Data from a major commercial health insurer found that five broadly defined clinical conditions comprise approximately 50% of healthcare costs.

For payers, this research underlines the importance of understanding your population so you can design effective, targeted interventions to mitigate costs and improve member outcomes. This requires accurate and informative healthcare analytics. And for that, you need high-quality, clinical data.

The research is summarized in a whitepaper titled “Costly Conditions: Identifying and Addressing Top Clinical Cost Drivers” from UnitedHealthcare (UHC) and the nonprofit Health Action Council (HAC), which represents employers in efforts to improve healthcare quality and lower costs. It ranked the five conditions as follows:

• Cancer, which comprised 15% of spend in the study, or $553 million, on nearly 103,000 claims
• Musculoskeletal conditions, including joint wear and tear, lower back pain, and hip pain, accounted for 13%, or $477 million, on 317,000 claims
• Cardiovascular conditions such as arrhythmia, stroke, heart attack, and heart failure, at 9%, or $357 million, and 169,000 claims
• Gastrointestinal conditions such as colitis, Crohn’s disease, and celiac disease, at 7%, $284 million, and 136,000 claims
• Neurological conditions like carpal tunnel syndrome, Parkinson’s disease, and migraines, at 6% or $225 million, representing 240,000 claims

The white paper analyzed nationwide medical and pharmacy plan data from more than 320,000 covered HAC members comprising midsize to large employer groups for a three-year period through June 2021. The five categories account for nearly $2 billion in healthcare spend.

“Employers who empower employees with more information about their care options, while also providing advocacy and encouragement to engage, can help employees and dependents make more informed and effective decisions and save time and money,” Patty Starr, Health Action Council’s president and CEO, said in a statement.

It’s another sign of the rising value of high-quality, complete, and accurate clinical data to help employers and payers detect these conditions early in their course, when interventions are most effective in helping members and limiting costs.

The report highlights data-driven suggestions for how employers can identify risks within their employee populations. For example, women have a 52% higher prevalence than men of having a cancer claim, due to breast cancer, and the report says cancer claims are higher among older populations and members with incomes above $75,000. What’s more, hypertension is a risk factor for several conditions, including heart disease, as well as a common comorbidity for cancer, neurological conditions, and gastrointestinal diseases.

Payers typically have no shortage of clinical data at their disposal, with information from health screenings, health assessments, electronic health records (EHRs), clinician notes, test results, and more. But the quality of the data is suspect.

In our experience, only about 40% of the clinical data our clients receive from providers or health information exchanges are usable, without need for curation and enrichment. The remaining 60% are inaccurate, incomplete, duplicative, or unstandardized. It requires various levels of curation and enrichment to make data standardized, accurate, and complete.

Payers are also challenged by the latency of data. Claims data can lag for months and often laboratory and biometric data are missing, limiting the ability to analyze conditions and spot timely opportunities for clinical interventions.

Members and employer groups deserve better and demand health plan collaboration in designing highly targeted benefit plans and care management programs that address the needs of each unique individual.

Contact us to learn how we can assist in accessing high-quality clinical data needed for the design of these programs.