Putting claims data to work: Using analytics in an evolving healthcare ecosystem
Abstract
As the US healthcare ecosystem undergoes rapid evolution, hospitals and health systems need up-to-date analytics to manoeuvre and thrive. National claims data that is both robust and reliable can provide the basis for such analytics. Data reflecting billed charges and negotiated (or allowed) amounts can inform fee schedule development, payer negotiations and dispute resolution. Claims data, which includes procedure and diagnostic codes and relevant demographic factors, also reveals important trends and patterns in four alternative venues of care: retail clinics, telehealth, urgent care centres and ambulatory surgery centres. Factors considered include rural versus urban growth in utilisation, patient age groups, gender utilisation and common diagnoses. The paper also presents clinical trends illuminated by claims data analysis for the following conditions or procedures: obesity and type 2 diabetes in paediatric patients, psoriatic arthritis, Lyme disease, breast cancer, knee and hip surgeries and opioid abuse and dependence. Issues in the analyses include comorbidities, costs and gender and age disparities. Finally, the paper suggest how claims data can be a basis for bundled payments and associated analytics to aid in the transition from a fee-for-service model to value-based reimbursement or otherwise shed light on provider performance.
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Author's Biography
Robin Gelburd is President of FAIR Health, a national, independent, non-profit organisation with the mission of bringing transparency to healthcare costs and health insurance information. FAIR Health possesses the largest collection of private healthcare claims data in the United States, with over 28 billion claim records contributed by payers and administrators who insure or process claims for private insurance plans covering more than 150 million individuals. Certified by the Centers for Medicare & Medicaid Services (CMS) as a Qualified Entity, FAIR Health also receives data representing the experience of all individuals enrolled in traditional Medicare Parts A, B and D; FAIR Health houses data on Medicare Advantage enrollees in its private claims data repository. Robin is a nationally recognised expert on healthcare policy, data and transparency. Recipient of a 2016 Dig|Benefits Technology Innovator Award bestowed by Employee Benefit News, she has published numerous articles and has been invited to speak to organisations across the country on topics of critical importance to healthcare stakeholders.
Citation
Gelburd, Robin (2019, March 1). Putting claims data to work: Using analytics in an evolving healthcare ecosystem. In the Management in Healthcare: A Peer-Reviewed Journal, Volume 3, Issue 4. https://doi.org/10.69554/FPGN1686.
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