Although this information has resided in the claims-payment systems of carriers and third-party administrators for years, the development of programs to effectively mine this data has been fairly recent.
Data mining is the process of finding trends and patterns by going through large amounts of claims, pharmacy and medical data by using statistical and mathematically based methodologies.
Predictive modeling is the most recognized form of data mining. However, predictive modeling is not the only tool available. Claims and pharmacy data can also be utilized to identify individuals who could benefit from case- or disease-management programs, to track compliance with evidence-based medicine protocols, or to identify patterns in provider utilization and performance that can then be used to establish a unique network, contracting strategies or provider-incentive strategies.
What to look for in data mining products
- Flexibility What information will be truly accessible to my company, my network provider and to the nurses or other staff that deliver medical management services to my employees? Can my HIPAA benefits administrator and or finance analyst access the data directly?
A good system allows more than one individual to have direct Web access to at least aggregate-level information and reporting. Look for a system that allows easily developed adhoc reports at no additional cost to you.
Staff providing wellness and care-management services (utilization management, case management and disease management) need more that just reports provided periodically from a data vendor. Care management staff should have direct access to the database information and reporting functions.
- Data It is important to preload the database with, ideally, 24 to 36 months of historical medical and pharmacy claims data. New data should then be added on at least a monthly basis going forward.
This provides the opportunity to fully utilize the system from day one and to ensure that your care management vendor is able to identify new opportunities for intervention as they present themselves.
- Cost Be sure you have had all costs disclosed to you. In addition to a base cost, there are often additional costs for mapping data from your current and potentially past plan administrator, loading historical claims data or updating future claims data more often than annually, implementing future upgrades to the system and/or processing requests for adhoc reports.
- Uses How should I expect this system to be used by my care management and network vendors?
It is important to know what your vendors actually do with the data. How do they utilize data to deliver the product to employees? Data should easily allow the care-management staff to routinely identify new candidates for care-management services based on utilization patterns, anticipated costs and cases that may hit stop-loss.
It should also be capable of monitoring physicians’ prescriptions and members’ compliance with condition-specific evidence-based medicine standards. The system should also allow care managers to measure outcomes and changes in any of this data resulting from their interventions.
Predictive modeling should provide overall anticipated costs for the health plan through the next 12-month period. Your network provider should be able to utilize this data to more accurately identify and report the performance of the network and plan.
This should provide you, in partnership with your network manager, opportunities to modify the plan and/or network design to more effectively manage the population.
Barbarra Eisenhardt is vice president of HealthSpan operations and director of care-management and wellness. HealthSpan is a provider-owned PPO network, serving more than 125,000 members and more than 160 self-funded employer groups throughout the tri-state region. Reach HealthSpan at (888) 914-7726.
Employers can no longer afford to overlook the value of investing in employees’ health care. Helping employees and their families stay healthy, encouraging healthier behaviors and promoting effective health-care decisions make all-around good business sense. We all know the benefits of a healthier work force increased productivity, reduced absenteeism and reduced health care costs. Despite this, many employers have been reluctant to take this important step. Why? Because the challenge for most employers has been finding a program that has impact and offers more than just a concept of wellness.
To make the search easier, here are some components to look for in a wellness program.
- Convenience. To determine a baseline health status for employees and their families, a screening and assessment must be given. However, if employees have to jump through hoops to get screened, they probably won’t. Have screenings delivered at the work site during business hours.
- Completeness of screening. The more thorough the screening, the better. A health-risk assessment (HRA) alone is not enough. Concrete clinical data in the form of laboratory tests, combined with an HRA and health history, is the comprehensive way to assess health and risk factors. A blood draw is typically more complete than a finger-stick program.
Most tests will screen for cholesterol and lifestyle. However, more effective programs test for diabetes, thyroid problems and other health conditions. And in some cases, it makes sense to make gender-specific tests available, such as prostate cancer screenings in men over 45.
- Don’t overlook mental health. Depression is one of the leading causes of employee absenteeism. It is important to have a component of the screening that addresses this important area. It is also important that the program has a plan so individuals who need help can get appropriate care.
- Putting it to work. Ideally, the wellness program will be connected to your health plan. After screenings are completed, it is important that care managers or advocates can confidentially help individuals access the care that they need. The goal is to make the process seamless to encourage employees to follow through appropriately.
- Reporting. Results should be easy to understand and delivered in a timely manner. Reports should clearly convey overall health status and provide alerts for areas of concern.
- Assurance of confidentiality. HIPAA laws require confidentiality and the protection of employee health information. It is important that employees be assured that their personal results will not be shared with their employer. Confirming that the program is administered by a third party can alleviate concerns.
- Ability to engage participants. Because programs are voluntary, it is a good idea to add incentives to encourage participation. Some employers offer small door prizes to participants at the time of screenings, raffles for a large prize or contests between departments.
- Health education. Once employees get their results, what’s next? They must be given the tools to make the necessary changes. A multifaceted approach that accommodates different learning styles is most effective. Consider interactive Web sites, telephone hotlines, on-site training sessions and one-on-one counseling.
- Cost Effective. It is important to measure the results of any program to make sure that it adds the value you want. Therefore, it is important that your wellness program be able to deliver aggregate (nonemployee-specific) data to allow you to monitor trends and impact over time.
Although there can be immediate results, employers should look at the long-term to see significant changes. Increases in productivity, decreases in absenteeism and lower health care costs are a few of the many benefits employers can look forward to. And, for self-funded employers, those savings can go directly to the bottom line.
Barbara Eisenhardt is vice president of HealthSpan operations and director of care-management and wellness. HealthSpan is a provider-owned PPO network, serving more than 125,000 members and over 160 self funded employer groups through out the tri-state region. Reach HealthSpan at (888) 914-7726.