Wyoming Department of Health Presents on Multi-Payer Claims Database

By Tom Lacock
Wyoming Medical Society
CHEYENNE – The much-discussed concept of a Multi-Payer Claims Data Database was center stage during the Joint Appropriations Committee (JAC) meeting in Casper on Monday.

The JAC heard the findings of a study performed by the Wyoming Department of Health, which studied both a voluntary multi-payer claims database and; expanding the Wyoming Employees and Officials Group Insurance Program to allow private employers to join.

The studies were not originally slated to be combined, but the Department of Health suggested that if more companies were to join the current state health insurance plan it would reinforce the ability to gain more data due to more covered lives.

Wyoming Department of Health Director Tom Forslund and WDH policy analyst Franz Fuchs presented the study saying it aimed at containing costs and increasing quality in healthcare through market-based approaches. The study suggests claims data is necessary but not sufficient to make decisions.

Fuchs pointed out a multi-payer claims database (MPCD) turns raw and often-unintelligible claims data from multiple healthcare payers into actionable information used to make informed policy decisions. The Department of Health believed such a database could provide:

  • Situational awareness of cost and utilization trends, by payers, groups, regions and over time;
  • Cost, by provider type or service area, and payment levels, by provider and payer;
  • Utilization rates, from emergency department (ED) visits to inpatient admits and re-admits, to C-section and elective delivery rates, to joint-replacement and spinal fusion rates, etc.  Identification of the providers who offer the most value to insured members;
  • Overall costs for episodes of care;
  • Standardized pricing comparisons;
  • Quality outcomes, adjusted for patient acuity. Proactive identification of high-risk members through predictive risk-scoring.
  • Risk models can be developed from administrative claims data, but could be adapted to use electronic medical records as well.

The report went on to say having this data is necessary to lead to positive change for employers, but isn’t enough. The report also said there is no evidence that healthcare costs spontaneously decrease just from having a multi-payer claims database.

Having a database for database sake is a waste of money,” Forslund re-iterated. The question is what do you do with the data once you have it.”

“Out of all currently-operational All Payer Claims Databases (APCD), New Hampshire’s has been the most studied; two reports (2009 and 2014) have shown little impact on provider price variation since its inception in 2007. Indications are that the APCD’s associated website is still not yet widely used by consumers for price-shopping, but has been used by insurance plans to increase their leverage over providers,” the study said. “In general, studies indicate that these claims databases benefits payers who have the greatest incentives to consider prices: plans negotiating with providers for lower rates, as well as those consumers who are exposed most directly to price (e.g. with high deductibles).

The Department of Health would go on to suggest that the Colorado Center for Improving Value in Health Care and Physicians in Wisconsin have both used claims data to develop bundled payment opportunities.

The Wyoming Liberty Group testified in favor of the state continuing to study multi payer claims databases. Charlie Katebi told the JAC that patients need a more simplified pricing structure as it relates to medical costs and patients can use tools such as a multi payer claims database to select lower-cost medical options.

He suggested a product called SmartShopper, which offers online costs of a variety of treatments from a variety of providers nationwide. He claims the program has saved companies an estimated $12 million by rewarding patients who choose lower cost options with cash payments. SmartShopper them takes a cut of the shared savings as well. Katebi said the State of Kentucky has used the program very successfully already.

Anne Ladd, the director of the Wyoming Business Coalition on Health, said they have been developing a multi payer claims database for 10 years and is intrigued by the concept of SmartShopper. However, she points out SmartShopper only works with employers with 10,000 or more workers. In Wyoming, only the state has numbers of employees over 10,000. She said her own organization currently represents companies with a total of 9,000 covered lives.

“I’m intrigued by SmartShopper, but smaller employers can’t take advantage of that,” she said.

Ladd also brought a representative from the Montana Association of Health Care Purchasers (MAHCP), which claimed to have over 40,000 covered lives.

Ladd said if the state would join The Business Coalition on Health’s database they would ask for the past 24 months of stats immediately, and then request a data drop monthly.

The Department of Health said it would cost the state $320,000 to join an established database. They also suggested it would make more sense to join a database than to develop its own. Once again, the Department stressed the need for proper analysis of the data.

“It cannot be stressed enough, however, that merely having actionable information is a necessary, but not sufficient step to actually containing healthcare costs,” read the study. “It is important to know where to go. But without the reforms to the insurance plan itself, it is unlikely that either option will end up containing healthcare costs for the State of Wyoming.”

Mike Greear (R-Big Horn/Washakie) asked the Department what the next steps would be if the JAC was interested in joining such a database.

Forslund said the footnote which commissioned the study suggested the database study was to be presented to the Joint Labor, Health, and Social Services as well as the JAC and Wyoming Department of Health was awaiting a policy decision.

“We need direction however the legislature wishes to guide us,” Forslund said.

There was no direction offered before the JAC moved on to accept another report.

State Employees Health Group Insurance
Program Manager of the Wyoming Employees Group Insurance Ralph Hayes presented a report on changes in the Wyoming State Employees Group Health Insurance. During Monday’s meeting, Hayes presented a Segal Consulting actuarial report outlining claims experience projections for 2016-19. Those numbers will be used in helping to outline new insurance plan features for the state employees group insurance plan.

In his letter to the JAC, Hayes says in lieu of a rate increase of 7.4 percent, recommended by Segal Consulting, the firm doing an actuarial study for the state, A&I is making benefit changes to the state plan. They include:

  • Increasing the lower deductible options to $500 single/$1,000 family (previously the lowest option was $350 for single) and $900 single (replacing the $750 option) /$1,800 family;
  • Moving the base coinsurance from (for providers who are not in-network) from 80 percent to 75 percent coverage in hopes of incentivizing members to use lower cost in-state providers;
  • Moving non-participating provider maximum allowable cost reimbursement from 90 percent to 80 percent;
  • Increasing co-insurance payment for Dental basic restorative services from 50 percent to 80 percent.