UnitedHealth Group provides a continuum of health care and specialty services to more than 16 million members throughout the United States through HMOs.
UNITEDHEALTH GROUP
UnitedHealth
Group provides a continuum of health care and specialty services to more than
16 million members throughout the United States through HMOs, point-of-service
arrangements, preferred provider organizations, managed indem-nity programmes,
Medicare and Medicaid managed care programmes and senior and retiree insur-ance
programmes (Shatin, Rawson and Stergachis, 2005). Specialized services include
mental health, substance abuse, utilization management, special-ized provider
networks, third-party administration services, employee assistance services, managed
phar-macy services and information systems. Although the plan structures vary
and range from staff or group models to independent practice associations,
affiliated health plans are typically the latter, with open access to a wide
network of providers. Unique member iden-tifiers allow for tracking across
enrollment periods, so that a member can be followed through disen-rollment and
re-enrollment. Participating providers include 3300 hospitals and more than 400
000 physi-cians (Shatin, Rawson and Stergachis, 2005).
The
11 UnitedHealth Group-affiliated health plans in the research databases are
geographically diverse, with plans in the Northeastern, Southeastern,
Midwestern and Western regions of the United States. These databases were begun
in 1990, with 3.8 million members and 2.8 million member-years, represent-ing
commercial, Medicaid, and Medicare recipients (Shatin, Rawson and Stergachis,
2005). Most of the commercial and Medicaid members have a drug bene-fit.
Medicare drug benefits vary depending on the plan, so the pharmacy files may
not capture all prescriptions in this age range. The elderly are
under-represented in other databases as well, since most UnitedHealth members
are enrolled in employment-based plans.
The
research databases are compiled from member-ship data, medical and pharmacy
claims and health professional data. Data elements in the membership file
include, besides the unique member identifier, date of birth, gender, place and
type of employment, benefit package and links to dates of enrollment and
disenrollment. Medical claims include outpatient as well as inpatient,
emergency room, surgery, specialty, preventive and office-based treatment.
Claim forms must be submitted by a health care provider in order to receive
payment for a covered service. Pharmacy claims typically are submitted
electronically by the pharmacy at the time a prescription is filled. The data
submitted specify the patient’s and pharmacy’s identi-fiers, drug name, date
dispensed, dosage of medication dispensed, duration of the prescription in days
and quantity dispensed. Provider data include physician specialty, and enable
researchers to locate medical records for the collection of detailed
information not provided in the claims data. The resulting files have been incorporated
into software developed by Unit-edHealth to facilitate the investigation of
questions such as those regarding drug exposures and adverse drug events.
Research capabilities include perform-ing record and file linkages,
constructing longitudinal histories, identifying denominators to calculate
rates, identifying specific treatments at a particular point in time, and
calculating person-time at risk and time of event occurrence.
Given
the large size of the databases available to UnitedHealth, it is possible to
detect rare expo-sures and rare outcomes. Feasibility studies have been
conducted using these data to evaluate drug usage and to study adverse events
that are first identified through the Spontaneous Reporting System of the FDA.
UnitedHealth
Group has no data on drugs that cost less than the copayment amount, and
inconsistent data on those eligible for Medicare, as noted above. Not all drugs
are on the preferred drug list. Medical record retrieval is still necessary for
obtaining infor-mation such as race/ethnicity, confirming a diagnosis,
obtaining information on risk factors and outcomes, or determining whether a
member is deceased. Another limitation is the time lag in receiving information
from claims data, which can be 1 month for pharmacy claims but up to 6 months
for physician and facility claims.
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