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Helping Consumers Navigate Claims Data

July 11, 2013
by Gabriel Perna
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If the age of medical cost transparency is in fact upon us, then perhaps Oct. 27, 2009 might be cited as one of the key dates for this burgeoning movement. It was on that date that an organization by the name of Fair Health was created.

Fair Health is a non-profit organization developed in large part to the efforts of then-New York State Attorney General, Andrew Cuomo (now Governor of N.Y.). Cuomo, who was investigating how out-of-network claims were being priced, settled with the various insurance companies out of court. From that settlement, the insurance companies agreed to establish a non-profit organization that would feature an independent database of healthcare charge information.

Unlike the database that was allegedly being used by health insurance companies to determine “usual, customary and reasonable” (UCR) charges for out-of-network services, the one assigned to Fair Health was to be “fair” and “neutral.” After a few years of development, Fair Health and a number of partnering research institutions went live with the database in January of 2011. While the transparency ideal is important, Fair Health says contextualization is big.

“We’ve realized…that whenever data is being made available to consumers, it’s important that it’s properly contextualized so consumers can understand what they are looking at, and they understand how they can evaluate it inform better decision making. Just making data available can actually create more confusion if you’re not comparing the right elements and properly contextualized, says Fair Health President Robin Gelburd.

Large Database

Since its go-live, the database has been able to collect charge information on more than 16 billion billed medical and dental services covering 129 million lives from 60 different contributors. It’s constantly updated, reveals Gelburd.

“Some of that data is updated monthly, some quarterly, and some of it is updated twice-quarterly. We have to have systems and storage and processing capabilities that are extremely sophisticated and standardized disparate data elements because obviously every data contributor may have different ways to organize the data,” says Gelburd, who was recruited to be CEO of the organization back when it was formed in 2009.

Fair Health uses infrastructure from the San Jose, Calif.-based networking provider, Brocade, and other software and hardware solutions, and integrates the capabilities with algorithms and methodologies acquired from the scientific and research community. According to Gelburd, the settlement from 2009 actually required the organization to integrate the expertise of statisticians, economists, and other experts into the work it does.

Gelburd credits Fair Health’s chief technology officer Ben Casado for adopting strategies from other industries to help create the database.

“We tried to bring over into the healthcare industry some of the architecture that we have been using in the financial market for a decade now. We have sophisticated, state-of-the-art low-balance data centers, we have sophisticated warehouses, and we have stored the data that comes in from contributors into fast, smart storage units. On top of that, we have a processing layer and an application layer, that’s how we maintain and continue to grow, by capturing the data and studying it,” Casado says.

Currently, the database is just claims data, but Gelburd says there are efforts under way to create patient portals to access electronic medical records (EMRs). She expects this to lead to better health outcomes, less duplication of tests, and lower cost for the patient.

Robin Gelburd

Other Uses

Along with making available the data for consumers for free, Gelburd also says Fair Health serves payers, third-party administrators, not-for-profits, researchers, and policymakers, by licensing different sets of data. This licensing allows Fair Health to integrate the proper technology that keeps the database updated and accurate. It also opens it up to people who could use it for a greater good, Gelburd says.

“Researchers are using it in a variety of ways. They’re using it to detect emerging trends, like for instance, around Type 2 diabetes. They can look at the data to detect where diabetes is increasing at alarming rates and that could help form different types of educational campaigns,” explains Gelburd. She adds policymakers can use the database to determine the unintended consequences of public health laws and regulations, while providers can use to figure out clinical trends in certain regions.

The recent decision by the Centers for Medicare & Medicaid Services (CMS) to release data on hospital outpatient charges and Medicare spending and utilization was met with overwhelming approval at Fair Health. Gelburd says she senses that this movement is beginning to start a number of constructive dialogues around the country between patients and providers, patients and payers, and other stakeholders.

“Cost is now one element that consumers are raising, that providers are raising, to help inform and flesh out these talks. Likewise cost transparency is helping inform conversations between the consumer and health plan to help understand benefit design so they can be more proactive in the way they navigate that insurance landscape, so there are no surprises,” Gelburd says.

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