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Common Questions Your Healthcare Data Can Answer

Are you leveraging medical and pharmacy claims data to answer key questions about plan utilization?


Using claims data to your advantage can help you understand how plan participants utilize their benefits, which subsequently allows you to manage trends and reduce costs for you and your employees. Overall, the goal is to make meaningful connections between plan utilization and associated costs.


Claims data gives you access to employee demographics, diagnosis codes, dates of service, and the cost of services—all of which can be used to better understand concerns employees are facing.


The amount of data available to you through medical and pharmacy claims can be overwhelming, so it is key to have clear questions you would like to answer when evaluating your data.


Here are some questions to keep in mind when reviewing claims data in order to dig deeper to address red flags and work toward reducing healthcare costs.


Are members getting routine care?

Routine care is key to preventing illness and disease. Studies suggest that patients with an ongoing relationship with their primary care physician have lower healthcare costs, including emergency room and hospitalization costs. Regularly seeing a primary care doctor allows employees to get the recommended screenings and services needed to detect and prevent illnesses that could potentially become larger health risks. Doctors can also create care plans for employees and help them manage chronic diseases, resulting in less absenteeism and lower overall healthcare costs for employers and employees.


What percentage of your employee population is driving cost?

Your data offers valuable insight into the top drivers of cost among your employee population. Are healthcare costs varying across different employee classes or plans? Reviewing your claims data allows you to analyze trends among common demographics and identify ways to improve employee health, mitigate risks and reduce costs.


What does plan utilization look like?

If you are looking to manage your company’s healthcare costs, it all starts with utilization. The best way to use your data is by measuring year-over-year results against your plans’ unique demographics to analyze success. This provides you with specific insights into your employee population’s utilization trends versus a national benchmarking program.


It’s necessary to understand why plan participants use the plan the way they do if you’re truly aiming to manage trends and make meaningful connections between plan utilization and associated costs.


Where are plan members seeking care?

While network status is important, it’s critical to look at the quality of care your employees are receiving from their physicians. Employees have better results and less complications, and the impact of claims is significantly better when they see providers who are receiving high performance scores based on patient-reported outcomes.


You can also tap into your data to evaluate if there are scenarios where you can encourage employees to use their telehealth benefits—a great alternative that saves employees time and reduces out-of-pocket expenses.


What does treatment cost at different facilities?

To gauge employee health spending, you want to look at where plan members are seeking care and how much spending occurs at these facilities.


Do you have influx of employees that are not seeing primary care physicians but are seeking medical attention at Urgent Care Centers or the Emergency Room? How much could these employees be saving if they had better access to a primary care physician?


Does a particular surgery cost less a few towns away and still have a highly-rated outcome? Having insights on the costs of different facilities can allow you to guide employees to solutions that may be more beneficial and cost effective for the employee and your business.


What diagnoses/treatments are driving cost?

Once you uncover what treatments and diagnoses are driving costs for your business, you will be able to pinpoint ways to prevent and manage them within your employee population. Identifying chronic conditions and implementing valuable programs is another way to help employees manage these illnesses and drive down costs.


Utilizing Third Party Administrators (TPAs), you can set up programs to support employee wellness and manage chronic conditions in your employee population. These programs allow you to spend wellness program money more efficiently with better results and protect the privacy of employee health and wellness concerns.


Additionally, some prescriptions can be discounted by partnering with a Pharmacy Benefits Manager to help you provide more affordable prices on prescriptions your employees frequently use.


Insights drive better employee health engagement.

Tapping into your data can allow you to tailor your plan to address the unique utilization trends in your employee population. Data can also help you identify the top cost drivers and adjust and adapt plans accordingly.


Contact our team today for a claims data assessment to identify ways to reduce costs and maximize your benefits package.


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