Transcript Overview of All-Payer Claims Databases

NAHDO Annual Conference
October 2009
Patrick Miller, MPH
Research Associate Professor
NAHDO Annual Conference October 2009
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Topics
 RAPHIC
 Overview of APCDs
 Examples of APCD Output
 Standardization
 The Future? APCD and HIE
 Questions
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•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)
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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….
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RAPHIC
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Overview of APCDs
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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)
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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)
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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
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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.)
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Status of State Government Administered
All Payer / All Provider Claims Databases
NH
MN
OR
MA
NY
ID
RI
PA
CT
MD
WV
UT
CA
ME
VT
WA
KS
TN
Existing
Under Development
Strong Interest
HI
FL
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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
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APCD Data Sources
State
Medicaid
Medicare
Commercial Uninsured
MA
No
No
Yes
No
ME
Yes
Yes
Yes
Partial
NH
Yes, But Not No
Integrated
Yes
No
MN
Yes
Planned
Yes
No
UT
Yes
No
Yes
No
VT
Planned
Planned
Yes
No
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APCD Data Files
State
Eligibility Provider
Medical
Pharmacy Dental
MA
Yes
Planned
Yes
Yes
No
ME
Yes
Yes
Yes
Yes
Yes
NH
Yes
Yes
Yes
Yes
In process
MN
Yes
Planned
Yes
Yes
No
UT
Yes
Yes
Yes
Yes
In process
VT
Yes
Planned
Yes
Yes
No
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APCD Data Submitters
State
Carriers
TPAs
PBMs
Dental
MA
30
1
0
Planned
ME
53
45
0
18
NH
18
14
2
Planned
MN
20
20
0
N/A
UT
12
2
2
N/A
VT
36
16
2
N/A
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Typically Included Information
 Encrypted social security
 Revenue codes
 Type of product (HMO, POS,
 Service dates





Indemnity, etc.)
Type of contract (single person,
family, etc.)
Patient demographics (date of
birth, gender, residence,
relationship to subscriber)
Diagnosis codes (including Ecodes)
Procedure codes (ICD, CPT,
HCPC, CDT)
NDC code / generic indicator
 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
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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
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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
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APCD versus(?) HIE
 Cost
 Timeliness to launch
 Completeness of data
 Return on investment
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Examples of APCD Output
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NAHDOAPCD
Annual
Meeting
Conference
May 6,October
2009 2009
Source: www.nhhealthcost.org
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Pricing Difference by Carrier and
Provider: Colonoscopy
FACILITY
Carrier A
Carrier B
Carrier C
Hospital A
2,091.22
1,552.98
1,757.94
Hospital B
1,243.94
1,169.12
1,192.33
Hospital C
2,325.32
2,148.21
2,065.92
Hospital D
1,658.53
1,200.62
1,431.43
Hospital E
1,715.74
2,075.38
1,514.17
Hospital F
1,381.96
--
1,087.22
Hospital G
1,906.15
1,942.21
1,949.79
Source: www.nhhealthcost.org
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Payment Rate Benchmarking
Procedure Code
99203 Office/Outpatient Visit New
Patient, 30min
99212 Office/Outpatient Visit
Established Patient, 10min
99391 Preventive Medicine Visit
Established Patient Age <1
90806 Individual psychotherapy in
office/outpatient, 45-50min
Average Payment Including Patient Share, 2006
Health Plan 1 Health Plan 2 Health Plan 3 NH Medicaid
$124
$115
$130
$42
$51
$48
$52
$30
$111
$102
$107
$61
$72
$71
$71
$61
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October 2009
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Prevalence of Asthma by Age, NH Medicaid (non-Dual) and NH
Commercial Members, 2005
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
25-34
CHIS Commercial
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NAHDOAPCD
Annual
Meeting
Conference
May 6,October
2009 2009
33
Figure 3c: Plymouth Out Migration vs. In Migration, Outpatient Facility
Encounters, In-State Only, Pharmacy
Excluded, CY2006
4,143
4,500
4,000
3,505
Encounters
3,500
3,000
2,500
2,000
1,718
1,471
1,500
1,379
1,306
29 2
101
273
220
56161
21 27
5 22
26 14
5 37
Rochester
274
65 28
Portsmouth
183
Peterborough
18 74
North Conway
29 88
Nashua
22 47
Manchester
Colebrook
187
Exeter
3 8
Dover
3 8
Derry
12 8
Claremont
500
Berlin
1,000
11 38
236
155
Out Migration
In Migration
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Woodsville
Wolfeboro
Littleton
Lebanon
Lancaster
Laconia
Keene
Franklin
Concord
0
Standardization
With a thank you to
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Areas for Standardization
 Data collection
 Data release
 Metadata
 Reporting / Analysis
 Applications
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The Future?
APCD and HIE?
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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)?
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How Might We Accomplish It?
Data Linking and Repository Architecture, Source: University of New Hampshire 2009
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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, [email protected]
 Josephine Porter, University of New Hampshire /
RAPHIC, [email protected]
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Questions and Discussion
[email protected]
603.536.4265
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