Key Claims Experience Metrics
| Metric | What It Tells You | Plan Design Implication |
|---|---|---|
| Total claims PEPM | Average monthly cost per member | Benchmark against industry; identify trend |
| Medical vs. pharmacy split | Proportion of claims from each category | Focus cost management on the larger category |
| Top 5 diagnosis categories | Primary disease categories driving cost | Target cost-containment programs at top categories |
| ER utilization rate | ER visits per 1,000 members | High rate suggests telemedicine or DPC opportunity |
| Generic dispensing rate | Percentage of Rx filled with generics | Low rate suggests formulary or cost-sharing opportunity |
| Preventive care utilization | Percentage of members using preventive services | Low rate suggests communication or access barrier |
High-Cost Claimant Analysis
High-cost claimant analysis identifies the members with the highest claims costs and the disease categories driving those costs. This analysis is the foundation of targeted cost-containment strategy — it tells you where to focus your investment for the highest ROI.
Utilization Analysis
IQ Insight
Utilization analysis identifies both overutilization (ER visits for non-emergency conditions, unnecessary imaging) and underutilization (low preventive care rates, low medication adherence). Both are costly — overutilization wastes money on unnecessary care; underutilization leads to higher costs later when conditions worsen. Address both in your plan design strategy.