The Colorado All Payer Claims Database (CO APCD) contains medical, pharmacy, vision, and dental claims from the majority of insured individuals in the state and collects non-claims data on additional components that impact individual health and cost of care. However, collecting all this data is only the beginning for those investigating how the health care system is functioning.
The CO APCD is one of the few APCDs in the country to allow access to this non-claim data. Once in the CO APCD, Change Agents and CIVHC analysts can use them to gain valuable insights to improve health care through specialized analytics. Examples of these specialized analytics are two reports that use special software tools: Low Value Care in Colorado and Medicare Reference Based Pricing.
Medicare Reference Based Pricing
Using CO APCD data, CIVHC’s Medicare Reference Based Pricing analysis reports the prices paid to facilities by Medicare for combined inpatient and outpatient services as a point-of-reference and compares them to what commercial health insurance companies pay for those same services. These comparisons can identify opportunities for Change Agents to lower the cost of care in Colorado.
CIVHC continually evolves our analytic methodologies, with the Medicare reference pricing report as a standout example. In earlier iterations of this report, CIVHC relied on nationally reported benchmarks. As CIVHC’s analytic capabilities have expanded, the report has adapted to use a more precise and localized approach.
Beginning in 2024, CIVHC transitioned to a new methodology built on Medicare Fee-for-Service (FFS) claims submitted to the CO APCD. To perform the analysis, CIVHC engaged the health care actuarial and consulting firm Milliman to leverage its Medicare Repricer Tool – a sophisticated system that applies Medicare reimbursement logic to commercial claims. The tool accounts for provider type, geography, service setting, procedure complexity, and billing variations to create a more accurate Medicare benchmark tailored to Colorado’s health care system.
To learn more about the Medicare reference pricing analysis, read CIVHC’s full methodology and view the interactive dashboard.
Low Value Care
CIVHC’s Low Value Care analysis identifies health care services that are often costly and do not improve health or, in some cases, even cause harm. Spending on these “low value” services accounts for millions of dollars in excess spending. Coloradans can use this analysis to identify which of these services are happening most often and where.
Low value care services have been defined in a variety of ways by many organizations, but a consensus has formed around the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely guidelines, which identifies more than 700 services as low value. CIVHC used these guidelines to identify and define over 50 low value services that could be measured from claims data in the CO APCD.
To augment the analysis, CIVHC engaged Milliman to apply their MedInsight Health Waste Calculator software to CO APCD data to measure the use of these low value services.
The Milliman Health Waste calculator is able to identify patients who have received one of these potentially wasteful services and determine if the service was necessary, likely wasteful, or wasteful based on patient history and the conditions around which the service was received.
Ultimately, both analyses underscore CIVHC’s commitment to analytic excellence. By leveraging the power of the CO APCD in combination with advanced tools from Milliman, CIVHC continues to deliver rigorous and actionable insights that help drive improvements in health care affordability and equity across the state.
If you have questions about either of these reports or analytics used in the CO APCD, contact us at info@civhc.org.