What is "claims data" and how is it used in evaluating delivery models like MIPS and APMs?

• A. Administrative data from claims used to calculate costs, outcomes, and performance metrics for payment adjustments.
• B. Data from clinical trials used to evaluate new therapies.
• C. Patient satisfaction survey data.
• D. Hospital capacity and occupancy data.

Answer: (A)

Claims data are administrative records insurers generate when services are billed. They capture what was done, when, by whom, for whom, and at what cost, including diagnosis codes, procedures, dates of service, payer, patient demographics, charges, and payments.

Because they cover large patient populations across many settings, claims data are ideal for tracking costs and utilization, which are core in evaluating delivery models. In models like MIPS and APMs, payment adjustments depend on performance metrics that include cost and quality. Claims data are used to estimate total cost of care per patient or episode and to identify key events such as hospitalizations, readmissions, emergency visits, and medication use. They also support derived quality indicators, such as complication rates and avoidable events, by linking services and outcomes through coded information.

They are widely available and standardized for large-scale analysis, making them useful for comparing performance across providers and regions. At the same time, they have limitations: they lack detailed clinical information, can be affected by coding practices, and may lag behind real-time care. Often, they’re used in combination with clinical data to get a fuller picture of performance.