Strategy
Data-Driven Health Plan Management
The single biggest advantage of self-funding is claims data ownership. Fully insured employers are flying blind; self-funded employers can see exactly what's driving costs and target interventions precisely. But most employers don't use their data effectively.
What to look for in your claims data
Top 10 cost drivers by diagnosis — where is the money going?
High-cost claimant concentration — what % of cost comes from the top 5% of members?
Pharmacy vs. medical split — is pharmacy growing faster than medical?
Specialty drug utilization — which specialty drugs are driving pharmacy costs?
ER utilization — how many ER visits could have been handled in primary care?
Site-of-care patterns — are members using hospital outpatient when ASC is available?
Preventive care gaps — are members getting recommended screenings?
Chronic condition management — are members with diabetes, hypertension, etc. getting appropriate care?
The monthly claims review cadence
Effective data-driven plan management requires a regular review cadence. Monthly reviews catch emerging trends early. Quarterly reviews assess the impact of interventions. Annual reviews inform renewal strategy and plan design changes. Your TPA should provide standard reports; supplement with a third-party analytics vendor for deeper insights.