Claims data still a secret weapon in care, cost containment

October 1, 2009 | Ken Krizner , Managed Healthcare Executive

The most potent weapon in the campaign to control costs—until EMRs reach critical mass—might be claims data. All the pertinent information is found there, including the provider, type of treatment or procedure, prescriptions, as well as the cost of service for the plan, sponsor and member.

While that information is useful, it only scratches the surface of what claims data can tell health plans and payers about their members. By accessing electronic claims data, health plans can mine, analyze and download information about members individually or collectively. This data can be used to determine which members are at risk for specific health issues and inform disease management program design to help them before the event occurs.

"So much of the information that would tell a plan what is driving the cost of healthcare is either unavailable or late," says Keith Lemer, president of WellNet Healthcare in Bethesda, Md. "What winds up happening is you don't get to the root cause of the problem—what is driving costs and what type of action can be implemented on the appropriate segment of the population to keep those costs down."


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