Leverage databases to target members in need of care

It all boils down to information, information and more information-located in thousands of specially developed databases, on thousands of healthcare Web sites, in electronic medical records and elsewhere.

As technology improves, it is possible to leverage databases of information to target members and ensure they receive appropriate care and disease management. Databases also compile claims data, aggregate costs and utilization of healthcare services, track provider performance and relieve the administrative hassles associated with claims and reimbursement.

Blues plans have introduced two new initiatives, which integrate and analyze member, payer and provider data through an interoperable framework. Health Care Service Corp. (HCSC), which operates the Blue Cross and Blue Shield plans in Illinois, New Mexico, Oklahoma and Texas, has developed Blue Care Connection. It is based on the concept of integrated total health management, which applies a comprehensive set of clinical rules and treatment protocols to a combination of claims data, physician and hospital records and self-reported patient information. The objectives are to identify best practices and prevention opportunities, decrease healthcare costs, reduce redundancies in care and improve quality of care. In addition, HCSC anticipates that the project will offer incentives to providers for better performance and allow transparency so that members can make more informed decisions.

HCSC's solution focuses on the total population of members, addressing wellness and prevention, health counseling, care management, case and high-risk condition management and complex case management.

William Gerardi, MD, clinical advisor for HCSC's managed healthcare and delivery initiatives, says that Blue Care Connection produces data not only accessible to the provider and payer but also to the member in a patient-friendly format that encourages dialogue between patients and their physicians. The information, available through a personal health record, includes hospitalizations and emergency room visits, lab and screenings, medications and a list of a member's providers. In addition, the data are available to Blue Care Advisor nurses.

Blue Cross and Blue Shield of Minnesota has joined 19 other Blue Cross plans in the Blue Health Intelligence (BHI) project, which will enable participating plans to access aggregated claims from 79 million covered lives from a database.

The participating plans created a common data dictionary to eliminate variations when reporting information to the database. Started as a pilot with three plans, the BHI project had loaded claims from 25 million members as of February. David Plocher, MD, chief medical officer of Blue Cross and Blue Shield of Minnesota and the head of informatics business intelligence, says the completed database will be two times larger than Medicare's.

The data can be analyzed by type of facility, severity of conditions, geographic regions and by industry and type of service, and it uses standard utilization categories such as hospital days per 1,000. It will also help determine what is driving healthcare costs.

Dr. Plocher says the data should enable employers to determine healthcare cost drivers among employers and allow them to compare their employees' utilization with companies in the same geographic area and in the same industries. The project anticipates adding pharmacy claims to the database, as well as more data on specialty providers.

Woodland Hills, Calif.-based Health Net has created large databases to identify patients with chronic or complex disease that could benefit from case management. The health plan's disease management vendor uses the data to determine appropriate interventions with higher-risk members.

"We can build risk files based on pharmacy, medical and lab claims for every member and do outreach so that no one falls through the cracks," says Chuck Payton, MD, chief medical officer for Health Net. "With this information, we can predict needed healthcare resources for the next year. We know who is likely to experience some kind of costly health episode and get ahead of the curve."