Analytics drives cost, quality improvements for NC insurance provider

Blue Cross and Blue Shield of North Carolina has a lot of data. Its network includes 99 percent of the state's hospitals and 93 percent of its health-care providers, covering 3.6 million customers. The data generated by this huge network holds the key to providing high-quality and cost-efficient health care – and it's Daryl Wansink's job to find it.

Wansink, Director of Health Economics at BCBSNC, needed to understand how to use that data to help providers offer higher-quality care to their members. To improve physician and hospital performance, provide more personalized service, and keep costs low for employees, BCBSNC uses SAS® Analytics to dive into millions of claims.

"Advanced analytics allow us to understand utilization patterns and quality-of-care issues and to share that information with our network providers so they can take action on it," Wansink says.

Health-care quality and efficiency has a Rubik's Cube-like dimension. Researchers have to look at the issue from multiple perspectives. One of Wansink's projects is to explore the relationship between providers.

"As a payer, we have access to information that, unfortunately, providers don't always have," Wansink says. "We might know that a member was re-admitted to a hospital – but the initial provider might not know that because the person went to a different hospital.''

Harnessing big data to make a difference

BCBSNC’s provider project draws from research methods pioneered by the Dartmouth Atlas of Health Care and the Foundation for Informed Medical Decision Making. Using Medicare data, Dartmouth is known for its studies that show more spending on health care doesn’t necessarily lead to better health care and that where people live might determine whether they receive conservative or aggressive treatment – regardless of which treatment is most likely to lead to a better outcome.

What Dartmouth researchers are only now starting to work with is what Blue Cross and Blue Shield of North Carolina already has – a database on the commercially insured population under 65. Wansink's group can now explore why some providers are treating chronic-pain patients more effectively – and at much lower costs -- than other providers; or tease out referral patterns that lead to high rates of costly and minimally effective treatment in one part of the state versus less-expensive, better-quality care in others.

"We're trying to model the relationships that drive efficiency and quality," Wansink says.

We want to reward existing relationships between providers that are very efficient already, and encourage change for those that aren't.

Daryl Wansink
Director of Health Economics

Connecting the dots

Wansink says his group is particularly interested in looking at referral patterns that lead to cost-effective care. Are some non-interventional cardiologists sending their patients to an interventional cardiologist to weigh the option of having a procedure done at the right time? Which obstetricians appropriately send high-risk pregnancies to perinatologists?

BCBSNC logo"We want to reward existing relationships between providers that are very efficient already and encourage change for those that aren't," Wansink says.

BCBSNC is also looking at geographic practice patterns. Is a patient more likely to have spinal surgery for chronic back pain in one part of the state versus another? Do some providers recommend surgery much more frequently in one town versus another?

Wansink's group then creates an index score that factors practice patterns as they relate to others in the state and to national standards for effective care. It shares the score with providers. Wansink is quick to note that his team adjusts for providers who might see a much sicker subset of patients, or have a more limited set of resources given their particular locale.

"We are trying to be as transparent in that scoring methodology as possible to generate trust with the providers," Wansink says.

"How has this been received by providers? "They have been very receptive,'' Wansink says. "With health-care reform, the pressure on providers to improve efficiency and quality has never been stronger. So the ability to provide actionable information has been welcomed."

Providing a competitive advantage

Information from the provider-analytics project flows to the benefit consultants who work with BCBSNC's employer clients to design their benefit plans.

"This actually helps employers do a better job of designing benefit plans," explains Wansink.

It allows companies to design plans with incentives that drive utilization to the providers who offer the best combination of quality and efficiency.

"We've also received very strong feedback from a large employer in the state who is based overseas," Wansink says. "They find health-care costs so high in the US that they lose money on some of their US operations due primarily to this employee benefit. With provider analytics, we can help them structure a high-quality, cost-effective benefits program.''



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