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11 Cards in this Set

  • Front
  • Back
Information Management
Data, when organized, sufficient, and used correctly, is information, and is used to create action.

Management Information Systems are collections of data and computer programs designed to help managers handle information.

There are also Actuarial Information Systems and Provider Information Systems.
Building a Data Warehouse
Data warehousing means gathering and integrating data from different sources in order to do reporting and analysis.

Steps in Data Warehousing:
1. Define needed data.
 Make sure all necessary diagnosis/procedure codes are captured
2. Collect the data
3. Assure integrity of the data
 make sure totals match after each transfer from system to system
4. Put data into context (e.g. make it useful to the audiences using it)
5. Do “data mining”
This means looking for hidden meanings, trends, and facts by using sophisticated algorithms.
(But wait!!! Wasn’t one of the Course 7 Pretest study notes all about how you shouldn’t do data mining, because if you look hard enough you’ll always find some kind of apparent trend no matter what the data, and most of the time it’s fake?) Anyway, data mining is a big topic in health care.
Information Management Groups (IMG’s)
IMGs are Function-oriented business units that are charged with making business measurements
Companies tend to decentralize info mgmt directly to the business units, because the people on the front line know what they need the best.

Requirements for the implementation of IMG's:
 Corporate direction about the role of the IMG’s
 A data warehouse (above)
 Trained and skilled staff
 a method of dealing with the overlap of the data among different business units
 Standardized terminology
 Centralized IT support
The Technologies a Company Needs in order to Integrate its MIS’s
 A Client-Server System
In a Client-Server system, all the data is kept in a centralized source (server), and the users access that centralized data from their personal computers (clients) using specialized application programs.
This is clearly ideal for a company that uses an IMG structure (above)
 Open System Architecture (means that data can be moved between systems)
 the Internet, and a corporate intranet
 Document Imaging – the means to store paper documents electronically
 Workflow Management Software
tracks who is working on each case, the current status, and how long the job has taken
 a Data Warehouse
Components of an Insurance Company’s Management Information
The specific contents depend on the Audience and the intended use of the information, but in general, MIS includes:
 Financial Reporting Info
 revenue; profit
 premiums
 expenses
 Event Info
 Frequency, Severity, Causes, and Correlations among benefit plans, pricing, provider contracting,care management,customer behavior and future results
 Results should be compared with trends or bench marks
 People Info
 Choices are influenced by each individual expects to consume versus the cost and Antiselection statistics;
 effect of antiselection on Utilization and Enrollment
 Hospitals, doctors, pharmacies, and Insurance Companies all have unconnected systems and technologies
 All the Data Quality Issues (see General-Data Quality Issues for this often-needed list)
 estimating the Value of the Data (is a report cost-effective to produce?)
 Clearly presenting the data (graphics, numbers, report readability, appropriateness for the audience)
Management Information is used to create reports.

If an exam question asks for the “Applications of Management Information Systems”, they mean “What types of reports can an Insurance Company produce using its data and reporting systems?” (This terminology was used in the Third Edition of GI.)
Historical Studies reporting
Current reporting (as opposed to historical reporting)
Projecting the Future reporting
HEDIS reporting
Historical Studies reporting
 Financial results (loss ratio, expenses, profits)
 Persistency studies (lapses)
 Mortality studies (by age, sex, industry, location, etc.)
 Disability studies (frequency, severity, recovery rates of disabilities)
 Claim Lag statistics
claim lag = time from submission to payment of a claim
Current reporting (as opposed to historical reporting)
 Income Statements
 There’s a sample income statement on the case study. List a bunch of the rows from it (e.g. investment income, claims incurred, expenses, premiums, reserve increases...)
 analyze income statements by block of business, too.

 Expenses
 chief components: Acquisitions, Administrative, Marketing, Commissions, Overhead, Premium Taxes.

 Reporting to Policyholders (employer groups)
 Accounting reports:
 Premiums employer has paid; premiums still owed
 breakdown of Claims, Expenses, Loadings, and Pooling Charges

 Benefit Analysis Reports
 large claim reports
 breakdown of submitted charges by “source” — that means “type of care”
 Hospital (inpatient, outpatient), Physician fees, Surgeon fees, Anesthesia, Radiology, Dental, Drugs.
(you can just copy this list from the 8M case study.)

 Managed Care Reports
 What was the effectiveness of managed care?
 price discounts achieved
 utilization savings; drug utilization
 network effectiveness

 Provider and Network Monitoring Reports
 cost vs. quality of the various providers
 Cost must be normalized; that is, adjusted for case mix and severity mix.
 rank the providers by compliance with clinical guidelines
 provider credentialing reports
 # office visits to particular doctors
 # patient complaints

 Sales and Marketing Monitoring Reports
 Sales and marketing affect:
 revenue
 customer relations
 public image

Should monitor:
 sales-in-progress and closing ratios
closing ratio = sold business / quoted business
 agent performance
 key accounts
Projecting the Future reporting
 Cash Flow and Asset Projections
 Ins Cpy should produce projected income statements the way they might look in the future
HEDIS reporting
The Healthplan Employer Data & Information Set is a standard format for managed care reporting.
 HEDIS reporting is done in 8 categories:
 Effectiveness of care, Access, Satisfaction, Plan stability, Utilization, Cost of care, Informed choices, and Descriptive information

 widely accepted
 emphasizes quality of care