Insurance & Technology is part of the Informa Tech Division of Informa PLC

This site is operated by a business or businesses owned by Informa PLC and all copyright resides with them. Informa PLC's registered office is 5 Howick Place, London SW1P 1WG. Registered in England and Wales. Number 8860726.


10:00 PM
Connect Directly

Highmark Shares Claims Data with Docs

Health insurer's SMART Registry targets treatment of chronic conditions.

Health insurers are often perceived as running disease management programs that actually interfere with patient care and work at cross-purposes with doctors, but Camp Hill, Pa.-based Highmark ($8.1 billion in revenue) has begun a collaborative program that it says is making the opposite impression. Through a report called the SMART Registry, the carrier is sharing available claims data with 44 medical care provider locations in central Pennsylvania to identify potential opportunities for improving care for physicians' patients with five common chronic illnesses.

Treatment Gaps

SMART Registry is designed to improve the treatment of patients with diabetes, asthma, congestive heart failure, coronary artery disease and chronic lung disease by revealing possible gaps in appropriate testing and therapy, according to Donald Fischer, M.D., medical director, Highmark. The report delivers information in population-specific, patient-specific and peer comparison formats, indicating adherence or non-adherence to proper test and treatment guidelines.

"We think we can bring value to physicians' practices by sharing claims data, showing that a claim occurred for a given test, or that no such claim was received, pointing out opportunities to improve systems of care so that the right thing happens for the right patient every time," Fischer says.

Highmark's medical informatics works with disease management firm Health Dialog (Boston) to produce the report, which is based on diagnostic, procedural and pharmaceutical prescription codes that are passed through algorithms to generate meaningful conclusions relative to chronic disease occurrence, testing and treatment parameters. The report's content is based entirely on claims data.

"It's basically non-clinical data, which is not as refined as what a physician might stratify, based on what he knows about his clinical condition," Fischer explains. "So we have the opportunity through the SMART Registry to bring to physicians' attention somebody who might need, for instance, targeted outreach from a health coach, as being in a very high risk group, when not having been formerly identified as such."

The SMART Registry is currently available in either paper copy or a Microsoft Excel file. "Our goal is to put this online, as an up-to-the-minute, real-time resource that could be queried by a physician who had rights to the information," Fischer says.

The concept of a health plan using disease management as an outreach to patients with chronic diseases is controversial in the physician community, as some perceive the practice as implying that physicians have not done a thorough job, according to Fischer. But, he says, "We are in no way trying to lay blame and say, 'You're a bad doc.' Rather, it's a matter of saying, 'Here's evidence we have that might be helpful in improving the quality of care that you otherwise might not have had.'"

No Complaints

While Fischer says he "would not presume" to say that every physician who receives the SMART Registry finds it useful, he has seen indications that doctors see utility in the report as a collaborative tool. For one thing, "I've had virtually no complaints from anybody, and it's a major coup for a health plan to send something out and not have somebody call and say, 'What the hell are you doing!'" he asserts. "Most responses have been very positive. In turn, we've been very receptive to suggestions to alter the SMART Registry so that it's more useful to physicians and more accurate."

Anthony O'Donnell has covered technology in the insurance industry since 2000, when he joined the editorial staff of Insurance & Technology. As an editor and reporter for I&T and the InformationWeek Financial Services of TechWeb he has written on all areas of information ... View Full Bio

Register for Insurance & Technology Newsletters