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:

1. Total health care costs (e.g., percent of total costs and average cost per enrollee)
2. 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).   

3. 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

4. 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

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