Getting the Most from your Clinical Claims Data Platform
Ron Leopold, MD, MBA, MPH
High-Cost Medical & Rx Claims Consulting for Employers / Brokers
We're getting the claims data.
We just don't know what to do with it.
Getting the most from your clinical claims data platform
Clinical Claims Data Analytics for Employers and Brokers.
Employee benefits 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. 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 disease, 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 your medical and Rx claims data:
1) What is our data telling us to do?
2) Let’s ask the data about a strategy we’re considering
Both are valid and both approaches help employers target in on the strategies with the best value.
It’s not about the claims data.
It’s about the strategies the data can inform.
Data-Driven Healthcare Strategies for Employers.
What is our data telling us to do?
Often, employers (and their advisors) are faced with 210 pages of charts and graphs. Often, these 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.?
Identifying the?handful of key findings?that have an?actionable solution?is harder. This requires seasoned familiarity with the data set, as well as an up to date understanding of available marketplace solutions.
?Condition Management
Your data can help identify conditions that would benefit from disease-specific carve-out point solutions that can enhance what your members get from their health plan. The prevalence of a condition informs how widespread it is in the population. Average dollars spend 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. Likewise 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 your covered member population can help 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 your members and your health plan costs at tremendous risk down the road. Virtual care can improve access to health care resources and the frequency that member patients interact with health care professionals.
领英推荐
Care Management
High-cost claims analytics can help employers determine what 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 your 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 what serious conditions our members may be facing. Looking, for instance, at the cohort of claimants who spend between $10,000 and $50,000 a year may help justify second medical opinion solutions based on what types of diagnoses dominate 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 your 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 your 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. Considerations for 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 your 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 my wellness program running? Are the right people joining the program?
Key Points:
There’s a lot you can do with your data. You’ve invested in health plans and point solutions and data analytics resources. The data should be fully informing what you know about your 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 your plan’s data requires:
As is typically the case Ron Leopold's post is so accurate and should be read and undererstood by all employer benefit decision makers.