Developing and Using an All-Payer Database: Kansas’ Experience

1. Developing and Using an All-Payer Database: Kansas’ Experience State Coverage Institute Meeting Albuquerque, New Mexico July 31, 2009 Andy Allison, PhD Executive Director Kansas Health Policy Authority

2. Overview • Origins of Kansas’ All-Payer Database • New data regime initiated in 2005 • KHPA’s plans to manage and use the data • Challenges and hurdles • Lessons learned • Next steps and expected milestones

3. Origins of Kansas’ All-Payer Database

4. Created in 1994 in the Wake of Clinton Health Reform Era • Statutory purpose is to collect information from state-regulated carriers • “…in such form and detail as may be necessary to …determin[e] whether rates and rating systems…produce premiums and subscriber charges…that are reasonable in relation to the benefits provided and to identify any….insurance benefits that may be unduly influencing the cost.” • Named the Kansas Health Insurance Information System (KHIIS) • Funded by a small premium assessment • Dataset is the property of the Kansas Insurance Department, but the state’s health agency was assigned in statute as the statistical agent

5. First Ten Years’ Experience • Limited use of data for estimates of insurance mandates • No published studies of premiums nor its determinants • Data managed by state agency staff as a collection of files rather than a database • Reporting inconsistencies and incomplete data in core fields such as monthly premiums • Limited and laborious access to data • Eroding support among carriers for the administrative premium assessment and mandatory collection

6. KHIIS' Contents • Data from the major health insurance carriers in Kansas (Commercial group insurance plans) • Health benefit, enrollment and claims data • Payment data includes charges and write-offs, copays and deductibles • 700,000+ members represented • Examples of aggregate reports shared publicly: • Payment Summaries for Providers by Specialty • Payment Summaries for Hospitals by Service • Claims & Charges for Services Affected by Mandates

7. New Data Regime Initiated in 2005

8. Reorganization of Kansas’ Health Programs • KHPA created in 2005 Legislative Session • Built on Governor Sebelius’ “Executive Reorganization Order” • Combine administration of state health insurance programs and state health databases • To be housed in quasi-independent cabinet agency • Modified by State Legislature to: • Create a nine member governing Board • Executive Director reports to Board • Added a specific focus on coordinating state health policy, health promotion and data-driven policy making • Assumed management for Medicaid, SCHIP and state employee health plan in July 2006

9. Broad Legislative Intent for Health Data • ..”urgent need to provide health care consumers, third-party payers, providers and health care planners with information regarding the trends in use and cost of health care services in this state for improved decision-making • “it is the intent of the legislature to require that the information necessary for a review and comparison of utilization patterns, cost, quality and quantity of health care services be supplied to [KHPA] by all providers of health care services and third-party payers“ Source: KSA 65-6801

10. KHPA’s Responsibilities: Collect, Govern, and Use • “… [collect and compile] a uniform set of data and establish mechanisms through which the data will be disseminated • “… develop or adopt health indicators • “…may appoint a task force or task forces … for the purpose of studying technical issues relating to the collection of health care data • “…develop policy regarding the collection of health care data • “…coordinate … analysis of health data for the state of Kansas with respect to [its] health programs“ Source: KHPA Authorizing Statute, 2005

11. Summary of Statutory Framework for Management of Public Health Care Data • Broad legislative intent • Public governance through independent board-run agency • Clear accountability for KHPA • Huge stock of available data in one agency: • Medicaid/SCHIP • State Employee Health Plan (SEHP) • Private group insurance data from major carriers (KHIIS) • Licensure information from 8 boards • Hospital Inpatient Claims

12. KHPA’s Plans to Manage and Use the Data

13. Description, documentation, and manipulation Description, documentation, and manipulation Increasing demand Initial policy + Consumer application (foster understanding) Policy & Consumer application Data development Data development Addl. policy + Consumer application (facilitate choice) Guiding Model of Data Use and Development

14. Principal Strategies for Managing and Using Data • Establish public governance of health data • to create statewide health indicators • to develop guidelines for the use of data • to drive expanded collection and use of data • Make existing data accessible and informative • User-friendly interface with core datasets • Combined administration of core datasets to enable comparisons across payers • Make use of available data for policy and programs • Produce data-intensive program evaluations to drive policy • Tie data sources to program management and public expenditures • Organize agency to emphasize outcomes and facilitate use of data • Create venues for dissemination to the public

15. Public Governance through the new “Data Consortium” • Chartered by the Board in April 2006 to: • Guide KHPA in the management of programmatic and non-programmatic health data • Advise the Board as to the appropriate collection and use of health data • Ensure continued public and private stakeholder investment in the use of data to advance health policy • Disseminate Agency’s wealth of data in partnership with stakeholders

16. Consortium’s Progress to Date • December 2007 – First meeting of Data Consortium • December 2007 to October 2008 – Development of statewide health indicator recommendations • November 2008 – Recommendations presented to and approved by Board • January 2009 – Kansas Health Indicators Document published online (1st Release – Tier I) • March 2009 – Unsolicited reports using private insurance data shared publicly for first time

17. Elements of Successful Management of KHIIS • Respond to analytic questions and requests for information from diverse stakeholders • Access to data by staff with different levels of need and skill • Rapid response to wide range of questions and data requests • User-friendly, intuitive access to information • Data-sharing (with suitable privacy controls) with other state agencies and external researchers • Modern analytic tools • Episode groupers • Record linkage to create master patient/provider index • Built-in calculation of widely-accepted measures for acute/long-term healthcare quality • Allow benchmarking of Kansas data to other states and payers

18. Solution: “Data Analytic Interface” (DAI) • Repository for three data sets • Medicaid-400,000+ enrollees annually • State Employee Health-90,000+ enrollees • Private Insurance -700,000+ enrollees • Additional data as available • Web based interface with data • Easily accessed by most staff • Quick response time • User friendly • Accurate reporting with ability to change and save queries • Meet needs of administrators, program staff, analytical staff • Training for each level of staff

19. DAI Timeline and Status • First proposed to KHPA Board in August 2006 • Funded by Legislature in 2007 • Procured by KHPA in 2008 – Contract to Thomson Reuters (Medstat) • Currently in testing and implementation phase • Anticipated Go-Live dates • November 2009 - Medicaid and state employee data available to staff • February 2010 – First installments of private insurance data available to some staff

20. Challenges and Hurdles

21. Challenges of the New Environment in Kansas • A new economy • Large reductions in agency resources • Large structural deficit in state budget • Large structural deficit in federal budget • Increasing levels of need for access to care and health insurance coverage • New political leadership in Kansas • Limited success for comprehensive health reform agenda • Legislative founders no longer in leadership role • Some legislative interest in revisiting KHPA’s governance model • KHPA response: refocus resources on core program operations • Scale back communications, outreach and policy capacity, and executive leadership capacity • Accelerate focus on data-driven, outcomes-oriented management • Develop new savings and efficiencies through program evaluation process and remake the agency to engage in continual review and improvement • Data is no frill!

22. Hurdles in Developing and Using the KHIIS • Data quality and integrity issues • Resource and budget restrictions • Political barriers • Provider-oriented state • Optimizing the governance model for effective multi-stakeholder data policy development • Inertia in use of price and quality data • Obtaining stakeholder buy-in and addressing privacy and trade-secret protection concerns • Identifying sustained demand for information

23. Lessons Learned

24. Key Success Factors • Successful governance of KHIIS and other health data • Clear legislative mandate • Clear vision for intended uses • Inclusive process through the Data Consortium • Public governance of KHPA provides sustained impetus • Successful management of KHIIS • Requires strategy for using data • Recruitment of key staff to a leading-edge effort • Requires capacity to monitor, understand and communicate information • Adequate and sustained funding • Successful use of KHIIS • Fostering demand for new data • Public venue for sharing and improving data • Political accountability to the use of health data • Application of data to management of taxpayer-funded programs

25. Next steps and expected milestones

26. Next Steps in Management and Use of KHIIS • Implement new data submission requirements – Summer 2009 • Overcome questions of the use of proprietary data and successfully share data with external researchers- Summer 2009 • Receive legislative requests for information from the all-payer database – Spring 2010 • Implement web-based, user-friendly data warehouse to enable comparisons of public and private payers – 2010 • Compile regular report of insurance benefits -- 2010 or 2011 • Use comparative data to develop cost-saving program initiatives in Medicaid or the state employee health plan – Summer 2011

27. http://www.khpa.ks.gov/