Approaching the Colorado All Payer Claims Database (CO APCD) to get answers to even the simplest of questions can feel daunting. How do you begin to craft a question when the entity you’re querying contains billions of data elements stored in 1s and 0s in cyberspace somewhere? How do you get your mind around what answers are even possible, much less come up with a coherent question that helps you solve your problem?
First, step away from the void; the answer does not lie in the macro. The secret decoder ring for unlocking the potential of the CO APCD is on the micro-level. One of the best ways to grasp what the CO APCD can do is to consider what it is used for – collecting payment. Claims data contains the information necessary for a provider to file a claim with an insurance company and be reimbursed for services rendered. This information is passed along via a special set of codes on forms that specify diagnoses, treatments, lab tests, and prescriptions. Claims have no clinical data because it is not necessary for the insurance company to know the height, weight, blood type, or medical history of a patient in order to reimburse a provider.
Claims identify which provider a patient saw, what health insurance the patient has, the types of tests and services that were performed, what the patient diagnosis was, and how much the insurance company paid and how much the patient was responsible for. In order to reimburse providers accurately, the insurance company needs to know what services were provided to each patient, so diagnosis and treatment codes are used to quickly fill in this information. Associated with each hospital, office and remote telemedicine visit, and each prescription drug that gets filled, there are codes that tell the insurance company how much to reimburse the provider and how much of the bill the patient pays.
Now it is possible to break the components of the claim down to understand potential applications of the information it contains.
- Payment/Cost Information – Change Agents can investigate how care is paid for in any number of ways – reimbursement, cost of care, patient out of pocket spending, etc.
- Utilization – using site of service, provider, treatment, and other codes, Change Agents can explore what type of care Coloradans are accessing, when, where and for what reasons
- Chronic Conditions – diagnosis codes can help define populations or groups with certain types of conditions such as diabetes or hypertension for Change Agents to study the most effective interventions, treatments, ways to reduce cost, or the impact of demographic or geographic factors such as age, race or location.
Once you get your mind around the building blocks of the claim, the combinations and possibilities for investigation can seem endless. However, there are some limitations to the CO APCD due to federal or state rules or data submission guidelines. To help keep everything straight, CIVHC created a guide to the capabilities of the CO APCD. This handy list explains what information is usually not found in claims data, what cannot be collected, what is possible to get from claims but not available currently, and what is already available in the CO APCD. Additionally, to help illustrate the range of potential questions to be answered, the Change Agent Index contains many examples of how the CO APCD has been used to improve the lives of Coloradans.