Are APCDs just what the doctor ordered?


With all the changes the Affordable Care Act brings, including new care and payment models, there is an increase in provider’s need for data.  While some large health systems are able to learn much about a patient’s full course of treatment by integrating their systems, the majority of health care is provided by smaller, less integrated systems. Regardless of size, all systems can benefit from a state claims database, commonly referred to as All-Payer Claims Databases (APCDs), which are now available in 11 states.

Take for example something as straight forward as a knee replacement. It requires many visits and can vary in treatment.  The full course of treatment could include: patient’s primary care visit with the referral to the surgeon, knee surgeon visit, tests to determine a replacement is needed, pre-op testing, surgery, follow up doctor’s visits, prescriptions, post physical therapy, applicable readmissions, and so on.

What about someone who has a chronic condition like diabetes that spans over time? How complex could this be to track if many of these facilities and providers aren’t linked?

The state of New Hampshire is giving physicians, providers and other parties the full view of a patient’s path with their Accountable Care Project, a program out of the NH Citizens Health Initiative. Previously, they sent out a 700-page PDF that had to be searched manually. Now, the Initiative provides participating organizations web-based interactive reporting and ad hoc search capabilities to access the information they need from the state’s APCD and other sources. Providers glean insights into patient care, outcomes and costs that were not possible before. From the UNH website:

Sharon Beaty, the CEO of Mid-State Health Center in Bristol and Plymouth, says the Accountable Care Project gives her organization a much broader perspective on the quality of care it is providing. Because the data includes all claims for patients (even if they received some of their care elsewhere), she can examine trends in use that she would not have been able to see otherwise. For instance, she can look at the percentage of diabetics who received retinal exams—a measure of whether they are receiving proper care. Or she can determine if patients are following up on their providers’ recommendations to get mammograms.

She can also compare the average monthly costs of caring for similar groups of patients at her facility versus elsewhere in the state. “Before we couldn’t tell what value we were providing the system because we had no data to gauge it from,” she says. “Now we do.”

Many of these data bases contain health insurance claims information from both public and private insurers.  Because it is claims information, providers would be able to see all the visits a patient had for their knee replacement or their diabetes care, whether or not they were seen by a facility or a physician in their organization.

Over my 25 years in health care, I have heard many health systems, hospitals, and physicians affirm the potential value of claims data.  Not only does this information provide a more complete view of a care path, but its impact would increase exponentially if states offered web based reporting with query capabilities to the providers. Having the state create the infrastructure, improve the data and develop reporting capabilities once versus each provider network creating its own would save substantial health care dollars.  In addition, this model would offer the capabilities to many small organizations who would never be able to do it on their own.

Hopefully great examples like NH’s Accountable Care Project will spread throughout the states showing the real value these data bases can bring.  What is your state doing, if anything, to improve care and reduce costs by integrating claims data?


About Author

Cindy Berry

Health Care Strategist

With more than 28 years experience with health care and health reform, Cindy is an authority on the implications of the Affordable Care Act, including new care and payment models, improving population health and managing Medicaid. As a member of the SAS State & Local Government practice, Cindy works with the public sector to help them understand how analytics can help them wade the tumultuous health reform waters. Cindy was a member of SAS’ Center for Health Care Analytics and Insights, leading the initial development of SAS’ Episode Analytics. She currently serves on the North Carolina Center for Hospital Quality and Patient Safety Board of Trustees.

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