Health Care Quality and Cost Council

1
Health Care Quality and Cost Council

• Proposal for DHCFP Management of
• QCC Claims Data Intake and Analytic File
  Production
• March 18, 2009

2
DHCFP Proposal

• Building on expertise and experience with health
  care claims data, the Division of Health Care
  Finance and Policy would be ready to assume
  responsibility for the intake and storage of QCC
  claims data and production of public use data
  sets beginning July 1st, 2009.

3
Project Management Team

• David Wessman, CIO, Division of Health Care
  Finance and Policy
• Will supervise design efforts ensure continuing
  integrity of hardware and software systems and
  implement technical architecture
• Related experience
• Implemented Health Safety Net claims processing
  in house, on time, under short deadline.
• Oversees intake of casemix data as well as
  hospital and community health center financial
  filings
• Extensive development of analytic tables for use
  in edit and QA of major datasets
• Dave will oversee Chloen Systems Inc.
• Chris Campeau, Chloen lead, has extensive
  experience designing claims adjudication systems
• Will design and test the claims intake functions
  develop, test and implement key reference and
  edit tables and provide overall technical
  management of the process.
• Projects completed include HSN Claims Data
  Collection (medical, eligibility and pharmacy)
  UCP Pharmacy Claims Data Collection UCP
  Hospital/CHC Claims Data Collection Insurer and
  Third Party Payer Surcharge Collection
• Linda Green, Director, Health Data Analytics,
  Division of Health Care Finance and Policy
• Will oversee development of QA metrics, design of
  public use file specifications production of
  related documentation annual dataset updates
  liaison to MHQP data staff and review of public
  use data requests
• Related experience
• Liaison to HCQCC staff during 2008 website
  analytics development
• Supervises analytic staff responsible for
  Division reports, including utilization and
  casemix data verification and public data file
  production

4
Advantages of DHCFP Management of QCC Claims
Intake and Public Use File Production

• Expertise in MA health data environment
• Streamlined data intake
• Enhanced quality assurance
• Enhanced collaboration with insurers
• Production of analysis-ready public use files
• Integrated data intake and analysis

4
5
DHCFPs Expertise with Health Data

• Experience with similar claims data
• Health Safety Net claims processing
• Intake, payment and analysis with links to
  eligibility files
• Retrieval of pharmacy data incorporated into
  payment system
• Built claims processing model in less than 6
  months
• Long experience with Hospital Inpatient, ED, and
  Observation Stay datasets
• Over 20 years of increasing access and
  availability to the public
• Continuous, reliable data security maintained
  from intake through storage
• Successful annual creation of six levels of
  regulation-compliant datasets
• Experience with 2008 HCQCC Data
• Implemented rigorous data quality tests on MHIC
  data extracts
• Filled MHIC knowledge gaps about MA hospital
  volume and naming conventions
• Developed and produced summary analytics for
  comparison and review by HCQCC members and staff

5
6
Data Intake Model

• Utilize existing secure, streamlined file
  transfer system
• Data passed into warehouse is fully encrypted and
  edited for accuracy
• Security conforms to highest standards
• Advantages
• Minimal transition for carriers
• Uninterrupted data submissions
• Ability to implement automated submission process
  (currently staff at each insurer must manually
  manage the file transfer process)

7
Enhanced Quality Assurance

• Evaluate data integrity and consistency
• QA testing for internal logic
• Review distribution of values across time and
  within particular parameters
• Compare current month submission to historical
  averages
• Establish benchmarks for common data quality
  metrics
• Create documentation of issues to allow analysts
  to account for unanticipated effects
• Verification checks with carriers
• Reports developed with input of carriers
• Advantage
• Develop and apply testing protocols to ensure
  that QCC claims dataset is reliable for research,
  health care trend monitoring and calculation of
  measures for QCC website
• Opportunity for carriers to review and validate
  QA reports

7
8
Collaboration with Insurers

• Convene Technical Advisory Group
• Venue during transition for reviewing data
  submission issues common to all plans
• Provides standard point of contact to communicate
  with both in-state and out-of-state insurers
• Provide input on data verification report design
• Advantage
• Discuss submission issues affecting more than one
  insurer

9
Public Use File Creation

• Regulatory Guidance (129 CMR 4.00)
• Certain fields are not included at any level
  (name, date of birth, address)
• Level 1 contains only utilization information by
  type of service
• Level 2 contains more detailed claims information
• Level 3 will only be released to state agencies
• Data Release Review Board to develop regulatory
  clarifications and fee schedule for review by QCC
  
• Public Use File specifications and documentation
• Time periods and how different types of services
  are grouped
• Member demographic information (as permitted by
  regulation for the specific level) to expedite
  analysis
• Describe how any summaries or value added fields
  were created
• Document known issues about the data
• Advantages
• Accurate, analyst ready files in accordance with
  existing regulatory guidance
• Timeline
• Non-grouped, flat file would be available
  starting summer 2009

10
Integrated Data Intake and Analysis

• Local data management allows more flexible
  queries and investigation of issues
• Allows rapid resolution of questions and concerns
• Access will support testing of MHQP-proposed
  measurements early in the development process

11
Next Steps Expand Dataset to All Payers

• MassHealth conversations initiated
• Medicare application process now underway
• Drafting required supporting documentation
• Schedule for dental claims in-take to be reviewed
  in conjunction with MHQP recommendations

12
Proposed Timetable
12
13
Cost of Claims Intake, Warehousing and Analytic
Dataset Production
13
14
Additional Information
15
Role of the Maine Health Information Center (MHIC)

• MHIC became the HCQCC Data Intake Coordinator in
  late 2007
• Contract covered carrier claims intake process,
  including
• application of encryption software,
• running edits,
• storing the passed submissions, and
• coordinating with carriers to resolve issues with
  submitted files.
• Deliverables included statistical plan and data
  dictionaries
• Based on Maine and New Hampshire documentation.
• Began data intake in early 2008
• Contract amendment needed to create analysis
  ready extract for website measure calculation
• Limited to 8 carriers and one year
• Extract only included for 19 specified conditions
  or surgeries
• Outpatient file

16
Dataset Status

• MHIC warehouse holds billions of paid claims
  lines from 28 carriers
• Date of service July 2006 forward
• To date, includes fully insured and some self
  insured
• Minimal data quality edits are run
• Passed files are loaded into the data warehouse
• Failed files are reported to carrier for
  resubmission or edit criteria are overwritten on
  a plan-by-plan, month-by-month basis to allow the
  file to pass
• Carriers are largely compliant
• Data is then stored in the MHIC warehouse until
  analytic data is requested via contract amendment
• One time development of analytic extract dataset
  for website launch occurred in spring 2008 at a
  cost of 40,000

16
17
Recent Experience From Claims Lines to
Inpatient Discharges for the 2008 Cost Measures

• Carriers submit line by line claims data
• MHIC holds these claims lines in its warehouse
• Includes all versions of the claim paid, voided,
  adjusted
• May include a variety of product lines
  commercial, Medicare
• Organized by date paid
• Includes over 30,000 home grown codes that do
  not match standard ICD-9
• More than 640,000 unique provider names records
  in MA alone
• Member information is valid within a particular
  carrier but has not been verified across all
  carriers
• To build an analytic dataset, the data must be
• Reviewed to determine the final claim status and
  exclude earlier versions
• Limited to MA providers and given a standardized
  hospital name
• Edited for non-MA providers and non-MA residents
• Aggregated into discharges
• Run through a severity grouper (inpatient claims
  only)
• Examined for obvious differences in payment rules
  (such as mom/baby rates for obstetrical stays)

17