By Tom DeGemmis, Vice President - Commercial Healthcare and Alan Ashurst, Healthcare Product Manager
In an earlier post on this blog, Bringing Healthcare Systems Together via a Holistic Approach, it was stated that the healthcare industry is going through a sea change. While that characterization may seem overused, the fact is that the change is, indeed, dramatic. And a myriad of existing and new mandates ensure this “change” is in constant motion, making it difficult for even the most experienced healthcare professional to stay up-to-date.
While All-Payer Claims Databases (APCDs) are not a new concept, they are emerging as important to support healthcare transparency (with respect to pricing, quality and utilization), healthcare reform initiatives and databases created by state mandates. They include data (both private and public payers) from:
- Medical claims
- Pharmacy claims
- Eligibility files
- Provider files
- Dental claims
For example, APCDs typically include data on diagnoses, procedures, care locations, providers and provider payments. They offer both baseline and trend data, with the objective of improving healthcare information transparency that is critical to so many healthcare reform initiatives.
What Stakeholders Might Benefit From APCDs?
- Consumers – APCDs provide access to information, helping consumers and their health care providers make informed decisions about the cost, quality of care and effectiveness of treatments.
- Businesses – APCDs help businesses know where they stand when compared with their peers in regards to the cost and covered services of their health insurance policies. APCDs also allow businesses to choose insurance products for employees based on price and quality.
- Providers – APCDs support provider efforts to design targeted quality improvement initiatives and enable them to compare their own performance with those of their peers.
- Health Plans – APCDs help identify utilization patterns and rates thus assisting with benefit design and planning.
- Policymakers – APCDs help health care policymakers identify communities that provide cost-effective care and learn from their successes –best practices. They also allow for targeted population health initiatives and for assessment of healthcare disparities and target interventions with the objectives of improving health status outcomes.
To date, 12 states have passed APCD legislation and 8 more have APCDs in flight. And while they have proven to be valuable in states where they are being used, developing and implementing APCDs is far from straightforward. There are technical and political challenges, and success depends on engaging internal stakeholders and ensuring appropriate governance structures are in place.
What has your experience with APCDs been? Are you developing an APCD? If so, what challenges are you facing? What tools are you using to ensure success? If you have developed and implemented an APCD what advice would you give about the process (what are the pitfalls and snags to be aware of)?
To learn more about APCD check out the APCD Council web site.
If you’d like to learn more about how HP can help you create your state-wide APCD, check out the resources below. HP has a tremendous amount of experience integrating medical, dental and vision health benefits information: