Plaintalk Blog Series - Introduction
You spoke, and we listened. In late 2015, CIVHC sent out a survey asking for ways to advance our mission - better health, lower costs, and a healthier Colorado.
We heard a recurring theme; many of you are unclear about what we do and how we do it, and would like to better understand CIVHC and all our moving parts. Additionally, we were asked to clarify the language of claims data and discuss how we interpret this unique information for the stakeholders we serve, from policy makers to providers and consumers.
This blog is our answer to your call to action. On a regular basis, we will examine the language surrounding claims data and general health care innovation; terms like allowed amount, plan paid amount, and coinsurance will be explored alongside delivery system redesign, payment reform, and data transparency. We will also explain just what CIVHC does with the data by investigating the processing stream, the data extract process, and the role of our data warehouse manager.
Through these Plaintalk discussions, we want to enhance data and health care literacy across Colorado and begin a dialogue with you, our stakeholders. We want to help you use our websites, analyses, and reports to support your Triple Aim efforts to improve health, quality and lower costs for us all.
Plaintalk Blog Series – Administrating the CO APCD
CIVHC is the administrator of the Colorado All Payer Claims Database (CO APCD) and we use the information in claims data to illuminate opportunities for our stakeholders to improve health, improve care, and lower costs in Colorado. This is probably something that you have heard many times, but what exactly is an APCD anyway, and what does CIVHC actually do as the administrator?
Each time you visit a doctor or other health care provider, a claim is filed with your health insurance company. Included in the claim is information about you (name, phone number, zip code, etc.) and information about the service you received (provider you saw, prescription filled, diagnosis, location of service, etc.). Providers enter this information into the claim using codes representing procedures and conditions.
Keep in mind, while an insurance claim has a lot of detailed data, it does not show results. For example, let’s say you went to the doctor for a routine exam and received blood tests to check your cholesterol and lipid levels. The claims show you had a routine exam and that your doctor ran lab tests and the cost for those services, but it would not show whether your cholesterol and lipid levels were within normal range. That type of information remains in your medical record.
Colorado law requires large commercial health care insurers and Medicaid to provide claims information to the CO APCD. The CO APCD also collects claims from Medicare through a federal process called a State Agency Request. Right now, the CO APCD receives claims from 33 different commercial health plans, Medicaid and Medicare. As you can imagine, this information is not always consistent. Everything from a provider’s handwriting while doing paperwork to different sets of procedure codes for the same thing adds complexity to understanding what Coloradans are being treated for, how, and at what price.
After the insurance company pays a claim, they submit the information through a secure portal to CIVHC’s data warehouse vendor where patient specific information is removed to protect privacy, and the claims are processed and stored. CIVHC analysts then run quality checks on the data to ensure the information is as complete, clean, and accurate as possible. The processed claims then make up the CO APCD.
Sounds simple, right? Yet, each health insurance plan collects and processes claims differently, making for a jumble of data for CIVHC to sort out.
To break it down further, imagine that one claim in the CO APCD is a mixed up Rubik’s cube.
- The blue side is encrypted personal information that doesn’t identify you specifically, but does have your gender, zip code, age, etc.
- The yellow side contains information about your doctor or other health care provider.
- The red side has information coded by your provider about the reason for your visit and what condition(s) you were diagnosed with.
- The green side is any tests your provider ordered or performed like cancer screenings, blood tests, and x-rays.
- The white side pieces are elements of complexity that are included in the claim. For example, you came to the doctor’s office for cold symptoms and found out you had strep throat. Now your claim includes information regarding the initial visit, that you had a strep test, and your strep diagnosis.
- The orange pieces represent payments, including those made by you and your insurance company. These numbers vary based on factors such as what health plan you have and which facility or clinic you were treated at.
Now, multiply this one mixed up Rubik’s cube claim by 450 million. This is the number of claims that are currently in the CO APCD warehouse.
In order to get a complete picture of this one claim, CIVHC has to get all nine squares on each of the six sides of the cube to be the same color.
…and, to get a complete picture of health care in Colorado, 54 squares on 2.7 billion sides of 450 million cubes all have to be aligned.
Solving this puzzle is part of CIVHC’s job as the administrator; the other part is making sense of it all to help Coloradans understand vital things about health care in our state. Information like how much it costs to get knee surgery or have a baby, whether rural areas have more people with diabetes or asthma, and if Coloradans are getting screened for colon cancer can help all of us make better decisions.
It is important that CIVHC understands where the variation in prices and utilization exist and present this information so our stakeholders can ask questions and understand the root causes and contributing factors and in turn, create programs and policies aimed at combating this mounting issue. Until we have that understanding as a state, we can’t do much to improve upon our current situation.
For some, solving one individual Rubik’s cube is a challenge. Thankfully, CIVHC analysts are adept problem-solvers and have developed standard data sets and processing rules that we use to make sense of the claims. We then share what we learn with you, our stakeholders, through publications and www.comedprice.org.
When someone has a request for a custom data set or analysis, the process is a little different. For each request, our analysts figure out how to align the sides of many cubes to provide the best solution to match the specific question or problem. Each requestor is interested in different pieces that make up the whole health care puzzle, so our analysts have to figure out which solution will best serve their need.
CIVHC is honored to serve as the administrator of this powerful resource created to benefit all Coloradans, and we do not take this privilege lightly. Each day, our analytics team finds new ways to look at the data, leading to compelling insights and innovative ways to help you, our stakeholders and partners, move forward on our shared journey to better health, lower costs, and a healthier Colorado.