As of April 2021, the Colorado All Payer Claims Database (CO APCD) contained nearly 920 million claims for approximately 65 percent of insured individuals in Colorado with medical coverage, reflecting over 3.4 million lives.When those with dental and pharmacy coverage are added, the CO APCD spans 4.5 million unique lives with information from commercial health insurance plans, including Medicare Advantage as well as voluntarily submitted Employee Retirement Income Security Act (ERISA) and mandated non-ERISA self-insured employer plans, Medicaid, and Medicare Fee-for-Service (FFS) claims. The CO APCD does not contain claims for people covered by Federal health insurance programs such as the Veterans Administration, TRICARE federal employees, or Indian Health Services, and does not include information for uninsured Coloradans.
This and the next two installments of the Query: CO APCD Data Quality series will focus on the data submitted by payer line of business – commercial insurance, Medicaid, and Medicare. The data in each line of business has different nuances that are helpful to be aware of when using the CO APCD.
Payers v Submitters
CIVHC began collecting claims in the CO APCD in 2012, with eight payers submitting information. By 2013, that number doubled. In 2019, it doubled again. It is important to recognize that while many payers have multiple lines of business and submit them separately to the CO APCD, CIVHC counts and reports them as one “payer family” – or payer. For example, Aetna’s PPO, HMO and self-insured claims may be provided as separate submissions, but “Aetna” as the payer family category is counted as only one payer. When discussing the lines of business that make up a payer family, they are referred to as submitters. Thus, it is possible to have more submitters than payers in the CO APCD. More details about individual payer families is available for download.
Commercially Insured Lives in the CO APCD
The number of commercial lives in the CO APCD has increased by 60% since 2013 and represents information for about 34 percent of people with commercial medical coverage in Colorado, based on the 2019 Census estimate and claims from the same year. Statewide, individuals with commercial medical insurance make up approximately 24 percent of the total population. Both of these figures include self-insured and fully insured plans. Additional population-level information about the contents of the CO APCD is available in the CO APCD Insights Dashboard.
Self-insured claims are estimated to represent half of the total commercially insured lives in Colorado and CIVHC estimates that the CO APCD currently contains approximately a quarter of those lives. Due to a 2016 ruling by the United States Supreme Court, states cannot mandate submission of claims data from self-insured ERISA plans to APCDs.
However, the ruling did not impact collection of data from non-ERISA self-insured employers or those ERISA-based employers who chose to voluntarily submit claims to APCDs. CIVHC continues to collect non-ERISA self-insured employer claims and conducts robust outreach to encourage voluntary submissions from ERISA-based employers.
As part of this outreach, CIVHC has partnered with different employer groups to ensure that business owners and operators understand how CO APCD data can help them lower costs for their employees while continuing to offer high value care. A number of these groups created employer alliances and bargaining collectives have negotiated ground-breaking contracts with facilities for their employees. The majority of self-funded employers that CIVHC has engaged are in favor of voluntarily submitting their claims to the CO APCD and understand how benchmarking data to compare their costs to others in their region provides them valuable information to use when it comes time to renew benefits and make changes to health plan designs.
In some cases, the obstacle to submission to the CO APCD is not the employer but the third-party administrator (TPA) or administrative service organization (ASO) who processes the claims on their behalf. Submission of claims to an APCD may not be in the service contract between the employer and the ASO/TPA, and may in fact be prohibited in their provider network contracts. Additionally, there are no legal requirements for ASOs and TPAs to submit claims on behalf of the employers, even if it is requested. CIVHC continues to work with employers to find ways to provide them with as much cost and quality information as possible for their region or county, even if it is not specific to their employees.