Taking Action: Using data to fight high costs and low quality in healthcare

By Scott Bennett, Vice President of Access Innovation

Featured in BenefitsPRO’s Broker Innovation Lab


When it comes to helping clients get more out of their health benefits, the richest insights come from robust data sets. While most brokers & consultants know the power of robust data, they don’t always know where to seek it out, or what to do once they have data sets in hand. Here’s a couple of frequently asked questions innovative brokers & consultants can reference when helping clients drive down costs and improve health outcomes for their clients’ employees:

How can I pull cost and quality data on providers in order to help clients make informed decisions about where to direct care?

A number of data sources are downloadable from Medicare’s official website and tutorials on how to analyze datasets on the Medicare Research Data Assistance Center Website (RESDAC). However, there are a few healthcare companies that take this public data and organize it into decision support tools for cost, quality and market analysis.

Let’s say you want to gather more information for your clients on a cost-intensive procedure like an MRI. A third party administrator (TPA) can help identify any costly referral patterns. With the proper data from a TPA, you can help clients reduce costs by finding if there are cheaper referral options available. With the right cost transparency tools, you can draw direct connections for employers to these beneficial partners.

Maestro Health™ makes its own proprietary insights dashboard—the RBP Insights Tool—available to premier industry partners. This tool helps foster innovation and continue conversations that can inform and benefit a self-funded employer.

Is there a resource I can use to compare commercial cost data by region?

A recent RAND study released commercial payment data on hospitals all over the nation, which now allows for a complete comparison across many regions at one time. This RAND data combined with federal quality data, hospital cost data and Medicare-average payment data can equip a self-funded employer with the same benchmarks previously only available to large employers and major carriers.  These benchmarks allow employers to review their present network arrangements and work with receptive providers to negotiate from a position of knowledge with objective criteria. Further, when providers choose not to enter into a reasonable agreement with an employer, this data could support out-of-network negotiations. 

How can employees take a more active role in their healthcare so they can avoid low quality, low-cost hospitals?

To strengthen their high-quality care networks, self-funded companies can use aggregated data to help identify providers that stand out for cost and quality in their geographic area.

A self-funded plan that utilizes a TPA can incorporate cost/quality transparency tools with built-in plan incentives so employees can take a more active role in care navigation. If your client is using a network, there may be more of an opportunity to provide steerage and incentives within that network due to recent case law and settlements between the Department of Justice and large hospital systems. In these settlements, anti-competitive steering restrictions have been removed from many hospital contracts with carriers. Without these restrictions, employers could allow their employees to learn about and seek care from more cost-efficient healthcare providers inside of a network.

Securing access to quality data is easier said than done for many brokers and consultants who work with traditional health plans. But by understanding the benefits of rich data, brokers and consultants can make a major impact on clients’ bottom lines.


The top 7 self-funded data points you shouldn’t ignore

By Scott Bennett, Vice President of Access Innovation

Featured in BenefitsPRO’s Broker Innovation Lab


For brokers, one of the most commonly identified perks for self-funded clients is better access to data for analytics. However, knowing where to begin when digging into the data can be an overwhelming task.

If you’re looking to paint a clearer picture for your clients around achieved and potential cost-savings, you should start by securing access to past hospital claims data (inpatient and outpatient) in a machine-readable format. This can typically be acquired from your client’s Third-Party Administrator (TPA) or Administrative Services Organization (ASO). From there, you can craft a data-driven strategy around medical costs and how they impact your clients’ bottom line.

Here are seven data points to look for within those claims and the assumptions you can make once you have access.

1. The hospital National Provider Identifier (NPI). The hospital NPI allows you to uniquely identify hospitals. There are also data tables with equivalent elements, also known as crosswalks, available to identify the hospital’s “provider number” or Medicare number related to public reports. 

2. The hospital name, address, city and state.* These fields provide good circumstantial evidence to help narrow down a provider. 

3. The hospital revenue code. This field identifies the department related to the billing on the claim line. 

4. An identifier as to whether the claim is inpatient or outpatient. This field is typically on the claim (in the form of a number) and helps if the analysis is filtered for just outpatient or inpatient. 

5. The hospital Current Procedural Terminology (CPT) Code (if outpatient) and the hospital related diagnosis-related group (DRG) (if inpatient). These fields help identify the procedure or services related to the billing on the claim line, and the modifier identifies how the services relate to other services in the same claim. 

6. The hospital billed charge. This field is typically on the claim (in the form of a number) and acts as a starting point when comparing external public hospital financial data or external public claim pricing data (like Medicare). 

7. The hospital allowed amount. If this is provided, it is an excellent way to look at what was actually paid. Using the billed charge and other data, you can compare the payment to external public hospital financial data or external public claim pricing data (like Medicare) to see how the payment/discount matches costs and/or Medicare benchmarks. 

*Note: This field is not always reliable and can vary greatly from claim to claim.

Once you have access to these data points, use a charting software to visualize the findings and identify outliers or trends across provider utilization, payment amounts compared to public market data or procedure trends that may lead to future issues for the plan. In doing so, you can begin to craft a data-driven benefits strategy for your clients that focuses on cost-containment and easily paint yourself as the expert they need on their side. Not sure where to start? Give us a shout.

To take a deeper dive into cost-containment strategies that may be a valuable solution for your clients, register for our upcoming webinar, “Build the dream: Constructing a cost-containment ecosystem for your organization.”