Clinical Claims Data Analytics | Employee Benefits
210 pages of charts and graphs......but what is this telling you? Employers and their trusted advisors increasingly require a clinically-trained data expert to find genuine meaning and actionable recommendations from their claims data.
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.
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.
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 overutilization of emergency departments and medical specialists.
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. These programs can mitigate member population risk migration and offset further costs.
Measuring quality of care requires an ability to measure gaps in care for members. Overutilization, or misuse of key diagnostics and treatments can also assist in identifying foci of lower quality care.
For a plan of 10,000 members costing the employer sponsor $50 million: 300 people account for $28 million. Understanding who is high cost this year, and who will be high cost next year will help shape critical medical cost strategies.
High medical cost solutions for a working family population warrant targeted strategies. The concentration of expenses for this year’s medical costs is found claimants spending more than $25,000/year. Condition-specific solutions are often required for back surgeries, cancers, neonatal care, extended substance abuse treatment, auto-immune disorders, and complications of hospitalization.