Claims data has become one of the most powerful and increasingly essential tools for employers managing self-funded health plans — shaping decision-making, highlighting cost drivers, and creating new opportunities to improve outcomes, efficiency, and long-term plan sustainability.
Over the past several years, access to data has expanded significantly, giving employers greater visibility into utilization patterns, emerging risks, and areas of potential improvement. In many cases, however, the challenge is no longer access to data itself, but rather how to interpret, prioritize, and translate it into meaningful, strategic action.
In our March Health Risk Management webinar, Captive Resources’ Todd Peterson and Mike Van Ham explored what employers need to understand about today’s data landscape. The discussion focused on how to move beyond static reports, identify key cost drivers and trends, and apply a practical framework for turning insights into action.
The presentation emphasized practical, repeatable strategies that employers — particularly those in Medical Stop Loss (MSL) group captives — can use to build a consistent approach to data analysis and decision-making.
Employers now have access to detailed claims data through analytics platforms, consultants, and captive-level insights. This includes visibility into employer-specific experience, broader trends across captive peers, and benchmarking against market data. While this level of access is valuable, the true advantage comes from using it consistently to guide strategy and inform decisions over time.
During the webinar, Van Ham and Peterson stressed that healthcare costs continue to trend upward, with projections approaching 9% overall and pharmacy costs rising even faster. At the same time, spending is becoming more concentrated among a small percentage of plan members, with a limited number of high-cost claimants driving a disproportionate share of total spend. Understanding where and why this concentration occurs is critical for effective plan management.
Within group captives, employers are seeing more favorable results, with overall cost trends significantly below national averages, according to Van Ham and Peterson. This reflects the impact of proactive plan management, strong engagement, and collaboration among members. However, even with strong performance, pharmacy spend and chronic conditions remain key areas of focus moving forward.
A relatively small group of medications accounts for a large share of total pharmacy spend, with GLP-1 drugs and specialty autoimmune therapies leading the way. This concentration reinforces the importance of focusing on targeted strategies rather than broad cost-cutting measures, as a few categories can significantly influence overall plan performance.
Employers have several tools available to better manage pharmacy costs while maintaining appropriate access to care. These include prior authorization, step therapy protocols, biosimilar adoption, and thoughtful formulary management. For GLP-1 medications in particular, clear coverage strategies and clinical criteria are essential to balancing demand with long-term affordability.
On the medical side, a large share of costs is tied to chronic conditions, particularly in areas such as cardiometabolic health, cancer, and musculoskeletal issues. These conditions often require ongoing management and can lead to higher costs over time if not addressed early and effectively.
Data enables employers to identify high-impact areas and implement focused strategies, such as improving access to preventive care, enhancing care coordination, and supporting early intervention. Strengthening primary care relationships and guiding members to appropriate care settings can also play a critical role in improving outcomes and reducing unnecessary spend.
To make data more actionable, employers can apply a framework that focuses on key areas such as pharmacy management, condition management, network strategy, patient experience, and plan design. This approach helps prioritize efforts and ensures that strategies are aligned with the most significant cost drivers and opportunities.
Employers do not need to be data experts to get value from their claims information. Instead, success comes from regularly reviewing key reports, tracking changes over time, and asking the right questions. Establishing a consistent cadence and focusing on a small number of key metrics can lead to meaningful insights and better decision-making.
In a group captive environment, shared data and collaboration create a powerful advantage. Employers can work together to identify trends, exchange best practices, and implement strategies proven effective across similar populations. This collective approach enhances visibility, strengthens decision-making, and helps reduce long-term cost volatility.
As data capabilities continue to evolve, employers will have even greater opportunities to analyze trends, benchmark performance, and refine their health plan strategies. By building strong data habits now and focusing on actionable insights, organizations can better navigate rising costs and improve both financial and clinical outcomes over time.
Moving beyond the report is not just about having access to data — it is about using that data intentionally to drive smarter, more sustainable health plan decisions.
This presentation was part of Captive Resources’ Medical Stop Loss (MSL) Webinar Series — regular installments of webinars to educate the MSL group, captive members. The thoughts and opinions expressed in these webinars are those of the presenters and do not necessarily reflect Captive Resources’ positions on any of the above topics.
