States might find it useful to have a database replete with health care service claims data to identify Medicaid fraud, evaluate disease trends, establish cost and utilization rates, and share price information with consumers. Typically such comprehensive data is difficult to gather because it comes from various public and private sector sources. A recent white paper from Milliman gives a few tips to states that want to establish a central data repository, called an all-payor claims database (APCD), to gather claims information from commercial insurers and providers, and government health insurance plans, such as Medicaid, Medicare, and TRICARE.

Nine states currently have APCDs, and more will do so, the Milliman paper predicts, because they offer an effective way to collect and share comprehensive data about health care usage.

The white paper describes best practices for overcoming the technical and operational difficulties of establishing all-payor claims databases:

  • Must have a sophisticated system for data submission and registration, to ensure integrity and accuracy of the data.
  • Plan for multiple terabytes of storage space and significant processing power.
  • Link the new database to health insurance exchanges, part of the Affordable Care Act (ACA) health reform law, and to existing databases for hospital administrative statistics and vital statistics.
  • Enter into a formal agreement with the Centers for Medicare and Medicaid Services (CMS) for access to their program data.
  • Collect member demographics, provider demographics, clinical, financial, and utilization data.

Non-state entities such as nonprofit corporations, in addition to states, have established all-payor claims databases, but they typically are less successful for a variety of reasons: Nonprofits cannot compel private organizations to submit data. States, in passing legislation to establish the databases, can require commercial payors to submit claims. In addition, CMS has been reluctant to give non-state entities access to Medicare and Medicaid data.

With a comprehensive resource for health care data, payors and providers could create well-informed incentive programs to raise quality and lower cost. Consumers also could access the data to make informed health choices. For more information, visit the All-Payor Claims Database Council website, which has a variety of resources.

The APCD Council is convened and coordinated by the New Hampshire Institute for Health Policy and Practice (NHIHPP) at the University of New Hampshire (UNH) and the National Association of Health Data Organizations (NAHDO).

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Kip Piper is a Medicaid, Medicare, and health reform consultant, speaker, and author.  For more, visit KipPiper.com.  Follow on Twitter at @KipPiper and connect with Kip on LinkedIn.