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Information is power--powerful enough to tame healthcare costs and assure the delivery of appropriate care.

Medical providers and patients have demonstrated as much, when they have had data in hand when making health care decisions.

-- More than 75 sources of evidence-based medicine have produced in excess of 500 medical standards. How can providers keep up to date on those standards?

-- Only 55 percent of physician care standards are consistent with scientific evidence, the New England Journal of Medicine reports. How can adherence to evidence-based standards be monitored?

-- In more than 40 percent of cases, we've seen patients make less than optimal healthcare decisions. How can patients become better educated and more engaged health care consumers?

UnitedHealthcare has developed a series of processes to fill those information voids, and a multi-pronged approach that is producing significant results.

BETTER INFORMATION

Using claims data from 30 million members, the U.S. health insurer has developed a technology platform that provides the company unprecedented analytic capabilities on health issues. UnitedHealthcare draws on those capabilities to identify the best clinical practices and advocate them to its provider network in an effort to improve medical outcomes and reduce waste. A proprietary eSync technology platform provides UnitedHealthcare the ability to synchronize healthcare management data from multiple sources to develop insights and a broad array of targeted, personalized care approaches.

For example, eSync allows UnitedHealthcare to monitor and measure the outcomes of every member and provider interaction, including medical and pharmacy claims and individual health assessments.

With this data, they can evaluate whether their network and individual providers are both following the medical standards established by professional associations worldwide and offering the appropriate level of care based on evidence-based care guidelines. The analytical power of eSync also allows UnitedHealthcare to examine whether members are making optimal health care decisions, such as using an in-network provider and filling prescriptions. This gives UnitedHealthcare the opportunity to respond in time to make a difference in the effectiveness and cost of members' health care choices.

IMPROVED ADHERENCE TO QUALITY CARE

With data and analytic strengths, and clinical practices that best adhere to established medical standards in a cost-effective way, UnitedHealthcare can spot where improvements in inpatient and outpatient utilization management are needed.

UnitedHealthcare's inpatient care initiatives--to reduce treatments that do not meet evidence-based medical standards--have reduced bed days per 1,000 admissions by 4.8 percent over the past three years, generating typical savings of $4.89 per employee per month. During the same period, bed days industrywide rose 6 percent to 12 percent, according to the National Committee for Quality Assurance Quality.

One initiative, for example, the "One Hospital/One Nurse" facility utilization program, has been implemented in all hospitals in the UnitedHealthcare network. One nurse or a small team, depending on patient volume, strive to reduce unnecessary hospital stays. This is important to quality of care as well as cost containment issues, because the chance of a health crisis or complication increases 6 percent with every unnecessary day in the hospital, according to a 2004 study published in the American Journal of Medical Quality. Inpatient care initiatives also provide evidence-based clinical criteria that medical staff can consider in future inpatient cases and after patients are discharged.

For example, in the Transitional Care Management (TCM) program, the insurer identifies hospital patients whose medical history and health conditions greatly increase their risk of readmission after discharge. With that information, providers can ensure that those patients receive the case management and other special post-discharge support they need to recover without another hospital stay. Under the TCM program, readmissions decreased 50 percent between April 2007 and June 2008, according to a July 2009 study by OptumHealth Inc.

With outpatient services, treating physicians historically have improved their delivery of evidence-based care by 24 percent after UnitedHealthcare has shared its data and analysis. It focuses on the three most critical medical conditions in typical employee populations: cardiovascular disease, spinal/low-back pain, and cancer.

Claims data identified seven high-cost conditions for which there are wide variations in treatment and outcomes that can be significantly different depending on the type of specialist consulted. Among those conditions are spinal problems and cancer.

In response, UnitedHealthcare has developed programs to educate providers and consumers about treatment options, outcomes and costs. For example, for some patients with back pain, a chiropractor can deliver the same results as a neurosurgeon but at less than half the cost. In treating cancer, physicians over utilize by 30 percent a drug formulated to combat chemotherapy-induced anemia.

Two additional areas UnitedHealthcare is focusing on are:

-- Radiology/imaging. The goal is not simply to avoid unnecessary testing and, therefore, costs--it is also to reduce exposure to unnecessary radiation, which can create health problems. Its initiatives in this area last year produced savings of about $2 per employee per month (PEPM).

-- Complex care. Specialized and complex procedures and treatments, with poor outcomes typically lead to dramatically higher costs. So the insurer has focused on identifying and contracting with the recognized best-practice Centers of Excellence for care involving organ transplants, congenital heart disease, cancer, kidney disease and neonatal intensive care. Depending on the type of care, its initiatives have led to savings of 66 cents to $1.54 PEPM.

BETTER INDIVIDUAL DECISIONS

The eSync platform allows UnitedHealthcare to study the behavior of high-risk and potentially high-risk members to provide them personalized information to help make more informed decisions before major health issues arise. This significantly helps individuals manage the daily challenges of living with a chronic health condition. By segmenting workforce populations by demographics, medical conditions, cultural categories and life stages, UnitedHealthcare is offering more robust and effective prevention, wellness, education utilization and case management programs that speak more effectively to every targeted member.

As a result of all of its initiatives, the typical large UnitedHealthcare customer using clinical services and programs in 2009 got a 3 to 4 percent medical cost reduction, a savings of $22.30 per employee per month. In addition, consumers' health care decisions will be 45 percent more optimal. The savings would be less if moving from another carrier, and depends on the illness burden of the employer, final program adoption and any customization. That shows consumers who make more informed medical decisions and live healthier lifestyles might have a greater impact on lowering overall health care costs than any insurance or government program could accomplish.

(The above piece is part of our continuing Perspectives series designed to highlight key products and services to our readers. This paid-for Perspectives was written and edited by Risk & Insurance® in conjunction with our marketing partner. Additional Perspectives can be found on our Web site at www.riskandinsurance.com/.)

October 1, 2010

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