Compiling & Analyzing Health Claims Data
Calculating the following statistics (e.g., by employment status, by sex, by age) will help in identifying major contributors to health care expenditures:
- Total health care costs (e.g., percent of total costs and average cost per enrollee)
- 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).
Tools and Resources
Preventive services recommendations
- 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
- 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 |
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: Employees only: Spouses: Retirees: |
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 |
Same as above | Health plans |
- Page last reviewed: December 8, 2015
- Page last updated: December 8, 2015
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