Looking for data, transparency in health care

You’re in the market for arthroscopic knee surgery. Like most patients, you might decide where to get it done based on word of mouth, or a hospital preference.

If you live in Maine, you can use another tool: Price. With an Internet connection and few clicks of a mouse, you can find out how much you and your insurance plan will likely pay for the procedure at each hospital in the state — with quotes ranging from $3,033 to $9,427. 

The cost comparison is the result of a data collection effort being eyed and emulated across the country, including by Connecticut officials.

So-called all-payer claims databases contain medical, pharmacy and, sometimes, dental claims information from health insurance carriers and public insurers like Medicare and Medicaid.

A comparison of COPD rates in people with Medicaid and private insurance, a product of New Hampshire’s database (NH Dept of HHS)

The data doesn’t identify individual patients, but can offer insights into a wide range of health topics, like what government and private insurance programs pay for specific medical services, what parts of the state or age groups have the highest rates of diseases or preventive care, and what medical services residents get out-of-state.

The databases are gaining popularity, particularly in the Northeast, as businesses and policymakers seek to use data to improve transparency and quality and get a handle on health care costs that are increasingly eating into government, business and family budgets. Maine, New Hampshire, Vermont and Massachusetts have databases already, and New York and Rhode Island are working on them.

“People are spending a lot of money on health care and they don’t know where it’s all going,” said Patrick Miller, a professor at the University of New Hampshire and co-chairman of the All-Payer Claims Database Council, who will be speaking to the state’s Health Care Cabinet Thursday. “And they also want to know quality and safety indicators, things that have been hidden in the past.”

In states that have them, many employers use the databases to design benefit plans to steer workers toward health care providers who deliver high quality at lower costs, or to target their wellness programs to encourage preventive care their employees aren’t getting.

Public health officials can use the data to determine how to deploy scarce resources, identifying the highest-need areas or conditions that are most prevalent.

But knowing what to do with the data can be more challenging when it comes to public policy.

A look at the data from Maine could show colonoscopy prices that vary by thousands of dollars, noted Alan Prysunka, executive director of the Maine Health Data Organization, which runs the state’s database.

“That begs the question,” he said. “What are you going to do about it?”

Need to be targeted

Spearheading Connecticut’s attempt to create an all-payer claims database is Jeannette DeJesús, special adviser to the governor for health care reform, who heads the recently created Office of Health Reform and Innovation.

She’s hoping to develop a pilot program to address the needs of people who use a disproportionately large amount of health care services, who often aren’t receiving the care they need — repeatedly going to the emergency room rather than a doctor who could help them avoid the need for emergency visits, for example — and contribute significant costs to the health care system. The idea is based on a model used in Camden, N.J., in which health care providers work closely with patients to address their needs. (The concept gained attention in a New Yorker article by Atul Gawande called “The Hot Spotters.”)

But doing that requires data to focus the effort. What area of the state has the biggest problem with high-utilizers? What hospitals do they go to? What services are they repeatedly using?

“We can no longer afford to cast a broad net and see what you get,” DeJesús said. “We’ve got to be more targeted.”

DeJesús’ job includes leading the state’s effort to implement federal health reform, and she points out that improving the system patients encounter is a key part. But whatever happens with the national debate over the reform law, she said, there will still be a need to address the problems that prompted it — costs are too high, people don’t have access to adequate health care and care quality needs to be addressed.

DeJesús hopes the state’s database can be developed over a two-year period. She noted that four of the five major insurers in the state already or will soon participate in similar databases elsewhere.

Keith Stover, a lobbyist for the Connecticut Association of Health Plans, said a claims database could provide information that helps answer “macro-level questions,” such as whether particular treatments are effective, if Connecticut is an outlier in the way it deals with prostate cancer, or whether there are parts of the state where outcomes for a certain procedure or illness appear better than others.

“There is clearly a willingness on the part of the industry to participate, and I think we’ve demonstrated that and have been very clear about that,” Stover said.

But he cautioned that creating a database, and feeding it, isn’t simple.

“It’s not a ‘push the enter button’ and all of a sudden, poof, there’s a database,” he said. “Even if Connecticut’s model is entirely consistent with state X’s model, you still have state-specific programming that needs to be done.”

Aetna spokeswoman Susan Millerick said the company is actively engaged in the process, and supports the creation “of a well-designed” all-payer claims database. Other insurers in the state declined to comment or referred comments to Stover.

In other states, efforts to create claims databases have drawn some reluctance from insurers and health care providers, who have raised concerns about reporting on care quality and the effects the public data could have on negotiations.

But Miller said insurers in some states have come to see databases as a tool to use in reforming the way payments are made, and providers have come to sense that there can be something in the databases for them, too. Miller’s council is leading an effort to develop national standards for what data gets collected, allowing insurers to avoid the added cost of having to provide different information to different states.

Apples, oranges and colonscopies

Back to your surgery. That search might be fairly straightforward. But searching for payment information to guide your decisions isn’t always as easy as, say, comparison shopping for shoes.

Take colonoscopies. There are 16 different billing codes for the procedure, depending on, among other things, whether it turns up a polyp, whether the polyp gets removed in the same procedure, or whether you have a biopsy done at the same time. Each nets a different payment, and Prysunka noted, it’s inaccurate to lump them all together when providing data on colonoscopy costs.

Similarly, the payments for almost any procedure will vary depending on who your insurer is, and which of their plans you have. Comparing the cost for a PPO and an HMO is like apples and oranges.

That’s one challenge for the database administrators, Prysunka said. It helps for the public to have clear, simple information. But there are limits to how simple or concise health care cost data can be, particularly if you want to avoid complaints from providers and insurers that it’s not all valid.

As with anything involving the use of people’s health information, assuring privacy is a major factor in designing the databases. In Maine, each patient in the system has a unique identifier based on his or her Social Security number that has been encrypted twice. In Minnesota, by contrast, the data can’t be used outside the state’s health department.

People often ask whether the databases have had an effect on costs. Miller said the answer isn’t clear, and in most places, hasn’t been studied. A better question, he said, is whether you want transparency in your health care system, and a tool to start digging into it.

DeJesús sees another possible outcome: Identifying more flaws in the health care system that need to be addressed.

“I would consider that part of a major success,” she said.