All-Payer Claims Database –
Current Status and Future Capabilities
October 24, 2013
1
Objective
• Develop a strategy for establishing All-Payer Claims Database (“APCD”)
• The purpose of APCD is to create “… health care information relating to
safety, quality, cost effectiveness, access and efficiency for all levels of
health care in Connecticut”
• APCD will include data from commercial carriers, PBMs, CT State
Employee Insurance, Medicaid and Medicare enrollees for the residents
of CT
• The database will contain historical data (≥ 3 years) and then monthly
additions starting from August, 2014
• APCD primary database will be isolated and secured from the
analytic/reporting database, differentiated by the process of
deidentification
• Analytic and public use data will be derived from a secondary datamart
• Includes a high level overview of HIX information architecture
2
History of Connecticut’s APCD Initiative
• In 2012, Connecticut’s Office of Health Reform and Innovation developed
a plan for a multi-payer data initiative as required by Public Act 11-58
• Public Act 12-166 implemented governor’s recommendations to build
APCD
• Subsequently, Public Act 13-247 transferred APCD to Access Health CT
• Policy & Procedure (P&P) & Data Submission Guide (DSG) were developed
in the summer of 2013
• First draft of both documents were approved by the Board for placement
for public review in Aug/Sep, 2013
• We anticipate that the Board will approve the P&P and DSG on Nov. 21,
2013
• The approval of the P&P and DSG documents is vital for other items to
follow subsequently
3
Projected Timeline for APCD’s Data Submissions
Data Submission Timeline
Closure of any gaps in
data .
Submission of YTD
Data (+ 45 Days)
Submission of 36
Months of Historic
Data (+60 Days)
Submission of Test
Data (+150 days)
Circa 4/20/2014
Vote and
Release of
Policies and
Procedures
Circa
11/21/2013
4
Circa 6/20/2014
Circa 8/05/2014
Begin Monthly Data
Submissions (+30
Days)
Future Elements:
•Provision of Dental
Data (TBD)
Other Decisions for Connecticut’s APCD
Data Management –
– should it be managed internally or assign it to a vendor?
– Should analytics be assigned to external vendor or brought in-house?
Denial Data – should it be part of the data submission requirement?
Identify stakeholders –
– Identify how various stakeholders can use the APCD data
– We have yet to identify how the various state agencies can use this data
Sustainability Plan – we have not yet developed a data use and data
governance set of P&Ps, including user fees
5
Decision – Insourcing vs. Outsourcing
Categories
Vendor
Experience
Resources
Secure Environment
Technology
Content Knowledge
Quality
Reporting Depth / Quality
Flexibility
Knowledge Curve
Research
Integration to Exchange
Sustainability
Budget
High
6
Favorability
Medium
Low
AHCT
Overview of HIX Infrastructure Integration Opportunity
AHCT Operations
Bswift SHOP
QuickBooks
Data Warehouse
with Views By
Function
Marketing
Database
ETL
Process
7
ScanOptics
Database
MAXIMUS
Call Center
AHCT Deloitte
Application
APCD
Data
HIX Data Warehouse
Consumer
Reports
(web)
ETL Process
NIPA/Broker
Database
Carriers
Datamarts
Ad hoc /
Research
Reports
AHCT
Operations,
Fin / Mkt
Healthcare Analytics - Techniques and Capabilities
• Statistical Techniques
–
–
–
–
–
–
–
–
–
Multiple Regression/GML
Limited Variable Regression Techniques - Logistic, Tobit, Heckman & Others
Forecasting/Prediction Modeling
Conjoint Analysis, Discriminant Analysis, Factor Analysis, Cluster Analysis
Data Reduction Techniques - Principal Component, Factor
Quantile Regression
Data
Statistics/
Bootstrapping
Clinical
Management
BioGroupers
Propensity Matching Analysis
statistics
Neural Network Analysis
• Clinical Insights
–
–
–
–
–
–
8
Econometrics
Health
Services
Research
Methodology
Clinical Groupers – ERG, CDPS, DxCG, CRG, CMS-HCC
Epidemiology
Surgery episodes – ETG, Prometheus
Disease mapping – medical & pharmacy
Various risk models
Expertise in health services research
Deep bench-strength in advanced analytic research
Solution
APCD’s Capabilities Enabling Enhanced Care Models
Analytic Capabilities
Data management Capabilities
 Cleanse, standardize and
integrate:
‒ Clinical
‒ Administrative
‒ Census and Lifestyle
‒ Member Engagement
‒ EMR Data
 Apply Benchmark Data
Population Health
Management
(e.g., advanced risk
analytics)






Provider
Performance
Management
Enhanced
Care
(e.g., gain-share, P4P)
Predictive Analytics
Opportunity Assessment
Risk Stratification and Care
Gaps
Provider Performance
Gain/risk Sharing and
Bundled Payment Models
Clinical Groupers
Clinical Cost
Management
(e.g., clinical
interventions)
Reporting Capabilities
Information Transparency
 Cost, Quality and Utilization
Reports
 CMS/Compliance Reports
 Intervention Outcomes
Reports
 Provider Performance Reports
 Payment Reconciliation

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Payment
Management
(e.g., bundled payment)



Variations in specific services
costs/utilization by counties
Variations in costs per
episodes for select surgeries
by sites and counties
Variations in preventative care
by counties
Self-service platform
APCD’s Analytics - Stakeholders
Providers
• Comparative effectiveness research (w/inclusion of clinical data)
• Cost and Quality of care variations for hospitals and physicians
• Provider practice analyses with risk-share
• Allocation of benefits based on efficiency/quality of care , in ACO or PCMH
models
• Initiate large-scale studies involving alternative reimbursements
Payors – Health-plan, Medicaid, Medicare
•
•
•
•
•
•
Medical trend
Cost of Care
Risk variations by population groups and geographic locations
Risk analyses of newly enrolled members versus current insureds
Various Medicare and Medicaid Analyses
Others based on various state department-specific needs
Members / Beneficiaries
•
•
•
•
•
10
Cost Transparency
Safety and quality of care
Access to care
Personalized healthcare purchase decision making tool
Total episode cost of diseases and/or surgeries