HA415 Unit 7 Claims Database Stakeholder Analysis Example

A Claims Database Missing Four in Ten Workers: A Stakeholder Analysis of a Composite State's All-Payer Claims Database After Self-Funded Employer Plans Stopped Submitting Data, Mapping Who Gains, Who Pays and Who Holds Back

[Student Name]

Purdue University Global

HA415: Health Care Policy and Economics

Unit 7 Stakeholder Analysis

[Instructor Name]

[Date]

The state, its database and every figure are composite and bracketed; the legal discussion is simplified for a course and is not legal advice.

The Rule and the Gap

The state's law requires insurers and plan administrators to submit claims data to the state health data agency. In 2016 the Supreme Court held that federal law governing employer benefit plans preempts state reporting requirements as applied to self-funded employer plans (Gobeille v. Liberty Mutual Insurance Co., 2016). The federal statute broadly supersedes state laws that relate to employee benefit plans (29 U.S.C. § 1144, 2024). Fully insured plans, Medicaid and, by agreement, Medicare data still flow in. Self-funded plans may submit voluntarily; few do.

The Composite Market

[1.9 million] residents have commercial coverage; about [760,000] are in self-funded plans. Of [24] large self-funded employers, [three] submit data voluntarily. Researchers and the state's price comparison tool therefore see only part of the commercial market, and prices paid by large employers, often the most important for understanding hospital pricing, are largely missing. The database can describe what fully insured plans pay, but the employers who pay the most for hospital care are mostly absent from it.

Stakeholders, Their Interests and Their Costs

1. State health data agency: gains a complete picture for policy; bears the cost of running the database and persuading employers.

2. Fully insured carriers: required to submit; bear reporting costs; may resent that self-funded competitors do not.

3. Self-funded employers: could gain data to compare their costs with others; bear administrative costs and fear exposure of their benefit decisions; have no legal obligation.

4. Third-party administrators: hold the employers' data; bear the cost of extraction; follow their clients' instructions.

5. Hospitals and health systems: may gain from evidence on quality and cost; fear that published negotiated prices weaken their bargaining positions.

6. Researchers and policy analysts: gain the most from complete data; bear no costs; have little power.

7. Consumers: gain from better price tools; rarely know the database exists.

8. Legislators: want evidence for cost-control bills; respond to employers and hospitals more than to researchers.

Power and Interest

High power, low interest: self-funded employers and their administrators. They control the missing data and have little reason to share it. High power, high interest: hospitals, which can lobby against uses of the data they dislike. Low power, high interest: researchers, the agency and consumer advocates. Low power, low interest: most consumers.

Why Employers Hold Back

Large employers worry about confidentiality, administrative burden and the use of their data to judge their benefits. Some also fear that sharing data could later become mandatory. Commentators writing as the case reached the Court pointed out how much state databases stood to lose if self-funded plans were exempted (Shachar & Curfman, 2016).

What Would Change the Balance

1. Lower the cost: adopt a common data layout so administrators submit once in a standard format, reducing work for employers in several states.

2. Raise the benefit: give each submitting employer free reports comparing its prices and use with others in the state.

3. Address the fear: write confidentiality rules that prevent publication of any single employer's data.

4. Federal action: a federal grant program or a federal reporting requirement could bring self-funded plans back in, which states cannot do alone.

5. Find a champion: recruit one well-known employer to submit and speak publicly about the reports it receives.

The First Steps, in Order

The agency should begin with the stakeholders who can move the most data at the lowest cost. The three largest third-party administrators handle claims for about [60] percent of self-funded lives in the state; persuading them to offer a one-step submission option to their clients would do more than approaching employers one by one. Next, the agency should approach the state employee plan and two large public universities, which are self-funded but answer to public officials who want the data. Only then should it approach private employers, with reports from the public plans in hand as proof of value.

Measures of Progress

Share of commercial lives covered; number of self-funded employers submitting; number of research reports and price tool queries using the data.

Risks

If the agency publishes reports that embarrass a submitting employer or hospital, voluntary submission will stop. Each report should be reviewed against the confidentiality rules before release.

Limits

The analysis relies on composite figures and the stakeholders' likely interests; actual positions may differ, especially among hospitals, some of which support transparency for their own reasons.

Conclusion

The database's gap is not technical but political and economic. The stakeholders who hold the missing data bear its costs and gain little, while those who would gain most have little power. Changing the balance means lowering costs, raising benefits and protecting confidentiality for employers, or federal action.

References

Gobeille v. Liberty Mutual Insurance Co., 577 U.S. 312 (2016).

Shachar, C., & Curfman, G. (2016). Supreme Court scrutinizes all-payer claims databases. Healthcare, 4(2), 84-85. https://doi.org/10.1016/j.hjdsi.2015.12.001

29 U.S.C. § 1144 (2024). https://www.law.cornell.edu/uscode/text/29/1144