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Q&A: Building an All-Payer Claims Database—The Wisconsin Model

By Sarah Klein

As CEO of the Wisconsin Health Information Organization (WHIO), Josephine Musser has helped to build the state's all-payer claims database into one of the most sophisticated and effective in the country, capable of, among other things, identifying how individual physicians and medical groups fare in treating a broad range of medical conditions. Unfortunately, the very things that have made her organization a success make it difficult to participate in Medicare's new Data Sharing for Performance Measurement Program, at least as it is currently structured. Quality Matters asked her how not having Medicare's fee-for-service claims affects the state's efforts to foster quality improvement.

Quality Matters: You've amassed a lot of claims data, collecting it from commercial payers, the state's Medicaid program, and Medicare Advantage plans (though the latter cover only a fraction of Medicare beneficiaries in Wisconsin). You've made this data available to providers, payers, and state agencies to help them assess and improve performance in treating conditions such as asthma and hypertension. But, you're not—at least for now—able to access Medicare's fee-for-service claims under the new data-sharing program. Why is that?

Musser: It's a function of our business model and our approach to using the data. Unlike a lot of other all-payer claims databases, ours is a voluntary one that was started with the five largest Wisconsin insurers and other stakeholders such as the hospital association and the medical society, all of which pay membership or subscription fees to directly access the data and/or obtain customized reports. The way it's currently structured, the Medicare data-sharing program doesn't allow groups receiving the data to sell it or redisclose it. There are also significant limitations on how WHIO may analyze and report the data, which is how we add value. 
Quality Matters: How so?

Musser: Our data has enabled providers, health plans, and others to determine how they perform relative to state or regional benchmarks on measures that capture both quality and resource use. They are able to do this because we track patients through different settings of care. Each patient gets a number, so we don't know them by name, but we can watch them through time and see how their diabetes or other conditions progress, who is treating them, and how effectively they are being treated. It is very granular. For example, the data are able to show individual practices that they have a problem getting 40-year-old diabetic men in the office for care and need an outreach program. The ability to do analytics is what makes it so powerful. Providers can peel back the onion to know where the data come from and what the confidence levels are, etc., and this helps them to identify opportunities for actionable changes in their practices.

Quality Matters: You've also expressed concern about the limitations that would be placed on your organization in terms of how you measure performance?  What are your biggest concerns about that?

Musser: If we combined the Medicare fee-for-service claims with those we have now, we'd have to report on fewer measures. For instance, we wouldn't be able to use episode treatment groups as a way of understanding variations in the total cost of care.

Quality Matters: Given what you are already able to accomplish, how important is adding the Medicare fee-for-service claims?

Musser: I tell providers we have 100 percent of Medicaid claims and 68 percent of the commercially insured population, and both of those are statistically valid in reporting your performance for those populations. We can report with great accuracy on pediatric asthma, but we have difficulty reporting on congestive heart failure, which is more significant in its incidence and cost and occurs predominantly in the over-65 population. We'd like to be able to show providers treating these types of Medicare patients how they differ in their use of laboratory tests, X-rays, emergency department use, and hospitalizations from their peers who are treating patients with the same conditions and severity levels. Given the amount of services the Medicare program covers for elderly patients, there are huge quality improvement opportunities that may be lost under the current regulations. 

Quality Matters: Let's say you are able to get Medicare's fee-for-service claims, what it's going to take to integrate it into the system you have? What are the challenges your organization and others might face?

Musser: The cost that is most obvious and the least expensive is the cost of obtaining the claims. The real cost barrier is in providing the required review and reconsideration process. This process allows providers 60 days prior to the release of any data or reports to review their own data and request a reconsideration/correction of potential error. We know that the software to do that would cost between $350,000 and $500,000 a year. It has to be very secure and there are numerous authentication rules. Further costs are incurred when a doctor challenges the data, because someone must research it and say whether it is correct or not in a HIPPA-compliant way. This may require correcting the source data that comes from health plan data contributors.

Quality Matters: Based on your experience, do you think physicians are ready to make use of this data? Won't it be a burden to them?

Musser: Our state is a little different than many others. It's unique in its number of large, multispecialty group practices. When I go to a meeting at these big systems, sometimes five or six data analysts show up with a team leader, ready to dig into the data. Two or three years ago that was not the case as most provider systems did not use data for business intelligence and strategic initiatives. The smaller practices need to be able to turn to someone like the Wisconsin Medical Society or a consulting firm to help them understand the data. Our medical society has an entire business unit set up to help these smaller practices dig into the data. We have spent most of our time trying to whet the providers' appetite for this information by showing them how they compare with their peers in terms of lab use, pharmacy use, hospitalizations, and specialty referrals, among other things. We often hear, "Aha! Now I get it." 

Quality Matters: Are you able to look at coordination of care for the population? Or segment the population by needs (e.g., maternal child care, end-of-life care, low-income patients, etc.) to look at whether these groups are getting the care they need? 

Musser:  WHIO currently only provides "whet your appetite reports" to demonstrate how organizations can gain increasing value from the data. A number of our members and subscribers are performing the analyses you ask about and taking actions on their own and in their communities. That is the WHIO model: distribute the data to the frontline people who can effect change by understanding the data at its most granular level. Our model supports the philosophy that the providers themselves—working with the payer community and their patients—are the ones that need to ask the questions of the data, find the opportunities for improvement, and make the necessary changes. If that work is left to the qualified entities and/or CMS, we will have greatly diminished that capacity to learn from the data, failed to fully leverage the power in the data to support improvements, slowed the process unnecessarily, and narrowed the cost burden to the qualified entities and CMS.

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