Data for Change: How States Have Used APCDs to Drive Innovation

State-run all-payer claims databases (APCDs) are a critical public resource and serve a unique function in the current era of health care reform. APCDs, which are operating in 18 states, provide fair and equal access to independently validated data that can both support evidence-based policymaking as well as help patients navigate the health care system. These databases are also the only publicly accessible, independent resources available to analyze the billions of dollars spent on health care through private health insurance markets.

APCDs saw a setback earlier this year in Gobeille v. Liberty Mutual ,when the Supreme Court held that ERISA prohibits state mandated reporting by self-insured plans. Without claims data from self-funded sources, APCDs will be unable to provide a comprehensive picture of health care spending and use,[1] and as a result these databases will be considerably less valuable to the leaders and consumers that have come to rely on them.

Before Gobeille, states were making important strides in collecting and validating claims data from payers and beginning to leverage this information to drive health care reform efforts. Below are just a few examples of the ways states have been able to use APCD data to improve care and lower costs.

  • Colorado. The state’s APCD entity is a key partner in a variety of health reform efforts in the state, serving as the main source of data for Colorado’s Commission on Affordable Health Care and the convener of a statewide Palliative Care task force that published findings highlighting gaps in access to care.
  • Maine. Prior to the decision in Gobeille, Maine’s APCD was capturing 97 percent of all claims transactions in the state by compiling claims files for medical, pharmacy, and dental treatments paid for by both private and public insurers. This data has been leveraged to support a variety of state efforts, including evaluation of the state’s Medicaid initiative to reduce inappropriate use of opioid drugs and to develop patient-level utilization and quality care reports for practices participating in Maine’s medical home program.
  • Maryland. Maryland’s APCD administers the state’s multi-payer medical home program, and plays a key role in assessing the model’s impact on quality of patient care, access to and delivery of health care services, fluctuation of costs due to changes in utilization, and health disparities. Representatives from the state have said that without the availability of the APCD this program would likely not have launched, and the decision in Gobeille will likely limit the ability for self-insured payers to participate. Maryland’s legislature has also been able to utilize the APCD to develop reports that allows policymakers to closely track important trends in utilization and billing, including a recent review of surprise billing of patients for out-of-network services and a report monitoring compliance with state law preventing providers from self-referring for imaging services.
  • New Hampshire. The state has been able to leverage the data available from its APCD to create an interactive, public website (http://www.nhhealthcost.org/) that provides information to consumers and employers about the price of medical care in New Hampshire, broken down by insurance plan and procedure. The tool can also provide price estimates of medical care for the uninsured. New Hampshire has also used its APCD to study how carrier market share affects patient cost, impact of patient age on medical and premium costs, and hospital cost shifting.
  • Vermont. A study based on six years of data made available to researchers through the state’s APCD confirmed that Vermont’s All-Payer Medical Home Model achieved the Triple Aim – reducing expenditures and utilization while increasing delivery of high-quality care. These findings will be able to helpful to states around the country as they consider how to develop new and successful care delivery models.

Losing states as a resource for independently verified, high-quality cost and use data represents a setback in a nationwide push towards increased transparency and data-driven decision making in health care. This past week the Department of Labor took a preliminary step in addressing the void created by Gobeille by proposing the addition of high-level health insurance claims information to an annual ERISA filing. NASHP will be doing a deeper dive on this proposed rule on the blog in the coming weeks.

[1] Data from 2011 indicated that the number of employees covered by self-funded plans is on the rise, with almost 60% of employers electing this coverage type, up from 40.9% in 1998.