Posted by: Jenny Laurello
All Payer Claims Database, APCD, health information exchange, HIE
Guest Post by: Keely Cofrin Allen, Ph.D., Director, Office of Health Care Statistics, Utah Department of Health
If All Payer Claims Databases (APCDs) were a fashion trend, one could say they are “all the rage.” As of June 2011, 27 states either have one or are trying to get one. But what are these vast datasets promising? Vast riches of data and analysis? Where did they come from? How do they differ from the health care data that many states have been collecting for years? And what sorts of reporting do APCDs make possible?
APCDs comprise data from three sources: enrollment, pharmacy and medical claims from health plans. As such, they give an unprecedented look at health care in a wider range of settings than in the pastin facility datasets, which comprise data only from inpatient hospital discharge records. Moreover, because APCDs collect claims data from health plans, they contain information not only on what was billed, but also the allowed charges and what was paid, both by the health plan and by the patient.
The “All Payer” in APCD should be titled “Multi-Payer” since, so far, no APCD actually captures all claims. Smaller plans are often exempt from data submission requirements and APCD do not capture uncompensated care or the uninsured. That said, APCDs collect a lot of data. Health plans in APCD states are mandated to report all of their claims to a designated entity. Most state Medicaid programs also participate. Strong and concerted efforts are underway for states to obtain Medicare data so APCDs can provide a more complete picture of healthcare.
In 2003, Maine became the first state to build an APCD and in doing so set the bar for the rest of the states. By leveraging what Maine had built, New Hampshire and Vermont were able to build their datasets (2005 and 2007, respectively) and soon the three states were working on a cooperative partnership. This New England-based project expanded rapidly starting in 2008 to include Massachusetts, Maryland , Kansas, Utah, Tennessee and Minnesota. Today, nearly two dozen states associate with the APCD Council — a New Hampshire based non-profit organization that provides support and networking for APCD and soon-to-be-APCD states.
Datasets this big don’t come cheap. Annual APCD budgets are in the $1 million range. Establishing an APCD also involves many challenges. They require a complex infrastructure of staff and IT architecture, a specific set of data standards, encryption protocols, highly secure servers and software to house and analyze the data. Setting up an APCD also requires navigating a complex political path, balancing the need for data with concerns for patient privacy, data security, cost burden to the health plans and scarce resources.
Although challenging to implement, the result of all this effort creates an APCD with an extraordinary ability to report on care across a variety of settings ranging from hospital inpatient through primary care in outpatient clinics and doctor’s offices. APCDs also have the ability to report not only on quality indicators for that care, but on how much that care actually cost. The inclusion of demographic information means that data can be examined by patient characteristics such as age and sex. Geographic indicators– a the residence of a patient and where they received care– allows examination of how often or how far people have to travel to access care.
APCDs promise better estimates of what type of care patients receive, where and how often they received it, and how much it cost both the patient and the health plan. This improved information is critical during health care reform as it allows an examination of the major cost drivers of health care. Such information is meaningful to policy makers, payers and consumers as they try to understand the many variables associated with a complex health care system.
For more information on the Utah All Payer Claims Database, please visit utahatlas.health.utah.gov.