Leveraging medical and Rx claims data for your employer clients

Employee benefits advisors and HR professionals are often overwhelmed by their carrier reports. They are usually looking to identify a handful of smart strategies supported by their data. But it’s not about the claims data; it’s about the strategies the data can inform. Where and how should we invest and what will be our metric for success?

Brokers and other advisors to employers in this area often don’t have the clinical resources to meet the demands of today’s health plan data. Newer treatment and diagnostic technologies, rare diseases, specialty medicines and new places of service introduce increased complexities to the clinical issues that should be considered when thinking through new strategies for employer clients.

There are two ways to think about using medical and Rx claims data: 1) What is our data telling us to do? 2) Can we ask the data about a strategy we’re considering?

Both are valid approaches that help employers target the strategies with the best value.

Data-driven health care strategies

What is our data telling us to do?

All too often, employers and their advisors are faced with 200 pages of charts and graphs. Often, the stats come from standard reporting and are usually quite easy to produce once they’ve been set up. These reports can provide a breadth of significant information that might meet an employer’s needs.

But identifying the handful of key findings that have an actionable solution is harder. This requires familiarity with the data set, as well as an up-to-date understanding of available marketplace solutions.

Condition management Data can help identify conditions that would benefit from disease-specific carve-out point solutions that can enhance what members get from their health plan. The prevalence of a condition informs how widespread it is in the population. Average dollars spent on members for that condition, as well as average total dollars spent for members with that condition, are two ways of analyzing cost burden. Members with diabetes need specific solutions for diabetics. Members with cancer need cancer-specific strategies. The same is true for orthopedic surgeries, behavioral health conditions, cardiac care, asthma support and reproductive health. The marketplace is currently teeming with smart condition management solutions in a growing number of areas.

Virtual care Utilization data and risk migration of a covered member population can help advisors and employers understand how members are (or are not) accessing health care services. A plethora of new and enhanced alternatives can supplement where and how members seek routine care and preventive screening. Underutilization and avoidance of health care put members and health plan costs at tremendous risk down the road. Virtual care can improve access to health care resources and the frequency at which member patients interact with health care professionals.

Care management High-cost claims analytics can help employers determine which care management carve-outs make sense for their members. Care management carve-outs are increasingly in demand for certain chronic conditions; post-op care; high-risk pregnancies; pre-term infant home care; cancer hospice; rare diseases and many other clinical scenarios. When data shows inadequate care metrics through low utilization, gaps in care, or migration to higher-risk categories, condition management solutions are worth considering.

Let’s ask the data

Other times, employers and their advisors approach the data with a solution they are considering.

Expert medical opinion What can our “cost stratification” data tell us about the serious conditions members may be facing? Looking at the cohort of claimants who spend between $10,000 and $50,000 a year may help justify second medical opinion solutions based on the types of diagnoses predominant in this group. Second medical opinions, virtual centers of medicine, and specialty telemedicine are revolutionizing how employer health plan members can access top medical expertise. It has never been easier to go beyond a health plan’s network and provide plan members with access to top oncologists, neurosurgeons, rheumatologists, and internal medicine sub-specialists.

Bricks and mortar Place of service medical and Rx data analytics can provide valuable information on where, when and how members are receiving service. Many employers look to enhance their plan’s solutions with better retail medical delivery services or local outpatient conveniences. Many strategy considerations will benefit from understanding claimant health care access. Consideration of plan design, coverage of retail primary care, provider network assessment and hospital-based outpatient services warrant deeper claims data analytics.

Integrated program metrics Risk stratification and risk migration claims data analytics offer valuable insights into the health profile of employees and covered members in a plan. These data can be coupled with wellness programs metrics, such as participation rates, utilization and outcomes data to help employers determine the efficacy and progress of their wellness interventions. How well is the wellness program running? Are the right people joining the program?

Key takeaways:

There’s a lot employers and advisors can do with their data. You’ve invested in health plans and point solutions and data analytics resources and the data should be fully informing what you know about the medical plans and the programs you have in place. If you’re not getting the types of solutions recommendations described in this article, search harder for that clinical support.

Effectively leveraging a plan’s data requires: Familiarity with the many ways claims data may be analyzed, including how the organization is structured and plan design considerations.

An understanding of disease and clinical conditions and an appreciation of how those entities evolve over time. Which conditions are relatively acute, and which ones require extended spending over time? Which conditions impact workforce productivity the most?

A full understanding of the scope of available health and medical marketplace solutions for employee benefits.