Delaware

Title or Name of APCD System: 
Delaware Health Care Claims Database
Category: 
In Implementation
Who Maintains the System: 
Delaware Health Information Network (DHIN) Board of Directors, in continued consultation with the Department of Health and Social Services, the Health Care Commission, and stakeholders in the health care community.
First Year APCD Collected Data: 
2017
State Specific Resources: 

In short, this Act will help Delaware answer the following questions:

(1) How much does Delaware spend on health care?

(2) How much does a service cost at a specific facility?

(3) How have health care prices changed over time?

(4) Are Delaware’s efforts to establish value-based alternatives to the traditional “fee for service” health care system effective?

The Delaware Health Care Claims Database will help advance the ongoing work to transform the State’s health care system from a fee-for-service system to a value-based system that rewards health care providers for quality and efficiency of care. To complete that transformation, health care providers and other health care entities accepting financial risk for a population must have an appropriate level of access to health care claims data—particularly data that provides some transparency into health care pricing. Centralized and standardized access to claims data is also critical to maximizing population health initiatives, including the study of occurrences of injury or illness across the continuum of care in Delaware or in specific neighborhoods. This Act sets forth the basic structure and parameters of the Health Care Claims Database, subject to further guidance to be set forth in rules and regulations to be promulgated by the DHIN, in continued consultation with the Department of Health and Social Services, the Health Care Commission, and stakeholders in the health care community. Specific Requirements for Claims Data Reporting This Act requires certain types of claims data defined as “required claims data” to be reported by the entities specified as “mandatory reporting entities” in the Act. The Act only mandates reporting of claims data for the Medicaid Program, the State Group Health Insurance Program, and any qualified health plan in the Delaware Health Insurance Marketplace for plan year 2017 and any subsequent plan year. This Act also authorizes health insurers and providers who are not required to participate in the Health Care Claims Database to voluntarily report “claims data” pursuant to appropriate data submission and use agreements between the voluntary reporting entity and the DHIN. In both mandatory and voluntary claims data reporting, the Delaware Health Care Claims Database will maintain the privacy and confidentiality of individually identifiable health information in accordance with all federal and state privacy and security laws, including compliance with guidance found in Statement 6 of the Department of Justice and Federal Trade Commission Enforcement Policy regarding the exchange of price and cost information, and with appropriate limits on the disclosure of potentially proprietary contracted unit price information. In order to comply with a recent decision of the United States Supreme Court, the mandatory reporting requirements of this Act do not apply to self-insured commercial health plans that are regulated pursuant to the Employee Retirement Income Security Act of 1974 (ERISA).

The Delaware Health Care Claims Database will be administered and operated by the DHIN Board of Directors, whose membership consists of a broad coalition of health care stakeholder representatives, including representatives of hospitals, physicians, providers, insurers, the business community, and government officials. This Act authorizes the DHIN Board, or a subcommittee established by the DHIN Board to administer the APCD, to review a request for claims data to determine if the requesting party or entity should have access to the requested claims data for a legitimate purpose in accordance with the goals of the statute. The determination by the DHIN Board shall be made in accordance with its bylaws, including those pertaining to conflict of interest recusal, and is not subject to appeal or to any other private right of action. This Act is revenue-neutral; it will be funded with grant money and other independent funding sources to be identified by the DHIN, in accordance with the DHIN’s existing statutory authority.