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Overview of All-Payer Claims Databases

Overview of All-Payer Claims Databases. NAHDO Annual Conference October 2009 Patrick Miller, MPH Research Associate Professor. Topics. RAPHIC Overview of APCDs Examples of APCD Output Standardization The Future? APCD and HIE Questions. 2. 2. Going Where States Have Not Gone Before

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Overview of All-Payer Claims Databases

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  1. Overview of All-Payer Claims Databases NAHDO Annual Conference October 2009 Patrick Miller, MPH Research Associate Professor NAHDO Annual Conference October 2009

  2. Topics • RAPHIC • Overview of APCDs • Examples of APCD Output • Standardization • The Future? APCD and HIE • Questions NAHDO Annual Conference October 2009 2 2

  3. Going Where States Have Not Gone Before • A Federation of States is Emerging (RAPHIC / NAHDO) • New Life Forms Being Met Along The Way (Supporters and Champions) NAHDO Annual Conference October 2009

  4. This Is All About Transparency • Which hospitals have the highest prices? • Which health plan has the best discounts? • What percentage of my employees have had a mammogram? • If emergency room usage in Medicaid is higher than the commercial population, what are the drivers? • What is the average length of time people are using antidepressant medications and what are the patient demographics? • How far do people travel for services? Which services? • Hundreds of additional questions could be asked…. NAHDO Annual Conference October 2009

  5. RAPHIC NAHDO Annual Conference October 2009 5

  6. NAHDO Annual Conference October 2009

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  10. Overview of APCDs NAHDO Annual Conference October 2009 10

  11. What Are APCDs? • Databases, created by state mandate, that typically include data derived from medical, eligibility, provider, pharmacy, and/or dental files from private and public payers: • Insurance companies • Public payers (Medicaid, Medicare) NAHDO Annual Conference October 2009 11 11

  12. Why APCDs? • Supplement other data for health services research • Medicare: Complete picture of care, but limited population • Medicaid: Complete picture of care, but limited population • Hospital inpatient/outpatient data: Complete picture of hospital-based care only • MEPS (and other surveys): Picture of office-based care, but not population-based (and not robust for states) NAHDO Annual Conference October 2009 12 12

  13. Why APCDs? • To answer research and policy questions • Determine utilization patterns and rates • Identify gaps in needed disease prevention and health promotion services • Evaluate access to care • Assist with benefit design and planning • Analyze statewide and local health care expenditures by provider, employer, geography, etc. • Establish clinical guideline measurements related to quality, safety, and continuity of care NAHDO Annual Conference October 2009 13 13

  14. Something for Everyone…An Evolution • Consumers • Employers • Health Plans/Payers • Providers • Researchers (public policy, academic, etc.) • State government (policy makers, Medicaid, public health, insurance department, etc.) • TBD (Federal government, etc.) NAHDO Annual Conference October 2009

  15. ME VT WA NH MN MA OR NY ID RI PA CT MD WV UT KS CA TN Existing Under Development Strong Interest HI FL Status of State Government Administered All Payer / All Provider Claims Databases NAHDO Annual Conference October 2009

  16. What Data Are Being Collected? • Sources (private, Medicaid, Medicare, uninsured, others are envisioned such as TRICARE) • File Types (eligibility, medical, provider, pharmacy, dental) • Submitters (carriers, TPAs, PBMs) • Data Elements/Variables NAHDO Annual Conference October 2009 16 16

  17. APCD Data Sources NAHDO Annual Conference October 2009 17 17

  18. APCD Data Files NAHDO Annual Conference October 2009 18 18

  19. APCD Data Submitters NAHDO Annual Conference October 2009 19 19

  20. Typically Included Information • Encrypted social security • Type of product (HMO, POS, Indemnity, etc.) • Type of contract (single person, family, etc.) • Patient demographics (date of birth, gender, residence, relationship to subscriber) • Diagnosis codes (including E-codes) • Procedure codes (ICD, CPT, HCPC, CDT) • NDC code / generic indicator • Revenue codes • Service dates • Service provider (name, tax id, payer id, specialty code, city, state, zip code) • Prescribing physician • Plan payments • Member payment responsibility (co-pay, coinsurance, deductible) • Date paid • Type of bill • Facility type NAHDO Annual Conference October 2009 20 20

  21. Typically Excluded Information • Services provided to uninsured (few exceptions) • Denied claims • Workers’ compensation claims • Premium information • Capitation fees • Administrative fees • Back end settlement amounts • Referrals • Test results from lab work, imaging, etc. • Provider affiliation with group practice • Provider networks NAHDO Annual Conference October 2009 21 21

  22. Other Considerations • State Authority by Statute Resides Where? • Health and Human Services • Insurance Department • Health Data Organization • Thresholds and Exclusions Examples • Number of covered lives by a carrier in a state • Filling frequencies also vary by covered lives • Standalone DME policies • Standalone vision coverage NAHDO Annual Conference October 2009 22 22

  23. APCD versus(?) HIE • Cost • Timeliness to launch • Completeness of data • Return on investment NAHDO Annual Conference October 2009

  24. Examples of APCD Output NAHDO Annual Conference October 2009 24

  25. NAHDO Annual Conference October 2009

  26. NAHDO Annual Conference October 2009 APCD Meeting May 6, 2009 26 Source: www.nhhealthcost.org

  27. Pricing Difference by Carrier and Provider: Colonoscopy Source: www.nhhealthcost.org NAHDO Annual Conference October 2009 27

  28. NAHDO Annual Conference October 2009

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  30. Payment Rate Benchmarking NAHDO Annual Conference October 2009 30

  31. NAHDO Annual Conference October 2009

  32. Prevalence of Asthma by Age, NH Medicaid (non-Dual) and NH Commercial Members, 2005 NAHDO Annual Conference October 2009 32

  33. NAHDO Annual Conference October 2009 APCD Meeting May 6, 2009 33

  34. NAHDO Annual Conference October 2009

  35. Standardization With a thank you to NAHDO Annual Conference October 2009 35

  36. Areas for Standardization • Data collection • Data release • Metadata • Reporting / Analysis • Applications NAHDO Annual Conference October 2009 36 36

  37. The Future? APCD and HIE? NAHDO Annual Conference October 2009 37

  38. Questions We Might Ask • For those patients in the clinical database with certain public health measures (BMI, smoking, heavy alcohol usage, etc), what services are patients seeking, and where? • How often does service duplication occur due to lack of electronic communications or other factors? Can we determine cost in addition to frequency? • What are the implications of risk adjusting the entire patient data set (clinical and APCD merged)? How will the groupers perform with more information (ie, # of Dx & procedure codes)? • What are the implications of using episodic grouping software with data from the entire patient data set (clinical and APCD merged)? NAHDO Annual Conference October 2009

  39. Data Linking and Repository Architecture, Source: University of New Hampshire 2009 How Might We Accomplish It? NAHDO Annual Conference October 2009

  40. Resources & Contact Information • Regional All Payer Health Information Council (RAPHIC): www.raphic.org • National Association of Health Data Organizations (NAHDO): www.nahdo.org • Patrick Miller, University of New Hampshire / RAPHIC, patrick.miller@unh.edu • Josephine Porter, University of New Hampshire / RAPHIC, jo.porter@unh.edu NAHDO Annual Conference October 2009 40

  41. Questions and Discussionpatrick.miller@unh.edu603.536.4265 NAHDO Annual Conference October 2009

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