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Compiling and Analyzing Health Claims Data

StethoscopeCalculating the following statistics (e.g., by employment status, by sex, by age) will help in identifying major contributors to health care expenditures:

  1. Total health care costs (e.g., percent of total costs and average cost per enrollee)
  2. Percent of insured individuals receiving the following preventive services (utilization):

Note:  It is important to look at screening and vaccination recommendations when analyzing preventive services data. Individual totals should be calculated using the number of eligible or recommended individuals (e.g., by sex or age) for the particular service being examined.

  • General exams (physicals, Ob/Gyn visits)
  • Physical exams
  • Diabetes screening (age)
  • Influenza immunization
  • Pneumococcal immunization (age)
  • General Ob/Gyn visit  (females only)
  • Breast cancer screening  (females only+age)
  • Cervical cancer screening (females only+age)
  • Colon cancer screening (age)

Note: Utilization of preventive health services depends on many factors including those related to how the benefit package is designed such as whether the service is covered or not; copayment, deductible, and premium levels; or eligibility to enroll in coverage as a result of waiting periods or minimum work-hour rules (full time/part time).  


  1. Percent of insured individuals with each condition below and average health care cost per person with each condition (Note: This list is not exhaustive but accounts for the leading causes of death and disability in U.S. adults):
  1. Costs of services by enrollees with chronic conditions and place of service:
  • Outpatient
  • Inpatient
  • Pharmacy
  • Emergency services
  • Home health
  • Physical therapy

Please note that when calculating percentages the denominator should include all individuals (within a specified group, e.g., females) covered by the health plan rather than only those who had a health claim during a specified time period.  (See table below for examples.)

Potential Types of Health Claims Data Related to Worksite Health

Indicator
Data Elements
Strata
Source
Use of preventive health Percent of employees receiving
    Physical exam (annual)
    Colorectal cancer screening
    Mammography
    Pap smear
    Immunizations (influenza,
        pneumonia)
    Screening for diabetes
       Fasting lipid profile
       2 Hba1c’s in last year
       Microalbuminuria screening
       Dilated eye exam
       Comprehensive eye exam
       Comprehensive foot screen
    Hearing screening
    Tobacco cessation
    Counseling for obesity
    Counseling for diabetes
By worksite

By unit

By age

By sex

By employees vs. dependents
vs.
retirees
Health plan cost tracking
Health claims  Number and percent of employees & costs for:
Number of any health care visits
Total Health Care costs
    CVD & Risk Factors (total)
      Heart disease
      Diabetes
      Diabetes complications
      Hypertension
      High cholesterol
    Arthritis
    COPD & Allied Conditions
      Bronchitis & chronic bronchitis
      Asthma
      Emphysema  
    Cancer
      Breast cancer
      Colon cancer
      Lung cancer
      Prostate cancer
      Skin cancer
Total Chronic Disease
    Depression
    Other mental health
    Hearing loss
    Influenza
    Injury
    Chronic liver disease, cirrhosis
       and hepatitis
    Oral Health 
    Reproductive health
Within worksite and unit by:

All insured:
Age
Gender
Age x Sex

Employees only:
Age
Gender
Age x Sex

Spouses:
Age
Gender
Age x Sex

Retirees:
Age
Gender
Age x Sex
Health plan  cost tracking
Medication use Number of patients and total costs for selected drug classes:
      Anti-hypertensives
      ACE inhibitors
      Statins (Cholesterol lowering)
      Beta blockers
      Diabetes (e.g. insulin)
      Antidepressants
      Anti-anxiety
      Asthma
      Chemotherapy
      NSAID (Non-steroidal anti-
       inflammatory drugs)
      Contraceptives
Same as above Health plans
Quality of care: Screening Percent of adults age 50+ with appropriate colorectal cancer (CRC) screening

Percent women age 40+ with a mammogram in previous 2 years

Percent of women over 21 years who have had PAP smear
Same as above Health plans
Quality of care CVD control Percentage of CVD patients with hypertension and appropriate blood pressure control (as measured by receipt of medication for hypertension)

Number and percent of prescriptions filled by CVD patients  
Same as above Health plans
Quality of Care Diabetes Percent of people with diabetes:

    Percent receiving eye exam
    Percent receiving foot exams
    Percent receiving medication or
     insulin
Same as above Health plans
 

Contact Us:
  • Division of Population Health/Workplace Health Promotion
    Centers for Disease Control and Prevention
    4770 Buford Highway, Northeast, Mailstop K-45
    Atlanta, GA 30341
  • 800-CDC-INFO
    (800-232-4636)
    TTY: (888) 232-6348
  • Contact CDC-INFO
USA.gov: The U.S. Government's Official Web PortalDepartment of Health and Human Services
Centers for Disease Control and Prevention   1600 Clifton Road Atlanta, GA 30329-4027, USA
800-CDC-INFO (800-232-4636) TTY: (888) 232-6348 - Contact CDC–INFO
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