On an annual basis, CIVHC works with the Department of Health Care Policy and Financing (HCPF) and commercial health insurance payers to enhance data elements being submitted to the Colorado All Payer Claims Database (CO APCD). We do this through the Data Submission Guide (DSG) rule change process executed by the Executive Director of HCPF. In 2018, CIVHC and HCPF promulgated several important enhancements to the DSG into the CO APCD Rule that will make the database even more robust and provide more transparency around two key aspects of health care in Colorado: alternative payment models (APMs) and drug rebates.

APMs and drug rebates are important pieces of the health care puzzle and understanding them will help stakeholders identify ways to improve care and lower costs. Since the data will address very different aspects of the payment system for health care services, we’ll break them down individually and identify why they are important and what information will be available.

Alternative Payment Models

What they are:

Alternative payment models (APMs) offer new ways to pay providers (including hospitals) outside of the traditional fee-for-service (FFS) payment system. These new models are intended to reward outcomes over volume and improve quality while simultaneously reducing health care spending.

Why we need to understand them:

The Centers for Medicare & Medicaid Services (CMS) and other payers are beginning to shift from traditional payment models towards APMs. With a growing number of APMs being tested and implemented, including the information in the CO APCD will support understanding the full breadth and impact of these new payment models on cost of care in Colorado. Transparency around APMs will enable researchers, payers, policy makers and other stakeholders to measure the use and effect of APMs, identify the most effective ways to reduce costs, and inform the development of positive policy solutions.

What will be available:

Payers will be submitting data identifying who they paid under APMs, how long members were covered under APMs, and total primary care and non-primary care payments for the following types of APMs:

  • Pay for Performance Payment/Penalty
  • Shared Savings/Risk
  • Global Budget
  • Limited Budget
  • Capitation
  • Bundled/Episode-Based
  • Integrated Delivery System
  • Patient-Centered Primary Care/Medical Home
  • Other non-FFS payments to develop infrastructure for better patient management

For more details on the guidelines that payers are following to submit APM data, click here.

Drug Rebates

What they are:

After making payments for certain prescription drugs, payers and pharmacy benefit managers frequently receive discounts in the form of rebates, discounts or other price concessions. These payments are not associated with claims submitted to the CO APCD as they occur after a prescription drug has been filled and paid for.

Why we need to understand them:

Prescription drug costs represent a major category of health care spending in Colorado, and one that has been growing steadily. The CO APCD currently contains pharmacy claim data identifying how much is initially paid by payers and patients, however, it does include any information about rebates that were provided to the payer or pharmacy benefit manager after the initial payment. Understanding prescription drug rebates will provide transparency around how much is actually being paid for in total for prescription drugs and to better understand how savings from rebates are being passed along to employers and consumers. This information will enable Colorado to more fully identify and track trends in total pharmacy spending, and will ultimately help isolate cost-savings opportunities.

What will be available:

Payers will submit prescription drug rebate information identifying the total amount of prescription drug rebates and other pharmaceutical manufacturer price concessions paid by manufacturers to a payer or their pharmacy benefit manager(s). Specific data elements include:

  • Insurance product type code
  • Pharmacy Spend and Drug Rebate Amount in total and by category:
    • Specialty Drugs
    • Non-Specialty Brand Drugs
    • Non-Specialty Generic Drugs
  • Per Member Per Month Pharmacy Spend
  • Per Member Per Month Prescription Drug Rebate Amount

For more details on the guidelines that payers are following to submit drug rebate data, click here.

Timeline

Payers began submitting test files to CIVHC in July for both APMs and drug rebates. On September 30, 2019, complete APM and drug rebate files are required from payers that will include three years of historic information (2016-2018). On an annual basis thereafter, payers will submit a file for the previous year’s information to include in the database. It is important to note that the annual submission process for APM and drug rebates is different than the monthly claims submissions process that payers follow.

CIVHC is currently working with HCPF and other stakeholders to identify what information on APMs and drug rebates will be valuable to share publicly and what information will be available through the non-public release process for data in the CO APCD.

We anticipate that the first views of the public data will be available at the end of the year. If you have any questions about the APM and drug rebate submission or reporting process, please contact us at info@civhc.org.