Unitedhealth Group

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.