Claims Data: The Key to Wellness Initiatives

The thing I love about partial self-funding is getting access to claims data. Once we get into the partial self-funding plan environment, we get access to data about the types of claims that are being paid on behalf of employees. The data tells us, from a group perspective, the sorts of issues going on within the group that we might want to attack that will then allow us to reduce future claims costs. For example, somewhere near 80 percent of claims are lifestyle and behavior driven. They relate to things over which people do have control, which creates a big opportunity for employers who want to reach out and engage their employee base to participate, play and really do their part to help stem the rise in health care costs. To slow the increase in health care costs, it is going to take people embracing their parts by examining their lifestyle and behavior so that they can make changes and do things that are going to eventually curb the cost of claims down the road.

One thing that having data allows us to do is a data dump into a platform we have called The Wellness Decision Engine. The Wellness Decision Engine mines the claims data and actually sets it up for us to be able to see what percentage of employees and covered members in the group would be considered healthy individuals who live healthy lifestyles and have healthy behaviors. The Wellness Decision Engine does not just mine the employee claims data. It includes data from their families’ claims as well. It will also let us know which of those covered individuals is in a preventive state where they could potentially be moved up to a healthy state or slide down a continuum into a high-risk state where they are chronically ill. High-risk people suffer from conditions like high blood pressure, cholesterol problems, diabetes and obesity. These are chronic issues that drive claims, and in the long run, they will lead to larger shock claims.

When we have data, we are able to see what sorts of things are driving the claims in the group. With that knowledge, we can determine the sorts of wellness initiatives we need to employ and then reach out and try to engage a group to embrace and help us and the employer look at doing things that are going to reduce the cost of claims down the road. Our wellness programs will be designed specifically around the issues happening within the group that are going to potentially lead to large shock claims down the road.

The data analytics that we drive into our platform that allow us to slice and dice the claims to see what is happening have been available to very large companies such as Fortune 500 companies. Wellness and data analytics professionals have delivered analytics to large companies via an on-site platform that is very customizable. It is very expensive, and for years it has been something that only large mega-companies could afford. Today, we have a platform and the ability to deliver it to smaller groups, and it is very affordable for companies of 100 or more employees.