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All All-Pay ayer er Claims Claims Da Data tabas bases es: : What’s Next After the Sup Supreme eme Cou Court t Dec Decision? ision?

AcademyHealth Annual Research Meeting New Orleans, Louisiana

Craig Schneider, senior health researcher Mathematica Policy Research

June 26, 2017

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Outline

• Background on APCDs
• Gobeille v. Liberty Mutual Insurance Company case
• Methodology
• Findings
• Conclusions

Disclaimer: The contents of this presentation are solely the responsibility of the author and do not necessarily represent the official views of the Massachusetts Center for Health Information and Analysis or the U.S. Department of Health and Human Services or any of its agencies.

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Background on APCDs

• Relatively new – before 2008, only in 2 states (Maine and

Maryland)

• Growing rapidly
• Mix of state agencies and multi-stakeholder nonprofits
• APCD Council – a collaboration of the National Association of

Health Data Organizations (NAHDO) and Institute for Health Policy and Practice at UNH – is a learning network that supports state APCDs

• “All-payer” term

– Commercial plans, Medicare, Medicaid, TPAs, PBMs, dental benefits

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Data in (and not in) APCDs

Information typically collected

• Encrypted member ID
• Type of product (HMO, etc.)
• Type of contract (family, single, etc.)
• Patient demographics
• Diagnosis and procedure codes
• Service provider information
• Prescribing physician, facility type
• Plan and member payments
• Revenue codes and dates of service

Data elements excluded

• Uninsured
• Denied claims
• Workers’ comp
• Premium information
• Capitation and administration fees
• Referrals
• Test results
• Provider affiliation with group practice
• Provider networks

Source: APCD Fact Sheet, NAHDO and APCD Council, UNH Institute for Health Policy and Practice, funded by The Commonwealth Fund, 2010.

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APCD Implementation Map

Sl Slide ide co courtesy sy of APCD APCD Co Council il, , www.a .apcdcouncil il.or .org

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Value of APCDs

• Contains almost complete sample of a state’s insured population – can

support broad range of information needs and studies

• Data used to support websites on public cost information
• Calculate hospital aggregate costs
• Analyze cost-shifting between payers
• Evaluate access issues
• Study dual-eligible population
• Evaluate payment reform initiatives
• Assess community health

See www.apcdshowcase.org for case studies of how states are using APCD data

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Gobeille v. Liberty Mutual Insurance Company

• Supreme Court decision March 1, 2016
• Question: Does ERISA preempt state statutes that require insurers to submit

data to APCDs?

• ERISA covers self-insured plans
• Argument against: Burden on plans to comply with varying data submission

requirements of multiple states

• Argument for: The “burdens” are trivial (supported by U.S. Solicitor General)
• Decision:

– Because different regulations from various jurisdictions “could” create wasteful administrative costs, Vermont’s statute is preempted. – SCOTUS acknowledged that Vermont doesn’t actually create such burdens. – Justice Breyer said DoL could create regulations for standardized data submission format across states/jurisdictions.

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Methodology

• Consulting engagement with Massachusetts Center for Health Information and

Analysis

• Semistructured interviews with 10 states
• Surveys of 4 other states
• Interviews and survey asked about:

– organizational structure, data collection process, data release rules, budget, views on a “finished” APCD, data matching approach, provider attribution process, patient identification and re-identification procedures, website content, resources to produce analytics, contracting approach, fees for sharing data, marketing materials, presence of state laws that are more restrictive than federal law, impact of and responses to Gobeille decision, transparency strategy in the state, and anything else the state APCD wanted to mention

• This presentation focuses on findings regarding Gobeille and the “finished”

APCD questions

Findings

• Vision for a completed APCD
• Impact of and responses to Gobeille
• Issues regarding substance use data

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Features/Functionality for “Completed” APCD

• Merge claims with clinical data, registry data, EMR data, social determinants of

health, or vital records

• Meticulous processes for cleaning data
• Ability to change when users’ needs change
• All stakeholders have confidence in data quality
• Acquire self-funded plan data lacking after Gobeille
• Better race/ethnicity data
• Non-claims payment (i.e., value-based purchasing)
• A rich set of public use files (PUFs) updated regularly that people may query
• Dashboard of relevant information build on database with business intelligence

tools

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Features/Functionality for “Completed” APCD (2)

• Contain all payers and uninsured (via dummy claim),

sitting on server with one seamless longitudinal data set that produces standard extracts

• Effectively use cost data
• Enable analysis of competitiveness of insurance market
• Break down data silos into integrated consolidated

source, with user-friendly dashboard to visualize results

• Fully financed by the stakeholders
• Data users issue publications to drive transparency
• Address capitation and back-end payments

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Impact of Gobeille

• States reported losing a number of claims in their

database, ranging from 15% to 40%

• Conversely, one state is receiving more data – the

SCOTUS decision raised awareness among employers

• Generally, states are experiencing a greater decline in

data from national employers than from state-based employers

• States commented that, although the loss of this data

is disappointing, the APCD remains a valuable resource

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State responses to Gobeille

Approaches reported by states:

• Reaching out to employers, brokers, coalitions, data

users

• Issuing regulations
• Enacting a law that requires opt-in; working with

employers on info needs/promotion; establishing Employer Advisory Commission

• Creating opt-in for employers; reaching out to

employers

• Planning to move to opt-in; engaging employers,

hospitals, and Chambers of Commerce

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Next steps following Gobeille

• State APCD statutes are still enforceable – fully insured plans,

non-ERISA plans, and TPAs if employer supports data submission

• Most TPAs are concluding that the plan sponsor (the employer)

has right to determine whether TPA submits data

• DoL issued proposed regulation 7/21/16 – final release not

known

• In late May, NAHDO and APCD Council completed Common Data

Layout effort – convened states and payers to develop consensus content and format for payers to report APCD administrative data

Source: NAHDO, APCD Council, and NASHP, Key Regulatory Issues Facing APCD States Post Gobeille, April 2016.

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A Bigger Challenge for APCDs than Gobeille?

• 42 CFR Part 2, Confidentiality of Substance Use

Disorder Patient Records

• Final rule issued by SAMHSA on 3/21/17
• Rule limits data shared by providers
• Challenges:

– No universal ID system to isolate “Part 2” providers in claims data feeds – More confusing for APCDs than hospital discharge databases because source is payers who have both Part 2 and non-Part 2 providers and might be reluctant to submit data

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Conclusions

• APCDs are a critical resource for health services

researchers, value-based purchasing organizations, and policymakers

• Gobeille decision problematic but “not a fatal blow”

to APCDs

• 42 CFR Part 2 is an additional challenge to APCDs
• States, NAHDO, and APCD Council working with

payers and federal agencies to resolve these issues – “Burden” and privacy concerns can be addressed, enabling APCDs to continue to be valuable assets to states

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Contact Information

Craig Schneider Senior health researcher Mathematica Policy Research cschneider@mathematica-mpr.com (617) 715-6955 Resources: www.nahdo.org www.apcdcouncil.org