nahdo annual conference october 2009 patrick miller, mph research associate professor 1 nahdo annual...

NAHDO Annual ConferenceOctober 2009

Patrick Miller, MPHResearch Associate Professor

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TopicsRAPHICOverview of APCDsExamples of APCD OutputStandardizationThe Future? APCD and HIEQuestions

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•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 TransparencyWhich 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….

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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 companiesPublic payers (Medicaid, Medicare)

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Why APCDs?Supplement other data for health services

researchMedicare: Complete picture of care, but

limited populationMedicaid: Complete picture of care, but limited

populationHospital inpatient/outpatient data: Complete

picture of hospital-based care onlyMEPS (and other surveys): Picture of office-

based care, but not population-based (and not robust for states)

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Why APCDs?To answer research and policy questions

Determine utilization patterns and ratesIdentify gaps in needed disease prevention and

health promotion servicesEvaluate access to careAssist with benefit design and planningAnalyze statewide and local health care

expenditures by provider, employer, geography, etc.

Establish clinical guideline measurements related to quality, safety, and continuity of care

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Something for Everyone…An EvolutionConsumersEmployersHealth Plans/PayersProvidersResearchers (public policy, academic, etc.)State government (policy makers, Medicaid,

public health, insurance department, etc.)TBD (Federal government, etc.)

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Status of State Government AdministeredAll Payer / All Provider Claims Databases

ExistingUnder DevelopmentStrong InterestHI

NYOR

CA

FL

WA

WV

VT

CT

NH MA

ME

RI

KSUT

MD

MN

TN

PAID

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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

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APCD Data SourcesState Medicai

dMedicare

Commercial

Uninsured

MA No No Yes No

ME Yes Yes Yes Partial

NH Yes, But Not Integrated

No Yes No

MN Yes Planned Yes No

UT Yes No Yes No

VT Planned Planned Yes No

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APCD Data FilesState Eligibilit

yProvider

Medical Pharmacy

Dental

MA Yes Planned Yes Yes No

ME Yes Yes Yes Yes Yes

NH Yes Yes Yes Yes In process

MN Yes Planned Yes Yes No

UT Yes Yes Yes Yes In process

VT Yes Planned Yes Yes No

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APCD Data SubmittersState Carriers TPAs PBMs Dental

MA 30 1 0 Planned

ME 53 45 0 18

NH 18 14 2 Planned

MN 20 20 0 N/A

UT 12 2 2 N/A

VT 36 16 2 N/A

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Typically Included InformationEncrypted 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 codesService datesService provider (name,

tax id, payer id, specialty code, city, state, zip code)

Prescribing physicianPlan paymentsMember payment

responsibility (co-pay, coinsurance, deductible)

Date paidType of billFacility type

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Typically Excluded InformationServices provided to uninsured (few exceptions)Denied claimsWorkers’ compensation claimsPremium informationCapitation feesAdministrative feesBack end settlement amountsReferralsTest results from lab work, imaging, etc.Provider affiliation with group practiceProvider networks

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Other ConsiderationsState Authority by Statute Resides Where?

Health and Human ServicesInsurance DepartmentHealth Data Organization

Thresholds and Exclusions ExamplesNumber of covered lives by a carrier in a

stateFilling frequencies also vary by covered lives

Standalone DME policiesStandalone vision coverage

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APCD versus(?) HIECostTimeliness to launchCompleteness of dataReturn on investment

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NAHDO Annual Conference October 2009 26APCD Meeting May 6, 2009 26Source: www.nhhealthcost.org

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FACILITY Carrier ACarrier

B Carrier C

Hospital A 2,091.22 1,552.98 1,757.94

Hospital B 1,243.94 1,169.12 1,192.33

Hospital C 2,325.32 2,148.21 2,065.92

Hospital D 1,658.53 1,200.62 1,431.43

Hospital E 1,715.74 2,075.38 1,514.17

Hospital F 1,381.96 -- 1,087.22

Hospital G 1,906.15 1,942.21 1,949.79

Pricing Difference by Carrier and Provider: Colonoscopy

Source: www.nhhealthcost.org

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Payment Rate BenchmarkingPayment Rate Benchmarking

Procedure Code Health Plan 1 Health Plan 2 Health Plan 3 NH Medicaid99203 Office/Outpatient Visit New Patient, 30min $124 $115 $130 $4299212 Office/Outpatient Visit Established Patient, 10min $51 $48 $52 $3099391 Preventive Medicine Visit Established Patient Age <1 $111 $102 $107 $6190806 Individual psychotherapy in office/outpatient, 45-50min $72 $71 $71 $61

Average Payment Including Patient Share, 2006

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10% 10%

9%

7%8%

9%

11%

13%

15%

17% 17%

16%

17%

5%

7% 7%

6%

6%

4% 4%

5%5% 5% 5% 5% 5%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

All Ages 0-4 5-9 10-14 15-18 19-20 21-24 25-34 35-44 45-49 50-54 55-59 60-64

Medicaid-only CHIS Commercial

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With a thank you to

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Areas for StandardizationData collectionData releaseMetadataReporting / AnalysisApplications

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Questions We Might AskFor 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)?

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How Might We Accomplish It?

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Data Linking and Repository Architecture, Source: University of New Hampshire 2009

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Resources & Contact InformationRegional All Payer Health Information

Council (RAPHIC): www.raphic.orgNational Association of Health Data

Organizations (NAHDO): www.nahdo.org

Patrick Miller, University of New Hampshire / RAPHIC, patrick.miller@unh.edu

Josephine Porter, University of New Hampshire / RAPHIC, jo.porter@unh.edu

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Questions and Discussion

patrick.miller@unh.edu603.536.4265

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