All Payer Claims Database (APCD)

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What is the Virginia APCD?

The Virginia All-Payer Claims Database (APCD) is a program under authority of the Virginia Department of Health (VDH) that collects paid medical and pharmacy claims for roughly 4 - 4.5 million Virginia residents with commercial, Medicaid and Medicare coverage across all types of healthcare services.

Who submits data to the Virginia APCD? How comprehensive is it?

Under Senate Bill 1216, which went into effect on July 1, 2019, all of the following entities are required to submit paid claims data to the Virginia APCD:

  1. Issuers of individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; corporations providing individual or group accident and sickness subscription contracts; and health maintenance organizations providing a health care plan for health care services, for at least 1,000 covered lives in the most recent calendar year;
  2. Third-party administrators and any other entities that receive or collect charges, contributions, or premiums for, or adjust or settle health care claims for, at least 1,000 Virginia covered lives on behalf of group health plans other than ERISA plans;
  3. Third-party administrators, and any other entities, that receive or collect charges, contributions, or premiums for, or adjust or settle health care claims for, an employer that maintains an ERISA plan that has opted-in to data submission to the All-Payer Claims Database pursuant to subsection P;
  4. The Department of Medical Assistance Services with respect to services provided under programs administered pursuant to Titles XIX and XXI of the Social Security Act;
  5. State government health insurance plans;
  6. Local government health insurance plans, subject to their ability to provide such data and to the extent permitted by state and federal law; and
  7. Federal health insurance plans, to the extent permitted by federal law, including to Medicare, TRICARE, and the Federal Employees Health Benefits Plan.

What type of information is included on a health insurance claim submitted to the Virginia APCD?

Each claim and corresponding enrollment record submitted to the Virginia APCD includes information such as patient demographics, location of care across all settings, who provided care to the patient, any diagnoses presented by the patient, and the actual allowed amount or “cost” of a particular service.

Refer to the Data Dictionary for more details.

What timeframe is available?

Data from the Virginia APCD is currently available for claims paid between January 2011 (January 2015 for Medicare FFS claims) and December 2017.

What are common uses of the Virginia APCD?

Population Health, including the prevalence and cost burden of individual diseases, immunization rates, and patient medication adherence;

Provider and Health Plan Comparisons, including variances in the care provided by episodes of care, referral patterns and leakage, industry standard and custom quality metrics, and market share information for all inpatient and outpatient services; and

Trends in the Cost and Utilization of Healthcare Services, including rates of emergency room utilization, opioid prescription trends, and the average cost of healthcare services such as those displayed within the VHI Healthcare Pricing Report.

Are there any major limitations of claims data within the Virginia APCD?

While claims are a robust and flexible source of healthcare data, they are subject to certain limitations that should be considered before requesting data from the Virginia APCD for analysis:

  • Timeliness- Claims often take several months to be completely adjudicated and are subject to revisions and reversals long after a patient’s date of service.
  • Structure- Claims data are submitted in what is referred to as a “line” format, meaning that an individual claim may contain several records of data. An individual patient encounter or procedure may also result in claims being submitted for payment by multiple entities (e.g., one from a facility, such as a surgery center, and one from an independent practitioner, such as an anesthesiologist). Given this nuance, analyzing the “complete picture” of a particular service may be more difficult with claims as opposed to other sources of administrative healthcare data.
  • Provider Identifiers- Determining the unique identity of healthcare practitioners and facilities is completely dependent on the quality of the information submitted on a claim. There may be instances where a claim is missing a unique numerical National Provider Identifier (NPI) for a provider, a provider has multiple associated NPIs, or the name associated with an NPI is different than the name typically associated with a given provider.

Does the data identify individual patients?

No; both VHI and VDH, as well as all outside groups that can request access to data from the Virginia APCD, do not have access to personally identifiable information (PII) for each patient. If justified, VHI is able to provide access to an encrypted, unique key that can be used to link services to the same patient over time for analysis and research.

How much does the data cost?

The cost of datasets and reports from the Virginia APCD can vary greatly depending on the amount of data requested and estimated VHI staff time.

How do I request data from the Virginia APCD?

Datasets and reports from the Virginia APCD can be requested here. If you have questions as you fill out the request form, please contact Nicole Sidrak, VHI Business Analyst, at nicole@vhi.org.