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.