Extracting value-based care insights from claims data

Unlike clinical data, which is often limited to information collected within a specific healthcare organization, claims data provides a longitudinal record of patient encounters across the healthcare system, including hospitalizations, outpatient visits, prescriptions, diagnostic procedures and more. By sharing this data with providers, payers can create a comprehensive view of a patient’s healthcare history, allowing for more effective population health management.

Claims data is vital for understanding patient risk profiles and identifying opportunities for closing potential gaps in care. Additionally, it plays a critical role in Medicare Advantage (MA), Medicaid and Affordable Care Act (ACA) risk adjustment models by ensuring that accurate diagnostic information is captured and reported. This helps ensure that the health plans and accountable care organizations (ACOs) get accurately reimbursed while improving quality of care.

Here are 5 actionable insights that will enable health plans and providers in taking a data-driven approach to achieving the goals of value-based care by making informed, evidence-based decisions to improve patient care.

By analyzing claims, healthcare teams can segment patients based on specific risk factors and prioritize them for targeted interventions. Prioritization can be based on, but not limited to, the following factors:

• Members with a high number of chronic conditions: Chronic conditions such as diabetes, hypertension and heart disease often require consistent management to prevent complications and improve quality of life. Claims data can help identify patients with multiple chronic diseases through diagnosis codes, prescription fills and specialist visits. 
   
  By segmenting these patients, healthcare teams can prioritize them for interventions such as chronic disease management programs, regular follow-ups and medication reviews. These interventions aim to keep these members stable, improve adherence to treatment and reduce the likelihood of costly emergency care. Additionally, care coordinators can be assigned to support these patients in managing their conditions, helping them navigate the healthcare system and ensuring they receive necessary preventative care.

• Members with high utilization or frequent visits: High utilization, such as frequent visits to emergency rooms or multiple hospitalizations within a short period, often signals underlying health issues or care gaps. Claims data provides insight into patients’ utilization patterns by tracking the frequency and type of healthcare visits, including emergency, inpatient and outpatient services. 
   
  Through claims analysis, payers and providers can identify members who frequently visit healthcare facilities, possibly indicating unmanaged health conditions, lack of access to primary care or behavioral health needs. These patients can be prioritized for interventions such as care coordination, telemedicine visits and access to urgent care alternatives or addressing social determinants of health (SDOH).

• Members diagnosed with conditions associated with high-cost treatments or high readmissions: Claims data can help identify members with conditions that need complex care and can lead to readmissions if the condition isn’t optimally managed outside the hospital. Once identified, these members can be prioritized for care transition programs, home health visits and regular follow ups aimed at preventing readmissions.  
  
  Payers and providers can work together to address gaps in care, such as medication adherence and post-discharge follow-up, which can significantly reduce the likelihood of readmissions and associated costs. In addition, providing personalized support and education to these members can help prevent future hospitalizations and improve their overall health outcomes.

Analyzing claims data can be a powerful approach to understanding patient engagement, particularly for programs focused on preventative care, annual wellness visits (AWVs) and other health management services. Combining claims data with demographic, geographic and disease-specific information can highlight where member engagement is high or low, identify underlying factors driving these patterns and reveal opportunities for targeted interventions.

For example, we can segment and analyze patient populations by various dimensions such as zip code, age group, gender or specific chronic conditions and identify areas where preventative care engagement is lower. This insight can help tailor outreach efforts, perhaps by working with local health providers, community leaders, or social service organizations, to address barriers unique to those areas. If a specific zip code shows low engagement in annual wellness visits, it may signal issues such as lack of nearby healthcare providers or transportation challenges, which could be addressed through collaboration with health plans.

Leveraging claims data to design targeted interventions tailored to members not only enhances individual patient outcomes, which is the cornerstone of value-based care, but also contributes to population health by fostering a more engaged and health-conscious member base.

Designing and tracking key performance indicators (KPIs) to measure provider performance is paramount to achieving success in value-based care. Since primary care providers (PCPs) play a key role in ensuring positive health outcomes for their attributed members as well as meeting value-based care goals, claims data can help create a comprehensive evaluation of metrics that reflect key aspects of care quality, efficiency and patient satisfaction. Examples of these metrics are:

• Preventative screening rates and annual wellness visit completion, to evaluate member engagement and care coordination efforts

• Hospital readmission rates and emergency department (ED) visit rates, to track support provided to members in managing chronic conditions

• Coding performance, to evaluate adherence to coding guidelines and accuracy of documentation on member conditions

Referral leakage occurs when patients are referred or self-refer to providers outside of a preferred network. Claims data analysis provides a structured approach to tracking this leakage as healthcare plans and ACOs can identify when and where patients are seeking services outside their established network. When a patient seeks care outside the network, it can increase the overall cost of member care and add complexities to care management and data exchange within different healthcare organizations.

High rates of leakage may occur in specific specialties, such as orthopedics or cardiology, or in high-demand services such as imaging or lab work. These insights enable organizations to focus on high-leakage areas, giving them an opportunity to strengthen internal referral practices, add-in network options, or educate patients with options within the network, to retain patients within their care network.

Value-based care relies on the efficient use of resources and the delivery of patient-centered, coordinated care that avoids unnecessary procedures and optimizes outcomes. Specialists bring in valuable expertise in managing chronic and complex conditions such as diabetes, cancer and cardiovascular disease, which often requires specialized treatment plans.

For members with complex conditions, improved outcomes can be achieved when specialists collaborate with primary care providers to ensure patients receive comprehensive care across the continuum, from preventative screenings and lifestyle interventions to acute care and rehabilitation.

More direct impact can be achieved in members where we see a higher engagement with specialists than primary care providers due to complexity of their treatment or the need for ongoing monitoring. For example, members with advanced chronic kidney disease (CKD) or end-stage renal disease (ESRD) often need to see nephrologists regularly for management and undergo dialysis multiple times per week. In these members specialists can play a major role in care management and preventative care programs.

Claims data is a powerful tool for driving value-based care success. By leveraging insights from this data, health plans can enhance care coordination, reduce costs and improve patient outcomes. From increasing AWV completion rates to targeting high-risk conditions, claims data offers actionable insights that can help payers thrive under value-based contracts. In the era of value-based care, those who effectively harness claims data will be well-positioned for long-term success.