On February 6, 2020, the U.S. Department of Health & Human Services (HHS) published its annual draft rule governing core provisions of the Affordable Care Act (ACA), including the operation of the marketplaces, standards for individual and small-group market health plans, and premium stabilization programs. This expert perspective focuses on several policies that would have implications for state insurance regulation and the operation of the state-based marketplaces (SBMs). Comments on the rule are due March 2, 2020.
Applicability of All-Payer Claims Databases for Rate Review and Other Regulatory Functions
Wakely Consulting Group – Julia Lerche and Ross Winkelman
All-payer claims databases (APCDs) collect and compile medical, pharmacy, and sometimes dental claims, eligibility, and provider files from public and private payers. APCDs are currently being used for a variety of functions, including population health analysis, comparative analysis of provider and facility quality, cost management for Medicaid and other public programs, support for provider payment reform initiatives, and consumer transparency tools. This issue brief, prepared by Wakely Consulting Group, builds on conversations with a number of states at the State Network All-Payer Claims Database Small Group Convening in January 2014, and is intended to explain the potential uses of APCDs for rate review and other regulatory functions. It includes descriptions of possible uses for APCDs and ranks the level of effort necessary to use an APCD for those purposes, along with the relative value of doing so.