HEALTHCARE CLAIMS DATA – THE HOLY GRAIL? Part 2

One of the biggest frustrations that I hear from employers is that their health insurance carrier does not provide them with the data that they need in order to best manage their healthcare plan.  One of our distinct “value propositions” is our ability to capture detailed claims data – every claim from every member for any size employer.  As previously discussed, armed with that information, we can help employers in strategic ways including predicting renewals; negotiating renewals; better decision making when looking at alternative financing programs and alternative plan designs, etc.  But we can also help EMPLOYEES.  Here’s what we can do from the member’s perspective:

  1. Categorize each claimant (employee/spouse/child) in one of five risk-tiers based on their annual claims spending patterns.
  2. Meet with employees and/or spouses (preferably one-on-one) to clearly review the economic impact to THEM as it relates to incremental improvements in their health.  We clearly show what’s in it for THEM!  Did you know that a border-line chronically ill patient can PERSONALLY save $100,000 over 20 years by making a modest improvement in his or her health rather than slipping into the chronically ill category?
  3. Provide employees with the educational resources that they need in order to become better healthcare consumers.  It is a complicated environment for patients and we can help people make decisions that align with the mantra of getting the right care at the right place at the right time.  “Savvy” consumers can save a lot of money for themselves as well as for the plan, but most patients (through no fault of their own) aren’t focused on the most efficient and effective options for care, and the cost is often an afterthought.  We need to help patients understand their choices with respect to each healthcare encounter and help them make decisions that deliver the best results.
  4. Where choices of plans exist, we help employees ELECT the plan that makes the most sense for them based on their actual claims history.  Many people elect “the best” coverage when the math clearly shows that the best plan for them would have been the least expensive option.  Many people are “over-insured.”  We recently conducted an analysis of a $5,000 HSA Option vs a $1,500 PPO Option for the plan participants of a client company.  Almost all of the plan participants would spend less money annually (especially those with very small claims and very large claims) if they were to elect the HSA Plan.  It is difficult for employees to understand that total cost includes not only what they pay when they use the plan, but also what comes out of their paychecks to participate.  We build models that help employees understand their total annual cost by combining payroll deductions with utilization costs based on their actual claims history.
  5. We provide ongoing advocacy services to help them resolve claims/billing issues most efficiently.
  6. For patients with chronic health conditions, we enlist the service of our Physician Advisor who will review cases from a clinical perspective to make sure that the patient is receiving the right care at the right time.

Unfortunately, most small and some mid-market employers don’t have the data that they need in order to effectively manage one of their greatest expenses.  For information about how you can begin capturing game-changing claims data and how we can use that data to achieve better outcomes for all of the money that you and your employees spend on healthcare, please contact your CPI-HR benefits consultant, or call 440-542-7800.

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