All Payer Claims Database (APCD) Vendor Approval

Transcription

1 All Payer Claims Database (APCD) Vendor Approval Presented by: Marina Coleridge & David Flores 1

2 Background Over the past 10 years a growing number of all-payer claims databases (APCD) have been established. APCDs are a response to a need for comprehensive multipayer data that allows stakeholders to understand the cost, quality, and utilization of health care. APCDs are large-scale databases that systematically collect medical claims, pharmacy claims, dental claims, and eligibility and provider files from private and public payers 1. Recommendations from health policy fellowships and organizations for employers and consumers advocate establishing APCDs in the overall effort of containing healthcare costs. 2 In March of 2014 HSS submitted a comprehensive RFP for an APCD to 13 vendors. 1 The Basics of All-Payer Claims Databases APCD 2 PBGH Policy Brief: Price Transparency 2013, Catalyst for Payment Reform 2014 Model Health Plan Contract Language on Payment Reform 2

3 The Path to an All Payer Claims Database The Health Service System has maintained a consistent objective for enhanced reporting and informatics. Implement and improve dashboard HSS Strategic Plan Improve data collection standards and presentation, Make data more flexible, informative and actionable, Apply industry standard trend analysis and forecasting, include industry benchmarks HSS Strategic Goals establish(ing) baseline data to measure the effectiveness of pilot projects related to physical and mental health, disease prevention, early detection, chronic condition management, smoking cessation and stress reduction, enhance dashboard reporting and informatics, Monitor effectiveness of ACOs, Provide data analysis, Report on trends HSS Strategic Plan HSS Initiatives to improve care and reduce costs: Obtaining full claims data files to support analytics October 2013, Accountability & Transparency Hearing 3

4 The Path to an All Payer Claims Database The Health Service System has acknowledged challenges and delays. Enhancing the dashboard is off to a late start.. March 2012 HSS Strategic Plan Status Update HSS is behind on developing the statistical tools needed to effectively manage flex-funding Dashboard enhancements and tools for trend analysis and forecasting, have been deferred February 2013 HSS Strategic Plan Update Lack of transparency prohibits HSS from more clearly understanding medical service utilization and the cost for medical services February 2013 HSS Strategic Plan Update 4

5 The Path to an All Payer Claims Database Excerpt from May 2013 Statement in Support of Accountability & Transparency signed by the Mayor, the Mayor, Controller, DHR, HSS, SEIU, PEC: To that end, we agree to work toward: Establishment of multi-payer databases pooling claims and other health data.. Excerpt from July 2013 Board of Supervisors Transparency Resolution: FURTHER RESOLVED, That the Board of Supervisors recommends that Health Service system healthcare vendor contracts should contain contract language requiring health plans, health care providers and physician groups to submit data to the HSS all payer claims database per data specifications negotiated with the Health Service System. Excerpt from HSS Wellness Plan approved June 2014 by Health Service Board HSS is developing a new claims database that will enable streamlined tracking and reporting of claims data from the health plan providers. This database will contain medical and Rx claims and will form the core of a benchmarking system. The claims database will provide information necessary for cost analysis, quality metric development, plan design based on coverage and utilization and rate setting. The third party vendor will be tasked with bringing the claims data from each health provider into the database, and running standard summary level reports. A claims database maintained by a third party compliant with all privacy and security requirements ensures employee data will remain completely confidential 5

6 Milestones July 2013 HSS Transparency Resolution approved by Board of Supervisors May 2013 JLMCHW Statement in Support of Accountability & Transparency April 2013 draft Transparency Resolution presented to HSB September 2012 JLMCHW Kickoff November 2013 Transparency & Accountability Hearing BOS Budget & Finance Committee August 2013 Initiated Process for KP claims data June 2014 Draft Wellness Plan January 2014 $2.05 Budget recommendation to HSB for Claims Database July 2014 Oct 2014 Direct Negotiations with Vendor and Data Sources June 2014 Notice of Intent to Negotiate February 2014 APCD RFP Black-Out Notice, March 2014 RFP Released to Market 6

7 HSS APCD Overview DATA SOURCES CHARACTERISTICS ANALYTICS Rx and Medical Claims from United HealthCare, Blue Shield, Kaiser Permanente Well-Being Assessment Summary Scores Eligibility File MarketScan Benchmarks Claims information will be de-identified. Employee data will remain completely confidential Claims data will be updated quarterly / Well- Being Assessment data annually Analysis of Wellness Initiatives / Disease Management Programs Medical Risk Scores / Risk Adjusted Episodes Potentially Avoidable Costs/Complications Gaps in Care (Evidenced Based Guidelines) Audits / Ad-hoc Analysis Cost & Utilization Trends Clinical Performance Measures Integrated, Summary Information, Dashboards 7

8 Executive Summary In March of 2014 HSS submitted a comprehensive RFP for an APCD to 13 vendors. Truven Health Analytics was selected through Request for Proposals HSS1401. HSS recommends that the HS Board approve entering a contract with Truven Health Analytics for the period of February 1, 2015 June 30, 2018, in an amount not to exceed $632,500. The purpose of the contract is to develop, implement and maintain an All-Payer Claims Database. Upon approval by the Board, HSS will continue the procurement process. Outlined on the following slides are the summary of services to be provided and the calculation of charges. 8

9 Summary of Services to be Provided Contractor will provide the following services under this Agreement: Design and develop an Initial Database using the standard Advantage Suite Employer data model. Advantage Suite is the Contractor s set of decision support solutions. Create and maintain demographic fields in the database only from source data provided by the eligibility Data Source(s) listed. Create reporting dimensions using the standard Advantage Suite Employer Eligibility table and up to 15 custom eligibility-based fields. Build, test and produce the Initial Database. Deliver with the Initial Database the standard templates and reports populated for the covered population. Provide a security view with all member data de-identified. All PHI will be restricted and not accessible. Refresh the data as required by HSS. 9

10 Summary of Services to be Provided Cont. Contractor will provide the following services under this Agreement: Provide basic end user training. Conduct status calls on a regular basis at HSS desired frequency. Deliver Analytic alerts customized to reflect HSS data. Invite HSS to join multi-customer workgroups. Invite HSS to periodic webinars and educational series. Provide HSS with standard static quarterly dashboards (Key Trends reports). Provide focused account team to provide customer service, customer advocacy, and support future business opportunities. Periodically review HSS recent healthcare experience and business climate, discuss industry trends and opportunities and refine analytic agenda. 10

11 Calculation of Charges The total not to exceed amount of this Agreement for the term February 1, 2015 through June 30, 2018 shall not exceed $632,500. HSS retains the right to renew this Agreement for two (2) additional years at its sole discretion based on availability of funding and satisfactory Contractor performance. The annual fees are summarized as follows: Contract Year Development Service Fees License Fees Total Fees 2/1/15 6/30/15 $85,000 $85,000 7/1/15 6/30/16 $110,900 71,600 $182,500 7/1/16 6/30/17 $108,700 $73,800 $182,500 7/1/17 6/30/18 $108,700 $73,800 $182,500 TOTAL $85,000 $328,300 $219,200 $632,500 11

12 Appendix Statement in Support of Accountability and Transparency HSS Draft Resolution: Health Benefits Purchasing and Data Transparency on.pdf Board of Supervisors Transparency Resolution S pdf CITY & COUNTY OF SAN FRANCISCO Wellness Plan CalPERS Transparency Resolution 12

13 Appendix PBGH Policy Brief: Price Transparency Catalyst for Payment Reform: 2014 Model Contract Language Basics of All-Payer Claims Databases 13