Transcript Overview of All Payer Claims Data

Overview of
All Payer Claims Data
Suanne Singer, Senior Consultant
Maine Health Information Center
State Coverage Initiatives
Annual Meeting
July 31, 2009
July 31, 2009
Prepared by the Maine Health Information Center
Maine Health Information Center
• Independent, nonprofit health data research
organization, established in 1976
• Partner with a wide range of public and
private sector clients to solve problems and
support informed decision-making through
customized data collection, database
development and management, and
comprehensive reports and analyses
July 31, 2009
Prepared by the Maine Health Information Center
Maine Health Information Center
• Data aggregator for Maine (2004), New
Hampshire (2005), Massachusetts (2007),
Vermont (2008) and Minnesota (2009) as well
as a number of private claims databases
• Data analysis contractor for New Hampshire
and Vermont
July 31, 2009
Prepared by the Maine Health Information Center
What do we mean by
“All Payer Claims Data”?
• Claims data collected after adjudication – either on
an incurred basis or a paid basis
– Includes medical (aka professional and institutional) and
pharmacy claims. Some states also collect dental claims
• Enrollment or eligibility data that describes the
covered population
• Data collection and dissemination governed by state
or federal agency
July 31, 2009
Prepared by the Maine Health Information Center
What can be collected?
Medical claims data available from HIPAA 837 and
835 transaction standards offer most of the
desired and readily available data elements
• HIPAA 837 (from provider to payer) includes
member demographics, charges, provider and clinical
information
• HIPAA 835 (from payer to provider) includes
member demographics and payment information
July 31, 2009
Prepared by the Maine Health Information Center
What can be collected?
Pharmacy claims data available from NCPDP
Telecommunication Standard Format is the
primary source of data elements for
pharmacy claims
July 31, 2009
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Data Standards
– Enrollment data available from HIPAA 270 and
271 transaction standards offer most of the
desired and readily available data elements
– HIPAA 270 (from provider to payer)
– HIPAA 271 (from payer to provider)
July 31, 2009
Prepared by the Maine Health Information Center
What is NOT in a Claims Database?
•
•
•
•
•
•
•
Uninsured
Workers’ Compensation bills
Premium information
Referral information (e.g., who ordered dx tests)
Test results from lab work, imaging, etc.
Capitation and administrative fees
Diagnosis associated with prescription drug
July 31, 2009
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What is NOT in a Claims Database?
• Unique id for a provider that crosses all plans
• Identification of in network providers
• Provider affiliation with group practice
And, depending upon the state rule, …..
• Public payers (Medicaid, TRICARE, Medicare,
Part D)
• Data on national employers (e.g., WalMart)
July 31, 2009
Prepared by the Maine Health Information Center
What IS in a Claims Database?
• All covered services for the population –
regardless of the setting or the geographic
location of the provider
• Patient demographics – DOB, gender,
residence, relationship to subscriber, type of
product and type of contract
• Payments made for services
July 31, 2009
Prepared by the Maine Health Information Center
What can NOT be done
with Claims Databases?
• Directly identify patients
• Identify discount rates (state specific)
Cannot determine
• Results of a diagnostic test
• Allergies
• Lag time between when a bill was submitted
and paid
July 31, 2009
Prepared by the Maine Health Information Center
What CAN be done with Claims Databases?
• Count services
• Count individuals with various conditions or
procedures
• Compare payments for specific services by
provider
July 31, 2009
Prepared by the Maine Health Information Center
What CAN be done with Claims Databases?
• Access – geographic distribution of insured
population vs. distribution of providers
• Monitor cost shifting from the employer to
the member
• Study episodes of care
• Track members longitudinally across plans
July 31, 2009
Prepared by the Maine Health Information Center
What is the most common challenge when
using claims data?
Provider data
– Unique identification across payers
– Rendering or servicing provider vs. billing
provider
– Clustering providers into group practices
– Attributing services to the appropriate providers
– Hospital owned practices
– Linking pharmacy claims to rendering providers
July 31, 2009
Prepared by the Maine Health Information Center
How are claims data being used?
• Evaluation of payment reform initiatives
• Comparison of rates of utilization across
geographic areas
• Payment variation by provider
• Patient centered medical home
• Disease prevalence
• Tracking medical service encounters leaving
home areas
July 31, 2009
Prepared by the Maine Health Information Center
Prevalence of Asthma by Age
2005 NH Medicaid (non-Dual)
and Commercial Lives
18%
17%
17%
17%
16%
16%
15%
14%
13%
12%
11%
10%
10%
10%
9%
9%
8%
8%
7%
7%
7%
6%
6%
6%
5%
5%
4%
4%
19-20
21-24
5%
5%
5%
5%
5%
35-44
45-49
50-54
55-59
60-64
4%
2%
0%
All Ages
0-4
5-9
10-14
15-18
Medicaid-only
July 31, 2009
25-34
CHIS Commercial
Prepared by the Maine Health Information Center
Rate of
Emergency Department Visits
per 1000 Commercial
Insurance Members
286.0
Emergency Visit Rates
<200
200.0 - 249.9
250.0 - 299.9
300.0 - 349.9
344.3
>350
329.1
This study is based on
emergency department visits
that do not result in an
inpatient hospitalization.
260.4
State Rate
Emergency Department Visits =
236.1/1000 Members
241.7
243.9
387.0
290.9
255.4
231.7
378.6
237.6
277.8
246.9
247.8
235.8
181.8
192.0
July 31, 2009
219.2
185.4
205.5
Prepared by the Maine Health Information Center
191.8
Ratio of
Emergency Department Visits
To Office Visits
0.122
Ratio
<.07
0.070 - 0.079
0.080 - 0.089
0.090 - 0.099
0.124
>.10
0.113
This study is based on
emergency department visits
that do not result in an
inpatient hospitalization.
0.090
State Ratio
Emergency Department Visits
to Office Visits = 0.08
0.078
0.073
0.096
0.130
0.093
0.081
0.123
0.083
0.089
0.081
0.083
0.074
0.058
0.068
July 31, 2009
0.073
0.069 Health
Prepared by the Maine
Information Center
0.065
0.064
% Continuously Enrolled Members
By # of Physicians Seen in 2007
One Physician
25%
33%
Two Physicians
Three Physicians
17%
25%
July 31, 2009
Prepared by the Maine Health Information Center
More Than Three
Physicians
% Continuously Enrolled Members
By # Drug Groups Prescribed in 2007
Total Members By Drug Group Size
15%
23%
Seven or more Drug Groups
6%
Six Drug Groups
Five Drug Groups
9%
Four Drug Groups
Three Drug Groups
Two Drug Groups
20%
15%
July 31, 2009
12%
Prepared by the Maine Health Information Center
One Drug Group
State Utilization Web Sites
Based on All Payer Claims Data
NH www.nhchis.org
Chronic Diseases (e.g. Diabetes, CVD)
Use and Cost (e.g. Emergency Department,
Prescription Drugs, Category of Service)
Enrollment (e.g., age and gender, geography,
insurance product)
Special Studies
July 31, 2009
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State Cost Web Sites
Based on All Payer Claims Data
MA
http://hcqcc.hcf.state.ma.us/
Procedure cost rating of hospitals
ME www.healthweb.maine.gov/
claims/healthcost
NH www.nhhealthcost.org
Average procedural charges and payments –
total, professional, and facility
July 31, 2009
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Informational Web Sites
on All Payer Claims Databases
www.ncdms.org – MHIC’s portal for claims
data collection; includes public state pages
with links to data collection and data
dissemination rules
www.rahpic.org – information regarding
harmonization of data standards
www.nahdo.org – state government activity in
all payer claims databases
July 31, 2009
Prepared by the Maine Health Information Center
Thank you
Suanne Singer
[email protected]
207-430-0656
www.mhic.org
July 31, 2009
Prepared by the Maine Health Information Center