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Abstract

Purpose

The National Association of Health Data Organizations (NAHDO) and the APCD Council brought together States aggregating health care claims data from payers to transfer knowledge and best practices in all-payer claims database (APCD) collection and use. The purpose of the Fifth All Payer Claims Database Conference, "Expanding and Enhancing All Payer Claims Database System Capacity in States," was to: (1) expand and enhance APCD collection and reporting capacity across States; (2) promote uniformity in APCD data collection and release; and (3) enhance the utility of State APCDs.

Scope

Planning for the November 2011 conference began July 2011. The 108 attendees included State, Federal, and private sector health care data experts with an interest in APCDs.

Methods

NAHDO and the APCD Council targeted all States with an existing or planned APCD to participate in the meeting. The day long conference included panel presentations and facilitated roundtable discussions.

Results

The conference supported 23 State APCD officials to attend the only national meeting dedicated to the advancement of APCDs. The conference laid the foundation for the 2012 NAHDO and APCD Council State technical support activities. The meeting generated postconference success in negotiating a State-specific Centers for Medicare & Medicaid Services data application process that has streamlined the Medicare data acquisition process for APCD States and set the direction for the 2012 APCD meeting and second conference grant, "Laying the Groundwork for Consumer Reporting on Cost and Quality; Putting APCD Systems to Work."

Keywords

All payer claims databases.

Purpose

Statewide all-payer claims databases (APCDs) are filling important data and information gaps for States seeking solutions to facilitate cost containment and health care reform. Since the first APCD system was established in 2003, the number of States collecting claims and other administrative data from commercial and public payers has increased steadily. In 2013, 11 States had active reporting systems and at least 7 States are in the early stages of development. States at the forefront of aggregating health care claims data from payers are facing unique challenges and continue to seek technical assistance for addressing these challenges but have limited funding.

To meet these growing technical demands, the National Association of Health Data Organizations (NAHDO) and the APCD Council (Council) have expanded beyond the initial Northeast regional State learning network to include a national network of States, transferring best practices and technical knowledge across States in various stages of APCD implementation. Convening States together with key stakeholder groups has been a powerful force in expanding these State APCD initiatives; since 2008, NAHDO has hosted four national APCD conferences with attendance from new States every year.

Because face-to-face interaction is a key tool for State-to-State transfer of knowledge, travel limits on State staff have the potential to inhibit the expansion of APCD reporting systems across States. These restrictions are likely to negatively affect States in the prelegislative or early development stages the most, as these States benefit the most from learning from their peers in States with successful implementation experiences. Therefore, NAHDO, in partnership with the APCD Council, sought support for State travel subsidies for State representatives to attend a Fifth National APCD Conference and to offset conference costs.

The purpose of the Fifth All Payer Claims Database (APCD) Conference was to build on the past four national APCD conferences and:

• Expand and enhance APCD collection and reporting capacity across States.
• Promote uniformity in APCD data collection and release across States.
• Enhance the utility of State APCDs by highlighting best practice in applications for health services research, quality, public health, health policy, and consumer information.

In addition, the APCD conference aimed to provide a forum and networking opportunity for States and other APCD stakeholders to meet and network in person with the aim of transferring knowledge and experiences across States to advance APCD collection and use.

Scope

With the interest in State APCD initiatives at an all-time high, the Fifth Annual All Payer Claims Database Conference, "Expanding and Enhancing All Payer Claims Database System Capacity in States," was held November 14, 2011, in Alexandria, Virginia. We had anticipated approximately 80 attendees but accommodations were made for a total of 108 due to higher than expected interest by APCD stakeholders.

Funding from the Agency for Healthcare Research and Quality (AHRQ) supported the travel expenses for representatives from States at all stages of the APCD implementation continuum. Additional funding from meeting sponsors, Milliman, University of Nevada at Las Vegas' Center for Health Information Analysis, OptumInsight, Freedman Healthcare, and Onpoint Health Data , plus nonstate registrations offset the additional conference costs. This 1-day event was held in conjunction with the National Association of Health Data Organizations (NAHDO) 26^th Annual Conference, "Analytics, Accountability, Action," on November 15-16, 2011.

Methods

NAHDO and the APCD Council recruited and convened a planning committee composed of State data agency staff, vendors, and researchers across the APCD community. The planning committee was responsible for designing the agenda content and identifying and recruiting speakers. The planning committee used feedback from past APCD meeting evaluations as well as their knowledge of the current needs and interests of the States with APCD activities. NAHDO coordinated the speaker recruitment and travel logistics.

Before the grant award was approved, NAHDO had polled target States about their interest in attending the APCD conference and alerted them about the potential travel support. Once the grant award was finalized, a notification letter was sent and a followup phone call was made to each target State (approximately 1 month before the scheduled meeting). In addition, NAHDO and the APCD Council publicized the meeting through their networks. NAHDO assisted all State data agency staff who applied for the scholarship with travel/meeting logistics.

Because of the late notice secondary to the delayed grant review approval, several States were not able to obtain administrative approval to attend this meeting. Therefore, NAHDO did not exhaust all the funding that was available in the grant.

Twenty-three travel scholarships were awarded to representatives from the following States:

• Arkansas.
• Colorado.
• Connecticut.
• Florida.
• Hawaii.
• Louisiana.
• Maine.
• Maryland.
• Massachusetts.
• Minnesota.
• Mississippi.
• Nebraska.
• New Hampshire.
• New York.
• Oregon.
• Rhode Island.
• Tennessee.
• Utah.
• Vermont.
• Wisconsin.

An APCD meeting registration page was created on the NAHDO Web site for all meeting attendees not supported by an AHRQ travel scholarship to register for the conference.

The 1-day conference included panel presentations, followed by a lunch discussion on the next generation of APCDs. Facilitated roundtable discussions on priority areas concluded the day's events. A summary of the sessions follows. (An agenda appears at the end of this report).

Irene Fraser, Ph.D., then Director of the Center for Delivery, Organization, and Markets at AHRQ, opened the meeting and emphasized the need for cost and quality information that is patient centered. She underscored that there is a growing need for State and local data and emphasized the importance of connecting new Federal initiatives with State APCDs.

Session 1: Federal Initiatives

A Federal panel outlined initiatives from their respective agencies important to State APCDs:

• Assistant Secretary for Planning and Evaluation (ASPE) staff updated attendees on the status of the Multi Payer Claims Data Base (MPCD).
• The Centers for Medicare & Medicaid Services (CMS) discussed CMS' activities to "liberate" CMS data for multiple users and uses.
• The National Association of Insurance Commissioners (NAIC) is preparing States for health benefits exchanges (HBEs) and health reform implementation, which is transforming markets from risk avoidance (underwriting) to risk management (community rate, single risk pool requirements, and elimination of pre-existing condition exclusions). Risk adjustment will require detailed data to create composite risk scores.
• The Food and Drug Administration's (FDA) mini-sentinel network has 17 carrier data partners in a distributed data network that collects claims and other administrative data using a common data model with centralized analytics.

It was clear that there are important overlapping issues between Federal and State initiatives:

• States' access to Medicare data and the unique needs of States.
• How Federal and State initiatives can work together and build sustainable systems without undue burden on the payers.

Session 2: Innovative Uses of APCDs

APCD initiatives at all stages of development must demonstrate the value of the data in improving the cost and quality of the health care delivery system. Sustainability is closely linked to the analytic capacity of an APCD, and both private and public systems are under pressure to provide value to funders and other stakeholders.

The second panel, "Innovative Uses of APCDs for Policy and Market Improvements," showcased a broad range of APCD applications from State and regional APCDs. APCD data fill critical information gaps and are being used in some States to inform benefit design, identify disparities in care, and drive community improvements.

In summary, APCDs are becoming an essential piece of a State health information infrastructure with capacity to "connect the dots" across the system. Local improvements will be driven by data collected and used to solve each community's unique problems. Funding to meet the public health goals of a statewide APCD remains an issue for each initiative, so States are seeking use cases that document overall and specific effects of an APCD.

Session 3: The Next Generation of APCDs

What will the APCD system of the future look like? Early APCDs were established before national health care reform legislation was passed (Patient Protection and Affordable Care Act). In addition to the push for transparency and State-based reforms, States are exploring options for a health information infrastructure in the context of accountable care organizations (ACOs), health information exchanges (HIEs), and HBEs. Many States have inquired about how APCDs might fit into these reform initiatives.

A session, "Future Visions of APCDs - APCDs 2.0: System Wide Integration," presented highlights from the APCD Council's white paper , which poses considerations for States reviewing health infrastructure investments. This information laid the groundwork for the facilitated roundtable discussions that followed.

Session 4: Roundtables and Discussion Highlights

Six roundtable discussions were designed for interactive discussion between designated experts and participants. There were two sessions, each 45 minutes in length. Participants had the option to move to another table/topic or stay with one topic.

Expert facilitators for each topic were recruited through the APCD Council networks. They were asked to prepare a few structured questions to begin discussion and to propose potential action items to NAHDO and the APCD Council.

At each roundtable, a designated scribe prepared a summary of the discussion, including possible action items relevant to the topic. Based on the roundtable discussion, a 3-minute summary was presented to the larger meeting audience at the final session of the meeting. A summary of each roundtable follows.

Standards

NAHDO and the APCD Council have worked with States and national payers to harmonize State APCD data elements and align them with national standards. The X12N Post Adjudicated Claims Data Reporting (PACDR) Workgroup is developing an implementation guide for State APCD and Medicare/Medicaid encounter reporting.

Provider and eligibility data file standards and methods for verification and audit of claims will be among the future priorities. Representatives from States with APCDs (or those developing one) were encouraged to participate on the weekly PACDR workgroup calls to ensure that their needs are heard.

In addition, States should work together to identify emerging data needs, including clinical enhancements to administrative data, to ensure that appropriate sources of data are identified. This goal can be achieved through dedicated discussion on State-only APCD Council calls.

Sustainability

Discussants grappled with the issue of APCD sustainability. How do States move from legislative funding to more sustainable business models? Since there is no significant source of Federal funding for State APCDs, States must rely on general appropriations and seek additional revenue sources for sustainability. Data release policies and analytic capacity work to create a market for APCD data and thus are tied to sustainability. If the data products are not intended to be market driven, as in States that restrict access to government agencies only, there will be a need to create an artificial environment where money can flow to support the program.

The group believed that APCD models in the future will likely be public-private partnerships that combine public funding with multiple sources of other revenues, including data sales and foundation support. The group asked NAHDO and the APCD Council to develop a matrix summarizing funding sources available for State APCDs, including an explanation of the funding available through Medicaid programs.

Data Release

States vary in their APCD release practices. This roundtable identified several core principles of data release that should apply to APCDs:

1. Maintain the privacy of the patient at all times.
2. If specified in law or regulation do not release/identify individual payers and/or providers.
3. Promote use of the data by data agency and researchers outside the organization for the public good.
4. Balance the minimum necessary release with operational overhead of cutting multiple files. Data sales can be an important source of revenue to ensure the APCD's sustainability and should be considered when drafting release policies. However, pricing considerations should factor in research and public agency applications.

Discussants requested a State-based user group to identify best practices in creating APCD release files, including methods to create de-identified data files and research files. Multistate coordination will promote comparability across States and reduce the time and effort related to individual State design efforts.

Nonclaims Payments

APCDs provide comprehensive information about health care costs and services, but because they are derived from insurance claims, there are gaps in information. For example, uninsured and self-pay patients will not be included and managed care encounters may lack financial transaction information.

The lack of specific data may be acceptable, as long as all parties are aware of the omissions and these are taken into account in the analysis and interpretation. However, as States advance APCD reporting, options for filling gaps in APCD reporting will be essential. Improving the collection of these data should remain on the agenda of health data organizations going forward.

Public Payer and Other Data Source Integration

Successful data integration requires upfront planning (e.g., who owns the data and how they can be used) and a robust information technology infrastructure. Whether it is handled by the data agency or a vendor, an APCD data warehouse is a place to begin data integration. Agencies need to identify the common format for data integration across payers and be aware of incompatibilities in formats and submission lag times across payers.

Agencies should be aware of important fields used by other data sources that will be important as they build their data warehouses, such as:

• National plan and provider data.
• Physician identifier directories and provider service files.
• Census data.
• Discharge datasets.

In the future, States may expand to other Federal payers (e.g., Indian Health Service and Department of Defense), but the group acknowledged that these payers are less of a priority than Medicaid and Medicare data sources, which are a priority for most States.

Challenges specific to integrating Medicare and Medicaid datasets factored heavily in these discussions. The issues are both technical (e.g., duplication of records, especially if Part D is also coming in from Medicare) and political (e.g., custodianship of the combined data), and States agreed that they need to work together to solve these challenges going forward. Postmeeting followup calls on the Medicare data acquisition process were scheduled.

Measures and Reporting

States are seeking to enhance the analytic capability of their APCDs and to demonstrate the value of their existing (or future) APCDs. It was acknowledged that, currently, there is little consistency across States in report formats, measures, analytic approaches, or in the types of information generated from APCDs.

Participants also agreed that there are huge opportunities for Federal-State collaboration to create measures and reports generated from APCDs that will address multiple stakeholder information needs. State APCDs face political and technical challenges to advancing APCD analytics. These challenges and possible solutions include those noted in the table below.

The group suggested that NAHDO and the APCD Council collaborate with AHRQ to develop a "starter" set of measures for use across States that can be derived from the core set of data elements States collect currently. Over time, these measures can be refined, validated, and enhanced, along a continuum such as used with hospital discharge data.

To begin this process, the roundtable participants thought the following were logical starting points:

• Collect current measures from existing reports and Web sites (e.g., measures reported on individual State APCD Web sites) to derive a starter set of measures.
• Categorize these measures into broad types (e.g., costs/efficiency, quality of care [process and outcome], episodes of care).
• Compile specifications for these measures (e.g., definitions of populations, ICD and CPT * code definitions, inclusion/exclusion criteria, reporting unit, such as provider).
• Because policymakers expect a dashboard of measures (cost, efficiency, population metrics), integrate a set of existing measures to provide summarized information at one or more key reporting units (e.g., providers).
• Come to agreement on methods for aggregating and displaying information such as expenditures in both the commercial and Medicaid sectors.

Results

The conference enabled 23 State APCD officials who are restricted by travel budgets to attend the only national meeting dedicated to the advancement of APCDs and network with others, including Federal agency representatives, researchers, and vendors. Convening State officials on a regular basis has proven to be valuable in keeping the momentum of expanding APCDs across the country. Postmeeting, we have observed:

• Increased activity in APCD planning in approximately 10 States. Postmeeting, the APCD Council site has experienced more requests for technical assistance and stakeholder presentations.
• Negotiations with CMS to create a State-specific application process for accessing Medicare data. Postconference negotiations resulted in a template and process for State requests.
• Development and approval of the X12N Workgroup Post Adjudicated Claims Data Reporting Guides for Professional and Institutional claims that accommodate State reporting needs.

The conference discussions and roundtables laid the foundation for the 2012 NAHDO and APCD Council activities. Medicare data acquisition was high on the list of priorities. Using the momentum generated during the meeting, NAHDO and the APCD Council facilitated a series of calls and in-person meetings between State representatives and CMS personnel to understand the issues and propose solutions.

NAHDO and the APCD Council also helped CMS staff develop a State-specific CMS data application. In August 2012, CMS approved a State-specific application process. This work, which began at the November 2011 meeting, resulted in what has, to date, been reported by States as a cost-effective and satisfactory process for States to apply for Medicare data. (The first States using this application and process received CMS approval within 3 weeks of submission, significantly less time than months or years that States previously reported.)

During the 2011 conference, States requested that future conferences shift from implementation basics to content that emphasizes the value proposition for APCDs—what specific information can APCDs provide and how can that information be used in decisionmaking? What are compelling use cases? With this goal in mind, NAHDO proposed to AHRQ another small conference grant project titled "Laying the Groundwork for Consumer Reporting on Cost and Quality; Putting APCD Systems to Work." This project was approved on September 1, 2012.

NAHDO convened a preconference webinar and a working meeting in October 2012. Preconference research on State APCD reporting initiatives was summarized in a table of APCD measures and reports and to develop a framework for an eventual guidance document for States drafting APCD analytic plans. These materials will be available on the NAHDO Web site at the completion of the project in the summer of 2013.

As requested in the sustainability roundtable discussion, NAHDO and the APCD Council continue to keep States informed on funding sources that may be available to them to develop and/or improve their APCDs. They are using the APCD Council Web site and conducting quarterly calls with States. Several States have successfully obtained Medicaid match and HIE funding support to cover APCD startup costs. A vendor pricing survey was completed, and a model request for proposal template for State APCD development is being drafted to guide State purchasing decisions.

NAHDO and the Council continue to seek funding to work on other priorities identified during the meeting, such as developing guidelines for an APCD public use file. NAHDO and the APCD Council are seeking vendor contributions to fund the ongoing technical assistance needs of States. NAHDO and the Council have been providing these services at no or low cost to States; as more States embark on APCD development, the capacity for providing services must also increase. There is also a growing need for common open source measures, analytic tools, and robust standards if APCDs are to meet their original objectives.

As more States implement APCD systems, priorities are expected to shift. Through quarterly calls with States and national in-person meetings, NAHDO and the APCD Council can stay current on State needs, and States can continue to network and learn from the experiences of their peers.

Meeting Agenda

Expanding and Enhancing All Payer Claims Database System Capacity in States

5^th Annual All Payer Claims Database Conference November 14^th 2011, Alexandria, Virginia