May 2011 State Data Spotlight: Maine’s Health Care Claims Database All-payer claims databases are emerging as a vital source of information for states implementing health reforms. Thirteen states currently operate all- payer claims databases (APCDs) and collect data on health care utilization and costs that can be used to inform consumers, researchers, policymakers and health industry stakeholders. These APCDs exist in various forms with different functionalities, but the state of Maine has been a useful example for states looking to create their own claims databases. Maine currently maintains the most comprehensive APCD, administered by the Maine Health Data Processing Center (DPC). The Health Care Claims Database is the result of the DPC’s collaborative partnership between the Maine Health Data Organization (MHDO), the state agency authorized to collect data, and Onpoint Health Data, a non-profit responsible for data integrity and quality. The types of data typically collected in all-payer claims databases are listed below. The DPC collects and disseminates claims data from 53 commercial private payers, 45 third-party All-Payer Claims Database Data Elements administrators (TPAs), the Centers for Medicaid and Medicare Services  Patient identifier (typically encrypted Social (CMS) and the Maine Office of Security Number)  Type of insurance product (HMO, POS, etc.) MaineCare Services (Medicaid),  Type of contract (single, family) representing one of the only states  Patient demographics (age, gender, residence) to have combined public and  Diagnosis codes private claims information in one  Procedure codes (ICD, CPT) database. Also unique to Maine is its  Revenue codes collection of Medicare data.  Services dates Currently, Maine is the only state  Service provider receiving Part A and B Medicare  Prescribing physician health care claims from CMS and  Payment details (member co-pay, date paid) integrating those data with  Type of bill Medicaid and commercial claims.  Facility type Medicare Part C and D claims data Source: NAHDO RAPHIC, 2009 are collected through the commercial carriers. Maine estimates that health care claims information for 95% of residents with some type of health coverage are included in their database, excluding only certain self-insured plans, the uninsured, and 1 people covered under TRICARE, the Federal Employees Health Benefits Program (FEHBP) and Veterans Affairs. Health care services provided to the uninsured are difficult to track in this type of database, since there is no insurance claim generated. Maine is the only state that has attempted to gather this data in the form of “pseudo-claims.” The Health Care Claims Database contains “pseudo-claims” for the uninsured who utilize services at MaineHealth, an integrated health system representing various hospitals and medical centers in southern Maine. To track uncompensated care and the utilization of health services by the uninsured, MaineHealth distributes identification cards to uninsured patients. When patients use services, MaineHealth submits “pseudo-claims” (or charges for services where no payments are made) to the database as if they were from insured patients. Collecting health care utilization and cost information for the uninsured population holds many challenges, but Maine’s acquisition of “pseudo-claims” provides a mechanism that could be used to fill this gap in all-payer claims databases. Legislative History The development of APCDs is typically facilitated through legislative action. In Maine, legislation was passed in 1996 establishing the Maine Health Data Organization (MHDO) as an independent agency that would collect hospital data. In 2001, the statutes were amended to include the collection of data from insurance carriers and TPAs and to establish the DPC . Maine’s success in collecting comprehensive data is largely the result of the MHDO’s ability as a designated public health authority to require submission of the data, including from TPAs and Pharmacy Benefit Managers (PBMs) for self-insured plans. In 2004 a federal judge ruled that the Employee Retirement Income Security Act (ERISA) does not preempt the state’s authority to collect the data from TPAs. Of all the entities submitting claims to MHDO, nearly half are TPAs. As stated by MHDO Executive Director Al Prysunka, “If TPA’s data were not included in Maine’s claims database, there would be a large void of data for a particular segment of covered lives – employees who are covered under a self-insured health plan.” There are still self-insured plans without TPAs that are exempt from submitting claims information, but these plans account for a small percentage of total health care claims in Maine. Federal Reform Implications Maine will be poised to utilize its APCD to provide needed information on health care cost and utilization as federal health reform is implemented. This information can be used to understand variations in cost, utilization and quality, and therefore identify opportunities to reduce costs while maintaining quality and access to care for all populations. About the Data Spotlight Series State Data Spotlight is a SHADAC series highlighting states’ unique data tools, datasets, and uses of existing data systems. The series aims to provide information and insight on innovations that can be applied in other states. States pursuing similar strategies can contact SHADAC for technical assistance and support in developing these types of innovations. 2 Sources Centers for Medicare and Medicaid Services. (2011). Multi-Payer Advanced Primary Care Practice Demonstration: Questions and Answers. Accessible at https://www.cms.gov/DemoProjectsEvalRpts/downloads/mapcpdemo_QA.pdf. Dirigo Health. (2010). CMS Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Fact Sheet. November 2010. Accessible at http://www.dirigohealth.maine.gov/Documents/MAPCP%20Demo_Maine%20PCMH%20Pilot%20Fact %20Sheet_11-10%20_3_.pdf. Health Dialog. (2009). All-Payer Analysis of Variation in Healthcare in Maine. Dirigo Health Agency Maine Quality Forum and the Advisory Council on Health Systems Development. Accessible at http://www.mainequalityforum.gov/HDAS%20MQF%20Report_FINAL%205.1.09.pdf. Love D, Custer W, Miller P. (2010). All-Payer Claims Databases: State Initiatives to Improve Health Care Transparency. The Commonwealth Fund. Accessible at http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2010/Sep/1439_Lov e_allpayer_claims_databases_ib_v2.pdf. Miller PB, Love D, Sullivan E, Porter J, Costello A. (2010). All-Payer Claims Databases: An Overview for Policymakers. State Coverage Initiatives. Accessible at http://www.statecoverage.org/files/SCI_All_Payer_Claims_ReportREV.pdf. National Association of Health Data Organizations (NAHDO) Regional All-Payer Health Information Council (RAPHIC). (2009). Establishing a Plan for Standardized All-Payer Claims Data Collection – Meeting Minutes. May 6, 2009. Accessible at http://www.raphic.org/pdf/200905_stakeholders_meeting_minutes.pdf. National Association of Health Data Organizations (NAHDO) (2011). Cost and Funding Considerations for a Statewide All-Payer Claims Database (APCD). Fact sheet prepared by the All-Payer Claims Database (APCD) Council, accessible at http://www.nahdo.org/LinkClick.aspx?fileticket=0xsHynh8hHE%3D&tabid=111 Prysunka AM. (2009). Letter to Senator Laurie Monnes Anderson, Chair of the Senate Committee on Health Care and Veteran’s Affairs in Ohio. April 8, 2009. Accessible at http://www.oregon.gov/OHPPR/HFB/docs/2009_Legislature_Presentations/4.09.09/Al_Prysunka_4809 .pdf?ga=t. Prysunka AM. (2010). Maine All Provider/All Payer Claims Database: What You Need To Know But Were Too Afraid To Ask. Presentation at the All-Payer Claims Database Workshop. October 15, 2010. Accessible at http://www.nahdo.org/LinkClick.aspx?fileticket=a4UNe7B9B6w%3d&tabid=173. 3