State-Level Impact of Health
Reform: What Can Existing
Data Sources Tell Us?
State Health Research and Policy Interest Group
AcademyHealth Annual Research Meeting
June 11, 2011
Julie Sonier, Deputy Director
State Health Access Data Assistance Center
University of Minnesota
SHADAC is supported by a grant from the Robert Wood Johnson Foundation.
Goals
• How can state-level data be used to inform
planning, implementation, and evaluation
of the ACA?
• Focus on four types of data:
– Population surveys
– Medicaid administrative data
– All-payer claims databases
– Health plan data reported to insurance
regulators
www.shadac.org
2
Overview
• Background on data and how they are
collected
• Opportunities and challenges for using
existing data
• What changes would make the data more
useful for policymakers and/or
researchers?
• What important gaps need to be filled?
www.shadac.org
3
Panelists
• Sharon Long, Ph.D., University of Minnesota
• Chris Peterson, MPP, Medicaid and CHIP
Payment and Access Commission (MACPAC)
• Sean Kolmer, MPH, Office of Oregon Governor
John Kitzhaber
• Deborah Chollet, Ph.D., Mathematica Policy
Research
www.shadac.org
4
Using Federal and State
Survey Data to Inform State
Health Reform
Sharon K. Long
University of Minnesota
State Health Research Policy Interest Group
AcademyHealth Annual Research Meeting
Seattle, WA
June 11, 2011
Key Federal Surveys
• General household survey
– ACS: American Community Survey
• Employment/Income surveys
– CPS: Current Population Survey
– SIPP: Survey of Income and Program Participation
• Health surveys
– NHIS: National Health Interview Survey
– MEPS-HC: Medical Expenditure Panel SurveyHousehold Component
– BRFSS: Behavioral Risk Factor Surveillance System
www.shadac.org
6
Feasibility of State-Level Estimates from
Federal Surveys
ACS
SIPP
CPS NHIS
MEPS
HC
BRFSS
State-level estimates possible?

All states
Some states
State identifiers available on
public use files?
*
~20

~20
~35




High
353K
9K
20K
13K
5K
20K
Median
44K
1K
3K
1K
400
7K
Low
6K
160
2K
110
<100
2K
Sample size by state
www.shadac.org
* Two-year averages recommended.
7
Potential Outcomes of Interest
• Health insurance coverage
• Affordability and scope of insurance
coverage
• Access to care/barriers to care
• Health care use
• Affordability of care
• Quality of care
www.shadac.org
8
Availability of Outcome Measures in
Federal Surveys
ACS
CPS
SIPP
NHIS
MEPS
HC
BRFSS







Affordability of coverage/
comprehensiveness of coverage
-
-

Access to care/barriers to care
-
-

-

+
-
-

Insurance coverage
Point in time
Prior calendar year

-
Health care use
Affordability of care
-
Quality of care
www.shadac.org
9
Timeliness of Data Release for Federal
Surveys
• Data files available now:
– ACS
– SIPP
– CPS
– NHIS
– MEPS-HC
– BRFSS
www.shadac.org
2009
2008
2010 (data for 2009)
2010
2008
2010
10
Strategies to Increase the Value of
Federal Surveys for State Studies
• Expand state-level estimates
– Increase state sample sizes
– Expand use of small area estimation methods
• Expand survey content
• Improve data availability
– More timely data release
– Make state identifiers available outside of
Research Data Center settings
www.shadac.org
11
Changes in NHIS and BRFSS to
Address Needs Under Health Reform
• NHIS
– State-level estimates: Added sample size & exploring
use of small area estimation methods
– Content:
• Added questions
• Expanding links with administrative data
– Availability: More timely release of data
• BRFSS
– State-level estimates: States can add sample size
– Content:
• Core questions include emerging issues
• States can add their own questions
www.shadac.org
12
The Bottom Line on Federal Surveys for
State-Level Analyses of Health Reform
• No single data source is “best”
– CPS, ACS, and BRFSS have accessible 50state estimates but are limited in scope
– NHIS and MEPS-HC have greater scope but
can’t provide estimates for all states and
access to state identifiers is restricted
– MEPS-HC on slow track for data release
• No good alternatives available for some
states and for some outcome measures
www.shadac.org
13
State Survey: One Strategy for
Addressing Gaps in Federal Surveys
• Larger state sample sizes
• Potential to oversample key subgroups
• Information on state-specific insurance and
health care programs
• More outcomes: health care access & use,
costs, quality, barriers to care, awareness of
reform, attitudes toward reform
• More timely access to data to inform policy
and program design
www.shadac.org
14
State Surveys Addressing Health
Insurance Coverage and Other Issues
Last 5 years
Considering
Long ago/no survey
www.shadac.org
15
Federal and State surveys will play an
important role under health reform, but…
• Sample sizes often can’t support analyses
of important subgroups, including
Medicaid/CHIP enrollees
• Surveys rely on self-reported information,
including type of insurance coverage
• Some outcomes are difficult to capture in
surveys—such as costs, diagnoses,
quality of care
www.shadac.org
16
References
• SHADAC. 2011. “Monitoring the Impacts of
Health Reform at the State Level: Using Federal
Survey Data.” Brief #24. Minneapolis, MN:
University of Minnesota.
• Sonier, J. and E. Lukanen. Forthcoming. “A
Framework for Tracking the Impacts of the
Affordable Care Act in California.” Minneapolis,
MN: University of Minnesota.
www.shadac.org
17
Federal Medicaid
Administrative Data
for State Use
Chris L. Peterson
Director—Eligibility, Enrollment & Benefits
June 11, 2011
Seattle, WA
Presentation Overview
• Brief MACPAC background
• A few key sources of federal Medicaid
administrative data and how to use them
– Form CMS-64 and Form CMS-21
– MSIS
– Form CMS-416
• Policy issues regarding federal
Medicaid/CHIP administrative data
19
MACPAC Statutory Charge
Legislative History
•
Established in February 2009 (Children’s Health Insurance Program
Reauthorization Act, CHIPRA)
•
Expanded and funded in March 2010 (Patient Protection and Affordable
Care Act, PPACA)
Commission
•
Appointed by the Comptroller General of the United States to 3-year
terms
•
17 Commissioners represent broad spectrum of interests and expertise
on Medicaid and CHIP
Goals
•
Serve as a federal non-partisan and analytic resource on Medicaid and
CHIP policy for the Congress
•
Review federal and state Medicaid and CHIP policies and data sources
•
Regularly consult with states
20
MACPAC Duties
• Review Medicaid and CHIP policy issues listed in statute:
– Payment policies and payment methodologies
– Access
– Eligibility and enrollment
– Quality
– Interactions between Medicaid and Medicare
– Data for policy analysis and program accountability
• Review and comment on Secretarial reports and regulations
that relate to policies under Medicaid and CHIP
• Submit two annual reports to the Congress—March 15 and
June 15
– March 2011 report Chapter 6 on federal administrative data
– June 2011 report on managed care
– MACStats in every report
21
MACStats
• State-level and national data on Medicaid and CHIP
• March 2011 MACStats state-by-state tables include:
– Medicaid enrollment by eligibility group
– CHIP enrollment by FPL (e.g., 90% of CHIP kids <200% FPL)
– Medicaid and CHIP income eligibility levels
– Medicaid spending by service, federal and state dollars
– Medicaid as a share of states budgets (total and state-funded)
• Preview of MACStats in June 2011 Report
– Trends in Medicaid enrollment and spending
– Health characteristics, enrollment and spending among Medicaid and
CHIP populations
– State-by-state info on Medicaid managed care enrollment & spending
22
Key Sources
of Federal Medicaid
Administrative Data
23
Form CMS-64 & Form-CMS 21
• Overview/purpose
– Form used by states to report actual Medicaid and
CHIP spending
– Basis of federal payment
• Available on CMS website as Excel file thru FY09
• Policy application—Examine each state’s
Medicaid and CHIP aggregate spending
– Medicaid services: 40+ categories, $360B
– Medicaid administration: 30+ categories, $18B
– Medicaid-expansion CHIP: 30+ service and premiumcollection categories, $2.8B
– Separate CHIP: 30+ service, premium-collection, and
administration categories: $7.9B
– §2105(g) spending in up to 11 states, $0.02B
24
Form CMS-64 and CMS-21, cont.
• Limitations
– “As submitted by states”
• States may report spending in different places
• A line of spending may not actually include everything
– Only about spending; no enrollment numbers
• Availability and usage tips
– Annual summary spreadsheets:
https://www.cms.gov/MedicaidBudgetExpendSystem/Downl
oads/FY1998throughFY2009MedicaidCHIPTotals.zip
– Detailed Financial Management Report (FMR)
spreadsheets from CMS-64 and CMS-21 data:
https://www.cms.gov/MedicaidBudgetExpendSystem/Downl
oads/NetExpendituresFY2002throughFY2009a.zip
25
Medicaid Statistical Information
System (MSIS)
• Overview/purpose of MSIS:
Provide person-level eligibility and claims info
on every Medicaid enrollee in every state
• Available in a variety of forms, including:
– Online state summary “Datamart” (FY)
– Annual person summary file (FY)
– MAX (cleaned up, by CY, but long lag)
• Policy application—Examine each state’s
Medicaid enrollment and spending by
individuals’ characteristics (basis of eligibility,
BOE)
26
MSIS, cont.
• Limitations
– 9% of records have “unknown” BOE—usually
prior-year enrollees with a claim paid this year
– MSIS spending does not align with CMS-64
• MSIS 13% lower nationally
• By state, ranges from 40% lower to 19% higher
– About 25% of spending is for managed care
payments, but little is known about enrollees’
encounters
• Availability and usage tips
– State summary Datamart available (Internet Explorer):
http://msis.cms.hhs.gov/
27
MSIS Datamart Cheat Sheet
• For “annual,” click on “quarterly” (FY08=all states; FY09=80%)
• 3rd icon at bottom: Get data later
• Take out CHIP enrollees
– Drag CHIP folder onto line under “2009 annual”
– Right-click to “insert calculation” to create a new No-CHIP variable, based
on adding: NON-CHIP, CHIP UNKNOWN
– Right click to “Hide/show” and hide everything but new No-CHIP
• Break by Basis of Eligibility (BOE)
– Drag BOE folder onto line under “Uniq Elgbls Cnt”
– Right-click to “insert calculation” to create a new NondisabKids variable,
based on adding: CHILDREN, CHILDREN (UNEMPLOYED PARENT),
FOSTER CARE CHILDREN
– Right-click to “insert calculation” to create a new NondisabAdults (under
65) variable, based on adding: ADULTS, UNEMPLOYED ADULTS, BCCA
WOMEN
– Right click to “Hide/show” and hide everything used to build new
variables (i.e., capped names in last two bullets)
• Click “Get Data”
• Once numbers are shown, click penultimate button to “export to
CSV”
28
Form CMS-416
• Overview/purpose of Form CMS-416
– State Medicaid programs must provide children
<21 with early and periodic screening, diagnostic,
and treatment services (EPSDT)
– CMS-416 is the 2-page state-required report on
EPSDT, by state, age group, and categorically
needy (CN) vs. medically needy (MN)
• Reports available online as pdfs
• Policy application: Assess Medicaid children’s
utilization of a handful of services
(screenings, whether referred for treatment,
dental services, blood lead test)
29
CMS Form-416, cont.
• Limitations
– Many concerns about accuracy of data (see GAO
and OIG reports)
– However, may be better than MSIS because of
broader inclusion of managed care
• Availability and usage tips
– https://www.cms.gov/MedicaidEarlyPeriodicScrn/0
3_StateAgencyResponsibilities.asp
30
Policy issues regarding
Medicaid/CHIP
administrative data
31
Selected Policy Issues on Data
• Competing desires on data quality
– If data aren’t being used by policymakers and researchers,
states won’t (can’t) make data quality a priority
– If data quality isn’t a state priority, policymakers and
researchers won’t use the data
– Use the data
• Competing needs—states and federal government
– Example 1: Voluntary initial core quality measures for
Medicaid/CHIP children could inform policymakers about
what works
– Example 2: Encounter data in MSIS could be used to
reduce federal reporting redundancies
– Requires state and federal investment
32
Selected Data Issues, cont.
• Federal Medicaid and CHIP administrative
data only tell you so much about Medicaid
and CHIP. Other sources of data:
– Survey data
• Surveys of households
• Surveys of providers
– States’ own Medicaid and CHIP administrative
data, state all-payer claims databases (APCDs)
– All are being used in MACPAC analyses
33
Health reform in Oregon
Using data to drive reform
Sean Kolmer, MPH
Deputy Health Policy Advisor
Office of Governor Kitzhaber
34
The challenge before us
• Health care has become increasingly unaffordable for
businesses large and small, families and individuals and
state and local governments, due in large part to
inefficiencies in the system that waste dollars and drive
people to more expensive care.
• Public and private dollars are being spent in an inefficient
system at a time when there is no public dollar to spare.
• Inefficiencies in care drive people to getting care in the
most expensive settings such as hospitalization and
institutionalization.
• Between 30-40 percent of health care costs are attributed
to inefficiencies and waste.
35
The challenge before Oregon
•
There are too many uninsured in Oregon: 16.5 percent
uninsured, or approximately 614,000 Oregonians, are without
health insurance.
•
Costs are unsustainable for individuals and families in Oregon:
– Average family health insurance premiums in Oregon
increased by 44 percent between 2003 and 2009.
– Average premiums accounted for 19 percent of the median
income in Oregon in 2009.
– The average deductible for family coverage increased by 94
percent between 2003 and 2009.
Source: Uninsured: 2008 American Community Survey.
Premium data: The Commonwealth Fund, December 2010.
36
The imperative and the opportunity
• Medicaid is eating up an increasing portion of Oregon’s
budget – unnecessary health care costs that are depleting
dollars that could be used for education and other
important public services. T
• The state can no longer afford to throw dollars into an
inefficient system that drives people to the most expensive
care and services.
• Today, the state’s fiscal reality gives Oregon an
opportunity to remake the Medicaid service and health
delivery system to help address the immediate shortfall
and reap savings in the years to come.
• If we don’t take action now, we will pay the price later.
37
The imperative and the opportunity
Comparing the rate of increase in Medicaid and PEBB health care expenditures vs rate of increase in state General Fund revenue Percent Change (Index=100)
400
350
300
250
200
150
100
2001‐2003 2003‐2005 2005‐2007 2007‐2009 2009‐2011 2011‐2013 2013‐2015 2015‐2017 2017‐2019
(proj)
(proj)
(proj)
(proj)
Medicaid (TF)
38
PEBB (TF)
Statewide General Fund Revenue
Health system transformation
principles
•
•
•
•
•
39
Local coordination and accountability of all benefits,
including physical health, mental health and addiction services,
oral health and long-term care services.
Coordination of social supports that promote health and keep
people out of high cost medical care.
Oregonians who are qualified for both Medicaid and Medicare
should be included in improvements. Blend funding to create
more efficient use of resources, care management, aligned
incentives.
Set global budgets at levels that are sustainable, affordable,
and sufficient for best-practices, incentives for prevention efforts,
and lower costs.
Build on best practices in local communities where health
entities partner with each other and consumers and are
accountable for improved health.
Coordination Care Organization
Principles
•
•
•
•
40
An organization that serves as a single-point of accountability
for the cost of health care within a global budget and for access
to and quality of a coordinated system of physical health,
behavioral health and oral health care services delivered to the
specific population of patients enrolled with the organization.
Global budget should be configured to hold CCOs accountable
for outcomes.
Responsible for the full integration of physical, behavioral and
oral health care services for the Medicaid enrollees, including
their members who are dually eligible for Medicaid and
Medicare.
Governance reflect the responsibility for risk, the major
components of the health care delivery system, and the
community at large.
Oregon Health Authority spending projected with and without system transformation 3.5
Billions of $ General Fund
3.0
2.5
2.0
1.5
1.0
0.5
0.0
2009‐11 Actual
2011‐13
2013‐15
With system transformationBienniumWithout system transformation
41
2015‐17
We don’t know, what we don’t know
• Oregonians pay for health care without comparable
information about cost and quality across the
health care system settings.
• Currently, Oregon has fragmented, inconsistent
and incomplete information about how our health
care system is performing
• An all payer, all claims data database is a tool for
better understanding of cost, quality, and utilization
across Oregon’s health care system.
What is all payer, all claims (APAC)
data?
•
•
Data includes
– Claims (medical, pharmacy, and/or dental)
– Health plan member demographic information
– Health plan provider information
– Pharmacy, and/or dental files from:
Data from
– Commercial health insurers
– Third party administrators
– Public payers (Medicaid, Medicare)
– Pharmacy benefit managers
APAC data includes
• Plan payments
• Member financial responsibility (co-pay, coinsurance,
deductible)
• Patient demographics (date of birth, gender,
geography, race/ethnicity)
• Diagnoses
• Procedures performed
• Type of bill (i.e. inpatient, outpatient, emergency
department)
Statutory framework
• Oregon Law Chapter 595, Section 1200-1202
• OHA has authority to:
– Require collection
•
•
•
•
Commercial insurers (all lines of business)
Third party administrators
Medicaid managed care organizations
Pharmacy benefit managers
– Write administrative rules
– Penalties for non-compliance
45
Statutory framework of uses
• Determining the maximum capacity and distribution
of existing resources allocated to health care.
• Identifying the demands for health care.
• Allowing health care policymakers to make informed
choices.
• Evaluating the effectiveness of intervention programs
in improving health outcomes.
• Comparing the costs and effectiveness of various
treatment settings and approaches.
46
Statutory framework of uses
• Providing information to consumers and purchasers
of health care.
• Improving the quality and affordability of health care
and health care coverage.
• Assisting the administrator in furthering the health
policies expressed by the Legislative Assembly in
ORS 442.025.
• Evaluating health disparities, including but not limited
to disparities related to race and ethnicity.
47
APAC data value
• APAC data provides information necessary to
describe health care utilization, patterns of care,
disease prevalence, and cost of care.
• Bringing in all payers eliminates biases created when
assessing only Medicare, commercial or Medicaid in
isolation—much greater precision.
• Community level assessment and comparisons
– Comparison of the current world
– Comparison of a future world (i.e. accountable care
organizations)
49
Variation in payments by geography
State A average rate = $4,614
If State A avg Pmt = State B avg pmt:
Potential Payment savings = $1.5M
State B average rate = $4,064
50
Variation in asthma by payers
18%
17%
17%
17%
16%
16%
15%
14%
13%
12%
11%
10%
10%
10%
9%
9%
8%
8%
7%
7%
7%
6%
6%
6%
5%
5%
4%
4%
19-20
21-24
5%
5%
5%
5%
5%
35-44
45-49
50-54
55-59
60-64
4%
2%
0%
All Ages
0-4
5-9
10-14
15-18
Medicaid-only
25-34
CHIS Commercial
Essential element for reform
• Metrics are critical to accountability
• Accountability for health outcomes requires robust,
dynamic information systems
• System integration across public and private payers
requires across payer information
– Active purchasing (850,000 OHA lives)
52
Health reform in Oregon
Sean Kolmer, MPH
Deputy Health Policy Advisor
Office of Governor Kitzhaber
sean.p.kolmer@state.or.us
503-798-2208
53
What Do States Need to Know about
Their Health Insurance Markets?
Deborah Chollet
AcademyHealth State Health Research and Policy
Interest Group Meeting
June 11, 2011
ACA is business not as usual

Minimum medical loss ratios, rate oversight

Health insurance exchanges for individuals

SHOP exchanges for small groups
– Group size redefined from 2-50 to 2-100

Qualified health plans
– Minimum essential benefits
– Quality improvement
– Tiered products in the Exchange

Navigators + brokers/agents

State risk adjustment - individuals and small groups
55
What do states know now?

Annual statement data
– Company-wide financial/solvency data
– “State page” data, aggregated to line of business
(individual, all group, large and small)
• Premiums (earned, written)
• Losses (paid, incurred)
• Enrollees (lives, member months)

In ~15 states, supplemental filing of smallgroup data
56
What else do states know now?

Rate filing
– Highly variable among states
– Some, not all companies: nonprofits/HMOs only
– Some, not all lines: individual, not group

Product filing
– Original + amendments, but not updated original
57
What do states need to know to manage their markets?

What does the ACA small group market (2-50 and 51-100)
look like?
– Number of lives; number of groups
– Demographics
– Disease characteristics
– Burden of illness
– Products offered and taken (minimum essential coverage)
– Quality improvement activities (activities to improve health
outcomes, prevent hospital readmissions, improve patient safety,
reduce, medical errors, wellness and health promotion, HIT)

What does the association market look like?

What do self-insured small (stop loss) groups look like?
58
What do states need to know to evaluate impacts?

Market dynamics
– Individual exit to/from Medicaid and the exchange
– Small group exit to/from self-insured status
– Small group/individual exit to/from insured and selfinsured association plans
– Navigators/licensure

Risk adjustment
– Distribution of lives and burden of illness among products
and carriers, individuals and small groups

Market efficiency
– Product variation inside/outside the exchange/SHOP
– Meaningful choice: fewer or more products?
59
More information

National Association of Insurance Commissioners
http://www.naic.org/index_health_reform_section.htm

The Center for Consumer Information and Insurance
Oversight www.cciio.cms.gov

States’ insurance department web sites
60
State Health Access Data Assistance Center
University of Minnesota, Minneapolis, MN
612-624-4802
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