July 31, 2009Prepared by the Maine Health Information Center Overview of All Payer Claims Data Suanne Singer, Senior Consultant Maine Health Information Center State Coverage Initiatives Annual Meeting July 31, 2009

July 31, 2009Prepared by the Maine Health Information Center Maine Health Information Center Independent, nonprofit health data research organization, established in 1976 Partner with a wide range of public and private sector clients to solve problems and support informed decision-making through customized data collection, database development and management, and comprehensive reports and analyses

July 31, 2009Prepared by the Maine Health Information Center Maine Health Information Center Data aggregator for Maine (2004), New Hampshire (2005), Massachusetts (2007), Vermont (2008) and Minnesota (2009) as well as a number of private claims databases Data analysis contractor for New Hampshire and Vermont

July 31, 2009Prepared by the Maine Health Information Center What do we mean by “All Payer Claims Data”? Claims data collected after adjudication – either on an incurred basis or a paid basis –Includes medical (aka professional and institutional) and pharmacy claims. Some states also collect dental claims Enrollment or eligibility data that describes the covered population Data collection and dissemination governed by state or federal agency

July 31, 2009Prepared by the Maine Health Information Center What can be collected? Medical claims data available from HIPAA 837 and 835 transaction standards offer most of the desired and readily available data elements HIPAA 837 (from provider to payer) includes member demographics, charges, provider and clinical information HIPAA 835 (from payer to provider) includes member demographics and payment information

July 31, 2009Prepared by the Maine Health Information Center What can be collected? Pharmacy claims data available from NCPDP Telecommunication Standard Format is the primary source of data elements for pharmacy claims

July 31, 2009Prepared by the Maine Health Information Center Data Standards –Enrollment data available from HIPAA 270 and 271 transaction standards offer most of the desired and readily available data elements –HIPAA 270 (from provider to payer) –HIPAA 271 (from payer to provider)

July 31, 2009Prepared by the Maine Health Information Center What is NOT in a Claims Database? Uninsured Workers’ Compensation bills Premium information Referral information (e.g., who ordered dx tests) Test results from lab work, imaging, etc. Capitation and administrative fees Diagnosis associated with prescription drug

July 31, 2009Prepared by the Maine Health Information Center What is NOT in a Claims Database? Unique id for a provider that crosses all plans Identification of in network providers Provider affiliation with group practice And, depending upon the state rule, ….. Public payers (Medicaid, TRICARE, Medicare, Part D) Data on national employers (e.g., WalMart)

July 31, 2009Prepared by the Maine Health Information Center What IS in a Claims Database? All covered services for the population – regardless of the setting or the geographic location of the provider Patient demographics – DOB, gender, residence, relationship to subscriber, type of product and type of contract Payments made for services

July 31, 2009Prepared by the Maine Health Information Center What can NOT be done with Claims Databases? Directly identify patients Identify discount rates (state specific) Cannot determine Results of a diagnostic test Allergies Lag time between when a bill was submitted and paid

July 31, 2009Prepared by the Maine Health Information Center What CAN be done with Claims Databases? Count services Count individuals with various conditions or procedures Compare payments for specific services by provider

July 31, 2009Prepared by the Maine Health Information Center What CAN be done with Claims Databases? Access – geographic distribution of insured population vs. distribution of providers Monitor cost shifting from the employer to the member Study episodes of care Track members longitudinally across plans

July 31, 2009Prepared by the Maine Health Information Center What is the most common challenge when using claims data? Provider data –Unique identification across payers –Rendering or servicing provider vs. billing provider –Clustering providers into group practices –Attributing services to the appropriate providers –Hospital owned practices –Linking pharmacy claims to rendering providers

July 31, 2009Prepared by the Maine Health Information Center How are claims data being used? Evaluation of payment reform initiatives Comparison of rates of utilization across geographic areas Payment variation by provider Patient centered medical home Disease prevalence Tracking medical service encounters leaving home areas

July 31, 2009Prepared by the Maine Health Information Center Prevalence of Asthma by Age 2005 NH Medicaid (non-Dual) and Commercial Lives

July 31, 2009Prepared by the Maine Health Information Center

July 31, 2009Prepared by the Maine Health Information Center

July 31, 2009Prepared by the Maine Health Information Center % Continuously Enrolled Members By # of Physicians Seen in 2007

July 31, 2009Prepared by the Maine Health Information Center % Continuously Enrolled Members By # Drug Groups Prescribed in 2007

July 31, 2009Prepared by the Maine Health Information Center State Utilization Web Sites Based on All Payer Claims Data NHwww.nhchis.org Chronic Diseases (e.g. Diabetes, CVD) Use and Cost (e.g. Emergency Department, Prescription Drugs, Category of Service) Enrollment (e.g., age and gender, geography, insurance product) Special Studies

July 31, 2009Prepared by the Maine Health Information Center State Cost Web Sites Based on All Payer Claims Data MAhttp://hcqcc.hcf.state.ma.us/ Procedure cost rating of hospitals ME claims/healthcost NH Average procedural charges and payments – total, professional, and facility

July 31, 2009Prepared by the Maine Health Information Center Informational Web Sites on All Payer Claims Databases – MHIC’s portal for claims data collection; includes public state pages with links to data collection and data dissemination rules – information regarding harmonization of data standards – state government activity in all payer claims databases

July 31, 2009Prepared by the Maine Health Information Center Thank you Suanne Singer