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July 31, 2009 Prepared by the Maine Health Information Center
Overview of All Payer Claims Data
Suanne Singer, Senior ConsultantMaine Health Information Center
State Coverage Initiatives Annual Meeting
July 31, 2009
July 31, 2009 Prepared 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, 2009 Prepared 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, 2009 Prepared 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, 2009 Prepared 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, 2009 Prepared 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, 2009 Prepared 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, 2009 Prepared 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, 2009 Prepared 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 practiceAnd, depending upon the state rule, …..• Public payers (Medicaid, TRICARE,
Medicare, Part D)• Data on national employers (e.g.,
WalMart)
July 31, 2009 Prepared 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, 2009 Prepared 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, 2009 Prepared 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, 2009 Prepared 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, 2009 Prepared 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, 2009 Prepared 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, 2009 Prepared by the Maine Health Information Center
Prevalence of Asthma by Age 2005 NH Medicaid (non-Dual)
and Commercial Lives
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
July 31, 2009 Prepared by the Maine Health Information Center
246.9
231.7
290.9
192.0
387.0
181.8
255.4
185.4
191.8
219.2
237.6
247.8
205.5
378.6
286.0
241.7
260.4
329.1
344.3
243.9
277.8
235.8
Rate of Emergency Department Visits
per 1000 Commercial Insurance Members
This study is based on emergency department visitsthat do not result in an inpatient hospitalization.
Emergency Visit Rates
<200
200.0 - 249.9
250.0 - 299.9
300.0 - 349.9
>350
State Rate Emergency Department Visits =
236.1/1000 Members
July 31, 2009 Prepared by the Maine Health Information Center
Ratio of Emergency Department Visits
To Office Visits
0.081
0.096
0.122
0.068
0.078
0.090
0.058
0.113
0.069 0.065
0.124
0.073
0.073
0.083
0.064
0.081
0.130
0.093
0.083
0.089
0.123
0.074
Ratio
<.07
0.070 - 0.079
0.080 - 0.089
0.090 - 0.099
>.10
This study is based on emergency department visitsthat do not result in an inpatient hospitalization.
State Ratio Emergency Department Visits
to Office Visits = 0.08
July 31, 2009 Prepared by the Maine Health Information Center
% Continuously Enrolled Members By # of Physicians Seen in 2007
33%
25%
17%
25%One Physician
Two Physicians
Three Physicians
More Than ThreePhysicians
July 31, 2009 Prepared by the Maine Health Information Center
% Continuously Enrolled Members
By # Drug Groups Prescribed in 2007
Total Members By Drug Group Size
15%
6%
9%
12%15%20%
23% Seven or more Drug Groups
Six Drug Groups
Five Drug Groups
Four Drug Groups
Three Drug Groups
Two Drug Groups
One Drug Group
July 31, 2009 Prepared by the Maine Health Information Center
State Utilization Web SitesBased on All Payer Claims Data
NH www.nhchis.orgChronic 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, 2009 Prepared by the Maine Health Information Center
State Cost Web Sites Based on All Payer Claims Data
MA http://hcqcc.hcf.state.ma.us/ Procedure cost rating of hospitals
ME www.healthweb.maine.gov/ claims/healthcostNH www.nhhealthcost.org
Average procedural charges and payments – total, professional, and facility
July 31, 2009 Prepared by the Maine Health Information Center
Informational Web Siteson All Payer Claims Databases
www.ncdms.org – MHIC’s portal for claims data collection; includes public state pages with links to data collection and data dissemination rules
www.rahpic.org – information regarding harmonization of data standards
www.nahdo.org – state government activity in all payer claims databases
July 31, 2009 Prepared by the Maine Health Information Center
Thank you
Suanne [email protected]
207-430-0656www.mhic.org
