How claims data technology is becoming an expectation
We recently chatted with Anne Brunson, VP of Service Operations at Maestro Health, about the future of claims data, technology and self-funding.
1. How can self-funded employers leverage their health plan data?
Anne Brunson: One of the benefits of moving to a self-funded model is having better access to claims data and the ability to pull its insights. With the help of an independent third-party administrator (TPA), employers have access to their claims and data around the services they’ve utilized, which helps the TPA and employer identify cost drivers, tailor the plan to their members’ needs and forecast what their claim spend will look like.
For example, if your data shows that you have a high percentage of avoidable ER visits, this indicates that members are going there instead of to a physician’s office or urgent care for primary and non-emergency care. With these insights, the employer could work with the TPA to work disincentives into the plan, like higher co-pays for unnecessary ER visits or member education materials about where to seek the right care at the right time, etc.
Related: Infographic: Trends in self-funded group health plans
Utilization and claims data like this can help employers better understand their members’ needs, where they need to provide additional resources and how to tailor the plan to be as cost-effective and accessible as possible.
Companies who are fully-insured typically don’t have this level of visibility into their costs and employee needs, which is why this is a unique benefit of moving to a self-funded model.
2. How can employers who are considering going self-funded get access to their data? What if they can’t get access?
AB: For a fully insured employer, the best bet is to work through their broker to obtain the information. While the insurer will probably not provide the claims data to analyze, they should be able to obtain specific reports, such as ER usage and high dollar claims, for example.
3. What are some of the key features of health care and claims analytics tools?
AB: Just as companies expect sophisticated and well-rounded tools for their marketing and business efforts, employers want technology that allows teams to make important decisions about the health plan of the company. Some key features of these reporting tools include looking at cost drivers, plan utilization, and member needs/gaps in care and high-cost claim trends. Make sure the tool has the ability to drill down, as well as the ability to create cohorts within the participating population. And most importantly, make sure the employer and broker can access the reporting tool themselves. They may choose to let the TPA run the reports, but it is their data and they should have on-demand access to it. Due to the regulations around health care data and the complex nature of health claims, having tools that can pull out valuable insights with the correct reference points or pricing is crucial. This will help TPAs and employers design the benefits plan that fits their employee base and reduce unnecessary costs.
4. What types of programs can employers put in place?
AB: Employers can work with their TPA to analyze data and pull valuable insights to address the cost drivers and health needs of their workforce. For example, programs that offer dashboards and easy-to-use tools are preferred for stakeholders to convert claims into unique visits, identify incomplete data and categorize providers to identify cost trends. TPAs are able to assist employers in pulling this data to make cost-saving or care management recommendations. With data insights readily accessible, employers can create more customized health plans, meet the clinical care needs of employees and drive down costs at the organization.
5. Why isn’t it standard practice to provide employers with their members’ claims history and data?
AB: Companies that are fully-insured do not have the capabilities to see into past claims, trends and costs associated with regular claim outcomes, since the insurer does not provide the information. Larger insurance companies use the claims data in aggregate, and are not interested in it on a group by group basis. By moving to a self-funded model with the help of a TPA, employers are given access to their claims data and can truly see into how costs are being distributed.