The CO APCD contains nearly 800 million claims representing approximately 65 percent of lives in Colorado, including medical, dental, and pharmacy claims. However, claims data only shows a portion of how the health care system functions. There are numerous behind-the-scenes factors that impact an individual’s health or cost of their care. CIVHC regularly works with the Department of Health Care Policy and Finance (HCPF) and other APCDs to capture this information. CIVHC is one of the few APCDs in the country to collect data on Alternative Payment Models (APMs) and prescription drug rebates, helping to give the fuller picture of the health care landscape in Colorado. With information on both, the CO APCD offers a unique glimpse into the less explored aspects of health care.
Alternative Payment Models
As health care costs continue to rise, stakeholders across Colorado have be
en seeking solutions with the aim of curbing prices while improving quality of care and overall population health. Health insurers especially have been partnering with providers and facilities to gradually shift away from the fee-for-service model and link payments to high value care and create more affordable care options through payment reform, or alternative payment models.
CIVHC began collecting APM data into the CO APCD in 2019, with the files legislatively mandated to be included in annual reporting on primary care spending in Colorado for the newly established Primary Care Payment Reform Collaborative, led by the Division of Insurance (DOI). By working with the Collaborative, the DOI, and other stakeholders, CIVHC has gradually refined and improved APM file submission guidelines to more accurately and specifically report APM use in Colorado. Beginning in 2020, all files were required to align with APM categories based on standards created by the CMS-sponsored Health Care Payment Learning & Action Network.
The newest APM files will be collected for 2019-2021 in September under specifications in Data Submission Guide (DSG) 13, which went into effect in March 2022. CIVHC will continue to evaluate submitted files and identify opportunities to improve data specifications around collection of APM data.
A public report on use of APMs in Colorado will be released on CIVHC’s Affordability Dashboard in the coming months.
Prescription drugs represent one of the biggest drivers of rising health care costs in the nation. But the system through which they move is historically opaque, and until recently, not much was known about the amount of drug rebates being collected by commercial payers in Colorado.
To address this issue, and as part of state efforts to constrain health care costs, CIVHC began collecting drug rebate information in 2019 to start understanding how dollars are exchanged in the system and whether any savings from rebates are being passed along to consumers or employers. Like APM files, drug rebate information is submitted annually and collected each September according to the rules laid out in the DSG.
In April of 2022, CIVHC released an update to the CO APCD interactive report analyzing prescription drug spending and rebates based on data collected for 2018-2020. Each year, payers will provide drug rebate data for the three previous years, and CIVHC plans to update the interactive public report annually.
CIVHC continues to work in close collaboration with payers along the way to evaluate submissions and continue to establish clear requirements. DSG 13 adds two new file submissions to collect information on prescription drug costs and support state-led work:
- Data to support the Prescription Drug Affordability Board (PDAB) created by SB 21-175 by allowing them to see which drugs account for the highest spending in Colorado
- Data regarding value-based pharmaceutical contracts (VBPC) to understand how prescriptions reimbursements are structured.
Additionally, as with APM data, DSG 13 contains updates to previously collected elements to clarify and add collections to data fields to improve the quality of submitted data.
To learn more about APM and drug rebate file submissions, visit CIVHC’s submissions page and to view the current interactive report on drug rebates, with APMs soon to be added, visit the Affordability Dashboard.