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When energy producers challenged North Dakota’s ambient air quality standards a few years ago, the state’s public health infrastructure had a response. By linking air quality data to health insurance claims data, public health officials were able to show a connection between poor air quality and increased demand for asthma care. Though the statistical correlation was too small to have immediate practical significance, it put public health officials on their guard.
"It was the feeling of the department that this finding alone was enough to at least provide a foundation for a continuing survey of these people," says Alana Knudson-Buresh, PhD, chief of the preventive health section of the state’s Department of Health.
Projects like the asthma analysis are possible because of North Dakota’s unique demographic circumstances and extraordinary commitment to sophisticated data analysis. Since 1987, the state’s public health departments have had the statutory authority to collect from payers inpatient and similar data collected on what was then the UB-82 form. In 1991, the scope of the law was expanded to cover physician data such as that collected on Health Care Financing Administration 1500 forms.
Collection of data from private payers is easier in North Dakota than it would be in most other states. The population is small, about 640,000, and one insurer—Blue Cross Blue Shield of North Dakota—claims to cover 75% of the state’s privately insured population, or about 370,000 people. As Ms. Knudson puts it, "Blue Cross Blue Shield has the state wired."
The limitations of claims-based analyses became apparent, though, when officials looked at the asthma data by age and payer. Residents younger than 65 seemed to use asthma services at a rate much lower than could be explained by age alone, prompting follow-up interviews with physicians around the state.
"One of the things we learned from our providers in North Dakota—which I don’t think is very different from what you’d find in other parts of the country—is that health care providers are less likely to provide an asthma diagnosis for someone under 65 because of the potential of having a pre-existing condition," says Ms. Knudson-Buresh.
"No matter what we looked at, we always had higher prevalence rates among the under-65 as well as less intensive services used by that population."
When bronchitis and emphysema were analyzed with asthma to produce a combined prevalence rate for the three conditions, the difference between younger and older residents shrank dramatically.
The other challenge of claims-based analysis was and continues to be finding a way to capture data about the uninsured. While state officials are confident they can work out arrangements under which the insurers collect and process the information, they are far less sanguine about their chances of getting physicians to fill out a "dummy" claims form that doesn’t result in any reimbursement.
Nevertheless, North Dakota officials have been able, with the help of Ann Arbor, MI-based MedStat, to construct a data warehouse that can address a staggering array of health policy questions. For example, they learned that, after mental conditions, the most common reason for hospitalization of children with an outpatient diagnosis of attention deficit-hyperactivity disorder (ADHD) is alcohol and drug abuse. ADHD children with Medicaid coverage were found to be far more likely to be hospitalized than privately insured children with the same diagnosis, a difference that the state and Blue Cross Blue Shield still are investigating. Because the financial data describe the amount paid, as opposed to merely charges, officials are able to estimate the costs associated with ADHD for public or private payers.
Still, North Dakota does not capture the entire range of claims data available. An early goal of integrating workers’ compensation information into the data warehouse still eludes state officials. Ms. Knudson-Buresh says she would love to be able to test whether workers’ comp pays more for a given condition than other insurers.
In the meantime, the data warehouse is serving as Medicaid’s decision support system and is being prepared for use in additional health policy analyses. The North Dakota Lignite Energy Council, which state health officials had challenged with their data on air quality and health, has proposed to fund further research in the field.
Contact Ms. Knudson-Buresh at (701) 328-2493.