Tag Archives: APCD

APCDs and health insurance exchanges

For those states establishing insurance exchanges under the Patient Protection and Affordable Care Act (PPACA), all payor claims databases (APCDs) can provide much of the data needed for two of the key components of an exchange: a transitional reinsurance program and a permanent risk adjustment program. Both are critical to minimizing the effects of adverse selection that may occur in the initial years of operation of and during implementation of market-wide insurance reforms.

Transitional Reinsurance Program
The purpose of a transitional reinsurance program is to help stabilize premiums for coverage in the individual market during the years 2014 through 2016. The PPACA Transitional Reinsurance Program is an important element in helping states to level the playing field across the non-group health insurance market, to moderate premium changes from the implementation of insurance reforms both inside and outside of exchanges, and to set the foundation for the establishment of the exchanges. Under this program, reinsurance would be based on high-cost enrollees’ claims, and not on a list of medical conditions. The data contained in APCDs can be utilized to establish the attachment points of the high-cost enrollees and help to better define the upper limits of the coinsurance amounts.

In a bulletin of May 31, 2012, entitled, “Transitional Reinsurance Program: Proposed Payment Operations by the Department of Health and Human Services,” the U.S. Department of Health and Human Services (HHS) suggested that, in order to derive the reinsurance payment calculations, a minimum amount of data is necessary, which would contain the following:

Data Types Data Elements Use of Data Types
Enrollee-level data Enrollment effective dates Enrollment plan type
Location (e.g., zip code, geographic rating area or both)
Reinsurance payments calculation
Verification of data
State parameters selection for reinsurance payments calculation
Plan-level data Benefit year
Individual versus small-group
Reinsurance payments calculation
Verification of data
Medical claims data Date of service
Paid claim amount
Reinsurance payments calculation
Verification of data
Pharmacy claims data Date of service
Paid claim amount
Reinsurance payments calculation
Verification of data

All of the data elements suggested by HHS reside in a typical APCD and would be available for most commercial healthcare payors operating in a state. To minimize the data collection burden, HHS would like to leverage commonly used data elements from existing claims data standards. This could be accomplished in a comprehensive cost-effective manner with data provided by an APCD.

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APCDs: Moving toward standardization of data collection

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.

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APCDs and HIEs: A potentially powerful merger, but…

All Payer Claims Databases (APCDs) currently exist in 10 states, with another 12 in the development stage. In addition, there are a number of non-state government claims databases that exist throughout the country. As APCDs are being created, the next step in the progression of obtaining more comprehensive, timely, and accurate healthcare data is to link the APCDs with other databases. The three databases most commonly discussed include two historical databases (hospital administrative and vital statistics) and data from the newly created health information exchanges (HIEs), which will be the focus of this discussion.

HIEs have the potential to enhance existing APCDs with clinical information for quality and outcomes reporting. Because of their content and purpose, HIEs and APCDs will be distinctly separate initiatives as they are developed. If both are integrated, data will exist for comparative effective research, population health applications, and to improve risk adjustment, clinical studies, and outcomes research.

With the rollout of electronic health records with the Health Information Technology for Economic and Clinical Health Act (HITECH) and the establishment of federal grants to expand health information technology (e.g., American Recovery and Reinvestment Act State Grants to Promote Health Information Technology), which greatly augmented existing private initiatives, HIEs now can be found in some form in every state in the United States. Simultaneously, a number of federal initiatives associated with, or driven by, the Patient Protection and Affordable Care Act (e.g., creation of accountable care organizations, patient-centered medical homes, and the Multi-Payer Advanced Primary Care Practice Demonstration pilots and Performance Measurement pilots funded by the Centers for Medicare and Medicaid Services) have elevated the discussion regarding the integration of administrative data derived from APCDs with clinical data generated by HIEs to a new level.

However, while the linkage of claims data with clinical data has taken on a greater significance, overlapping technical and legal impediments exist that may prevent the successful merger of these two robust data sources.

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Best practices for launching and operating an all-payor claims database

The high and sustained growth rate of healthcare in the United States over the past two decades has created significant financial pressures for both government payors (Medicare/Medicaid/VA) and private sector employers who offer health insurance to their employees. Additionally, while per capita healthcare expenditures have increased at an alarming rate, many believe that the overall quality of healthcare in the United States is not commensurate with the expenditures and that significant improvements in health outcomes for the general populace have not been realized.

In order to address the cost and quality issues in the U.S. healthcare system, both government policy makers and employers have found it critical that a comprehensive and timely source of data be available to better define the problems and to set forth proposed solutions. The data set that has emerged to meet those requirements is the all-payor claims database (APCD). This paper provides an overview of the structure and key considerations for planning, launching, and operating an APCD, and lists a number of potential uses for the data, once collected.