Today's guest blogger maintains benefits managers and plan administrators speak different languages. There's a big difference between questions and data requests. Read on and let me know what you think. —Andrea Davis, Managing Editor

Why can’t we get useful data from our health plan? 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. 

You say tomahhto . . .

Imagine a benefit manager faced with this question:

  • How much did we spend last year on depression? 

Each part of the question is a data point.  The phrase “how much did we spend” could mean how much the plan actually paid in benefits (after co-pays or benefits from other plans) or how much the plan benefit or allowed amount was. It could include or exclude how much employee paid in co-pays 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 the 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 code of 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 30, 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 was 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 data 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 contacted at LRiddell@HealthEconomy.net.

Does this sound familiar to you? Do you struggle with getting the most from your health plan data? Share your thoughts in the comments.

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