The Colorado All Payer Claims Database (CO APCD) contains medical, dental, and pharmacy claims from the majority of insured individuals in the state. However, claims data only shows a portion of how the health care system functions. There are numerous other components within the system that impact an individual’s health or cost of their care that don’t center on claims. The CO APCD is one of the few APCDs in the country to receive this non-claims data about two of these components: Alternative Payment Models (APMs) and prescription drug rebates. With information on both, the CO APCD offers a unique glimpse into the less explored aspects of health care.

Alternative Payment Models

Alternative Payment Models (APM) are ways of paying providers that encourage higher quality and more coordinated, cost-efficient care. By focusing on value of services over volume, APM models bring more holistic, efficient, person-centered care into focus.

As health care costs continue to rise, legislators, community partners, and providers across Colorado have been seeking solutions to curb prices while improving the quality of care and overall population health. Health insurers 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 partners, CIVHC has improved APM file submission guidelines to more accurately report APM use in Colorado. Beginning in 2020, all files were required to align with APM categories based on standards created by the Health Care Payment Learning & Action Network.

APM files for 2020-2022 will be collected in September 2023 according to the specifications in the Data Submission Guide (DSG) 14, which went into effect in March. CIVHC continues to evaluate submitted files and identify opportunities to improve data specifications around collection of APM data.

An updated public report on the use of APMs in Colorado between 2019 and 2021 was recently released on CIVHC’s Affordability Dashboard. For more information, view the interactive dashboard, download our infographic, and review our issue brief.

Drug Rebates

Total rebates, compensation, remuneration, and any other price concessions (including concessions from price protection and hold harmless contract clauses) provided by pharmaceutical manufacturers for prescription drugs with specified dates of fill, excluding manufacturer-provided fair market value bona fide service fees.

Prescription drugs represent one of the nation’s most significant drivers of rising health care costs. But the system through which they move is historically opaque, and until recently, not much was known about the amount of drug rebates 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 2023, CIVHC will release an update to the CO APCD interactive report analyzing prescription drug spending and rebates based on data collected for 2019-2021 in September 2022. The analysis currently available on the Affordability Dashboard covers drug spending data for 2018-2020. CIVHC will continue 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. Two new prescription drugs files were added recently submissions to 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. The bill requires the addition of a new PDAB file new file to the CO APCD to collect additional drug affordability data. The first set of data was delivered to the Division of Insurance (DOI) for analysis in February 2022.
  • Data to better understand how reimbursements for value-based pharmaceutical contracts (VBPC) are structured.

Additionally, as with APM data, the current DSG 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 most current interactive report on drug rebates and APMs, visit the Affordability Dashboard.