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Compiling & Analyzing Health Claims Data

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Calculating 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):
  • Hypertension
  • High cholesterol
  • Heart disease
  • Stroke
  • Cancer
  • Chronic obstructive pulmonary disease (COPD)
  • Diabetes
  • Arthritis/musculoskeletal
  • Anxiety and depression
  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

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