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How Data is Driving 2021 Benefits Strategies

By Rani Aravamudhan, MD CPHIMS

Health plans typically design benefit offerings by assessing patterns of utilization and cost data in previous years. Thanks to disruptor-in-chief, COVID-19, this traditional approach was rendered inadequate to say the least.

With the pandemic demanding agility, many health plans turned to flexible data analytics and infrastructures capable of generating original, actionable intelligence at a moment’s notice. Having the ability to respond rapidly to their clients’ immediate data needs, despite ongoing uncertainties, is much like having a fire truck ready to put out fires whenever and wherever they arise.

Demonstrating agility through analytics in a crisis

Health plans needed to quickly pivot business processes to align with evolving customer needs. For healthcare benefits administrator Meritain Health, the large-scale shift in the consumption of care that followed the onset of the pandemic required swift adjustments to accommodate changes in multiple areas: fluctuating sites of service and code sets and payment structures, to name a few. Hence Meritain implemented several strategic variations to their business processes. Working with their data warehousing and analytics’ vendor partner, HDMS, Meritain Health rapidly deployed these changes:

  • Faster reporting cadence. Meritain Health added weekly and (in a limited capacity) daily reporting in addition to their standard monthly and quarterly data snapshots. A tiered approach to disseminating the right analytics at the right time was crucial to providing direction that would drive strategic decisions by their employer clients. This was a shift from their usual process, where financial and utilization trends were measured using post adjudicated (paid) claims, which inherently carry a lag factor.
  • Expanded analytics:  Navigating through a myriad of legislative changes at the federal & state levels (e.g. the CARES act mandating coverage of all COVID-19 testing costs by plan sponsors and lifting of restrictions for telemedicine access), meant that Meritain Health had to guide their clients through critical coverage decisions (e.g. coverage for telemedicine or virtual visits under medical plans through existing provider networks). Expanded coverage meant expanded reporting and thus expanded analytics with swift incorporation of new code sets, altered payment structures (e.g. waived member cost shares) and more. Additionally, expanding the line of sight to include incurred claims, paid claims, and claims in inventory helped with staying on top of evolving patterns of utilization. 
  • Adaptable analytics. Meritain Health understood that these unique times demanded views with new or adjusted definitions, metrics and performance indicators. They leveraged their existing infrastructure, framework and time-tested analytic methods to interpret emerging trends from newer angles (e.g. apply CDC criteria for high risk individuals for stratification of members). Having a robust and flexible analytic platform allowed them to develop additional reporting templates that could be easily accessed by their clients on demand.
  • Consistent analytics. HDMS’ analytic platform incorporates industry standard methodologies and they published content informed by the most current guidance from CDC, WHO, NIH and other agencies. Using these ensured that Meritain Health had consistent data comparisons. Thus they were able to leverage these code clinical mappings to create new metrics as they adapted their deliverables to meet customer needs

Looking ahead to 2021

As the country moves through the latest surge of new COVID-19 infections with daily new case totals exceeding 100k, Meritain Health plans to stay focused on their goal to provide their clients with the power of data by staying nimble and relying on their collective experience and partnership to effect meaningful change in the health of their members and their business. So, when asked where they plan to target their energies on in 2021, Meritain Health cited 4 major areas:

  1. Gaps in care. The effects of doctor’s visits, elective surgeries and other preventive services that were delayed, deferred or canceled earlier in the year due to lockdown protocols will likely start to show now and in the upcoming months in the form of adverse events (e.g. loss of mobility due to canceled joint replacement surgery), lower immunity (e.g. due to reduced vaccination rates) or deterioration of a chronic disease. Identifying these to rapidly intervene and bridge these gaps is crucial to the well-being of members and the financial health of a business.
  1. Telemedicine utilization. Telemedicine is here to stay. Hence keeping a finger on the pulse of telemedicine and virtual care trends- utilization by age, type of care (primary vs. specialty), reasons for visit, shifts in sites of care (traditional office visits or urgent care visits to telemedicine) - will be pivotal for plan design and network coverage.
  1. Mental health conditions/Substance Use Disorders (SUD). Several studies have reported the heavy toll on mental and emotional health caused by COVID-19- the disease itself, the isolation factor, financial stress and much more. Mental health conditions and SUD are associated with a much higher total cost of care.  As such, it is essential to monitor metrics indicating the illness burden due to common conditions for quick intervention (e.g.  rate of new prescriptions for anti-anxiety and anti-depressant medications)
  2. High risk member distribution. As the infection rates surge in various states, it is important to constantly assess and stratify member populations at risk for poorer outcomes at emerging “hot-spot” locations.

Meritain Health exemplifies resilience which has been defined in some cases as “the ability to pivot repeatedly and stay standing” by planning for the unexpected with HDMS as an able partner and data as their powerful armor.

Health Data & Management Solutions, Inc. (HDMS) is a trusted leader in healthcare analytics across the care continuum. The company transforms data into a high-value, decision-support asset for hundreds of health plan, employer, provider and broker customers. The company’s solutions put unparalleled analytic power into the hands of customers, guiding them to make actionable and confident decisions to improve the health of their population. HDMS is a part of the CVS Health family of companies. For more visit hdms.com or email [email protected]

This article was created in collaboration with the sponsoring company and our sales and marketing team. The editorial team does not contribute.