Lost in translation

Benefit managers bemoan the scarcity of useful data, though they may have reams of reports from their plan. The real answer lies in the words you use. Imagine a benefit manager faced with this question: How much did we spend last year on depression?

The phrase "how much did we spend?" could mean how much the plan actually paid in benefits (after copays or benefits from other plans), or how much the plan benefit or allowed amount was. It could include or exclude how much the employee paid in copays and deductibles. "Last year" could mean calendar year, plan year or fiscal year. It could mean the most recent 12 months. Furthermore, it leaves vague whether the manager wants only the dollars that left the plan during the "year" (incurred and paid claims) or the dollars that were spent to cover all the services that occurred during the "year," regardless of when the claim was actually paid (incurred).

"On depression" could mean medical bills that have "depression" as the principal (first) reason for care. Or it could mean medical bills that have depression as a diagnosis anywhere on the claim. Furthermore, it could include or exclude prescription drugs that are typically used for depression.

Here is the same question translated into a data request:

* What was the net plan payment for medical claims with a principal diagnosis of code 311 where the claim date of service occurred during the 12-month period ending June 30, 2012, and the claim was paid during the 15-month period ending September 20, 2012?

If you also wanted the figures for depression-related medications, you would ask:

* What was the net plan payment for pharmacy claims for drugs with ATC code N06A where the claim date of service occurred during the 12-month period ending June 30, 2012, and the claims were paid during the 15-month period ending September 30, 2012?

Somewhere in those stacks of reports, the data to answer the manager's question is hiding - cloaked in another language, but there nonetheless. As a result, plan administrators throw up their hands and say: "We've given them all the data!" and benefit managers say: "We have no data!"

As you can see from the translated request, health data is not intuitive. You cannot look at diagnosis codes and guess what they mean. It is a specialized skill to make lists of numbers and codes useful for decision-making. Without this skill, benefit managers will stay in the drought even while they are deluged by data.

Linda K. Riddell is a principal at Health Economy, LLC. She can be reached at LRiddell@HealthEconomy.net. This article first appeared on EBN's blog.