How All Payer Claims Databases Could Resolve Patient Payment Issues
For over a decade now, states across the US have been trying to get all payer claims databases, or APCD’s, off the ground. Essentially, these state-managed databases collect information from insurers about many aspects of the healthcare, claims, and payment system, including ICD-10 diagnosis codes, charges for services at each care provider, how much was paid by both the insurer and the insured, and demographic information about the patient.
When consumers can access these databases, either regionally or nationwide, it could influence their role in the revenue cycle in several significant ways. First, patients with access to these systems will be able to compare costs across health systems before consenting to treatment. Second, patients will know in advance how much their insurer usually pays out for claims like theirs. And third, patients will be able to better understand their own financial obligation before treatment is even undertaken.
The most immediate benefit to consumers using a robust APCD will be their ability to compare prices across different care providers in their area. Whether it’s a clinical service like an x-ray, a surgery, or a consultation with a specialist, patients will be able to see which health system costs the least.
However, more established APCD systems in states like Minnesota are also trying to relay information to both insurers and consumers about provider outcomes. With that information, consumers can ensure a reduction in cost doesn’t mean a reduction in the likelihood of a positive outcome from a procedure or treatment.
One roadblock that has impeded broader roll-out of this type of information sharing is a recommendation by industry experts that care providers be able to review regional cost comparisons before that information is made public. On the one hand, this would allow care providers to confirm the accuracy of the data and know what outcomes to expect once the data goes public. However, each additional layer of review also slows that pace at which healthcare consumers are able to access this type of information.
Insurer Claim Payout
Another compelling angle of the APCD interface is that it will allow both consumers and hospitals to see how much insurers have paid for claims in the past. Therefore, if a consumer logs into the APCD to check out costs for a procedure, they will also be able to see what insurers have paid out for other claims related to that procedure, and compare it to the cost.
One major hurdle facing the implementation of APCD’s across the US is coordinating this reporting with insurers. Both private insurance companies and Medicare/Medicaid are always concerned first and foremost with patient security. Even though the APCD’s are maintained at a state level, secure, accurate, and timely reporting is a major project to coordinate.
The ability to compare prices, coupled with the concrete knowledge of the average insurer payout, will empower healthcare consumers to better understand their own financial obligation before procedures even take place. One element of reporting from health systems in some APCD’s is how much patients themselves paid out of pocket toward services. For hospitals, the APCD can reveal what areas of treatment and procedures are more likely to have payout and which typically might not be paid for by patients.
The system can also reveal valuable trends about consumer use of healthcare. For example, Oregon’s first APCD report in 2015 revealed a 9% increase in primary care visits and a 10% decrease in emergency room visits from 2011-2013. Hospitals, lawmakers, and insurers can use this information to better serve the population and allocate funds accordingly.
Though the first APCD was formed in Maine in 2003, today, many privacy, user interface, and insurer reporting issues are still largely unresolved in the thirteen states which have some form of functional APCD.
The implementation of an all payer claims database is not an easy thing. But, the projects have proven worthwhile in states where they’ve begun to find success. As technology begins to be more holistically integrated into the healthcare sector, the benefits of these systems and others like them will only grow for all involved. From policy makers, to insurers, to consumers, to hospital decision makers, everyone seems to benefit when transparency and data analysis go hand in hand.