Heathcare Data Privacy and Self-Insured Employers

Merge Data

In the rush to control healthcare costs, many employers are self-insuring.  As part of this move, most self-insured networks have become intensely interested in analyzing their own claims and medication cost data.  This type of analysis can be highly informative.  For example, Fred Trotter has created an enormous Medicare referral network graph (DocGraph) for all physicians and providers in the United States.  Essentially, he took Medicare claims data and counted the number of instances that two physicians billed for care on the same patients.  Physicians were identified by a unique National Practitioner Identifier (NPI) number, which is publicly available here.   By some very simple matrix manipulation on this very large data set of 2011 Medicare claims, he created DocGraph. The resulting data is very simple:  {provider #1, provider #2, number instances where P#1 billed for seeing patients that p#2 also saw at some point}, but very large (49 million relationships).  This graph can be used to identify referral “cliques” (who refers to whom), and other patterns.  The bottom line is that any organization that has claims data, big data storage and processing capabilities, and some very simple analytics can do this.  Similar analyses can be done for medication prescribing patterns, disability claim numbers, and other care-delivery metrics.

Now, this can be a good thing from a business standpoint.  For example, to contain costs, you want most of your patients treated by providers in your network where you have negotiated contracts.  Out-of-network treatments are termed “leakage” by the industry. Network “leakage” analysis can rapidly identify which physicians are referring out-of-network and how often.   Assuming that the equivalent services are available in-network, and this is the key question, you could make these physicians aware of the resources and craft a referral process that makes it easier for them and their patients to access care.

You can also identify physicians who are the “hubs” of your network,  practitioners who are widely connected to others by patient care. These may be the movers-and-shakers of care standards, and the group that you  want to involve in development of new patient care strategies.  For a great example, see this innovative social network analysis of physicians in Italy and their attitudes towards evidence based medicine.

These types of analyses are not without problems and could be used unwisely.  For example, physicians who prescribe expensive, non-generic medications may be highly informed specialists.  Programs that do not take such information into account may unfairly penalize network providers.  In addition, some services may not be available in-network, so providers referring out of network in these cases are actually providing the best care for their patients.  Finally, these analytics could easily be used to identify “high utilizers” of healthcare services, and to better manage their healthcare.  Network analytics are really good at such pattern recognition.  As we move forward, a balanced approach to such analytics is needed, especially to prevent premature conclusions from being drawn from the data.

There is a larger issue also lurking beneath the surface:  employee discrimination based on healthcare data.  Some healthcare networks are triple agents:  healthcare provider, employer, and insurer.  It may be tempting from a business side to use complex analytics to hire or promote employees based on a combined analysis of performance, healthcare and other data.  Google already uses such “people analytics” for hiring.  Some businesses may try to use such profiling, including internal healthcare claims data, to shape their workforce.  Even if individual health data is not used by a company, it seems likely that businesses will use de-identified healthcare data to develop HR  management systems.  See Don Peck’s article in the Atlantic for some interesting reading on “people management” systems.

As a last thought, it’s a bit ironic that we, as a healthcare system in the United States, will be spending hundreds of millions of dollars analyzing whether our patients going “out-of-network” for care, and designing strategies to keep them in network, when this problem does not exist for single-payer National Healthcare Systems…