Widen Your Outpatient Planning Opportunities

Widen Your Outpatient Planning Opportunities

How APCD Insights Can Empower Healthcare Growth Planners

By Charles Glover and Sean Conway

The trend toward outpatient healthcare is here to stay, and for several reasons revolving around cost savings. For starters, while outpatient facilities may vary in size and services offered, they are almost always less expensive to build than traditional hospitals. Second, without the need for extensive nursing units and housekeeping functions required within a hospital, they are more affordable to operate. Finally, staffing expenses are lower as offices are typically closed on nights and weekends.  

There are other factors driving the increase in outpatient care, including:

  • Changes in insurance reimbursement rules, and the adoption of site-neutral payments, are incentivizing providers to rethink their care delivery strategy.  
  • New technologies and better drugs have allowed medical tests, procedures, and therapies to be provided outside of acute care settings. (Rehab Insights)
  • The easier access to care, along with the potential for lower out-of-pocket costs, has made outpatient care a popular choice for patients.

With all these pressures pushing the development of outpatient care, healthcare growth planners need solid strategies for tracking patient movement, leveraging trends in reimbursement, and addressing physician leakage. In this post, we’ll discuss which data is the right data for planners to use to access the critical information needed for informed outpatient planning.  


Understanding All-Payer Claims Data

All-Payer Claims Data (APCD) is anonymized patient-level data. It consists of electronic files that contain information about patient visits with a provider. Each patient visit results in one or more claims being submitted by the provider to the payer for reimbursement (self-pay or charity care situations are not included). These files are handed over to a clearinghouse or insurance company so that the provider can be reimbursed for the service they provided to the patient. 

The information that comes with these claims can include the following:

  • Patient information
  • The condition that the patient was treated for
  • The services that were provided
  • Details about the site of service
  • The physician rendering services

APCD is broken down into two segments - 837 submit data and 835 remit data.

  • APCD 837 submit data allows for the tracking of patients longitudinally through the continuum of care. It makes it possible for physician referral pattern comparisons, patient demographic analysis, leakage and keepage measurements, and patient migration tracking. Broad coverage and high raw claim volume are key for the most complete market picture. 
  • APCD 835 remit data is chiefly used for financial analysis and benchmarking. This data provides professional and institutional detail and allowed amounts. It can help answer the question of “What is being paid for a particular code, at a location, by a specific plan?” The value of this data can be realized with a sufficient, critical mass of claims that permits the identification of the allowed amount rate. 

No APCD provides 100% market coverage. While it’s easy to see why that would be incredible to have, it’s just not something that exists. The key is to have enough coverage to allow for informed, reliable planning.

How APCD Opens up the Outpatient World

With more patients than ever utilizing outpatient care settings for what used to be handled inside an inpatient hospital facility, APCD provides great value by allowing planners to see that shift from both the patient view as well as from the physician referral side. 

Stratasan’s 837 submit APCD enables longitudinal analysis, tracking patients through the continuum within a market and even across state lines when needed. It allows for insights into care settings notoriously not well known such as physician offices, urgent cares, ASC’s, etc. It hones in on:

  • Physician referrals
  • Service line development
  • Market demand
  • Consumer behavior

With these insights, healthcare planners are better equipped to track patient movement and understand where leakage is happening. It’s then possible to create a strategy for physician recruitment and address problem areas.

Stratasan’s 835 remit APCD illuminates trends in the payer reimbursement landscape at the most granular levels—by provider, health plan, and procedure code. It enables rate analysis by:

  • Service line
  • Sub-service line
  • Provider
  • Specific payer
  • Plan or coverage type

Stratasan’s Market Reimbursement Analyzer (MRA) is a visualization tool that sits on top of, and analyzes, remit APCD. MRA enables standardized, reliable, and granular rate transparency across entire markets. 

MRA benchmarks actual allowed amounts against the Centers for Medicare & Medicaid Services pro or physician fee schedules. On the institutional side, it benchmarks against ambulatory surgery centers or hospital-based outpatient department fee schedules. The insights derived from this tool and the APCD analysis it enables, provide the opportunity for more effective mergers and acquisitions (M&A) analysis, as well as more informed reimbursement negotiations. 

The Takeaway

Stratasan’s APCD illuminates the entire country, providing planners with recent and accurate snapshots of physician and patient behavior, as well as that of competitors. It ID’s pockets of a service area where a hyper-focused strategy is needed, as the data has illustrated problematic outmigration or leakage. It also helps planners to identify where new facility placements are needed, or where M&A opportunities are worth considering. 

If these are data insights that would be beneficial for your planning team, then let us know. To learn more about Stratasan's APCD and the tools we use to analyze this data—how they could help you to analyze referral patterns in your market, increase in-network utilization, and identify which physicians you can re-align with your network—then schedule time to talk with one of our experts today.

Article by Charles Glover, Director of Strategic Solutions, and Sean Conway, National VP of Sales for Stratasan