Collecting Health Data: All-Payer Claims Databases

Cost Containment header

Updated
April 1, 2018


Cost Containment Strategy and Logic

In recent years, a growing number of states have established databases that collect health insurance claims information from all health care payers into a statewide information repository. By early 2018 at least 18 states had enacted “all-payer claims databases” (or APCDs) of these 16 are operational. More than a dozen others have considered such a law or program

They are designed to inform cost containment and quality improvement efforts. Payers include private health insurers, Medicaid, children’s health insurance and state employee health benefit programs, prescription drug plans, dental insurers, self-insured employer plans and Medicare (where it is available to a state). The databases contain eligibility and claims data (medical, pharmacy and dental) and  are used to report cost, use and quality information. The data consist of “service-level” information based on valid claims processed by  health payers. Service-level information includes charges and payments, the provider(s) receiving payment, clinical diagnosis and procedure codes, and patient demographics. To mask the identity of patients and ensure privacy, states usually encrypt, aggregate and suppress patient identifiers.

Summary of Health Cost Containment and Efficiency Strategies- Collecting Health Data: All-Payer Claims Databases

State/Private Sector Examples

 Strategy Description

Target of Cost Containment

Evidence of Effect on Costs

Colorado, Kansas, Minnesota, Tennessee, Maine, Maryland, Massachusetts, New Hampshire, Rhode Island, Utah and Vermont All-payer Claims Databases were in operation by 2010.  

A statewide repository of health insurance claims information from all health care payers, including health insurers, government programs and self-insured employer plans.

Inability to identify and reward high quality/lowcost providers.
Lack of data to enable consumers to compare
provider prices and care quality.

It is too early to determine whether all-payer claims databases can help states control costs.

States that have been implementing APCDs more recently include Connecticut, Nebraska, New York, Virginia and West Virginia. States that have had existing voluntary efforts to maintain an APCD include Virginia, Washington and Wisconsin.

Breaking News and Recent Information and Resources on APCDs

  • 2018 Status of APCD programs in the 50 states - interactive edition of map, online at http://www.apcdcouncil.org/state/map - All Payer Claims Database (APCD) Council.
  • NCSL Postcard: All-Payer Claims Databases (APCDs). States recognize all-payer claims databases (APCDs) as a promising tool that can help achieve the triple aim of better care, smarter spending.  Posted June 2, 2016
    • Informing Health System Change - Use of All-Payer Claims Databases. -A brief highlighting the value of APCDs in informing health system change. Published online by the APCD Council, 2018
    • Minnesota: State-Based Risk Adjustment and Feasibility Study – 

    A report studied the feasibility of Minnesota performing risk adjustment for the individual and small group market in place of the federal government. This report used the state’s Minnesota All Payer Claims Data (MN APCD).  This study, for which MDH retained actuarial expertise, involved assessment of data quality of the MN APCD, statistical and actuarial modeling, and analysis of the policy context for operationalizing risk adjustment in Minnesota’s individual and small group health insurance markets. In conducting the study, MDH partnered with experts at the Minnesota Departments of Commerce and Human Services and sought input from the general public and the health insurance industry through webinars, a Request for Information, and one-on-one interviews with health plan experts.

  • Minnesota's key findings from the study, which have broad relevance to a range of discussions about ensuring stability of the individual and small group markets overall, include:A state-based risk adjustment program developed using Minnesota data and adopting a number of select refinements to the federal model would significantly improve the accuracy of risk adjustment in Minnesota and thereby help stabilize the market. Such an approach offers Minnesota the opportunity to enhance other policy priorities, such as driving towards value-based payment, ensuring broad access to key medical benefits and moderating market volatility. Report to the Minnesota Legislature September 2016.
  • 2016 U.S. Supreme Court: APCD Council:
    • 2017 Harvard Conference reviews APCDs: All-Payer Claims Databases After Gobeille‚Äč- Health Affairs, March3, 2017
      Recently,  the National Association of Health Data Organizations,the National Academy for State Health Policy, and the APCD Council announced that together they are developing a Common Data Layout (CDL) for the collection of claims data in a single national standard format. The CDL will contain uniform reporting elements, which would be applicable to both self-insured and fully insured plans.
    • SCOTUS Rules that ERISA Preempts Vermont Law in Gobeille v. Liberty Mutual Insurance Company. Posted 3/1/2016.

    • News - Gobeille v. Liberty Mutual: Defeat for State All-Payer Claims Databases. From NASHP: "In a 6-2 decision  the U.S. Supreme Court has dealt a blow to state all-payer claims databases. By upholding a lower court’s decision, the Court ruled that states may no longer require self funded plans to submit claims data – that action is preempted by ERISA. In its decision in Gobeille v. Liberty Mutual, the Court was unpersuaded by the arguments presented by Vermont and the 11 amicus briefs filed in support of that state’s position. The Court concluded that “[P]reemption is necessary to prevent States from imposing novel, inconsistent and burdensome reporting requirements on plans.” Read the full blog. 3/1/2016. 
    • SCOTUS Pre-empts State All-Payers Claims Database Laws - NCSL news post, 3/2/2016.  www.ncsl.org/blog/2016/03/02/scotus-pre-empts-state-all-payers-claims-database-laws.aspx
    • The Federal Law: Stuart Gerson, an attorney in the Litigation and Health Care and Life Sciences practices for Epstein Becker & Green, P.C., tells HPW that the decision is an important win for pre-emption advocates. “The court held that this law was pre-empted by ERISA, which expressly pre-empts ‘any and all state laws insofar as they may now or hereafter relate to any employee benefit plan.’ And this includes any state law that has an impermissible ‘connection with’ ERISA plans, i.e., a law that governs, or interferes with the uniformity of, plan administration,” he says.
    • Overview of State Programs that Utilize an Assessment of Self-Funded ERISA Plans and/or Third Party Administrators - This 2016 state table provides new detail on current practices within state APCDs. <http://nashp.org/states-with-assessments-on-self-funded-plans-andor-third-party-administrators/> Posted by  NASHP, 4/6/2016.
    • U.S. Supreme Court Examines: HEALTH CARE CLAIMS DATA: WHAT IS IT GOOD FOR?  Sept. 8, 2015 NCSL Blog1 - Certainly not absolutely nothing. But how the U.S. Supreme Court views why states want this information and how they use it will likely determine the outcome of this case. 
           Vermont and at least 16 other states collect health care claims data. In Gobeille v. Liberty Mutual Insurance Company, the Supreme Court will decide whether the Employee Retirement Income Security Act (ERISA) pre-empts Vermont’s all-payers claims database (APCD) law. The State and Local Legal Center (SLLC) filed an amicus brief arguing against ERISA pre-emption. 
            ERISA applies to most health insurance plans and requires them to report detailed financial and actuarial information to the Department of Labor (DOL). ERISA pre-empts state laws if they “relate to” the core functions of an ERISA plan. Vermont’s APCD law seeks the following medical claims data: services provided, charges and payments for services, and demographic information about those covered.
            The 2nd U.S. Circuit Court of Appeals concluded that ERISA pre-empts Vermont’s law because one of the key functions of ERISA is reporting. Vermont’s law imposes “burdensome, time-consuming, and risky” reporting obligations that are multiplied by other states’ APCD laws.  One judge dissented. He opined that that the ERISA and Vermont reporting requirements are too different to warrant pre-emption and that Vermont’s data collection isn’t burdensome. ERISA requires data reporting focused on asset allocation to avoid the mismanagement of funds or the failure to pay employee benefits. Vermont seeks different information “to fulfill its role of providing health care to its citizens.” Vermont’s law isn’t burdensome because it seeks data that health insurance companies already possess.

The SLLC amicus brief provides examples of how states, consumers, and health insurance companies are using APCD data to reduce the cost and increase the quality of health care. The brief also argues that the 2nd Circuit should have applied the presumption against pre-emption in this case because DOL doesn’t collect the same data as the states. The brief also points out that efforts towards uniformity among state APCD laws minimize the burden of reporting this already-available data.

The National Governors AssociationNational Conference of State LegislaturesCouncil of State Governments,National Association of Health Insurance Commissioner, and Association of State and Territorial Health Officials joined the SLLC amicus brief, which was written by Jennifer McAdams of the National Association of Insurance Commissioners.
1 -Lisa Soronen is the executive director of the State and Local Legal Center and writes frequently for the NCSL blog about the U.S. Supreme Court.

NASHP has been following the case for some time.  See related materials: Chart of All Amicus Briefs

The APCD Council is a federation of government, private, non-profit, and academic organizations focused on improving the development and deployment of state-based all payer claims databases (APCD). The APCD Council is convened and coordinated by the Institute for Health Policy and Practice (IHPP) at the University of New Hampshire (UNH) and the National Association of Health Data Organizations (NAHDO). Denise Love is a member of the Council.  An APDC presentation is online at http://www.youtube.com/watch?v=sRtDbIupbkM

The following are examples of legislation that enable the collection of health care claims data, as compiled by APCD Council, as of April 2018.

The Commonwealth Fund provides some financial support to the Council and also maintains information on their website on all payer claims database issues.  See http://www.commonwealthfund.org/Resources/2011/All-Payer-Claims-Databases.aspx

Reports

  • New England Journal of Medicine on the Future of APCDs

    In Nov. 2016 the New England Journal of Medicine featured an "Online First" perspective piece by John Freedman and Linda Green along with Professor Bruce Landon of Harvard Medical School. "All-Payer Claims Databases-Uses and Expanded Prospects after Gobeille" highlights the history of APCDs and their value for understanding population health and supporting evidence-based health policy. It describes some of the challenges posed by the post-Gobeille rule including:

    • Sustaining and funding APCDs, which may be resource intensive for states
    • Encouraging payers to participate despite reporting requirements, which are often perceived to be burdensome
    • Linking provider and patient identities across time and carriers in order to unlock the full potential of APCD data, and
    • Obtaining complete and timely data, something that is a key determinant of the success of APCDs in the post-Gobeille era

    Despite Gobeille's impact on APCD data collection, the resulting movement toward data standardization offers the opportunity for a faster and less expensive expansion of APCDs.

    US Department of Labor Comment Period in Response to SCOTUS Gobeille Decision Closes Dec. 5, 2016

    A reminder that the Department of Labor's comment period for new data collection rules will close on December 5. In the wake of the Supreme Court's decision in Gobeille v. Liberty Mutual the Department of Labor (DOL) specifically requested comments on how to address collection of data from the Employee Retirement & Income Security Act of 1974 (ERISA) plans in a nationally standardized way. FHC's submitted comments emphasize that:

    • All-Payer Claims Databases (APCDs) are valuable public assets that serve many current and future needs, including protecting plan sponsors and beneficiaries from poor quality and high costs. Other existing data sources do not offer the same breadth or value.
    • Although the Gobeille decision significantly impairs the value of APCDs by curtailing state authority over collecting ERISA Plan data, the DOL has the authority and opportunity to remedy this injury.
    • The DOL should expand the proposed rule so that ERISA plans regularly submit detailed eligibility, claims and provider information to APCD states. The rule should adopt the Common Data Layout that has been collaboratively created by state and industry participants.
    • The DOL should also create standards for data quality and timeliness, as well as establish a long-term process for ensuring that the Common Data Layout remains updated and viable.

    The collaborative efforts around the Common Data Layout signals a growing understanding that uniformity and standardization offer significant benefits to all the APCDs. Less variation points to administrative simplification for submitters, common data standards and greater opportunities for multi-state initiatives.

     

    The National Academy of State Health Policy (NASHP), HCI3, nearly all APCD states and other interested parties have submitted comments for DOL.  APCD states and interested parties may submit comments prior to the DEADLINE of December 5th.  Posted 11/2016

    APCD Data is Available for Release in Rhode Island

    On behalf of the Rhode Island APCD, Freedman Healthcare, the Project Manager and Data Release Advisor for the project, announced that APCD data is now available for release. Rhode Island joins only a handful of APCD states that have made a treasure trove of data available to the public.  Data available for release includes information for dates of service between 2011 and 2015, with information for the same period about member enrollment and the health care providers that delivered services. Applications for summary and claims-level data can be found at the state department of health website. 11/2016

  • Minnesota All Payer Claims Database Workgroup Report to the Minnesota Legislature-2014 - Contains recommendations regarding the use of APCDs within the states. The Workgroup was created by the Minnesota Department of Health. 2/3/2015
  • Resources on Using All-Payer Claims Databases for Rate Review - from St@teside, a publication of AcademyHealth and the State Coverage Initiatives. The webpage contains several articles on the use of APCDs. 2/2014.
  • Intermountain Generating Population Health Data, Revenue -A healthcare toolset Deloitte and Intermountain in Utah have launched this year applies treatment and outcomes across an entire population of patients and is able to focus on specific therapeutic areas. Licensing the data is a revenue stream. Posted by HealthLeaders Meadia,October 2013.

About this NCSL project

NCSL’s Health Cost Containment and Efficiency Series describes two dozen alternative policy approaches, with an emphasis on documented and fiscally calculated results.

Project Staff are based at the NCSL Health Program in Denver. Project leaders: Richard Cauchi, program director; Martha King, group director; additional project research and support provided by: Ashley Noble (policy specialist, 2013-present), Leann Steltzer (editor) and Alise Garcia (senior staff assistant).

NCSL appreciates the support in 2009-2011 from The Colorado Health Foundation and the Rose Community Foundation (Denver) for this project.

For additional information, please contact Richard Cauchi, Health Program director or Ashley Noble, policy specialist.