Data Warehouse: Decision Support Solution Reduces Patient Admissions, Saves Payor Millions - Sun Microsystems, Ultra 4000/ The 1199 National Benefit Fund - Product Information

Health Management Technology, May, 1999

SOURCE:

Geoffrey Gibson, Ph.D.
Research Director, Epidemiologist
The 1199 National Benefit Fund
330 West 42nd St., New. York, NY 10036
Phone: (212) 465-4837
geoffrey@1199nbf.com

PROBLEM:

The 1199 National Benefit Fund (NBF) is a New York-based, self-insured, self-administered Taft-Hartley health and welfare fund responsible for the delivery of healthcare benefits to over 225,000 members of the 1199 National Health and Human Services Workers Union and their dependants.

As a payer, NBF must assess the scope and quality of healthcare benefits provided to its members and their families. Although NBF provides fee-for-service care, it was determined to seek ways to more effectively improve quality and outcomes, and control costs.

SOLUTION:

To effectively influence member health and control costs, NBF sought a healthcare data warehouse and decision support solution that would provide its analysts and decision makers with better information about member health status and the provision and consumption of healthcare services. In addition, NBF was interested in applying managed care methodologies such as HEDIS measures and disease management protocols to improve outcomes and control costs.

After reviewing available solutions, NBF licensed Towson, Md. based, VIPS Healthcare Information Solutions' MCSource data warehouse and decision support solution. VIPS also provided implementation services that addressed data editing, mapping and integrity, system set up, and training.

NBF's four member analytical group uses MCSource to provide ongoing support for all of the operational staff's information needs. Some of these include:

* Identifying members for inclusion in disease management programs for a number of conditions, including asthma, diabetes, hypertension, prenatal care, and HIV;

* Utilization and cost analysis and;

* Evaluating its PBM for:

a) Effectiveness of pharmaceutical use in association with episodes of care;

b) Patient drug compliance by identifying, for example, patients with hypertension who did not refill their prescriptions;

c) Drug utilization of generic vs. brand name drugs and use this information to determine whether they should expand the list of formulary drugs;

d) Percentage of diabetics who are receiving ACE Inhibitors, or the percentage of asthmatics who are receiving anti-inflammatory medication;

e) Inappropriate use of drugs. For example: identifying physicians who may be prescribing expensive drugs for specific conditions (or for a long period of time); and,

f) Potential fraud.

NBF monitors the effectiveness of disease management programs by tracking ER or hospital admissions, and evaluating other measures of appropriate care. For example, NBF reviews the treatment of members with HIV to determine whether they have been prescribed protease inhibitors. If not, the member's physician is made aware of the potential treatment. Another example focused on NBF's C-section rate, which had reached 38 percent. Today, NBF proactively identifies pregnant members who've previously had C-sections and provides them with special educational materials--at the same time, sending their physicians information aimed at reducing unnecessary C-sections.

Although the NBF data warehouse is updated monthly, enabling early intervention for a number of conditions, the organization also performs a range of year-to-date analyses to assess trends in hospitalizations, pharmaceutical usage, mammography rates and other interventions.

COMPONENTS:

Hardware: Sun Microsystems, Ultra 4000

Software: VIPS Healthcare Information Solutions' MCSource[TM]

Networks: Ethernet

Consultants: VIPS Healthcare Information Solutions

Installation:

Implementation involves mapping, editing, and reformatting provider, enrollment, claims, pharmacy, and carveout data from NBF's legacy systems to MCSource. A significant amount of time is spent cleansing data so that it can be trusted for analysis. Overall, the entire implementation was completed in eight months.

STAFF, PATIENTS SERVED:

MCSource delivers benefits impacting members, our entire organization, and our analytical staff. By influencing treatment protocols, MCSource helps assure all 225,000 NBF members get the most appropriate care for their conditions. For example, this reduces emergency room visits for asthmatics and diabetics, results in healthier moms and babies, and reduces HIV mortality rates. Over the long-term, such interventions will lower NBF's costs.

Concurrently, members receiving preventive or more appropriate care will stay healthier. Healthier members are more likely to be satisfied with their benefits and in out case, with their union.

Finally, MCSource frees our analytical staff from dependence on our IS department. The system is extremely user friendly, enabling end-users to generate their own queries and reports using an intuitive browser-based interface.

BENEFITS:

Savings:

* MCSource automates the process of linking pharmacy records and interventions for individual members. Previously we would manually identify members with a disease and then have our pharmacists review their drug record. This has generated savings equivalent to 50 percent of a pharmacist's time, one RN, and 60 percent of a social worker or about $275,000.