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Vermont Healthcare Claims Uniform Reporting & Evaluation System: Evolving Analytical Applications for Claims Data Dian Kahn, B.S.N., M.P.A.

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Presentation on theme: "Vermont Healthcare Claims Uniform Reporting & Evaluation System: Evolving Analytical Applications for Claims Data Dian Kahn, B.S.N., M.P.A."— Presentation transcript:

1 Vermont Healthcare Claims Uniform Reporting & Evaluation System: Evolving Analytical Applications for Claims Data Dian Kahn, B.S.N., M.P.A. Presented at the 6th Annual All Payer Database Conference National Association of Health Data Organizations State Uses of APCDs for Policy, Healthcare Reform, and Reporting October 25, Department of Financial Regulation

2 Building the “RES” in VHCURES? Vermont Healthcare Claims Uniform Reporting & Evaluation System Broad State Mandate (18 V.S.A. §9410): To the extent allowed by HIPAA, the data shall be available as a resource for insurers, employers, providers, purchasers of health care and state agencies to continuously review health care utilization, expenditures, and performance in Vermont. Only a single specified mandated annual report of insurer paid claims amounts by insurer is the basis for the calculation of two state assessments on insurers. Who can use the data? Proposed use must meets statutory and regulatory criteria. “Serves the needs of the State of Vermont and/or the public interest.” Not approved for proprietary commercial use. Analytical uses are evolving and expanding as Vermont’s health care reforms are planned, implemented, monitored, and evaluated. State Financing Model Insurance Exchange Planning Advanced Primary Care Medical Home Payment Reform, etc. 2

3 VHCURES Development Drives and Responds to Needs for Analytics Phase 1: Commercial Insurers and Insured Population Get the data! Start collecting the data, get reporting compliance, and achieve basic data completeness/quality. Report the basics! Commercial enrollment, expenditures, HEDIS process measures, in- state geographic variation; test utility of APCD for enhancing insurance rate review. Utilization and expenditures measures applied to subset of commercial insurers participating in Blueprint primary care medical home program. Start to think regional! Interstate agreement to support the Vermont Tri-state Report on Variation in commercial insurance utilization and expenditures (VT, NH,ME). Phase 2: Integration of Medicaid and Medicare Increased demand ! Proliferation of data use agreements including 5 state agencies. 150 data user affidavits on file linked to 17 DUAs including state employees, state contractors, and approved researchers. Some DUAs approved for both commercial and Medicaid data. Medicare Use Limited ! Obtained through CMMI MAPCP grant with use limited to medical home program evaluation and CMS conditions of use. Deeper Analytics! Comparative cohort study for Blueprint medical home program. 3

4 VHCURES Development Drives and Responds to Needs for Analytics Phase 3: 2012 and Future: Informatics and Technology Convergence for Big Data Continuous Data Quality Improvement! Data Users Group includes users, researchers, and insurers to identify issues with current data- prioritization, points of accountability, action plan; recommend future enhancements to reporting requirements- feasibility, prioritization, action plan; and share knowledge about using claims data in health care services, public health, and health policy research. Planning wiki site for information sharing. Current distribution list for data users group= 150+ individuals. Urge to Merge! Exploring legal and technical issues related to data linkage across administrative, financial, clinical, registry, vital records data to support longitudinal and comprehensive person-level records. More Robust Analytics! “What if” modeling for predicting risk, utilization, cost, access to services (provider and service detail); spatial analysis with richer geographic, demographic, health status/risk, socioeconomic detail. Inclusion of both commercial and Medicaid populations in standard report series and approved studies. Will seek CMS DUA for broader use of Medicare data than currently authorized under MAPCP grant. Comparative Benchmarks! Explore options for interstate data sharing agreements with other APCD states and participate in CMS/ASPE MCDB as data submitter and user. 4

5 Tri-State Variation in Health Services Outpatient Use – Potentially Avoidable Outpatient ED Visits 5 Newport (50.8) Burlington (16.1) Caribou (136.3) Tri-State Variation in Health Services Utilization & Expenditures in Northern New England, June Sore throat, strep Viral infection, unspecified Anxiety, unspecified or generalized Conjunctivitis, acute or unspecified External & middle ear infections, acute or unspecified Upper respiratory infections, acute or unspecified Bronchitis, acute or unspecified, & cough Asthma Dermatitis & rash Joint pain Lower/unspecified back pain Muscle/soft tissue limb pain Fatigue Headache

6 SAMPLE MEASURE- Per Member Per Month Claims Expenditures Comprehensive chart book of measures for health status, utilization, and expenditures to be released in November 2012 with commercial and Medicaid data for under 65 populations enrolled with comprehensive benefits spanning incurred service period of January 1, December 31, THIS IS A TEMPLATE AND DOES NOT INCLUDE ACTUAL DATA 6

7 % of Each Vermont Town’s Primary Care Visits to Burlington 49.6% of Burlington member visits (05401 Zip Code) were to providers in the Zip Code. These data (05401 to 05401) cannot be shown using a spider diagram. 7 Primary Care Service Area Study: Merges and reconciles provider data from claims with primary care practice roster, HIE practice registry, and licensure data for physicians, ARNPs, and PAs.

8 VHCURES program information including listing of reports: claims-uniform-reporting-and-evaluation-system-vhcure VHCURES Data Users Listing: Dian Kahn, Director of Analysis and Data Management or (802) 8


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