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All Payer Claims Database APCD

All Payer Claims Database APCD. Databases created by state mandate, that includes data derived from medical, eligibility, provider, pharmacy and /or dental files from private and public payers. 17 states collecting claims data. All Payer Claims Database APCD. Why create an APCD in Delaware:

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All Payer Claims Database APCD

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  1. All Payer Claims DatabaseAPCD Databases created by state mandate, that includes data derived from medical, eligibility, provider, pharmacy and /or dental files from private and public payers. 17 states collecting claims data.

  2. All Payer Claims DatabaseAPCD • Why create an APCD in Delaware: 1) Unified strategy for development & use of Health information infrastructure including: • Claims Data (APCD) • Clinical Data (DHIN) • DHIN + APCD = more efficient “ Medical Home” 2) Reduce costs. 3) Increase quality of care.

  3. All Payer Claims DatabaseAPCD • Employer Benefits: 1) Allow employer coalitions to benchmark cost, preventive service measures & high cost cases across their populations. 2) Data used to improve health & wellness programs & engage employers’ carriers in joint program development.

  4. All Payer Claims DatabaseAPCD • Policymakers Benefits: • Allow estimated & actual impact of policy changes. • Inform options for payment reform, provider accountability.

  5. All Payer Claims DatabaseAPCD • Consumer Benefits: 1) Provide cost information on specific procedures for specific providers. 2) Help patients select high quality, low cost providers. 3) Even if consumers do not directly access data, they will benefit as providers improve quality in areas with public quality reports.

  6. All Payer Claims DatabaseAPCD • Commercial Payers Benefits: 1) Provides data for provider contracting negotiations. 2) Allows payers to benchmark themselves against their competitors, as well as public programs. (CHIP, Medicaid)

  7. All Payer Claims DatabaseAPCD • Providers Benefits: 1) Allow informed negotiations with payers. 2) Ability to have reimbursement data for all types of payers. 3) Move beyond analysis of physician performance using Medicare data alone.

  8. All Payer Claims DatabaseAPCD • Researcher/Public Health Benefits: 1) Measure accurate rates of disease prevalence. 2) Geographic comparisons to study variations in care between providers. 3) Provide first ever source of data about health care delivery in the primary care setting & the majority of the population.

  9. All Payer Claims DatabaseAPCD • What can APCD Tell Us? • Quality of Care Data • Identify gaps in disease prevention and health promotion services. • Evaluate access to care among at-risk populations. • Cost-Effectiveness Data • Assist employers and employees with benefit design and planning. • Estimate the cost of potential legislative changes affecting health care.

  10. All Payer Claims DatabaseAPCD • What can APCD Tell Us? (continued) • Evaluation Data • Calculate the actual financial impact of legislation. • Evaluate public health interventions. • Provide data related to changes in provider practices. • Assess the impact of health care reform.

  11. All Payer Claims DatabaseAPCD • Why is APCD better than what we have now: • 1) Current health care databases are limited and incapable of “talking” to one another. • Medicare & Medicaid: represent a fraction of the population. • Hospital Discharge: no treatment data; only inpatient care. • Behavioral Risk Factor Surveillance System: no individual-level data; only data for survey items. • Delaware Cancer Registry: missing demographic indicators, screening data, etc.

  12. All Payer Claims DatabaseLimitations • APCDs capture charges , allowable & payment amounts & patient liabilities from claims data. • However, carriers reimburse providers outside of claims in several ways: • Pay for performance payments. • Pharmacy benefit manager rebates. • Capitation fees. • Data on uninsured generally not included but Delaware’s FQHC’s use EMR and we could be the only state with usable data on the uninsured.

  13. All Payer Claims DatabaseLimitations • APCDs contain one side of the fiscal health care equation – expenditures. • They don’t currently contain on the eligibility files the premium collected at the employee or employer level. (New Hampshire). • Clinical data generally not included, but connection with DHIN can result in more complete clinical ,quality, utilization & cost data.

  14. All Payer Claims DatabaseConclusions • APCDs are of great value to policy makers, consumers, employers, carriers, providers as health reform moves forward & transparency requirements increase. • Without APCDs we will be limited to another “silo” of data that loses great potential as an important piece of our health data management infrastructure.

  15. Thank you

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