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

Scott bennett

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.