Overview of All-Payer Claims Databases
For the past three decades, measures of health care quality have been embraced as tools for quality improvement, transparency, and accountability. As health care costs continue to rise, more stakeholders are calling for such measures to be used as part of value assessments, to understand how high health care expenditures, high out-of-pocket costs, and high local and Federal spending on health care can be shifted toward better care at better prices.
Price transparency, or readily available access to information on variations in cost across health care providers, alongside access to quality metrics, may help shape innovative policies, improve health care efficiency, and promote value in the health care system. Comprehensive datasets that support the development of quality and cost measures across large populations are well suited to reach these goals.
All-payer claims databases (APCDs) incorporate utilization and cost across the health care system and may fill critical data needs for State agencies and other stakeholders. The hope is that these databases can serve to inform policy and provide transparency for decisionmakers, including consumers, purchasers, and policymakers. APCDs are large datasets that aggregate medical, facility, pharmacy, and sometimes dental claims, as well as eligibility and provider data from private and public payers.1
Currently, 18 States have legislation mandating the creation and use of APCDs or are actively establishing APCDs. More than 30 States are maintaining or developing an APCD, or have a strong interest in developing an APCD. Seven States have public reporting Web sites with cost and quality information either wholly or in part coming from APCD data.1
Uses of All-Payer Claims Databases
APCDs represent a new approach to providing information about care. Before the advent of APCDs, datasets tended to be limited to certain groups (e.g., Medicare and Medicaid claims, which omit a large portion of the overall population) or to particular components of care (e.g., hospital discharge abstract databases, which cover only inpatient care) and posed challenges making it difficult or expensive to follow patients longitudinally.
The promise of APCDs is that they allow creation of a more comprehensive picture of care than is otherwise available in most States.2 By collecting data from all payers, State APCDs capture encounters for all but a small minority of patients (e.g., patients who are uninsured or are covered by a Federal health care plan such as Veterans Affairs benefits) and across settings.
This expanded database has several advantages, including that patients in a well-implemented APCD can be followed over time and across settings, to capture full episodes of care and account for variations in the type of care received. APCDs are not limited by turnover in patients among providers or payers because the records are captured for each patient regardless of provider or payer. This unique aspect of an APCD can facilitate measures of continuity of care, coordination of care, and other traditionally difficult constructs to measure.3 Compared with single-payer databases, APCDs may have larger sample sizes, potentially facilitating measures for rarer events and among smaller entities (e.g., individual providers, small areas).
APCDs have a variety of other potential uses as tools for improving quality of care and population health. As mentioned at the outset, they create a more comprehensive picture of outpatient and pharmacy care than is otherwise available in most States as they include a large percentage of insured individuals, which allows APCDs to reflect the health of the population.2
APCDs also facilitate price transparency and highlight significant price variation in the system. Such transparency may allow purchasers to negotiate with providers more effectively. In addition, it can help providers assess their own quality and value in shared risk and accountability payment models and allows consumers to weigh value in health care decisions as they assume greater financial responsibility.4
Local data aggregated into APCDs can be used to understand local market functioning and assess whether spending variations reflect pricing, utilization, or both. APCDs also can provide data to help States develop strategic plans for public health legislation or to determine the impact of policy changes at the State level.5 In addition, APCDs can support research that may be of interest to State policymakers, such as comparative effectiveness studies or the development and evaluation of targeted interventions to improve chronic disease care.
The comprehensive nature of APCD data allows:
- Estimations of disease prevalence across a population.
- Identification of patterns of utilization and potential areas for targeted interventions, and
- Planning and evaluation of health reform programs and legislation on cost, quality, and access to care.
While APCDs offer many advantages over other databases, they do have known limitations. These include lack of data for uninsured patients, questions about the feasibility of gathering and maintaining datasets, variation in data quality among submitters, and lack of clinical detail (e.g., laboratory values, biometric details). It is unknown how these limitations affect the ability to use APCD data for quality and value measures locally, within States, and nationally.
Purpose of Project
The Agency for Healthcare Research and Quality (AHRQ) funded the APCD project, which focused on three areas:
- Review of the overall landscape of APCDs.
- Identification of measures of cost, utilization, and quality that can be defined using APCDs; and
- Evaluation of current APCD data for measurement use.
In addition, the project team convened a Technical Expert Panel (TEP) to provide input on the overall direction of the project and provide check-in opportunities on key project milestones. The TEP provided input for the environmental scan and literature review that was conducted for the measure inventory. The TEP also provided critical feedback on priorities for the measure inventory.
The project focused on measures that address aspects of the health care system not covered well by other datasets, such as ambulatory care, pharmacy, and cost. Multiple use cases were considered for APCD-based measures:
- Supporting States in achieving overall high-value care for their population.
- Assisting physicians and physician groups in understanding quality and cost in managing their own patient populations.
- Supporting consumer choice when choosing providers or health plans, although currently this application is limited by the lag in price and quality information, and in some cases lack of relevant measures to support the decision.
After internal deliberations and TEP consultations, the team agreed to focus on measures that supported population health management.
This APCD project resulted in three specific work products:
- A report on the current APCD measurement landscape: The goal of the environmental scan was to assess potential use cases for APCD measures and to understand and summarize the current evidence for and limitations of APCD measures. The environmental scan informed both the measure inventory and data analytics.
- An inventory of measures that could be constructed using APCD data: The overall goal of the measure inventory was to provide a useful and usable inventory of measures that could be derived from APCDs, to provide a framework and basic measure specifications for assessing existing measures for use with APCDs, and to inform future measure assessment for other APCD users and use cases.
- A preliminary analytic assessment of three existing APCDs: The goal of the data assessment was to acquire three APCDs and assess data availability, documentation, and data completeness. The analysis focused on aspects that were relevant to measures and provided a preliminary assessment of the completeness and face validity of critical data elements.
