With the interest in establishing all payor claims databases (APCDs) continuing to grow (currently APCDs exist, are being developed, or are being contemplated in over 25 states), the need to standardize the data collection component of APCDs is now much greater. In this context, the term standardization means that states and substate entities collecting APCD data would do so in the same manner (i.e., identical file structures, data elements, data type, positioning, lengths, and code sets). Also, because individual states and substate entities will need to collect some data elements that are unique, standardization must also include a uniform process, which involves both data submitters and data collectors, for modifying the accepted file structure.
While the states of Maine, Massachusetts, Minnesota, New Hampshire, Tennessee, and Vermont have very similar data collection requirements, differences do exist, and Maryland, Utah, and Oregon, even with many of the data elements collected identical to those collected by the six states listed above, have considerably different data file formats. This nonuniform approach to developing APCDs has resulted in increased costs to all stakeholders: states and other substate entities using “one-off” data collection systems cannot easily adopt or leverage the advancements made by those employing a more standardized format, resulting in increased costs. Because different extracts must be created for each data collection entity, costs for payors submitting data, especially for payors operating in multiple states, are significantly higher than the ideal. The ability of data users (including federal and state government agencies) to share analyses and applications across states is more complicated, resulting in additional analytic costs to normalize the data.
In an effort to bring standardization to the APCD data collection process, during the past two years the All Payer Claims Database Council worked with both the National Council for Prescription Drug Programs (NCPDP) and the Accredited Standards Committee (ASC) to establish reporting APCD guides for eligibility as well as medical, pharmacy, and dental claims files. These initiatives resulted in the following:
• In October 2011, the NCPDP released the Uniform Healthcare Payer Data Standard, which creates administrative efficiencies and supports the reporting requirements for pharmacy claim data submissions to states or their designees. It also established criteria to be used for all entities sharing historical pharmacy-related healthcare data.
• In October 2012, the Accredited Standards Committee (ASC) X12 released Institutional, Professional, and Dental Implementation Post-Adjudicated Claims Data Reporting (PACDR) guides. These guides were developed by a special appointed committee that will continue to meet to develop standards and implementation guides for the eligibility file component of an APCD.
While the resulting reporting guides are an important component of the standardization process and provide clear and precise mapping to the source data used (including the data type, field lengths, and codes) to populate the data elements within an APCD, the guides do not identify (or recommend) a description of the specific data elements within each file that would define a national, uniform data submission structure. By default, a state or substate entity could adopt all of the elements in the reporting guides for submission, but this is unlikely because of the large number. Consequently, it is still necessary to continue the quest to create a core set of files and data elements to foster a more harmonized data collection process across the country, culminating in a formal national standard for APCD data submissions that will be augmented by the NCPDP and ASC reporting guides. Because APCDs are not static and the creators of APCDs may have unique requirements, it is also critical to create a formal process that oversees the modification of the standard file formats and content.
In order for this to happen, serious discussions must continue to take place among the key stakeholders: state government data agencies and substate data collection entities through the APCD Council or NAHDO; healthcare payors (carriers, TPAs, PBMs) through AHIP and other trade organizations, and impacted federal government agencies (CMS, AHRQ, CDC). This has not been, and will not be, an easy undertaking because of the large number of parties involved with their own diverse interests. However, failing to address the APCD standardization issues will result in higher costs for all concerned. Having standardized files and data elements, a formal process to ensure a predictable schedule with sufficient lead time for modifications to the standardized files and elements, and an ongoing collaborative process with all of the key stakeholders involved will support efficient, cost-effective APCDs across the country.
This article first appeared at Milliman MedInsight.