MedInitiatives

Situation

The claims processing environment for Medicaid impedes the ability to provide quality, responsive insight for its beneficiaries and their providers. There is a lack of consistently available data for information management due to the multiple claims processors currently administering the benefit. The lack of access to timely, detailed

Medicaid beneficiary healthcare data does not provide program managers, providers and beneficiaries the information and transparency they require to effectively manage the healthcare continuum. Health care data is typically captured through legacy or proprietary transaction processing systems. These systems are designed to process claims but are unable to provide easy access to data, and with multiple claims processors on a variety of transaction processing systems, Medicaid data is captured and stored in multiple locations. Medicaid providers lack adequate, affordable business intelligence and decision support solutions to efficiently aggregate and integrate disparate beneficiary pharmacy, medical and lab data, making it “actionable” to impact clinical and financial outcomes supporting the Medicaid strategy.

Solution

MedInitiatives provides a suite of end-to-end analytical tools that deliver market differentiating financial, clinical and business value to the health care segment. The MedInitiatives’ solution provides health care, business or information technology users with direct access to integrated healthcare data in a suite of modularized HIPAA-compliant, Web-based solutions. Examples include benefit modeling, disease management and fraud and abuse detection, which accounts for 3 – 10% of every health care dollar.

MedInitiatives’ healthcare business intelligence solutions integrate and analyze disparate pharmaceutical, medical and lab data from a comprehensive list of data sources including legacy systems, ERP systems, flat files and data warehouses. Health care organizations can gain insight, drill into details and make decisions about patient safety, fraud and abuse, clinical outcomes, healthcare benefit designs, rebate performance and cost structure. Rather than just providing traditional retrospective analysis, “look back” capability, our solutions enable users to lead their clients with concurrent and prospective analyses. This “look forward” capability allows them to model, budget, forecast and implement changes based on their historical data or any data set being utilized. Our solutions make it possible to proactively analyze longitudinally aligned data to affect the health care continuum.

Specifically, through MedInitiatives’ solutions, aberrant patterns and trends can be revealed, pinpointing opportunities for improvement through intervention and integrated communication at the beneficiary and provider levels. With the ability to drill into any granular element of health care data, those opportunities emerge for specific members, physicians, pharmacies, drugs, diseases and medical diagnoses.

MedInitiatives’ user friendly, 360-degree solution specifically provides:

• Modules for monitoring most chronic diseases based on HEDIS®-like parameters and nationally recognized best practice guidelines
  
• Fraud & abuse detection; to research, identify, monitor and take immediate action against clinical as well as administrative exceptions
  
• Specialized development support for custom alert modifications to incorporate your own best practice guidelines and appropriate therapy initiatives within each disease area
  
• Programmed outcomes tracking to verify change in therapy successes and identification of members for further evaluation
  
• Utilization trending, demographic analysis and vector analysis by manufacturer and retail pharmacy to secure best price agreements
  
• Specialty drug utilization between pharmacy benefit and specialty benefit for cost savings
  
• Rebate forecasts & models by quickly building potential contracts
  
• Optimized plan and benefit design through modeling
  
• Compliance monitoring and enhanced utilization review
  
• Access to secure on-line beneficiary profiles
  
• Risk assessment capabilities
  
• Clinical monitoring capabilities with pharmacy data only or integrated pharmacy, medical and lab data
  

MedInitiatives’ technology allows organizations to improve service levels to beneficiaries and providers through:

• HIPAA-compliant Web-based data access and distributed reporting and analytics
  
• Better and timely access to quality data
  
• Information sharing for collaboration and care coordination/disease management
  
• Timely implementations of new solutions according to initiatives 

Better Health Lower Costs

Analytics is MedInitiatives’ primary focus, as evidenced by its successful implementations and 100% client retention rate. Our clients include some of the largest managed care organizations and pharmacy benefit managers (PBMs) across the country. MedInitiatives’ technology is used by health care companies managing more than 83 million lives and more than $25 billion in health care expenditures and named as the #1 Fastest Growing Company in the Sacramento region by the Sacramento Business Journal in 2004. MedInitiatives will serve as a “behind-the-scenes” technology partner, resulting in risk mitigation, resource optimization and speed-to-market.

In the case of one client, a PBM, they had to access data from seven databases on three database platforms using six tools to extract and analyze data. Challenges:

• Restricted direct access to data for information consumers
  
• Required IT resources for information gathering and distribution
  
• Ad hoc queries requests had become a “deafening roar” to data managers
  
• Heavy resource investments: one standard report took 10 full days of staff time to run
  
• Overproduction of unnecessary reports: Of 7,000 reports, run in batch, only 33% were used
  
• Latency on data was high (16 to 45 days)
  

Strategy:
The PBM wanted to offer internal and external customers access to interactive, on-line data analysis and on-demand reporting through a single data source that allows the PBM to combine data from multiple operational systems. Project objectives included:

• Consolidate data into one place for a single version of the truth
  
• Deliver data as near “real time” as possible for low latency by loading data daily
  
• Consolidate the number of applications used for data analysis to a single application
  
• Reduce impact to IT for ad hoc requests
  
• Push data directly to information consumers with drill-down capabilities
  
• Increase performance on return of data
  
• Offer a proprietary, branded Web-based product for customer reporting, a competitive advantage
  

Solution:
The PBM chose MedInitiatives’ technology, which offered a proven foundation upon which to build its own business intelligence technology solution. From health care data integration and security to Web delivery, MedInitiatives had all the components required for secure and easy access to health care data. MedInitiatives worked with members from the PBM’s information technology, marketing/product development and business analyst teams to fast track the build for its private labeled, on-line reporting and analysis product. Working with the marketing team, MedInitiatives modified its user interface to reflect the PBM’s brand, including colors, fonts, nomenclature, graphics, etc. For speed-to-market, the PBM initially used MedInitiatives’ technology “out of the box,” as it was built for health care data and can be used immediately for simplified, anywhere, anytime data access. MedInitiatives then worked with the PBM’s business group to create its own proprietary Data views (on-line, interactive Web-based reports) to advance its strategic initiatives.

Working in partnership with the IT team at the PBM, MedInitiatives developed a unique schema, creating data marts, extraction, load and transformation (ETL) programs to integrate and consolidate their health data for single-source access to data for analysis.

Results:
With the flexibility of MedInitiatives’ technology, the PBM was able to develop additional products for their customers, which is a source of revenue, as well as a differentiator. The PBM now offers on-demand mass information distribution for every user level in a secure environment. MedInitiatives’ security model supports restriction of access to specific products; Data views or to data by user type or by client, down to the data element, and is set at the User ID level for every user.

Users have direct, anywhere, anytime access to all the data they need – when they need it. Through a standard Web browser, users can log in from any computer with Internet access. MedInitiatives’ solutions are designed for business and clinical users, offering standard Web functionality for familiar navigation and ease of use, such as hyperlink text to navigate drill-down opportunities, drop-down menus and radio buttons. If the initial Data view returns aberrant patterns/results, the user can conduct more detailed analyses through simple point-and-click drill-down functionality that leads to detail on member, drug, provider, pharmacy, etc.

As an example of clinical use, the PBM offers Clinical Account Pharmacists (CAPs) the ability to identify the top physicians for Women’s Health. Once they have been identified, CAPs run individual reports for each of the physicians. CAPS then take these reports with them to visit physicians in their offices to ensure therapy is appropriate for members. The documentation allows the CAPs to discuss potential therapy changes for improvements on a physician-focused, member-specific basis.

These reports were previously run by coordinators for clinical use and took 480 hours to process and were delivered in hard copy for CAPs to sort through. With the MedInitiatives’ solution, CAPs now have direct, anywhere, anytime access to near real-time data delivered through these reports. Effectiveness has been improved in four areas:

1. Direct access to information has improved accuracy through additional fact finding with results returned in less than one minute
   
2. Turn-around time has been reduced by 85%
   
3. Single version of the truth has eliminated need for unnecessary research based on incorrect original results
   
4. Latency on data has been reduced from up to forty-five days to one
   

“MedInitiatives reduced our internal build timeline by providing a flexible tool with a health care-focused foundation for our PBM decision support solution (DSS). We have experienced an exceptional response to this tool within our organization. Our users are very excited about this on-demand information distribution tool, and our customers are coming to expect on-line analysis tools and data integration capabilities. MedInitiatives allowed us to advance our technology offering very quickly and provides a single tool for our future product development needs, including medical data integration and associated analytics.”
— PBM Product Manager.