healthcare financial management association...• the hdi’s strategic direction is advised by the...
TRANSCRIPT
4/9/2016
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ADMINISTERED BY
Healthcare Financial Management Association
The Arkansas Healthcare Transparency
Initiative and the Arkansas All-Payer
Claims Database (APCD)
Kenley MoneyApril 14, 2016
ADMINISTERED BY
• The Arkansas Center for Health Improvement (ACHI)
• Arkansas Health Data Initiative
• Why Healthcare Transparency?
• What is an All-Payer Claims Database?
• Partnership with the Arkansas Insurance Department
• The Arkansas Healthcare Transparency Initiative: Act 1233 of 2015
• Arkansas All-Payer Claims Database Solution
• APCD Website
• APCD Reporting Strategy
• Sustainability
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Agenda
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ADMINISTERED BY
Arkansas Center for Health Improvement (ACHI)
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ADMINISTERED BY4
About ACHI
• The Arkansas Center for Health Improvement
(ACHI) is a nonpartisan, independent health
policy center dedicated to improving the health
of Arkansans
• Established in 1998, creating a much needed
intersection between research and policy
• ACHI has proven experience in the management
and integration of health data to support
research and health policy
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ADMINISTERED BY
Mission Statement
To be a catalyst for improving the health of Arkansans through
evidence-based research, public issue advocacy, and
collaborative program development.
Vision Statement
To be a trusted health policy leader committed to innovations that
improve the health of Arkansans.
Core Values
Trust, Innovation, Initiative, Commitment
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ACHI’s Mission, Vision & Values
ADMINISTERED BY
ACHI Major Accomplishments
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Year Accomplishment
2000 Tobacco Settlement Proceeds Act
2003 Act 1035 of 2003 – Arkansas Health Data Initiative
2006 ARHealth Networks established
2006 Act 8 of 2006 - Clean Indoor Air Act
2009 Act 180 of 2009 - Tobacco Excise Tax
2009 Act 394 of 2009 - Graduated Driver License regulations
2009 Act 308 of 2009 - Primary Seat Belt Law
2010 Establishment of the Office of Health Information Technology
(OHIT) and State Health Alliance Records Exchange (SHARE)
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ACHI Major Accomplishmentscontinued
Year Accomplishment
2011 Act 197 Of 2011 – Fluoridated Drinking Water
2011 – Present Multi-Payer Arkansas Healthcare Payment Improvement
Initiative (ACHPII)
2012 Arkansas Workforce Strategic Plan
2013 – present State Innovation Model – Population Health
2013 – present Arkansas Health Care Independence Program and Health
Insurance Marketplace
2015 Act 1233 of 2015 – Arkansas Healthcare Transparency
Initiative
ADMINISTERED BY
Arkansas Health Data Initiative
• ACHI established the Health Data Initiative (HDI)
with Act 1035 of 2003
• The HDI provides health data and an analytic
platform for health policy research
• Act 1035:
• Gives authority to ACHI to access personally identifiable
information collected by state agencies with state agency
permission
• Enabled the development and maintenance of a robust,
scalable analytic data warehouse for health policy research
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• The HDI’s strategic direction is advised by the
Health Data Initiative Advisory Committee made
up of one representative from each contributing
agency
• The HDI maintains Institutional Review Board (IRB)
approval to ensure appropriate use of personally
identifiable information
• External researchers from agency and academic
institutions across Arkansas and other states utilize
the HDI
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Arkansas Health Data Initiative
ADMINISTERED BY
Why Healthcare Transparency?
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ADMINISTERED BY
• Newly insured patients gaining coverage through
state and local marketplaces mandated by the ACA
are also expected to take on high deductibles
• With increased exposure to healthcare costs,
patients have an urgent need for meaningful and
transparent price information
• Patients are being asked to act as consumers in a
marketplace in which price is largely unknown
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Why Healthcare Cost Transparency?
SOURCE: Healthcare Financial Management Association, Price Transparency in Health Care – Report from the
HFMA Price Transparency Task Force, 2014, p. 4.
ADMINISTERED BY
• Price transparency also benefits employers who
need to identify high-value providers for employer-
sponsored health plans
• Emerging payment models ask healthcare
providers to take on risk for managing the total
cost of care for a patient population. These
providers need reliable price information from
other providers when making referral decisions to
manage total cost of care
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Why Healthcare Cost Transparency?
SOURCE: Healthcare Financial Management Association, Price Transparency in Health Care – Report from the
HFMA Price Transparency Task Force, 2014, p. 4.
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ADMINISTERED BY
Why Healthcare Cost Transparency?
ADMINISTERED BY
What is an All-Payer Claims Database (APCD)?
• An APCD is a large-scale database that
systematically collects healthcare data from a
variety of sources
• Data collected typically include medical, pharmacy,
and dental claims with eligibility and provider files
• Some APCDs link with existing data including
hospital discharge, immunization, and clinical
information
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ADMINISTERED BY
Benefits of an APCD
• Helps consumers make informed decisions about
their health care by providing healthcare price and
quality information
• Supports research and quality improvement
activities
• Allows for peer-to-peer comparison
• Helps target and assess population health
initiatives
• Provides more robust data for healthcare
transformation efforts and evaluation
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ADMINISTERED BY
How Can Data Be Used?
• Provide information about utilization, quality, and
pricing to evaluation of health programs
• Monitor the success and efficiency of efforts to
enhance access, reduce costs, and improve quality
and population health
• Integrate and provide information for research
• Study of the evolving landscape of the state's health
and healthcare system
• Support efforts to design targeted quality-
improvement initiatives and to compare performance
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ADMINISTERED BY
APCDs in Other States
• 15 states with active APCDs; several others in
implementation
• Variation in APCDs
– Requirements for submission of data
– Variables collected
– Functionality and ability to use data
– Governance
– Sustainability models
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ADMINISTERED BY
Source: http://www.apcdcouncil.org/state/map
State Progress Map
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ADMINISTERED BY
Colorado
Source: https://www.comedprice.org/#/map
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ADMINISTERED BY
Source:
https://www.apcdcouncil.org/state/massachusetts
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ADMINISTERED BY
Source: http://myhealthwi.org/HealthReport.aspx?p=FAMILY&l=54601&d=30%20miles&c=
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APCD Showcase
Source: https://www.apcdshowcase.org/
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ADMINISTERED BY
Rhode Island
Source: https://www.apcdshowcase.org/
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Potentially
Preventable
Emergency
Room Visits
ADMINISTERED BY
• In 2012, ACHI developed a voluntary APCD
prototype based on the HDI data warehouse
• The prototype was called the All-Payer Claims
Database Plus (APCD+) for Health System Change
• The ‘+’ represented alignment with Arkansas
Health Department (ADH) vital statistics data
• Focus was health policy research with expanded
emphasis on health system change for cost
reduction and delivery improvement
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ACHI’s Early Vision –The APCD+
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ADMINISTERED BY
Arkansas Insurance Department Transparency Funding
• In 2013, the Arkansas Insurance Department
(AID) Health Insurance Rate Review Division
(HIRRD) received Cycle III and Cycle IV grant
funding from the Center for Consumer
Information and Insurance Oversight (CCIIO).
• This funding is to “Support Health Insurance Rate
Review and Increase Transparency in Health Care
Pricing”
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ADMINISTERED BY
• AID HIRRD opened a competitive bid process to fulfill
Cycle III requirements
– Awarded $1.7 million over 18 months to establish a voluntary
APCD
– RFP awarded to ACHI in March 2014
– Contract authorized June 2014
• ACHI contracted with AID HIRRD for Cycle IV funding
from CCIIO
– $1.05 million over 18 months for additional APCD
development
– Contract authorized June 2015
Partnership with Arkansas Insurance Department
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ACHI’s Voluntary Data Solution
• Outside vendor not selected
– Data security concerns
– Restrictions in data use agreements for PII
outside ACHI
• In-house solution utilizes
– Existing infrastructure and processes
– ACHI Generic Match Engine for data
integration
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ADMINISTERED BY
ACHI’s Voluntary Data Solution
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APCD Data Landing
Zone
APCD
Air-Gapped Zone
APCD Data Analyses
Zone
Data Warehouse
-Health system analyses
using de-identified data
-Medical reimbursement
transparency reporting
APCD Website
Researchers
Providers
APCD Secure Processing Zones
Da
ta r
ele
ase
of
de
-id
en
tifi
ed
da
ta o
nly
APCD Data
Submission
Secure Data
Center
-No external connectivity
-Data decryption dual
authentication
-Data de-identification
-APCD ID assignment
Encrypt Data
for APCD
Encrypted Data
Receipt
- Authorized access
only
- No decrypted data
UAMS Information Secure Infrastructure
Secu
re D
ata
Tra
nsf
er
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ADMINISTERED BY
Voluntary Data Solution Challenges• Carrier Concerns
– Data security
– HIPAA compliance
– Published reimbursement rates
– Explicit contractual restrictions on the release of provider
information
– Lack of ownership of self-funded employer data
– Lack of ownership of self-funded employer data
• Provider Concerns
– Published quality measures
– Published reimbursement rates29
ADMINISTERED BY
The Arkansas Healthcare Transparency Initiative:
Act 1233 of 2015
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APCD Mandatory Data Submission
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ADMINISTERED BY
What does Act 1233 of 2015 do?
• Creates the Arkansas Healthcare Transparency Initiative
inclusive of the APCD and governance
• Establishes a mandate for certain entities to submit
claims information
• Provides authority for AID to develop rules for data
collection and use requirements, including penalties
• Ensures data protection—Freedom of Information Act,
trade secrets, re-identification
• Establishes fund for operations and makes data
availability contingent on available funds
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ADMINISTERED BY
Purpose of the Initiative
VISION
Empower Arkansans to drive, deliver, and
seek out value in the health system
MISSION
Serve as a trusted and timely source of
dynamic information to guide meaningful
action to improve health, enhance quality,
and lower cost
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ADMINISTERED BY
Objectives of the Initiative
• Support efforts to improve healthcare quality
• Support the development of cost-containment
strategies
• Provide information about healthcare spending and
utilization
• Inform consumers, health insurance carriers,
policymakers, and providers in healthcare decision-
making
• Serve as a public good
• Support research
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ADMINISTERED BY
What Will Be Submitted?
Submitting entities must provide the following data categories unless granted an exemption:
• Enrollment data
– Unique identifiers (no personal identifiers)
– Demographic and geographic information
• Medical claims
• Pharmacy claims
• Dental claims
• Provider data
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Who Will Submit Data?
• Issuers of health and dental plans in Arkansas (2,000
covered individuals as threshold)
• Medicaid/Medicare
• State/public school employee benefit plans
• Arkansas Workers’ Compensation Commission
• Third-party administrators and pharmacy benefit managers
(same threshold as issuers)
• Entities providing medical services under contract with
state prison system
• Self-funded plans as allowed by federal law*
*Pending Gobeille v. Liberty Mutual Insurance, 746 F. 3d 497 (2d Cir. 2014), petition
for cert. granted, (No. 14-181). Update March 2016: this did not pass
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Governance Structure
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Roles and Responsibilities
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• Arkansas Insurance Department– Rulemaking, submission compliance, policy
establishment
• Arkansas Center for Health Improvement– Database administrator
• Healthcare Transparency Initiative Board– Policy recommendation, data request review/approval
– Data Oversight Subcommittee
• Data request recommendations
– Scientific Advisory Subcommittee
• Peer review for academic researchers
ADMINISTERED BY
Arkansas Healthcare Transparency Initiative Board
• Arkansas Department of Human Services
• Arkansas Department of Health
• Office of Health Information Technology
• Arkansas Surgeon General
• Governor-appointed members:– 2 from health insurance industry (domestic and multi-state)
– 2 from healthcare provider community
– 1 self-insured employer
– 1 small employer with coverage through fully-insured product
– 1 healthcare consumer organization
– 1 from academic research community
– 1 with expertise in health data privacy and security
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ADMINISTERED BY
Arkansas Insurance Department Rule 100
• Further defines covered individual thresholds
submitting entities
• Describes test data and historical files
• Provides exemption process for submitting
entities
• References the Data Submission Guide (DSG)
for technical specifications
• Provides phased data submission timeline
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ADMINISTERED BY
Submission Timeline
• Test files were to be submitted no later than
January 1, 2016
• Historical data and quarterly submission will
based on a phased data submission schedule
– Submitting entities are divided into four groups
– First historical data submission will be received by
3/31/2016 and the last on 12/31/2016
– First quarterly submission will be on 3/31/2017 for all
groups
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Submitting Entity Exemption
• A submitting entity may submit an exemption
request to the AID Commissioner requesting
an extension, variation, or waiver of a Rule
requirement
• A submitting entity may submit an exception
request to the APCD Administrator requesting
changes to the data requirements
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ADMINISTERED BY
Arkansas All-Payer Claims Database Solution
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Arkansas APCD Solution• APCD solution components redefined by Act 1233
of 2015
• Several APCD solution components were
redesigned and rebuilt
– Updated APCD Data Submission Guide
– Use of “unique identifiers” in lieu of personally
identifiable data, including name, address, and Social
Security number
– Quarterly data submission schedule based on number
of covered lives
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ADMINISTERED BY
APCD Mandatory Data Solution
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APCD Data Landing
Zone
APCD
Staging Zone
APCD Data Analyses
Zone
Data Warehouse
-Health system analyses
using de-identified data
-Medical reimbursement
transparency reporting
APCD Website
Researchers
Providers
APCD Secure Processing Zones
Da
ta r
ele
ase
of
de
-id
en
tifi
ed
da
ta o
nly
APCD Data
SubmissionData Load and
Validation
-Data decryption dual
authentication
-Data transformation
- Data quality reporting
-Unique ID hashing
Encrypt Data
for APCD
Encrypted Data
Receipt
- Authorized access
only
- No decrypted data
UAMS Information Secure Infrastructure
Secu
re D
ata
Tra
nsf
er
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ADMINISTERED BY
Arkansas APCD Development
Data
Validation
Reports
Data
Transformation
Data Validation
Data Load
Arkansas APCD
Data Submission
Automated dynamic data validation of
submitted files to verify conformity to
DSG. Automated data quality report
generation for submitting entities
Automated decryption and file transfer
process to move data into APCD database
structure
Automated data intake process
utilizing secure file transfer protocols
(SFTP) onto secure data landing zone
Automated dynamic data transformation
process to build data relationships,
aggregate costs, and build final database
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APCD
WebsiteAPCD data is aggregated for reporting
and analyses for the APCD website
DSK2
ADMINISTERED BY
APCD Websitehttps://www.arkansasapcd.net/Home/
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Slide 45
DSK2 Reformatted slide; removed underlying layer from the arrows on the left.Dodson, Sheila K, 3/30/2016
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ADMINISTERED BY
• Medical Services Pricing Tool
– A dynamic web tool that allows the user to select from a list
of medical services to find average price per service per
Arkansas Insurance Marketplace region
– Medicaid, Medicare, and private carrier claims are examined
to define the thresholds and triggers of selected medical
services events, inclusions and exclusions developed using an
interquartile range (25% to 75%) to best represent the true
price
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APCD Website Consumer Tools
ADMINISTERED BY
APCD Reporting Strategy• In 2016 and forward, ACHI will provide consumer-
facing population health analytic reports focused on
state issues to demonstrate value and build interest
from consumers, agencies, and researchers
• Selected reports are identified based on stakeholder
input
• Selected reports have been prioritized based on a
scoring system, assessing each by value to
consumers, businesses, legislators, carriers, and
providers
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Potential APCD Reports
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Report NameConsumer
Interest
Legislative
Interest
Agency
Interest
Business
Interest
Provider
Interest
Potential
for Future Risks Score
Long Term Care 2 2 2 0 1 2 -1 8
End of Life Care Report (Legislature) 3 1 2 0 2 3 -2 9
Geographic Procedure Based Screening Rates Report 0 2 3 1 2 2 0 10
Report to Inform Red County Report (ADH) 0 2 3 0 1 2 0 8
Traumatic Injury Report (State Police) 0 1 3 1 1 1 0 7
Report to Inform Community Needs Assessment 0 0 1 0 3 3 0 7
PCMH Report - cost and quality by episode 0 1 2 2 3 2 -3 7
Provider Network Participation Report 2 1 2 2 3 2 -2 10
Hospital Acquired Conditions Report 2 1 2 2 2 1 -2 8
Infection Rates Report 2 1 2 1 2 1 -1 8
Readmission Rates Report 1 1 2 2 2 2 -1 9
C-section Rates Report 2 1 1 1 2 1 0 8
Procedure Count by Surgeon Report 2 1 1 2 2 2 -2 8
Report to Inform Hospital Classification for Neo-Natal Care 0 2 2 2 1 1 -1 7
ADHD Diagnosis Rates Report (ADE) 0 1 1 0 0 0 0 2
Recidivism Report (DOC) 0 2 2 0 0 1 -2 3
Opioid Use Reports (ADH) 1 3 2 2 2 2 -1 11
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• Cost and Utilization Report
– Provides a broad look at health care spending among
Arkansans utilizing Arkansas Medicaid between January 2012
and December 2013. This report shows the amount paid Per
Member Per Year (PMPY) for three specific facility types—
inpatient, outpatient, and emergency department services
• Risk-Adjusted Population Health Reports
– Shows a risk-adjusted estimated value for the total paid
dollars PMPY for inpatient, outpatient, and emergency
department services for Arkansas and for specific geographic
regions within the state
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2016 APCD Reporting
DSK9
Slide 50
DSK9 Izzy, please check for consistency of context with "health care" versus "healthcare". I remember you talking about the way it appears in different mediums. Thanks.Dodson, Sheila K, 3/30/2016
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ADMINISTERED BY
• Medicare Bilateral Cataract Episode Report
– Provides an overview of provider-level cost variability
associated with the Arkansas Medicare population who
underwent bilateral cataract removal procedures during
calendar year (CY) 2013
• Arkansas Medicare Hemoglobin HbA1c Utilization
Report
– Examines CY 2013 county rates of type II diabetes among
Arkansas Medicare beneficiaries aged 65 years and over and
rates of annual hemoglobin A1c (HbA1c) testing as a measure
of diabetes control. The association between the prevalence
of type II diabetes and HbA1c testing across counties is also
examined.
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2016 APCD Reporting
ADMINISTERED BY
• Chronic Conditions Rate Maps
– Includes maps and key findings illustrating the impact of
chronic conditions in Arkansas. Chronic conditions for focus
include asthma, COPD, Hypertension, Ischemic heart disease,
lung cancer, and stroke (this map fulfills the Geographic
Procedure Based Screening Rates Report identified on the APCD
Reporting Strategy table)
• Statewide Diabetes Rates, Complications, Costs Analyses
– Expands on the Arkansas Medicare Hemoglobin HbA1c
Utilization report to include analyses of costs related to
complications and rates by county and statewide (this report is
positioned to be the first component of a long-term care
reporting project focusing on stroke)
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2016 APCD Reporting
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APCD Showcase
Source: https://www.apcdshowcase.org/
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ADMINISTERED BY
Healthcare Transparency Website
• AID engaged Public Consulting Group (PCG) to
develop a consumer-facing website focusing on
healthcare transparency initiatives in Arkansas
• It will link to the Arkansas APCD website to access
APCD reporting and the medical service pricing tool
• It will provide consumers with unbiased, easy to
understand information to assist in healthcare
decision making
• The new Healthcare Transparency website will be the
cornerstone of the APCD public launch scheduled for
late summer 2016
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APCD Sustainability
• The Arkansas APCD has been developed using
monies awarded through Cycle III and Cycle IV grants
• ACHI is working with AID and the Initiative Board to
further identify, refine, and prioritize sustainability
strategies in order to develop and implement a
sustainability plan required by Act 1233 of 2015
• Using information collected from other state
strategies and work with Arkansas stakeholders, the
several potential sustainability strategies are being
vetted
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ADMINISTERED BY
APCD Sustainability Strategies
• Analytics and Reporting
– The APCD will provide population health reporting focused
on state issues to demonstrate value
• Data Purchase
– The APCD may charge a fee for access and use of datasets;
additional fees may be applied to cover costs of developing
customized reports
• Governmental Sources
– Federal, state, and local funds are available to support
APCDs
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APCD Sustainability Strategies
• Shared Resources with Other Entities
– APCDs may work with state agencies or other partners to
develop a mutual solution to data needs
• Assessments on Premiums
– Health insurers pay a tax on premiums to support various
operations and, in some states, a portion of these funds
are dedicated to the APCD
• Research Grants
– APCDs have been used to generate and promote new
scientific evidence, particularly for population health,
patient safety, disparities, and chronic disease
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ADMINISTERED BY
APCD Sustainability Strategies
• Membership or Subscription Fees
– Access to data is given to members or subscribers for
research and analyses
– Groups that typically apply for this access include payers,
providers, academic researchers, and healthcare
organizations
• Penalties
– Regulatory agencies may impose penalties for data
submitter non-compliance
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Q&A
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