The proof of the pudding, as they say,                            is in the eating.

Clinical Programs and Medical Informatics

The Client

Our client, a leading health insurer, has been providing health care coverage for over 70 years. They serve over 4 million members, covering approximately $20 billion in claims annually, and offer customers access to an extensive network of nearly 40,000 participating physicians and other medical professionals in over 8,000 facilities.

As a prominent health plan with a strong reputation, our client’s nationally recognized value partnership programs and collaborative quality incentives with its physician organizations and hospitals are leading the way in controlling health care costs and improving health outcomes.

In a continuing effort to grow and evolve their programs, our client, in close collaboration with X by 2, is developing advanced medical informatics and reporting capabilities that enable them to better evaluate the impact of systemic improvements in care processes and more quickly adapt to industry-wide changes that result from health care reform.

Business Situation

Managing the cost of health care is a multi-faceted problem that has no single solution, but as part of its efforts, our client has developed one of the largest and most successful physician incentive and Patient Centered Medical Home (PCMH) programs in the U.S. bringing together over 8,000 physicians and specialists. Physicians participate in initiatives aimed at improving care delivery through the collection of data, sharing of information, and closer payerprovider collaboration on patient care. The more than 20 physician incentive initiatives range from service-focused delivery such as radiology utilization management to clinical-focused services such as evidence-based health care tracking. Through its promotion of a PCMH model, our client is working to dramatically improve care quality, lower costs, and increase satisfaction by incenting physicians to focus on the overall health and wellness of each patient and empowering members to take more control of their own health and ultimately their health spend.

The health insurer’s ability to grow its programs, however, had become hindered by its inability to efficiently collect and analyze data for various initiatives. 75% of analyst’s time was being consumed aggregating and enriching data from a number of sources rather than being spent conducting meaningful analysis; researching and evaluating new initiative opportunities, goals, and intervention design; and implementing initiatives.

For example, an extensive amount of analyst effort was necessary for creating semi-annual Evidence-Based Care Reports. Additionally, the insurer needed sophisticated analytic capabilities for identifying members and their current and historical care relationships (i.e. member PCPs vs. specialists), etc.

To help maintain its edge and continually evolve the incentive programs our client needed consolidated data, analytics, and reporting capabilities that would enable the identification and evaluation of systemic improvements in care processes and the measurement of initiative effectiveness and value add from the perspective of results, incentive payout, projected savings, impact on the quality of care, among other views.

Services Provided

  • Application Architecture and Strategy
  • Integration Architecture and Strategy
  • Project Management
  • Detailed Design
  • Advanced Software Development

Our Work

In close collaboration with key business and IT leadership, X by 2 developed a single clinical programs and medical informatics database (data mart) in 9 months that consolidated the insurer’s vast amount of core data related to its incentive programs and enabled streamlined, accurate, and consistent analytic capabilities and reports.

Consolidation of Core Data and Integration of Analytical Engine

The data mart brought together core membership, claims, and provider data from disparate sources (e.g. Commercial, Medicare Advantage, etc.) into a consolidated repository and automated advanced methods to enable analysts to identify and better understand the relationships between concepts such as:

  • A Unified Person - identification of a person and the tracking of a person’s membership over their lifetime.
  • Care Relationship - identification and tracking of a person’s Primary Care Physician (PCP) over their lifetime.
  • Encounter - identification of inpatient, emergency, and outpatient encounters and the tracking of a person’s interactions with a health facility.

The data mart was also integrated with analytical engines like HEDIS engine and Symmetry to provide industry standard best practice metrics for measuring a person’s health.

Reports

This combination of data allowed our client to more thoroughly evaluate a person’s health experience, holistically view how they were doing when it came to a person’s care, and conduct advanced reporting so that results could be shared internally and with providers. Reports related to evidence based care, generic prescription dispensing, inpatient use, claims, etc.

Benefits Realized

With the implementation of the data mart, the health insurer is better equipped to evolve and grow its industry leading physician incentive and PCMH programs with advanced analytics. Additionally, as industry-wide changes continue to come through health care reform (e.g. performance-based payments), our client will be positioned to better adapt.