All Payer Database

Overview

Advancing health care transformation in an effective and accelerated manner requires integrated population-based health and health-related data to address challenges of access, quality, and affordability. New York State enacted legislation in 2011 that allowed for the creation of an All Payer Database (APD). The complexities of the health care system and the lack of comparative information about how services are accessed, provided, and paid for were the driving force behind this legislation. The goal of the APD is to serve as a key data and analytical resource for supporting policy makers and researchers.

New York State has recognized the need for an All Payer Database to provide a more complete and accurate picture of the health care delivery system across public and private payers and to improve population health.

In 2016, the Department secured a warehousing and analytics vendor, issued proposed regulations, and started the implementation of the APD. Once fully developed, the APD will house data from public and private insurance payers, including insurance carriers, health plans, third-party administrators, and pharmacy benefit managers, as well as Medicaid and Medicare. Eventually, the APD will add other health related data that includes functional assessments, surveys, public health registries, social determinants of health, and clinical data from electronic health records.

The APD is creating new capability within the Department, including more advanced and comprehensive analytics to support decision making, policy development, and research, while enhancing data security by protecting patient privacy through encryption and de-identification of potentially identifying information.

Nationwide, states started adopting APDs in 1996 and have concluded the data resource is a valuable tool for health care transformation. With the APD, the Department will have a comprehensive picture of the health care being provided to New Yorkers by supporting consumer transparency needs on quality, safety, and costs of care. The systematic integration of data technology and weaving of the previously fragmented sources of data will create a key resource to support data analyses that address health care trends, needs, improvements, and opportunities. The APD is anticipated to enter operations in March 2018 with additional releases and users being added over time.

Stakeholders and Benefits

The key benefits are described in the following table.

STAKEHOLDER BENEFIT
State Policy Makers /
Public Health
- Enable targeted public health initiatives and interventions based on strategic assessment of health care disparities.
- Identify high-performing communities that provide cost-effective care, and leverage that success to promote similar activities.
- Evaluate reform efforts to identify and duplicate successful initiatives, and identify opportunities for reform.
Health Plans - Measure and collect data related to safety, quality, utilization, health outcomes, and cost.
- Evaluate programs, implement new innovations, and expand upon successful programs.
- Promote or incentivize higher quality and lower cost treatments or refine reimbursement models.
- Modify contracts with providers in a geographic location based on the health needs of that area.
- Compare health care facilities and providers, quality, and cost.
Employers - Empower businesses to design insurance products and select providers based on quality, cost, and efficiency.
- Benchmark performance compared to peers, comparing cost and covered services of health insurance policies.
- Provide reporting access to information to enable better negotiations.
Providers - Reduce recording burden due to transition to a coordinated data set.
- Improve treatment quality through a coordinated feedback loop and performance benchmarking.
- Strengthen quality measurement, and provide tools that help providers better manage their entire panel of patients.
Researchers - Evaluate costs, quality, efficiency, patient satisfaction indicators across different models, settings, geographic areas, and patient populations.
- Analyze treatment options across a broader cross-section of patients- spread across age, gender, ethnicity, exploring what subgroups of patients respond best to each treatment.
- Generate reports to inform clinical policies, training, and legislation.
- Identify gaps in existing treatment methodologies and the needs of clinical practice.
- Determine variations in costs of health care services across regions and influence policy to promote equity.
Consumers - Empower consumers to make informed decisions on health plans and providers through access to valuable information about their health care treatment options and to compare quality, cost, and efficiency among potential insurers.

Data Sources

The APD will contain multiple data sources. The initial focus of the APD is on enrollment data, provider data, SPARCS data, and Vital Statistics-Death data. Other data sources will be phased in, especially claims (public payer and commercial), as the APD solution is fully implemented.

Timeline

APD Timeline

Technical Overview

Three main technical components comprise the NYS APD: Data Intake and Acquisition, Warehousing and Analytics. A data intake system was developed for the collection of data, initially focusing on the collection of encounter data. New York’s APD is collecting data for Qualified Health Plans (QHPs), Medicaid managed care plans, and Essential Plan (EP).

APD Warehousing Solution

The APD Team is working with their procured vendor (Optum) on the development and construction of APD’s data warehousing and analytics solutions. The analytics solution is envisioned to provide data enrichment to an expanded number of covered lives using a Master Provider Index, Master Patient Index, full suite of quality measures, disease and risk profiles with cost data and national benchmarking.

Data Intake and Acquisition: Data Submission Technical Guidance

Entities that submit data to the APD ("data submitters") will submit data to the APD using the Encounter Intake System (EIS). Currently, the APD’s EIS accepts data submissions in the following formats:

  • X12 Post Adjudicated Claims Data Reporting (PACDR)
  • National Council for Prescription Drug Programs (NCPDP) Post Adjudication Standard

DOH requires that data submitters submit post-adjudicated claims data for all members and for all health care related claims that have been adjudicated. After adjudication, claims data is submitted using X12 PACDR and the NCPDP Post Adjudication Standard transactions. X12 PACDR is used for institutional, professional, and dental claims. The NCPDP Post Adjudication Standard is used for pharmacy claims. The EIS Companion Guides define specific NYS DOH requirements to be used for processing encounter data. It is important to note that the below three EIS Companion Guides supplement and do not contradict any requirements in the X12 Implementation Guides (Version 5010), the NCPDP Post Adjudication Standard Version 4.2 Implementation Guide, or related documents.

  • EIS STANDARD COMPANION GUIDE - TRADING PARTNER INFORMATION: Instructions Related to the Exchange of Electronic Data Interchange (EDI) with the EIS. Based on X12 Implementation Guides, Version 5010 and the NCPDP Implementation Guide, Version 4.2. The EIS Trading Partner Information Companion Guide is intended to provide information needed by trading partners to exchange Electronic Data Interchange (EDI) data with the Encounter Intake System (EIS). It includes information about registration, testing, support, and other information.
  • EIS STANDARD COMPANION GUIDE - X12: Instructions related to Transactions Based on X12 Implementation Guides, Version 5010, and related documents. To acquire copies of the X12 Implementation Guides, Version 5010, and related documents, please visit http://store.x12.org/store/healthcare-5010-original-guides.
  • EIS STANDARD COMPANION GUIDE - NCPDP: Instructions related Transactions Based on NCPDP Post Adjudication Standard Implementation Guide, Version 4.2, and related documents. To acquire a copy of the NCPDP Implementation Guide, Version 4.2, visit http://www.ncpdp.org.
  • TIER 2 EDIT DISPOSITION SPREADSHEET: If a submission file passes Tier 1 editing (standard level syntax and structure editing), the EIS will perform Tier 2 editing on each claim. The EIS process will check to ensure functional edits are met (external code sets and logical validation). This involves testing for valid Implementation Guide specific code set values and other code sets adopted as HIPAA standards, as well as DOH required edits. Edit descriptions and logic for each EIS edit are found on the Tier 2 edit document.

Program Governance

The APD regulation has been adopted and is published in the New York State Register. The APD Guidance Manual, which contains detailed information on Program Operations, Data Governance and Submission Specifications, is also available for stakeholders.

Resources

Stakeholder Meetings

Stakeholder engagement and communication are vital to a successful APD program. The links below provide details about our most recent stakeholder forums.

Reports

The New York Academy of Medicine conducted several focus groups with consumers of health care services. The focus groups focused on how consumers look for and use available data on price and quality to help them make decisions about their health care. The final report, titled Consumer Perspectives on Health Care Decision-Making, Quality Cost and Access to Information, was released in April 2016.

The New York's All-Payer Database: A New Lens for Consumer Transparency report, sponsored by the NYS Health Foundation and conducted by the national APCD Council, was completed in September 2015. Using targeted stakeholder interviews and research about state APCDs, the study provided an analysis of the opportunities, challenges, and barriers that are specific to New York State’s goals of building an APD. The report provided recommendations for ensuring a quality system that achieves NY’s goals and meets stakeholder needs and expectations.

Additional Links/Information

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