IBM Helps HIP Pioneer Managed Care Performance System

IBM announced that HIP Health Plans will be the first health insurance organization to implement customized software and services to assess and evaluate the quality of care given to its members by providers.

HIP Health Plans, a nonprofit HMO with 800,000 members in New York, will pioneer a first-of-a-kind business intelligence solution fusing IBM's Fraud and Abuse Management System (FAMS) technology with Symmetry Health Data Systems Inc and ProfSoft Inc software to refine how managed care organizations assess provider performance.

"HIP realizes that quality of care is vital in distinguishing ourselves from competitors," said Dr. Randall Spoeri, HIP vice president for Medical and Quality Informatics. HIP Special Investigations Unit (SIU) and Medical and Quality Informatics (MaQI) staff wanted to develop a system allowing payers to measure the performance of providers of health care services so that both the efficiency and quality of care can be evaluated and continuously improved.

The system IBM, ProfSoft and Symmetry designed for HIP incorporates information on all care provided during a course of treatment and also accounts for differences in the severity of illnesses on a case-by-case basis. It supports both the medical management and fraud detection business functions. Therefore, HIP can aggressively combat fraudulent claims and also measure and improve the quality of care providers give their patients.

"This alliance provides a wide range of information that health care organizations can use to make decisions and take action," said Dr. Ed Bassin, president of ProfSoft Inc. "The product and services offer providers a better understanding of their actual use of resources, in order to control the cost and improve overall quality of care for their patients."

IBM is adapting the underlying technology of FAMS -- a complete business intelligence solution encompassing entity profiling, data visualization, and advanced analytics -- to work with Symmetry Health Data Systems' software solution that groups raw health claim data into Episode Treatment Groups (ETG's). IBM's FAMS, an open and flexible solution, works with IBM's DB2 and data mining technologies and is designed to help insurance companies, government agencies, and health care payors identify and prevent fraudulent and abusive billing practices. ProfSoftEpisode software analyzes, summarizes and builds data models from the ETG information, adjusting for age, sex and severity of illness. This customized solution will enable HIP's Medical and Quality Informatics group to gauge the quality and efficiency of physician care.

"We are energized about working with IBM and ProfSoft," said Mitchell Portnoy, Symmetry Health co-founder and chief operating officer. "IBM's wealth of technology and business intelligence gives us new and exciting ways to fulfill a customer's needs."

"The IBM/Symmetry/ProfSoft solution for HIP highlights the power of the FAMS technologies and the flexibility of its architecture which enable the integration of a wide range of third party data analysis, mining and management tools," said Michael Fuller, vice president & global practice leader, IBM Business Intelligence Consulting & Services. "This new solution illustrates the broad applicability of the FAMS components to other business intelligence solutions across multiple industries."

The IBM Fraud and Abuse Management System is a set of technology-based tools designed to assist knowledge workers in detecting aberrant behavior exhibited by providers. FAMS has been successfully implemented for Medicare clients, private health insurers, Blue Cross and Blue Shield plans, HMO's, and compliance organizations worldwide. IBM provides consulting, application customization, implementation services, education and project management to assist clients in addressing complex business problems.

"The effort to utilize FAMS software for more than standard fraud detection and prevention techniques was a major collaborative effort that will save HIP hundreds of thousands of dollars," said Thomas Cantwell, HIP SIU's managing director. "HIP will be the role model for other insurers."

About HIP Health Plans

HIP is a company with a distinguished 53-year history of providing its members with quality, affordable health care, and has been universally recognized for health care excellence. HIP New York, established in 1947, is an award-winning, mixed model leader in the delivery of quality health care. It is the largest HMO in the New York metropolitan area with an increasing membership of almost 800,000 in the five boroughs of New York City, Nassau, Suffolk, Westchester, Rockland and Orange Counties. For more information on HIP, see www.hipusa.com.

About Symmetry Health Data Systems Inc

Symmetry Health Data Systems Inc, a health care analytic tool developer, was founded in 1993. Symmetry's principals invented many of the techniques and software platforms which today are industry standards for Managed Care organizations, insurance carriers, Fortune 1000 corporations, as well as the Federal government. Episode Treatment Groups(ETGs) are protected under United States Patent 5,835,897. United States and International patents pending. Visit Symmetry Health Data Systems Inc on the Web at www.symmetry-health.com.

About ProfSoft Inc

ProfSoft provides software and services that allow managed care organizations to derive useful information from existing claims and administrative data. The Cambridge, Mass. software company focuses on the analytic techniques required to provide actionable, statistically reliable information, while providing the flexibility to address a wide range of business issues. For more information on ProfSoft Inc see www.profsoft-health.com.

About IBM

With 80 years of leadership in helping businesses innovate, IBM is one of the world's largest information technology companies, a leading IT services provider, and a leader in business intelligence solutions. For more information on IBM business intelligence, visit: www.ibm.com/bi.

Contact Anthony Suarez, TSI Communications, IBM Global Business Intelligence Solutions, 212-320-2316, asuarez@tsicomm.com.