Expanding Maryland s APCD: the Role of the Health Insurance Exchange Establishment Funding

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1 Expanding Maryland s APCD: the Role of the Health Insurance Exchange Establishment Funding Ben Steffen Maryland Health Care Commission October 23, 2012

2 Legislative History MCDB created by the Maryland Legislature in 1993 Requires private carriers (with $1 million in premiums) to submit paid claims information for Maryland residents to the MHCC Originally limited to paid claims for professional services (for possible rate-setting) Authority expanded in 1999 to include prescription drug claims In 2007, authority was expanded to permit collection of institutional claims, eligibility information, health plan descriptions Required to issue annual reports on cost & utilization of services 2

3 Data Flows Annual private insurer data submissions to MCDB Content for each year set by MHCC, with carrier input 20 Payer Units, representing 11 carriers, submit data Created as of April 30 th ; due to vendor by June 30 th Data components of our APCD (All Payer Claims Database) MCDB files (professional, institutional, Rx, eligibility) Medicare data files (eligibility, all service types except Rx) No Medicaid data 3

4 Data Analysis from MCDB Mission: The mission for the MCDB is to be the source of information on health care payments and services that could be used to support the development of cost containment strategies and assist payers, policymakers, practitioners, and the public in health care decision-making. Current Uses Data supports legislatively required analyses, MHCC programs (small group market and privately insured large group), and Commission originated studies Use in incubator projects -- PCMH functions attribution and shared savings The glory: new uses focus on measurement Source for risk adjustment under the Health Benefit Exchange Provider measurement Impact on transition in coverage (churn) The dream: Broader studies for building on health reform Population health -- monitoring health status of smaller areas -- Hot spotting Tool to examine value-based benefits 4

5 Plans for APCD Expansion Creation of a reliable unique patient identifier suitable for use across all payers Addition of Rx data from PBMs carved out products Collection of plan information from carriers (EPO, PPO, CDHP designs) Addition of Medicaid MCO data Direct submission from MCOs until 2015 Post-2015 access through MMIS II Addition of dental claims from dental insurance providers 5

6 Federal Exchange planning funds may offer an opportunity to expand APCDs Exchanges (connection, connector) - marketplaces in which individuals and small businesses can choose affordable, comprehensive health insurance plans. The ACA authorizes states to establish an exchange; if a state elects not to or is unable to do so, the Federal government will establish a Federallyfacilitated Exchange in the state.

7 State actions to establish Health Insurance Exchanges vary Source: Kaiser Family Foundation Health Reform site as of September 27,

8 The Federal Government has funded Health Insurance Exchange planning in most states State Health Insurance Exchange Establishment Grants Source: HEALTHCARE.GOV, 8

9 Taking advantage of Exchange Planning Grants States that intend to establish an Exchange have access to Establishment Grants Federal funds can be used to establish the exchange, must graduate to state funding in 2015 Funding can not be used for the navigator programs Federal funds can be requested for functions that the state plans to take on.. State-Based Exchange Model five core functions - (1) consumer assistance and outreach, (2) plan management, (3) eligibility, (4) enrollment, and (5) financial management State-Federal Partnership Model - state selects from core functions State operates plan management functions State operates selected consumer assistance functions State operates plan management and selected consumer assistance functions HHS performs remaining exchange functions and ensures the exchange meets ACA standards Federal Facilitated Exchange not a vehicle for financing APCD 9

10 Align APCD goals with core functions that can be funded under an Establishment Grant APCD Goals: Track individuals through a anonymous master patient identifier number Develop a more comprehensive APCD Expand existing database by collecting Medicaid data Support broader health reform requirements Exchange functions that could be funded: Reinsurance and risk adjustment programs and analyses Enhance Quality reporting for QHPs Increased price and efficiency reporting a first step to enable valuebased product development which could be funded Establishment grants cannot fund ongoing operations of an exchange! 10

11 To access Establishment funds engage with the Exchange Maryland Insurance Admin. Maryland Health Department (Medicaid) Maryland Health Care Comm (APCD) Governor s Office of Health Reform Maryland Health Benefit Exchange CCIO The Center for Consumer Information & Insurance Oversight CRISP (State Health Information Exchange) Establishment grant development was characterized by significant collaboration among multiple state organizations 11

12 Link APCD Development to Health Insurance Exchange Establishment Grant Level Two Application Summary Award Amount: $123,048,693 Award Date: August 23, 2012 Application Due Date: June 29, 2012 Level of Funding: Level Two Summary: On behalf of the Maryland Health Benefit Exchange, the Maryland Department of Health and Mental Hygiene (DHMH) is receiving a Level Two Establishment grant to accomplish the necessary activities to achieve certification by January 2013 and begin enrolling individuals through a state-based exchange for coverage effective January 1, Specifically, the funding will enable the Maryland Health Benefit Exchange to meet the rapid implementation requirements of the ACA, including IT systems, business operations, and program integration with state and federal agencies, stakeholder engagement, consumer assistance, as well as outreach and education. 12

13 Establishment funds will allow meaningful expansion of the APCD Enhancement of Maryland s All Payer Claims Database (APCD) by expanded collection and establishing master patient index linked to core functions of a state-based exchange: Reinsurance and risk adjustment programs Quality reporting Transparency in pricing and evaluation

14 MPI: Opportunities for Deeper Analysis Correlating a statewide MPI identifier to the APCD can enable a series of data linkages across administrative and clinical data sets. The linkage of the MPI identifier will allow for a specific analysis of expected churn between Medicaid and HBE-offered QHPs as member eligibility status changes over time. These linkage opportunities will enhance capabilities to link the APCD with hospital discharge data, statewide HIE data, and HBE information. Analyses enabled by linkages could provide insights into how members migrate among health plans and into utilization costs and patterns, and allow for new studies of the relationship between benefits and care delivery to support HBE quality rankings. Correlating APCD data to HIE clinical data can support study of small areas that are resulting in disproportionally high levels of high costs health service utilization.

15 Master Patient Index Overview In the absence of a unique healthcare patient identifier, tools to link patient identities and records across hospitals, practices, and other data sources are necessary to create a holistic view of a patient. The core function of an MPI is to link medical record numbers from individual data sources (such as hospitals). The Establishment funding will build on the capability to generate a unique identifier that will be based on the MPI, but separate. The challenge in master patient indexing (MPI) is accurate identity linking that reduces the risk of false positive correlations (linking patient identities that should not be linked) to a near zero level while ensuring limited false negative correlations (not linking patient identities that should be linked). The CRISP HIE relies on the IBM InfoSphere (formerly called Initiate ) MPI. This MPI uses a probabilistic matching algorithm that compares demographic data (such as name, address and, and DOB) and can account for the variation inherent in patient registration processes and record keeping.

16 What are the concerns? Extreme Deadlines Grant ends 12/2014 Multiple oversight Federal oversight Exchange has oversight responsibilities Grant funds are for establishment, how to sustain? Select expansions that require planning or one time investments MPI licensing costs will decline overtime Integration of Medicaid migration to new MMIS will lower costs Grant approach must recognize APCD overall funding strategy avoid overreach At least four states have used Establishment funds to align APCD with requirements under the ACA.