Applied Health IT

Supreme Court Scrutinizes All-Payer Claims Database

By Carmel Shachar, J.D., M.D. , Gregory Curfman, M.D.

In an era of heightened demand for health care cost-control, transparency, and quality, state all-payer claims databases (APCDs) are uniquely positioned to unlock an array of value. APCDs systematically collect medical and pharmacy claims from public and private payers within a state, offering a comprehensive view of patients’ interactions with the health care system. APCDs could soon be harnessed to evaluate prescription drug and medical device safety and effectiveness; currently, more than thirty states have or are implementing an APCD.[1] However, the growth of state APCDs has also raised an important legal question: whether the Employment Retirement Income Security Act of 1974 (ERISA)[2]—a federal statute setting minimum standards for most voluntarily established pensions and other employee benefit plans including self funded health care plans—precludes states from compelling self-funded health insurance plans to participate.

The US Supreme Court will address this question in the case Gobeille v. Liberty Mutual, Ins. Co. By providing self-funded health care coverage for fewer than 200 citizens of the state of Vermont, Liberty Mutual Insurance Company (Liberty Mutual) fell below the mandatory reporting threshold for the Vermont APCD.[3] However, Blue Cross/Blue Shield of Massachusetts (Blue Cross)—the third-party administrator for Liberty Mutual’s Vermont participants—did not. In 2011, Vermont subpoenaed Blue Cross, seeking claims data and other required information for its APCD. In response, Liberty Mutual directed Blue Cross not to comply and filed suit against the state, arguing that ERISA preempted the APCD-authorizing statute.[4] A federal district court ruled that the state law was not preempted,[5] but the Court of Appeals for the Second Circuit reversed the decision in a 2-1 ruling.[6] Oral arguments took place before the Supreme Court on December 2nd, and a decision is expected in the spring of 2016.

The details of Gobeille provide a microcosm for the tensions between health care and law that arise with big data collection and use. ERISA’s relationship to Vermont’s APCD-authorizing statute should be examined not only in the context of relevant case law, but also with practical and ethical health policy considerations in mind. Whichever way the Supreme Court rules, Gobeille has the potential to strongly impact the generation and collection of health care data, and this in turn will affect health policy.

[1] APCD Council, The Basics of All-Payer Claims Databases. Robert Wood Johnson Foundation (2014).

[2] U.S.C. § 1001

[3] Petition for Writ of Certiorari, Gobeille v. Liberty Mut. Ins. 135 S. Ct. 2887 (U.S., 2015)

[4] Brief in Opposition, Gobeille v. Liberty Mut. Ins., 135 S. Ct. 2887 (U.S., 2015) (No. 14-181).

[5] Liberty Mut. Ins. Co. v. Kimbell, 2012 U.S. Dist. LEXIS 161069 (D. Vt., Nov. 9, 2012)

[6] Liberty Mut. Ins. Co. v. Donegan, 746 F.3d 497, 2014 U.S. App. LEXIS 2088 (2d Cir. Vt., 2014)

Carmel Shachar is the Clinical Instructor on Law in the Health Law and Policy Clinic at the Center for Health Law & Policy Innovation, Harvard Law School.
Gregory Curfman is a Editor of Harvard Health Publications, Harvard Medical School

Photo by David, used under CC BY / No alterations from the original

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