Healthcare Benchmark Data Transparency

The Healthcare Benchmark Initiative collects two types of data:

1. Aggregate total medical expense (TME) data, used to calculate performance against the benchmark
2. Claims level data used to identify cost-drivers

The type of data OHS collects and utilizes is displayed in the Spending Data Collection and Analysis Table.

OHS reports TME data at the market and state level. OHS adjusts the age/sex for the underlying population and truncates outlying claims, for the payer and advanced network levels. For more information about these adjustments, refer to the Methodology for Assessing Performance Against the Cost Growth Benchmark.

Age/Sex Adjustments

Total medical expense at the payer and advanced network level are adjusted for differences in their population’s age and sex from the aggregate population and over time. This methodology is consistent with Healthcare Benchmarking best practices and is used by other state benchmarking programs including those in California, New Jersey, Oregon, Rhode Island, and Washington.

Truncation 

The claims-based spending used to assess payer and Advanced Network cost growth benchmark performance is truncated for high-cost outliers. This means that for a given member in a given year, the dollars above the truncation point are excluded from analysis and will not adversely impact a payer’s or Advanced network’s performance against the benchmark. The truncation point generally varies between approximately $150,000 and $250,000 per member based on the insurance category.

OHS uses claims and category level data to determine annual “cost drivers”: areas of spending that are driving TME growth. The following non-exhaustive list represents 10 high priority areas, based on collected data, that OHS examines to identify cost-drivers:

We draw data from two sources to support Healthcare Benchmark Initiative data collection and analysis.

Cost Growth Benchmark Data

OHS collects Cost Growth Benchmark annually at the payer level by market, including commercial, Medicaid and Medicare, and at the Advanced Network level by market, as available. This includes:

• Aggregate TME data collected in broad claims service categories, such as hospital inpatient, and non-claims categories, such as performance incentive payments

• Insurer administrative costs and profit

The following markets are included in the data:

• Commercial fully and self-insured
• Student health plans
• State employees, retirees, and municipalities
• Medicare Advantage
• Medicare Fee-for-Service
• Medicaid

All-Payer Claims Database Data

OHS collects All-Payer Claims Database (APCD) data monthly and makes updates available for analysis each quarter. APCD includes:

• Medical claims
• Pharmacy claims
• Enrollment data

The APCD does not include non-claims payments, such as capitated payments or performance bonuses, drug rebates from manufacturers, or insurer administration costs and profit.

The following markets are included in the data:

• Commercial fully insured
• State employees and retirees, municipal employees in State Partnership 2.0 plan and some other but not all self-insured employers
• Medicaid
• Medicare Advantage
• Medicare Fee-For-Service

More detail is available in our Spending Data Collection and Analysis Table .