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Health Plans Come Together for Better Outcomes Research

MANAGED CARE March 2008. © MediMedia USA

Health Plans Come Together for Better Outcomes Research

Companies that participate in large research cooperatives such as the HMO Research Network are helping the whole medical system
Lola Butcher
Contributing Editor
MANAGED CARE March 2008. ©MediMedia USA

Companies that participate in large research cooperatives such as the HMO Research Network are helping the whole medical system

Lola Butcher

Contributing Editor

Health plans are known more for competing with one another than collaborating, but the HMO Research Network is an exception to that rule.

After more than two decades of working on research projects, the HMO RN, as it is called, recently won federal funding for what may be its biggest effort yet.

The National Heart, Lung, and Blood Institute will finance the creation of the Cardiovascular Research Network — the newest initiative of the HMO RN — with $7.5 million over five years. The goal of the researchers is to study the epidemiology, prevention, management, and outcomes of cardiovascular diseases.

The CVRN is a multiyear initiative to learn about cardiovascular disease using an unusual information source — patient data available to researchers affiliated with some of the nation’s largest HMOs.

The research network, headed by Alan S. Go, MD, assistant director of clinical research at the Kaiser Permanente Division of Research, is the first to follow patients over time, using information about their care, medications, hospitalizations, and health status to learn how to improve care and patient outcomes.

The researchers will collaborate with the American College of Cardiology and the American Heart Association, both of which maintain clinical registries, as well as with government agencies that seek to improve cardiovascular quality of care and outcomes. “One of the unique aspects is that we’re doing this in such a large scale and particularly among diverse, community-based populations,” Go says.

“We see this as setting a new way of leveraging everyone’s various investments to get at these answers,” Go says. “That’s the vision we all have.”

That is the vision of the HMO Research Network, a collaboration of 15 not-for-profit health plans that allows hundreds of researchers to share their expertise — and the data about their members’ health care — to conduct major research studies.

“This is a hidden gem,” says Andrew F. Nelson, MPH, executive director of HealthPartners Research Foundation. “Some of the discoveries that happen here have an impact on individual health — for those people that are in the health plans — as well as public health, when that knowledge is shared.”

HMO Research Network

The HMO RN, established in the early 1990s by researchers affiliated with four health plans — Kaiser Permanente Northwest in Portland, Kaiser Permanente Northern California in Oakland, Group Health in Seattle, and Health Partners in Minneapolis — has grown to 15 members.

The network builds on the substantial research capacity of the individual health plans. In most cases, the research enterprise is an independent entity that is hosted by the health plan but receives most of its funding from external sources.

For example, Group Health established the Center for Health Studies, which has about 30 researchers and nearly 240 employees, more than 20 years ago. Roughly 10 percent of the center’s budget is covered by Group Health, but its research funding comes from the National Institutes of Health, the Centers for Disease Control & Prevention, and other agencies and foundations.

Although researchers participating in the HMO RN are affiliated with health plans, the research findings are not proprietary. Rather, the results of the studies are published in peer-reviewed scientific journals or presented at research conferences.

HealthPartners, for example, shared its research results in more than 900 publications and presentations in 2006, ranging from posters at the American Diabetes Association’s annual scientific meeting to articles in the International Journal of Cancer.

While the health plan-based researchers sometimes pursue studies at the request of their affiliated health plan, they more typically pursue their own research agenda.

“We are especially interested in optimizing health and health care through research,” says Nelson, who studies organizational innovation.

Katherine Newton, PhD, associate director of external research at the Group Health Center for Health Studies, says the health plan-affiliated researchers generally aspire to generate information that can be translated into clinical practice.

“We are informed by basic science and the efficacy studies, but our work lives much closer to real world patient care,” she says.

While some for-profit insurers have a research capability, they generally apply themselves to concerns specific to their affiliated health plan. In the mid-1990s, Nelson, at HealthPartners, surveyed all health plans across the country and about 50 plans responded to say they conducted research.

“When I went to interview each one of them, I learned that about half of that 50 were really not research organizations,” says Nelson, whose study was published in Health Affairs. “They were inside strategic planning groups.”

Using two criteria — whether research results were published in the public domain and whether external funding supports specific studies — he found that only 20 health plans made the cut.

“Most of the largest and substantial ones are part of the HMO Research Network,” he says.

The researchers benefit from access to information about health plan members (always subject to federal research regulations, of course) and the health plans benefit from rapid access to the research results.

If health plan researchers discover, for example, a problem with a medical device or a better strategy to treat a condition, they notify health plan representatives who, in turn, pass the information on to their affiliated clinicians. This can happen very quickly.

“This is as opposed to the normal way that research findings are disseminated — which is to publish and hope people read the article,” he says.

One example: Researchers at Kaiser Permanente of northern California, studying COX-2 inhibitors, discovered a potential problem long before the risks of the drugs were well known.

“We immediately got data to the executives, they made decisions, it went through pharmacy and therapeutics, and we stopped prescribing that medication,” Go says.

Perhaps the most widely known research to emanate from the Group Health Center for Health Studies is the work underlying the Free & Clear smoking cessation program. The researchers determined that copayments deterred smokers from participating in smoking cessation programs. Group Health later eliminated the copayment.

While the research organizations that are affiliated with health plans work primarily on individual projects, they come together to collaborate on HMO RN endeavors such as the CVRN. A lead organization — in this case, the Kaiser Permanente division of research in Oakland — receives the research grant, and other plans participate as subcontractors.

“What is unique about this group is the goodwill between these institutions and their investigators,” Newton says. “These organizations collaborate in ways that make the research dollar go a lot further, and we can have access to national populations for research studies. It is really a national model for collaboration.”

Cardiovascular research network

The new research network is tackling the leading cause of death and disability in the United States — and one of the fastest-rising causes of death and disability worldwide. The initial funding will support three research projects planned in the next five years:

  • Hypertension recognition, treatment, and control
  • Quality of care and outcomes of the blood thinner warfarin for atrial fibrillation and blood clots
  • Use and outcomes of implantable cardiac defibrillators

“We have knowledge of what to do to help people in terms of cardiovascular risk, and some of this work is trying to figure out how to do it better, how to implement all this great science and do it well,” says Go, co-principal investigator for the cardiovascular network.

An overall goal will be to create an infrastructure that allows researchers to create multicenter, pooled data files to address cardiovascular research questions.

“A lot of the effort will be to make these data systems harmonize so we can feel confident that we’re comparing apples to apples across each of these health plans,” Go says. “That won’t be just for technology. It will mean developing the local expertise to leverage each health plan’s data systems and to assist in larger and more efficient involvement in key clinical trials.”

The first project, which started in late 2007, will be of interest to all health care purchasers and payers: In light of the many medications and interventions available to treat hypertension, why is optimal control so hard to achieve?

“Most assessments have been done on limited surveys, in single health plans, or only in subgroups like Medicare,” Go says. “This project will involve more than a million patients with hypertension, either diagnosed or undiagnosed.”

Three of the HMO RN plans will participate in that project. The researchers will try to determine the factors that drive people to be treated for hypertension and to achieve the levels of control that are supported by national guidelines and by the scientific evidence that underpins them.

The project will also attempt to make a significant breakthrough in research practice. The blood pressure measurements used in the study will have been collected electronically in physician offices, and the researchers will extract the readings for individuals and review their clinical history to find out whether and how they were treated and how well their blood pressure was controlled.

They will also compare the electronic data to the information in paper medical charts to see whether it matches.

“That will give critical information as other health plans begin to get electronic data collected on their populations,” Go says. “We will be right in front, trying to help figure out what works and what doesn’t work.”

The second CVRN project, which will begin this year, will involve 80,000 members from five plans who are prescribed the blood thinner warfarin.

Patient registry

The third project, scheduled to begin in 2009, will make use of a registry of patients who have implanted cardioverter defibrillators. For the past three years, the ICD Registry, sponsored by the American College of Cardiology Foundation and the Heart Rhythm Society, has been asking hospitals to submit names of patients who have received ICDs. Medicare, in fact, requires a patient to be listed in the ICD Registry for it to pay for the ICD implantation.

The registry, however, has no way of collecting information about how those patients fared — until now. “We’re going to leverage what Medicare has invested and the American College of Cardiology has invested and get a lot more information about who’s getting these procedures and what happens to them over time,” says Go. -

What makes health plan collaboration so beautiful is that it can bring together data representative of the entire population, says Alan S. Go, MD, at the Kaiser Permanente Division of Research.

Government works with HMO researchers

The new Cardiovascular Research Network builds on the long-term success of the Cancer Research Network, a collaborative of health plan researchers now in its ninth year, and the Centers for Education and Research on Therapeutics (CERTs) and Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Network, a national initiative to conduct research and provide education that increases the appropriate use of drugs, medical devices, and biological therapies.

The CERTS initiative, led by Richard Platt, MD, at Harvard Pilgrim Health Care and funded primarily by the Agency for Healthcare Research and Quality (AHRQ), seeks to provide comparative information on the risks, benefits, and interactions of new and older therapies and to guide cost-effective use of treatment options. The HMO RN is one of 14 participating organizations; its peers include the University of Chicago and Duke University Medical Center.

Meanwhile, the cancer network researchers, funded by the National Cancer Institute and AHRQ, are studying the accuracy of automated data on colorectal cancer screening, disparities in lung cancer outcomes, how women who have preventive mastectomies fare, and more.

The Cancer Research Network’s unusual feature is its population laboratory of more than 11 million enrollees in health plans around the country. Because of their affiliations with HMOs, the researchers can pool pharmacy, lab, claims, enrollment, and other administrative data with patient survey data from patient portals and electronic medical record data.

The CRN’s goal is to increase the effectiveness of cancer interventions — whether they prevent, cure, or support patients undergoing treatment. To date, more than 40 studies have been undertaken.

“Epidemiologic, behavioral, health services, biophysical — it’s all of those things,” says Katherine Newton, PhD, associate director for external research at the Center for Health Studies at Group Health.

The CRN members have overcome the common hurdle that comes from data stored in myriad ways, using variables that do not match from one data set to the next. The CRN virtual data warehouse — essentially a series of data standards and automated processes at each of the HMO research centers — allows software written at one site to pull data from all the other sites’ databases. This gives researchers rapid access to data with many fewer data-matching hassles than most collaborators experience.

Members of HMO Research Network

  • Fallon Community Health Plan/Meyers Primary Care Institute, Worcester, Mass.
  • Geisinger Health System, Danville, Pa.
  • Group Health Cooperative, Seattle, Wash.
  • Harvard Pilgrim Health Care, Boston, Mass.
  • Henry Ford Health System, Detroit, Mich.
  • Health Partners Research Foundation, Minneapolis, Minn.
  • Kaiser Permanente Colorado, Denver, Colo.
  • Kaiser Permanente, Hawaii, Honolulu, Hawaii
  • Kaiser Permanente Northern California, Oakland, Calif.
  • Kaiser Permanente Northwest, Portland, Ore.
  • Kaiser Permanente Southeast, Atlanta, Ga.
  • Kaiser Permanente Southern California, Pasadena, Calif.
  • Lovelace Clinic Foundation, Albuquerque, N.M.
  • Marshfield Clinic Research Foundation, Marshfield, Wis.
  • Scott and White, Temple, Texas