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In the United States it is well established that prices for the same healthcare service can differ significantly across providers—even within the same geographic area. Yet, it is almost impossible for consumers and policymakers to get reliable information about this pricing landscape. The opaque nature of healthcare spending flows undermine our ability to address costs that are too high, unwarranted variation in costs and uneven quality.
All-Payer Claims Databases (APCDs) are a strategy to combat this issue. APCDs include claims data from private insurance companies, state employee health benefit programs, and, in some cases, Medicare and Medicaid. APCDs provide a wide range of payment, utilization, and disease pattern information—depending on how they are set up. When states create their APCDs through legislative mandate, they decide what type of information the database should contain. Not all states choose to include the same data in their APCDs, which leads to variation between APCDs across states.
Have access to this data is foundational for many of the other healthcare value strategies that a state may want to employ. When correctly structured, APCDs can:
Provide total care costs, prices, use and quality and results of care for different providers, treatments and populations.
Provide comprehensive data on spending flows that can help to identify and eliminate waste in the healthcare system.
Identify high value providers so that consumers can be steered to them and their provider colleagues can strive to emulate them.
A consumer friendly website or portal allows consumers to compare price information for specific procedures across providers.
Enable policymakers to evaluate the effects of state reforms.
Provide general health status and disease burden of the state's population, both in terms of health equity and improving the general health of the state’s residents.
There are many variations in the governance and rules surrounding state APCDs. Consumer advocates should carefully examine the evidence around the governance alternative, voluntary vs mandatory reporting, and other issues.
On March 1, 2016, in a 6-2 decision, the U.S. Supreme Court ruled that Vermont cannot force self-insured health plans to submit medical claims data to the state’s all-payer claims dataset. The Supreme Court cited the U.S. Employee Retirement Security Act (ERISA) law preempted any state laws related to employee benefits plans—an affirmation of an earlier ruling by the Second Circuit Court of Appeals. (see here for ProPublica article on decision)
Self-funded plans cover 93 million workers, somewhat more than half of all privately insured people. If these data are excluded, all-payer claims database (APCD) data will be far less representative and complete. The Health Care Cost Institute’s study comparing the APCD data submitted by ERISA (self-funded insurance plan) and non-ERISA (fully insured status) populations found that although overall average prices were similar, the differences in plan type distributions suggested utilization differences.
Key for advocates and those that use APCD data: the court’s majority opinion states “the Secretary of Labor, not the States, is authorized to administer the reporting requirements of plans governed by ERISA. He may exempt plans from ERISA reporting requirements altogether…and, he may be authorized to require ERISA plans to report data similar to that which Vermont seeks, though that question is not presented here. Either way, the uniform rule design of ERISA makes it clear that these decisions are for federal authorities, not the separate states.”
This provides a potential pathway for continued inclusion of self-funded claims data in APCDs.
Healthcare Value Hub, All-Payer Claims Databases: Unlocking Data to Improve Healthcare Value, Research Brief No. 8 (September 2015).
The APCD Showcase, APCD Council.
Patrick B. Miller, Denise Love, Emily Sullivan, Jo Porter, and Amy Costello, All-Payer Claims Databases: An Overview for Policymakers, State Coverage Initiative, AcademyHealth (May 2010).