SPONSOR SPOTLIGHT
How Clinical Informatics Applied Health Plan Data Manages Risks and Costs
With a median 8% increase in health plan premiums as medical cost trends continue to soar, Massachusetts employers find themselves challenged to balance conflicting pressures: effectively managing health plan costs without sacrificing the well-being of the workforce – and ultimately, the organization.
The most common solutions, an American Society of Employers survey found, have been more employee education about health plan features and costs, along with expanded wellness programs (both at 25%). Also popular is upping employees’ share of plan costs (21%). While the former two can have positive consequences, the latter can lead to negative outcomes in the form of financial strain and impacts on morale and productivity.
A more effective and sustainable approach involves combining advanced data analytics with clinical expertise – known as health informatics – to analyze health claims data.
Once exclusive to large corporations, this sophisticated practice is now accessible to small and mid-sized employers. With greater access to their benefits data, these organizations gain enhanced transparency into how their health plans are performing and what factors are driving costs.
Understanding Data Analytics and Clinical Informatics
Analytics, applied to healthcare claims information, provides a “snapshot” of diseases and dollars. This is explicit knowledge that among other things, involves data correlation, and is pattern driven and observational.
Clinical informatics is an interdisciplinary medical subspecialty that applies data analysis and technology to generate actionable insights and tacit knowledge.
As academia’s adage would have it, analytics tells you your hair’s on fire. Informatics tells you why.
The combination of analytics and clinical informatics provides a clearer understanding of plan utilization fundamentals. But more importantly, it offers deeper insights into the conditions behind the claims and the scope of the risk they pose.
Data analytics applied to health claims gives employers a good overview of plan utilization, prevalent conditions among employees, and basic cost drivers. But clinical informatics’ medical lens enables a deeper dive: how conditions are manifesting, the extent of their risk, and whether treatments align with medical policy.
Clinical informatics can suggest alternate regimens of patient care. It can identify outdated or unnecessarily expensive treatments as well as billing errors, instrumental when employers are charged with the fiduciary duty to manage against waste, fraud and abuse. It can assist in navigating stop-loss lasers, enhancing control over plan management.
And used in tandem with predictive modeling and generative artificial intelligence, clinical informatics can identify potential issues before costs to the health plan become untenable.
The impact
The one-two punch of data analytics and clinical informatics allowed HUB International to take a deep dive into the pain one client was experiencing with its mental health claims. Informatics uncovered several serious issues. First, there was a gap between the provision of medications and therapy follow up visits. Another serious concern was the underutilization of the employee assistance plan’s provision of three appointments per plan member annually.
This fault didn’t lie with employees: in-network mental health professionals were overbooked and unavailable.
The employer addressed the issue by introducing mental health resources, which not only enhanced access to care but also significantly improved employee well-being. An added benefit: the financial health of the plan improved as medical claims declined with increased access to mental health support.
As plan fiduciaries, the onus is on employers to take advantage of all the advanced tools increasingly available to help them monitor and manage health plan performance and costs. A knowledgeable insurance broker is a key partner on this front who can also open the door to important resources.
About the Author
Stacey Hyland is the President of Employee Benefit at global insurance brokerage HUB International in New England. In her role, she is responsible for implementing comprehensive strategies, developing programs, managing operations, and promoting talent growth within the employee benefits team. Stacey brings 33 years of experience in the insurance industry, having worked in various positions in consulting brokerage and national and regional health plan markets.