Date post: | 28-Dec-2015 |
Category: |
Documents |
Upload: | oscar-goodman |
View: | 219 times |
Download: | 2 times |
NAHDO Annual ConferenceOctober 2009
Patrick Miller, MPHResearch Associate Professor
1NAHDO Annual Conference October 2009
222
TopicsRAPHICOverview of APCDsExamples of APCD OutputStandardizationThe Future? APCD and HIEQuestions
NAHDO Annual Conference October 2009
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 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….
NAHDO Annual Conference October 2009 4
55NAHDO Annual Conference October 2009
NAHDO Annual Conference October 2009 6
NAHDO Annual Conference October 2009 7
NAHDO Annual Conference October 2009 8
NAHDO Annual Conference October 2009 9
1010NAHDO Annual Conference October 2009
111111
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)
NAHDO Annual Conference October 2009
121212
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)
NAHDO Annual Conference October 2009
131313
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
NAHDO Annual Conference October 2009
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.)
NAHDO Annual Conference October 2009 14
15
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
NAHDO Annual Conference October 2009
161616
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
171717
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
NAHDO Annual Conference October 2009
181818
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
NAHDO Annual Conference October 2009
191919
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
NAHDO Annual Conference October 2009
202020
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
NAHDO Annual Conference October 2009
212121
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
NAHDO Annual Conference October 2009
222222
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
NAHDO Annual Conference October 2009
APCD versus(?) HIECostTimeliness to launchCompleteness of dataReturn on investment
NAHDO Annual Conference October 2009 23
2424NAHDO Annual Conference October 2009
NAHDO Annual Conference October 2009 25
NAHDO Annual Conference October 2009 26APCD Meeting May 6, 2009 26Source: www.nhhealthcost.org
2727
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
NAHDO Annual Conference October 2009
28NAHDO Annual Conference October 2009
29NAHDO Annual Conference October 2009
3030
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
NAHDO Annual Conference October 2009
31NAHDO Annual Conference October 2009
32 32
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
NAHDO Annual Conference October 2009
NAHDO Annual Conference October 2009 33APCD Meeting May 6, 2009 33
NAHDO Annual Conference October 2009 34
3535
With a thank you to
NAHDO Annual Conference October 2009
363636
Areas for StandardizationData collectionData releaseMetadataReporting / AnalysisApplications
NAHDO Annual Conference October 2009
3737NAHDO Annual Conference October 2009
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)?
NAHDO Annual Conference October 2009 38
How Might We Accomplish It?
39
Data Linking and Repository Architecture, Source: University of New Hampshire 2009
NAHDO Annual Conference October 2009
4040
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, [email protected]
Josephine Porter, University of New Hampshire / RAPHIC, [email protected]
NAHDO Annual Conference October 2009