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The Health Insurance Challenge: Going Beyond Business Intelligence

By Rick Ingraham

Health plans in 2007 are being pushed to become more innovative in the manner in which information is used to drive decisions and action. A merging of pressures, external and internal, is forcing the organization to capitalize upon the “silos of intelligences” built by discipline to facilitate an intelligence platform that crosses the enterprise. These silos, primarily focused around the data related to employer groups, membership, provider network, outcomes and claims, are repeatedly being drawn upon in ways not anticipated when initially built. Yet IT groups should not spend resources rebuilding the silos as much as enabling a return on the investment in their creation. The ability to apply an advanced analytic platform across the entire scope of these data stores and to empower all organizational units to facilitate exploration, prediction and reporting will be crucial in determining which health plans respond to the demands of their customers, deliver value and drive the competition through innovation.

Most organizations traditionally direct business intelligence at understanding the past. Technology has addressed this approach through data access, data management, reporting and on-line analytic process capabilities that allow an organization to explore and summarize historical events in terms of “What happened?”, “How much?” and “How many?” Through data access and OLAP of data silos, health insurers have focused on answering concerns like: “What was our average per-member, per-month cost last year?”, “What members presented claims at a higher than average claims rate?” or “How many employer groups presented claims to a degree greater than our actuaries had anticipated?”

Health insurers must go Beyond BI™ in order to respond to the market demands of today. Forecasting , predictive modeling and optimization capacities allow an insurer to stop the historical benchmarking and move to predicting what will happen next and understanding the best that can happen. Moving Beyond BI allows insurers to address issues such as “What will the impact be on specific categories of medical expenses if changes in health plan benefits are made?”, “Who will next year’s high-risk individuals be?”, “What changes in member utilization will CDHP drive, and what changes to benefits must we enact as a result?” or “What provider networks are most likely to provide care to optimize outcomes and minimize costs?”

Increasingly, disciplines such as medical care and disease management require the capacity to risk score individuals for intervention in a manner that goes beyond utilizing claims data but also capitalizes upon the intelligence gained through an analysis of provider specialties, membership demographics and regional patterns of care. Furthermore, the manner in which health plans engage their provider network now requires high-end analytics applied against both medical outcomes, the facilitation of evidence-based medicine and expected impact on claims/loss ratios to arrive at tiered-networks and pay-for-performance contracts driven through collaboration with the providers. The movement toward focusing on the member as the consumer, via consumer-directed healthcare, is also requiring an expanded scope of data considerations to facilitate both the reporting and analysis of data driving cost, satisfaction and outcomes decision making at the consumer level. In addition, the 23 million individuals, either self-employed or whose employer no longer offers health insurance, are driving a new focus on marketing and plan design to the individual market in ways further requiring an across-the-enterprise analytic platform. These trends are just a few of many that find IT units struggling with the rebuild approach when an enterprise analytic layer, leveraging all data captured, can not only respond to the pressures of today but expand as the payment of healthcare continues to be redefined. This will become even more critical as collaboration extends to the provider and regulatory community through state health information exchanges and regional health information organizations.

Beyond BI, via SAS^® Enterprise Intelligence, enables health plans to improve reporting functions in a manner streamlined to the user and integrated with capabilities of forecasting, optimization and modeling, which allows plans to respond to their new business demands. Health plans can consider the entire healthcare delivery and payment process to enable improvement, growth and, ultimately, demonstrate to its members an insight into care opportunities that are both cost beneficial and improve quality of life.

Bio: Rick Ingraham is the Global Marketing Manager for SAS' Health Benefit Plan industry and has served in executive positions within the insurance industry.

Rick Ingraham
Global Marketing Manager, SAS