CIVHC administers the Colorado All Payer Claims Database (CO APCD) and we use the health insurance claims information to help Change Agents identify ways to lower costs, improve care, and make us all healthier. But what exactly is in the CO APCD and what does it mean when CIVHC talks about the scope of the database?
Each time you visit a doctor or other health care provider, if you have health insurance, the provider files a claim with your health insurance company to receive payment. 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.
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.
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 about the initial reason for your visit.
- The green side is any tests your provider ordered or performed like cancer screenings, blood tests, and x-rays.
- The white side pieces contain information about your primary and any secondary diagnoses. For example, cold symptoms may have been the primary reason for your visit, but you may also have diabetes and got your insulin levels tested during the same visit.
- 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 visited.
Now, multiply this one mixed up Rubik’s cube claim by over 800 million. This is the number of claims that are in the CO APCD warehouse, and that number grows monthly with new submissions.
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, which Colorado counties are at higher risk of severe illness from COVID-19, and what services Coloradans are receiving that are considered low value and potentially harmful, can help all of us make better decisions.