States demand comprehensive data from local payer claims systems

June 1, 2011

When it comes to all-payer claims databases, states are driving the trend.

Key Points

WHEN IT COMES TO ALL-PAYER claims databases (APCDs), states are driving the trend. Plans need to be proactive in their IT strategies and anticipate that such collaborative data sharing will become a rule rather than an exception. There are 11 APCDs nationwide currently. Most were created through state legislation, and most expect mandatory participation.

"What's behind the APCD is escalating healthcare costs, so state legislators are driving this aggregation of information across the whole system," says Denise Love, executive director of the National Association of Health Data Organizations (NAHDO). "APCDs are an attempt to try to follow the money through the entire healthcare delivery system as well as the population of the state across healthcare settings."

She says states are particularly interested, but the main hindrance is a lack of funding. Otherwise it's likely every state would adopt the strategy.

Jonah Frohlich, managing director of Manatt Health Solutions, says that most of the APCDs have been created in the past five years. Manatt has been hired to help California investigate the potential for an APCD.

"The rate of legislation requiring APCDs seems to be accelerating," Frohlich says. "With health reform and a number of the provisions in the Patient Protection and Affordable Care Act, there is increasing interest in having better access to administrative data to try to control costs, understand utilization patterns, understand quality, understand variation, and try to do something about it."

There isn't universal agreement that APCDs will help achieve these outcomes. Robert Zirkelbach, press secretary for America's Health Insurance Plans (AHIP), questions the execution of the efforts.

"The goal should be to have more information out in the public domain about the factors driving up healthcare costs, and how best to address those," Zirkelbach says.

He agrees that more information about prices, trends and drivers is needed, which would allow a more informed public discussion.

"However," he says, "there needs to be a discussion about what the states are looking for and how to provide that information in a way that is less costly and complex than creating a new entity, and that will better protect patient privacy-which is another big issue with a database full of claims and patient information."

APCDs shouldn't be reporting simply for reporting's sake, says Frohlich. To drive any real value and improvement in outcomes, stakeholders need reliable data that is validated and actionable.

REAP WHAT YOU SOW

Love agrees that the early APCDs-which are still in their infancy-have involved a lot of resolution for data-collection issues.

"We start with educating the state that carriers' data systems are built to pay claims," she says. "States can make a list of data fields and data elements they want, but if a health plan doesn't collect that information, it's not going to work to put it in the requirements. In the early states, this process was lengthy."

NAHDO has been working with the All Payer Claims Database Council, the states, and national plans through AHIP to develop a core data set. That means a national standard is emerging that has been crossmapped across the states and represents a minimum list of data elements that payers can provide.

As with other large-scale data systems, states adopting the APCD model must decide whether to build or outsource its development. There are a few vendors with data management programs in this area. States that choose to expand or build on existing platforms should be able to look at other states' rules and adapt them to their legal environment.

"States can look at core data elements that other states are now getting from payers successfully and have somewhere to start. Some of the analytic tools that are being developed by other states can be applied to avoid each state having to develop its reports from scratch," says Love.