A Payer’s View of All-Payer Claims Data Requests

All-Payer Claims Database Conference October 14, 2009

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Proposed general principles

Use a consistent set of data elements

Collect data from the source most likely to have it as part of the normal course of business

Weigh the value of the data element collected against the cost involved in payer collection and provision of the data

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Proposed general principles

Include all stakeholders in the development of data collection standards and procedures

Establish a standard schedule for data requirement additions/changes

Implement strong privacy and security safeguards to protect against inappropriate disclosure and use of data

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Consistent set of data elements

Reduces carrier time/resources needed to begin data submission

Speeds implementation for new states, which benefit from the work done by others

Saves carrier resources/money; possibility of running multiple states at one time

Supports accuracy of data, since issues that are identified and resolved benefit all states

Encourages carriers to refine and improve data – focus is on one data set rather than 10

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Data needed for normal course of business

Is it needed to: pay a claim? enroll a member/subscriber? bill a member/subscriber?

If so, a Payer should have this data.

If not, another entity may be a better resource for the data.

In some cases, Payers may be interested in serving as an intermediary for another entity because the data is of interest to the Payer. A dialogue among the parties will help identify these opportunities.

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Cost/benefit assessment of data elements

CostsCosts Payer systems collect and store data needed to support core business needs;

not all data on claim forms may be stored/reportable Adding data elements to systems can be costly – $1 million or more Storage costs for data elements not needed for core business can be

substantial (183 million claims processed ytd)

Benefits Measurable improvement in quality of care for state residents Greater transparency in health care Overall cost savings in the health care system

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Stakeholder dialogue

Current efforts by RAPHIC, NAHDO, University of New Hampshire, AHRQ and others are critical

Do we need others at the table – what other entities collect needed data in the normal course of business?

Engage states considering or just beginning their data collection efforts so they benefit from what is already in place and are part of the development of the future state

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Why follow a standard schedule for changes/additions?

Payers must plan for changes well in advance

Payer system release procedures control which system changes are funded and resourced and when changes go into the system

Release schedules begin to fill up by June of the prior year – Aetna’s 2010 schedule was largely filled by August 2009

Aggregate funding/resources for 2010 releases were assigned by August 2009

System changes may be frozen during open enrollment periods

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Proposed schedule for changes and additions

Schedule allows payers to put a placeholder in each year’s release schedule, and reserve the resources and funding needed for the changes to assure timely implementation.

April/May - Stakeholder discussion on possible additions/changes June 1st - Formally propose additions/changes for next calendar year July 1st – Communicate required changes January 1st - Changes effective (for claims processed on or after 1/1)

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Privacy and security

Residents rely on state government to protect their personal information

Members rely on payers to handle Protected Health Information as required by state and federal law

Moving vast quantities of data and aggregating data that still may identify individuals is high risk

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Other considerations

Penalties for payer non-compliance Automation of submission process Anti-trust concerns Impact of incomplete provider-submitted claims Vendor-owned systems Quality check transparency Accuracy and completeness of historical data Impact of claim volume for states Inclusion/exclusion of lines of business, such as limited benefit plans,

student plans