Center for Improving Value in Health Care
Apr 19, 2016 | 0 comments | Posted by Global Administrator
Health Reform, Colorado All Payer Claims Database
Recently, I had the opportunity to chat with a national reporter about how the Supreme Court’s Gobeille vs. Liberty Mutual decision impacts Colorado’s All Payer Claims Database (CO APCD). She was surprised to learn that our perspective is significantly different from that of other states with APCDs, who feel the decision greatly affects the value of their database. While the CO APCD would certainly benefit from adding claims from self-insured employers that fall under the Employee Retirement Income Security Act (ERISA), Colorado is already gaining valuable insights from the database and those insights will only improve as we add voluntary claims from ERISA self-insured employers.
First, it is important to understand what the CO APCD currently contains, and which claims are impacted by the Supreme Court decision. In essence, Gobeille vs. Liberty Mutual, prohibits states from requiring ERISA self-insured employers to submit claims to an APCD. Under the original Colorado legislation, enacted in 2012, and through the Medicare State Agency request process, the CO APCD contains claims from Medicare (Fee-for-Service and Medicare Advantage), Medicaid, and the largest 33 commercial health plans (large group, small group and individual lines of business). This represents the majority (over 65%) of covered lives in Colorado and is the most comprehensive source of health care claims information for the state.
Within the 35% of insured lives not currently in the CO APCD, 10% are covered under federal programs like TRICARE and Veterans Affairs. The remaining 25% represent self-insured employers, and only some of those are subject to the federal ERISA laws affected by the Supreme Court decision. Non-ERISA self-insured employers, including state and local government agencies, school districts and churches, are not subject to the Gobeille vs. Liberty Mutual ruling and are still required to submit claims to the CO APCD under the rule change that went into effect last year.
The same rule change allowed ERISA self-insured employers to opt-out of submission for 2015 and 2016. The Department of Health Care Policy and Financing (HCPF) included the opt-out option to give first time ERISA employer submitters and their third party administrators (TPAs) or Administrative Service Organizations (ASO) time to prepare to submit to the CO APCD and to allow for ruling from the Supreme Court.
Based on information from the Division of Insurance, CIVHC estimates that there are a little over 1 million lives covered by self-insured employers in the state, some subject to ERISA and some not. Since the rule change was effective prior to the Supreme Court ruling, CIVHC began receiving the first round of self-insured employer claims in January of 2016. These new claims represent over 700,000 lives in addition to the already 3.5 million lives included in the database.
To align with the Supreme Court decision, CIVHC is working with HCPF to revise the rule and remove the requirement for ERISA self-insured employers. However, as we engage and educate the employer community in the upcoming months, we believe employers will continue to submit claims on a voluntary basis once they understand the value the data can provide to their business, employees, and to Colorado.
As an example, one large employer in the state began voluntarily submitting their claims to the CO APCD long before the rule change went into effect. This employer is using CO APCD data to compare their health care costs to the fully insured market and to see trends in employee spending and utilization of services. This information will help them identify ways they can save on premiums and simultaneously provide better care for their employees. CIVHC plans to share specific use cases like this and others with the employer community to demonstrate the value of submitting claims to the CO APCD. Through this discussion, we believe we will continue to receive submissions from the ERISA self-insured employers on a voluntary basis.
In the meantime, policy makers, consumers, and others already benefit from the extensive data available publicly on the CO APCD website, www.comedprice.org. In addition, organizations working to achieve the Triple Aim of better health, better care and lower costs are regularly receiving custom CO APCD data. In fact, CIVHC has fulfilled over 80 unique requests for data sets and analytics in the last four years. We anticipate that number to increase significantly as we launch new online subscriber tools to provide facilities, payers, providers, and other stakeholders with ways to improve care that they’ve never considered.
Was the Supreme Court decision what we’d hoped it would be? No.
Does it impact transparency efforts nationally? Absolutely.
Does it make the CO APCD obsolete now or in the future? Absolutely not.
Since 2013, the CO APCD has been a neutral and unbiased source of health care information in Colorado and the Gobeille vs. Liberty Mutual decision does not change its importance or utility. Over the upcoming months and years, CIVHC is committed to increasing the scope of the CO APCD and to engaging and educating self-insured employers, providers, consumers, and other stakeholders across the state about the value inherent in this incredible asset.
CIVHC will continue to provide updates on the status of the rule change in Colorado and ways employers can benefit from the CO APCD. For more information about the impact of the Supreme Court decision, view our FAQs and the HCPF press release.
About the Author: Ana English is CIVHC's President and CEO. Contact her at firstname.lastname@example.org
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