Claims Data Analytics: Medical and Pharmacy


Medical and Pharmacy Claims Data

210 pages of charts and graphs is easy to produce. 

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.

  • What are the 3-5 key takeaways from the medical and pharmacy claims report?
  • What’s driving those key findings? How impactable are they?
  • What marketplace solutions might be appropriate given the findings?
  • Which solutions are applicable for this specific employer client?
  • What are other employers doing to address each issue?

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Cost Stratification

Your CFO is watching cost trends. Looking at cost stratification is as important as risk stratification. Percentage of "zero dollar" members may represent inadequate access to care. Higher than benchmark spend on very expensive claims may provide insights to more aggressive medical and pharmacy cost solutions.

Diseases and Conditions

Every major condition has a story. The solutions for different diseases and conditions vary greatly, and often require specialized clinical resources. Members with cancer, diabetes, back injuries or high risk maternity each require approaches that leverage expertise in their respective areas.

High Cost Claims

3% of your claimants drive 56.5% of your dollars. In other words, for 10,000 members, 300 people are driving well over half of your expenditure. How much of that is specialty pharmacy? Which members are potential stop-loss risks? What targeted strategies should you consider?


Underutilization of primary care, preventive services and behavioral health may eventually drive greater costs than over utilization of emergency departments and medical specialists.

Risk Stratification

The long game, for employers, is mitigating higher risk. The value of health risk solutions, such as wellness and lifestyle programs, are seen in the migration of members from higher risk strata, to lower risk strata.

Quality of Care

Measuring quality of care requires an ability to measure gaps in care for members. Over-utilization, or misuse of key diagnostics and treatments can also assist in identifying foci of lower quality care.