In today’s evolving healthcare landscape, data is a powerful tool for employers to optimize health plans, control costs, and improve employee well-being. Harnessing healthcare data to make informed, strategic decisions is more important than ever.
With this in mind, Captive Resources’ Todd Peterson and Mike Van Ham discussed how self-funded employers can own their data, analyze trends, and take action for a smarter, more sustainable health plan.
Continue reading to uncover key data sources and learn best practices for monitoring and interpreting claims data, which can lead to smarter benefits decisions.
Utilizing Data to Drive Health Plan Strategy
In today’s healthcare landscape, data is a powerful tool that can help employers optimize health plans, manage costs, and improve employee well-being. With rising healthcare and pharmacy costs, leveraging analytics is more critical than ever for self-funded employers.
Understanding Key Healthcare Data Sources
To make informed decisions, according to Peterson and Van Ham, businesses must access and analyze data from multiple sources, including:
- Third-Party Administrators (TPAs): Provide insights into medical claims and plan performance.
- Pharmacy Benefit Managers (PBMs): Help track prescription drug utilization and costs.
- Point Solution Partners: Offer targeted data on specific conditions like diabetes or mental health.
- Benefit Consultants and Advisors: Assist in interpreting data trends for strategic planning.
- Third-Party Analytics Providers: Deliver deeper insights into overall plan performance.
Best Practices for Data-Driven Decision-Making
According to the presentation, employers should adopt a structured approach to monitor, interpret, and act on healthcare data:
- Own Your Data: Ensure you have full access to your healthcare and pharmacy data to make strategic decisions.
- Analyze and Benchmark: Compare costs and utilization patterns against industry benchmarks to identify opportunities for improvement.
- Identify High-Cost Trends: Monitor claimants with expenses between $25,000 and $300,000, as they are key cost drivers.
- Evaluate Pharmacy Spend: Track generic dispensing rates, specialty drug costs, and formulary compliance.
- Monitor Care Gaps and Utilization Trends: Identify areas where intervention can improve outcomes, such as redirecting ER visits or managing chronic diseases more effectively.
Transforming Data into Actionable Insights
Raw data must be processed and analyzed to generate meaningful information. Peterson and Van Ham provided the following overview for example:
- Data: Individual claims with diagnosis codes, billed amounts, and insurance payments.
- Information: Aggregated data showing total visits, average costs, and common diagnoses.
- Analysis: Identifying trends, such as reduced hospitalization rates for diabetes patients who attend regular follow-ups.
Key Metrics to Monitor
Tracking the right metrics helps organizations refine their health plan strategies. Some essential indicators include:
Medical Metrics
- Per Member Per Month (PMPM) medical spend.
- Site-of-care cost comparisons (inpatient vs. outpatient vs. office).
- ER utilization and opportunities for redirection.
- Chronic disease cost trends and prevention efforts.
Pharmacy Metrics
- Specialty drug spending and cost-saving opportunities.
- Top 10 drugs by claimants and allowed amounts.
- Generic dispensing rate and biosimilar adoption.
Takeaways for Employers
Here are a few key takeaways from the presentation that will help employers harness the full potential of their data, uncover meaningful insights, and implement more effective health strategies. By leveraging data-driven decision-making, employers can identify cost drivers, recognize trends in employee health, and tailor wellness initiatives to improve outcomes while optimizing overall healthcare spending.
- Own Your Data: Access and control the information needed for strategic decision-making.
- Dive In: Collaborate with advisors and vendors to interpret and act on data insights.
- Take Action: Implement changes based on findings and continuously monitor outcomes.
About the Webinar
This presentation was part of Captive Resources’ Medical Stop Loss Webinar Series — regular installments of webinars to educate medical stop loss 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.
