Clinical Claims Data Analytics | Employee Benefits
210 pages of charts and graphs is actually quite 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.
Whether your firm has an enterprise solution for your employer clients' clinical claims data analytics, or you rely on carriers or third-parties vendors- it is ultimately up to you to provide recognized value as a trusted advisor.
I help brokers with the clinically rich data they need to interpret and help them bring relevant, marketplace-ready innovative solutions to their employer clients.
Self-insured employers need a clinically-savvy advocate on their side. Whether you are meeting with your health plans, or determining the progress of key point solutions, the data you face can almost always benefit from a seasoned clinician familiar with claims data reporting.
I help employers extract value from their carrier reports and measure the progress of your health and wellness programs and point solutions.
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. 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.
Utilization data 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.
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.
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.
Medical and Rx data analytics can provide valuable information on where, when and how your members are receiving service. 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.
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.
In 2021, the average health insurance cost for employers was $16,253 annually, or 73% of the premium, to cover a family and $6,440, or 83% of the premium for an individual. These premiums for families and individuals have increased 22% over the last five years and 47% during the previous 10 years. [Kaiser Family Foundation; 2021]
Compared with high-income peer countries, the United States has a 46 to 50 percent higher disease burden rate for 20- to 40-year-old workers, and a 17 to 33 percent higher disease burden rate for those over 40 years old. [Innovating employee health: Time to break the mold?; McKinsey; Sept 2021]
Self-insured employer plans usually cover employees and their spouse/partners and dependents. Employers depend on their medical carriers and their administrative services to provide access to good medical care, pay an appropriate (and pre-specified) amount and respond to covered members as customers.
At the heart of employer health plans are employees on whom companies depend for business success. The relationship between health and productivity is strong, but complex. Direct costs of health-related absence and disability can be dwarfed by "presenteeism." The focus on wellness and wellbeing is shifting to employee engagement and performance.
Employer-provided health coverage is important for recruiting, but even more important for retention. A recent AHIP survey shows that: 56 percent of U.S. adults with employer-sponsored health benefits said that whether or not they like their health coverage is a key factor in deciding to stay at their current job. 46 percent said health insurance was either the deciding factor or a positive influence in choosing their current job. The role that healthcare innovation can play to support this is considerable.
Rule of thumb: Larger employers tend to work with larger consultant organizations who charge by the hour and bring sophisticated resources and broad subject matter expertise. Smaller employers tend to work with brokers who earn commission from placing medical insurance business- but often include value-added services to those client relationships. Knowing the players and understanding the working dynamics (and how they may vary) is invaluable to successful growth in the self-insured employer marketplace.
Health care purchasing coalitions, executive roundtables, industry membership organizations are among those influencers who help employer decision-makers navigate the complex landscape. These influencers offer powerful potential for healthcare innovators looking to shape and showcase their solutions.