What is an APCD?

1. Student Project: UCF College of Health and Public AffairsAll-Payer Claims DatabaseValue Proposition

2. What is an APCD? APCDs are large-scale databases that systematically collect medical claims, pharmacy claims, dental claims (typically, but not always), eligibility and provider files from private and public payers. http://apcdcouncil.org/sites/apcdcouncil.org/files/The%20Basics%20of%20All-Payer%20Claims%20Databases.pdf

3. Benefits of an APCD Consumers • Provides consumers with access to information on healthcare cost and quality to help them make informed healthcare purchasing decisions. Providers • Supports provider efforts to design targeted quality improvement initiatives. • Enables providers to compare their performance with that of their peers. Policymakers • Identify communities that provide cost-effective care and learn from their successes. • Allows targeted population health initiatives. • Allows reform efforts to be evaluated so successful initiatives can be identified and replicated • Allows identification of opportunities for further reform http://www.oregon.gov/OHA/OHPR/RSCH/docs/All_Payer_all_Claims/APAC_fact_sheet.pdf

4. Benefits of an APCD cont. • Enables businesses to shop for health plans with the lowest cost, highest quality providers in network. • Employees and consumers can compare prices for procedures or find specialists based on their quality rankings and costs. • Health policy experts and health care leaders can examine where the major trends in health care spending and utilization exist. • Provider costs paired with quality outcomes allows consumers make value-based purchasing decisions. • Payers, providers and facilities have new ways to evaluate the value of the care critical to moving away from pay for volume model to a more patient-centric and value- based payment model. • Hospitals may realize that improved coordination with home-based or outpatient care could reduce the frequency and costs associated with a particular complication • Cost calculators help consumer get a sense of the relative cost impacts of different insurer and benefit options. • http://civhc.org/Voices-On-Value/November-2012/New-Database-will-Provide-Valuable-Health-Care-Cos.aspx/ • http://civhc.org/Voices-On-Value/October-2014/New-Ways-to-Evaluate-the-Value-of-Care-Coming-Soon.aspx/

5. Tools of an APCD • A review of the Colorado APCD site revealed the following available reports that were produced from collected data: • CO Medical Price Compare Hospital Volume and Completeness • CO Medical Price Compare Overview • New CO APCD Analysis: C-Section Reduction Could Save $6.5 Million Annually • Total Cost of Care by Service Line • Spot Analysis: PT/OT, Chiropractic Services, Commercial • Medicare, Medicaid and Commercial Payment Comparisons • Knee Replacement Average Facility Payments Graph • Medicaid Per Capita Cost of Care by County Map • Commercial Payer Per Capita Cost of Care by County Map • All Payer Average Cost Per ED Visit by County Map • Percent of Total Expenditures By Service Line • Imaging Payment Variation for Highest-Volume Facilities

6. Tools of an APCD cont. • Maine HealthCost(reports available in braces) • Cost Compare: Compare Average Procedure Costs • Emergency Visits (2) • Lab Tests (70) • Office Visits (19) • Outpatient Procedures (57) • Radiology & Diagnostic Imaging (36) Ranked by: Facility Name, Avg. Professional Cost, Avg. Facility Cost, Avg. Total Cost, Patient Complexity Distance to Facility, Number Performed • Uniform reporting system for hospital quality data sets. • Five year trend hospital financial reports. • MONAHRQ Website • Hospital Quality, Utilization, Avoidable Stays; (Chronic Lung conditions, Diabetes Heart Conditions, other, composites, Patient Safety and Procedure Rates) • County Rates (by DRG, Condition and Procedure)

7. Barriers to Acceptance Financial Political Technical Costs Implementation costs On-going maintenance cost Member costs & fees Government Funding Legislative approval Privacy HIPAA Identified/De-Identified data Provider financial information Payer rate information Education Many unaware of purpose/benefits Skeptical of oversight and information release Implementation Existing Infrastructure Technical Ability On-Going Maintenance Existing Infrastructure Technical Ability Request Servicing Staffing availability Availability Data Collection Standardization Methods

8. Barriers to AcceptanceFinancial • Costs • Implementation Costs • $350,000 – $5 million • On-Going Maintenance Cost • $5 million recurring funds , depending on the number of functions a system is performing, the size of a state’s health-care system, population, number of carriers and data feeds • Government Funding • Legislative Approval • Possible Member Costs • Data request fees • Percentage of claims paid amounts (.001%) • Annual membership fees • Fines and penalties

9. Barriers to AcceptancePolitical • Privacy • HIPAA • 45 C.F.R. § 160.103 • Identified/De-Identified Data • Provider Financial Information • Require access to information prior to release and opportunity to dispute findings. • Payer Rate Information • Resistant to releasing “Trade Secret” payment information • Education • Many unaware of purpose/benefits • Skeptical of oversight and information release

10. Barriers to AcceptanceTechnical • Implementation • Existing Infrastructure • Technical Ability • Data Collection • Standardization • Methods • Request Servicing • Staffing availability

11. Exemplary Implementations • Maine • Mandatory Compliance - Established in 2003. The most modelled system. Leveraged a voluntary pilot into a statewide initiative. $4-5 million across MHDO/MHDPC for hardware and staff time since 2002. • Holds claims from commercial insurance carriers, third party administrators (TPAs), pharmacy benefit managers (PBMs), dental benefit administrators, MaineCare(Maine Medicaid), and CMS (Medicare). • Oversight committee consisting of consumers, employers, payers and providers (2 year appointed term). • Established Payer, Data User and Consumer User Groups. • Received Cycle I grants from the Health Insurance Rate Review Grant Program (CMS) August, 2010 ($1,000,000) • Received Cycle III grant in September 2013, ($2,621,098) • Received Cycle IV grant in September 2014, ($1,179,000) • Colorado • Voluntary Compliance - Established in 2012. Supported by grants from the Colorado Health Foundation and The Colorado Trust ($4.5 million). Full finding by fees in 2017. • Holds claims from commercial payers and Medicaid. Medicare claims are planned. • External oversight committee is non-Profit organization, Center for Improving Value in Health Care.

12. Data components of an APCD • Diagnosis, procedure, and National Drug Codes • Information on service provider • Prescribing physician • Health plan payments • Type and date of bill paid • Facility type • Revenue codes • Service dates • Member payment responsibility

13. Funding Options Some of the options available to fund an APCD are: • General appropriations • Fee assessments possibly a small percentage of total claim payout • Medicaid match • Sale for Data access • Center for Medicare & Medicaid Innovation • Beacon Community Cooperative Agreement Program • Private Foundation Grants

14. FloridaHealthFinder.gov Online searching Inpatient, Ambulatory & Emergency Department Data • Hospital, County, Service Type, Hospital Type • Patient: Age Group, Condition Code, Discharge Status, Ethnicity, External Cause of Injury, Gender, Principal Payer • Services: DRG, Diagnosis &Procedure • Time period: Quarter, Year • Data Sets • General Information/Key Differences • Hospital Discharge Data • Ambulatory/Outpatient Data • Emergency Department Data • Comprehensive Rehabilitation Data • Hospital Financial Data • Health Plan Data

15. FloridaHealthFinder.gov cont. Limitations: • Coding differences between hospitals. • The data is limited to only what occurred during that encounter. It will not reflect any events that occur after the patient was discharged. • The codes contained in the patient record may not be specific enough to adequately characterize a patient's condition. • The volume data displayed on this website only report on the first procedure listed on the patient record. Hospital stays may include many more procedures in a single stay. • The physician volume methodology varies from the Compare Hospitals facility level information as they utilize different coding methodologies thus the totals are not comparable. • Data is strictly facility related (including physicians). Does not include Independent providers, outpatient, RX, labs and radiology. • Does not display what a consumer would expect to pay or the actual ‘cost’ (based on insurance, deductible, etc.) • http://www.floridahealthfinder.gov/CompareCare/Disclaimer.aspx

16. Possible Improvements with APCD • Collected from claims, data could contain facilities both in and outpatient, all providers, outpatient procedures, prescriptions, laboratory results, radiology, diagnosis, dental & eligibility . • Can include Medicare ad Medicaid data. • More thorough reporting and data mining capabilities. • Infection reporting and population health analysis. • Providers , payers and consumers would have more complete data to perform comparisons.

17. Recent Florida Initiatives The Agency for Health Care Administration released AHCA RFI 002-12/13 in 2012 stating: • 8.061, F.S., provides the authority for the Agency to collect claims, premium, and financial information from health insurers. Collecting and analyzing data derived from medical claims, pharmacy claims, and dental claims, along with eligibility and provider data files, from both private and public payers, will provide the Agency information on how and where health care is being delivered, and how much is actually being spent. • In May of 2014, The Center for Healthcare Transparency has released an RFP to fund up to three research projects focused on the development and evaluation of novel approaches to making information available to the public while building upon existing regional healthcare cost and quality data aggregation and measurement efforts, such as state APCDs, Regional Health Improvement Collaboratives and Medicare Qualified Entities. • In summer of 2014, The Florida Health Care Coalition applied for funding.

18. Next Steps • State Consumer Health Information and Policy Advisory Council • Investigate grant funding to finance an APCD. • Center for Healthcare Transparency. • State Health and Value Strategies • State Health Reform Assistance Network (Robert Wood Johnson Foundation) • The Center for Consumer Information & Insurance Oversight (CMS) • Provide structure recommendations for data collection and dissemination. • Utilize APCD Council Technical Advisory Panel (TAP). • Ensure stakeholder support through education pertaining to APCD benefits.