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					All-Payer Claims Database:
Briefing for the Health Care Quality and Cost Council

April 21, 2010

What Are APCDs?

• Databases that typically include data derived from medical, eligibility, provider,
  pharmacy, and/or dental claims from private and public payers:
     – Fully Insured
     – Self-Insured
     – Public payers (Medicaid, Medicare)

• The result is a dataset that allows a broad understanding of cost and utilization
  across institutions and populations.


Status of State Government Administered All Payer / All Provider Claims
Databases



                                                                     VT        ME
              WA

                                             MN                           NH    MA
         OR                                                         NY
                   ID                                                          RI
                                                               PA          CT


                                                          WV               MD
                        UT
        CA                              KS

                                                     TN



                                                                                     Existing
   HI
                                                                                     Under
                                                               FL
                                                                                     Development
                                                                                     Strong Interest

*Slide from NAHDO Annual Conference, October 2009
Patrick Miller, MPH Research Associate Professor, University of New Hampshire


APCD Efforts in other States

State                        Medicaid         Medicare     Commercial                      Uninsured

Maine                        Yes              Yes          Yes                             Partial
   New               Yes, But Not      No               Yes                  No
   Hampshire         Integrated

   Minnesota         Yes               Planned          Yes                  No


   Utah              Yes               No               Yes                  No

   Vermont           Planned           Planned          Yes                  No



Current Claims Data Collection Efforts

   • Claims data is currently collected by a variety of government entities in various
     formats and levels of completeness
        – Health Care Quality and Cost Council (to populate website and to create
            public use or limited use datasets for research purposes)
        – Group Insurance Commission (Clinical Performance Improvement
            Initiative)
        – Division of Insurance (HMO utilization reports)
        – Division of Health Care Finance and Policy (cost trends analysis and other
            reporting/analytics)

   • Other state entities, such as the Department of Public Health, Commonwealth
     Connector Authority, and researchers, have also requested access to claims data

   • The claims data collected currently is limited and does not fully meet the needs of
     its users:
          – Does not include self-insured (approximately 34% of $$), Medicare
             (15%), and Medicaid (15%) claims
          – Does not include other payments to providers that would be required to
             estimate the full cost of care
          – Does not include member benefit/coverage information

   • Current Duplicative Data Submissions
   M.G.L. c. 118G, §§ 6 and 6A provide the Division of Health Care Finance and Policy
   with broad authority to collect health care data (“without limitation”).
                                           DHCFP
  Member Data                               “Without
                                           limitation”                     HCQCC
                                                                        Fully-insured only
                                                         DOI
                                                     Fully-insured
                                                          only



   Claims Data
                                                                           GIC
                                                                     All, except BCBSMA




Vision for Massachusetts All-Payer Claims Database (APCD)

The Division will:

• Reduce administrative costs
     – collect claims data from all payers serving MA residents
     – produce edited, cleaned data files from these submissions
     – provide these datasets to agencies to meet their carrier claims data
        reporting needs and support their cost containment & quality improvement
        initiatives

• Facilitate development of coordinated care delivery system & payment models
     – enable cross-payer, cross-provider, cross-benefit design analysis of cost,
          quality, and utilization
     – support access to consumer information, performance measurement, cost
          containment, and payment reform


Benefits of and Need for APCD
• Administrative simplification                   • Harvesting quality indicators
    – One intake portal for all carrier                – Claims data for quality
       data                                               improvement

• Monitoring health care reform                   • Population health management
    – Cost, access, quality                            – Public and private, full
                                                          enumeration
• Continuum of care
     – From hospital discharges to all            • Better precision for P4P
        activity                                       – Full book of experience for
                                                           each clinician
• Supporting health care delivery
  system transformation                           • Democratizing information
      – Global payments, system-level                  – Access to information for
        measures                                          innovation
                                                    and competition
• Cost mitigation
     – Readmissions and ambulatory                • Facilitating research to support
        sensitive care measures                     state goals
                                                        – Comparative effectiveness,
                                                            patient-centered medical
                                                            home


Proposed Streamlined Carrier Submission

                                                                               CCA

  Provider Data

                                                                              Medicai
                                                                                d



                                                                               DPH

  Member Data

                                                                               GIC

                                  DHCFP collects data,
                                  constructs public use files
                                  including data cleaning
                                                                               DOI
                                  and verification
                                  processes.
    Claims Data

                                                                              HCQCC
APCD: Relationship to HCQCC

• HCQCC Regulation 129 CMR 2.00: UNIFORM REPORTING SYSTEM FOR
  HEALTH CARE CLAIMS DATA SETS
    – HCQCC has authority to collect fully-insured claims data but lacks
       authority to collect self-insured and public payer claims data
    – HCQCC has a data review process for release of its data
    – HCQCC’s data vendor (i.e. DHCFP) collects data and constructs public
       use files (data cleaning and verification)

• HCQCC’s use of the APCD will lead to administrative simplification
    – One data vendor for data intake and construction of public use files
    – One set of technical specifications on what data is requested from carriers
    – One centralized entity for all data release review processes


Issue #1: Data Intake Vendor

• HCQCC commitment to DHCFP’s role as data intake vendor

Option A: Retain current Interagency Service Agreement (ISA)
       – Enables the HCQCC to change data intake vendors at a future date
              • Leads to administrative complexity for payers if this happens and
                  adds additional costs to the Commonwealth

Option B: Agree to a new ISA between HCQCC and DHCFP that includes
    commitment to utilize DHCFP as sole data vendor
       – Ensures administrative simplification through centralized data intake
          process but is this legal and binding?

Option C: Rescind current regulation and enter into an ISA with DHCFP to     allow
collection of all-payer claims on behalf of the HCQCC
        – Centralized data intake for the Commonwealth through APCD

Recommendation: Option C


Issue #2: Data Specifications

• Potential for conflicting data specifications between HCQCC and DHCFP
  regulations

Option A: Retain current HCQCC regulation
       – Potential for administrative complexity if the data specifications diverge
         between the two state entities
       – All future data specification changes would require alignment of
         regulations by both entities

Option B: Amend HCQCC regulation to defer to DHCFP’s APCD data
specifications to establish single standard for all state entities
        – Ensures administrative simplification through aligned data specifications
            but is this necessary?

Option C: Rescind current HCQCC regulation
       – Centralized data specifications for Commonwealth through APCD
       – Provides opportunity to improve upon HCQCC dataset (e.g. provider file
          will facilitate mapping physician practices across health plans, which is
          currently difficult)

Recommendation: Option C


Issue #3: Data Review Board

• Potential for multiple data release processes between HCQCC and DHCFP

Option A: Retain separate HCQCC and DHCFP data release review processes
       – Potential for conflicting release policies
       – Administrative complexity and cost - requires additional staff support
       – Market confusion regarding which process to utilize

Option B: Amend HCQCC regulation to defer to DHCFP’s APCD review
process
        – Administrative simplification through centralized data release review
          process but is this necessary?

Option C: Rescind current HCQCC regulation
       – Centralized data review process for the Commonwealth through APCD

Recommendation: Option C


Issue #4: Data Release Revenue

• Potential for HCQCC to continue to receive a limited dataset for the
  purposes of selling the data to external parties

Pros
       – HCQCC retains the potential for revenue
              • Actual revenue in FY 2010 from the sale of data was only a
                fraction of the budgeted amount

Cons
       – Potential for revenue will be severely limited by the demand for a more
         robust all-payer claims database
       – Requires additional administrative complexity and cost for DHCFP to cut
         a specific file from the larger dataset for the HCQCC
             • These costs may equal or exceed the generated revenue

Recommendation
     – Rescind current HCQCC regulation
           • HCQCC will no longer “sell” its data


Benefits for the HCQCC

• HCQCC will have access to a broader set of claims data for analysis -- including
  self-insured, Medicaid, and ultimately Medicare
      – Calculate cost and quality measures for My Health Care Options website
          based on broader data (i.e. expand from posting only fully insured to all
          private and publicly insured data)
      – Provide measures for Roadmap to Cost Containment and strategic goals of
          the HCQCC
      – Provide data to support future policy initiatives

• Sends clear message of HCQCC’s commitment to administrative simplification &
  transparency
      – Alignment with Roadmap to Cost Containment goals
      – Establishes centralized data intake process for Commonwealth
      – Reduces cost for carriers and government


Continued DHCFP Support to the HCQCC

• DHCFP is currently reimbursed for a small portion (approximately $123K) of its
  activities related to HCQCC support
      – Collect and manage claims data
      – Calculate the selected quality and cost measures that are displayed on the
           Council’s website
      – Support development of performance measures for public reporting
      – Provide programmatic, fiscal, legal, IT, and administrative support

• DHCFP anticipates continued support to the HCQCC, e.g.
    – Expand analyses of data to meet needs of Council’s transparency goals
Proposed Timeline: Critical Milestones

• Enlisted support of state clients, understood their data needs, and developed data
  and systems requirements: January-February 2010
• Drafted regulations for collection and release, and posted notice of public hearing:
  April 2010
• Hold public hearing: Mid-May 2010
• Promulgate regulations: July 1, 2010
• 2010: Current HCQCC data collection and reporting process remains in place for
  the collection of 2009 data
• 2011: Seamless cutover from current HCQCC process to use of APCD data for
  collection and reporting

				
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