NAHDO Annual Conference October 2009 Patrick Miller, MPH Research Associate Professor 1 NAHDO Annual Conference October 2009

2 22 Topics RAPHIC Overview of APCDs Examples of APCD Output Standardization The Future? APCD and HIE Questions NAHDO Annual Conference October 2009

3 Going Where States Have Not Gone Before A Federation of States is Emerging (RAPHIC / NAHDO) New Life Forms Being Met Along The Way (Supporters and Champions)

This Is All About Transparency Which hospitals have the highest prices? Which health plan has the best discounts? What percentage of my employees have had a mammogram? If emergency room usage in Medicaid is higher than the commercial population, what are the drivers? What is the average length of time people are using antidepressant medications and what are the patient demographics? How far do people travel for services? Which services? Hundreds of additional questions could be asked…. NAHDO Annual Conference October

5 5 RAPHIC NAHDO Annual Conference October 2009

6

7

8

9

10 Overview of APCDs NAHDO Annual Conference October 2009

11 What Are APCDs? Databases, created by state mandate, that typically include data derived from medical, eligibility, provider, pharmacy, and/or dental files from private and public payers: Insurance companies Public payers (Medicaid, Medicare) NAHDO Annual Conference October 2009

12 Why APCDs? Supplement other data for health services research Medicare: Complete picture of care, but limited population Medicaid: Complete picture of care, but limited population Hospital inpatient/outpatient data: Complete picture of hospital-based care only MEPS (and other surveys): Picture of office-based care, but not population-based (and not robust for states) NAHDO Annual Conference October 2009

13 Why APCDs? To answer research and policy questions Determine utilization patterns and rates Identify gaps in needed disease prevention and health promotion services Evaluate access to care Assist with benefit design and planning Analyze statewide and local health care expenditures by provider, employer, geography, etc. Establish clinical guideline measurements related to quality, safety, and continuity of care NAHDO Annual Conference October 2009

Something for Everyone…An Evolution Consumers Employers Health Plans/Payers Providers Researchers (public policy, academic, etc.) State government (policy makers, Medicaid, public health, insurance department, etc.) TBD (Federal government, etc.) NAHDO Annual Conference October

15 Status of State Government Administered All Payer / All Provider Claims Databases Existing Under Development Strong Interest HI NYOR CA FL WA WV VT CT NH MA ME RI KS UT MD MN TN PA ID NAHDO Annual Conference October 2009

16 What Data Are Being Collected? Sources (private, Medicaid, Medicare, uninsured, others are envisioned such as TRICARE) File Types (eligibility, medical, provider, pharmacy, dental) Submitters (carriers, TPAs, PBMs) Data Elements/Variables NAHDO Annual Conference October 2009

17 APCD Data Sources StateMedicaidMedicareCommercialUninsured MANo YesNo MEYes Partial NHYes, But Not Integrated NoYesNo MNYesPlannedYesNo UTYesNoYesNo VTPlanned YesNo NAHDO Annual Conference October 2009

18 APCD Data Files StateEligibilityProviderMedicalPharmacyDental MAYesPlannedYes No MEYes NHYes In process MNYesPlannedYes No UTYes In process VTYesPlannedYes No NAHDO Annual Conference October 2009

19 APCD Data Submitters StateCarriersTPAsPBMsDental MA3010Planned ME NH18142Planned MN20 0N/A UT1222N/A VT36162N/A NAHDO Annual Conference October 2009

20 Typically Included Information Encrypted social security Type of product (HMO, POS, Indemnity, etc.) Type of contract (single person, family, etc.) Patient demographics (date of birth, gender, residence, relationship to subscriber) Diagnosis codes (including E- codes) Procedure codes (ICD, CPT, HCPC, CDT) NDC code / generic indicator Revenue codes Service dates Service provider (name, tax id, payer id, specialty code, city, state, zip code) Prescribing physician Plan payments Member payment responsibility (co-pay, coinsurance, deductible) Date paid Type of bill Facility type NAHDO Annual Conference October 2009

21 Typically Excluded Information Services provided to uninsured (few exceptions) Denied claims Workers’ compensation claims Premium information Capitation fees Administrative fees Back end settlement amounts Referrals Test results from lab work, imaging, etc. Provider affiliation with group practice Provider networks NAHDO Annual Conference October 2009

22 Other Considerations State Authority by Statute Resides Where? Health and Human Services Insurance Department Health Data Organization Thresholds and Exclusions Examples Number of covered lives by a carrier in a state Filling frequencies also vary by covered lives Standalone DME policies Standalone vision coverage NAHDO Annual Conference October 2009

APCD versus(?) HIE Cost Timeliness to launch Completeness of data Return on investment NAHDO Annual Conference October

24 Examples of APCD Output NAHDO Annual Conference October 2009

25

NAHDO Annual Conference October APCD Meeting May 6, Source:

27 FACILITYCarrier ACarrier BCarrier C Hospital A2, , , Hospital B1, , , Hospital C2, , , Hospital D1, , , Hospital E1, , , Hospital F1, , Hospital G1, , , Pricing Difference by Carrier and Provider: Colonoscopy Source: NAHDO Annual Conference October 2009

28 NAHDO Annual Conference October 2009

29 NAHDO Annual Conference October 2009

30 Payment Rate Benchmarking NAHDO Annual Conference October 2009

31 NAHDO Annual Conference October 2009

32 Prevalence of Asthma by Age, NH Medicaid (non-Dual) and NH Commercial Members, 2005 NAHDO Annual Conference October 2009

33 APCD Meeting May 6,

NAHDO Annual Conference October

35 Standardization With a thank you to NAHDO Annual Conference October 2009

36 Areas for Standardization Data collection Data release Metadata Reporting / Analysis Applications NAHDO Annual Conference October 2009

37 The Future? APCD and HIE? NAHDO Annual Conference October 2009

Questions We Might Ask For those patients in the clinical database with certain public health measures (BMI, smoking, heavy alcohol usage, etc), what services are patients seeking, and where? How often does service duplication occur due to lack of electronic communications or other factors? Can we determine cost in addition to frequency? What are the implications of risk adjusting the entire patient data set (clinical and APCD merged)? How will the groupers perform with more information (ie, # of Dx & procedure codes)? What are the implications of using episodic grouping software with data from the entire patient data set (clinical and APCD merged)? NAHDO Annual Conference October

How Might We Accomplish It? 39 Data Linking and Repository Architecture, Source: University of New Hampshire 2009 NAHDO Annual Conference October 2009

40 Resources & Contact Information Regional All Payer Health Information Council (RAPHIC): National Association of Health Data Organizations (NAHDO): Patrick Miller, University of New Hampshire / RAPHIC, Josephine Porter, University of New Hampshire / RAPHIC, NAHDO Annual Conference October 2009

Questions and Discussion NAHDO Annual Conference October 2009