With a resource the size of the Colorado All Payer Claims Database (CO APCD), it is easy to presume that the possibilities for exploration are endless. In some senses, it is true that comprehending the potential combinations of data elements from over one billion claims is nearly impossible. However, the scale of the database doesn’t translate into unlimited capabilities. Some limitations exist because of the nature of claims data itself, and others are created due to information not being submitted to the CO APCD, elements not being collected by payers, or regulations around certain types of data.

Claims Data Limitations

Claims data is administrative data and meant to transmit reimbursement information between provider and health plan. Given this most basic function, it does not include clinical information such as test results or patient health histories. It also, by necessity, is retroactive as it takes time for the claim to move through the system of processing and payment before it reaches the CO APCD. Finally, because the database only contains information that comes in from paid health insurance claims, any service paid for out-of-pocket, or that does not have a claim attached, is not included. This means that the CO APCD does not capture the uninsured population in Colorado or services where a fee is not charged.

Information Not Submitted to the CO APCD

Despite its name, the CO APCD does not include all payers in Colorado. Some, such as self-funded employer plans subject to the Employee Retirement Income Security Act (ERISA) or Worker’s Compensation insurers do not submit claims because they are not required by law like other payers. Similarly, data from Federal health insurance programs such as TriCare, the Veterans Administration, Indian Health Service, Federal Employee Health Benefits (FEHB), or other Federally sponsored programs is not part of the database.

The Data Submission Guide (DSG) provides the payers with the data elements that should be submitted each month, and not all of the potential information on a claim is included. Currently, CIVHC does not collect premium or health plan design information or data about capitated fees or provider incentive payments. These items could be collected in the future via a Rule Change with the Colorado Department of Health Care Policy and Financing (HCPF).

Elements Not Collected by Payers

In some cases, data cannot be included in the CO APCD because it is not collected by the submitters. For example, free-standing emergency rooms (FSED) are frequently billed by the hospital with which they are affiliated rather than as a stand-alone facility. Lumping the two types of facilities under one billing entity makes it difficult to determine where a service actually took place. Another example is demographic and socioeconomic information about patients, which has become increasingly vital in identifying and eliminating health disparities during COVID. Fields in the claims designed to capture race and ethnicity in particular are frequently indicated as “Unknown” for most commercial payers. This is because the majority of commercial payers do not ask for this information at the time of enrollment, and if they do, it is not a required field and may be left intentionally blank by the enrollee. CIVHC is taking steps to improve the collection of race and ethnicity data through a variety of methods, however,  gaps still exist. Efforts to improvement in the collection of data for both examples above are ongoing.

Data Not Submitted Due to Regulations

Federal and state regulations also play a role in determining what data is included in the CO APCD. The two types of information currently most impacted by regulation are claims from self-funded ERISA employers and substance use disorder (SUD) claims.

Self-funded ERISA Claims

Due to a 2016 ruling by the United States Supreme Court, states cannot mandate submission of claims data from self-insured Employee Retirement Income Security Act (ERISA) plans to APCDs. The ruling did not impact collection of data from non-ERISA self-insured employers or those ERISA-based employers who choose to voluntarily submit claims to APCDs. CIVHC continues to collect non-ERISA self-insured employer claims and conducts robust outreach to encourage voluntary submission from the ERISA employers. Self-insured claims are estimated to represent half of the total commercially insured lives in Colorado and CIVHC estimates that the CO APCD currently contains approximately a quarter of ERISA self-insured lives and half of all self-insured lives.

Data Subject to Circumstantial Release

The Data Submission Guide (DSG) provides payers with the data elements that should be submitted each month, but not all data elements collected in the CO APCD are available for public or non-public release. Some data CIVHC collects can currently only be paid with specific audiences due to policy regulations.

Under DSG 13, CIVHC now collects premium and health plan design information, as well as data on capitated fees and provider incentive payments. However, this data is not used in public nor non-public reporting and is only shared with the Division of Insurance (DOI) as background to support DOI’s initiatives to investigate cost of care in Colorado.

Additionally, while CIVHC collects information on Alternative Payment Models (APMs) and prescription drug rebates, that information is released exclusively as aggregated data in CIVHC’s public reporting releases and is not available to be released to partners or clients in non-public reports.

Substance Use Disorder Claims

Federal regulations on the use and release of Substance Use Disorder (SUD) claims data have undergone changes in recent years, which has broadened CIVHC’s ability to collect and process SUD claims. Previously, part two of item 42 in the Code of Federal Regulations (CFR), which sets criteria for the release of SUD information, imposed very narrow limitations for the release of SUD information that submitting claims to the CO APCD did not meet the criteria for.

However, under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), passed in March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) significantly expanded the use of SUD data. As a result, CIVHC was able to put the proper measures in place to open SUD data collection and began collecting those claims in July 2022. To learn more about SUD claims in the CO APCD and how CIVHC manages the unique regulations and requirements around collecting this data, read our Query on the topic.

These are a handful of the limitations that can arise when working with claims data and the CO APCD. Others may stem from external factors like incompatible computer systems or data files – like those between claims and clinical data. There is also no consistent format for payers to house their claims information with each devising their own systems and ability to produce analytics (a problem common to many other types of health care data as well). Therefore, some payers are unable to produce all of the data elements according to the DSG and in some cases have to apply for a submission waiver until they can figure out a solution.