucoma screening | |
| Vision screening | |
| Diabetic Retinopathy Telemedicine Screening | |
| Vision correction | Any vision correction |
| Contact lens or fitting | |
| Eyeglasses |
Eye Health Conditions
VEHSS categorizes diagnosis codes into medical diagnosis categories and subgroups. Individual patient were assigned to diagnosis categories and subgroups based on International Classification of Diseases (ICD) 9 (permissible in 2014) or ICD10 diagnosis codes on any patient claim during the year of observation. As reported in the “VEHSS Diagnosis Code Categories and Crosswalk,” we identified all eye and vision related ICD10 diagnosis codes, and organized them into a two-level categorization structure, including 17 categories and 78 subgroups, as listed in Table 2.
VEHSS calculates the proportion of patients who had at least one claims represented in each subgroup and condition group. Subgroups and condition groups are not mutually exclusive, but patients may only be counted once per group.
| Eye Condition | Included subgroups | Subgroup description |
|---|---|---|
| Retinal Detachment and Defects | Retinal Detachment and Defects | Retinal detachment and retinal breaks without detachment. |
| Diabetic eye diseases | Early/mild diabetic retinopathy | Early/Mild Diabetic Retinopathy includes diagnosis codes for background diabetic retinopathy, nonproliferative diabetic retinopathy, or mild nonproliferative diabetic retinopathy. |
| Moderate /severe non-proliferative diabetic retinopathy | Moderate /Severe Non-proliferative Diabetic Retinopathy includes diagnosis codes indicating moderate or severe nonproliferative diabetic retinopathy, without macular edema. | |
| Proliferative diabetic retinopathy | Proliferative Diabetic Retinopathy includes diagnosis codes indicating proliferative diabetic retinopathy, without macular edema. | |
| Diabetic macular edema (DME) | Diabetic Macular Edema (DME, CSDME) includes diagnosis codes indicating diabetic retinopathy of any type with the presence of macular edema (DME), including clinically significant diabetic macular edema (CSDME). | |
| Other/unspecified diabetes related eye conditions | Other/unspecified diabetes related eye conditions includes diagnosis codes indicating diabetic retinopathy of unspecified type, other ophthalmic complications of diabetes including diabetic cataract, or diabetes mellitus with ophthalmic complication resolved after treatment. | |
| Age related macular degeneration (AMD) | AMD, unspecified | Unspecified macular degeneration includes diagnosis codes indicating degeneration of macula and/or posterior pole, but does not specify stage. |
| Early AMD | Early AMD includes diagnosis codes indicating the presence of drusen (degenerative) of the macula. | |
| Dry-form AMD | Dry-form AMD indicates the presence of diagnosis codes for nonexudative age-related macular degeneration. | |
| Geographic atrophy AMD | Geographic atrophy AMD indicates the presence of ICD10 codes indicating advanced atrophic stage of dry-form AMD. | |
| Wet-form AMD | Wet-form AMD indicates the presence of diagnosis codes for exudative age-related macular degeneration. | |
| Choroidal neovascularization AMD | Choroidal neovascularization AMD indicates the presence of ICD10 codes specifying active choroidal neovascularization; advanced wet-form AMD. | |
| Other Retinal Disorders | Retina vascular disease, Occlusive (arterial, venous) | Retina vascular disease, Occlusive (arterial, venous) includes diagnosis codes indicating unspecified or transient retinal vascular occlusion. |
| Other/unspecified retinal disorders | Other/unspecified retinal disorders include diagnosis codes indicating age-related choroidal atrophy, diffuse secondary atrophy of choroid, retinoschisis, retinal cysts, cyst of ora serrata, retinopathy of prematurity, non-diabetic proliferative retinopathy, unspecified separation of retinal layers, central serous chorioretinopathy, detachment of retinal pigment epithelium, macular cyst, hole, or pseudohole, toxic maculopathy, puckering of macula, various forms of retinal degeneration, retinal hemorrhage, and other or unspecified retinal disorders. | |
| Central retinal vein occlusion | Central retinal vein occlusion indicates diagnosis codes for central retinal vein occlusion, with or without macular edema or retinal neovascularization. | |
| Branch retinal vein occlusion | Branch retinal vein occlusion indicates diagnosis codes for tributary (branch) retinal vein occlusion, with or without macular edema or retinal neovascularization, or venous engorgement. | |
| Central retinal arterial occlusion | Central retinal arterial occlusion indicates diagnosis codes for central retinal arterial occlusion, with or without macular edema or retinal neovascularization. | |
| Branch retinal artery occlusion | Branch retinal artery occlusion indicates diagnosis codes for tributary (branch) retinal arterial occlusion. | |
| Retina vascular disease, Non-Occlusive | Retina vascular disease, Non-Occlusive includes diagnosis codes indicating hypertensive or exudative retinopathy, changes in retinal vascular appearance, retinal micro-aneurysms, retinal telangiectasis, neovascularization, or vasculitis, intraretinal microvascular abnormalities, or unspecified background retinopathy. | |
| Macular edema (Cystoid or non-diabetic) | Macular edema (Cystoid or non-diabetic) indicates diagnosis codes for cystoid macular degeneration. | |
| Hereditary chorioretinal dystrophy | Hereditary chorioretinal dystrophy includes diagnosis codes indicating various types of chiorioretinal dystrophy, including circumpapillary, central choroidal atrophy, and choroideremia. | |
| Myopic degeneration | Myopic degeneration includes diagnosis codes indicating progressive high (degenerative) myopia. | |
| Glaucoma | Open-angle glaucoma | Open-angle glaucoma includes diagnosis codes indicating unspecified open-angle glaucoma, pigmentary glaucoma, or capsular glaucoma with pseudoexfoliation of lens. |
| Primary open-angle glaucoma | Primary open-angle glaucoma includes diagnosis codes for primary open-angle glaucoma of any stage. | |
| Low-tension glaucoma | Low-tension glaucoma includes diagnosis codes for low-tension glaucoma of any stage. | |
| Glaucoma suspect | Glaucoma suspect indicates diagnosis codes for pre-glaucoma, open-angle with borderline findings, ocular hypertension, steroid responder, or primary angle closure without damage. | |
| Primary angle-closure glaucoma | Primary angle-closure glaucoma includes diagnosis codes indicating primary, acute, chronic, intermittent or unspecified angle-closure glaucoma. | |
| Narrow-angle glaucoma | Narrow-angle glaucoma includes diagnosis codes indicating narrow angle glaucoma, anatomical or secondary to eye trauma. | |
| Congenital glaucoma | Congenital glaucoma includes diagnosis codes for congenital glaucoma or buphthalmos (enlargement of the eye in children). | |
| Neovascular glaucoma | Neovascular glaucoma includes diagnosis codes indicating glaucoma associated with vascular disorders, phacolytic or other specified glaucoma. | |
| Other/unspecified glaucoma | Other/unspecified glaucoma includes diagnosis codes indicating unspecified glaucoma, glaucoma secondary to drugs, other eye disorders or inflammation, hypersecretion glaucoma, increased episcleral venous pressure, or aqueous misdirection. | |
| Cataracts | Age-related cataract | Age-related cataract indicates the presence of diagnosis codes for age-related incipient, polar, cortical, nuclear, morgagnian, other or unspecified cataract |
| Other or unspecified cataract | Other or unspecified cataract includes diagnosis codes for various cataracts not specified as age-related or congenital, including traumatic cataract, drug-induced cataract, cataract with neovascularization, cataract secondary to ocular disorders, or unspecified cataracts. | |
| Congenital Cataract | Congenital Cataract includes diagnosis codes indicating congenital cataract, congenital aphakia, coloboma of lens, spherophakia, congenital lens malformations, or infantile or juvenile cataracts of any type. | |
| Posterior capsular opacity | Posterior capsular opacity includes diagnosis codes indicating posterior capsular opacity, Soemmering’s ring, or other secondary cataract. | |
| Pseudophakia | Pseudophakia includes diagnosis codes indicating the presence of intraocular lens, aphakia | |
| Aphakia and other disorders of lens | Aphakia and other disorders of lens includes diagnosis codes indicating aphakia, subluxation of lens, anterior dislocation of lens, posterior dislocation of lens, or other disorders of lens | |
| Refraction and accommodation | Myopia | Myopia includes diagnosis codes indicating myopia in one or both eyes. |
| Hypermetropia | Hypermetropia includes diagnosis codes indicating hypermetropia in one or both eyes. | |
| Astigmatism | Astigmatism includes diagnosis codes indicating regular, irregular, or unspecified astigmatism in one or both eyes. | |
| Presbyopia | Presbyopia includes diagnosis codes indicating presbyopia in one or both eyes. | |
| Other disorder of refraction and accommodation | Other disorder of refraction and accommodation includes diagnosis codes indicating anisometropia and aniseikonia, disorders of accommodation, internal ophthalmoplegia, paresis of accommodation, or spasm of accommodation. | |
| Diagnosed Blindness and low vision | Unqualified visual loss, both eyes | Unqualified vision loss, both eyes includes a diagnosis code indicating unqualified visual loss in both eyes. |
| Unqualified vision loss in one eye, or unspecified visual loss | Unqualified vision loss in one eye or unspecified vision loss includes diagnosis codes indicating unqualified vision loss in one eye, unspecified visual loss, or problems with sight. | |
| Low vision or blindness, one eye | Low vision or blindness in one eye includes diagnosis codes indicating low vision or blindness in one eye, normal vision in the other eye. | |
| Blindness one eye, low vision other eye | Blindness in one eye, low vision in other eye includes diagnosis codes indicating blindness in one eye, low vision in other eye. | |
| Low vision, both eyes | Low vision, both eyes includes diagnosis codes indicating low vision in both eyes. | |
| Blindness, both eyes, including legal blindness | Blindness, both eyes, including legal blindness includes diagnosis codes indicating blindness in both eyes, legal blindness, or cortical blindness. | |
| Strabismus and amblyopia | Strabismus | Strabismus includes diagnosis codes indicating monocular or binocular strabismus, including esotropia, exotropia, heterophoria and other types, nerve palsy of the eye, ophthalmoplegia, Brown’s sheath syndrome, disorders of convergence or binocular movement, or other unspecified disorders of binocular vision. |
| Amblyopia | Amblyopia includes diagnosis codes indicating amblyopia, including deprivation, strabismic, refractive, or unspecified amblyopia type, or ablyopia suspect. | |
| Injury, burns and surgical complications of the eye | Injury | Injury includes diagnosis codes indicating injury to the eye or ocular adnexa, due to trauma, foreign bodies, penetrating wounds, bites, abrasions or other causes, or injury secondary to other ocular disorders. |
| Burn | Burn includes diagnosis codes indicating any type of burn or corrosion of the eye or ocular adnexa. | |
| Surgical complication | Surgical complication includes diagnosis codes indicating or typically associated with surgical complications, including postprocedural inflammation or infection, mechanical complications, cataract fragments, and other conditions usually associated with procedures. | |
| Disorders of optic nerve and visual pathways | Optic nerve disorders | Optic nerve disorders includes diagnosis codes indicating optic neuritis and other disorders of the optic nerve. |
| Disorders of the visual pathway and visual cortex | Disorders of the visual pathway and visual cortex includes diagnosis codes indicating disorders of visual pathways and visual cortex. | |
| Other visual disturbances | Visual field defect | Visual field defect includes diagnosis codes indicating defects of the visual field, including scotoma, sector or arcuate defects, localized visual field defects, homonymous bilateral field defects or contraction of the visual field. |
| Color blindness | Color blindness included diagnosis codes indicating color vision deficiencies. | |
| Night blindness | Night blindness includes diagnosis codes indicating night blindness, abnormal dark adaptation and glare sensitivity. | |
| Other/unspecified visual disturbances | Other/unspecified visual disturbances includes other disturbances or defects of sight including subjective visual disturbances, diplopia, other and unspecified disorders of binocular vision, and vision sensitivity deficiencies. | |
| All Infectious and inflammatory diseases | Infectious diseases | Infectious diseases includes diagnosis codes indicating an infection of the eye or ocular adnexa. |
| Keratitis | Keratitis includes diagnosis codes indicating keratitis, including corneal ulcer, other and unspecified superficial keratitis without conjunctivitis, keratoconjunctivitis, corneal neovascularization, or other or unspecified forms of keratitis. | |
| Conjunctivitis | Conjunctivitis includes diagnosis codes indicating most forms of conjunctivitis, including mucopurulent, acute, chronic, blepharoconjunctivitis, or other disorders of conjunctiva, including pterygium, conjunctival degenerations and deposits, or conjunctival scars, hemorrhage, vascular disorders, or cysts. | |
| Eyelid disorders | Eyelid disorders includes diagnosis codes indicating hordeolum and chalazion or other inflammation of the eyelid, including Blepharitis, noninfectious dermatosis or other inflammation of the eyelid. | |
| Other inflammatory conditions | Other inflammatory conditions includes diagnosis codes indicating inflammation of the eye or ocular adnexa not otherwise classified. | |
| Lacrimal system and orbit inflammation | Lacrimal system and orbit inflammation includes diagnosis codes indicating disorders of the lacrimal system and inflammatory disorders of the orbit. | |
| Endophthalmitis | Endophthalmitis includes diagnosis codes indicating enophthalmitis and disorders of the globe including degenerative myopia and uveitis. | |
| Orbital and external disease | Congenital anomalies | Congenital anomalies includes diagnosis codes indicating congenital malformations of the eye and ocular adnexa. |
| Other/unspecified orbital or external disease | Other/unspecified orbital or external disease includes diagnosis codes indicating non-inflammatory disorders of the orbit. | |
| Lacrimal diseases | Lacrimal diseases includes diagnosis codes indicating disorders of the lacrimal system, including dacryoadenitis, epiphora, stenosis and insufficiency of lacrimal passages, or other changes or disorders of the lacrimal system. | |
| Eyelid disorders | Eyelid disorders includes diagnosis codes indicating non-inflammatory disorders of the eyelid, including entropion, ectropion, lagophthalmos, ptosis, blepharochalasis, xanthelasma disorders of the eyelid, or other non-specified, non-inflammatory eyelid disorders. | |
| Dry eye syndrome | Dry eye syndrome includes diagnosis codes indicating dry eye syndrome. | |
| Disorders of the globe | Disorders of the globe includes diagnosis codes indicating disorders of the globe, excluding endoophthalmitis, degenerative myopia, and hypotony of the eye. | |
| Cancer and neoplasms of the eye diseases | Malignant neoplasm of the eye | Malignant neoplasm of the eye includes diagnosis codes indicating malignant neoplasm of the eye, or carcinoma in situ of the eye. |
| Benign neoplasm of the eye | Benign neoplasm of the eye includes diagnosis codes indicating benign neoplasm of the eye. | |
| Cornea disorders | Keratoconus | Keratoconus includes diagnosis codes indicating keratoconus or conical cornea conditions. |
| Endothelial dystrophy (inc Fuchs) | Endothelial dystrophy includes diagnosis codes indicating Endothelial or Fuchs dystrophy. | |
| Other Corneal disorders | Other Corneal disorders includes diagnosis codes indicating corneal scars, opacities and other disorders of the cornea. | |
| All Other eye disorders | Other eye disorders | Other eye disorders includes diagnosis codes related to vision, the eye and ocular adnexa that are not otherwise classified. |
Potential Limitations
The VEHSS analysis of MarketScan commercial insurance data is subject to a number of potential limitations:
- Commercial insurance claims are intended for billing purposes only. Diagnosis information included on claims is intended to justify payment. Therefore, diagnosis data on claims may suffer from bias or limited detail.
- Commercial insurance does not cover all healthcare services and coverage differs by patient, plan and insurer. Commercial insurance patients may utilize these services using a different payer, and thus these services are not captured in commercial insurance data.
- Patients may be insured by multiple insurers. Thus, even normally covered ophthalmology services may not be indicated in commercial insurance data if services were reimbursed by another payer.
- MarketScan is a convenience sample and is only representative of the insurance programs included within it.
Page last reviewed: August 10, 2021