Is claims data part of a PHM platform?
Robust PHM platforms can be implemented without incorporating adjudicated health insurance claims.
Nonetheless, when available, paid claims offer rich and important insights not possible with clinical data alone.
Paid Claims data helps administrators manage complex value-based contracts in which some level of
accountability (and thus risk) for cost and quality is assumed by the practice. Both risk and gain sharing
arrangements require knowledge of patient’s clinical activities outside of the practice, knowledge that can
only be derived from adjudicated claims. Claims data informs multiple other important insights, among
them understanding health care resource utilization and the tracking of in and out of network referrals
(“leakage and keepage”). Many of the commonly used predictive analytics and risk stratification tools
are greatly enhanced by the combination of claims and clinical data. Additionally, claims data supports
measurement of Practice Pattern Variation which allows generating savings by identifying and reducing
over utilization of low value care.
This blog comes from a white paper published by EHR Integration Services and EagleDream Health.
Click here to read the white paper in its entirety, or visit our blog regularly to read all Top Ten
Essentials of Population Health.