CO APCD

APCD - General

1. What is the APCD?

   The All Payer Claims Database (APCD) is a statewide data warehouse that includes medical claims, pharmacy claims, and eligibility and provider data from public and private health insurance carriers.

2. Where does the data come from?

   As of November 1, 2012, the APCD includes health insurance claims from the eight largest health plans for individual, large group fully-insured and some self-insured lives, as well as Medicaid. These claims represent more than 2 million unique covered lives and over 40 percent of the insured population in Colorado. By 2014 the APCD will contain remaining segments of the commercial market as well as Medicare, reflecting approximately 90 percent of insured Coloradans.

   Click here for a timeline to add additional claims.

    

3. What information is being submitted in the APCD?

   The following information is collected in the Colorado APCD, which includes information submitted to a payer through health claims. Public data reports only show grouped data by zip code or region to protect personal health information.

   • Medical Claims
     • Payer info, insurance type, patient info/demographics, admission type/discharge status, service(s) provided and facility, service provider info, diagnosis codes and procedure, and payment amounts
   • Pharmacy Claims
     • Payer/Plan info, patient info/demographics, pharmacy info, drug name/dosage, generic or branded, payment amounts, and prescribing physician
   • Medical Eligibility File
     • Patient info/demographics, coverage type/category, subscriber info, payer, insurance type
   • Provider File
     • Name, identification numbers, organization, specialty, location
        

    

4. What does the APCD do?

   The APCD provides Coloradans access to aggregate claims information (cost, diagnosis, location, provider type) to identify the costs, utilization and quality of health care services provided in Colorado. As the data in the APCD grows and more claims data is analyzed and reported, the APCD will help consumers, providers, health plans and businesses by answering the following types of questions:

   • Which part of the state has the highest obesity rate?
   • Which procedures cost the most?
   • Which hospitals have the lowest prices?
   • What are the variations in cost for common procedures?
   • What is driving Emergency Room visits?
   • What is the average length of time people use antidepressant medications?
   • Which facility charges the least for chemotherapy treatment?
   • How far do people in rural areas travel for health care services?

    

5. Why do we need the APCD in Colorado?

   We cannot manage what we cannot measure. Every state throughout the country is struggling with increasing health care costs that are far outstripping inflation. Additionally, it is estimated that 30-40% of the care provided is not contributing to better health. Without a firm understanding of how, where and how much health care spending occurs, Colorado is not in a position to change this trend. Without changes, health care will continue to take up a greater share of Colorado’s budget, and erode the dollars to fund other things we value, such as education, roads, infrastructure and our wonderful natural resources. Gathering all health care claims helps us create a far more complete picture of our health care system and equips us with important information to support achieving better health, better care and lower costs.

6. What can we do with claims data?

   Claims data includes information such as costs, facility type and diagnosis that will allow us to identify areas for improvement across our health care system. Consumers and employer purchasers will be able to use this comparative data to make informed choices about purchasing health care and coverage. It will enable providers to compare their performance across payers, and it will provide policymakers and researchers an in-depth picture of health care spending trends to inform policy and public health initiatives.

   Examples of questions we can answer with this data include:

   • Which hospitals have the highest prices?
   • Which part of the state has the lowest obesity rate?
   • What is the variation in cost for the most common procedures?
   • What is driving Emergency Room visits?
   • What is the average length of time people use antidepressant medications?
   • How far do people travel for health care services?

   The accuracy and fairness of comparisons are vastly better when there are more examples to assess, which is why it’s important to have claims information from all major payers. Click here to view the timeline to add additional payers to the database. One of the uses of the data is to inform patients and employers about where to find the highest quality, best value care. We are working to ensure that reports reflect a provider’s overall care for as many patients as possible and that they are statistically accurate and methodologically sound. By the end of 2013, the APCD will contain reports that consumers can rely upon to make choices about their health care.

7. How will organizations and individuals use this information?

   All stakeholders agree that our health care system is cumbersome, confusing and costly. While the specifics of those views vary, all share a common theme: changing this starts with better data. Here are some needs and concerns that have emerged in CIVHC’s conversations with Colorado’s health care community and how the APCD will address those concerns:

   • Individuals: Facing higher out-of-pocket expenditures, they need better and more accessible information about the cost and quality of the care available to them. By the end of 2013 the APCD will provide specific information on the actual cost of common procedures and how various providers compare in cost, utilization and quality.
   • Employers (Purchasers): They want to see the cost of health coverage stabilize and get value for their, and their employees’, premium dollar. And, more than ever, they want to have good data about provider quality to drive their purchasing decisions.
   • Clinicians: They want to understand how their cost, utilization and quality compares to their peers so that they can continue to improve the care for their patients. The APCD will provide a comprehensive risk and severity-adjusted view of their performance relative to other providers across all insurers.
   • Health care policy experts: They look for trends in cost and utilization, and meaningful ways to measure quality, in order to develop targeted policy interventions.
   • Health care finance experts: They seek to understand where health dollars are spent and why, and the relationship between short term investments and long term health status.
   • Public health agencies: They want to understand the trends in disease diagnosis and treatment, and whether specific public education campaigns are followed by increased preventive services provided to patients.
   • Researchers: They want to explore the effects of investments in emerging technologies and interventions on the cost of care and the rate of hospitalizations.

8. How will this information be useful to patients?

   Imagine buying a car without being able to compare its features or consumer satisfaction ratings compared to other brands. Now imagine having no idea what the car will cost you until you receive a bill in the mail.

   The APCD data will allow you to find the best care at the lowest price. By the end of 2013, www.cohealthdata.org will include reports that will give you an estimate of the amount that a hospital, surgery center, physician, or other health care professional receives for its services, and how much you will have to pay out of pocket for that service.

   The APCD is designed to help Coloradans make informed decisions about their health care. Similar to how you shop for other products and services, the APCD will let you compare hospital and physicians to find high value services and decide how to spend your health care dollar.

9. CIVHC says we need the APCD because “we can’t manage what we can’t measure.” What do you mean by “managing” my health care?

   The APCD is about empowering individuals, businesses and anyone paying for health care by giving them the information to help manage their choices about cost and quality. It is about understanding where and how Coloradans spend their health care dollars on a broad basis, and if they are getting the most bang for their bucks. It also enables providers to understand how they are doing relative to other providers. The APCD is not about dictating care and treatment for individuals. We Coloradans cannot effectively bend the health care cost curve in Colorado if we do not know what is driving it.

10. Do other states have APCDs?

    As of November 2012, there are eleven other states in addition to Colorado that have implemented, or are in the process of implementing, an APCD and 18 others expressing strong interest, according to the national APCD Council. At the recent national Governor’s conference, implementation of an APCD was seen as one of the most important steps a state could do to improve the care and lower the cost of health care.

11. What has been the experience in other states?

    The potential of APCDs is already being demonstrated in the states that have implemented this technology. The citizens of these states are beginning to benefit from the increased transparency and data availability. However, as APCDs are quite new, it will take several more years to determine their long-term impact on improving quality and controlling costs.

    APCDs initial uses have been to publish data that allow the public to compare health care prices and quality and to allow better understand statewide variations in in the amounts paid amounts for health care. Each state with an APCD has utilized the information in ways unique to its own population and specific needs.

    The following are some examples of how APCD information is being used across the county:

    • New Hampshire was among the first states to build an APCD and allows consumers to input their own insurance information and see what specific procedures will cost.
    • Utah’s APCD is being used to draw a portrait of spending and utilization for healthy people as a baseline for future analysis of changes.
    • Massachusetts developed a consumer-friendly Web site showing the amount paid and quality side by side.
    • Wisconsin’s health care community came together to support a physician-quality Web site that drives ongoing performance measurement and quality improvement.
    • Maryland’s Medical Care Database has been used to analyze spending in the small and individual group market place, including patterns of spending and utilization.

12. Will this information go into some sort of national database?

    There is no national APCD database nor is there any known basis upon which the federal government could compel states to contribute to such a database.

13. Will the APCD bring about competition that lowers costs?

    We do expect increased competition to be just one of the many benefits of the APCD. As transparency of cost and quality grows, it is expected that purchasers of health care services will go to those providers who provide the highest value. This same cost and quality data will also benefit providers and, for the first time, give them aggregated data that illuminates how their cost and quality compares to other providers. We feel the combination of this transparency will lead to improvement of quality and more competition on cost and quality performance.

14. What if providing transparent prices actually encourages hospitals and physicians with lower costs than their peers to raise their rates?

    That’s certainly a potential unintended consequence. Experience in other states, however, demonstrates that purchasers and consumers migrate toward the providers who demonstrate high quality and low costs in the APCD—we’ve seen that happen in Massachusetts, for example, as consumers have used the data in that state’s APCD. And when consumers vote with their feet and their checkbooks in that fashion, other providers don’t want to miss out. They look for ways to change the way they provide care in order to improve quality and lower costs.

15. If you won’t have information from all Coloradans in the APCD (uninsured, or those who work for selfinsured or small businesses), won’t people be making choices and policy decision based on bad data?

    The key benefit of the APCD is to shed light on the cost, utilization and quality of healthcare in our state by looking at patterns in the data as a whole. Even without every Coloradan in the database, statistically we will be able to discern accurate pictures of cost and quality to help consumers make better choices. Currently, we have NO timely data about health care cost and quality in Colorado. As we roll more information into the APCD, it may not be perfect—but it will be vastly superior to any data source we currently have.

16. Recent data has shown that health care spending in this country is, in fact, steadying. Is saying health care costs are increasing just a mythical justification to allow the government to intrude in our personal lives?

    To say that the rate of growth is slowing is simply to say that it will take slightly longer for health care costs to bankrupt our country. The rate of growth in health care spending in this country may be slowing—but spending is still growing, despite the fact that we’ve been in a recession for the last few years and spending in other major categories has fallen. And, the rate of health care spending growth is still higher than inflation at a time when median household incomes have fallen.

    The United States spends more per capita on health care than any other industrialized country—yet our health outcomes put us in the ballpark of Costa Rica and Slovenia. The value of an APCD is that it rebalances the dynamics of the health care marketplace to make it function more efficiently. A major problem with our health care market has been an imbalance of information: the individuals using health care services don’t know what they cost, whether or not they have insurance. The APCD brings more transparency to the system—a key ingredient for any well-functioning market.

17. If Colorado does indeed move toward more integrated, Kaiser-like health systems—which don’t process “claims” in the same fashion as other health plans—won’t that make the APCD obsolete?

    Not at all. The majority of the information collected from payers is the same regardless of the payment mechanism and will allow understanding of utilization, effectiveness, quality and overall costs. The APCD will allow services and their costs to be aggregated so that appropriate comparisons can be made. Over time, elements of how health plans submit their data to us will evolve along with the payment mechanisms. But there will still be a need for the type of information in the database.

18. How do hospitals feels about having their prices publicized?

    CIVHC can’t speak for any industry group. But Colorado’s hospitals have embraced the notion of transparency for some time, with the hospital report card that shows charges and some quality information. They themselves were not able to provide the kind of data the APCD will gather, and it will be useful for both them and their patients.

APCD - Privacy and Security

1. Why should the government, or a private entity like CIVHC, be able to track the health care services I’m using?

   The APCD is designed to identify population patterns. Health care is unique in that there is virtually no publicly available information on cost and quality. The intent of the APCD is to even the playing field for consumers, businesses and others to make educated and informed decisions that will improve the health of Coloradans. The aggregate data in the APCD allows consumers and others to begin answering questions such as:

   • What will this procedure cost me?
   • Which providers provide the best quality at a reasonable cost?
   • How does payment differ by location?
   • What are the trends in disease prevalence?
   • What are the trends in treatment choices?
   • How does quality vary across regions of the state?

2. How will the APCD keep information private and safe?

   The safety and privacy of personal information is a foundational principle of how the Colorado APCD is designed and operated. Not only is data always encrypted and protected but personal information will never appear in any public APCD data output or report.

   Data Security: When carriers submit files to the APCD, the datasets are always encrypted and sent over a secure connection (File Transfer Protocol or FTP) to Treo Solutions, the APCD Data Manager. The FTP will be limited to a pre-determined list of users and IP addresses (internet connections) reserved for the carriers submitting the data. When Treo Solutions receives a file, security protocols run automatically, without manual intervention and in a secure environment, to confirm that the files contain the expected information before they are stored in the secured data warehouse.

   Treo Solutions specializes in providing secure solutions that comply with the Health Information Portability and Accountability Act of 1996 (including HITECH act), Federal Information Processing Standards, as well as conforming to standards published by the National Institute of Standards and Technology. Treo Solutions also engages third party review of its services and uses modern technologies, including advanced encryption, biometrics and intrusion prevention and detection, to secure its facilities providing solutions to healthcare organizations throughout the United States.

   Elimination of personal identifiers: As data are loaded into the warehouse, all personal information is removed from the record and replaced with an identification number that is generated by a separate software tool. This tool allows the assignment of an identification number that is completely unique and is not based on reconfiguring personal information. Additionally, birth date will be replaced with age category and zip codes will be reduced to the first 3 digits (or 000 if from a zip code with fewer than 20,000 people).

   Controls on how the database is used for analysis and research: Simply stated: your personal information will never appear in any public APCD data output or report.

   The APCD is establishing a data release process for specialized reports and data requests. All requests must detail the purpose of the project, the methodology, the qualifications of the research entity and, by executing a data use agreement, comply with the requirements of HIPAA.

   The data release review committee will review the request and advise CIVHC whether release of the data is consistent with the statutory purpose of the APCD, contributes to efforts to improve health care for Colorado residents, and complies with the requirements of HIPAA.

3. Will my medical information be at risk to data breaches I’ve read about?

   No. The APCD data warehouse is never exposed to the public and is housed in a high security facility, with rolebased security. Data is encrypted at all times. Furthermore, all personal information is removed from the record and replaced with an identification number that is generated by a separate software tool. This tool allows the assignment of an identification number that is completely unique and is not based on reconfiguring personal information. Additionally, birth date will be replaced with age category and zip codes will be reduced to the first 3 digits (or "000" if from a zip code with fewer than 20,000 people).

4. How can you guarantee us that no one will hack into the APCD?

   It’s impossible for any organization to make such a guarantee. However, we take our responsibility to safeguard the information in the database very, very seriously—and do everything in our power to ensure its security. A proven track record of data security was one of our paramount criteria for selecting the database vendor. Treo Solutions has robust systems in place for protecting the data as well as the hardware that houses it, and has not had a security breach in over 10 years. They use best practices and follow widely-accepted standards for their security controls. They conduct regular tests in which they hire hackers to try to penetrate their defenses, and adjust their systems as necessary. They require and provide continuing education to their staff about the latest in security and protection. Moreover, CIVHC holds Treo accountable for its security practices through our contract with them, so Treo is highly motivated to maintain a strong security posture.

   In the very unlikely event that someone was able to penetrate the multiple levels of security that Treo uses, data in the APCD is encrypted such that it would be unintelligible.

5. As a patient, can I opt out of having my information included in the APCD?

   Under Colorado state law, the APCD collects claims information from insurance companies and public payer programs, such as Medicaid, about health care services received by Colorado residents. Federal laws, including the Health Insurance Portability and Accountability Act (HIPAA), permit such disclosures from payers to be made. Because the APCD is designed to facilitate the reporting of aggregated health care and health quality data in a manner that results in transparent and public reporting of safety, quality, efficiency and cost information for all Coloradans, there is not a mechanism for individuals to opt-out. Like other states that support APCDs, Colorado’s APCD law requires that all state and federal laws be strictly met in order to protect the database and the sensitive information it holds.

6. Will my detailed health history and family health questionnaire that I filled out for my doctor or insurance company going to be stored in the APCD?

   The APCD isn’t a medical record, and doesn’t capture information from questionnaires or your doctor’s notes. It only includes the information from insurance claims, such as what services were received and how much was paid for those services.

7. Insurance claims show diagnosis codes, not just treatment codes, so could someone get into the APCD and see that I have cancer, or AIDS?

   The APCD is built from the same information found on insurance claims, including diagnoses and procedure codes. However, the APCD is very different from insurance claims systems, physician billing systems and the millions of Explanation of Benefit letters sent to patient homes. All of those are designed to identify and track specific patients. The APCD however, is designed to aggregate data in order to perceive and display patterns of cost and utilization. While identification data are in the APCD, they are encrypted and stored separately from the utilization and cost data.

8. How can you adequately protect the health information of people living in rural areas where the population is so low that it wouldn’t be difficult to determine who a person of a certain age with a certain diagnosis is?

   Colorado does have a lot of sparsely populated areas. That’s why it’s so important to understand that the reports from the APCD gathers all the information for zip codes with fewer than 20,000 residents into one zip code of “000”—it won’t be possible to tell where those claims came from.

9. If you take out the zip codes from sparsely-populated areas, won’t it be difficult to be able to see health care utilization from, say, the eastern plains?

   Five-digit zip codes are retained and encrypted in the database. Some analysis of APCD data will allow distinctions among geographic areas. However, any reports that are produced from this data will group zip codes with fewer than 20,000 residents into a single group.

10. I’ve heard that 87 percent of the population can be accurately identified with just 3 pieces of information: zip code, birthday and gender, so can’t someone get into the APCD and get enough information to steal my identity?

    The APCD won’t provide that kind of information in published reports or datasets. Reports will distill zip codes down to 3 digits, and strip them out entirely if fewer than 20,000 people live there. Date of birth will be changed to age or age range.

11. What do you mean by “date of birth will be changed to age or age range”?

    Date of birth is in the APCD in an encrypted state. Depending on the type of report pulled from the database, it is translated into either an age or age range. Published reports do not reflect dates of birth.

12. What would a hacker see if he got into the database?

    Encrypted information. All information in the APCD is encrypted during transmission from the health plans and while it is “at rest” in the database.

13. How does Treo Solutions ensure their employees with access to the database don’t hack in remotely or that a disgruntled former employee doesn’t hack in?

    Treo does not allow their employees to have remote access to the database or the infrastructure that supports the APCD. When Treo terminates an employee or the employee leaves, that individual’s “role” relative to the database—i.e., access—is also terminated. This process includes removing physical and electronic access.

14. Could an employer or a law enforcement agency requisition information about an individual from the APCD?

    Based on the APCD statute and Health Care Policy and Finance rules, the APCD must adhere to federal privacy laws, specifically the Health Information Portability and Accountability Act (HIPAA) of 1996, regarding data disclosures, just as your insurance company must do with respect to claims information. The APCD statute and rules provide no special protection from law enforcement, and there are HIPAA exceptions that, under some circumstances, allow for data disclosures (e.g., certain law enforcement purposes, certain judicial proceedings, etc.). Any data that was released under such circumstances would, however, require that HIPAA’s privacy standards be met.

15. Could the federal government request information about an individual from the APCD?

    It’s possible that there could be homeland security or public health needs that would generate such a need. Again, any data released under such a scenario would still have to comply with the federal Health Information Portability and Accountability Act (HIPAA) privacy standards.

16. Will you ever release identified information?

    The Health Information Portability and Accountability Act (HIPAA) allows the release of certain, limited data fields for very narrow purposes: public health activity and research activity. The APCD Data Release Review Committee will review every request for APCD data reports to ensure that no information is released that goes beyond HIPAA rules.

17. Is CIVHC going to sell my health information to make the APCD sustainable?

    The APCD was created because of the important benefits it can provide to Coloradans, but in this era of tight budgets no dollars were allocated. Instead, the rules for the APCD allow data to be released in ways that are consistent with state and federal privacy laws and for the Administrator to be reasonably compensated for costs with operating the APCD. Any data reports granted will strictly follow federal Health Information Portability and Accountability Act (HIPAA) privacy and security rules.

APCD - Data and Types of Reports

1. What can we do with claims data?

   Claims data includes information such as costs, facility type and diagnosis that will allow us to identify areas for improvement across our health care system. Consumers and employer purchasers will be able to use this comparative data to make informed choices about purchasing health care and coverage. It will enable providers to compare their performance across payers, and it will provide policymakers and researchers an in-depth picture of health care spending trends to inform policy and public health initiatives.

   Examples of questions we can answer with this data include:

   • Which hospitals have the highest prices?
   • Which part of the state has the lowest obesity rate?
   • What is the variation in cost for the most common procedures?
   • What is driving Emergency Room visits?
   • What is the average length of time people use antidepressant medications?
   • How far do people travel for health care services?

   The accuracy and fairness of comparisons are vastly better when there are more examples to assess, which is why it’s important to have claims information from all major payers. One of the uses of the data is to inform patients and employers about where to find the highest quality, best value care. We need to ensure that reports reflect a provider’s overall care for as many patients as possible and that they are statistically accurate and methodologically sound. The goal is to create reports that Coloradans can rely upon to make choices about their health care.

2. There are Web sites and services that tell me the cost of medical procedures and the quality of care at hospitals or by provider; how is this different?

   There are multiple Web sites and services that attempt to provide data on the price of various services. However, information from such Web sites most often utilizes very limited data sets that are based on approximations of public Medicare reimbursement data that is several years old. The APCD will return a much more accurate picture of health care costs and quality using claims data from all payers that is both current and more comprehensive.

3. What data is currently included in the APCD, and when are more payers going to be added to the database?

   For the most up-to-date information on current data in the APCD, including a timeline to add additonal payers, click here.

4. What kind of reports can Coloradans expect from the APCD, and what’s the timeline?

   Reports generated from the APCD provide all key stakeholders (consumers, businesses, providers, insurers and policy makers) with high level cost and utilization comparisons that begin to identify potential areas of improvement.

   The initial launch of the APCD (November 1, 2012) is targeted to be meaningful to the broad policy, public health and provider communities, and supports health care reform policy activities. Reports in this category will present information at an aggregated level and describe patterns such as the incidence and variation of targeted medical conditions, state and regional cost patterns, and utilization of services.Examples include total cost of care, provider density, readmission comparisons and inpatient and outpatient cost of care by county. In addition, more detailed reports like variation in imaging costs by facility (names are blinded) are available as "snapshot" reports on the reports tab of cohealthdata.org.

   In 2013, the APCD will allow for more sophisticated analysis of overall value and performance of health care providers. Consumers will be able to compare providers’ reported cost of a procedure and obtain an estimate of the out of pocket cost. Employers will be able to understand the factors driving the cost of providing coverage to their employees. Health care purchasers will have the ability to compare hospital and physician providers to find high value services and receive better information on how to spend their health care dollars more efficiently.

   Reports will continue to become more advanced and informative through 2014 and beyond as more robust data from a wide array of health plans becomes available and validated. Part of the development of more advanced reports will include responding to the users of the data to make it increasingly meaningful.

5. Will www.cohealthdata.org eventually provide information that allows consumers to make more informed choices regarding their health care?

   Yes, by the end of 2013 we anticipate releasing a consumer focused section www.cohealthdata.org that will provide comparative cost, quality and value information. One of APCD’s core goals is to provide information that allows consumers to better manage resources and make value based decisions regarding their health care. Information based on the APCD will allow consumers, for the first time, to meaningfully shop for health services and better manage their own care.

6. When will it be possible to see more detailed data and reports like cost and quality reporting at the medical group, clinic or physician level?

   We expect to begin reporting comparative cost and utilization information at the level of named facilities, payers and provider groups beginning in late 2013. We are currently developing processes and procedures to share and vet information with affected groups.

7. Currently, I cannot see who the providers, facilities or counties are in the snapshot reports on imaging services, routine deliveries or knee arthroscopy. Will I be able to see data on a named facility or provider basis in future releases?

   Yes. As we add additional payers and the APCD becomes more representative of Colorado’s insured population, we plan to provide results at finer levels of detail. We anticipate providing cost and utilization data at the level of named facilities, payers and provider groups beginning in late 2013.
   

8. Will the Colorado APCD provide data and reports by payer type?

   Yes, once data from additional payers is added, users will be able to view data and reports by payer type, e.g., Medicare, Medicaid, commercial plans, etc. Click here for payers currently included in the APCD and the timeline for adding additional payers.

9. Will data or reports eventually be available for individual diagnoses?

   We expect to begin reporting on the incidence/prevalence and costs to treat common chronic diseases beginning in mid-2013. Entities with an interest in a specific diagnosis or set of diagnoses can request a specialized report through the Data Release Process.
   

10. Will you eventually capture and report on quality metrics?

    Yes, we are currently working with stakeholder groups both locally and nationally as well as APCDs in other states to identify appropriate and meaningful quality metrics to include in APCD cost and utilization reporting. We anticipate adding quality metrics by the end of 2013.

11. I’m a physician and my patients are relatively sicker than the patients my peers care for. Won’t my costs look too high compared to other physicians?

    Our plan for APCD reports and information is based on the following principles:

    • Comparative information is a tool for quality improvement.
    • Accuracy through rigorous data cleaning and quality processes.
    • Collaboration with providers, payers, institutions and organizations about data attribution, risk and severity adjustments and the ability to review data before its initial publication.
    • Providing public facing reports that support quality improvement and provide transparency to users related to quality, utilization and cost effectiveness. Allows for fair comparisons through appropriate risk and severity adjustments.

    Our reporting plan begins with aggregated reports that will provide high level portraits of service utilization and disease conditions. As the APCD becomes more robust, our data analysis plan calls for more detailed analytics that will allow consumers and purchasers to understand the best value. Our technology systems and analytic tools will allow us to statistically account for the differences so that comparisons are on a “level the playing field.”

12. Will risk adjustment be based on the same methodology used by Medicare?

    The Colorado APCD will begin generating reports based on risk-adjusted data in the mid-2013. Initially, risk adjustment of Colorado APCD data will be performed using tools developed by 3M. The Colorado APCD has the ability to use other tools for risk adjustment as well, including the Hierarchical Condition Categories (HCCs) currently used by the Centers for Medicare & Medicaid Services (CMS).

APCD - Administration

1. Why was CIVHC selected as APCD Administrator, and what does that mean?

   CIVHC was appointed as APCD Administrator in August 2010 because of its multi-stakeholder efforts and mission to help Colorado improve value in health care. CIVHC is a non-partisan independent non-profit organization, designed to support and foster important changes in the health care marketplace. It has no agenda other than improving health, quality and lowering health care costs.

   CIVHC’s work as the administrator of the APCD includes coordinating the efforts of the Advisory Committee, implementing recommendations, ensuring that the database operates in accordance with the legislation, raising necessary funds to support the planning and operation of the database, and ensuring self-sustainability of the APCD. CIVHC is identifying new strategies to improve the quality of medical care, contain costs, curb rising insurance premiums and create a more efficient, sustainable health care system in Colorado. As we convene diverse groups of stakeholders across the state, the APCD is used as a data source to supply information and analytics to advance system transformation.

2. Shouldn’t the APCD be run by a public entity that is subject to accountability standards like sunshine laws, the Open Records Act, or the scrutiny of state auditors since they are in charge of very sensitive health care data?

   On the contrary, CIVHC is subject to public oversight in a variety of ways. CIVHC was designated as the APCD Administrator by the Department of Health Care Policy and Finance (HCPF), acting with the authority granted to it under the APCD statute. HCPF itself is subject to the type of oversight indicated above. CIVHC is subject to HCPF’s rulemaking authority with respect to the APCD, including how and to whom data may be released, as well as minimum requirements for who must be appointed to the Data Release Review Committee.

3. How does the Department of Health Care Policy and Finance (HCPF) hold CIVHC accountable?

   HCPF and the federal government have the authority to monitor, audit and hold CIVHC fully accountable for compliance with all state and federal laws and rules associated with the APCD.

4. How much will it cost and how is the APCD paid for?

   It will cost approximately $2.0 million per year to implement, operate and provide ongoing enhancements to Colorado’s APCD. The planning process was supported through a generous grant from The Colorado Trust, and funding for the first 3 years of implementation and development necessary to reach self-sustainability is supported by both The Colorado Trust and the Colorado Health Foundation.

5. What happens if you don’t sell enough reports to sustain the APCD?

   We believe that the value of the APCD will be evident to consumers, businesses, policy makers and others such that they will want to continue to support its existence. Should that value not be demonstrated and funds aren’t available, then the APCD would have to be discontinued and data either returned or destroyed.

6. What power does CIVHC have to compel health plans to comply with the APCD reporting requirements?

   The APCD Statute mandates data submissions for certain payers, as further defined by HCPF in the APCD Rules, and provides HCPF with the authority to levy fines against non-compliant payers. As required by the APCD Rules, CIVHC will provide notice to payers who are out of compliance and may grant an extension of time for just cause, but it is HCPF’s role to issue any penalties.

   If a carrier misses a deadline, they would be notified. The Administrator would determine if there were any special extenuating circumstances for which a grace period might be warranted. If no such circumstances are determined, the Administrator would notify HCPF, which has the authority to levy fines according to its policies.

7. Have you included consumers in your planning?

   Yes. The APCD enabling legislation required the appointment of two consumer representatives to the APCD Advisory Committee, who provided valuable input in the development phase. In addition, consumer and other stakeholder input was gathered prior to determining the list of initial reports available at www.cohealthdata.org. CIVHC will continue seeking consumer input as we develop the consumer-friendly cost and quality reports due to launch at the end of 2013. Our consumer engagement white paper will be used as a guide as we engage consumers in helping us develop meaningful cost and quality reports over the next year.

APCD - Interface with Other Data Sources

1. How does the APCD link to the Health Insurance Exchange?

   When the Health Insurance Exchange goes live, individuals and small employers purchasing coverage through the Exchange will be able to look at cost and quality comparisons across the networks of the plans being offered. The APCD will give them a powerful tool for making informed choices within the Exchange.

2. How does the APCD fit with Health Information Exchanges being built in our state through CORHIO and QHN?

   The Colorado Regional Health Information Organization (CORHIO) and Quality Health Network (QHN) on the western slope are building information highways that enable providers to exchange clinical information in real time. The APCD is a warehouse of retrospective information about the services that were paid for by a third-party payer. They are two very different tools that serve very different uses. Down the road, we hope to be able to integrate them, but that’s a long way off.

3. Are there plans to link the Colorado APCD to other data such as clinical information maintained by the Colorado Regional Health Information Organization (CORHIO) or Quality Health Network (QHN)?

   Finding ways to link together cost and utilization information from the APCD with clinical information systems will eventually provide for a fuller picture of cost, quality and value. However, combining data sources from Health Information Exchanges and the APCD present numerous technical, privacy and resource challenges. No timetable has been established for this work.

APCD - Data Release Requests

1. How can my organization get more detailed reports from the APCD?

   The Data Release Process page of our website outlines the process for requesting data from the APCD and includes resources such as the Data Release Application and contact information to help guide you in the process.

2. Who decides who can get information from the APCD? What rules do they use?

   The APCD governance rules promulgated by HCPF require that the Data Release Review Committee develop protocols for the release of APCD data. The DRRC comprises health care data and analytical experts representing a variety of organizations and stakeholder perspectives. The rules require that the DRRC shall review the request and advise the Administrator on whether release of the data is consistent with the statutory purpose of the APCD, will contribute to efforts to improve health care for Colorado residents, complies with the requirements of HIPAA and will employ appropriate analytical methods. Requests must meet all these criteria in order to be approved. Approved data requests then require the requestor to enter into a very strict Data Use Agreement. Additionally, the APCD Administrator is required to report annually to HCPF listing data requests, their use and how they met HIPAA requirements.

    

3. What kind of information can organizations get from the APCD?

   By rule, the APCD Administrator is permitted to provide or “release” data at varying levels of detail and specificity. All releases of APCD data must meet all HIPAA privacy and security guidelines and are subject to DRRC review and advisement, which requires that the intended use supports reaching the Colorado Triple Aim of better health, better care, and lower costs. For example, public and private entities may request information on costs associated with treatment of a specific diagnosis or disease by region or county, variation in cost of procedures by facilities, and utilization of high cost services such as MRIs for a defined population.

    

4. Are there limitations on the data that organizations can get from the APCD?

   Yes, APCD data releases are subject to both HIPAA restrictions and state legal and regulatory restrictions to protect privacy:

   1. In keeping with the “minimum necessary” standard established under HIPAA, applicants must demonstrate need and provide justification for each data element requested. The DRRC will recommend and the APCD Administrator will release only those data elements which are specifically necessary to accomplish the applicant's intended use.
   2. Protected Health Information (PHI) may only be released in limited circumstances for public health, health care operations and pre-approved research purposes, and can never be shared publicly as a result of a research project or program.
   3. For research-related requests, applicants may be required to show written approval from an Institutional Review Board or a Privacy Board as part of the Application.
   4. As part of the Data Use Agreement, all Applicants must provide written assurances that:

   • Data will be used only for the purpose stated in the Application.
   • No attempt will be made to use any data supplied to ascertain the identity of specific insured individuals or patients, or to report data at a level of detail that could permit a reader to ascertain the identify of specific insured individuals or patients, nor will downstream linkages to outside data sources occur without specific authorization from the APCD Administrator.
   • Restricted data elements such as PHI will not be released except as specifically approved in the original Application and Data Use Agreement.
   • The Applicant will obtain these assurances in writing from any recipient of data or agent that processes data on behalf of the Applicant.
   • The data will not be re-released in any format to anyone except personnel identified and approved in the original Application and Data Use Agreement.
      

5. What information is required in order to submit a data request?

   According to both APCD statute and HCPF rules, all data release applications must be submitted in writing and describe in detail:

   • The purpose of the project and intended use of the data.
   • Methodologies to be employed.
   • Type of data and specific data elements requested along with justification.
   • Qualifications of the research entity requesting the data.
   • The specific Privacy and Security measures that will be employed to protect the data.
   • Description of how the results will be used, disseminated or published.

   The Data Release Review Committee reviews the data release applications and advises the Administrator on approval or denial.
    

6. What kind of organizations can get information from the APCD?

   Both public and private entities may receive APCD reports subject to approval of their request by the Data Release Review Committee. Organizations that have requested information from the APCD so far include university researchers, divisions of Colorado state government and private firms developing new pricing models for health care services.

7. What can APCD data be used for? Are there any restrictions on the purposes for which it may be used?

   Data requests may only be used to inform projects or support programs that support the achievement of one or more of the categories of the Triple Aim for Colorado: better population health, better quality of care and patient experience, and lower cost of health care. Data cannot be used to directly market to individuals for market gain of an individual or organization. For example, a data request identifying all diabetic patients for purposes of target marketing a new diabetic drug does not meet the intended use criteria. Personal health information can never be shared publicly as a result of a research project or program.

8. Can an organization charge others for information it gets from the APCD?

   Under an approved request, use of the released data is limited to the specific purpose as described in the original application. Further use of the data for a purpose not reflected in the original application would require a new request that fully complies with the privacy and security requirements of HIPAA.

9. Is there any circumstance in which a private company or individual could get personal, identifiable health information out of the APCD?

   HIPAA allows the release of certain, limited data fields for very narrow purposes: public health activity, health care operations, and research activity. The Data Release Review Committee will review every request for APCD data reports to ensure that no information is released that goes beyond HIPAA rules and the Administrator will deny any request for data or reports that would violate HIPAA or state law and rule.

10. Could a company get a report from the APCD identifying all the people in a given zip code who have a certain diagnosis or have been prescribed a certain drug?

    There is no circumstance we can envision in which a company could obtain this data without first directly obtaining patient authorization to do so. The company would then have to meet all other data release requirements including showing how this information would improve health, care or lower costs. Similar to HIPAA laws that govern providers or payers, release of specific names of patients can only occur in the most unusual public health circumstances or under research protocols that under HIPAA laws require patient authorization or Institutional Review Board research approval.

11. What happens if an entity misuses APCD data or uses it for a purpose other than that for which the entity applied?

    An approved applicant must sign and enter into a Data Use Agreement or contract with the APCD Administrator and agree to the following:

    • Restrictions on data disclosure and prohibitions on re-release of the data.
    • Prior approval from the APCD Administrator subject to DRRC guidelines is required to publicly release any reports based on the data. The APCD Administrator will carefully review all materials intended for publication or dissemination to determine whether the privacy rights of any individual would be violated by the release of the information.
    • Violation of the terms of the Data Use Agreement constitutes a breach of contract and may:

    1. Require the immediate surrender and return of all APCD data.
    2. Result in denial of future access to APCD data.
    3. Lead to civil action by the Administrator for breach of contract.
    4. Result in a complaint filed with the U. S. Department of Health & Human Services, Office for Civil Rights, as well as civil and criminal action and penalties.
    5. State Attorneys General are also empowered under the HITECH Act to take civil action regarding certain HIPAA violations.
        

     

12. How is the APCD Administrator held accountable for the use of APCD data?

    The APCD Administrator is required to provide HCPF with an annual report on or before April 1 of each year that includes:

    1. Any policies established or revised pursuant to state and federal medical privacy laws, including HIPAA.
    2. The number of requests for data and reports from the APCD, whether the request was by a state agency or private entity, the purpose of the project, a list of the requests for which the DRRC advised the Administrator that the release was consistent with rule and HIPAA, and a list of the requests not approved.
    3. For each request approved, the Administrator must provide the HIPAA regulation pursuant to which the use or disclosure was approved, and whether a data use agreement or limited data set data use agreement was executed for the use or disclosure.
    4. A description of any data breaches, actions taken to provide notifications, if applicable, and actions taken to prevent a recurrence.