APAC 101 1 Overview OFFICE OF HEALTH ANALYTICS Health Policy and - - PowerPoint PPT Presentation

APAC 101

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OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division

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Overview

What is APAC?

The Oregon All Payer All Claims Database (APAC) is a large database that houses administrative health care data for Oregon’s insured

• populations. Specifically, APAC includes medical and pharmacy claims,

enrollment data, premium information, and provider information for Oregonians who receive coverage through commercial insurers as well as through public payers such as Medicaid and Medicare.

OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division

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What is APAC?

The Oregon All Payer All Claims Database (APAC) is a large database that houses administrative health care data for Oregon’s insured

• populations. Specifically, APAC includes medical and pharmacy claims,

enrollment data, premium information, and provider information for Oregonians who receive coverage through commercial insurers as well as through public payers such as Medicaid and Medicare.

OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division

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APCDs Across the Country

. APAC is one of 13 state-led All Payer Claims Databases (APCDs) in the country, with four more in active development. States use these initiatives in much the same way as Oregon: to inform new policies and innovations for health care cost containment, quality improvement, and health access; to evaluate programs; and to bring transparency to the health care system.

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Data Collection

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What Data Is Included?

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Member Enrollment Information

Includes type of insurance, and member age, gender, and geography

APAC

Medical and Pharmacy Claims

Includes patient diagnoses, procedures performed by provider, and amount payer and patient will pay for services and prescription drugs

Provider Information

Includes provider identifier, location, and specialty

Premium Information

Includes total premium amounts billed for each month of coverage OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division

What Data Is Included?

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Member Enrollment Information

Includes type of insurance, and member age, gender, and geography

APAC

Medical and Pharmacy Claims

Includes patient diagnoses, procedures performed by provider, and amount payer and patient will pay for services and prescription drugs

Provider Information

Includes provider identifier, location, and specialty

Premium Information

Includes total premium amounts billed for each month of coverage OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division

What is a claim?

A claim is a request for payment that a medical provider sends to a payer (i.e. a health insurance company or health care program) for services rendered by the provider. A claim includes information about the patient’s diagnoses, the procedure(s) performed by the provider, the amount the payer and patient will pay for the service(s) under a health insurance plan, and–in the case of paid claims–the final amount paid for the treatment or service.

What Data Is Included?

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Member Enrollment Information

Includes type of insurance, and member age, gender, and geography

APAC

Medical and Pharmacy Claims

Includes patient diagnoses, procedures performed by provider, and amount payer and patient will pay for services and prescription drugs

Provider Information

Includes provider identifier, location, and specialty

Premium Information

Includes total premium amounts billed for each month of coverage

Non-Claims Payment Information (APMs)

Includes health care payments made to providers that are non-claims based—such as capitation, pay-for-performance, global budget, etc. OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division

New!

What Data is Not Included?

APAC does not include the following:

• Data from commercial health plans with fewer than 5,000 covered

lives;

• Data on individuals insured through federal programs including

Tricare, Federal Employees Health Benefits Program, Department of Veterans Affairs, and the Indian Health Service;

• Data on uninsured populations and other individuals who pay out of

pocket;

• Data for other types of insurance such as workers’ compensation

and stand-alone dental or vision policies; and

• Claims related to alcohol and drug treatment.

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Data Submitters

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≥ 5,000 lives All

Who does not submit to APAC

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Coverage for active duty military service members, National Guard and Reserve Members, and their families

TRICARE

Coverage for people who served in the active military

Veterans Administration

Provides federal health services for American Indians and Alaska Natives

Indian Health Service Some types of commercial coverage

Accident policies, dental-only insurance, disability policies, hospital indemnity policies, long-term care insurance, Medicare supplemental insurance, specific disease policies, stop-loss plans, student health insurance, vision-only insurance, workers compensation, and coverage from carriers and TPAs with fewer than 5,000 enrollees in Oregon

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Data Files Submitted to APAC

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Member Eligibility File (Appendix B) Medical Claims File (Appendix A) Pharmacy Claims File (Appendix D) Medical Provider File (Appendix C) Control File: Billed and Paid Amounts (Appendix E) Control File: Medical and Pharmacy Member Months (Appendix E)

Coming Soon!

APM File and Control File (Appendices G and H) Premium File (Appendix F)

Data Submissions Schedule

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Due date* Incurred Month, 2015 Incurred Month, 2016

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

01/31/2016 05/01/2016 07/31/2016 10/31/2016 Due date* Incurred Month, 2016 Incurred Month, 2017

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

01/31/2017 05/01/2017 07/31/2017 10/31/2017 Due date* Incurred Month, 2017 Incurred Month, 2018

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

01/31/2018 05/01/2018 07/31/2018 10/31/2018

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Data Submissions Schedule

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Due date* Incurred Month, 2015 Incurred Month, 2016

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

01/31/2016 05/01/2016 07/31/2016 10/31/2016 Due date* Incurred Month, 2016 Incurred Month, 2017

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

01/31/2017 05/01/2017 07/31/2017 10/31/2017 Due date* Incurred Month, 2017 Incurred Month, 2018

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

01/31/2018 05/01/2018 07/31/2018 10/31/2018

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Why require multiple resubmissions of the same incurred months?

When a medical or pharmacy visit takes place, the provider submits a claim to the patient’s insurer to bill for the

service. The insurer receives the claim, processes it, and pays it. This period of time is referred to as “claims lag” and can vary depending on the type of payer and provider. While some claims are paid within two months of the date of service, others can take up to 12 months or more. Furthermore, some claims require adjustments after they have been paid; for example, if the payer discovers an error in the claim. Once the claim is paid, the payer submits it to APAC during its next quarterly submission. However, OHA set up the rolling 12-month submission schedule to try to capture as many claims as possible—those that take longer to process as well as claims that have been adjusted.

Timeline for Claims Data Submitted to APAC

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Data Validation

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Validation Levels 1-3 (Milliman-led)

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Level 1: Automated File, Field and Quality Checks (within 24 hrs. of data submission) Level 2: Quarterly Data Audit sent to submitters before processing (within 15 days of data submission) Level 3: Annual Data Audit 2-year, processed data look-back (60 days after full years’ data submission) Level 4 Level 5

Validation Levels 4 and 5 (OHA-led)

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Level 1 Level 2 Level 3 Level 4: Annual Interagency Validation Comparing APAC to other data sources Level 5: Public Facing Reports

Additional validation work

• OHA will study the claims of particular interest to DCBS
• The primary objective will be to identify payer-specific algorithms to

de-duplicate and further clean the claims data

• OHA may seek feedback from individual payers regarding their own

claims data

• OHA will recommend claims data cleaning and de-duplication

algorithms for implementation by DCBS

(Enter) DEPARTMENT (ALL CAPS) (Enter) Division or Office (Mixed Case)

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APAC Functions

Statute establishes the purpose and framework for APAC

ORS 442.464, 442.466, and 442.993 define the purposes of APAC, and direct OHA to:

• Establish data submission standards
• Define limited data sets and make them accessible
• Make information available to insurers, employers,

providers, health care purchasers, and state agencies for review of utilization, spending, and performance

• Comply with state and federal privacy and security

laws, and protect trade secrets of reporting entities

• Establish civil penalties for failure to report as

required

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OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division

Increase Transparency

APAC is OHA’s most comprehensive database on health care costs and utilization in Oregon.

• APAC collects charged amount AND paid amount
• Understanding the amounts paid for health care

services provides a more accurate and useful understanding of health care prices and spending.

• Oregon was ranked 4th in the nation for its

performance in health care price due to APAC and the Hospital Payment Report

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Support Health Policy Efforts

APAC helps state agencies, policymakers, and other stakeholders evaluate the impact of existing policies and identify the need for new innovations.

• APAC is used to establish performance indicators

and measures progress of the Triple Aim— improved health, increased quality of care, and lowered health costs.

• APAC will be instrumental as OHA tackles rising

pharmaceutical costs—one of Director Saxton’s top 10 goals.

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Answer Complex Questions

APAC offers answers to a myriad of questions about health care spending, quality, and utilization.

• What are the most prevalent disease or

conditions among insured Oregonians? Is prevalence higher in certain areas of the state?

• What are the most common health care services

among insured Oregonians? Does this vary by age or types of health care coverage?

• What are the most commonly filled prescription

drugs?

• How does health care utilization vary among age

groups or other demographics?

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The End

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OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division