# https://medinsight.com/ llms-full.txt ## Healthcare Data Analytics [Skip to the content](https://medinsight.com/#content) Previous ### [Milliman MedInsight ACO clients achieve $658 million in savings for the 2024 Medicare Shared Savings Program. Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-aco-clients-achieve-658-million-in-savings-outperforming-national-averages-in-the-2024-medicare-shared-savings-program/) ### [Milliman MedInsight wins 2025 Best in KLAS for Data Analytics Platform (Payer). Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-wins-2025-best-in-klas-for-data-analytics-platform-payer/) ### [Milliman MedInsight celebrates 25+ years of trusted data and insights. Learn more](https://medinsight.com/healthcare-data-analytics-about/25th-anniversary/) ### [Milliman MedInsight ACO clients achieve $658 million in savings for the 2024 Medicare Shared Savings Program. Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-aco-clients-achieve-658-million-in-savings-outperforming-national-averages-in-the-2024-medicare-shared-savings-program/) ### [Milliman MedInsight wins 2025 Best in KLAS for Data Analytics Platform (Payer). Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-wins-2025-best-in-klas-for-data-analytics-platform-payer/) ### [Milliman MedInsight celebrates 25+ years of trusted data and insights. Learn more](https://medinsight.com/healthcare-data-analytics-about/25th-anniversary/) ### [Milliman MedInsight ACO clients achieve $658 million in savings for the 2024 Medicare Shared Savings Program. Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-aco-clients-achieve-658-million-in-savings-outperforming-national-averages-in-the-2024-medicare-shared-savings-program/) Next # Healthcare data analytics software for health plans and ACOs ### Unlock the power of your data: MedInsight advanced analytics and contextualized insights empower healthcare payers, providers, purchasers, and consultants. ![MedInsight Healthcare Data Analytics](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/08/homepage-graphic-2025-v2.png) ## MedInsight is trusted by: ![Southeastern Health Partners Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/07/southeastern-partners-logo-300x86.png) ![Community Health Plan of Washington Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/02/community-health-plan-wa-300x118.png) ![SSM Health Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/01/ssm-health-logo.png) ![Hartford Healthcare Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/01/hartford-healthcare-logo.png) ![Altais Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/01/altais-logo.png) ![AultCare Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/01/aultcare-logo.png) ![Virginia Health Information Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/virginia-health-logo.png) ![Genesys PHO Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/genesys-pho-logo.png) ![Atrio Health Plans Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/07/atrio-health-plans-logo-300x138.png) ![Care New England Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/care-new-england-logo.png) ![DMBA Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/dmba-logo.png) ![Quartz Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/quartz-logo.png) ![Washington Health Alliance Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/washington-health-alliance-300x150.png) ![Bon Secours Mercy Health Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/07/bs-mercy-health-300x150.png) ![Sharp Health Plan Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/11/sharp-health-plan-logo-300x192.png) ![Jefferson Health Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/11/jefferson-health-logo-300x150.png) ![Independent Health](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/11/independent-health-logo.png) ![Advanced Health logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/11/advanced-health-logo.png) ![CalPERS Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/11/calpers-logo.png) ![Delaware Valley ACO Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/07/delaware-valley-aco-logo-300x150.png) ## Who MedInsight serves ![Payers](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/payers.svg) ### Payers Gain a new competitive advantage by aggregating and benchmarking claims, clinical, lab, and third-party data to reduce costs, hospital re-admissions, and improve overall patient care [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/payer/) ![ACOs](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/acos.svg) ### ACOs Extend your analytics capability without hiring by aggregating and normalizing patient claims and clinical data to identify care gaps, reduce network leakage, and minimize financial risks [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/) ![Employers](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/employers.svg) ### Employers Understand your healthcare spend and gain insights for improving the quality of your benefits package to better serve and improve the health at-risk and all employee needs [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ![State Government](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/state-government.svg) ### State government Proactively monitor key healthcare trends to ensure that reimbursement rates are set appropriately and managed Medicaid plans are performing with a powerful analytics platform [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ## MedInsight platforms ![MedInsight VBC](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/MI__icon-PROVIDER_SOLUTION.svg) #### MedInsight ### Value-based Care Extend your analytics capability to identify care delivery, cost savings, and financial risk reduction opportunities with the MedInsight VBC Platform. [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/) ![MedInsight Payer](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/MI__icon-PAYER_SOLUTION.svg) #### MedInsight ### Payer Harness payer-focused capabilities such as benchmarking cost and utilization metrics, population health management, employer group reporting, and more. [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/payer/) ![MedInsight Risk Adjustment](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/MI__icon-RISK-ADJUSTMENT.svg) #### MedInsight ### Risk Adjustment Improve clinical documentation and coding, risk scoring, and quality outcomes with an integrated, comprehensive, enterprise solution for risk management. [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/risk-adjustment/) ## MedInsight platform overview video Trust your data and accurately price risk with MedInsight: relied on by over 300 payers and ACOs since 1997 to aggregate and enrich claims data with county-level benchmarks, risk adjusters, and groupers—all peer-reviewed as part of the MedInsight Data Confidence Model. Your data will be refreshed in days instead of weeks every month so you can identify insights that lead to improved health outcomes, lower cost, and reduced financial risk. [Let's talk](https://medinsight.com/healthcare-data-analytics-contact/) ## MedInsight components ![Insights](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/insights.svg) ### Insights Identify quality of care improvements, savings opportunities, and ways to lower financial risk – and visually communicate them to stakeholders through the MedInsight reporting interface. ![Analytics](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/analytics.svg) ### Analytics Perform advanced, custom analysis on claims data that is aggregated across payers, enriched with groupers and metrics, and run through the MedInsight Data Confidence Model. ## MedInsight applications [![Contracts](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/contracts.svg)\\ \\ **Contracts** \\ \\ View financial performance across contracts so you can analyze the likelihood of success by contract, set individual contract targets, and track performance over the year.](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/contracts/) [![AI](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/ai.svg)\\ \\ **AI** \\ \\ Apply artificial intelligence (AI) and machine learning (ML) models to your data for better insights, faster; you can also access our Emerging Experience dataset via AI.](https://medinsight.com/healthcare-data-analytics-software/applications/data-science-portal/) [![Group Reporting](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/group-reporting.svg)\\ \\ **Group reporting** \\ \\ Show your plan’s value by sharing detailed account and group reporting with employers and third-parties to enable better decisions and increase plan renewals.](https://medinsight.com/healthcare-data-analytics-software/applications/employer-group-insights-egi/) ## MedInsight analytics products ### Performance Benchmarking Suite MedInsight Performance Benchmarking Suite empowers organizations to compare their performance against Milliman’s highly respected benchmarks. With comprehensive metrics and key performance indicators, organizations gain a clear understanding of their strengths, weaknesses, and areas for improvement. [Learn more](https://medinsight.com/healthcare-data-analytics-software/analytic-products/performance-benchmarking-suite/) ### Risk Adjustment Suite MedInsight Risk Adjustment Suite offers advanced algorithms and predictive modeling capabilities that optimize coding accuracy, identify documentation gaps, and ensure appropriate reimbursement. [Learn more](https://medinsight.com/healthcare-data-analytics-software/analytic-products/risk-adjustment-suite/) ### Clinical Suite MedInsight Clinical Suite offers revolutionizes healthcare delivery by empowering organizations with advanced clinical analytics and decision support capabilities. This comprehensive suite enhances clinical decision-making, improves patient outcomes, and drives operational efficiency. [Learn more](https://medinsight.com/healthcare-data-analytics-software/analytic-products/clinical-suite/) ### Identify how to unlock insights from your data [Get an analytics assessment](https://medinsight.com/healthcare-data-analytics-assessment/) ## Testimonials “In partnering with MedInsight, we’ve been able to go deeper to put in custom strategies and formulas that have put us into a very high percentage of attribution identification. That’s huge when you are trying to go into a practice and develop change at point of care.” CEO, Southeastern Health Partners “When we work with other vendors, the tool doesn’t deliver what the presentation and demo showed. It takes more configuration and customization to get what you need. With MedInsight, you know what you’re getting on the front end: Milliman’s intellectual property in the development of tools. They know how to look at health information, medical claims, and health related work. They have stuff out-of-the-box that meets our teams’ needs and we’re not left empty handed.” VP, Enterprise Business Intelligence “I love the folks at MedInsight. I love collaborating with them. I love all that they bring to the table.” IT Consultant, Southeastern Health Partners “We’ve been using MedInsight for four years and it’s been a positive experience. The prior vendor experience was very frustrating in that they had a lot of trouble dealing with data, specifically normalizing the data. Milliman was able to come in and in six months, complete what this previous vendor couldn’t do in the space of 2 ½ to three years.” Director, Claims, Utilization & Trend Analysis “The team is fantastic. There’s a lot of transparency. We have a good working relationship. I get the support I need, which is really nice. **That data we get is very clean.** We can quickly aggregate and get at insights within the portal.” Analytics Director “Getting MedInsight data normalization provides us with the cleanest data, which has been a huge benefit and relief. **We haven’t found anyone else that can do it.** We need the benchmarking and all, but everything else is just icing on the cake.” VP, Healthcare Analytics and IT “HCG grouper allows us to pull Medicare data in the prescribed CMS format. It saves us significant labor every year. We just run our data through it, and it does what it needs to. Same for our other pricing …  we use MedInsight data for all of it because of the way it organizes data into neat spaces and it’s easy for us to use. We also launched Medicare Repricer on our commercial data. We make contracting decisions with providers based on that Repricer data, so we _know_ it’s saved us money to get our business on reference-based pricing rather than percentage billed.” Actuarial Department “It’s very easy to use, intuitive. When we have questions, there’s the reference library or we can go to our team at MedInsight for more in-depth questions.” VP, Healthcare Provider “They’ve helped us develop an education program for our analytics and executive community that’s been awesome. When we have technical or actuarial issues with groupers and software, we get immediate feedback. I don’t think of the tool, software, or suite. I think of the people support that sit behind it.” Director, Population Health Analytics “I spend a lot of time in MedInsight daily. I pull a bit of everything, depending on who’s asking. It’s super user-friendly and very easy to use. If you’re teaching someone else how to use it, you’re spending less time training and more time getting data out of there.” Data Analyst “We have three different claims payments – commercial, Medicare Advantage, and data from CMS for Medicare shared savings – and MedInsight aggregates all three of those data sources, normalizes them and makes it a uniform system where we can look at everything together on a similar basis. I don’t have to pull data out of this system or that system. The portal is understandable, intuitive, and easy to use.” SVP, Healthcare Analytics “As crazy as it sounds, we’re still evolving in our use of MedInsight after 10 years. There’s a lot of it we’re still trying to learn because our use of it has broadened, now spanning underwriting, sales, business development, actuarial, and finance. It’s a tool that’s used widely across the organization.” Chief Operations Officer “We’re under 50 people, so MedInsight is replacing 20–30 people that it would take to procure 250,000 beneficiaries and insurance claims on a regular basis while updating all of the benchmarks and creating new analyses. Utilizing MedInsight has made my organization extremely more efficient. It’s a partnership; they’re going to walk and talk with you throughout your business cases and really understand your business needs.” Director of Population Health Information Technology “First stop I go to for any request that comes to me: Can I get it from MedInsight? Because that’s the easiest way. It’s definitely the most comprehensive source for us. The things we can do now with a click of a button in MedInsight are just amazing – the financial link, the chronic condition, risk scoring, and benchmarking. We’ve customized everything, including the sales portal and attribution reporting.” Actuarial Director “We get our money’s worth from MedInsight, and I know there is even more that we have yet to flesh out.” Manager, Finance “MedInsight is highly engaged when it comes to training.” Director, Training “Our primary contact from MedInsight is on top of things for us. They have been a good ally for us throughout our relationship.” Manager, Analytics “MedInsight has been able to tailor things to our needs. The data mart enables us to integrate with our data warehouse, and we also like the integrity of the data.” VP Analytics “We really enjoy all aspects of MedInsight: Query Express, HCGs, and the Waste Calculator. MedInsight has great analytical groupers.” CEO & President “When I compare my options, MedInsight is my preferred data source simply because it is better than other vendors or what we have internally.” Director, Analytics [See more client testimonials](https://medinsight.com/healthcare-data-analytics-resources/client-testimonials/) ![Best in KLAS Payer Analytics](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/KLAS_Opt1v2.svg) ## Best in KLAS for the sixth year MedInsight’s platform for healthcare analytics and data warehousing was recognized as the Best in Payer Data Analytics Platforms in the 2025 Best in KLAS: Software and Services report. Best in KLAS awards are determined following extensive evaluations and conversations with thousands of healthcare providers. [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ## Blogs ### Transforming value-based care performance with the MedInsight VBC Platform Value-based care (VBC) shifts the focus from the quantity of healthcare services delivered to the quality and effectiveness of care provided. In this model, providers... [Read more](https://medinsight.com/healthcare-data-analytics-resources/blog/transforming-value-based-care-performance-with-the-medinsight-vbc-platform/) ### Precision is key: How payers can unlock strategic insights from claims and clinical data integration Today, payers face mounting pressure to deliver better outcomes, control the cost of care, and  manage financial risk. Meeting these goals requires more than access... [Read more](https://medinsight.com/healthcare-data-analytics-resources/blog/precision-is-key-how-payers-can-unlock-strategic-insights-from-claims-and-clinical-data-integration/) ### How healthcare payers can grow their analytic capabilities while staying vigilant against data breach threats Increasingly scalable, flexible, interoperable, cloud-based platforms supporting sophisticated analytic capabilities have created wide-ranging opportunities and profound insights for healthcare organizations, from improvements in quality of... [Read more](https://medinsight.com/healthcare-data-analytics-resources/blog/how-healthcare-payers-can-grow-their-analytic-capabilities-while-staying-vigilant-against-data-breach-threats/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) Live chat:Chat with an Expert ## Healthcare Analytics Use Cases https://medinsight.com/healthcare-data-analytics-use-cases/risk-adjustment-management/2023-07-24T21:45:35+00:00https://medinsight.com/healthcare-data-analytics-use-cases/quality-measurement-improvement/2023-07-24T21:46:20+00:00https://medinsight.com/healthcare-data-analytics-use-cases/medical-management/2023-07-24T21:47:26+00:00https://medinsight.com/healthcare-data-analytics-use-cases/network-leakage-analysis/2023-07-24T21:48:54+00:00https://medinsight.com/healthcare-data-analytics-use-cases/tcoc-analysis/2023-07-24T21:49:24+00:00https://medinsight.com/healthcare-data-analytics-use-cases/staff-augmentation/2023-07-24T21:51:13+00:00https://medinsight.com/healthcare-data-analytics-use-cases/health-equity-and-sdoh/2023-07-24T21:51:51+00:00https://medinsight.com/healthcare-data-analytics-use-cases/provider-profiling/2023-07-24T21:52:17+00:00https://medinsight.com/healthcare-data-analytics-use-cases/digital-transformation/2023-07-24T21:53:34+00:00https://medinsight.com/healthcare-data-analytics-use-cases/healthcare-analytics/2023-07-24T21:54:28+00:00https://medinsight.com/healthcare-data-analytics-use-cases/population-health-analytics/2024-06-14T15:59:36+00:00https://medinsight.com/healthcare-data-analytics-use-cases/value-based-contract-management/2024-06-14T16:08:31+00:00https://medinsight.com/healthcare-data-analytics-use-cases/employer-group-reporting/2024-06-14T16:16:48+00:00https://medinsight.com/healthcare-data-analytics-use-cases/utilization-management/2024-07-29T21:46:13+00:00https://medinsight.com/healthcare-data-analytics-use-cases/ehr-data-integration/2024-09-20T17:53:01+00:00https://medinsight.com/healthcare-data-analytics-use-cases/claims-data-aggregation-integration-and-management/2024-11-15T17:39:32+00:00https://medinsight.com/healthcare-data-analytics-use-cases/performance-benchmarking/2025-01-07T18:49:56+00:00https://medinsight.com/wp-content/themes/blankslate-child/assets/images/health-cost.svghttps://medinsight.com/wp-content/themes/blankslate-child/assets/images/benchmarks.svghttps://medinsight.com/wp-content/themes/blankslate-child/assets/images/contracts-dark.svghttps://medinsight.com/wp-content/themes/blankslate-child/assets/images/benefits-blue.svghttps://medinsight.com/healthcare-data-analytics-use-cases/provider-performance/2025-10-07T17:41:17+00:00 ## Healthcare Analytics Insights https://medinsight.com/healthcare-data-analytics-resources/blog/tag/accountable-care-organizations/2025-04-08T22:09:18+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/administrative-claims/2023-09-19T20:51:59+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/agentic-artificial-intelligence/2025-10-10T05:43:11+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/ahip-2024/2025-09-02T12:11:36+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/ai-challenges-in-healthcare/2025-09-02T12:16:02+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/ai-in-healthcare/2025-10-10T05:43:11+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/beckers-payer-issues-roundtable/2025-06-18T18:36:22+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/biologics/2025-10-10T05:43:29+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/biosimilars/2025-10-10T05:43:29+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/center-of-excellence/2023-09-06T17:46:02+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/claims-data-integration/2024-09-18T16:04:26+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/clinical-data-integration/2025-10-10T16:23:51+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/data-governance/2024-08-19T21:21:23+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/data-literacy/2024-08-19T21:21:23+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/data-security/2025-10-07T16:00:16+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/digital-transformation/2025-09-02T12:18:34+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/electronic-health-record-ehr/2025-07-10T13:24:46+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/employer-group-insights/2024-02-13T18:23:16+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/employer-group-reporting/2024-02-13T18:23:16+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/generative-artificial-intelligence/2025-10-10T05:43:11+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/health-waste-calculator/2023-10-05T16:43:26+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare/2024-01-31T23:35:23+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-ai/2025-04-08T22:23:57+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-analytics/2025-08-16T16:26:47+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-analytics-expertise/2024-01-22T22:16:22+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-analytics-reporting/2023-09-28T18:18:22+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-analytics-strategy/2024-06-05T16:15:10+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-artificial-intelligence/2025-09-02T12:16:02+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-chief-financial-officers/2024-05-31T20:11:54+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-cost-optimization/2025-05-23T15:55:14+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-cybersecurity/2025-10-07T16:00:16+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-data/2023-09-06T17:46:02+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-data-analytics/2025-10-10T17:36:34+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-data-infrastructure/2025-01-29T18:02:43+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-data-quality/2024-08-19T21:21:23+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-decision-making/2023-09-06T17:46:02+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-digital-transformation/2025-10-10T05:43:11+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-payer-outlook/2025-01-29T18:02:43+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-payer-strategies/2025-10-07T16:00:16+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/hedis-2025/2025-02-21T21:24:25+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/high-cost-claimant/2023-11-29T16:28:50+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/himss24/2025-09-02T12:18:34+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/himss25/2025-04-08T22:06:32+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/low-value-care/2025-02-04T20:46:38+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medicare-advantage/2025-05-20T17:53:33+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight/2023-10-02T16:17:09+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-health-cloud/2025-10-10T05:43:11+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/2024-10-15T17:52:31+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-payer-platform/2025-09-02T12:11:36+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/microsoft-azure-consumption-commitment/2025-09-02T12:19:46+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/milliman-medical-index/2023-07-25T22:49:46+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/naacos-spring-2025/2025-10-07T17:38:24+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/pharmacy-cost-management/2025-10-10T05:43:29+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/population-health-initiatives/2024-08-13T00:04:29+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/population-health-insights/2025-10-10T05:44:15+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/predictive-artificial-intelligence/2024-03-11T16:24:55+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/provider-performance/2025-10-10T05:42:43+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/radv-audits/2025-10-10T05:44:36+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/rise-national-2025/2025-04-08T22:03:20+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/risk-adjustment/2025-10-10T16:23:51+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/risk-adjustment-platform/2025-10-10T05:44:36+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/social-determinants-of-health-sdoh/2025-02-04T20:46:38+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/strategic-alliance-program/2023-09-06T17:45:40+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/thought-leadership/2024-01-31T23:35:23+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/total-cost-of-care/2023-10-05T16:43:26+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/transparent-vbp-reporting/2025-08-16T16:26:47+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/uri-antibiotic-prescriptions/2023-09-19T20:51:59+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/utilization-management/2025-10-10T05:43:29+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/value-based-care/2025-10-10T05:44:15+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/value-based-care-analytics/2025-10-10T05:43:46+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/value-based-performance/2025-08-16T16:26:47+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/vbc-analytics/2025-10-10T17:36:34+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/vbc-contracting/2025-10-07T17:38:24+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/vbc-platform/2025-10-10T17:36:34+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/tag/whitepaper/2023-09-06T17:46:02+00:00 ## Healthcare Analytics Ebooks https://medinsight.com/healthcare-data-analytics-resources/ebook/analytics-center-of-excellence-in-healthcare/2023-12-21T19:11:43+00:00https://medinsight.com/wp-content/uploads/2023/09/coe-healthcare-ebook.jpghttps://medinsight.com/healthcare-data-analytics-resources/ebook/navigating-the-hurricane-of-healthcare-data/2024-04-17T20:48:31+00:00https://medinsight.com/wp-content/uploads/2023/09/hurricane-healthcare-analytics.jpghttps://medinsight.com/healthcare-data-analytics-resources/ebook/vbc-contract-modeling-and-management-for-profitability-efficiency-and-better-outcomes/2025-02-21T22:34:28+00:00https://medinsight.com/wp-content/uploads/2025/01/vbc-contracts-ebook.jpghttps://medinsight.com/healthcare-data-analytics-resources/ebook/employer-group-reporting/2025-05-20T20:47:24+00:00https://medinsight.com/wp-content/uploads/2023/07/egi-ebook.jpghttps://medinsight.com/healthcare-data-analytics-resources/ebook/how-digital-transformation-drives-value-based-care/2025-05-23T15:53:24+00:00https://medinsight.com/wp-content/uploads/2024/04/vbc-digital-transformation-ebook.jpghttps://medinsight.com/healthcare-data-analytics-resources/ebook/value-based-care-best-practices-for-mitigating-risk/2025-05-23T15:54:19+00:00https://medinsight.com/wp-content/uploads/2024/01/medinsight-vbc-ebook.jpghttps://medinsight.com/healthcare-data-analytics-resources/ebook/modern-guide-to-risk-adjustment/2025-06-04T15:46:06+00:00https://medinsight.com/wp-content/uploads/2025/05/risk-adjustment-ebook.jpghttps://medinsight.com/healthcare-data-analytics-resources/ebook/accelerate-data-to-insights-the-enterprise-analytics-approach-for-health-plans/2025-07-16T02:12:56+00:00https://medinsight.com/wp-content/uploads/2024/05/payer-ebook.jpghttps://medinsight.com/healthcare-data-analytics-resources/ebook/the-intersection-of-clinical-data-integration-and-value-based-care-strategies-for-success/2025-08-16T16:38:05+00:00https://medinsight.com/wp-content/uploads/2025/07/ehr-ebook-2.png ## VBC Contract Management Insights [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/power-of-insight-enhancing-vbc-contract-management-and-outcomes-with-analytics/#content) # The power of insight: Enhancing VBC contract management and outcomes with analytics By Umang Gupta 9 October 2024 Print / PDF Share ![](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/05/cloase-icon-new.png) ## Share this page Copied The power of insight: Enhancing VBC contract management and outcomes with analytics Umang Gupta The transition towards value-based care (VBC) is rapidly reshaping the healthcare landscape. While this shift holds immense promise for improving patient outcomes and reducing costs, it also presents a unique set of challenges that demand careful consideration for successful contract negotiations and management. In this blog post Milliman MedInsight product manager, Umang Gupta, explains the intricacies of various VBC models and explores how healthcare organizations can leverage analytics to optimize financial performance and unlock the full potential of [value-based care](https://medinsight.com/healthcare-data-analytics-resources/blog/2024-outlook-five-key-analytic-capabilities-shaping-vbc/). #### Summary: - [What are the implications of entering VBC arrangements?](https://medinsight.com/healthcare-data-analytics-resources/blog/power-of-insight-enhancing-vbc-contract-management-and-outcomes-with-analytics/#vbc-arrangements) - [How do analytics support a successful VBC strategy?](https://medinsight.com/healthcare-data-analytics-resources/blog/power-of-insight-enhancing-vbc-contract-management-and-outcomes-with-analytics/#vbc-strategy) - [What resources are there to help payers and providers in VBC contracts?](https://medinsight.com/healthcare-data-analytics-resources/blog/power-of-insight-enhancing-vbc-contract-management-and-outcomes-with-analytics/#vbc-contracts) - [How does MedInsight VBC Contracts stand apart from other applications?](https://medinsight.com/healthcare-data-analytics-resources/blog/power-of-insight-enhancing-vbc-contract-management-and-outcomes-with-analytics/#other-applications) - [Where to get more information about MedInsight VBC Contracts?](https://medinsight.com/healthcare-data-analytics-resources/blog/power-of-insight-enhancing-vbc-contract-management-and-outcomes-with-analytics/#more-information) ## What are the implications of entering value-based care arrangements? The shift from fee-for-service (FFS) models to alternative payment models (APMs) brings both opportunities and challenges. Value-based care aims to enhance patient outcomes and care quality, yet it introduces considerable financial risks. One of the key drivers of these increased financial risks is the diverse agreements between providers (such as [ACOs](https://medinsight.com/healthcare-data-analytics-resources/blog/navigating-the-challenges-key-priorities-for-acos-in-the-journey-to-value-based-care/)) and payers, which link compensation to the cost and quality of care delivered to populations at risk. Each payment model has distinct features, benefits, and challenges, complicating management for organizations. For example, with pay for performance (P4P) models, healthcare providers are rewarded for achieving specific quality metrics or performance targets. P4P aims to incentivize providers to deliver high-quality care and improve patient outcomes. However, it can be difficult to determine the appropriate metrics and performance targets. With risk-sharing arrangements, there is shared financial risk between the healthcare provider and the payer. In these arrangements, providers are given targets for the expected costs of the population for which they are at risk. Providers can share in any savings that are produced if the population’s total spend is lower than the target.  Risk-sharing arrangements can incentivize providers to improve efficiency and reduce costs, but they also carry the risk of financial losses if targets are not achieved. > _“_ _As with many VBC contracts, the major challenges are situations where the transfer of risk and/or other financial incentives between payer and provider are misaligned or do not reflect each party’s ability to manage and control the risk being transferred.” 1_ ## How can analytics support a successful VBC strategy? To succeed in VBC, data analytic tools are an indispensable resource for organizations aiming to facilitate informed decision-making, drive continuous improvement and empower healthcare providers to deliver exceptional patient care. Unlike traditional FFS models, managing various APMs presents significant challenges due to issues related to standardization, detail, timeliness, and audit requirements. Common data challenges senior leaders at healthcare providers and payers often express: - **“We don’t know how we are performing until it is too late in the year to do anything about it.”** Tracking and monitoring performance is complex and requires both sound actuarial methodologies and timely data. Oftentimes, when a clearer picture of performance emerges, it may be too late in the year to right the ship if projected performance is negative. - **“We receive data from different sources, which causes significant issues.”** Providers involved in multiple contracts must manage data from various sources, leading to inconsistencies and complexities in data integration and analysis. - **“We don’t get the detailed insights we need to understand performance drivers.”** Standard reports typically offer a broad, top-level view—such as at the ACO level—without delivering the granular insights providers need to continually enhance performance throughout the year. Organizations need the ability to drill down to specific members and providers to track performance and distribute savings and losses equitably. Being unable to track VBC performance at a detailed level can prevent implementation of the right clinical interventions to achieve maximum savings. - **“Data comes at different times, disrupting our processes.”** Although organizations may routinely receive claims and membership data, the infrequent updates on target information can hinder their ability to precisely monitor their performance in VBC arrangements. Monitoring performance regularly allows organizations to budget for future years and understand their financial risk exposure. - **“The audit process is complex and time-consuming.”** The auditing process becomes laborious when validating final settlement calculations with partners. The need to precisely model complex and unique contract parameters adds to the difficulty of managing multiple VBC contracts, making the entire process intricate and time-consuming. - **“We have limited resources, and the complexity of these tasks is daunting.”** Teams are often lean and prefer to focus on delivering quality care rather than diving deep into data reports. Additionally, they may lack the specialized expertise needed to generate the precise reports required to access actionable insights and drive informed decision-making. Data analytics empowers organizations to reveal crucial insights that drive cost savings and highlight areas needing improvement. Investing in teams or solutions to unveil these insights is essential for organizations aiming to identify savings within their VBC contracts. The ability to quickly pinpoint these opportunities enables the design of targeted interventions and programs to reduce costs year-round, turning identified savings into realized ones. > _“While tracking direct impact is important, organizations will also need to know how all lives are performing.” 2_ ## What are some resources to help payers and providers with VBC contracts? Healthcare organizations can improve contract management and financial outcomes with the [Milliman MedInsight VBC Contracts](https://medinsight.com/healthcare-data-analytics-resources/video/value-based-care-contracts/) application. As part of the [VBC Platform](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/), it provides insight into current contract dynamics and financial performance. By leveraging Milliman’s actuarial expertise, the application helps organizations make informed decisions, offering clear projections for the current year at the ACO and individual provider level. VBC Contracts empowers organizations to: - Identify and model factors that enhance VBC contract performance. - Efficiently manage risk-based contracts, like MSSP and ACO REACH with actuarial oversight. - Maximize ROI from VBC contracts by quickly identifying opportunities to decrease costs and drive revenue growth. ## How does MedInsight VBC Contracts stand apart from other applications? MedInsight consolidates detailed claims and membership data from major national payers and CMS into a unified data model. It then models contract parameters based on the latest specifications along with monthly data refreshes. Savings and losses can be equitably distributed across the network by setting targets at the member level. The application’s robust auditing features ensure accuracy in projections and settlements, providing users with confidence during negotiations for future terms and payments with payer partners. ## **How can I learn more about MedInsight VBC Contracts?** **Schedule a Call:** [Connect](https://medinsight.com/healthcare-data-analytics-contact/) with one of our VBC Contracts experts. **Our Website:** Read more about our [VBC Contracts application](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/contracts/) or explore a [use case](https://medinsight.com/healthcare-data-analytics-use-cases/value-based-contract-management/). **VBC Contracts Webinar:** Learn how to overcome obstacles and succeed in VBC Contracts in this webinar “ [Contract Management Mastery: What you need to succeed in value-based care contracting”](https://milliman-medinsight.ubpages.com/contract-mastery/) 1 [https://us.milliman.com/-/media/milliman/pdfs/2024-articles/2-12-24\_the-winding-road-to-value\_vbc-dynamics.ashx](https://us.milliman.com/-/media/milliman/pdfs/2024-articles/2-12-24_the-winding-road-to-value_vbc-dynamics.ashx#:~:text=The%20types%20of%20VBC%20contracts%20vary%20across%20a) 2 [Value-Based Care Contract Management \| Milliman MedInsight](https://medinsight.com/healthcare-data-analytics-resources/webinar/contract-management-mastery-what-you-need-to-succeed-in-value-based-care-contracts/) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ## Explore more tags from this article [vbc contracting](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/vbc-contracting/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) Live chat:Chat with an Expert ## Healthcare Data Analytics https://medinsight.com/healthcare-data-analytics-resources/blog/category/healthcare-data-analytics-blog/2025-10-10T17:36:34+00:00 ## Payer Data Analytics Solutions [Skip to the content](https://medinsight.com/healthcare-data-analytics-software/platform/payer/#content) # Healthcare data insights and analytics for payers ### Harness payer-focused capabilities with unparalleled insights, data-driven decisions, and Milliman benchmarks to support financial, clinical, provider, and employer reporting so you can become an analytics center of excellence. [Get an analytics assessment](https://medinsight.com/healthcare-data-analytics-assessment/) [Download the brochure](https://medinsight.com/wp-content/uploads/2025/09/Brochure-Payer-Platform-2025-v2.pdf) ![MedInsight Healthcare Payer Data Analytics](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/08/payer-platform-banner-v2.png) ## Who MedInsight serves ### Commercial plans Gain a competitive advantage and trust your data again by aggregating and benchmarking claims data for actionable insights to reduce costs, waste, and financial risk, while increasing member satisfaction and employer group retention. [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ### Medicare Advantage plans Trust your data again by aggregating and benchmarking claims data for actionable insights to reduce the higher cost and risk of serving this population, while optimizing risk adjustment capabilities. [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ### Medicaid plans Improving health outcomes for your most underserved, at-risk members with data you can trust so that you can identify actionable insights to reduce costs, waste, and financial risk. [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ## MedInsight Payer users ![Data Analysts]() ### Data analysts Explore aggregated claims data quickly that integrates with your SQL and business intelligence (BI) tools. Custom dashboards enable information consumers with more complex analytics displayed with intuitive visuals. ![Data Scientists]() ### Data scientists and engineers Fully engage with aggregated claims data using R, Python, Scala, and SQL. Access MedInsight’s Referential Database for research, testing/training ML models, and utilize APIs to facilitate interoperability. ![Information Consumers]() ### Information consumers Experience visual reporting and the ability to slice-and-dice claims data without needing SQL experience so you can view financial and operational performance and identify savings and risk reduction opportunities. ![Financial Users]() ### Financial users MedInsight financial analytics support actuaries, finance professionals, and medical economics teams with key metrics and benchmarks. MedInsight identifies cost savings opportunities with playbooks to implement them. ![Clinical Users]() ### Clinical users Identify care gaps and opportunities to right-size utilization, improve health outcomes, and increase savings. You can also ingest EMR data from Epic and other systems to optimize care management resources. ## Key capabilities for payers ![Cost Drivers]() ### Identify cost drivers Zero in on major cost drivers and savings opportunities such as provider contracting, unnecessary utilization, site of service optimization, and more. [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ![Risk Adjustment]() ### Improve risk adjustment and modeling Analytics enhance your risk adjustment and risk modeling efforts to improve coding, optimize reimbursement, and prioritize patient care. [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ![VBC Support]() ### Value-based care support Quickly evaluate the effectiveness of your value-based care programs and assess what is and is not working. [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ![Provider Network]() ### Provider network management Analyze provider performance, improve contract negotiating positions, leverage price transparency data, and create narrow networks. [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ![Employer Group Reporting]() ### Employer group reporting Improve retention rates with Employer Group Insights (EGI). Extend visibility to employers and brokers, and demonstrate your value. [Learn more](https://medinsight.com/healthcare-data-analytics-software/applications/employer-group-insights-egi/) ![Cost of Care]() ### Measure total cost of care Evaluate total costs across multiple dimensions, enhance your value, and demonstrate your care and quality approaches. [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ## MedInsight Payer platform [![Insights]()\\ \\ **Insights** \\ \\ Identify quality of care improvements, savings opportunities, and ways to lower financial risk – and visually communicate them to stakeholders through the MedInsight reporting interface.](https://medinsight.com/healthcare-data-analytics-software/platform/payer/insights/) ![Analytics]() ### Analytics Perform advanced, custom analysis on claims data that is aggregated across payers, enriched with groupers and metrics, and run through the MedInsight Data Confidence Model. ## MedInsight Payer applications [![Contracts]()\\ \\ **Contracts** \\ \\ View financial performance across contracts so you can analyze the likelihood of success by contract, set individual contract targets, and track performance over the year.](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/contracts/) [![Bundles]()\\ \\ **Bundles** \\ \\ View all services provided to patients, streamline digital tools, and identify cost savings with the MedInsight bundled payment reporting.](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/bundles/) [![AI]()\\ \\ **Innovation Portal** \\ \\ Apply AI and ML for rapid insights; access enriched claims, market, and custom data; automate analytics tasks; and empower all users with intuitive, collaborative tools.](https://medinsight.com/healthcare-data-analytics-software/applications/innovation-portal/) [![Group Reporting]()\\ \\ **Group reporting** \\ \\ Show your plan’s value by sharing detailed account and group reporting with employers and third-parties to enable better decisions and increase plan renewals.](https://medinsight.com/healthcare-data-analytics-software/applications/employer-group-insights-egi/) ## MedInsight overview Trust your data and accurately price risk with MedInsight: relied on by over 300 payers and ACOs since 1997 to aggregate and enrich claims data with county-level benchmarks, risk adjusters, and groupers—all peer-reviewed as part of the MedInsight Data Confidence Model. Your data will be refreshed in days instead of weeks every month so you can identify insights that lead to improved health outcomes, lower cost, and reduced financial risk. [Let's talk](https://medinsight.com/healthcare-data-analytics-contact/) ## Testimonials “When I compare my options, MedInsight is my preferred data source simply because it is better than other vendors or what we have internally.” Director, Analytics “We really enjoy all aspects of MedInsight: Query Express, HCGs, and the Waste Calculator. MedInsight has great analytical groupers.” CEO & President “MedInsight has been able to tailor things to our needs. The data mart enables us to integrate with our data warehouse, and we also like the integrity of the data.” VP Analytics “Our primary contact from MedInsight is on top of things for us. They have been a good ally for us throughout our relationship.” Manager, Analytics “MedInsight is highly engaged when it comes to training.” Director, Training “We get our money’s worth from MedInsight, and I know there is even more that we have yet to flesh out.” Manager, Finance “First stop I go to for any request that comes to me: Can I get it from MedInsight? Because that’s the easiest way. It’s definitely the most comprehensive source for us. The things we can do now with a click of a button in MedInsight are just amazing – the financial link, the chronic condition, risk scoring, and benchmarking. We’ve customized everything, including the sales portal and attribution reporting.” Actuarial Director “As crazy as it sounds, we’re still evolving in our use of MedInsight after 10 years. There’s a lot of it we’re still trying to learn because our use of it has broadened, now spanning underwriting, sales, business development, actuarial, and finance. It’s a tool that’s used widely across the organization.” Chief Operations Officer “We have three different claims payments – commercial, Medicare Advantage, and data from CMS for Medicare shared savings – and MedInsight aggregates all three of those data sources, normalizes them and makes it a uniform system where we can look at everything together on a similar basis. I don’t have to pull data out of this system or that system. The portal is understandable, intuitive, and easy to use.” SVP, Healthcare Analytics “I spend a lot of time in MedInsight daily. I pull a bit of everything, depending on who’s asking. It’s super user-friendly and very easy to use. If you’re teaching someone else how to use it, you’re spending less time training and more time getting data out of there.” Data Analyst “They’ve helped us develop an education program for our analytics and executive community that’s been awesome. When we have technical or actuarial issues with groupers and software, we get immediate feedback. I don’t think of the tool, software, or suite. I think of the people support that sit behind it.” Director, Population Health Analytics ![Best in KLAS Payer Analytics]() ## Best in KLAS for the sixth year MedInsight’s platform for healthcare analytics and data warehousing was recognized as the Best in Payer Data Analytics Platforms in the 2025 Best in KLAS: Software and Services report. Best in KLAS awards are determined following extensive evaluations and conversations with thousands of healthcare providers. [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ## Blogs ### Transforming value-based care performance with the MedInsight VBC Platform Value-based care (VBC) shifts the focus from the quantity of healthcare services delivered to the quality and effectiveness of care provided. In this model, providers... [Read more](https://medinsight.com/healthcare-data-analytics-resources/blog/transforming-value-based-care-performance-with-the-medinsight-vbc-platform/) ### Precision is key: How payers can unlock strategic insights from claims and clinical data integration Today, payers face mounting pressure to deliver better outcomes, control the cost of care, and  manage financial risk. Meeting these goals requires more than access... [Read more](https://medinsight.com/healthcare-data-analytics-resources/blog/precision-is-key-how-payers-can-unlock-strategic-insights-from-claims-and-clinical-data-integration/) ### How healthcare payers can grow their analytic capabilities while staying vigilant against data breach threats Increasingly scalable, flexible, interoperable, cloud-based platforms supporting sophisticated analytic capabilities have created wide-ranging opportunities and profound insights for healthcare organizations, from improvements in quality of... [Read more](https://medinsight.com/healthcare-data-analytics-resources/blog/how-healthcare-payers-can-grow-their-analytic-capabilities-while-staying-vigilant-against-data-breach-threats/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() Live chat:Chat with an Expert ## Healthcare Analytics Insights 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## Healthcare Analytics Press Releases 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2T12:14:12+00:00https://medinsight.com/wp-content/uploads/2023/10/press-release.jpghttps://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-announces-solution-availability-in-microsoft-azure-marketplace/2025-09-02T12:21:49+00:00https://medinsight.com/wp-content/uploads/2023/10/press-release.jpghttps://medinsight.com/healthcare-data-analytics-about/press-releases/medinsight-unveils-enhanced-value-based-care-platform/2025-09-02T12:23:50+00:00https://medinsight.com/wp-content/uploads/2023/10/press-release.jpghttps://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-announces-expanded-capabilities-with-the-launch-of-the-innovation-portal-an-ai-powered-cloud-analytics-platform-for-healthcare-organizations/2025-09-08T15:00:42+00:00https://medinsight.com/wp-content/uploads/2023/10/press-release.jpghttps://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-aco-clients-achieve-658-million-in-savings-outperforming-national-averages-in-the-2024-medicare-shared-savings-program/2025-10-02T15:00:03+00:00https://medinsight.com/wp-content/uploads/2023/10/press-release.jpghttps://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-launches-comprehensive-risk-adjustment-platform-for-enhanced-performance/2025-10-07T17:43:13+00:00https://medinsight.com/wp-content/uploads/2023/10/press-release.jpg ## Healthcare Data Whitepapers https://medinsight.com/healthcare-data-analytics-resources/whitepaper/center-of-excellence/2023-12-21T19:07:46+00:00https://medinsight.com/wp-content/uploads/2023/07/coe-whitepaper.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/chronic-kidney-disease/2024-06-06T22:00:11+00:00https://medinsight.com/wp-content/uploads/2024/06/chronic-kidney-disease-wp.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/roses-and-thorns-the-nuanced-landscape-of-healthcare-provider-data/2024-08-23T21:21:52+00:00https://medinsight.com/wp-content/uploads/2024/06/nuanced-landscape-of-healthcare-provider-data.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/emergency-department-super-utilizers-more-than-meets-the-eye/2024-08-23T21:37:28+00:00https://medinsight.com/wp-content/uploads/2024/06/Emergency-department-super-utilizers.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/low-value-care-a-perspective-to-tackle-this-global-concern/2024-09-06T13:37:30+00:00https://medinsight.com/wp-content/uploads/2024/09/low-value-care.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/elevating-value-based-care-beyond-claims-data-with-ehr-insights/2024-09-18T16:03:37+00:00https://medinsight.com/wp-content/uploads/2024/06/Elevating-value-based-care.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/changing-patterns-in-telehealth/2024-09-20T15:53:29+00:00https://medinsight.com/wp-content/uploads/2024/09/Changing-Patterns-in-Telehealth.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/increased-spending-on-low-value-care-during-the-covid-19-pandemic-in-virginia/2024-10-31T21:43:07+00:00https://medinsight.com/wp-content/uploads/2024/10/health-affair-scholars.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/supercharging-healthcare-analysis-with-robust-provider-data/2024-11-21T17:53:18+00:00https://medinsight.com/wp-content/uploads/2024/11/provider-analysis.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/streamlining-provider-profiling-with-focused-reference-data/2025-01-14T14:49:33+00:00https://medinsight.com/wp-content/uploads/2025/01/streamlining-provider-wp.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/challenges-of-childhood-burden-of-cystic-fibrosis/2025-01-22T15:11:42+00:00https://medinsight.com/wp-content/uploads/2025/01/cystic-fibrosis-wp.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/cascading-impact-of-unnecessary-or-low-value-care-services/2025-02-28T19:21:15+00:00https://medinsight.com/wp-content/uploads/2025/02/low-value-care-services-wp.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/the-importance-of-clear-provider-groupings-in-healthcare-service-analysis/2025-03-17T19:47:38+00:00https://medinsight.com/wp-content/uploads/2025/03/provider-groupings-healthcare.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/measuring-the-unseen-differentiation-in-health-system-services/2025-07-22T11:49:28+00:00https://medinsight.com/wp-content/uploads/2025/07/differentation-in-healthcare-systems.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/exploring-the-provider-landscape-in-sickle-cell-disease-through-a-gene-therapy-lens/2025-08-22T01:24:19+00:00https://medinsight.com/wp-content/uploads/2024/11/sickle-cell-wp.jpghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/measuring-how-glp-1-medications-impact-the-total-cost-of-care/2025-08-26T16:40:02+00:00https://medinsight.com/wp-content/uploads/2025/08/milliman-wp.pnghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/survey-of-provider-information-in-medical-claims-data/2025-09-28T17:50:05+00:00https://medinsight.com/wp-content/uploads/2024/01/survey-provider-information-wp-2.jpghttps://medinsight.com/healthcare-data-analytics-resources/whitepaper/diabetes-prevalence-cost-and-healthcare-resource-utilization-trend-in-the-us/2025-09-28T17:52:23+00:00https://medinsight.com/wp-content/uploads/2024/05/diabetes-cost-utilization-wp.jpg ## EHR Workflows Impact https://medinsight.com/healthcare-data-analytics-resources/research-paper/how-ehr-workflows-impact-clinician-experience-patient-care-and-profitability/2023-11-21T20:11:33+00:00https://medinsight.com/wp-content/uploads/2023/11/insiteflow-research-paper.png ## Value-Based Care Implementation [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/navigating-value-based-care-in-2025-how-to-implement-it-successfully-in-your-practice/#content) # Navigating value-based care in 2025: How to implement it successfully in your practice By Francesca Hammerstrom 13 June 2025 Print / PDF Share ![]() ## Share this page Copied Navigating value-based care in 2025: How to implement it successfully in your practice Francesca Hammerstrom The healthcare industry is changing rapidly, influenced by new regulations, higher consumer expectations, and increasing cost pressures. In addition, the Centers for Medicare & Medicaid Services (CMS) has a big goal: by 2030, all Medicare beneficiaries should be in value-based care (VBC) arrangements. This means we’re seeing a fast shift away from the traditional fee-for-service (FFS) model, where providers are paid per treatment, to VBC, where payments are based on both the quality of care and the cost. Recent data from the [2025 Milliman Medical Index](https://www.milliman.com/en/insight/2025-milliman-medical-index) highlights the urgent need to address rising costs of healthcare. In 2005, the total healthcare cost for a family of four was $12,214; by 2025, that figure has nearly tripled. This increase far out paces wage growth over the same period, with wage growth reported at 84% compared to the 188% growth within healthcare costs. Annual outpatient facility care costs have risen from $3,704 to $9,876, and yearly pharmacy expenses have soared from$1,785 to $5,954. Value-based contracts present a potential path forward, focusing on improving care quality while managing and controlling costs. In this blog, we’ll explore the journey towards VBC, highlighting its benefits and impact on the healthcare landscape. We’ll provide practical insights and actionable steps for organizations to navigate this shift, ultimately leading to better patient outcomes and financial health. ## Market forces pushing for value-based care: A growing portion of healthcare revenue is being tied to VBC, signaling a fundamental shift in the industry. [The Affordable Care Act](https://us.milliman.com/en/Health/Affordable-Care-Act) (ACA) of 2010 was instrumental in accelerating this change, introducing policies that incentivized providers to prioritize higher-quality, more coordinated care. By the late 2010s, VBC models had become increasingly prevalent across healthcare systems, reflecting a collective push toward better patient outcomes, improved care coordination, and reduced overall costs. This momentum continues to build: in 2021, 35% of Medicare Advantage (MA) and 24% of Medicare FFS spending flowed through alternative payment models (APMs). Looking ahead, 83% of payers anticipate that APM activity will increase, with none expecting a decrease. Furthermore, 96% of payers agree or strongly agree that expanding APM adoption will lead to higher-quality care and enhanced care coordination—underscoring the industry’s strong commitment to VBC as a central driver of future revenue.1 According to the 2024 annual survey by the Health Care Payment Learning & Action Network (HCPLAN), 28.5 percent of U.S. healthcare payments flowed through APM contracts that included downside financial risk, up from 24.5 percent in 2022. This figure has continued to grow in response to the rising cost of care. There are four main types of value-based payment models: ![VBC journey chart]() When talking about value-based payment models, it’s helpful to understand the Health Care Payment Learning & Action Network (LAN) framework. This framework divides payment models into four levels, but not all are truly value-based. For example, Level 1 is your typical FFS with no tie to quality, so it doesn’t really fit the value-based mold. There’s also some debate about Level 2 models, which have a limited connection to quality, and whether they should be considered value-based. The real focus tends to be on Level 3 and Level 4 models. Level 3A involves shared savings, where providers benefit if they save money, while Level 3B includes both shared savings and losses, adding more risk. Level 4 is where you find partial or full capitation, which means providers are paid a set amount per patient, and 4C emphasizes integrated care. Understanding these distinctions helps explain how VBC aims to improve patient outcomes and manage costs. ## The benefits of value-based care: VBC is transforming healthcare by offering  long-term financial and clinical benefits. For organizations transitioning to VBC, it represents an opportunity to revolutionize care delivery by focusing on medical excellence. By receiving targeted interventions or education at the point of care, patients may become more receptive, potentially leading to fewer hospital visits, reduced costs, and improved care coordination. This approach enhances patient experiences by ensuring timely, personalized care. Historically, primary care has been central to achieving these improvements, focusing on preventative measures and chronic condition management. Building on the strengths of primary care, integrating specialists into VBC models is essential for further enhancing patient outcomes. Specialty care plays a crucial role in this transformation, as it represents a significant part of healthcare spending. By involving specialists, healthcare systems can harness their expertise to manage complex conditions effectively, resulting in better treatment plans and outcomes. Coordinated care teams, comprising both primary care providers and specialists, ensure patients receive comprehensive care without delays, improving the overall efficiency and quality of healthcare delivery. On the financial front, VBC drives cost savings by streamlining operations and using data insights to eliminate waste. Enhanced data sharing and transparency, facilitated through [Electronic Health Record](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-releases-value-based-care-platform-with-advanced-ehr-integration-and-contract-management-capabilities/) (EHR) systems, provide a comprehensive view of the patient journey, helping to reduce errors, close care gaps, and minimize readmissions. Near real-time access to patient information enables effective collaboration, ensuring timely and appropriate care. Additionally, leveraging claims data is crucial for managing financial performance, as it provides insights into cost patterns and resource utilization. By analyzing this data, hospitals can identify areas for improvement, optimize billing processes, and ultimately enhance their overall financial health. Embracing VBC not only enhances patient care but also positions organizations for sustainable financial success. By integrating specialists into VBC models, healthcare organizations improve care quality and efficiency, setting the stage for improved population health and financial stability. ## Challenges in transitioning to value-based care: Transitioning to VBC is like embarking on a new adventure for healthcare organizations, and it comes with its own set of challenges. ### Financial Risks: - Moving away from FFS to VBC payments introduces financial uncertainty. - Payments are tied to achieving specific health outcomes, requiring careful financial planning. - Organizations must manage finances carefully to ensure stability during the transition. ### Operational Changes: - Providers need to redesign care delivery processes and train staff in new coordination methods. - This shift demands a cultural change, prioritizing patient outcomes over service volume. - Changes can disrupt established workflows, necessitating strong leadership and clear communication. - VBC programs are subject to policy changes that need to be navigated to ensure financial success. Providers must stay informed and adapt to regulatory shifts to maintain viability. ### Data and technology requirements: - Organizations must invest in modern technology and analytics solutions. - These systems are essential for tracking patient data and guiding clinical decisions. - Integrating new technology requires significant investment and expertise for seamless operation. Facing these challenges head-on is key for organizations wanting to thrive in a VBC world. Success requires strategic planning, innovation, and a commitment to continuous improvement. ## Steps to implement value-based care: Implementing VBC requires strategic planning and execution to ensure improved patient outcomes while effectively managing costs. The process begins with a thorough assessment of the current healthcare system to identify opportunities for enhancing care delivery and financial models. Based on this assessment, a strategic plan should be developed, setting clear objectives and outlining a roadmap for transitioning to a value-based model. Investment in technology and [digital transformation](https://medinsight.com/healthcare-data-analytics-resources/blog/milliman-medinsight-perspective-driving-digital-transformation-in-health-plans/) is critical, as many healthcare systems currently operate in fragmented data environments. Organizations should adopt modern data management and advanced analytics technologies as part of their digital transformation strategies to integrate systems seamlessly and support effective change management. Building a collaborative team is another vital step. Providers must take responsibility for patient outcomes and costs, often assuming greater risk in advanced models. This necessitates effective collaboration with payer partners and proactive data sharing to ensure accountability for meeting cost and quality targets, which directly impact reimbursements. Finally, continuous monitoring and adjustment are necessary to ensure the success of the VBC model. This ongoing process allows organizations to refine strategies and achieve improved outcomes over time. ## What it means to take on risk in value-based care Taking on risk in VBC signifies a transformative shift in healthcare, where providers are financially accountable for the quality and efficiency of the care they deliver. This approach involves various risk models: **Upside Risk Models**: Providers earn a share of the savings when they reduce healthcare costs but face no financial penalties if they don’t achieve savings. **Downside Risk Models**: Providers must cover excess costs if expenses exceed targets, encouraging them to manage resources efficiently to avoid financial losses. **Full-Risk Models**: Providers share in savings if they reduce costs and incur penalties if costs exceed targets, balancing the incentives to improve care quality and efficiency. To successfully navigate these risk models, healthcare organizations must employ effective risk management strategies such as: - Leveraging data-driven decision-making to identify trends and opportunities. - Enhancing care coordination to ensure seamless patient transitions and reduce inefficiencies. - Adopting evidence-based practices to improve patient outcomes consistently. Milliman MedInsight offers a suite of innovative solutions to support providers in this complex landscape: - [**VBC Platform**](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/): Acts as a comprehensive hub for managing VBC. For example, a hospital can use the platform to centralize patient data, streamline care coordination, and track performance metrics in real-time. - [**VBC Insights**](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/insights/): Provides actionable intelligence to help providers understand their performance and identify areas for improvement. This might include pinpointing inefficiencies in care delivery or identifying trends in patient outcomes. - **VBC Analytics**: Offers advanced data analysis capabilities, enabling providers to forecast future trends, assess risk levels, and optimize resource allocation. An accountable care organization (ACO) can use these analytics to predict which patient populations are most likely to benefit from specific interventions, thereby improving outcomes and reducing costs. - [**VBC Contracts**](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/contracts/): Facilitates the structuring of agreements that align financial incentives with desired health outcomes, ensuring that all stakeholders are working towards common goals. - [**Innovation Portal**](https://medinsight.com/healthcare-data-analytics-software/applications/data-science-portal/) **– Powered by** [**Databricks**](https://www.databricks.com/): Enables advanced data analysis using R, Python, and SQL, allowing super-users to gain deep insights. It integrates diverse data sources for comprehensive reporting and offers an intuitive interface for both technical and non-technical users, promoting data-driven decision-making organization-wide. With Artificial Intelligence (AI) and Machine Learning (ML) capabilities, the portal enhances predictive analytics and automates complex data processes, enabling users to discover hidden patterns and trends for strategic advantages. Together these capabilities empower healthcare organizations to manage risk more effectively, enhance patient care, and achieve sustainable financial success in a VBC environment. With Milliman MedInsight tools, providers can confidently navigate the complexities of VBC, ensuring they not only meet but exceed the expectations of both patients and payers. ## Embrace the future of healthcare with value-based care The shift to VBC marks a significant evolution in the U.S. healthcare system, emphasizing improved patient outcomes and operational efficiency. While transitioning from a FFS model presents challenges, it also offers substantial benefits, including enhanced patient experiences and reduced costs. Now is the time to embrace VBC and redefine your approach to healthcare delivery. With Milliman MedInsight, you can confidently manage the complexities of this transition, ensuring better care for patients and sustainable financial success for your organization. For more information on how Milliman MedInsight can support your journey, visit our [website](https://medinsight.com/) to explore [client testimonials](https://medinsight.com/healthcare-data-analytics-resources/client-testimonials/), or [contact us directly](https://medinsight.com/get-a-demo/). Let’s work together to create a healthier, more efficient healthcare system. ## References 1\. Health Care Payment Learning and Action Network (HCPLAN) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ## Explore more tags from this article [healthcare analytics](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-analytics/), [healthcare data analytics](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-data-analytics/), [value-based care](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/value-based-care/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Healthcare Case Studies https://medinsight.com/healthcare-data-analytics-resources/case-study/measuring-waste-to-improve-care/2024-05-14T18:38:45+00:00https://medinsight.com/wp-content/uploads/2023/07/virgina-health-case-study.jpghttps://medinsight.com/healthcare-data-analytics-resources/case-study/advanced-health/2025-07-01T20:54:45+00:00https://medinsight.com/wp-content/uploads/2024/01/advanced-health-cs.jpghttps://medinsight.com/healthcare-data-analytics-resources/case-study/cfin/2025-07-01T20:55:36+00:00https://medinsight.com/wp-content/uploads/2024/02/cfin-case-study.jpghttps://medinsight.com/healthcare-data-analytics-resources/case-study/from-insight-to-impact/2025-07-01T20:56:24+00:00https://medinsight.com/wp-content/uploads/2023/07/atrio-case-study.jpghttps://medinsight.com/healthcare-data-analytics-resources/case-study/improve-patient-outcomes/2025-07-01T20:57:29+00:00https://medinsight.com/wp-content/uploads/2023/09/non-profit-case-study.jpghttps://medinsight.com/healthcare-data-analytics-resources/case-study/independent-health/2025-07-01T20:58:28+00:00https://medinsight.com/wp-content/uploads/2025/01/independent-health-case-study.jpghttps://medinsight.com/healthcare-data-analytics-resources/case-study/genesys-pho/2025-08-01T17:55:59+00:00https://medinsight.com/wp-content/uploads/2025/02/genesys-pho-case-study-1.pnghttps://medinsight.com/wp-content/uploads/2025/02/genesys-pho-graphic-resized.pnghttps://medinsight.com/healthcare-data-analytics-resources/case-study/power-of-data-organization-and-standardization/2025-08-16T16:36:54+00:00https://medinsight.com/wp-content/uploads/2023/09/case-studies.jpghttps://medinsight.com/healthcare-data-analytics-resources/case-study/sehp/2025-09-02T23:11:25+00:00https://medinsight.com/wp-content/uploads/2023/09/webinars.jpg ## Health Waste Insights https://medinsight.com/healthcare-data-analytics-resources/blog/health-waste-measure/vitamin-d-deficiency/2024-01-10T15:57:17+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/health-waste-measure/ekg/2024-01-09T17:15:35+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/health-waste-measure/imaging/2024-01-19T16:56:00+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/health-waste-measure/inappropriate-opioid-prescription/2024-01-18T19:10:51+00:00https://medinsight.com/healthcare-data-analytics-resources/blog/health-waste-measure/psa/2024-01-19T15:42:06+00:00 ## Value-Based Care Contracts [Skip to the content](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/contracts/#content) # Value-Based Care Contracts ### Optimize contract performance and profits [Download the brochure](https://medinsight.com/wp-content/uploads/2025/09/medinsight-vbc-contracts-brochure.pdf) Healthcare is undergoing a significant shift from a volume-based model to one focused on value. New cost of care and reimbursement models mean organizations must think more strategically about their value-based contracts, including their partners in risk sharing and overall performance. Effective financial success in the accountable care environment now hinges on providers’ ability to manage revenue and risk differently than they ever have before. The right insights and data are required to enable accountable care organizations (ACOs) and health systems to make the best decisions possible to secure effective reimbursement and remain competitive in an evolving landscape. The MedInsight® Value-Based Care (VBC) Contracts application provides ACOs, health systems, and independent physician associations (IPAs) with a full view of their financial performance across different types of VBC agreements. Interactive dashboards enable users to accurately model the potential success of each contract, set individual targets, and monitor their progress over time. With VBC Contracts, your organization can benefit from the following capabilities to monitor revenue and manage risk: ![Maximize Profitability](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/profit-spring.svg) #### Maximize profitability Gain insight into your organization’s financial health and identify areas to increase revenue generation with a clearer understanding of total assigned beneficiaries, revenue, and overall at-risk expenditures. ![Data Confidence](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/advanced-workflow-spring.svg) #### Rock-solid data confidence Leverage a reliable and accurate application that draws from trusted Milliman methodologies and extensive experience in loading Medicare CCLF data feeds, as well as commercial/Medicaid data feeds. ![Data Value](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/source/rev-eca805e/medinsight.com/wp-content/themes/blankslate-child/assets/images/patient-management-spring.svg) #### Holistic population views & risk-unit level detail View key risk contract inputs like membership, risk score, claims, and target at the ACO or individual provider level. Monitor performance to ensure savings and losses are distributed more equitably among all participating providers. ![Cost Projections]() #### Comprehensive projections Calculate and compare the performance of settlements for past, present, and future years. Our tool uses a variety of robust actuarial techniques to perform settlement projections for an ACOs risk arrangements throughout the life of the contract. ![Interactive Cost Modeling]() #### Interactive modeling Model impacts to expenditures and targets to see how changes could impact settlement revenue from commercial, Medicare Advantage, Medicare FFS, and Medicaid risk contracts. Set up scenarios based on user input and export them into Excel for further analysis. ### VBC Contracts in action ## Contracts dashboards ![VBC Contracts Dashboard]() ![VBC Contracts Dashboard]() ### Improve contract and cost management Gain a centralized view of all total cost of care (TCOC) value-based contracts for ACOs and take your analysis to the next level by comparing performance at the risk unit level. Whether it’s a provider group, region, TIN, or any other risk unit, Milliman’s robust actuarial methodology empowers your organizations to project savings or losses for the current performance year and identify additional opportunities for optimization. ### Optimize efficiencies and outcomes Leverage a single source of truth that aligns payer and provider data and eliminates manual modeling. Access multiple years’ worth of data effortlessly, allowing your organization to analyze trends, identify areas for improvement and make data-driven decisions. Stay ahead of the competition with more reliable data management and reporting capabilities. ### Increase performance and profitability Access a wealth of historical data to make informed decisions that optimize your overall performance. Create projection scenarios and explore potential savings or losses for the current performance year. With comprehensive insights, you can make strategic decisions to maximize your financial outcomes. ## Use cases: Payer & provider #### Provider ![Financial Performance Management]() #### Financial performance management & settlement forecasting Gain insights into big-picture financial performance using actuarial methodologies and compare current year projections to previous years ![Advanced Contract Management]() #### Advanced contract management Optimize financial performance across alternative payment agreements and compare contract payments to actual costs ![Increased Operational Efficiency]() #### Increased operational efficiency Develop various scenarios accessible to all team members, featuring detailed settlement and risk information, with the option to export to Excel for further custom modeling #### Payer ![Standardized Reporting & Transparency]() #### Standardized reporting & transparency Deliver top-quality, standardized reporting to provider partners, eliminating the need for in-house development ![Unified Performance Monitoring & Insights]() #### Unified performance monitoring & insights Access comprehensive performance insights for various contract types and providers, all in one convenient location ![Accurate Financial Reconciliation]() #### Accurate financial reconciliation Efficiently determine year-end settlement values to streamline your financial reconciliations ### Learn how MedInsight VBC Contracts can help your company [Schedule a demo](https://medinsight.com/healthcare-data-analytics-contact/) ## Relevant resources ![](https://medinsight.com/wp-content/themes/blankslate-child/assets/images/arrow-right-long-dark.svg) [![MedInsight Healthcare Data Analytics Blog]()](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [Post\\ **The right data for every model of value-based care contracting**](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [How MedInsight Supports Organizations on the Glide Path to Risk For healthcare provider organizations navigating the array of alternative payment models in use across all phases of value-based care contracting, the complexity can be daunting. From small physician groups operating on a largely fee-for-service basis to health plans managing the claims of tens of thousands](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [… The right data for every model of value-based care contracting](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [View the \\ Post](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [![MedInsight Healthcare Data Analytics Blog]()](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [Post\\ **Reducing risk to drive VBC success for ACOs**](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [As value-base care (VBC) progresses, accountable care organizations (ACOs) face a significant challenge in balancing the quality of care and financial outcomes while taking on increasing financial risk. This task becomes even more difficult without a comprehensive understanding of patient populations and overall performance, making it challenging to sustain value-based care effectively. ACOs typically have](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [… Reducing risk to drive VBC success for ACOs](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [View the \\ Post](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [![MedInsight Healthcare Data Analytics Blog]()](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) [Post\\ **Reporting Framework for Value Based Care**](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) [As the cost of healthcare continues to rise, both payers and providers continue the “triple aim” of delivering effective quality care while managing their costs. Value based care (VBC), or value based reimbursements, has emerged as an effective mechanism for achieving this goal. In fact, based on estimates developed by National Business Group on Health,](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) [… Reporting Framework for Value Based Care](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) [View the \\ Post](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) [![VBC Digital Transformation eBook]()](https://medinsight.com/healthcare-data-analytics-resources/ebook/how-digital-transformation-drives-value-based-care/) [eBook\\ **How digital transformation drives value-based care**](https://medinsight.com/healthcare-data-analytics-resources/ebook/how-digital-transformation-drives-value-based-care/) [As the transition to value-based care continues to accelerate, health plans are driven to deliver value-centric services through digital transformation. This can facilitate a more connected ecosystem for building greater transparency, trust, and interoperability. In this ebook, learn about how digital transformation can be beneficial for value-based care and how MedInsight can help you with](https://medinsight.com/healthcare-data-analytics-resources/ebook/how-digital-transformation-drives-value-based-care/) [… How digital transformation drives value-based care](https://medinsight.com/healthcare-data-analytics-resources/ebook/how-digital-transformation-drives-value-based-care/) [View the \\ eBook](https://medinsight.com/healthcare-data-analytics-resources/ebook/how-digital-transformation-drives-value-based-care/) [![MedInsight Healthcare Data Analytics Blog]()](https://medinsight.com/healthcare-data-analytics-resources/blog/2024-outlook-five-key-analytic-capabilities-shaping-vbc/) [Post\\ **2024 Outlook: Five key analytic capabilities shaping VBC**](https://medinsight.com/healthcare-data-analytics-resources/blog/2024-outlook-five-key-analytic-capabilities-shaping-vbc/) [The healthcare industry is undergoing a transformation, largely driven by value-based care (VBC), artificial intelligence (AI), and digital transformation. These trends, which gained significant momentum in 2023, will continue to shape the healthcare industry in 2024 and beyond. As organizations aim to improve efficiencies and the delivery of care, the increasing use of analytics emerges](https://medinsight.com/healthcare-data-analytics-resources/blog/2024-outlook-five-key-analytic-capabilities-shaping-vbc/) [… 2024 Outlook: Five key analytic capabilities shaping VBC](https://medinsight.com/healthcare-data-analytics-resources/blog/2024-outlook-five-key-analytic-capabilities-shaping-vbc/) [View the \\ Post](https://medinsight.com/healthcare-data-analytics-resources/blog/2024-outlook-five-key-analytic-capabilities-shaping-vbc/) [![MedInsight VBC eBook]()](https://medinsight.com/healthcare-data-analytics-resources/ebook/value-based-care-best-practices-for-mitigating-risk/) [eBook\\ **Leading the way in value-based care: Best practices for mitigating risk**](https://medinsight.com/healthcare-data-analytics-resources/ebook/value-based-care-best-practices-for-mitigating-risk/) [The healthcare landscape is rapidly evolving to one in which value and accountable care are the predominant measures for delivering high-quality, affordable care. It is an evolution that has been underway for more than a decade, but recent years – and the demands of an aging population – have brought transformation at a rapidly growing](https://medinsight.com/healthcare-data-analytics-resources/ebook/value-based-care-best-practices-for-mitigating-risk/) [… Leading the way in value-based care: Best practices for mitigating risk](https://medinsight.com/healthcare-data-analytics-resources/ebook/value-based-care-best-practices-for-mitigating-risk/) [View the \\ eBook](https://medinsight.com/healthcare-data-analytics-resources/ebook/value-based-care-best-practices-for-mitigating-risk/) [![Bundles]()\\ \\ Brochure\\ \\ **Bundles**\\ \\ The MedInsight Bundles application offers organizations participating in bundled payment programs the insights they need to efficiently manage the payment models implemented by the Center for Medicare and Medicaid Innovation (CMMI).](https://medinsight.com/wp-content/uploads/2025/09/medinsight-bundles-brochure.pdf) [View the \\ Brochure](https://medinsight.com/wp-content/uploads/2025/09/medinsight-bundles-brochure.pdf) [![Data Science Portal]()\\ \\ Brochure\\ \\ **Innovation Portal**\\ \\ You can quickly perform complex data modeling and analysis instead of collecting, cleaning and organizing an increasing amount of claims data from a multitude of sources with MedInsight’s AI application, the Innovation Portal.](https://medinsight.com/wp-content/uploads/2025/09/milliman-medinsight-innovation-portal-brochure.pdf) [View the \\ Brochure](https://medinsight.com/wp-content/uploads/2025/09/milliman-medinsight-innovation-portal-brochure.pdf) [![VBC Contracts]()\\ \\ Brochure\\ \\ **VBC Contracts**\\ \\ The MedInsight® Value-Based Care (VBC) Contracts application provides ACOs, health systems, and independent physician associations (IPAs) with a full view of their financial performance across different types of VBC agreements.](https://medinsight.com/wp-content/uploads/2025/09/medinsight-vbc-contracts-brochure.pdf) [View the \\ Brochure](https://medinsight.com/wp-content/uploads/2025/09/medinsight-vbc-contracts-brochure.pdf) [![MedInsight VBC Platform]()\\ \\ Brochure\\ \\ **VBC Platform**\\ \\ The MedInsight® VBC Platform is designed to support Accountable Care Organizations (ACOs) focusing on VBC by delivering the insights you need, when you need them.](https://medinsight.com/wp-content/uploads/2025/09/medinsight-vbc-platform-brochure.pdf) [View the \\ Brochure](https://medinsight.com/wp-content/uploads/2025/09/medinsight-vbc-platform-brochure.pdf) [![VBC Insights]()\\ \\ Brochure\\ \\ **VBC Insights**\\ \\ With VBC Insights, included in MedInsight’s Value-Based Care Platform, users can effortlessly track utilization trends over time and dive into individual patient cohorts to uncover cost-saving opportunities.](https://medinsight.com/wp-content/uploads/2025/09/medinsight-vbc-insights-brochure.pdf) [View the \\ Brochure](https://medinsight.com/wp-content/uploads/2025/09/medinsight-vbc-insights-brochure.pdf) [![MedInsight Healthcare Data Analytics Blog]()](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [Post\\ **The right data for every model of value-based care contracting**](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [How MedInsight Supports Organizations on the Glide Path to Risk For healthcare provider organizations navigating the array of alternative payment models in use across all phases of value-based care contracting, the complexity can be daunting. From small physician groups operating on a largely fee-for-service basis to health plans managing the claims of tens of thousands](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [… The right data for every model of value-based care contracting](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [View the \\ Post](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [![MedInsight Healthcare Data Analytics Blog]()](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [Post\\ **Reducing risk to drive VBC success for ACOs**](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [As value-base care (VBC) progresses, accountable care organizations (ACOs) face a significant challenge in balancing the quality of care and financial outcomes while taking on increasing financial risk. This task becomes even more difficult without a comprehensive understanding of patient populations and overall performance, making it challenging to sustain value-based care effectively. ACOs typically have](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [… Reducing risk to drive VBC success for ACOs](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [View the \\ Post](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [![MedInsight Healthcare Data Analytics Blog]()](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) [Post\\ **Reporting Framework for Value Based Care**](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) [As the cost of healthcare continues to rise, both payers and providers continue the “triple aim” of delivering effective quality care while managing their costs. Value based care (VBC), or value based reimbursements, has emerged as an effective mechanism for achieving this goal. In fact, based on estimates developed by National Business Group on Health,](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) [… Reporting Framework for Value Based Care](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) [View the \\ Post](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) [![VBC Digital Transformation eBook]()](https://medinsight.com/healthcare-data-analytics-resources/ebook/how-digital-transformation-drives-value-based-care/) [eBook\\ **How digital transformation drives value-based care**](https://medinsight.com/healthcare-data-analytics-resources/ebook/how-digital-transformation-drives-value-based-care/) [As the transition to value-based care continues to accelerate, health plans are driven to deliver value-centric services through digital transformation. This can facilitate a more connected ecosystem for building greater transparency, trust, and interoperability. In this ebook, learn about how digital transformation can be beneficial for value-based care and how MedInsight can help you with](https://medinsight.com/healthcare-data-analytics-resources/ebook/how-digital-transformation-drives-value-based-care/) [… How digital transformation drives value-based care](https://medinsight.com/healthcare-data-analytics-resources/ebook/how-digital-transformation-drives-value-based-care/) [View the \\ eBook](https://medinsight.com/healthcare-data-analytics-resources/ebook/how-digital-transformation-drives-value-based-care/) [![MedInsight Healthcare Data Analytics Blog]()](https://medinsight.com/healthcare-data-analytics-resources/blog/2024-outlook-five-key-analytic-capabilities-shaping-vbc/) [Post\\ **2024 Outlook: Five key analytic capabilities shaping VBC**](https://medinsight.com/healthcare-data-analytics-resources/blog/2024-outlook-five-key-analytic-capabilities-shaping-vbc/) [The healthcare industry is undergoing a transformation, largely driven by value-based care (VBC), artificial intelligence (AI), and digital transformation. These trends, which gained significant momentum in 2023, will continue to shape the healthcare industry in 2024 and beyond. As organizations aim to improve efficiencies and the delivery of care, the increasing use of analytics emerges](https://medinsight.com/healthcare-data-analytics-resources/blog/2024-outlook-five-key-analytic-capabilities-shaping-vbc/) [… 2024 Outlook: Five key analytic capabilities shaping VBC](https://medinsight.com/healthcare-data-analytics-resources/blog/2024-outlook-five-key-analytic-capabilities-shaping-vbc/) [View the \\ Post](https://medinsight.com/healthcare-data-analytics-resources/blog/2024-outlook-five-key-analytic-capabilities-shaping-vbc/) [![MedInsight VBC eBook]()](https://medinsight.com/healthcare-data-analytics-resources/ebook/value-based-care-best-practices-for-mitigating-risk/) [eBook\\ **Leading the way in value-based care: Best practices for mitigating risk**](https://medinsight.com/healthcare-data-analytics-resources/ebook/value-based-care-best-practices-for-mitigating-risk/) [The healthcare landscape is rapidly evolving to one in which value and accountable care are the predominant measures for delivering high-quality, affordable care. It is an evolution that has been underway for more than a decade, but recent years – and the demands of an aging population – have brought transformation at a rapidly growing](https://medinsight.com/healthcare-data-analytics-resources/ebook/value-based-care-best-practices-for-mitigating-risk/) [… Leading the way in value-based care: Best practices for mitigating risk](https://medinsight.com/healthcare-data-analytics-resources/ebook/value-based-care-best-practices-for-mitigating-risk/) [View the \\ eBook](https://medinsight.com/healthcare-data-analytics-resources/ebook/value-based-care-best-practices-for-mitigating-risk/) [![Bundles]()\\ \\ Brochure\\ \\ **Bundles**\\ \\ The MedInsight Bundles application offers organizations participating in bundled payment programs the insights they need to efficiently manage the payment models implemented by the Center for Medicare and Medicaid Innovation (CMMI).](https://medinsight.com/wp-content/uploads/2025/09/medinsight-bundles-brochure.pdf) [View the \\ Brochure](https://medinsight.com/wp-content/uploads/2025/09/medinsight-bundles-brochure.pdf) [![Data Science Portal]()\\ \\ Brochure\\ \\ **Innovation Portal**\\ \\ You can quickly perform complex data modeling and analysis instead of collecting, cleaning and organizing an increasing amount of claims data from a multitude of sources with MedInsight’s AI application, the Innovation Portal.](https://medinsight.com/wp-content/uploads/2025/09/milliman-medinsight-innovation-portal-brochure.pdf) [View the \\ Brochure](https://medinsight.com/wp-content/uploads/2025/09/milliman-medinsight-innovation-portal-brochure.pdf) [![VBC Contracts]()\\ \\ Brochure\\ \\ **VBC Contracts**\\ \\ The MedInsight® Value-Based Care (VBC) Contracts application provides ACOs, health systems, and independent physician associations (IPAs) with a full view of their financial performance across different types of VBC agreements.](https://medinsight.com/wp-content/uploads/2025/09/medinsight-vbc-contracts-brochure.pdf) [View the \\ Brochure](https://medinsight.com/wp-content/uploads/2025/09/medinsight-vbc-contracts-brochure.pdf) [![MedInsight VBC Platform]()\\ \\ Brochure\\ \\ **VBC Platform**\\ \\ The MedInsight® VBC Platform is designed to support Accountable Care Organizations (ACOs) focusing on VBC by delivering the insights you need, when you need them.](https://medinsight.com/wp-content/uploads/2025/09/medinsight-vbc-platform-brochure.pdf) [View the \\ Brochure](https://medinsight.com/wp-content/uploads/2025/09/medinsight-vbc-platform-brochure.pdf) [![VBC Insights]()\\ \\ Brochure\\ \\ **VBC Insights**\\ \\ With VBC Insights, included in MedInsight’s Value-Based Care Platform, users can effortlessly track utilization trends over time and dive into individual patient cohorts to uncover cost-saving opportunities.](https://medinsight.com/wp-content/uploads/2025/09/medinsight-vbc-insights-brochure.pdf) [View the \\ Brochure](https://medinsight.com/wp-content/uploads/2025/09/medinsight-vbc-insights-brochure.pdf) [![MedInsight Healthcare Data Analytics Blog]()](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [Post\\ **The right data for every model of value-based care contracting**](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [How MedInsight Supports Organizations on the Glide Path to Risk For healthcare provider organizations navigating the array of alternative payment models in use across all phases of value-based care contracting, the complexity can be daunting. From small physician groups operating on a largely fee-for-service basis to health plans managing the claims of tens of thousands](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [… The right data for every model of value-based care contracting](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [View the \\ Post](https://medinsight.com/healthcare-data-analytics-resources/blog/the-right-data-for-every-model-of-value-based-care-contracting/) [![MedInsight Healthcare Data Analytics Blog]()](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [Post\\ **Reducing risk to drive VBC success for ACOs**](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [As value-base care (VBC) progresses, accountable care organizations (ACOs) face a significant challenge in balancing the quality of care and financial outcomes while taking on increasing financial risk. This task becomes even more difficult without a comprehensive understanding of patient populations and overall performance, making it challenging to sustain value-based care effectively. ACOs typically have](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [… Reducing risk to drive VBC success for ACOs](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [View the \\ Post](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-risk-to-drive-vbc-success-for-acos/) [![MedInsight Healthcare Data Analytics Blog]()](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) [Post\\ **Reporting Framework for Value Based Care**](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) [As the cost of healthcare continues to rise, both payers and providers continue the “triple aim” of delivering effective quality care while managing their costs. Value based care (VBC), or value based reimbursements, has emerged as an effective mechanism for achieving this goal. In fact, based on estimates developed by National Business Group on Health,](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) [… Reporting Framework for Value Based Care](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) [View the \\ Post](https://medinsight.com/healthcare-data-analytics-resources/blog/reporting-framework-for-value-based-care/) ![](https://medinsight.com/wp-content/themes/blankslate-child/assets/images/arrow-right-long-dark.svg) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## CMS 2025 RADV Audits [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/cms-2025-radv-audit-expansion-key-changes-and-what-they-mean-to-ma-plans/#content) # CMS 2025 RADV audit expansion: Key changes and what they mean to MA plans By Marcos Dachary, Chief Market Strategist and General Manager of Payer Solutions, MedInsight 23 July 2025 Print / PDF Share ![]() ## Share this page Copied CMS 2025 RADV audit expansion: Key changes and what they mean to MA plans Marcos Dachary, Chief Market Strategist and General Manager of Payer Solutions, MedInsight In a significant move announced on May 21, 2025, the Centers for Medicare & Medicaid Services (CMS) revealed plans to initiate annual Risk Adjustment Data Validation (RADV) [audits for all Medicare Advantage (MA) plans](https://www.cms.gov/newsroom/press-releases/cms-rolls-out-aggressive-strategy-enhance-and-accelerate-medicare-advantage-audits). In this memo, CMS Administrator, Dr. Mehmet Oz, is quoted as saying “We are committed to crushing fraud, waste and abuse across all federal healthcare programs” and goes on to say, “While the Administration values the work that Medicare Advantage plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately for the coverage they provide to Medicare patients.”  This initiative will also address the backlog of audits from 2018 to 2024, with a targeted completion by early 2026. The RADV audits are designed to verify risk adjustment data, ensuring that the diagnoses submitted by MA plans for risk adjustment payments are supported by medical records. Leveraging advanced technology, CMS will expand its audit coverage from about 60 MA plans annually to encompass all eligible MA plans—approximately 550 plans each year. Furthermore, the number of records audited per health plan will increase substantially, ranging from 35 to as many as 200 records annually based on the size of the plan.  Although much remains to be seen about the roll-out timing of these new regulations, Medicare Advantage plans should be preparing for their implementation now.  To help organizations prepare for these changes, we will cover the following topics: 1. [The significance of expanding RADV audits](https://medinsight.com/healthcare-data-analytics-resources/blog/cms-2025-radv-audit-expansion-key-changes-and-what-they-mean-to-ma-plans/#radv) 2. [Maximizing efficiency in MA risk adjustment documentation](https://medinsight.com/healthcare-data-analytics-resources/blog/cms-2025-radv-audit-expansion-key-changes-and-what-they-mean-to-ma-plans/#efficiency) 3. [Understanding key deadlines for submission for payment years (2018 – 2024)](https://medinsight.com/healthcare-data-analytics-resources/blog/cms-2025-radv-audit-expansion-key-changes-and-what-they-mean-to-ma-plans/#deadlines) 4. [How Milliman MedInsight can support your organization](https://medinsight.com/healthcare-data-analytics-resources/blog/cms-2025-radv-audit-expansion-key-changes-and-what-they-mean-to-ma-plans/#support) 5. [Where to find additional resources](https://medinsight.com/healthcare-data-analytics-resources/blog/cms-2025-radv-audit-expansion-key-changes-and-what-they-mean-to-ma-plans/#guidance) ## 1\. The significance of expanding RADV audits CMS’s announcement represents a bold step in enforcing RADV recoveries, a decision that could bring considerable financial consequences for MA plans.  Facing payments ranging from thousands of dollars up to $600,000 or more for each unsubstantiated Hierarchical Condition Category (HCC) (under certain scenarios for a moderately-sized health plan) MA plans are now under pressure to ensure their submitted diagnoses are backed by medical record documentation. This move represents a significant shift towards stricter oversight and accountability within the Medicare Advantage landscape. MA organizations must prepare for more rigorous RADV audits, which may necessitate revamping their internal processes to meet CMS’s elevated standards. This could mean investing in advanced data management systems, enhancing staff training, and implementing tighter compliance protocols to guarantee that all diagnoses are thoroughly documented and validated. The impact of CMS’s approach will be closely watched by stakeholders across the healthcare sector, from providers to financial analysts, as they assess how these changes will affect the operational and financial dynamics of MA plans. The newly reestablished urgency on MA RADV presents a challenge for MA organizations to adapt swiftly and effectively, ensuring compliance and minimizing financial risks. These developments mark a pivotal moment in the industry, as all eyes turn to see how MA plans will navigate this new landscape and what it means for the future of healthcare accountability. ## 2\. Maximizing efficiency in MA risk adjustment documentation To address the backlog of audits, CMS plans to implement advanced systems to improve the review of medical records and efficiently pinpoint diagnoses that might be questionable or unsupported. This technological upgrade aims to streamline the audit process, enhancing accuracy and accountability in validating risk adjustment data submitted by MA plans. Given the CMS goal of completing all the backlog of PY 2018 – PY 2024 by early 2026, plans should prepare for the increased workload. While exact details of the upcoming RADVs and the advanced systems that would support this work are not yet known, our experience tells us that the workload for a single PY RADV is approximately as follows: - **Sample sizes**: Sample sizes are 35 to 200 members based on health plan size. - **HCCs requiring substantiation**: Approximately 200 to 650 HCCs will need to be validated. - **Medical records to collect**: Around 2,000 medical records will need to be collected and reviewed. - **Locations to contact**: You will need to reach out to approximately 300 to 400 healthcare facilities for record requests. - **Attestations**: Collection of between 150 to 600 medical attestations to correct any medical record signature issues. - **Provider office calls**: Anticipate making 2,000 to 3,000 calls to provider offices for record collection, follow up and attestation collection. Note, the number of locations depends on how centralized the provider network is for each plan, so it will vary. However, it should increase in a roughly linear way as more members are added to a plan audit. Attestation needs can change year to year, but generally, older records and longer inpatient hospital records require more attestations. As a result, effective collection of all risk-adjustable records is crucial for MA plans, even in instances where an HCC related ICD-10s did not appear on the initial claim. Collecting such records through an end-to-end risk adjustment solution can offer vital support to organizations with limited resources, particularly when other primary documentation is incomplete or unavailable. ![RADV audit graphic]() The first step for conducting RADV audits effectively is a claim analysis to identify all risk-adjustable visits and determine which provider locations will be included in outreach efforts. This analysis will also establish a minimum set of records that should be expected from each provider as well as the HCCs that should be represented in each record. To ensure the accuracy and completeness of submissions, it is advisable to pre-screen and review records thoroughly. This step is especially important for long inpatient stays where multiple physicians may have been involved. Addressing any missing information upfront can prevent potential issues down the line. Moreover, obtaining attestations for potential signature discrepancies is essential to avoid losing credit for HCCs. It’s also important to ensure that your systems are equipped to handle years with split HCC models effectively. In cases where hardship requests are necessary, submit them early with comprehensive details, as these are typically approved only in extreme situations. Lastly, establishing a robust system for quickly analyzing RADV feedback from CMS is crucial. This will enable you to home in on discrepancies and make informed decisions about which items to prioritize. By focusing on these areas, Medicare Advantage plans can enhance their risk adjustment processes and ensure more accurate and efficient fund allocation. ## 3\. Understanding key deadlines for submission for payment years (2018 – 2024) CMS is accelerating RADV audit activities for Payment Years (PYs) 2018 through 2024. As a result, MA plans must act quickly to meet deadlines for submitting corrections to risk adjustment data—particularly closed period deletions. For this reason, CMS has issued formal notifications to various health plans, detailing revised deadlines for processing deletions related to ICD-10 and HCC codes. Meeting these updated deadlines is essential to ensure all necessary corrections are made before CMS begins selecting samples for review or analysis. ### Table 1 The deadlines for submitting all closed period deletes for these samples are listed in the table below1: | Payment Year | Relevant CMS System | Dates of Service | RA Data Submission for RADV Sampling deadline | | --- | --- | --- | --- | | 2020 | RAPS/ EDPS | Jan 1, 2019 – Dec 31, 2019 | June 16, 2025 | | 2021 | RAPS/ EDPS | Jan 1, 2020 – Dec 31, 2020 | June 23, 2025 | | 2022 | EDPS | Jan 1, 2021 – Dec 31, 2021 | June 30, 2025 | | 2023 | EDPS | Jan 1, 2022 – Dec 31, 2022 | July 8, 2025 | | 2024 | EDPS | Jan 1, 2023 – Dec 31, 2023 | July 15, 2025 | ## 4\. How Milliman MedInsight can support your organization The [Milliman MedInsight® Risk Adjustment Platform](https://medinsight.com/healthcare-data-analytics-software/platform/risk-adjustment/) offers a comprehensive suite of tools and services designed to optimize the risk adjustment process for healthcare organizations. Key benefits include enhanced data accuracy and integrity, enabling organizations to effectively identify and manage high-risk patient populations using proven benchmarks and on-demand clinical support. Supported by a team of seasoned RADV specialists with expertise in managing MA audits since 2011 and Affordable Care Act (ACA) audits since 2014, our platform is purpose-built to fulfill RADV requirements, guaranteeing smooth and efficient audit processes. In addition, our full-time, on-shore, Registered Nurse-certified coders excel at finding the strongest support for your HCCs, while our administrative staff, with years of experience, ensures all details are handled correctly. We have developed effective strategies to collect even the most challenging records, knowing that every record is crucial for your audit success. If you need assistance navigating the RADV audit process, ensuring compliance, and optimizing your outcomes, the Milliman MedInsight team is here to help. ## 5\. Where to find additional resources ![Call icon]() **Schedule a call:** [Connect](https://medinsight.com/healthcare-data-analytics-contact/) with one of our healthcare analytics experts. ![Website icon]() **Visit our website:** [Learn](https://medinsight.com/healthcare-data-analytics-software/platform/risk-adjustment/) more about our Risk Adjustment Platform offering. ![Webinar icon]() **Watch the webinar:** [Explore](https://medinsight.com/healthcare-data-analytics-resources/webinar/integrated-risk-adjustment-solutions-enhancing-reimbursement-and-patient-care/) how the right risk adjustment solutions can optimize risk adjustment, RADV audits, and HEDIS gap closure. ## References 1\. [Deadlines for the Submission of Risk Adjustment Data for Risk Adjustment Data Validation Sampling](https://www.cms.gov/files/document/deadlinesforthesubmissionofriskadjustmentdataforriskadjustmentdatavalidationsamplingg.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ## Explore more tags from this article [healthcare data analytics](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-data-analytics/), [radv audits](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/radv-audits/), [risk adjustment platform](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/risk-adjustment-platform/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Milliman Privacy Policy [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/privacy-policy/#content) # Milliman USA data privacy policy #### Last updated January 2025 ## Important Information for Individuals in the U.S (United States) Milliman, Inc. and its affiliates (“Milliman” or “we”) take data privacy very seriously. This U.S. Data Privacy Policy (“Data Privacy Policy”) sets out the principles governing Milliman’s use and protection of personal information of individuals (consumers or residents) in the U.S. (“you”) that individuals and clients share with us. These disclosures are intended to supplement the disclosures contained in the Milliman Global Data Privacy Policy. This Data Privacy Policy applies to Milliman’s data collection and use through this website and through its business operations in the United States. ## Overview This Data Privacy Policy relates to U.S. state privacy laws, including state consumer health privacy laws, hereafter “U.S. State Privacy Laws”, including but not limited to the California Consumer Privacy Act, the Colorado Privacy Act, the Connecticut Data Privacy Act, the Montana Consumer Data Privacy Act, the Oregon Consumer Privacy Act, the Texas Data Privacy and Security Act, the Utah Consumer Privacy Act, the Virginia Consumer Data Protection Act, the Nevada My Health My Data and the My Washington My Data Act. Please also refer to [Milliman’s B2B Business Contact Notice](https://www.milliman.com/en/ccpa-business-contact-notice-at-collection) at Collection for disclosures related to the California Consumer Privacy Act. This Data Privacy Policy does not address or apply to Milliman’s handling of: - Publicly available information from government records. - Health or medical information covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). - Personal information covered by certain sector-specific privacy laws, including the Fair Credit Reporting Act (FCRA) and the Gramm-Leach-Bliley Act (GLBA). Milliman does not maintain a distinct Washington Health Data Privacy Policy due to its role as a Data Processor in handling personal information pertaining to Washington resident that identifies their past, present, or future physical or mental health status (“Health Data”). ## Data Collection on Milliman’s Proprietary Data Collection Platforms For some unique services, Milliman hosts and maintains its own proprietary software platforms (“Platforms”). These Platforms allow Milliman to offer enhanced services and more specialized products to our customers. In some cases, these software platforms may require submissions of personal information by customers. In cases where our data collection is materially different than what we describe in this Privacy Policy, we will provide additional disclosures regarding such data collection on the applicable Platforms. ## Rights of Individuals in the U.S. Depending on your state of residence and subject to certain exceptions, you may have certain data privacy rights. Privacy rights pertaining to personal information collected in a commercial or employment context are subject only to the California Consumer Privacy Act of 2018 (CCPA) and are processed by Milliman in its capacity as a Business (as defined in the California Consumer Privacy Act). Privacy rights associated to personal information processed by Milliman as a Service Provider or Data Processor (as these terms are defined under U.S. State Privacy Laws) are contingent upon our clients’ privacy policies. In such instances, Milliman would forward your request to its clients as per Milliman’s contractual obligations. California (for California residents) ColoradoConnecticutMontanaNevadaOregonTexasUtahVirginiaWashington ### California (for California residents) Under the California Consumer Privacy Act of 2018 (“CCPA”) as amended by the California Privacy Rights Act (“CPRA”), 2023: **Right to Access.** You have the right to confirm whether we are processing your personal information and to access that data. You have the right to know: - The categories of personal information we have collected about you. - The categories of sources from which personal information is collected. - Our business or commercial purpose for collecting, selling, or sharing personal information. - The categories of third parties to whom we disclose personal information, if any. - The specific pieces of personal information we have collected about you. In connection with any personal information, we may sell or share to a third party for a business purpose, you have the right to know: - The categories of personal information about you that we sold and shared and the categories of third parties to whom the personal information was sold and shared; and - The categories of personal information that we disclosed about you for a business purpose. **Right to Opt-Out of the Sale or Sharing of Personal Information.** You have the right to opt-out of the sale or sharing of your personal information. Please be aware that Milliman as a Business (as defined in the California Consumer Privacy Act) is not in the business of selling or sharing personal information and that Milliman has not sold nor shared personal information in the precedent twelve (12) months. Milliman does therefore not offer a mechanism to exercise the right to opt-out. If such requests are addressed to Milliman in its capacity as a Service Provider (as defined in the California Consumer Privacy Act), Milliman would forward your request to its clients in their capacity as Businesses as per Milliman’s contractual obligations. **Right to Limit the Use and Disclosure.** We use and/or disclose sensitive personal information for the permitted purposes specified in the CCPA and therefore do not offer a mechanism to exercise the right to limit the use of sensitive personal information. **Right to Deletion.** You have the right to request that Milliman delete the Personal Information it has collected or maintains about you. Once a verified request is received, Milliman will let you know what, if any, Personal Information can be deleted from its records, and Milliman will direct any service providers and contractors to whom it disclosed your Personal Information to also delete your Personal Information from their records. There may be circumstances where Milliman cannot delete your Personal Information or direct service providers or contractors to delete your Personal Information from their records. Such instances include, but are not limited to, enabling solely internal uses that are reasonably aligned with your expectations based on your relationship with Milliman and compatible with the context in which you provided the information or to comply with a legal obligation. **Right of Correction.** You have the right to correct inaccurate personal information that we maintain about you, taking into account the nature of that information and purpose for processing it. **Protection Against Discrimination.** You have the right to not be discriminated against by us because you exercise any of your rights. **Right of Portability.** You have the right to obtain your personal information in a portable and readily usable format that allows you to transmit the data to another entity without hindrance. ### Colorado Under the Colorado Privacy Act of 2021 (“CPA”): **Right to Access.** You have the right to confirm whether we are processing your personal information and to access that data. You have the right to know the categories of personal information we have collected and maintain about you. **Right of Correction.** You have the right to correct inaccurate personal information that we maintain about you. **Right to Deletion.** You have the right to request that we delete any of your personal information that we collected from you and retained, subject to certain exceptions. Once we receive and confirm your verifiable consumer request, we will delete (and direct our service providers to delete) your personal information from our records, unless an exception applies. **Right to Opt-Out.** You have the right to opt-out of the processing of your personal information for purposes of: - Targeted advertising - The sale of personal information, and - Profiling in furtherance of decisions that produce legal or similarly significant effects concerning you. Please be aware that Milliman is not in the business of targeted advertising, the selling of personal information and profiling. Milliman does therefore not offer a mechanism to exercise the right to opt-out. If such requests are addressed to Milliman in its capacity as a Data Processor (as defined in the CPA), Milliman would forward your request to its clients in their capacity as Data Controllers as per Milliman’s contractual obligations. **Right to Withdraw Consent.** You have the right to withdraw consent from the collection and sharing of personal information that concerns you. **Right of Portability.** You have the right to obtain your personal information in a portable and readily usable format that allows you to transmit the data to another entity without hindrance. ### Connecticut Under the Connecticut Act Concerning Personal Data Privacy and Online Monitoring of 2022 (“CTDPA”), as amended in 2023: **Right to Access.** You have the right to confirm whether we are processing your personal information and to access that data, unless such confirmation or access would require us to reveal a trade secret. **Right of Correction.** You have the right to correct inaccurate personal information that we maintain about you. **Right to Deletion.** You have the right to request that we delete any of your personal information that we collected from you and retained, subject to certain exceptions. Once we receive and confirm your verifiable request, we will delete (and direct our service providers to delete) your personal information from our records, unless an exception applies. **Right to Opt-Out.** You have the right to opt-out of the processing of your personal information for purposes of: - Targeted advertising - The sale of personal information, and - Profiling in furtherance of decisions that produce legal or similarly significant effects concerning you. Please be aware that Milliman is not in the business of targeted advertising, the selling of personal information and profiling. Milliman does therefore not offer a mechanism to exercise the right to opt-out. If such requests are addressed to Milliman in its capacity as a Data Processor (as defined in the CTDPA), Milliman would forward your request to its clients in their capacity as Data Controllers as per Milliman’s contractual obligations. **Right of Portability.** You have the right to obtain your personal information in a portable and readily usable format that allows you to transmit the data to another entity without hindrance. ### Montana Under the Montana Consumer Data Privacy Act of 2023 (“MCDPA”): **Right to Access.** You have the right to confirm whether we are processing your personal information and to access that data, unless such confirmation or access would require us to reveal a trade secret. **Right of Correction.** You have the right to correct inaccurate personal information that we maintain about you. **Right to Deletion.** You have the right to request that we delete any of your personal information that we collected from you and retained, subject to certain exceptions. Once we receive and confirm your verifiable consumer request, we will delete (and direct our service providers to delete) your personal information from our records, unless an exception applies. **Right to Opt-Out.** You have the right to opt-out of the processing of your personal information for purposes of: - Targeted advertising - The sale of personal information, and - Profiling in furtherance of decisions that produce legal or similarly significant effects concerning you. Please be aware that Milliman is not in the business of targeted advertising, the selling of personal information and profiling. Milliman does therefore not offer a mechanism to exercise the right to opt-out. If such requests are addressed to Milliman in its capacity as a Data Processor (as defined in the MCDPA), Milliman would forward your request to its clients in their capacity as Data Controllers as per Milliman’s contractual obligations. **Right of Portability.** You have the right to obtain your personal information in a portable and readily usable format that allows you to transmit the data to another entity without hindrance. **Protection Against Discrimination.** You have the right to not be discriminated against by us because you exercise any of your rights. ### Nevada Under the Nevada My Health My Data (“NMHMD”): **Right to Confirm.** You have the right to confirm whether a Regulated entity (as defined in the NMHMD) is collecting, sharing or selling your health data. **Right to Access.** You have the right to access health data held by a Regulated Entity, along with a list of all third parties with whom the Regulated Entity has shared or sold that health data. **Right to Request that a Regulated Entity Cease Processing.** You have the right to request that a Regulated Entity cease collection, sharing, or selling your health data. **Right to Withdraw Consent.** You have the right to withdraw consent for the collection, sharing or selling by the Regulated Entity. **Right to Delete.** You have the ask for the deletion of your health data from all of its records, including archived or network. If such requests are addressed to Milliman in its capacity as a Processor (as defined in the MWMDA), Milliman would forward your request to its clients in their capacity as Regulated Entities as per Milliman’s contractual obligations. ### Oregon Under the Oregon Consumer Privacy Act of July 2023 (“OCPA”): **Right to Access.** You have the right to confirm whether we are processing your personal information and to access that data. You have the right to know the categories of personal information we are processing or have processed. **Right of Correction.** You have the right to correct inaccurate personal information that we maintain about you. **Right to Deletion.** You have the right to request that we delete any of your personal information that we collected from you and retained, subject to certain exceptions. Once we receive and confirm your verifiable request, we will delete (and direct our service providers to delete) your personal information from our records, unless an exception applies. **Right to Opt-Out.** You have the right to opt-out of the processing of your personal information for purposes of: - Targeted advertising - The sale of personal information, and - Profiling in furtherance of decisions that produce legal or similarly significant effects concerning you. Please be aware that Milliman is not in the business of targeted advertising, the selling of personal information and profiling. Milliman does therefore not offer a mechanism to exercise the right to opt-out. If such requests are addressed to Milliman in its capacity as a Data Processor (as defined in the OCPA), Milliman would forward your request to its clients in their capacity as Data Controllers as per Milliman’s contractual obligations. **Right of Portability.** You have the right to obtain your personal information in a portable and readily usable format that allows you to transmit the data to another entity without hindrance. **Protection Against Discrimination.** You have the right to not be discriminated against by us because you exercise any of your rights. ### Texas Under the Texas Data Privacy and Security Act of June 2023 (“TDPSA”): **Right to Access.** You have the right to confirm whether we are processing your personal information and to access that data. **Right of Correction.** You have the right to correct inaccurate personal information that we maintain about you. **Right to Deletion.** You have the right to request that we delete any of your personal information that we collected from you and retained, subject to certain exceptions. Once we receive and confirm your verifiable consumer request, we will delete (and direct our service providers to delete) your personal information from our records, unless an exception applies. **Right to Opt-Out.** You have the right to opt-out of the processing of your personal information for purposes of: - Targeted advertising - The sale of personal information, and - Profiling in furtherance of decisions that produce legal or similarly significant effects concerning you. Please be aware that Milliman is not in the business of targeted advertising, the selling of personal information or the profiling. Milliman does therefore not offer a mechanism to exercise the right to opt-out. If such requests are addressed to Milliman in its capacity as a Data Processor (as defined in the TDPSA), Milliman would forward your request to its clients in their capacity as Data Controllers as per Milliman’s contractual obligations. **Right to Opt-Out of the Sale of Sensitive or Biometric Personal Information.** Please be aware that Milliman is not in the business the selling of biometric or sensitive personal information. Milliman does therefore not offer a mechanism to exercise the right to opt-out. If such requests are addressed to Milliman in its capacity as a Data Processor (as defined in the TDPSA), Milliman would forward your request to its clients in their capacity as Data Controllers as per Milliman’s contractual obligations. **Right of Portability.** You have the right to obtain your personal information in a portable and readily usable format that allows you to transmit the data to another entity without hindrance. ### Utah Under the Utah Consumer Privacy Act of March 2022 (“UCPA”): **Right to Access.** You have the right to access your personal information. **Right to Deletion.** You have the right to request that we delete any of your personal information that we collected from you and retained, subject to certain exceptions. Once we receive and confirm your verifiable consumer request, we will delete (and direct our service providers to delete) your personal information from our records, unless an exception applies. **Right to Opt-Out.** You have the right to opt-out of the processing of your personal information for purposes of: - Targeted advertising; and - The sale of personal information Please be aware that Milliman is not in the business of targeted advertising or the selling of personal information. Milliman does therefore not offer a mechanism to exercise the right to opt-out. If such requests are addressed to Milliman in its capacity as a Data Processor (as defined in the UCPA), Milliman would forward your request to its clients in their capacity as Data Controllers as per Milliman’s contractual obligations. **Right of Portability.** You have the right to obtain your personal information in a portable and readily usable format that allows you to transmit the data to another entity without hindrance. ### Virginia **Right to Access.** You have the right to confirm whether we are processing your personal information and to access that data. **Right of Correction.** You have the right to correct inaccurate personal information that we maintain about you. **Right to Deletion.** You have the right to request that we delete any of your personal information that we collected from you and retained, subject to certain exceptions. Once we receive and confirm your verifiable consumer request, we will delete (and direct our service providers to delete) your personal information from our records, unless an exception applies. **Right to Opt-Out.** You have the right to opt-out of the processing of your personal information for purposes of: - Targeted advertising - The sale of personal information, and - Profiling in furtherance of decisions that produce legal or similarly significant effects concerning you. Please be aware that Milliman is not in the business of targeted advertising, the selling of personal information or the profiling. Milliman does therefore not offer a mechanism to exercise the right to opt-out. If such requests are addressed to Milliman in its capacity as a Data Processor (as defined in the VCDPA), Milliman would forward your request to its clients in their capacity as Data Controllers as per Milliman’s contractual obligations. **Right of Portability.** You have the right to obtain your personal information in a portable and readily usable format that allows you to transmit the data to another entity without hindrance. ### Washington Under the My Washington My Data Act (“MWMDA”): **Right to Confirm.** You have the right to confirm whether a Regulated entity (as defined in the MWMDA) is collecting, sharing or selling your Health Data. **Right to Access.** You have the right to access Heath Data held by a Regulated Entity, along with a list of all third parties and affiliate with whom the Regulated Entity has shared or sold that Health Data. **Right to Withdraw Consent.** You have the right to withdraw consent for a Regulated Entity’s collection or sharing of their Health Data. **Right to Delete.** You have the ask for the deletion of your Health Data from all of its records, including archived or backup systems. If such requests are addressed to Milliman in its capacity as a Processor (as defined in the MWMDA), Milliman would forward your request to its clients in their capacity as Regulated Entities as per Milliman’s contractual obligations. ## Submitting Requests Requests for the application of your rights may be submitted by either: - Calling us at 1-866-467-8688 + service code 740 at prompt; or - By accessing our webform [Privacy Web Form](https://privacyportal-fr.onetrust.com/webform/89cb8d06-bfec-48f0-9fe8-f2dad777c3c3/draft/38083339-1ae3-4d6e-a6fc-3e4c8a166d8c) (onetrust.com). You will be asked to provide certain personal information when submitting your request including your first and last name, email address for us to determine if your information is in our systems. The verifiable request must: - Provide sufficient information that allows us to reasonably verify you are the person about whom we collected personal information or an authorized representative thereof; and - Describe your request with sufficient detail that allows us to properly understand, evaluate, and respond to it. We cannot respond to your request or provide you with personal information if we cannot verify your identity or authority to make the request and confirm the personal information relates to you. Making a verifiable request does not require you to create an account with us. We will only use personal information provided in a verifiable request to verify your identity or authority to make the request. The above applies regardless of whether a request is submitted by you on your own behalf, by an authorized representative on your behalf, or by you on behalf of your minor child. ## Response Timing and Format We endeavor to respond to a verifiable request within 45 days of its receipt. If we require more time (up to 90 days depending on applicable U.S. State Privacy Law), we will inform you of the reason and extension period in writing. For requests subject to California Consumer Privacy Act of 2018 (CCPA), any disclosures we provide will only cover the 12-month period preceding the verifiable request’s receipt. The response we provide will also explain the reasons we cannot comply with a request, if applicable. For data portability requests, we will select a format to provide your personal information that is readily useable and should allow you to transmit the information from one entity to another entity without hindrance. Depending on applicable U.S. State Privacy Law, we will not charge a fee to process or respond to your verifiable request unless it is excessive, repetitive, or manifestly unfounded. In addition, we may charge an additional amount for a second or subsequent request within a 12-month period. If we determine that the request warrants a fee, we will tell you why we made that decision and provide you with a cost estimate before completing your request. ## Collection of Personal Information We collect information that identifies, relates to, describes, is reasonably capable of being associated with, or could reasonably be linked, directly or indirectly, with a particular individual or household. Our collection, use and disclosure of personal information about individuals in the U.S. will vary depending upon the circumstances and nature of our interactions or relationship with such individuals. The sections below set out generally the categories of personal information about U.S. individuals that we collect from and disclose to others for a business purpose. We collect these categories of personal information from the sources described in the Sources of Information Collected section below, and for the purposes described in the Categories of Personal Information Collected and Purpose of Collection section below. ## Categories of Personal Information Collected and Purposes of Collection We have collected the following categories of personal information from U.S. individuals within the last twelve (12) months. Personal information related to individuals acting in a commercial or employment context are subject only to the California Consumer Privacy Act of 2018 (CCPA). This information pertains solely to California residents. We act as a Business (as defined in California Consumer Privacy Act) when processing such personal information. Additionally, we may process personal information as a Service Provider or Data Processor (as these terms are defined under U.S. State Privacy Laws) to our clients. That information is subject to our clients’ privacy policies. | Categories of Personal Information Collected | Purposes Personal Information, Including Sensitive Information, is Used | | --- | --- | | Identifiers and Contact Information. This category includes names, alias, postal address, gender, telephone numbers, mobile numbers, unique personal identifiers, online identifier, Internet Protocol address, email address, signature, account name, dates of birth, bank account information, citizenship status, marital status, demographic data (including age, nationality, place of birth), and other similar contact information and identifiers. | ·  Collect and process employment applications, including confirming eligibility for employment, recruitment, background and related checks, onboarding, and offboarding.
·  Process payroll, other forms of compensation, and employee benefit plan and program design and administration, including enrollment and claims handling, and leave of absence administration.
·  Maintain personnel and exam records, including evaluations, and record retention requirements.
·  Comply with applicable state and federal labor, employment, tax, benefits, workers’ compensation, disability, equal employment opportunity, workplace safety, and related laws.
·  Analyze human resources trends and metrics.
·  Provide career development, coaching, and training opportunities.
·  Communicate with employees and/or employees’ emergency contacts and plan beneficiaries.
·  Prevent unauthorized access to or use of Milliman’s property, including Milliman’s information systems, electronic devices, network, data, and information.
·  Ensure adherence to Milliman’s policies.
·  Investigate complaints, grievances, and suspected violations of internal policies.
·  Monitor attendance, including vacation, sick leave, and other absences.
·  Provide general corporate services.
·  Store, process, and manage employee information using human resources information systems.
·  Adhere to whistleblowing procedures.
·  Collect and process scholarship applications.
·  Provide global mobility and immigration services.
·  Contract administration.
·  Execute and perform client engagements (where it manages the administration of contracts).
·  Maintain client accounts.
·  Fulfill and respond to requests and inquiries about Milliman products or services.
·  Send marketing communications, surveys, and questionnaires.
·  Operate Milliman’s business.
·  Manage the relationship with clients’ representatives, officers, agents and employees, business partners, providers, parties to a contract.
·  Communicate with clients’ representatives, officers, agents and employees, business partners, providers, parties to a contract. | | Personal Information categories listed in California Civil Code § 1798.80(e). This category includes insurance policy number, employment history, medical information, or health insurance information (generally in pseudonymized form or de-identified). | ·  Collect and process employment applications, including confirming eligibility for employment, recruitment, background and related checks, onboarding, and offboarding.
·  Process payroll, other forms of compensation, and employee benefit plan and program design and administration, including enrollment and claims handling, and leave of absence administration.
· Provide various professional services to clients in its capacity as a Service Provider or Data Processor (the personal information is typically in pseudonymized form or de-identified). | | Protected Classification Information. This category includes characteristics of protected classifications under California or federal law, such as race, color, religion or creed, national origin or ancestry, citizenship, medical condition, physical or mental disability, age (40 years or older), sex (including gender, gender identity, gender expression, pregnancy or childbirth and related medical conditions), sexual orientation, and veteran or military status. | ·  Comply with applicable state and federal equal employment opportunity, pay equity, and pay transparency laws.
·  Design, implement, and promote Milliman’s diversity, equity, and inclusion programs.
·  Investigate complaints, grievances, and suspected violations of Milliman policies.
· Provide various professional services to clients in its capacity as a Service Provider or Data Processor (the personal information is typically in pseudonymized form or de-identified). | | Commercial information. This category includes products or services provided, obtained, or considered. | ·  Contract administration.
·  Execute and perform client engagements.
·  Provide various professional services to clients.
·  Activate and maintain client accounts.
·  Providing offers and information to you about products, services, or events offered.
·  Maintain client account.
·  Send marketing communications, surveys, and questionnaires. | | Biometric Information. This category can include identifiers or identifying information, such as fingerprints. | ·  Comply with industry and legal requirements, including background check requirements. | | Internet or other Electronic Data. This category includes, without limitation:
- All activity on Milliman’s information systems, such as anonymized internet browsing history, anonymized search history or intranet activity, email communications, stored documents and emails, IP addresses, login details, usernames, passwords, and
- All activity on communications systems including phone calls, call logs, voice mails, text messages, chat logs, app use, mobile browsing and search history, mobile email communications, and other information regarding an employee’s use of company-issued devices. | ·  Prevent unauthorized access to or use of Milliman’s property, including Milliman’s information systems, electronic devices, network, data, and information.
·  Information Technology (IT) security purposes, including incident responses.
·  IT administration, including providing backups, software installation, helpdesk services, the logging and monitoring of network activity and the administration of Milliman’s cloud platform.
·  Investigate complaints, grievances, and suspected violations of Milliman policies.
·  Analyze how our websites are used, accessed, and how they are performing.
·  Operate Milliman’s business.
·  Manage the relationship with clients’ representatives, officers, agents and employees, business partners, providers, parties to a contract.
·  Communicate with clients’ representatives, officers, agents and employees, business partners, providers, parties to a contract. | | Audio, electronic, and visual information. This category includes information collected from cameras, microphones, and similar devices. | ·  Prevent unauthorized access to or use of Milliman’s property, including Milliman’s server rooms.
·  Conduct interviews and meetings.
·  Providing offers and information to you about products, services, or events offered. | | Professional or Employment-related Information. This category includes, without limitation:
- Data submitted with employment applications including salary history, employment history, job titles, employment recommendations, etc.
- Professional and criminal background check information,
- Work authorization,
- Fitness for duty data and reports,
- Performance evaluations and disciplinary records,
- Salary, compensation, and bonus data,
- Timesheets,
- Practice group,
- Professional licenses, skills, and training records,
- Benefit plan enrollment, participation, and claims information, and
- Leave of absence information, including religious and family obligations, physical and mental health data concerning employee and their family members. | ·  Collect and process employment applications, including confirming eligibility for employment, recruitment, background and related checks, onboarding, and offboarding.
·  Process payroll, other forms of compensation, and employee benefit plan and program design and administration, including enrollment and claims handling, and leave of absence administration.
·  Maintain personnel and exam records, including evaluations, and comply with record retention requirements.
·  Communicate with employees and/or employees’ emergency contacts and plan beneficiaries.
·  Comply with applicable state and federal labor, employment, tax, benefits, workers compensation, disability, equal employment opportunity, workplace safety, and related laws.
·  Business management.
·  Investigate complaints, grievances, and suspected violations of Milliman policies.
·  Analyze human resources trends and metrics.
·  Provide learning and career development, coaching, and training opportunities.
·  Store, process, and manage employee information using human resources information systems.
·  Monitor attendance, including vacation, sick leave, and other absences.
·  Verification of employment.
·  Adhere to whistleblowing procedures, including collection of information and administration.
·  Provide global mobility and immigration services.
·  Provide various professional services to clients in its capacity as a Service Provider or Data Processor (the personal information is typically in pseudonymized form or de-identified). | | Education Data. This category includes education history, degrees, and related information that is not publicly available personally identifiable information as defined in the Family Educational Rights and Privacy Act (20 U.S.C. Sec. 1232g; 34 C.F.R. Part 99). | ·  Collect and process employment applications, including confirming eligibility for employment, recruitment, background and related checks, onboarding, and offboarding.
·  Collect and process scholarship applications, including confirming eligibility for scholarships for which Milliman acts as a sponsor.
·  Evaluate an individual’s appropriateness for hire or promotion at Milliman.
·  Analyze human resources trends and metrics.
·  Provide and track career development and training opportunities.
·  Design, implement, and promote Milliman’s diversity, equity, and inclusion programs.
·  Maintain employee records, including exam records.
·  Store, process, and manage employee/applicant information using human resources information systems.
·  Provide global mobility and immigration services.
·  Provide various professional services to clients in its capacity as a Service Provider or Data Processor (the personal information is typically in pseudonymized form or de-identified). | | Medical Information. This category includes, without limitation:
- Symptoms, test results, and other indicators of exposure to the coronavirus (COVID-19) and related vaccination status information,
- Medical conditions, device identifiers, record number, and treatment information,
- Dates of medical service, diagnosis, and disease/disorder information,
- Disability information,
- Insurance policy information,
- Leave of absence information, including family obligations, physical and mental health data concerning employee and their family members, and
- Travel information and information regarding close contacts. | ·  Communicate with employees and/or employees’ emergency contacts.
·   Maintain personnel records and documents.
·   Comply with applicable state and federal laws.
·   Adaptability to the workplace.
·   Monitor attendance, including sick leave.
·   Provide various professional services to clients in its capacity as a Service Provider or Data Processor (the personal information is typically in pseudonymized form or de-identified). | | Inferences. This category includes engaging in human capital analytics, including, but not limited to, identifying certain correlations about individuals and success on their jobs, analyzing data to improve retention, and analyzing employee preferences to inform HR policies, programs and procedures. | ·  Employee engagement and pulse survey analysis to determine retention strategies.
·  Provide various professional services to clients in its capacity as a Service Provider or Data Processor (the personal information is typically in pseudonymized form or de-identified). | | Sensitive Personal Information. This category includes sensitive information, such as:
- Social Security, driver’s license, state identification card, or passport number,
- Financial account information that allows access to an account, including log-in credentials, financial account numbers, passwords, etc.,
- Racial or ethnic origin, or religious or philosophical beliefs,
- Religious beliefs.
- Sexual Orientation.
- Citizenship or immigration status.
- Personal information from a known child.
- Mental of physical health condition.
- Content of mail, email, and text messages, unless Milliman is the intended recipient of the communication. | ·  Collect and process employment applications, including confirming eligibility for employment, recruitment, background and related checks, onboarding, and offboarding.
·  Comply with applicable state and federal labor, employment, tax, benefits, workers compensation, disability, equal employment opportunity, workplace safety, and related laws.
·  Process payroll, other forms of compensation, and employee benefit plan and program design and administration, including enrollment and claims handling, and leave of absence administration.
·  Monitor attendance, including vacation, sick leave, and other absences.
·  Design, implement, and promote Milliman’s diversity, equity, and inclusion programs.
·  Comply with applicable state and federal laws.
·  Maintain personnel records and documents.
·  Analyze human resources metrics and trends.
·  Monitor attendance, including vacation, sick leave, and other absences.
·  Provide global mobility and immigration services.
·  Verification of employment.
·  Provide various professional services to clients in its capacity as a Service Provider or Data Processor (the personal information is typically in pseudonymized form or de-identified). | | Health data (personal information that is linked or capable of being linked to the individuals’ past, present, or future physical or mental health status) | Provide various professional services to clients in its capacity as Data Processor (the personal information is typically in pseudonymized form or de-identified). | ## Sources of Information Collected We collect personal information directly from you, as well as automatically related to your use of our websites and other services, and from third parties. For example, we collect personal information: - From any form you may complete and submit through our websites, for example information collected from the ‘Contact Us’ page of our websites. - From the content of surveys that you may complete. - From ‘cookies’ and other similar tools deployed on parts of our websites that can only be accessed by authenticated users who are logged into the website (for further information regarding cookies used on our websites, please see [Cookie Policy](https://www.milliman.com/en/cookie-policy). - When you provide information as a client in connection with us providing professional services to you. - From other sources, such as public databases, joint marketing partners, social media platforms (including from people with whom you are friends or otherwise connected) and from other third parties; and - From or on behalf of clients when we provide professional services, which could include personal information about you in your capacity as their employees, benefits recipients, insureds, etc. ## Data Minimization In order to achieve the purposes identified above, the collection, use, and retention of personal information shall be reasonably necessary and proportionate. We collect the minimum personal information that is necessary to fulfill such purposes. When we act as a Service Provider, we only request the minimum personal information that is necessary to provide the services to our clients acting as Business or Data Controller. The terms Business, Data Controller and Service Provider are given the meanings set forth in U.S. State Privacy Laws. ## Disclosing Personal Information to a Third Party We may disclose your personal information to a third party for a business purpose. When we disclose personal information for a business purpose, we enter into a contract that describes the purpose and requires the recipient to both keep that personal information confidential and not use it for any purpose except performing the contract. In the preceding twelve (12) months, we have your personal information for a business purpose to the following categories of third parties: - Milliman affiliates. - Service providers and independent contractors we use to help deliver our products and/or services as well as human resources functions (for personal information collected in an employment context). - Other third parties we use to help us run our business, such as marketing agencies, website hosts, technical security solutions. - Designers and manufacturers of scholarships and other educational support programs for corporations, where Milliman acts as a sponsor for such scholarships. - Third parties approved by you, including social media sites you choose to link your account to or third-party payment providers. - Our insurers and brokers; and - Our banks. We may disclose your personal information in response to subpoenas, court orders, or other lawful requests by public authorities, including to meet national security or law enforcement requirements. We may also disclose personal information in order to enforce or apply our rights and agreements, or when we believe in good faith that disclosing this information is necessary or advisable, including, for example, to protect the rights, property, or safety of our businesses, our websites, our customers, our users, or others, as permitted under the applicable laws, or as otherwise required by law or by government and regulatory entities. This includes exchanging information with other companies and organizations for fraud protection and credit risk reduction. ## Use of Deidentified Information Milliman will take reasonable measures to ensure that deidentified information (as defined by the applicable U.S. State Privacy Laws) it receives or creates will not be associated with an individual or household and will maintain and use the information in deidentified form and not attempt reidentification. ## Personal Information of Minors Our services and website are not directed to minors under 13, and we do not knowingly sell or share for behavioral advertising the personal information of minors, including minors under 16 years of age. ## Changes to Our Privacy Disclosures We may update our privacy policy occasionally for changes in our business practice or the law.  Updates will be posted to this webpage. ## Accessibility To make accessibility-related requests or report barriers, please contact us at [data.protection@milliman.com](mailto:data.protection@milliman.com). ## How to Contact Us If you have questions or comments about this Data Privacy Policy, you may contact us at: [data.protection@milliman.com](mailto:data.protection@milliman.com). 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## Healthcare Events 2024-2025 https://medinsight.com/healthcare-data-analytics-resources/events/thma-spring-2024-cfo-forum/2024-04-01T16:32:55+00:00https://medinsight.com/wp-content/uploads/2024/02/hma-logo-new.pnghttps://medinsight.com/wp-content/uploads/2024/02/dachary.jpghttps://medinsight.com/wp-content/uploads/2024/02/fitch.jpghttps://medinsight.com/healthcare-data-analytics-resources/events/naacos-spring-2024/2024-05-13T16:11:37+00:00https://medinsight.com/wp-content/uploads/2023/09/naacos-logo.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/nahdo-networking-session-2024/2024-05-13T16:12:07+00:00https://medinsight.com/wp-content/uploads/2023/11/nahdo-logo-new.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/wha-conference-health-care-spend-more-get-better/2024-07-19T15:10:35+00:00https://medinsight.com/wp-content/uploads/2024/02/wha-logo-new.pnghttps://medinsight.com/wp-content/uploads/2024/02/fox.jpghttps://medinsight.com/healthcare-data-analytics-resources/events/ahip-2024/2024-07-19T15:10:51+00:00https://medinsight.com/wp-content/uploads/2023/11/ahip-logo.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/epic-ugm-2024/2024-08-29T18:02:36+00:00https://medinsight.com/wp-content/uploads/2023/09/medinsight-vbc-epic-ugm.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/milliman-healthcare-intelligence-client-forum-2024/2024-10-01T21:30:03+00:00https://medinsight.com/wp-content/uploads/2023/09/milliman-event.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/himss-2024/2024-10-28T19:32:40+00:00https://medinsight.com/wp-content/uploads/2023/09/himss-24-logo.pnghttps://medinsight.com/wp-content/themes/blankslate-child/assets/images/himss-graphic.svghttps://medinsight.com/healthcare-data-analytics-resources/events/hlth-2024/2024-11-06T17:27:20+00:00https://medinsight.com/wp-content/uploads/2023/09/hlth-23-logo.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/nahdo-virtual-conference-fall-2024/2024-11-18T21:44:03+00:00https://medinsight.com/wp-content/uploads/2023/11/nahdo-logo-new.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/thma-fall-2024-cfo-forum/2024-12-05T17:32:49+00:00https://medinsight.com/wp-content/uploads/2024/02/hma-logo-new.pnghttps://medinsight.com/wp-content/uploads/2024/02/fitch.jpghttps://medinsight.com/wp-content/uploads/2024/10/ivanovics-amanda.jpghttps://medinsight.com/healthcare-data-analytics-resources/events/lokahi-healthcare-accelerator/2024-12-10T20:28:29+00:00https://medinsight.com/wp-content/uploads/2024/11/lablab-ai-logo.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/beckers-spring-payer-issues-roundtable/2025-02-24T22:46:44+00:00https://medinsight.com/wp-content/uploads/2024/01/beckers-healthcare-logo-new.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/himss-2025/2025-03-11T14:05:32+00:00https://medinsight.com/wp-content/uploads/2024/11/himss-25-logo.pnghttps://medinsight.com/wp-content/themes/blankslate-child/assets/images/medinsight-himss-25-graphic.svghttps://medinsight.com/healthcare-data-analytics-resources/events/rise-national-2025/2025-03-25T22:23:28+00:00https://medinsight.com/wp-content/uploads/2024/12/rise-national-2025.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/thma-spring-2025-cfo-forum/2025-04-02T22:13:58+00:00https://medinsight.com/wp-content/uploads/2024/02/hma-logo-new.pnghttps://medinsight.com/wp-content/uploads/2023/09/fitch.jpghttps://medinsight.com/wp-content/uploads/2025/01/ted-barbeau.jpghttps://medinsight.com/healthcare-data-analytics-resources/events/naacos-spring-2025/2025-05-02T14:12:23+00:00https://medinsight.com/wp-content/uploads/2023/09/naacos-logo.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/beckers-spring-2025-payer-issues-roundtable/2025-05-02T14:13:03+00:00https://medinsight.com/wp-content/uploads/2024/01/beckers-healthcare-logo-new.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/epic-xgm-2025/2025-05-08T19:45:04+00:00https://medinsight.com/healthcare-data-analytics-resources/events/nahdo-2025-annual-conference-and-networking-sessions/2025-05-20T21:22:40+00:00https://medinsight.com/wp-content/uploads/2023/11/nahdo-logo-new.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/thma-spring-2025-value-based-strategy-collaborative/2025-05-20T21:23:11+00:00https://medinsight.com/wp-content/uploads/2025/04/THMA-logo-no-bg.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/ahip-2025/2025-06-24T16:06:58+00:00https://medinsight.com/wp-content/uploads/2023/11/ahip-logo.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/hlth-2025/2025-07-14T20:47:19+00:00https://medinsight.com/wp-content/uploads/2023/09/hlth-23-logo.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/thma-fall-2025-cfo-forum/2025-08-27T13:10:31+00:00https://medinsight.com/wp-content/uploads/2024/02/hma-logo-new.pnghttps://medinsight.com/wp-content/uploads/2024/02/fitch.jpghttps://medinsight.com/wp-content/uploads/2024/10/ivanovics-amanda.jpghttps://medinsight.com/healthcare-data-analytics-resources/events/thma-fall-2025-value-based-strategy-collaborative/2025-09-04T17:44:19+00:00https://medinsight.com/wp-content/uploads/2025/04/THMA-logo-no-bg.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/nahdo-virtual-conference-fall-2025/2025-09-10T13:38:25+00:00https://medinsight.com/wp-content/uploads/2023/11/nahdo-logo-new.pnghttps://medinsight.com/healthcare-data-analytics-resources/events/milliman-healthvision360-2025/2025-10-14T15:50:41+00:00https://medinsight.com/wp-content/uploads/2023/09/milliman-event.png ## Healthcare Analytics Webinars https://medinsight.com/healthcare-data-analytics-resources/webinar/transparency-and-trust-in-value-based-care-financial-reporting-best-practices-with-bluekc/2024-12-09T20:12:56+00:00https://medinsight.com/wp-content/uploads/2024/08/bluekc-financial-reporting-webinar.jpghttps://medinsight.com/wp-content/uploads/2024/10/hubka-kelly.jpghttps://medinsight.com/wp-content/uploads/2023/09/castle.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/unlocking-analytics-for-success-in-risk-contracts-a-case-study-from-genesys-pho/2024-12-09T20:13:23+00:00https://medinsight.com/wp-content/uploads/2024/08/genesys-pho-webinar.jpghttps://medinsight.com/wp-content/uploads/2024/10/samm-lewis.pnghttps://medinsight.com/wp-content/uploads/2024/10/John-McBride.pnghttps://medinsight.com/wp-content/uploads/2024/10/Mark-Leaman.pnghttps://medinsight.com/healthcare-data-analytics-resources/webinar/fostering-provider-efficiency-payer-strategies-for-optimizing-provider-networks/2024-12-09T20:13:41+00:00https://medinsight.com/wp-content/uploads/2024/02/payer-strategies-2.pnghttps://medinsight.com/wp-content/uploads/2024/02/busenburg-chas.jpghttps://medinsight.com/wp-content/uploads/2024/02/dachary.jpghttps://medinsight.com/wp-content/uploads/2024/02/milton-hall-jeff.jpghttps://medinsight.com/wp-content/uploads/2024/02/richards-robert.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/strategic-approaches-to-social-determinants-of-health-prioritizing-impactful-data-for-population-health/2024-12-09T20:22:00+00:00https://medinsight.com/wp-content/uploads/2024/02/strategic-approaches-sdoh-webinar.jpghttps://medinsight.com/wp-content/uploads/2024/02/naidu-adrian.jpghttps://medinsight.com/wp-content/uploads/2024/02/claire-de-castro.jpghttps://medinsight.com/wp-content/uploads/2024/02/yi-rong.jpghttps://medinsight.com/wp-content/uploads/2024/02/melody-craff.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/payer-market-outlook/2024-12-09T20:22:21+00:00https://medinsight.com/wp-content/uploads/2024/02/payer-market-webinar.jpghttps://medinsight.com/wp-content/uploads/2024/02/dachary.jpghttps://medinsight.com/wp-content/uploads/2024/02/yi-rong.jpghttps://medinsight.com/wp-content/uploads/2024/02/haughton-john.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/contract-management-mastery-what-you-need-to-succeed-in-value-based-care-contracts/2024-12-09T20:22:41+00:00https://medinsight.com/wp-content/uploads/2024/02/contract-management-mastery-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/ai-trends-and-predictions-for-payers-and-providers/2024-12-09T20:23:26+00:00https://medinsight.com/wp-content/uploads/2024/02/healthcare-ai-trends-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/surviving-and-thriving-under-movement-to-value-based-care-arrangements/2024-12-09T20:23:46+00:00https://medinsight.com/wp-content/uploads/2024/05/vbc-arrangements-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/how-ehr-workflows-impact-clinician-experience-patient-care-and-profitability/2024-12-09T20:24:10+00:00https://medinsight.com/wp-content/uploads/2023/11/insiteflow-webinar.pnghttps://medinsight.com/healthcare-data-analytics-resources/webinar/whats-new-in-medinsight-benchmark-portfolio/2024-12-09T20:24:29+00:00https://medinsight.com/wp-content/uploads/2023/07/medinsight-benchmarks-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/top-5-ways-to-leverage-milliman-data-assets-for-strategic-healthcare-market-analysis/2024-12-09T20:24:46+00:00https://medinsight.com/wp-content/uploads/2023/07/medinsight-market-analysis-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/telehealth-expansion-and-other-creative-strategies-for-covid19-patient-care/2024-12-09T20:25:13+00:00https://medinsight.com/wp-content/uploads/2023/07/telehealth-expansion-covid-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/pandemic-induced-medical-loss-ratio-opportunities/2024-12-09T20:25:34+00:00https://medinsight.com/wp-content/uploads/2023/07/pandemic-medical-loss-ratio-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/medical-action-planning-at-ochsner-health-network/2024-12-09T20:44:20+00:00https://medinsight.com/wp-content/uploads/2023/07/oschner-health-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/learn-how-covenant-health-and-scripps-aco-use-claims-based-analytics-to-manage-risk-contracts/2024-12-09T20:51:18+00:00https://medinsight.com/wp-content/uploads/2023/07/covenant-scripps-aco-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/knowing-your-population-risk-scores-and-risk-stratification/2024-12-09T21:28:28+00:00https://medinsight.com/wp-content/uploads/2023/07/risk-score-stratification-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/improving-clinical-documentation-for-risk-adjustment/2024-12-09T21:28:53+00:00https://medinsight.com/wp-content/uploads/2023/07/improving-clinical-doc-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/hospital-contracting-modernization-at-blue-cross-blue-shield-of-kansas-city/2024-12-09T21:29:13+00:00https://medinsight.com/wp-content/uploads/2023/07/bcbs-kc-webinar-e1700509228186.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/group-and-member-retention-strategies-post-covid/2024-12-09T21:29:36+00:00https://medinsight.com/wp-content/uploads/2023/07/retention-strategies-covid-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/employer-group-resources-the-new-standard-for-health-plans-in-employer-group-analytics/2024-12-09T21:29:55+00:00https://medinsight.com/wp-content/uploads/2023/07/egi-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/drive-to-value-based-results/2024-12-09T22:31:38+00:00https://medinsight.com/wp-content/uploads/2023/07/value-based-results-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/direct-primary-care-a-unique-healthcare-solution-for-employers/2024-12-09T22:31:56+00:00https://medinsight.com/wp-content/uploads/2023/07/direct-primary-care-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/direct-contracting-evaluating-opportunities-for-employers-and-providers-to-achieve/2024-12-09T22:32:29+00:00https://medinsight.com/wp-content/uploads/2023/07/direct-contracting-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/defining-your-organizations-path-in-analytics/2024-12-09T22:32:45+00:00https://medinsight.com/wp-content/uploads/2023/07/analytics-coe-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/deeper-dive-into-continuing-education/2024-12-09T22:33:13+00:00https://medinsight.com/wp-content/uploads/2023/07/continuing-education-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/covid-19-impact-on-healthcare-utilization-enrollment-and-cost/2024-12-09T22:33:30+00:00https://medinsight.com/wp-content/uploads/2023/07/covid-19-impact-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/cmmis-direct-contracting-model-participation-primer/2024-12-09T22:33:48+00:00https://medinsight.com/wp-content/uploads/2023/07/cmmi-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/assessing-the-impact-of-covid-19-on-risk-contracts/2024-12-09T22:34:07+00:00https://medinsight.com/wp-content/uploads/2023/07/covid-risk-contracts-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/advancements-in-quantifying-lowvalue-care-opportunity-reducing-harmful-cascades-of-care/2024-12-09T22:34:27+00:00https://medinsight.com/wp-content/uploads/2023/07/low-value-care-webinar.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/analytics-in-action-reflecting-on-2024-and-predicting-2025-trends/2024-12-20T18:42:55+00:00https://medinsight.com/wp-content/uploads/2024/08/reflecting-on-2024-webinar.jpghttps://medinsight.com/wp-content/uploads/2023/09/broulette.jpghttps://medinsight.com/wp-content/uploads/2024/02/dachary.jpghttps://medinsight.com/wp-content/uploads/2024/08/george-sarah.jpghttps://medinsight.com/wp-content/uploads/2024/08/krisle-erik.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/mastering-value-based-care-contracts-strategies-for-success/2025-02-11T15:45:28+00:00https://medinsight.com/wp-content/uploads/2024/12/vbc-contract-management-webinar.jpghttps://medinsight.com/wp-content/uploads/2023/09/broulette.jpghttps://medinsight.com/wp-content/uploads/2024/12/gupta-umang.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/integrated-risk-adjustment-solutions-enhancing-reimbursement-and-patient-care/2025-03-13T20:15:09+00:00https://medinsight.com/wp-content/uploads/2024/12/risk-adjustment-webinar.jpghttps://medinsight.com/wp-content/uploads/2024/02/dachary.jpghttps://medinsight.com/wp-content/uploads/2024/12/milne-brian.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/from-data-to-strategy-scaling-payer-analytics-for-growth/2025-05-23T14:30:40+00:00https://medinsight.com/wp-content/uploads/2025/02/scaling-payer-analytics-webinar.jpghttps://medinsight.com/wp-content/themes/blankslate-child/assets/images/2025-best-in-klas-data-analytics-platforms-payer.svghttps://medinsight.com/wp-content/uploads/2024/02/dachary.jpghttps://medinsight.com/wp-content/uploads/2025/02/piancentini-lauren.jpghttps://medinsight.com/wp-content/uploads/2025/02/connors-nick.jpghttps://medinsight.com/wp-content/uploads/2025/05/jones-shaun.jpghttps://medinsight.com/healthcare-data-analytics-resources/webinar/leading-through-change-2025-trends-and-2026-strategies-for-healthcare-analytics/2025-06-10T15:09:10+00:00https://medinsight.com/wp-content/uploads/202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## Pharmacy Drug Trends Reporting [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/addressing-pharmacy-drug-trends-with-employer-group-reporting/#content) # Addressing pharmacy drug trends with employer group reporting By Lauren Piacentini 29 November 2023 Print / PDF Share ![]() ## Share this page Copied Addressing pharmacy drug trends with employer group reporting Lauren Piacentini According to a new study by the Business Group on Health, over 90% of employers reported concern over high-cost drugs and increasing pharmacy costs. This figure is not surprising when you consider that the average list price increase was nearly $150 per drug in January 2022 and rose to $250 by July 2022. During the twelve-month period from July 2021 to July 2022, the price of 1,216 products surpassed the inflation rate of 8.5%.1 While manufacturer rebates help offset some of these cost increases, rising pharmacy costs pose a significant challenge for health plans, impacting their ability to provide affordable and comprehensive coverage to their members Even a small percentage of specialty pharmacy medications used to treat complex conditions can account for a significant portion of an employer’s pharmacy benefit plan costs – about 50% or more of total prescription spending.2 ## How can payers help employers make more informed decisions about their prescription benefits programs while staying ahead of these trends? Employer group reporting is a powerful tool that empowers health plans and their customers to make well-informed decisions, identify cost-saving opportunities, and improve the management of their pharmacy benefit programs. With these advanced reporting capabilities, health plans can gain enhanced visibility into the factors influencing their pharmacy drug spend, all while ensuring that members have access to clinically appropriate prescription medications. The value of employer group reporting extends beyond cost control, offering several key benefits that contribute to the overall success of pharmacy benefit management. ## Leverage reliable pharmacy spend data and insights Relying solely on reports from partners such as pharmacy benefit managers and pharmacy vendors to manage the cost and quality of your pharmacy benefit program may result in missing crucial information. These gaps can hinder your ability to effectively optimize where pharmacy dollars are allocated for your employer groups. Health plans need to know if their data has integrity issues – i.e. missing data on some percentage of members, having prescription counts but not costs, having too many classifications of “other/unknown,” or relying only on claims data without any pharmacy data at all – so they can avoid taking actions that are ineffective or cause new problems. Employer group reporting aggregates data from various sources such as pharmacy benefit managers (PBMs), health plans, and pharmacies to deliver a more accurate representation of pharmacy spend, allowing health plans to identify trends, patterns, and potential cost-saving opportunities with greater confidence. ## Look at both traditional pharmacy and medical pharmacy claims To gain a larger view of factors driving pharmacy spend, it’s important to have access to pharmacy data from all sources, including those prescriptions processed under the medical benefit. For example, specialty pharmacy drugs often require additional handling and are sometimes administered in a medical setting such as a hospital, resulting in a medical claim. Having access to drugs administered in a medical setting and present only in medical claims data can help employer groups understand and make decisions including whether to promote cost-effective specialty pharmacy delivery services for certain medications.  One example of cost-saving measures is the administration of certain drugs in an office setting instead of a more expensive hospital facility. Additionally, opting to have specific medications shipped from an in-network specialty pharmacy can also help reduce costs. Employer group reporting can help integrate pharmacy and medical pharmacy claims by providing a unified view of an individual’s healthcare utilization. By combining pharmacy claims data with medical claims data, health plans can gain a comprehensive understanding of the medications prescribed, the conditions being treated, and the overall impact on healthcare costs. ## Identify at-risk members Another important point to consider is the outcomes of members who present a combination of health challenges such as being diagnosed with diabetes and/or mental health disorders. By analyzing high-risk members or [high-cost claimants](https://medinsight.com/healthcare-data-analytics-resources/blog/mitigating-the-impact-of-high-cost-claimants-with-employer-group-insights/), health plans can determine if there are opportunities to fine-tune benefit plans, increase medication adherence, and promote care management programs.. With the help of employer group reporting, health plans can more closely monitor pharmacy claims data and track the effectiveness of these interventions and make necessary adjustments to optimize outcomes. ## Leverage benchmarking and trend analysis To help employer groups understand how they compare to their peers, benchmarking pharmacy costs and utilization can provide additional insights into how well they are managing pharmacy spend. Account management teams need to identify areas where their clients are either under or over performing to best assess and recommend where their management teams should focus resources and efforts to improve performance. Benchmarks provide credible external figures to form the basis of these analyses and provide detailed cuts of data specific to pharmacy claims which include generic, brand, specialty, and preventive pharmacy trends and opportunities. A pharmacy benchmark analysis positions you to explore “what if” scenarios and set different utilization targets that could drive to a desired bottom line financial outcome. A recent example involves using utilization benchmarks for glucagon-like peptide-1 (GLP-1) agonists, commonly used to treat Type-2 diabetes, to predict the usage of these drugs in weight loss treatment plans. Employer group reporting can help benchmark pharmacy spend by providing a comparative analysis of pharmacy costs and utilization across different employer groups. Armed with this information, health plans can identify emerging patterns, such as shifts in medication utilization or changes in drug pricing and adjust their pharmacy benefit strategies accordingly. ## Employer Group Insights brings it all together [MedInsight’s Employer Group Insights (EGI)](https://medinsight.com/healthcare-data-analytics-software/applications/employer-group-insights-egi/) application not only enables you to increase the quality and integrity of your pharmacy data but also effectively integrates pharmacy, medical, and other data sources to provide your plan with a more holistic view of its pharmacy management program. With EGI, health plans can: - Gain a deeper understanding of pharmacy utilization and costs and identify which areas require additional attention and which benefit plan designs to recommend to employer groups (e.g., prior authorization or step therapy to encourage appropriate utilization and cost controls). - Identify members who can benefit from additional services to better manage complex therapies and conditions. By ensuring members are actively involved in their treatment plans, health plans and their employer customers can prevent additional medical expenses that may arise from non-adherence to prescribed therapies. - Understand your future risk based on your pharmacy spend and prepare for emerging drugs by understanding median cost trends for therapies with the same designations (e.g., Orphan, Priority Review, and Accelerated Approval). ## Get started today [Speak with one of our employer group reporting experts](https://medinsight.com/healthcare-data-analytics-contact/) or [request an analytics assessment](https://medinsight.com/healthcare-data-analytics-assessment/) so you can gain the insights you need to serve your employer group clients more effectively. ## References: 1. [New HHS Reports Illustrate Potential Positive Impact of Inflation Reduction Act on Prescription Drug Prices \| HHS.gov](https://www.hhs.gov/about/news/2022/09/30/new-hhs-reports-illustrate-potential-positive-impact-inflation-reduction-act-prescription-drug-prices.html) 2. [Health Plans Brace For Specialty Drugs Eclipsing 50% Of Prescription Spending (forbes.com)](https://www.forbes.com/sites/brucejapsen/2022/05/03/health-plans-brace-for-specialty-drugs-eclipsing-50-of-prescription-spending/?sh=51319654307d) [Contact us to learn more about employer group reporting software](https://medinsight.com/healthcare-data-analytics-contact/) ## Explore more tags from this article [employer group insights](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/employer-group-insights/), [healthcare analytics](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/healthcare-analytics/), [high-cost claimant](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/high-cost-claimant/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Healthcare Analytics Case Studies [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/case-studies/#content) #### Case Studies # Healthcare data analytics case studies [See our client testimonials](https://medinsight.com/healthcare-data-analytics-resources/client-testimonials/) [![](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/02/genesys-pho-case-study-1.png)](https://medinsight.com/healthcare-data-analytics-resources/case-study/genesys-pho/) [**Genesys PHO: Optimizing patient risk stratification and clinical outreach**](https://medinsight.com/healthcare-data-analytics-resources/case-study/genesys-pho/) [Genesys PHO, a Michigan-based physician hospital organization and partnership between primary care physicians and investors Ascension and Henry Ford, serves about 120,000 patients. Recently, the organization began working to improve outcomes using risk stratification to improve provider performance. Working with analysts and leveraging the risk stratification tools in the Milliman MedInsight VBC Platform, nurses embedded](https://medinsight.com/healthcare-data-analytics-resources/case-study/genesys-pho/) [… Genesys PHO: Optimizing patient risk stratification and clinical outreach](https://medinsight.com/healthcare-data-analytics-resources/case-study/genesys-pho/) [View the case study](https://medinsight.com/healthcare-data-analytics-resources/case-study/genesys-pho/) [![Independent Health Case Study](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/01/independent-health-case-study.jpg)](https://medinsight.com/healthcare-data-analytics-resources/case-study/independent-health/) [**Independent Health: Next-generation employer group reporting**](https://medinsight.com/healthcare-data-analytics-resources/case-study/independent-health/) [Key sections: Action Results Looking ahead Download the story From its roots in a University of Buffalo graduate school project to its unique preventive care model, Independent Health Inc. has always taken an innovative approach to its role as a provider of health plans to approximately 380,000 residents of western New York. With a mission](https://medinsight.com/healthcare-data-analytics-resources/case-study/independent-health/) [… Independent Health: Next-generation employer group reporting](https://medinsight.com/healthcare-data-analytics-resources/case-study/independent-health/) [View the case study](https://medinsight.com/healthcare-data-analytics-resources/case-study/independent-health/) [![SEHP Case Study](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/09/webinars.jpg)](https://medinsight.com/healthcare-data-analytics-resources/case-study/sehp/) [**SEHP: Maximizing the power of integrated data with the Innovation Portal**](https://medinsight.com/healthcare-data-analytics-resources/case-study/sehp/) [Southeastern Health Partners (SEHP) – a clinically integrated network consisting of four healthcare systems, including 13 hospitals and 3,600 providers – sets its continuous improvement goals high. The Greenville, South Carolina-based organization is already recognized by the Centers for Medicare & Medicaid Services for consistently ranking among the most efficient Accountable Care Organizations. Even so,](https://medinsight.com/healthcare-data-analytics-resources/case-study/sehp/) [… SEHP: Maximizing the power of integrated data with the Innovation Portal](https://medinsight.com/healthcare-data-analytics-resources/case-study/sehp/) [View the case study](https://medinsight.com/healthcare-data-analytics-resources/case-study/sehp/) [![CFIN Case Study](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/02/cfin-case-study.jpg)](https://medinsight.com/healthcare-data-analytics-resources/case-study/cfin/) [**CFIN: Scaling value-based care with a proven data and analytics platform**](https://medinsight.com/healthcare-data-analytics-resources/case-study/cfin/) [With a population of over 250,000 lives spanning eight hospitals and nearly two dozen counties, a Northwest-based clinically and financially integrated network (CFIN) wanted to take the next step in its evolution as a pioneering driver of value-based care (VBC). With a business model incorporating partnerships with both commercial and public health plans and a](https://medinsight.com/healthcare-data-analytics-resources/case-study/cfin/) [… CFIN: Scaling value-based care with a proven data and analytics platform](https://medinsight.com/healthcare-data-analytics-resources/case-study/cfin/) [View the case study](https://medinsight.com/healthcare-data-analytics-resources/case-study/cfin/) [![Advanced Health Case Study]()](https://medinsight.com/healthcare-data-analytics-resources/case-study/advanced-health/) [**Advanced Health: Holistic population health improvement integrating claims and clinical data**](https://medinsight.com/healthcare-data-analytics-resources/case-study/advanced-health/) [Oregon-based Advanced Health is a coordinated care organization (CCO) – the state’s version of an accountable care organization (ACO) – that takes an innovative approach to the care of its 26,000 members. Serving two counties where 14-17% of residents live in poverty, according to U.S. Census data, Advanced Health manages a population with complex medical](https://medinsight.com/healthcare-data-analytics-resources/case-study/advanced-health/) [… Advanced Health: Holistic population health improvement integrating claims and clinical data](https://medinsight.com/healthcare-data-analytics-resources/case-study/advanced-health/) [View the case study](https://medinsight.com/healthcare-data-analytics-resources/case-study/advanced-health/) [![Non-Profit Case Study]()](https://medinsight.com/healthcare-data-analytics-resources/case-study/improve-patient-outcomes/) [**Nonprofit health system: Improve patient outcomes by “looking outside the silo”**](https://medinsight.com/healthcare-data-analytics-resources/case-study/improve-patient-outcomes/) [When one of the South’s largest not-for-profit healthcare systems recently searched for a new healthcare data analytics solution, a key goal was establishing a consistent methodology for identifying and solving problem areas. A previous attempt with another data aggregator and vendor had stalled: a messy implementation process had dragged on for years, and even worse,](https://medinsight.com/healthcare-data-analytics-resources/case-study/improve-patient-outcomes/) [… Nonprofit health system: Improve patient outcomes by “looking outside the silo”](https://medinsight.com/healthcare-data-analytics-resources/case-study/improve-patient-outcomes/) [View the case study](https://medinsight.com/healthcare-data-analytics-resources/case-study/improve-patient-outcomes/) [![]()](https://medinsight.com/healthcare-data-analytics-resources/case-study/power-of-data-organization-and-standardization/) [**DVACO: The power of data organization and standardization**](https://medinsight.com/healthcare-data-analytics-resources/case-study/power-of-data-organization-and-standardization/) [The Delaware Valley Accountable Care Organization (DVACO) aims to deliver better healthcare at a lower cost to around 250,000 members in the Greater Philadelphia region. DVACO is currently the region’s largest ACO, with more than 2,000 primary care physicians and 250,000 attributed patients. DVACO participates in the Medicare MSSP program, and six additional risk-based contracts](https://medinsight.com/healthcare-data-analytics-resources/case-study/power-of-data-organization-and-standardization/) [… DVACO: The power of data organization and standardization](https://medinsight.com/healthcare-data-analytics-resources/case-study/power-of-data-organization-and-standardization/) [View the case study](https://medinsight.com/healthcare-data-analytics-resources/case-study/power-of-data-organization-and-standardization/) [![Virgina Health Case Study]()](https://medinsight.com/healthcare-data-analytics-resources/case-study/measuring-waste-to-improve-care/) [**Virginia Health: Measuring waste to improve care**](https://medinsight.com/healthcare-data-analytics-resources/case-study/measuring-waste-to-improve-care/) [The challenge The Choosing Wisely® campaign’s success has renewed interest towards reducing low-value healthcare services, classified as “unnecessary care” in the healthcare industry. The Virginia Center for Health Innovation and Virginia Health Information were looking to translate the Choosing Wisely campaign into quantifiable results for their insured population. They partnered with Milliman’s healthcare analytics software](https://medinsight.com/healthcare-data-analytics-resources/case-study/measuring-waste-to-improve-care/) [… Virginia Health: Measuring waste to improve care](https://medinsight.com/healthcare-data-analytics-resources/case-study/measuring-waste-to-improve-care/) [View the case study](https://medinsight.com/healthcare-data-analytics-resources/case-study/measuring-waste-to-improve-care/) [![Atrio Case Study]()](https://medinsight.com/healthcare-data-analytics-resources/case-study/from-insight-to-impact/) [**ATRIO: From insight to impact**](https://medinsight.com/healthcare-data-analytics-resources/case-study/from-insight-to-impact/) [ATRIO Health Plans is an organization owned by several providers in and around Salem, Oregon. It has almost 30,000 members, and 90% are Medicare enrollees. The challenge As with every health plan, ATRIO is constantly looking for ways to improve patient care and the bottom line. The approach When ATRIO made the strategic decision to](https://medinsight.com/healthcare-data-analytics-resources/case-study/from-insight-to-impact/) [… ATRIO: From insight to impact](https://medinsight.com/healthcare-data-analytics-resources/case-study/from-insight-to-impact/) [View the case study](https://medinsight.com/healthcare-data-analytics-resources/case-study/from-insight-to-impact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## MSSP ACOs Savings 2022 [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/mssp-acos-using-milliman-medinsight-achieved-over-274m-shared-savings-in-2022/#content) #### Press Release # MSSP ACOs using Milliman MedInsight achieved over $274M shared savings in 2022 under CMS Medicare Shared Savings Program [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/mssp-acos-using-milliman-medinsight-achieved-over-274m-shared-savings-in-2022/) SEATTLE, WASH. – Nov. 17, 2023 – Milliman MedInsight, a leading healthcare data and analytics company, is pleased to announce the outstanding achievements of Accountable Care Organizations (ACOs) utilizing the Milliman MedInsight healthcare analytics platform in support of the Medicare Shared Savings Program (MSSP) for the 2022 performance year. Key Highlights of 2022 Performance Results for Milliman MedInsight clients: - **80% Success Rate:** 80% of MSSP MedInsight Platform users achieved shared savings, surpassing the 63% national average of MSSP ACOs. - **Substantial Savings:** Milliman MedInsight clients collectively achieved an impressive total of $274 million of shared savings, contributing significantly to the nationwide total of $2.52 billion. - **Exceptional Impact:** Out of 482 ACOs participating in MSSP, 25 are Milliman MedInsight users. Despite representing only 5% of total MSSP ACOs, MedInsight clients generated 11% of the total shared savings. Todd Fessler, Milliman MedInsight Chief Revenue Officer, expressed enthusiasm about the results, stating, “We are thrilled to announce that our MSSP ACO clients have once again outperformed national benchmarks, achieving shared savings under the CMS Medicare Shared Savings Program. This success underscores the potency of Milliman MedInsight in empowering ACOs to thrive in value-based payment models. We remain confident that Milliman MedInsight will continue to provide the necessary analytics and insights for organizations to excel in value-based payment models.” The Centers for Medicare & Medicaid Services (CMS) announced the 2022 MSSP savings in August, marking the sixth consecutive year of program savings, as reported by CMS. To participate in MSSP, providers must be affiliated with accountable care organizations (ACOs), which aim to decrease unnecessary healthcare expenses and foster cooperation among local physicians, hospitals, and providers to enhance patient care. The primary focus of ACOs is to improve quality of care, affordability, and overall patient experience. Overall, the program’s goal is to encourage healthcare providers to collaborate and coordinate care for Medicare beneficiaries, working towards reducing healthcare costs and improving quality of care. As a pioneer in enterprise data management in healthcare, Milliman MedInsight is one of the healthcare industry’s most highly regarded platforms for value-based care analytics. Since its inception in 1997, Milliman MedInsight has played a pivotal role in bridging the gap between cost management and care management. The platform supports actuarial, care, and data analytics teams with data warehousing, advanced analytics, prescriptive reporting, and tailored benchmarks. ## About Milliman MedInsight Milliman MedInsight provides the healthcare industry’s most powerful analytics on top of validated data sources from inside and outside healthcare organizations to drive informed decision-making across the enterprise. Milliman MedInsight analytics has been adopted by over 300 health plans, employers, at-risk providers/ACOs, state governments, community health coalitions, and third-party administrators. Milliman MedInsight offers a platform, application, and analytic products for the payer and provider market that provide preconfigured or custom reporting and data configurations that can address specific business needs. To learn more, visit [medinsight.com](http://medinsight.com/). [Download the press release.](https://medinsight.com/wp-content/uploads/2023/11/mssp-savings-2022-press-release.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Best in KLAS Award [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/best-in-klas-for-payer-quality-analytics-for-second-year-in-a-row/#content) #### Press Release # Milliman MedInsight ranked best in KLAS for payer quality analytics for second year in a row [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/best-in-klas-for-payer-quality-analytics-for-second-year-in-a-row/) Seattle – January 31, 2020 – MedInsight, Milliman, Inc.’s highly regarded platform for data warehousing and healthcare analytics, ranked number one in the 2020 Best in KLAS: Software and Services report for Payer Quality and Risk Analytics. MedInsight receives this honor for the second year in a row. KLAS, a research firm focused on the healthcare IT market since 1996, publishes this report every year, recognizing outstanding efforts to help healthcare organizations in their quest to deliver quality patient care. Based on thousands of interviews with healthcare organizations conducted by KLAS, this report ranks healthcare IT software and service vendors across numerous market segments. This year’s Best in KLAS report included grades across six targeted customer experience pillars: culture, relationship, operations, product, value, and loyalty. “Providers and payers demand better performance, usability, and interoperability from their vendor partners every year. Best in KLAS winners set the standard of excellence in their market segment. It serves as a signal to providers that they should expect only the best from the winning vendors,” said KLAS President, Adam Gale. During the preparation of the annual Best in KLAS report, KLAS reviews more than 30,000 interviews conducted with health systems and payers that year. The Best in KLAS designation is awarded only in those software and services market segments that have the broadest operational and clinical impact on healthcare organizations. “We are honored to have won the Best in KLAS for Payer Quality Analytics for a second year in a row. Client expectations in healthcare analytics are increasing as businesses use analytics to help transform their insurance and care processes. KLAS surveys and assessments help us identify what is working and what needs improvement to effectively meet the expanding needs of our clients,” said Rich Moyer, Chief Product Officer for MedInsight. For more information about Milliman MedInsight’s products go to [www.medinsight.milliman.com](https://medinsight.com/). ## About Milliman MedInsight Milliman MedInsight is one of the healthcare industry’s most highly regarded platforms for data warehousing and healthcare analytics. MedInsight Solutions have been adopted by over 300 health plans, employers, at-risk providers/ACOs, state governments, community health coalitions, and third party administrators. Additionally, MedInsight has standalone Products that provide preconfigured or custom reporting and data configurations that can address specific business needs. ## About Milliman Milliman is among the world’s largest providers of actuarial and related products and services. The firm has consulting practices in healthcare, property & casualty insurance, life insurance and financial services, and employee benefits. Founded in 1947, Milliman is an independent firm with offices in major cities around the globe. For further information, visit [milliman.com](https://milliman.com/). ## About KLAS KLAS is a data-driven company on a mission to improve the world’s healthcare by enabling provider and payer voices to be heard and counted. Working with thousands of healthcare professionals, KLAS collects insights on software, services and medical equipment to deliver reports, trending data and statistical overviews. KLAS data is accurate, honest and impartial. The research directly reflects the voice of healthcare professionals and acts as a catalyst for improving vendor performance. To learn more about KLAS and the insights we provide, visit [KLASresearch.com](https://klasresearch.com/) Contact: Bridget Watson Milliman, Inc. Tel: +1 206 504 5859 [bridget.watson@milliman.com](mailto:bridget.watson@milliman.com) [Download the press release.](https://medinsight.com/wp-content/uploads/2023/07/pr-best-in-klas-second-year.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Best in KLAS Award [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/best-in-klas-for-payer-quality-analytics-for-third-year-in-a-row/#content) #### Press Release # Milliman MedInsight ranked best in KLAS for payer quality analytics for third year in a row [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/best-in-klas-for-payer-quality-analytics-for-third-year-in-a-row/) Seattle, WA –February18,2021–MedInsight, Milliman, Inc.’s highly regarded platform for data warehousing and healthcare analytics, rankednumber onein the2021Best in KLAS: Software and Services report for Payer QualityAnalytics.MedInsight receives this honor for thethirdyear in a row. KLAS, a research firm focused on the healthcare IT market since 1996,publishes this report every year, recognizing outstanding efforts to help healthcare organizations in their quest to deliver quality patient care. Based on thousands of interviews with healthcare organizations conducted by KLAS,this report ranks healthcare IT software and service vendors across numerous market segments. Thisyear’s Best in KLAS report included grades acrosssixtargetedcustomer experience pillars: culture, relationship, operations, product, value, and loyalty. MedInsight’s Client Advisory Board, which consists of11 client organizations from the payer, provider, employer,state governmentandall–payer databasemarkets,isa sourceof constant guidance and feedback. Thisdedicated group of MedInsight clients adviseson new product releases and updates, as well as overall direction of the organization; the Client Advisory Board’s work is a notable contributor in the effort it takes to achieve this type of accomplishment. “Each year, thousands of healthcare professionals across the globe take the time to share their voice with KLAS. They know that sharing their perspective helps vendors to improve and helps their peers make better decisions. These conversations are a constant reminder to me of how necessary accurate, honest, and impartial reporting is in the healthcare industry,” said KLAS President, Adam Gale. “The Best in KLAS report and the awards it contains set the standard of excellence for software and services firms. Vendors who win the title of ‘Best in KLAS’ should celebrate and remember that providers now accept only the best from their products and services. The Best in KLAS award serves as a signal to provider and payer organizations that they should expect excellence from the winning vendors.” During thepreparation of the annual Best in KLAS report, KLAS reviews more than 30,000 interviews conducted with health systems and payers that year. The Best in KLAS designation is awarded only in those software and services market segments that have the broadest operational and clinical impact on healthcare organizations. “We’re honored to receive this recognition for the 3rd year in a row. I want to thank our staff and clients for persevering in a difficult past year. Despitethe challenges,we allcollaborated andworked together to use data and analytics to continue to improve healthcare insurance and delivery.”said Rich Moyer, Chief Product Officer for MedInsight. For more information about Milliman MedInsight’s products go to[www.medinsight.milliman.com](https://medinsight.com/). ## About Milliman MedInsight Milliman MedInsight is one of the healthcare industry’s most highly regarded platforms for data warehousing and healthcare analytics. MedInsight Solutions have been adopted by over 300 health plans, employers, at–risk providers/ACOs, state governments, community health coalitions, and thirdparty administrators. Additionally, MedInsight has standalone Products that provide preconfigured or custom reporting and data configurationsthat can address specific businessneeds. ## About Milliman Milliman is among the world’s largest providers of actuarial and related products and services. The firm has consultingpracticesinhealthcare,property&casualtyinsurance,lifeinsuranceandfinancialservices,and employeebenefits.Foundedin1947,Millimanisanindependentfirmwithofficesinmajorcitiesaroundthe globe. For further information, visit[milliman.com](https://milliman.com/). ## About KLAS KLAS is adata–driven company on a mission to improve the world’s healthcare by enablingprovider and payer voices to be heard and counted. Working with thousands of healthcareprofessionals, KLAS collects insights on software, services and medical equipment to deliverreports, trending data and statistical overviews. KLAS data is accurate, honest, and impartial.The research directly reflects the voice of healthcare professionals and acts as a catalyst forimproving vendor performance.To learn more about KLAS andthe insights we provide, visit [KLASresearch.com](https://klasresearch.com/). Contact: Bridget Watson Milliman, Inc. Tel: +1 206 504 5859 [bridget.watson@milliman.com](mailto:bridget.watson@milliman.com) [Download the press release.](https://medinsight.com/wp-content/uploads/2023/07/pr-best-in-klas-third-year.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Best in KLAS Award [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/best-in-klas-for-payer-quality-analytics/#content) #### Press Release # Milliman MedInsight ranked best in KLAS for payer quality analytics [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/best-in-klas-for-payer-quality-analytics/) Seattle–March 4, 2019–MedInsight, Milliman, Inc.’s highly regarded platform for data warehousing and healthcare analytics, was named number one in the 2019 Best in KLAS: Software and Services report for Payer Quality Analytics. KLAS, a research firm focused on the healthcare IT market since 1996, awarded this honor in recognition of MedInsight’s outstanding efforts to help healthcare organizations in their quest to deliver high–value, quality patient care. Based on thousands of interviews with healthcare organizations conducted by KLAS, the Best in KLAS recognition is only awarded to organizations that KLAS judges to have the broadest impact on healthcare. This year’s Best in KLAS report included grades across six targeted customer experience pillars: culture, relationship, operations, product, value, and loyalty. “We are incredibly proud to have been ranked number one in the Payer Quality Analytics category and to have gotten high marks in so many of KLAS’key customer experience pillars. This independent recognition demonstrates our ongoing focus on helping healthcare organizations maximize their effectiveness and also shows how much we invest in, and value, client success and satisfaction with the MedInsight analytic platform,” said Rich Moyer, Chief Product Officer for MedInsight. Every year, KLAS publishes the Best in KLAS report which ranks healthcare IT solutions across a variety of market segments including software, professional services, and medical equipment. KLAS reviews more than 30,000 interviews with health systems and payers each year to rank the vendors for the report. The Best in KLAS designation is reserved for the leading vendors in each market segment that have the broadest operational and clinical impact on healthcare organizations. “Best in KLAS is about raising the bar for healthcare technology. It’s providers and payers demanding better performance, usability, and interoperability. Ultimately, Best in KLAS is about giving providers and payers the tools they need to facilitate superior care and improved outcomes,” said KLAS President Adam Gale. For more information about Milliman MedInsight’s products go to [www.medinsight.milliman.com](https://medinsight.com/). ## About Milliman MedInsight Milliman MedInsight is one of the healthcare industry’s most highly regarded platforms for data warehousing and healthcare analytics.MedInsightSolutions havebeen adopted by over300 health plans, employers, at–risk providers/ACOs, state governments, community health coalitions, and third party administrators. Additionally,MedInsighthasstandalone Products that provide preconfiguredor custom reporting and data configurations that can address specific business needs. ## About Milliman Milliman is among the world’s largest providers of actuarial and related products and services. The firm has consulting practices in healthcare, property& casualty insurance, life insurance and financial services, and employee benefits. Founded in 1947, Milliman is an independent firm with offices in major cities around the globe.For further information, visit [milliman.com](https://milliman.com/). Contact:Bridget Watson Milliman, Inc. Tel: +1 206 5045859 [bridget.watson@milliman.com](mailto:bridget.watson@milliman.com) [Download the press release.](https://medinsight.com/wp-content/uploads/2023/07/pr-best-in-klas-payer-quality-analytics.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Health Waste Calculator Featured [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/health-waste-calculator-featured-in-health-affairs-third-most-read-article-of-2017/#content) #### Press Release # MedInsight Health Waste Calculator featured in Health Affairs’ third most-read article of 2017 [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/health-waste-calculator-featured-in-health-affairs-third-most-read-article-of-2017/) SEATTLE–February 27, 2018–Milliman, Inc.,a leading global provider of actuarial, risk management, and technology solutions, today announcedthatthefirm’sMedInsight Health WasteCalculator–a leadinganalytic platform that provides actionable data around healthcare quality, efficiency, and effectiveness–was featured in Health Affairs’ third most–read article of 2017. The article,“Low–Cost, High–Volume Health Services Contribute The Most To Unnecessary Health Spending,”highlightsthe Commonwealth of Virginia’s use of the MedInsight Health Waste Calculator,which found morethan $586 million in unnecessary costs in the Virginia All–Payer Claims Database. The Virginia Center for Health Innovation (VCHI), Virginia Health Information (VHI), and Value–Based Insurance Design (VBID)Healthpartnered with MedInsight to support Virginia’s statewide initiatives to identify andreduce low value, unnecessary medical tests and proceduresin their healthcare systems. VCHIbrought together Virginia’s leading health providers, payers, and employer groups to root out low–value care.Workingwith theVHI team, theyused the MedInsight Health Waste Calculator to aid their measurement, monitoring, and reporting on services that provide no net health benefit. Marcos Dachary,director ofproductmanagement at Milliman MedInsight, said, “Our product’s capability to illuminate the cost andinefficienciesin the state of Virginia’s healthcare systemisan important step in improving high value care.We look forward to our continued support of the VirginiaCenter forHealth Innovation team in their efforts tohighlightunnecessary, low valuespending amongphysiciansand patients.” The Health Affairs article outlines the forty–four low–value health services analyzed in the 2014 data, why they were so costly, and how the MedInsight Health Waste Calculator identified them. “In Virginia, an important component of our 2018 Health Value Dashboard is to reduce utilization of low value medical tests and procedures so that we can free up needed resources to advance high value care. Our medical and business communities want to do what they can to better ensure that patients and providers are choosing wisely when it comes to healthcare,” said Beth Bortz, Presidentand CEO of Virginia Center for Health Innovation. The MedInsight Health Waste Calculator is an analytic tool powered by Milliman’s MedInsight software and encapsulates VBID Health’s market knowledge on wasteful healthcare spending. The tool identifies andquantifies the use ofpotentially unnecessary orharmful clinical services, including those defined by national initiatives such as the U.S. Preventive Services Task Force and Choosing Wisely®. MedInsight is used by over 300 health plans, employers, at–risk providers/ACOs, state governments, community health coalitions, and third party administrators. For more information about Milliman’s MedInsight products, go to [https://www.medinsight.milliman.com](https://medinsight.com/). ## About Milliman Milliman is among the world’s largest providers ofactuarial, risk management and technology solutions.Ourconsultingand advanced analytics capabilities encompasshealthcare, property & casualty insurance, life insurance and financialservices, and employee benefits. Founded in 1947, Milliman is an independent firm with offices in major cities around the globe.For further information, visit [milliman.com](https://milliman.com/). Contact:Bridget Watson Milliman, Inc. Tel:+1206 5045859 [Bridget.Watson@milliman.com](mailto:Bridget.Watson@milliman.com) [Download the press release.](https://medinsight.com/wp-content/uploads/2023/07/pr-waste-calculator-health-affairs.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## HITRUST Certification Announcement [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/hitrust-csf-certification-to-mitigate-risk-and-enhance-security-posture/#content) #### Press Release # MedInsight achieves HITRUST CSF® Certification to mitigate risk and enhance security posture [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/hitrust-csf-certification-to-mitigate-risk-and-enhance-security-posture/) Seattle, WA – February 3, 2021 – MedInsight executives announced today the MedInsight Solution has achieved Certified status for information security by HITRUST. HITRUST CSF Certification recognizes that MedInsight, the industry leading healthcare analytics ecosystem from Milliman, adheres to the highest standards for healthcare data security and privacy. “Over 300 healthcare organizations trust MedInsight with their data; and we take the responsibility to safeguard that data very seriously. We are constantly working to advance our security posture as new threats emerge,” said MedInsight founder and Milliman principal Kent Sacia. “HITRUST CSF Certification provides independent validation that our clients can rely on MedInsight to protect their information.” HITRUST helps organizations establish a comprehensive information risk management and compliance program. It promotes an integrated approach that ensures all programs are aligned to support an organization’s information risk management and compliance objectives. Roger Connolly, MedInsight’s chief technology officer, stated, “The process to achieve HITRUST certification is rigorous and comprehensive. The standards are based on industry leading requirements for how information is accessed, transmitted, and stored in a cloud environment. Adherence to the comprehensive HITRUST compliance protocols is a direct demonstration of how MedInsight is committed to protecting the privacy and security of our clients’ data.” Achieving this Certification places MedInsight in an elite group of organizations worldwide. By including federal and state regulations, standards and frameworks, and incorporating a risk-based approach, the HITRUST CSF helps organizations address data protection and security challenges through a comprehensive and flexible framework of prescriptive and scalable security controls. ## About MedInsight MedInsight is one of the healthcare industry’s most highly regarded platforms for data warehousing and healthcare analytics. MedInsight solutions have been adopted by over 300 health plans, employers, at-risk providers and ACOs, state governments, community health coalitions, and third-party administrators. MedInsight also offers standalone products that provide preconfigured or custom reporting and data configurations that can address specific business needs. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## MedInsight Payer Solution [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/medinsight-payer-solution/#content) #### Press Release # Milliman MedInsight launches new MedInsight Payer Solution [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/medinsight-payer-solution/) Seattle–February 22, 2019–MedInsight, Milliman, Inc.’s highly regarded platform for data warehousing and healthcare analytics, recently launched the newest release of its flagship product: the MedInsight Solutions. Recognizing that different types ofusershave different needs and priorities, thenew MedInsight Solutions offer custom tailored versions of the MedInsight platform. The transformation of MedInsight intouser–centric versions begins with theMedInsight Payer Solution, which offers abrand newnavigationwith acustom homepage forpayerclients. The newMedInsight Payer Solutionhomepageisdesigned to meetpayerspecific business challenges,built on the powerful analyticsand data processing capabilities that have made more than 300 organizations choose MedInsight as their core analytic platform. The MedInsight Solutions represent a leap forward in the world ofhealthcare analytics withnew client–centric interfaces,customizable dashboards, advancedgraphing libraries,industry leading query tools, and a comprehensive online knowledgebase. Throughitsnewhomepage, the MedInsightPayerSolutionservesup the analytics that best meet the needs ofthe payersegmentthrough intuitive user interfaces.For example,users can accesspre–built content that responds to the data and analytic needs of payers such ascomprehensive cost and utilizationanalysesand benchmarking to support performance assessment.This new approach puts the information organizations need to manage their business front and center moving away from a one–size–fits–most approach to an environment optimized to the needs of theuser. “Thisnewversion of the MedInsight Solutions incorporatenewtechnologiescoupled with a brand new homepage and navigationthat enable us to tailor MedInsight topayers,” Rich Moyer, MedInsight’s Chief Product Officer said. “We’re excited to present this new version to our clients and market, as we expect this to be a huge leap forward for our product and healthcare analytics.” For more information about Milliman MedInsight’s products go to [www.medinsight.milliman.com](https://medinsight.com/). ## About Milliman MedInsight Milliman MedInsight isone of the healthcare industry’s most highly regarded platforms for data warehousing and healthcare analytics. MedInsightSolutions havebeen adopted by over300 health plans, employers, at–risk providers/ACOs, state governments, community health coalitions, and third party administrators. Additionally,MedInsighthasstandalone Products that provide preconfigured or custom reporting and data configurations that can address specific business needs. ## About Milliman Milliman is among the world’s largest providers of actuarial and related products and services. The firm has consulting practices in healthcare, property & casualty insurance, life insurance and financial services, and employee benefits. Founded in 1947, Milliman is an independent firm with officesin major cities around the globe. For further information, visit [milliman.com](https://milliman.com/). Contact:Bridget Watson Milliman, Inc. Tel: +1 206 504 5859 [bridget.watson@milliman.com](mailto:bridget.watson@milliman.com) [Download the press release.](https://medinsight.com/wp-content/uploads/2023/07/pr-medinsight-payer-solution.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Healthcare Alliance Program [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/strategic-alliance-program-helps-healthcare-organizations-thrive/#content) #### Press Release # Milliman MedInsight launches Strategic Alliance Program to help healthcare organizations thrive in a competitive market [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/strategic-alliance-program-helps-healthcare-organizations-thrive/) Seattle, WA – June 7, 2023 – Milliman MedInsight, Inc., a leading provider of healthcare data and analytics, is proud to announce the launch of the MedInsight Strategic Alliance Program to help organizations boost the value and scalability of their offerings. This program represents a significant step forward in the healthcare industry, as it aims to create a connected ecosystem of business-focused healthcare technology and strategic alliances to revolutionize the future of healthcare. “At Milliman MedInsight, we are passionate about improving healthcare through data-driven insights,” said Scott Ponder, Vice President of Strategic Alliances for Milliman MedInsight. “Our strategic alliance program is a powerful way to work together with other healthcare leaders and innovators to deliver meaningful improvements in healthcare delivery and outcomes. Companies that are part of our alliance program leverage MedInsight’s unique platform and data-as-a-service approach to enhance the insights provided to their clients. This approach allows them to create a more comprehensive solution, enabling quality improvement, cost reduction, and smarter decision-making for their clients.” MedInsight’s Strategic Alliance Program has already attracted a wide range of industry-leading organizations, including Microsoft, Databricks, Epic, and MCG Health, among others. These companies offer innovative technology, consulting services, and specialized healthcare solutions to help healthcare organizations enhance their offerings and optimize their business operations. Through these alliances, MedInsight customers can gain a competitive edge in the market, improve patient outcomes, and drive meaningful improvements in healthcare delivery. With our specialized healthcare analytics, data, and deep industry experience, Milliman MedInsight is uniquely positioned to help healthcare organizations accelerate data transformation and insights. “Our Strategic Alliance Program is designed to expand the reach of our data-driven insights and create an ecosystem of innovative alliances that support our customers in improving their outcomes and driving down costs,” said Kent Sacia, CEO of Milliman MedInsight. “We are confident that this program will help transform the healthcare industry and improve the lives of countless patients.” For more information about Milliman’s MedInsight Strategic Alliance Program, go to [medinsight.milliman.com/en/medinsight-strategic-alliance](https://medinsight.com/medinsight-strategic-alliance). ## About Milliman MedInsight Milliman MedInsight provides the healthcare industry’s most powerful analytics on top of validated data sources from inside and outside healthcare organizations to drive informed decision-making across the enterprise. MedInsight analytics has been adopted by over 300 health plans, employers, at-risk providers/ACOs, state governments, community health coalitions, and third-party administrators. Milliman MedInsight offers a platform, application, and analytic products for the payer and provider market that provide preconfigured or custom reporting and data configurations that can address specific business needs. To learn more, visit [medinsight.milliman.com](https://medinsight.com/). Contact: Todd Fessler Milliman, Inc. Tel: 206.504.5516 [todd.fessler@milliman.com](mailto:todd.fessler@milliman.com) [Download the press release.](https://medinsight.com/wp-content/uploads/2023/07/pr-strategic-alliance-program.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## New Machine Learning Product [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/new-machine-learning-product-medinsight-conditions-to-consider/#content) #### Press Release # Milliman MedInsight launches new machine-learning product: MedInsight Conditions to Consider [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/new-machine-learning-product-medinsight-conditions-to-consider/) Seattle–July24, 2019–MedInsight, Milliman, Inc.’s highly regarded platform for data warehousing and healthcare analytics,has launched anewmachine–learningproduct,MedInsightConditions to Consider™,whichuses collaborative filtering to highlight patterns in diagnoses. Manyonline retailers use collaborative filteringto help customers identify products thatmight be of interest to them.Collaborative filtering models workbyanalyzing purchase histories forother customers togeneratenew product suggestions.Conditions to Consider uses the same collaborative filteringmodels toidentify potentially missing conditions ina patient’smedical record.It estimates patient similarity using a mix ofa patient’s clinical, prescription, and demographic data. Conditions to Considerfeaturesdashboardsfocused onpresentingbothpopulation–and patient–level insights.Afinancial dashboard provides aview ofthe total potential risk score change for a population andidentifiesthe keyindicators ofthe predicted medical codingopportunity.A separatepoint of care dashboard allows office staff to generatea patient–specificreportof conditions for evaluationduring an office visit that can be included with a patient’s chart. “Accurate coding has become increasingly important in risk–based arrangements to ensureappropriate measurement ofpatient morbidity. Conditions to Consider helps us to improve coding accuracy by identifying conditions that may be appropriate to consider when evaluating a member,” Sarah Moore, a seniorproduct managerwho helped lead the development of the new productsaid.“The advanced machine–learning analytics in this new productcansolve a variety of business challengesfacing care managers today.” Conditions to Consider can beintegrated into the new MedInsight Solutions orimplemented as a standalone product.Both payers and providers/ACOswill find value from this product andits sophisticated machine learning analytics. For more information about Milliman MedInsight’s products go to [www.medinsight.milliman.com](https://medinsight.com/). ## About Milliman MedInsight Milliman MedInsight is one of the healthcare industry’s most highly regarded platforms for data warehousing and healthcare analytics. MedInsightSolutions havebeen adopted by over300 health plans, employers, at–riskproviders/ACOs, state governments, community health coalitions, and third party administrators. Additionally,MedInsighthasstandalone Products that provide preconfigured or custom reporting and data configurations that can address specific business needs. ## About Milliman Milliman is among the world’s largest providers of actuarial and related products and services. The firm has consulting practices in healthcare, property & casualty insurance, life insurance and financial services, and employee benefits.Founded in 1947, Milliman is an independent firm with offices in major cities around the globe.For further information, visit [milliman.com](https://milliman.com/). Contact:Todd Fessler Milliman, Inc. Tel: +1 206 5045516 [todd.fessler@milliman.com](mailto:todd.fessler@milliman.com) [Download the press release.](https://medinsight.com/wp-content/uploads/2023/07/pr-machine-learning-product-conditions-to-consider.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Milliman Acquires Torch Insight [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/torch-insight-industry-leading-portfolio-of-saas-health-market-intelligence-solutions/#content) #### Press Release # Milliman acquires Torch Insight, expanding industry’s leading portfolio of SAAS health market intelligence solutions [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/torch-insight-industry-leading-portfolio-of-saas-health-market-intelligence-solutions/) Seattle, WA —August18, 2020—Milliman, Inc.todayannouncedthe acquisition ofTorch Insight®from Leavitt Partners, LLC. This acquisition will combineTorch Insight’spowerfulmarket–centereddata and analytics with MedInsight, Milliman’s flagship healthcare analytics ecosystem. Torch InsightbringsMillimandecades of healthcare policy expertise andhealthcare analytic experiencebacked by Leavitt Partners–recognized expertsin the health sector. The team has integrated and linked thousands of data elementsfrom dozens of public and proprietary data sources. Theplatform is the culmination ofthousandsof hours spent cleaning and validating data and splicing together siloed data sets to enable powerful market–centered analysis and data visualization, and integration with business intelligence platforms. MedInsight founder andMilliman Principal Kent Sacia believes the acquisition of Torch Insight by Millimanrepresents a significant advancement in healthcare analytics.“Torch Insight and MedInsight are incredibly complementary to each other. MedInsightenables clients to applyrobust, value–added analytic techniquesto theirown data.Torch Insight expands thescope of theseanalyticsby layering incomprehensive data about thesurroundingenvironment and delivery system.Together, MedInsight and TorchInsightprovide a 360–degree view of client results in the context of their local healthcare marketdynamics,competition, and partnerrelationships.” Leavitt Partners Founder and Chairman, and former Secretary of the U.S. Department of Health and Human Services, Mike Leavitt,remarked, “CombiningTorch Insight’s comprehensive data on the unique attributes of ACOs, bundled payments, and healthcare stakeholder relationships with MedInsight’s analytic suite, creates the most thorough market intelligence assetavailable.” For more information, go to [milliman.com/en/products/milliman–torch–insight](https://medinsight.com/products/milliman-torch-insight) ## About Milliman Millimanis among the world’s largest providers of actuarial, risk management,and technology solutions. Our consulting and advanced analytics capabilities encompass healthcare, property & casualty insurance, life insurance and financial services, and employee benefits. Founded in 1947, Milliman is an independent firm with offices in major cities around the globe. For further information, visit[milliman.com](https://milliman.com/). ## AboutTorchInsight TorchInsight providestheTorch InsightSolution, a SaaS healthcare data and analytics tool developed and incubated at Leavitt Partners. The Torch Insight platform combines hundreds of disparate sources to provide a coherent overview of healthcare markets. Torch Insight uses blended data to develop analytical models that reveal trends and relationships enabling clients to make more intelligent decisions. For more information, please visit [torchinsight.com](https://torchinsight.com/). Contact: Jeremy Engdahl–Johnson Milliman, Inc Tel: (646) 473–3021 [Jeremy.Engdahl–Johnson@milliman.com](mailto:Jeremy.Engdahl-Johnson@milliman.com) [Download the press release.](https://medinsight.com/wp-content/uploads/2020/08/pr-torch-insight.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## MedInsight and Epic Partnership [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/selected-for-epics-new-value-based-performance-management-module/#content) #### Press Release # Milliman MedInsight selected for Epic’s new Value-Based Performance Management module [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/selected-for-epics-new-value-based-performance-management-module/) Seattle, WA — Sep. 14, 2022 — Milliman MedInsight announces a new strategic relationship with Epic, the most widely-used electronic health records system in the U.S., to offer advanced analytics to Epic customers. By integrating Milliman MedInsight’s industry-leading methodologies into its new Value-Based Performance Management module, Epic customers will be able to leverage the unparalleled expertise of two leading healthcare technology companies to build the foundation for population health improvement strategies. Epic’s new Value-Based Performance Management module will be available to the market in 2023. Customers of Epic’s new Value-Based Performance Management module will be able to access industry standard methodologies from Milliman MedInsight, including: - Utilization, cost, and provider efficiency measurement analytics - Stratifying patient populations using predictive risk modeling and chronic condition hierarchies - Evaluating performance against the gold standard MedInsight benchmarks These enhanced capabilities will be fully integrated into the Epic Value-Based Performance Management module. MedInsight’s contextualized insights will allow Epic customers to not only understand the drivers of financial and health risk, but also how to act in ways that will bring them closer to achieving their population health goals. “I’m thrilled with the promise that this strategic and collaborative relationship brings to our mission to improve healthcare quality and affordability,” said Kent Sacia, Milliman MedInsight’s founder and CEO. “Epic and Milliman MedInsight share a commitment to value-based care, and together, we bring unrivalled and synergistic technology to Epic’s customers.” “I’m excited to share the news of this important strategic relationship with the Epic community, and I’m grateful for both the Epic and Milliman MedInsight teams that came together to make this happen. I’m happiest for our customers; our Value-Based Performance Management module, with embedded MedInsight analytics, will give them an incredibly powerful toolset for achieving excellence in their value-based contracts,” said Joe McGuire, Development Lead, Value-Based Performance Management, Epic. ## About Milliman MedInsight Milliman MedInsight provides the healthcare industry’s most powerful analytics on top of validated data sources from inside and outside healthcare organizations to drive informed decision-making across the enterprise. MedInsight analytics have been adopted by over 300 health plans, employers, at-risk providers/ACOs, state governments, community health coalitions, and third-party administrators. Additionally, Milliman MedInsight offers standalone applications and products that provide preconfigured or custom reporting and data configurations that can address specific business needs. To learn more, visit [https://medinsight.com](https://medinsight.com/). Contact: Todd Fessler Milliman, Inc. Tel: 206.504.5516 [todd.fessler@milliman.com](mailto:todd.fessler@milliman.com) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Healthcare Waste Reduction Grant [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/virginia-center-for-health-innovation-receives-2-2-million-grant/#content) #### Press Release # Virginia Center for Health Innovation receives $2.2 Million grant to tackle healthcare waste through collaboration with Milliman MedInsight [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/virginia-center-for-health-innovation-receives-2-2-million-grant/) Seattle – March 15, 2019 – Earlier this week, at the University of Michigan’s Value-Based Insurance Design Summit, Virginia’s Secretary of Health and Human Resources, Dr. Daniel Carey, announced that the non-profit Virginia Center for Health Innovation (VCHI) had secured support from Arnold Ventures through a $2.2 M grant to launch a statewide pilot to reduce the provision of low value healthcare in Virginia. VCHI utilizes Milliman’s MedInsight Health Waste Calculator product to identify low value healthcare, which includes medical tests and procedures that research has proven add no value in particular clinical circumstances and can lead to potential patient harm and a higher total cost of care. A national dialogue around low value care has been growing since 2012 when the American Board for Internal Medicine’s Choosing Wisely ® initiative identified more than 550 tests and procedures that should be questioned by providers and patients. “VCHI looked at just 42 of these measures, using 2017 claims data for 5 M Virginians from Virginia’s All-Payer Claims Database and the Milliman MedInsight Health Waste Calculator, and identified 2.07 M unnecessary services costing $747 M,” stated Secretary Carey. “The data made it clear we needed to do much, much better.” Through VCHI’s ongoing collaboration with Milliman MedInsight, as well as Michigan’s VBID Center, the American Board of Internal Medicine, Virginia Health Information, they will now work with the leadership of six Virginia health systems and three clinically integrated networks (Ballad Health; Carilion Clinic; HCA and Virginia Care Partners; Inova and Signature Partners; Sentara and Sentara Quality Care Network; and VCU Health System). Together, these groups represent 900+ practice sites that will join to form a large-scale health system learning community targeting the reduction of seven low value care measures. “We are absolutely delighted that Virginia’s medical community has responded so positively to our early data reports and shown a commitment to advancing better value and better care,” said Beth Bortz, President and CEO of the Virginia Center for Health Innovation. “As partners in this initiative, each health system and clinically integrated network will review baseline and practice-level performance data from the Milliman MedInsight Health Waste Calculator, develop system improvements based on that data, and share best practices with other providers in the learning community.” With the financial support of Arnold Ventures, VCHI will leverage its considerable aligned assets to: - Increase clinician competence in reviewing performance reports and implementing targeted interventions to improve outcomes - Improve understanding of which interventions are effective in reducing seven provider-driven low value care tests and procedures and provide health systems and practice leaders throughout the country with tested best practices they can implement - Reduce the physical, emotional, and financial harm patients experience from unnecessary tests and procedures and - Educate Virginia employers (including state government) on the actions they can take to drive complementary payment reform that better incentivizes value in healthcare Beth Bortz readily acknowledges that this pilot would not be possible without the strong data infrastructure provided by Virginia Health Information and Milliman. Marcos Dachary, director of product management at Milliman MedInsight adds, “Beth and VCHI’s efforts began in 2013, and the MedInsight team has been honored to help the Commonwealth lead the nation in evaluating their data for potentially wasteful services and also creating a plan for action. Reducing financial, emotional, and physical harm from low value services is a difficult task and we’re proud to create a data driven path forward for providers, payers, and purchasers, so they can take actions that ultimately benefit consumers.” ## About Milliman MedInsight Milliman MedInsight is one of the healthcare industry’s most highly regarded platforms for data warehousing and healthcare analytics. MedInsight Solutions have been adopted by over 300 health plans, employers, at-risk providers/ACOs, state governments, community health coalitions, and third party administrators. Additionally, MedInsight has standalone products that provide preconfigured or custom reporting and data configurations that can address specific business needs. ## About Milliman Milliman is among the world’s largest providers of actuarial and related products and services. The firm has consulting practices in healthcare, property & casualty insurance, life insurance and financial services, and employee benefits. Founded in 1947, Milliman is an independent firm with offices in major cities around the globe. For further information, visit milliman.com ## About the Virginia Center for Health Innovation Incorporated in January 2012 following a recommendation from Gov. Robert McDonnell’s Virginia Health Reform Initiative, the Virginia Center for Health Innovation (VCHI) seeks to facilitate innovation by convening key stakeholders and securing the resources to accelerate value-driven models of wellness and healthcare throughout Virginia. VCHI’s work is focused on achieving three aims: reducing low value health care, increasing high value health care, and ensuring Virginia has the infrastructure in place to measure and reward value in health care. Among its many innovative projects, the most notable for their alignment with this initiative is the Virginia Health Value Dashboard and the Virginia Scorecards on Payment Reform. For more information visit: [www.vahealthinnovation.org](https://www.vahealthinnovation.org/) and follow on Twitter, Facebook and LinkedIn. ## About Arnold Ventures Arnold Ventures is a philanthropy dedicated to improving lives through evidence-based solutions that maximize opportunity and minimize injustice. Arnold Ventures invests in sustainable change, building it from the ground up based on research, deep thinking, and a strong foundation of evidence. With more than 80 employees in Houston, Washington, D.C., and New York City, [Arnold Ventures](https://www.arnoldventures.org/) focuses on criminal justice, health, education, and public finance. It is the 8th largest philanthropy in the United States based on annual giving, committing more than $250 million to grantees in 2018. [Download the press release.](https://medinsight.com/wp-content/uploads/2023/07/pr-virginia-center-medinsight.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Healthcare Price Transparency Tool [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/state-to-launch-healthcare-price-transparency-tool/#content) #### Press Release # State to launch healthcare price transparency tool [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/state-to-launch-healthcare-price-transparency-tool/) SANTA FE – August 10, 2022 – The New Mexico Department of Health (DOH) is a step closer to its goal of establishing an extensive new health insurance claims database designed to help monitor the growth of costs, improve quality, and make healthcare prices charged by providers and insurers across the state more accessible and transparent. When fully operational in late 2023, the state’s [All Payer Claims Database (APCD)](https://www.nmhealth.org/about/erd/hsep/apcd/) will include cost, quality and other data that’s never before been available to the public. DOH selected [Milliman MedInsight](https://medinsight.com/), a nationally recognized health data and analytics company, to work side-by-side with the state to collect paid medical and pharmacy claims information from private insurance companies as well as Medicare and Medicaid. More than 20 other states have established similar databases over the past two decades, creating important tools that are now being used to better understand and address factors driving up the cost and utilization of healthcare services and improve quality. For example, - [A 2019 study](https://pubmed.ncbi.nlm.nih.gov/31682546/) using Virginia APCD data revealing potential undertreatment of pain related to cancer. - Washington found through use of its APCD data [$282 million](https://wacommunitycheckup.org/media/47156/2018-first-do-no-harm.pdf) was unnecessarily spent on low-value care. (Examples of low-value care include inappropriately prescribing antibiotics, running lab tests for low-risk patients before low-risk medical procedures or performing surgeries when physical therapy would be equally effective.) - A May 2022 report using APCD data from four states uncovered [$630 million](https://vbidhealth.com/docs/APCD-LVC-Final.pdf) spent on low-value care in those states combined. New Mexico will join other states that have used their APCDs to create public-facing websites and other resources for consumers to compare prices and quality of care from one provider to another. “Creating this database will allow New Mexicans to make better informed decisions about their health care and help patients and their families choose where to receive care based on cost and quality,” said **Acting Department of Health Secretary David R. Scrase, M.D.**  “It will also allow researchers, policymakers and others to examine and work to reduce the tremendous variations that exist in health costs and quality from one community to another across our state.” New Mexico’s APCD will be designed from the ground up to protect individual patient privacy by “de-identifying” and aggregating data it will collect from a wide range of medical and pharmacy insurance claims provided by nearly every commercial and public insurers operating within the state. “Having this database will enable better informed health policy,” said **Russell Toal, New Mexico Superintendent of Insurance**. “Our Office is excited to be part of this venture. Milliman MedInsight, the data management company selected for New Mexico’s APCD, has performed similar work in Utah, Virginia, and New Hampshire.  More than 300 healthcare organizations, including accountable care organizations, payers, and employers, rely upon MedInsight for deep analysis, patient health improvement, cost management, and organizational improvement. For more information on how All-Payers Claims Databases work nationwide, visit [https://www.apcdcouncil.org](https://www.apcdcouncil.org/). [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Best in KLAS Award [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/best-in-klas-for-payer-quality-analytics-with-the-introduction-of-cloud-based-digital-integration/#content) #### Press Release # Milliman MedInsight named 2022 best in KLAS for payer quality analytics with the introduction of cloud-based digital integration ### MedInsight’s platform supports population health management analytics and interoperability of clinical and claims data [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/best-in-klas-for-payer-quality-analytics-with-the-introduction-of-cloud-based-digital-integration/) Seattle, WA–February17,2022–MedInsight, Milliman, Inc.’s highly regarded platform for data warehousing and healthcare analytics, was named the number one provider solution for Payer Quality Analytics in the2022 Best in KLAS: Software and Servicesreport. KLAS, a research firm focused on the healthcare IT market since 1996, publishes the Best in KLAS report annually, recognizing outstanding efforts to help healthcare organizations in their quest to deliver quality patient care. This is the fourth year in a row that MedInsight has been top–ranked for Payer Quality Analytics. The recognition comes as MedInsight rolls out its new analytics and integration capabilities in 2022. “Each year, thousands of healthcare professionals across the globe take the time to share their voice with KLAS,” said KLASCEOAdam Gale. “The Best in KLAS report and the awards it contains set the standard of excellence for software and services firms.” Given the rapidexpansion of the healthcare analytics landscape, the integration of clinical and claims data has never been more important. MedInsight’s cloud–based architecture will support greater interoperability between provider and payer systems and expand advanced analytic capabilities to support population health management. “Provider expectations around healthcare analytics are increasing as businesses use data to help transform their insurance and care processes,” says Iyibo Jack, Senior Vice President of Product Development for MedInsight. “We are honored to have won the Best in KLAS award for Payer Quality Analytics for a fourth year in a row as we focus on making data processes more integrated, efficient, and user–friendly.” During the preparation of the report, KLAS reviews more than 30,000 interviews conducted with health systems and payers that year. The Best in KLAS designation is awarded only in those software and services market segments that have the broadest operational and clinical impact on healthcare organizations. For more information about Milliman MedInsight’s products go to [www.medinsight.milliman.com](https://medinsight.com/). ## About Milliman MedInsight Milliman MedInsight is one of the healthcare industry’s most widely used analytics and data platforms. Leveraged by more than 300 payers, providers, and purchasers, MedInsight provides contextualized insights that fuel prescriptive outcomes tailored to its clients. ## About Milliman Milliman is among the world’s largest providers of actuarial and related products andservices. The firm has consulting practices in healthcare, property & casualty insurance, life insurance and financial services, and employee benefits. Founded in 1947, Milliman is an independent firm with offices in major cities around the globe.For further information, visit [milliman.com](https://milliman.com/). ## About KLAS KLAS is a data–driven company on a mission to improve the world’s healthcare by enabling provider and payer voices to be heard and counted. Working with thousands of healthcare professionals, KLAS collectsinsights on soft–ware, services and medical equipment to deliver reports, trending data and statistical overviews. KLAS data is accurate, honest and impartial. The research directly reflects the voice of healthcare professionals and acts as a catalyst forimproving vendor performance. To learn more about KLAS and the insights we provide, visit [KLASresearch.com](https://klasresearch.com/) Contact:Todd Fessler Milliman, Inc. Tel:+1 206 504 5516 [todd.fessler@milliman.com](mailto:todd.fessler@milliman.com) [Download the press release.](https://medinsight.com/wp-content/uploads/2023/07/pr-best-in-klas-2022.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Next-Gen Health Cloud [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/next-generation-health-cloud-for-improved-performance-and-scalability/#content) #### Press Release # Milliman MedInsight introduces next-generation health cloud for improved performance and scalability [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/next-generation-health-cloud-for-improved-performance-and-scalability/) _Leveraging top-tier analytics and methodologies, Milliman MedInsight offers a sophisticated, AI-enabled Health Cloud designed to enhance efficiencies and outcomes_ **SEATTLE – SEPT. 23, 2024** – Milliman MedInsight, a leading provider of healthcare data and analytics, unveiled today its next-generation data lake and data warehouse architecture that enables healthcare organizations to fully utilize their data and more quickly address increasingly complex healthcare challenges. With the new [Milliman MedInsight Health Cloud](https://medinsight.com/healthcare-data-analytics-software/health-cloud/), health plans, Accountable Care Organizations (ACOs), providers, and health systems can identify opportunities to improve cost efficiency and clinical outcomes in unprecedented ways. The Milliman MedInsight Health Cloud, featuring efficiency and agility enhancements through strategic alliances with Databricks and Microsoft Azure, serves as a powerful single-source-of-truth for analyzing cost, utilization, financial, and clinical data. These collaborations enable the integration of advanced technologies and Milliman methodologies, positioning Milliman MedInsight as the foremost authority on healthcare claim analytical processing and data management governance. At the heart of the MedInsight Health Cloud is the MedInsight Data Confidence Model (DCM), a validated approach that assures the accuracy, reliability, and clarity of healthcare data. In addition, the MedInsight Health Cloud is meticulously engineered to meet the highest standards of security and compliance, including HITRUST and SOC 2 certifications, powering both the VBC Platform and Payer Platform. “Our commitment to innovation is pivotal in ensuring that our customers receive timely and reliable data insights across their organizations and among various healthcare stakeholders,” said Kent Sacia, Principal and CEO, at Milliman MedInsight. “By optimizing our performance and analytical capabilities, we can empower organizations to accelerate digital transformation, advance value-based care (VBC), and more readily adopt artificial intelligence (AI).” Benefits of the new Milliman MedInsight Health Cloud include: 1. **Maximized speed to insight:** Milliman MedInsight’s strategic investment in cloud infrastructure significantly enhances operational efficiency by reducing data processing times from days or weeks to mere hours. This accelerated processing capability allows healthcare organizations to access critical data more quickly, enabling faster decision-making and more responsive healthcare delivery. 2. **Flexible data ingestion and delivery:** Milliman MedInsight empowers customers by accommodating a wide range of data types and offering the flexibility to independently create and execute their own models. This eliminates the need for third-party involvement, streamlining processes and conserving both time and resources. 3. **Enhanced customization options:** Shifting away from the traditional Software as a Service (SaaS) data warehouse model, the new MedInsight Health Cloud adopts a Platform as a Service (PaaS) approach. This transition not only modernizes the infrastructure but also enhances flexibility for users. By moving to a PaaS model, customers gain the ability to customize and manage their data environments more directly and efficiently. 4. **AI-ready infrastructure:** The platform supports historical analytical grouper methodologies and next-generation AI and machine learning (ML) technologies. This dual capability allows users to not only continue utilizing proven historical data analysis techniques but also to leverage the latest advancements in AI and ML for more complex, predictive analytics. “We are thrilled to introduce the new Milliman MedInsight Health Cloud, a testament to our commitment to innovation and excellence in healthcare data analytics,” said Iyibo Jack, Principal and Executive Vice President of Product Development at Milliman MedInsight. “By leveraging Milliman’s 75 years of healthcare and actuarial experience with our enhanced capabilities, we unlock new opportunities for customers to overcome their data challenges and usher in a new era of AI and machine learning in healthcare analytics at scale.” The new MedInsight Health Cloud is now available to all existing and new customers. For more information about the platform and how it can transform your healthcare data management and analytics, please visit [medinsight.com](https://medinsight.com/). ## About Milliman MedInsight Founded in 1998, Milliman MedInsight® is a leading provider of healthcare data and analytics, trusted by over 300 payers, providers/ACOs, employers, and government agencies worldwide. Our comprehensive suite of analytics and data solutions empowers organizations to leverage healthcare data for informed decision-making and improved clinical and financial outcomes. With deep industry expertise and advanced technology, we deliver actionable insights into healthcare utilization, costs, quality, and performance. From risk management to value-based care, Milliman MedInsight empowers stakeholders to navigate the complexities of the healthcare landscape and achieve sustainable success. [Download the press release.](https://medinsight.com/wp-content/uploads/2024/09/health-cloud-press-release.pdf) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) Live chat:Chat with an Expert ## MSSP ACOs Savings 2023 [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/mssp-acos-savings-in-2023/#content) #### Press Release # MSSP ACOs using Milliman MedInsight achieved over $549.3M of earned savings in 2023 under CMS Medicare Shared Savings Program ### Milliman MedInsight MSSP ACO clients see higher success rate than nationwide ACOs [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/mssp-acos-savings-in-2023/) **SEATTLE – DEC. 10, 2024** – Milliman MedInsight, a leading provider of healthcare data and analytics, is pleased to share the remarkable success of its Accountable Care Organization (ACO) clients for the 2023 Medicare Shared Savings Program (MSSP). ## Key highlights of 2023 performance results for Milliman MedInsight clients: **Milliman MedInsight clients lead the way**: Milliman MedInsight clients received a total of $549.3 million in total earned savings, a significant portion of the nationwide total of $3 billion. **74% Success Rate:** 74% of MSSP ACO clients of Milliman MedInsight achieved savings surpassing the national average of 69%. **Exceptional impact**: Over fifteen percent of MSSP ACO covered lives in 2023 are managed by clients of Milliman MedInsight. Out of 453 ACOs participating in MSSP, 38 ACO participants are Milliman MedInsight users. “We are excited to share that our MSSP ACO clients have again surpassed national benchmarks, securing shared savings in the CMS program,” said Meghan Fetherson, MedInsight’s Chief Client Officer. “We are proud to play a role in helping clients succeed in value-based models.” The Centers for Medicare & Medicaid Services (CMS) announced the 2023 MSSP savings in October, marking the seventh consecutive year of the program savings. Joining MSSP requires providers to align with Accountable Care Organizations (ACOs), driving collaboration among local healthcare entities to elevate patient care and curb unnecessary spending. ACOs prioritize enhancing care quality, affordability, and patient experience. The program aims to foster provider cooperation, coordinating care for Medicare beneficiaries to reduce costs and boost care quality. Milliman MedInsight, an innovator in healthcare data management, stands as a premier platform for value-based care analytics. Since their inception, Milliman MedInsight has been instrumental in helping ACOs optimize financial and care management.  Its advanced analytics and benchmarking tools help ACOs pinpoint opportunities for improving financial and quality performance, facilitating success in value-based care agreements like MSSP. Milliman MedInsight made significant investments in its [Value-Based Care (VBC) Platform](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/) over the past two years, to address evolving industry challenges. As a result, the platform continues to be at the forefront of empowering clients with actionable data and insights, as well as driving patient progress and performance objectives. “MedInsight’s commitment to our ACO clients is unwavering,” said Todd Fessler, Chief Revenue Officer. “We remain dedicated to continually investing in our products and capabilities to ensure our clients have the best tools and support needed to thrive in the evolving value-based healthcare landscape.” ## About Milliman MedInsight Founded in 1998, Milliman MedInsight® is a leading provider of healthcare data and analytics, trusted by over 300 payers, providers/ACOs, employers, and government agencies worldwide. Our comprehensive suite of analytics and data solutions empowers organizations to leverage healthcare data for informed decision-making and improved clinical and financial outcomes. With deep industry expertise and advanced technology, we deliver actionable insights into healthcare utilization, costs, quality, and performance. From risk management to value-based care, Milliman MedInsight empowers stakeholders to navigate the complexities of the healthcare landscape and achieve sustainable success. [Download the press release.](https://medinsight.com/wp-content/uploads/2024/12/mssp-results-2023-press-release.pdf) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Best in KLAS Award [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/best-in-klas-for-payer-quality-analytics-for-fifth-year-in-a-row/#content) #### Press Release # Milliman MedInsight ranked best in KLAS for payer quality analytics for the fifth year in a row [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/best-in-klas-for-payer-quality-analytics-for-fifth-year-in-a-row/) Seattle, WA — Feb. 2, 2023 — Milliman MedInsight’s leading platform for data warehousing and healthcare analytics was recognized as the Best in Payer Quality Analytics in the 2023 Best in KLAS: Software and Services report. KLAS, a research firm focused on the healthcare IT market since 1996, publishes the Best in KLAS report annually, recognizing outstanding efforts to help healthcare organizations in their quest to deliver quality patient care. This is the fifth year in a row that Milliman MedInsight has been top-ranked and top-performing for Quality Payer Analytics. “The 2023 Best in KLAS report highlights the top-performing healthcare IT solutions as determined by extensive evaluations and conversations with thousands of healthcare providers. These distinguished winners have demonstrated exceptional dedication to improving and innovating the industry, and their efforts are recognized through their inclusion in this report,” said KLAS President, Adam Gale. “Congratulations to all the winning vendors for setting the bar for excellence in healthcare IT! KLAS continues to be committed to creating transparency and helping providers make informed decisions through our accurate, honest, and impartial reporting.” “We strive to help our clients succeed in data-driven decision-making on important healthcare question,” said Meghan Fetherston, Chief Client Officer for Milliman MedInsight. “We are honored to have won the Best in KLAS award for Payer Quality Analytics for the fifth year in a row and we are committed to continuous improvement as we help healthcare organizations transform data into meaningful insights.” For more information about Milliman MedInsight’s products, visit [medinsight.milliman.com](https://medinsight.com/). ## About Milliman MedInsight Milliman MedInsight provides the healthcare industry’s most powerful analytics on top of validated data sources from inside and outside healthcare organizations to drive informed decision-making across the enterprise. MedInsight analytics has been adopted by over 300 health plans, employers, at-risk providers/ACOs, state governments, community health coalitions, and third-party administrators. Additionally, Milliman MedInsight offers a platform, application, and analytic products for the payer and provider market that provide preconfigured or custom reporting and data configurations that can address specific business needs. To learn more, visit [medinsight.milliman.com](https://medinsight.com/). ## About KLAS KLAS is a data-driven company on a mission to improve the world’s healthcare by enabling provider and payer voices to be heard and counted. Working with thousands of healthcare professionals, KLAS collects insights on software, services, and medical equipment to deliver reports, trending data and statistical overviews. KLAS data is accurate, honest, and impartial. The research directly reflects the voice of healthcare professionals and acts as a catalyst for improving vendor performance. To learn more about KLAS and their insights, visit [KLASresearch.com](https://klasresearch.com/). Contact: Todd Fessler Milliman, Inc. Tel: 206.504.5516 [todd.fessler@milliman.com](mailto:todd.fessler@milliman.com) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Best in KLAS Award [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-wins-2025-best-in-klas-for-data-analytics-platform-payer/#content) #### Press Release # Milliman MedInsight wins 2025 Best in KLAS for Data Analytics Platform (Payer) [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-wins-2025-best-in-klas-for-data-analytics-platform-payer/) ### _The Milliman MedInsight Payer Platform achieves top ranking with enhanced data analytics and clinical-claims interoperability_ **SEATTLE, WA – Feb. 18, 2025** – Milliman MedInsight® (MedInsight), a leading healthcare data and analytics division of [Milliman](https://us.milliman.com/en), has been awarded 2025 Best in KLAS® for Data Analytics Platform (Payer). KLAS Research, known for its independent evaluations of healthcare technology, recognized Milliman MedInsight in its [2025 Best in KLAS: Software & Services report.](https://klasresearch.com/report/2025-best-in-klas-awards-software-and-services/3621) This accolade aligns with Milliman MedInsight’s recent launch of enhanced analytics and integration features built on the [Milliman MedInsight Health Cloud](https://medinsight.com/healthcare-data-analytics-software/health-cloud/). “Being named the Best in KLAS for Data Analytics Platform (Payer) is a significant achievement and a testament to our team’s dedication to excellence,” said Kent Sacia, CEO of Milliman MedInsight. “Our [Payer Platform](https://medinsight.com/healthcare-data-analytics-software/platform/payer/) is designed to provide health payers with the insights needed for informed decision-making, improved member outcomes, and increased efficiency. This recognition highlights our commitment to delivering innovative and reliable solutions to the healthcare industry.” Payers interviewed by KLAS praised the company’s expertise, attentive service, and consistent value: - “(Milliman) MedInsight knows our data almost as well as we know our data, and they can help us figure out the best way to do something,” said one director at a payer organization (November 2024). - “The new platform is just a lot more robust and is more controlled,” said a payer director. “… \[it\] makes it easy to find insights and analytics that are helpful for clients” (April 2024). From 2019 to 2023, Milliman MedInsight had already been ranked Best in KLAS for [Payer Quality Analytics](https://medinsight.com/healthcare-data-analytics-about/press-releases/best-in-klas-for-payer-quality-analytics-for-fifth-year-in-a-row/). This latest recognition further solidifies Milliman MedInsight’s status as a trusted partner in payer data management. The Milliman MedInsight Payer Platform assists health plans in monitoring cost and utilization trends, understanding member populations, and targeting high-risk individuals to improve care quality. By combining comprehensive analytics, evidence-based methodologies, and deep industry expertise, Milliman MedInsight empowers payers to optimize performance with confidence. Milliman MedInsight will be formally recognized at the upcoming [Best in KLAS Awards Show](https://cts.businesswire.com/ct/CT?id=smartlink&url=https%3A%2F%2Fapp.himssconference.com%2Fwidget%2Fevent%2Fhimss-2025%2Fplanning%2FUGxhbm5pbmdfMjQ3NDAzNA%3D%3D&esheet=54199614&newsitemid=20250205191488&lan=en-US&anchor=Best+in+KLAS+Awards+Show&index=9&md5=a1b8fb183b3b1879bc1d2ead41f7f306) during the [HIMSS Global Health Conference](https://cts.businesswire.com/ct/CT?id=smartlink&url=https%3A%2F%2Fwww.himssconference.com%2F&esheet=54199614&newsitemid=20250205191488&lan=en-US&anchor=HIMSS+Global+Health+Conference&index=10&md5=f146b6f2e2503b886fd19371d69155e0)  in Las Vegas. Visit us at booth #2065 to learn more about the Milliman MedInsight Payer Platform. For additional information, visit [medinsight.com.](https://medinsight.com/) ## About Milliman MedInsight Founded in 1998, Milliman MedInsight® is a leading provider of healthcare data and analytics, trusted by over 300 payers, providers/ACOs, employers, and government agencies worldwide. Our comprehensive suite of analytics and data solutions empowers organizations to leverage healthcare data for informed decision-making and improved clinical and financial outcomes. With deep industry expertise and advanced technology, we deliver actionable insights into healthcare utilization, costs, quality, and performance. From risk management to value-based care, Milliman MedInsight empowers stakeholders to navigate the complexities of the healthcare landscape and achieve sustainable success. ## About KLAS KLAS is a research and insights firm on a global mission to improve healthcare. Working with thousands of healthcare professionals and clinicians, KLAS gathers data and insights on software and services to deliver timely reports and performance data that represent provider and payer voices and act as catalysts for improving vendor performance. The KLAS research team publishes reports covering the most pressing questions facing healthcare technology today, including emerging technology insights, that provide early insights on the future of healthcare technology solutions. KLAS also fosters measurement and collaboration between healthcare providers and payers and best practice adoption. Learn more at [klasresearch.com](https://c212.net/c/link/?t=0&l=en&o=4354229-1&h=2036463406&u=https%3A%2F%2Fklasresearch.com%2Fvendor-dashboard&a=klasresearch.com). Contact: Todd Fessler Milliman, Inc. Tel: 248.212.7140 [todd.fessler@milliman.com](mailto:todd.fessler@milliman.com) [Download the press release.](https://medinsight.com/wp-content/uploads/2025/02/press-release-2025-best-in-klas-data-analytics-platform.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Value-Based Care Platform [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-releases-value-based-care-platform-with-advanced-ehr-integration-and-contract-management-capabilities/#content) #### Press Release # Milliman MedInsight releases Value-Based Care Platform with advanced EHR integration and contract management capabilities [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-releases-value-based-care-platform-with-advanced-ehr-integration-and-contract-management-capabilities/) ### _Upgraded platform empowers ACOs with comprehensive data insights and predictive analytics for optimal care delivery and financial performance_ **SEATTLE, WA – Feb. 25, 2025** – [Milliman MedInsight](https://medinsight.com/) ® (MedInsight), a leading healthcare data and analytics division of [Milliman](https://us.milliman.com/en?_aiid=10249&teng=go&beng=b&deng=c&keng=milliman&meng=b&peng=&ieng=125302551809&kieng=kwd-12803756&cieng=554348232226&cpieng=134775553&feng=&cleng=CjwKCAiAzba9BhBhEiwA7glbauSC-r57SQb1I9BRhNaWTt27Oe18CTDdPxGDtUeSL3XrU1X5E204uRoCV7IQAvD_BwE&utm_source=google&utm_medium=cpc&utm_campaign=milliman_brand&gad_source=1), introduces its upgraded Value-Based Care (VBC) Platform®. Built on the [Milliman MedInsight Health Cloud](https://medinsight.com/healthcare-data-analytics-software/health-cloud/), the VBC Platform is designed to empower accountable care organizations (ACOs) with more than just analytics – it delivers value-based intelligence through advanced Electronic Health Record (EHR) clinical data integration and contract management capabilities. ## Empowering ACOs on the journey to value-based care The VBC Platform supports ACOs in their transition to value-based care with a scalable enterprise solution that streamlines analytical workflows and delivers essential data insights. Enhanced data visualization and a prescriptive reporting interface helps ACOs achieve success in value-based care initiatives. By integrating actionable insights, deep learning data analysis, and intelligent solutions, the VBC Platform accelerates the realization of value, enhancing data confidence and reliability for long-term success. ## Integrating EHR data for comprehensive patient insights The VBC Platform’s robust EHR integration provides timely and comprehensive patient data, offering near real-time insights into patient health, including treatments, risk factors, lab results, social determinants of health, and outcomes. By combining EHR data with claims data, healthcare organizations gain a more complete picture of patient health, enabling accurate targeting of populations and driving performance improvement. This comprehensive integration transforms raw data into actionable intelligence, ensuring that ACOs can make informed decisions that enhance patient care and optimize financial outcomes. “EHR integration and contract management are core to our VBC Platform,” said Rich Moyer, MedInsight Chief Product Officer. “These tools provide valuable insights and help organizations navigate the VBC landscape. Our platform’s comprehensive features offer the flexibility to adapt to economic changes, ensuring better monitoring and management of clinical outcomes and value-based care agreements. ## Streamlining VBC contracts for optimal performance The MedInsight Value-Based Care (VBC) Contracts application empowers ACOs, health systems, and independent physician associations (IPAs) to manage value-based agreements with strategic insight, optimizing revenue and managing risk effectively. Key Features: - **Financial Health Insights**: Identify revenue opportunities and manage at-risk costs. - **Reliable Data**: Utilize trusted Milliman methodologies for accurate data integration. - **Risk Analysis**: Monitor key metrics at both ACO and provider levels for equitable savings and loss distribution. - **Performance Projections**: Forecast settlements for past, present, and future years. - **Interaction Modeling**: Simulate impacts on expenditure and revenue across various contracts. - **Centralized Management**: View and compare all TCOC value-based contracts in one place. “Our VBC Platform simplifies contract management and provides essential tools to evaluate and optimize performance,” said Rich Moyer, MedInsight Chief Product Officer. “This ensures healthcare organizations can achieve their financial and quality goals in a dynamic environment.” ## Building on a decade of success Since 1998, over 300 clients, including 20% of the ACO market, have leveraged the Milliman MedInsight platform and analytics. The expansion of the Milliman MedInsight VBC Platform supports organizations in their transition to value-based care by providing tailored solutions for every stage of the analytic journey. As a scalable enterprise solution, it simplifies analytical workflows and delivers critical data insights into performance metrics, patient outcomes, and financial data, driving improvements in care quality and cost efficiency. We continue to seek ways to improve these capabilities to adapt to the evolving dynamics of our client’s environments. ## Leading healthcare transformation The Milliman MedInsight VBC Platform empowers organizations to optimize operations, manage financial risk, and enhance care delivery, fulfilling the commitment to value-based care. With 75 years of leadership in healthcare transformation and unparalleled expertise in actuarial science, clinical care, IT, and healthcare data, Milliman is a trusted advisor and innovative problem solver, helping organizations achieve their financial and quality goals. Visit [medinsight.com](https://medinsight.com/) or contact info@medinsight.com to learn more. ## About Milliman MedInsight Founded in 1998, Milliman MedInsight® is a leading provider of healthcare data and analytics, trusted by over 300 payers, providers/ACOs, employers, and government agencies worldwide. Our comprehensive suite of analytics and data solutions empowers organizations to leverage healthcare data for informed decision-making and improved clinical and financial outcomes. With deep industry expertise and advanced technology, we deliver actionable insights into healthcare utilization, costs, quality, and performance. From risk management to value-based care, Milliman MedInsight empowers stakeholders to navigate the complexities of the healthcare landscape and achieve sustainable success. [Download the press release.](https://medinsight.com/wp-content/uploads/2025/02/upgraded-vbc-platform-press-release-2025.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Expanded Payer Platform [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-unveils-expanded-payer-platform-capabilities-to-drive-operational-excellence/#content) #### Press Release # Milliman MedInsight unveils expanded Payer Platform capabilities to drive operational excellence ### New Payer Insights application empowers health plans with comprehensive data insights to enhance healthcare operations and outcomes [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-unveils-expanded-payer-platform-capabilities-to-drive-operational-excellence/) **Seattle, WA – June 17, 2025** – Milliman MedInsight® (MedInsight), a leading healthcare data and analytics software provider and division of Milliman, announced today the expansion of its [Payer Platform](https://medinsight.com/healthcare-data-analytics-software/platform/payer/) with the launch of the new Payer Insights application. Powered by the [Milliman MedInsight Health Cloud](https://medinsight.com/healthcare-data-analytics-software/health-cloud/), Payer Insights goes beyond traditional analytics by providing health plan organizations with actionable intelligence and comprehensive resources. Designed with accessibility in mind, the [Milliman MedInsight Payer Insights](https://medinsight.com/healthcare-data-analytics-software/platform/payer/insights/) application transforms complex information into clear, actionable intelligence. Even users with limited data experience can harness Milliman’s industry-leading methodologies to perform sophisticated analyses, uncover cost-saving opportunities, elevate care quality, and enhance operational efficiency. Featuring interactive dashboards and flexible reporting options, Payer Insights empowers stakeholders to make informed decisions, drive strategic initiatives, and achieve stronger outcomes for both members and the organization. “With the MedInsight Payer Insights application, we’re enabling users to easily analyze complex healthcare data and transform it into visually compelling, shareable insights,” said Marcos Dachary, Chief Market Strategist of Milliman MedInsight Payer Solutions. “This powerful capability helps organizations communicate key findings more effectively, drive better decision-making, and foster collaboration across teams.” Key features of Payer Insights include: - **Reliable insights for everyone:** Give teams access to consistent, trusted data to support collaboration and informed decisions across the organization. - **Speed to insight:** Quickly track costs, quality, and trends with easy-to-use dashboards and reports that can improve efficiency. - **Meaningful benchmarks:** Accurately measure plan performance with high-quality data and tailored benchmarks that reflect unique populations. - **Flexible data views:** Discover key insights with dynamic filters and views designed to match the organization’s needs. - **User-friendly access:** Get clear answers to complex questions through streamlined, advanced analytics and reporting. - **Greater transparency:** Ensure leaders and analysts alike can confidently make decisions using the same accurate, accessible information. “Payer Insights is designed to address the specific challenges health plans encounter, enabling them to discover deeper insights and drive meaningful improvements,” said Lauren Piacentini, Director of Payer Analytics at Milliman MedInsight. “We believe this application will be a valuable resource for health plans of any size, empowering them to make smarter decisions and deliver better results in today’s rapidly changing environment.” To learn more about the MedInsight Payer Platform and Payer Insights, visit [medinsight.com](https://medinsight.com/healthcare-data-analytics-software/platform/payer/insights/). ## About Milliman MedInsight Founded in 1998, Milliman MedInsight® is a leading provider of healthcare data and analytics, trusted by over 300 payers, providers/ACOs, employers, and government agencies worldwide. Our comprehensive suite of analytics and data solutions empowers organizations to leverage healthcare data for informed decision-making and improved clinical and financial outcomes. With deep industry expertise and advanced technology, we deliver actionable insights into healthcare utilization, costs, quality, and performance. From risk management to value-based care, Milliman MedInsight empowers stakeholders to navigate the complexities of the healthcare landscape and achieve sustainable success. [Download the press release.](https://medinsight.com/wp-content/uploads/2025/06/payer-platform-insights-press-release.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Dr. Kodama Appointed CMO [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-names-dr-christopher-kodama-as-chief-medical-officer/#content) #### Press Release # Milliman MedInsight names Dr. Christopher Kodama as Chief Medical Officer [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-names-dr-christopher-kodama-as-chief-medical-officer/) **Seattle, WA – July 31, 2025** – Milliman MedInsight®, a division of Milliman and a leading provider of healthcare data and analytics software, has named [Dr. Christopher Kodama](https://medinsight.com/healthcare-data-analytics-about/leadership-team/) as Chief Medical Officer. Dr. Kodama brings more than 25 years of experience in clinical practice, executive leadership, and healthcare innovation to the Milliman MedInsight leadership team. His background is expected to further strengthen the organization’s ability to deliver data-driven analytics solutions that improve outcomes, enhance operational efficiency, and support informed decision-making. “We are excited to welcome Dr. Kodama to the Milliman MedInsight leadership team,” said Kent Sacia, CEO of Milliman MedInsight. “Dr. Kodama is a highly accomplished healthcare executive and clinician with deep expertise in value-based care, population health, digital transformation, and leadership development. His experience will be instrumental in guiding our customers and partners through the evolving healthcare landscape and accelerating meaningful outcomes through advanced analytics.” Before joining Milliman MedInsight, Dr. Kodama led major initiatives in health system integration, accountable care organization (ACO) development, and performance improvement. As the founding President and CEO of Embright, he established a clinically integrated network serving more than 100,000 lives. At MultiCare Health System, he oversaw the launch of both commercial and Medicare Shared Savings ACOs encompassing more than 3,500 providers. “I am honored to join Milliman MedInsight, an organization known for its commitment to reliable, data-driven healthcare solutions,” Dr. Kodama said. “I am energized by Milliman MedInsight’s company culture, and look forward to contributing to sustainable healthcare transformation while partnering with our customers to solve today’s most complex challenges.” ## About Milliman MedInsight Founded in 1998, Milliman MedInsight® is a leading provider of healthcare data and analytics, trusted by over 300 payers, providers/ACOs, employers, and government agencies worldwide. Our comprehensive suite of analytics and data solutions empowers organizations to leverage healthcare data for informed decision-making and improved clinical and financial outcomes. With deep industry expertise and advanced technology, we deliver actionable insights into healthcare utilization, costs, quality, and performance. From risk management to value-based care, Milliman MedInsight empowers stakeholders to navigate the complexities of the healthcare landscape and achieve sustainable success. [Download the press release.](https://medinsight.com/wp-content/uploads/2025/07/dr-kodama-press-release.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Next Generation Payer Platform [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/next-generation-payer-platform-for-advanced-healthcare-analytics/#content) #### Press Release # Milliman MedInsight unveils next generation Payer Platform for advanced healthcare analytics [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/next-generation-payer-platform-for-advanced-healthcare-analytics/) Seattle, WA – June 4, 2024 – Milliman MedInsight®, a leading healthcare analytics and solutions provider, announced today the expansion of its Payer Platform. This comprehensive enterprise analytic solution harnesses Milliman’s renowned models, methodologies, and data interoperability and introduces expanded analytics capabilities to meet the unique needs of the payer/health insurance market. “We are fully committed to driving digital transformation, enabling both ourselves and our customers to achieve true economies of scale at the enterprise level,” said Marcos Dachary, Chief Market Strategist of Milliman MedInsight Payer Solutions. “Health plans’ business questions continue to grow, and now we have the capability to provide them with a wealth of referential data and benchmarks, seamlessly integrated into their user workflow tools. Whether it’s the care teams, support teams, or operational staff, we ensure that data is distributed to where the end users are. In this era of digital transformation, the concept of a ‘single source of truth’ takes on even greater significance. We are especially excited to scale out our support of EMR data for risk coding workflows, gaps in care closure and new innovations to improve real-time data streaming between payers and providers.” Through the Milliman MedInsight Data Confidence Model – an innovative and structured process that ensures the accuracy, reliability, and comprehension of healthcare data collected for customers – the expanded payer solution offering provides organizations with unparalleled flexibility and interoperability. This enhanced capability empowers health plan stakeholders and users to accelerate their own digital transformation efforts and seamlessly engage with a unified platform and solution across the enterprise. All of this enables organizations to unlock new levels of efficiency and effectiveness in their operations. The Milliman MedInsight Payer Platform has been assisting payers for over 25 years, and its latest version features a redesigned user experience and the addition of specialized applications to address department-specific use cases. The Milliman MedInsight Payer Platform helps health plans monitor cost and utilization trends, gain a deep understanding of member populations, target high-risk individuals, and optimize network performance with greater confidence. The Milliman MedInsight Payer Platform applications benefit health plans by: - **[Employer Group Insights](https://medinsight.com/healthcare-data-analytics-software/applications/employer-group-insights-egi/)**: Increasing revenue growth and customer retention via flexible, self-guided group reporting capabilities. - **[Value Base Care (VBC)](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/) Support for Payers:** - **[VBC Contracts](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/contracts/)**: Optimizing provider networks, performance tracking, and transparency by providing a comprehensive view of financial performance across contracts. - **Provider Portal**: In addition to new data streaming technologies we also offer information consumers at your provider partners portals for key insights. - **[Provider Profiling](https://medinsight.com/healthcare-data-analytics-use-cases/provider-profiling/):** Combine reference data and Milliman MedInsight analytics to create the latest in provider profiling. - **[Innovation Portal (previously known as Data Science Portal)](https://medinsight.com/healthcare-data-analytics-software/applications/innovation-portal/):** Reducing data scientists’ data preparation time by leveraging pre-packaged AI/ML models for use cases such as disease progression modeling. - **[EHR data integration](https://medinsight.com/healthcare-data-analytics-use-cases/ehr-data-integration/):** Leverage pre-built direct connections to EHR/EMR’s APIs, starting with Epic, or use Milliman for national network connectivity. - **Risk coding work-flows**: RADV documentation, [risk adjustment](https://medinsight.com/healthcare-data-analytics-software/analytic-products/risk-adjustment-suite/) coordination and data acquisition with provider and HCC coding audits tied to claims data and financial goals. “We are excited to launch the next generation of the Milliman MedInsight Payer Platform, which will empower health plans with the insights and tools they need to optimize their operations and improve outcomes,” said Lauren Piacentini, Director of Payer Analytics at Milliman MedInsight. “Our platform leverages actionable insights, deep learning data analysis, and intelligent solutions, and most importantly, trusted data to address the unique challenges faced by health plans.” To learn more about the Milliman MedInsight Payer Platform, visit [medinsight.com](https://medinsight.com/healthcare-data-analytics-software/platform/payer/). ## About Milliman MedInsight Founded in 1998, Milliman MedInsight® is a leading provider of healthcare data and analytics, trusted by over 300 payers, providers/ACOs, employers, and government agencies worldwide. Our comprehensive suite of analytics and data solutions empowers organizations to leverage healthcare data for informed decision-making and improved clinical and financial outcomes. With deep industry expertise and advanced technology, we deliver actionable insights into healthcare utilization, costs, quality, and performance. From risk management to value-based care, Milliman MedInsight empowers stakeholders to navigate the complexities of the healthcare landscape and achieve sustainable success. [Download the press release.](https://medinsight.com/wp-content/uploads/2025/09/payer-platform-press-release-updated.pdf) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## MedInsight Azure Solutions [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-announces-solution-availability-in-microsoft-azure-marketplace/#content) #### Press Release # Milliman MedInsight announces solution availability in Microsoft Azure Marketplace [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-announces-solution-availability-in-microsoft-azure-marketplace/) Seattle, WA – March 5, 2024  – [Milliman MedInsight](https://medinsight.com/), a leading provider of healthcare data and analytics, has made its industry-leading Payer and Provider software available on Microsoft Azure. Working with Microsoft in the healthcare industry enables Milliman MedInsight with a greater ability to offer clients powerful solutions that take aim at cost-reduction and enhancing high quality patient care. This is made possible by the Milliman MedInsight [Strategic Alliance Program](https://medinsight.com/healthcare-data-analytics-about/strategic-alliance-program/), Milliman MedInsight’s initiative to team up with other industry experts to change the future of healthcare. “We are excited to offer our products on [Microsoft Azure Marketplace](https://azuremarketplace.microsoft.com/en-us/home),” said Scott Ponder, VP of Strategic Business Development. “Milliman MedInsight on Azure brings cloud scale to clients’ analytics and drives contextualized insights from their data. By utilizing industry-leading benchmarks with the Milliman MedInsight Payer or Value-Based Care (VBC) Platforms, clients can make better decisions and act on information with confidence.” The Milliman MedInsight Payer and VBC Platforms are currently offered on Azure Marketplace. Through these listings, clients can also license other Milliman MedInsight software, including the [Innovation Portal (previously known as Data Science Portal)](https://medinsight.com/healthcare-data-analytics-software/applications/innovation-portal/) and standalone analytic products. Milliman MedInsight provides organizations with an environment that they can trust to host their critical data and continue using the services they know to run smoothly on Azure. Clients can also trust their organization and patient information is compliant with industry privacy and security standards including HIPAA, SOC2, and HITRUST combined with trusted Azure security capabilities. As an eligible solution on Azure Marketplace, Milliman MedInsight software customers can leverage the benefit of their purchase contributing towards their Microsoft Azure Consumption Commitment (MACC). In this way, clients can maximize the return on their Azure investments with a platform that seamlessly integrates into their environment enabling access to Milliman MedInsight data and analytics. “The combination of Milliman MedInsight’s advanced analytics and the trusted productivity and security services of Microsoft Azure will allow us to drive enhanced healthcare at every level, providing organizations with the tools they need to make data-driven decisions and improve patient care,” said Elena Bonfiglioli, General Manager, Healthcare, Pharma & Life Sciences at Microsoft. “With Milliman MedInsight’s Payer and VBC Platforms becoming Azure-benefit eligible, we will get these powerful data insights in the hands of more healthcare organizations, empowering change across the industry.” Find Milliman MedInsight products on Azure Marketplace: - [VBC Platform](https://azuremarketplace.microsoft.com/en-us/marketplace/apps/millimanmedinsight1686925018300.medinsight_provider?tab=Overview) - [Payer Platform](https://azuremarketplace.microsoft.com/en-us/marketplace/apps/millimanmedinsight1686925018300.medinsight_payer?tab=Overview) Talk to a [Milliman MedInsight representative](https://medinsight.com/healthcare-data-analytics-contact/) to learn more about how this strategic alliance can benefit you. ## About Milliman MedInsight Milliman MedInsight provides the healthcare industry’s most powerful analytics on top of validated data sources from inside and outside healthcare organizations to drive informed decision-making across the enterprise. Milliman MedInsight analytics has been adopted by over 300 health plans, employers, at-risk providers/ACOs, state governments, community health coalitions, and third-party administrators. Milliman MedInsight offers a platform, application, and analytic products for the payer and provider market that provide preconfigured or custom reporting and data configurations that can address specific business needs. To learn more, visit [medinsight.com](https://medinsight.com/). [Download the press release.](https://medinsight.com/wp-content/uploads/2024/03/solution-availability-microsoft-azure-press-release-updated.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Enhanced Value-Based Care Platform [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/medinsight-unveils-enhanced-value-based-care-platform/#content) #### Press Release # MedInsight unveils enhanced Value-Based Care Platform [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/medinsight-unveils-enhanced-value-based-care-platform/) Seattle, WA – Oct. 24, 2023 – Milliman MedInsight, a leading healthcare data and analytics company, proudly announces the launch of its upgraded Value-Based Care (VBC) Platform®. This advanced platform harnesses Milliman MedInsight’s renowned analytics expertise and introduces expanded features tailored to accountable care organizations (ACOs). ## Empowering ACOs on the Journey to Value-Based Care The newly unveiled VBC Platform is designed to support ACOs in their transition to value-based care. Offering a scalable enterprise solution, the platform streamlines analytical workflows and delivers essential data insights crucial for achieving success in value-based care initiatives. It also offers enhanced data visualization and a new prescriptive reporting interface. By integrating actionable insights, deep learning data analysis, and intelligent solutions, the VBC Platform accelerates the pace at which ACOs realize value. It not only enhances data confidence and reliability but also helps ensure long-term success for ACOs. “The MedInsight VBC Platform aligns with organizations’ needs, allowing them to comprehend financial and health risk drivers,” remarked Rich Moyer, MedInsight’s Chief Product Officer. “From data scientists to care managers, users can trust the consistency and quality of the data they work with.” ## Key Features of the MedInsight VBC Platform The Milliman MedInsight VBC Platform offers a comprehensive suite of applications to address specific use cases within the value-based care landscape: - **VBC Insights**: A prescriptive reporting application surfacing key cost-saving opportunities to drive VBC initiatives and delivering strategic data for key stakeholders to make data-driven decisions. - **VBC Analytics**: An advanced and dynamic analytics and reporting application, leveraging Milliman MedInsight methodologies and benchmarking. Perform advanced, custom analysis on claims and clinical data. - **VBC Contracts**: Filling a market gap, VBC Contracts models new risk contracts and manages ongoing financial performance to empower ACOs with predictive insights they can use to ensure success under VBC contracts. - **[Innovation Portal (previously known as Data Science Portal)](https://medinsight.com/healthcare-data-analytics-software/applications/innovation-portal/)**: The Innovation Portal enables sophisticated modeling and analysis, minimizing data preparation time for data scientists. Apply artificial intelligence (AI) and machine learning (ML) models to data for faster insights. - **Bundles**: Specifically designed to support healthcare organizations participating in CMS Bundled Payment programs, measuring and managing performance effectively. Review cost and utilization from initial diagnosis to post-discharge across bundles or episodes of care. ## Building on a Decade of Success Since 2011, over 300 clients, including 20% of the ACO market, have leveraged Milliman MedInsight platform and analytics. The launch of the Milliman MedInsight VBC Platform represents the next evolution of our cloud-based solution. The introduction of these specialized applications expands our capabilities, addressing the diverse requirements of ACOs beyond analytics and supporting value-based care strategies more comprehensively. ## Embracing the Promise of Value-Based Care The Milliman MedInsight VBC Platform empowers organizations to optimize operations, accommodate various payment models, mitigate financial risk, enhance care delivery, improve patient access, and foster care collaboration. Together, these features fulfill the commitment to value-based care. For more information about the MedInsight Value-Based Care Platform, please visit [medinsight.com](https://medinsight.com/). ## About Milliman MedInsight Milliman MedInsight provides the healthcare industry’s most powerful analytics on top of validated data sources from inside and outside healthcare organizations to drive informed decision-making across the enterprise. MedInsight analytics has been adopted by over 300 health plans, employers, at-risk providers/ACOs, state governments, community health coalitions, and third-party administrators. Milliman MedInsight offers a platform, application, and analytic products for the payer and provider market that provide preconfigured or custom reporting and data configurations that can address specific business needs. To learn more, visit [medinsight.com](https://medinsight.com/). [Download the press release.](https://medinsight.com/wp-content/uploads/2023/10/vbc-platform-press-release-updated.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Innovation Portal Launch [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-announces-expanded-capabilities-with-the-launch-of-the-innovation-portal-an-ai-powered-cloud-analytics-platform-for-healthcare-organizations/#content) #### Press Release # Milliman MedInsight announces expanded capabilities with the launch of the Innovation Portal, an AI-powered cloud analytics platform for healthcare organizations ### Empowering payers and providers with advanced AI, seamless data integration, and automated analytics for accelerated insights and operational efficiency [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-announces-expanded-capabilities-with-the-launch-of-the-innovation-portal-an-ai-powered-cloud-analytics-platform-for-healthcare-organizations/) **Seattle, WA – Sept. 8, 2025** – [Milliman MedInsight](https://medinsight.com/)®, a division of [Milliman](https://us.milliman.com/en) and leading provider of healthcare data and analytics, proudly announces the launch of the [MedInsight Innovation Portal](https://medinsight.com/healthcare-data-analytics-software/applications/innovation-portal/), the next-generation of its Data Science Portal (DSP). Purpose-built for healthcare organizations navigating increasingly complex environments, the MedInsight Innovation Portal delivers powerful new capabilities, intuitive workflows, and managed cloud services to drive innovation, accelerate analytics, and empower data-driven decision-making. ## Redefining healthcare analytics for the cloud era Building on the proven success of DSP, the MedInsight Innovation Portal is a fully managed, HITRUST-certified Databricks environment that streamlines advanced modeling and analytics for payers, health systems, clinically integrated networks, and other healthcare organizations. With support for multiple programming languages, robust integration with Milliman MedInsight’s enriched claims data, and seamless connectivity to industry-leading business intelligence tools, the Innovation Portal enables users to unlock deeper insights and address strategic business challenges efficiently. ## Unifying healthcare data, analytics, and AI for smarter, faster decisions Healthcare organizations face challenges in accessing, transforming, and analyzing data from disparate systems. The Innovation Portal addresses these needs by providing: - **Comprehensive data access**: Direct access to Milliman MedInsight’s enriched claims data, market data, including public use files, National Association of Insurance Commissioners (NAIC) filings, and cost reports, and the flexibility to securely upload proprietary datasets for tailored analytics. - **Advanced AI capabilities**: Integrated AI assistant support, low-code/no-code analytics, and automation of monthly and quarterly tasks to democratize analytics for users of all skill levels. - **Seamless cloud migration**: A managed, cloud-based environment that eliminates the need for internal Extract, Transform, and Load (ETL) pipelines and accelerates the transition to modern data infrastructure. - **Enhanced collaboration and security**: Secure, centralized workflows with notebook-based model management, versioning, and an environment that meets HITRUST certification standards to help support data integrity and compliance. “The MedInsight Innovation Portal is more than a rebrand, it’s a transformation,” said Kyle Rose, Senior Vice President of Product at Milliman MedInsight. “We believe every organization, whether staffed with in-house data scientists or relying on external expertise, should have the power to unlock the full potential of their data. Clients can now seamlessly access, integrate, and analyze both referential and non-referential data using tools like Databricks SQL, Python, and R, without the complexity of manual formatting or ETL pipelines. Our intuitive AI assistant empowers everyone, from business users to seasoned analysts, to accelerate discovery, drive smarter business decisions, and realize true value from their data.” “As leaders in data and AI, Databricks is proud to collaborate with Milliman MedInsight to power the Innovation Portal,” said Michael Sanky, VP, Industry GTM Leader, Healthcare and Life Sciences at Databricks. “By leveraging the Databricks Data Intelligence Platform and Milliman’s healthcare expertise, this solution helps payers and providers modernize analytics, break down data silos, and drive better outcomes for the communities they serve.” ## Use cases that drive business impact - **Enhanced claims data analysis**: Perform in-depth analyses with AI-powered tools and versatile programming environments. - **Seamless data integration**: Combine diverse data sources for comprehensive insights and enriched reporting. - **Automated reporting**: Streamline monthly and quarterly reporting cycles, reducing manual overhead and accelerating delivery of insights. - **Business user empowerment**: Enable nontechnical users to run natural language queries and explore data directly, fostering a culture of data-driven decision-making. ## Supporting existing and new customers For current Milliman MedInsight clients, the Innovation Portal offers an upgrade path, bringing new automation, cloud capabilities, and advanced analytics. For new clients, the Innovation Portal is an integral feature of the Milliman MedInsight platform, enabling rapid onboarding, flexible data access, and future-ready analytics from day one. ## Trusted in healthcare data transformation With more than 300 healthcare clients and more than two decades of leadership in healthcare analytics, Milliman MedInsight continues to innovate, helping organizations accelerate cloud adoption, enhance operational efficiency, and achieve sustainable success in a rapidly evolving landscape. For more information, visit medinsight.com or contact [info@medinsight.com](mailto:info@medinsight.com). ## About Milliman MedInsight Founded in 1998, Milliman MedInsight® is a leading provider of healthcare data and analytics, trusted by over 300 payers, providers/ACOs, employers, and government agencies worldwide. Our comprehensive suite of analytics and data solutions empower organizations to leverage healthcare data for informed decision-making and improved clinical and financial outcomes. With deep industry expertise and advanced technology, we deliver actionable insights into healthcare utilization, costs, quality, and performance. From risk management to value-based care, Milliman MedInsight empowers stakeholders to navigate the complexities of the healthcare landscape and achieve sustainable success. [Download the press release.](https://medinsight.com/wp-content/uploads/2025/09/innovation-portal-press-release-final.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## MedInsight ACO Savings [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-aco-clients-achieve-658-million-in-savings-outperforming-national-averages-in-the-2024-medicare-shared-savings-program/#content) #### Press Release # Milliman MedInsight ACO clients achieve $658 million in savings, outperforming national averages in the 2024 Medicare Shared Savings Program [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-aco-clients-achieve-658-million-in-savings-outperforming-national-averages-in-the-2024-medicare-shared-savings-program/) **Seattle, WA — Thursday, Oct. 2** — [Milliman MedInsight](https://medinsight.com/) ® (MedInsight), a leading healthcare data and analytics division of [Milliman](https://us.milliman.com/en), announced that its Accountable Care Organization (ACO) clients delivered exceptional results in the 2024 Medicare Shared Savings Program (MSSP), according to preliminary data released by the Centers for Medicare & Medicaid Services (CMS). In 2024, MedInsight ACO clients collectively generated **$658 million in shared savings**, reflecting performance that exceeded national averages across multiple measures, including savings rates, per-beneficiary savings, and year-over-year improvement. These results highlight our clients’ strong performance and underscore how advanced analytics and data-driven strategies can support success in value-based care models. ## Key highlights from the 2024 MSSP results for MedInsight ACO clients: - **Higher savings rate than the national average**: 80% of MedInsight ACO clients (33 of 41) earned shared savings, compared with 75% of all participating ACOs nationally (358 of 476). - **Greater per-beneficiary savings**: $509 per beneficiary — 29% higher than the national average of $394. - **Stronger year-over-year improvement**: 63% of MedInsight ACO clients increased their earned savings compared to 2023, versus 53% of all returning ACOs nationwide. “The exceptional performance of our ACO clients in the 2024 Medicare Shared Savings Program — achieving $658 million in shared savings and outperforming national benchmarks across key measures — demonstrates the power of combining advanced analytics with deep industry expertise to drive measurable improvements in quality, efficiency, and patient outcomes,” said Meghan Fetherston, Chief Client Officer at MedInsight. “Our commitment remains steadfast — to equip our clients with the insights and tools they need to thrive in value-based care.” The MSSP, now in its eighth consecutive year of generating overall program savings, is designed to encourage collaboration among healthcare providers to improve quality of care, enhance patient experience, and reduce unnecessary spending for Medicare beneficiaries. “These results illustrate how our ACO clients are leveraging data-driven strategies and deep expertise in value-based care to excel in the Medicare Shared Savings Program,” said Francesca Hammerstrom, General Manager, Value-Based Care at MedInsight. “By combining timely, reliable data with actionable insights, they are finding new ways to improve patient outcomes and manage costs, and we remain committed to equipping them with the tools they need to succeed.” Through its industry-leading [Value-Based Care (VBC) Platform](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/), MedInsight enables ACOs to leverage timely, reliable data to identify opportunities for quality improvement and cost efficiency. Over the past three years, the company has made significant investments in enhancing this platform by adding advanced features such as clinical data integration, predictive modeling, and user-friendly dashboards. These innovations help healthcare organizations address increasingly complex challenges, enabling ACO clients to achieve and sustain success in value-based care arrangements. For more information, visit medinsight.com or contact [info@medinsight.com](mailto:info@medinsight.com). ## About Milliman MedInsight Founded in 1998, Milliman MedInsight® is a leading provider of healthcare data and analytics, trusted by over 300 payers, providers/ACOs, employers, and government agencies worldwide. Our comprehensive suite of analytics and data solutions empower organizations to leverage healthcare data for informed decision-making and improved clinical and financial outcomes. With deep industry expertise and advanced technology, we deliver actionable insights into healthcare utilization, costs, quality, and performance. From risk management to value-based care, Milliman MedInsight empowers stakeholders to navigate the complexities of the healthcare landscape and achieve sustainable success. [Download the press release.](https://medinsight.com/wp-content/uploads/2025/10/MSSP-2024-Press-Release.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Risk Adjustment Platform Launch [Skip to the content](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-launches-comprehensive-risk-adjustment-platform-for-enhanced-performance/#content) #### Press Release # Milliman MedInsight launches comprehensive Risk Adjustment Platform for enhanced performance [Share on LinkedIn](https://www.linkedin.com/sharing/share-offsite/?url=https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-launches-comprehensive-risk-adjustment-platform-for-enhanced-performance/) ### _New Risk Adjustment Platform boosts accuracy and efficiency, enhancing patient outcomes, plan performance, and revenue_ **SEATTLE, WA – March 10, 2025 –** [Milliman MedInsight](https://medinsight.com/) ® (MedInsight), a leading provider of healthcare data and analytics, announced today the launch of a comprehensive, end-to-end risk adjustment workflow solution. The new [Milliman MedInsight® Risk Adjustment Platform](https://medinsight.com/healthcare-data-analytics-software/platform/risk-adjustment/) leverages industry expertise and AI-driven technology for improved risk workflow and clinical documentation. This powerful solution enables healthcare organizations to confidently track performance and better manage financial risks. “Risk adjustment accuracy is becoming increasingly important as Medicare ACOs (including those participating in Medicare Shared Savings Program (MSSP) and ACO REACH) and Medicare Advantage (MA) plans continue to grow. These programs rely on accurate risk assessment to ensure that health plans and providers are fairly compensated for the care they deliver.” said Noah Champagne, Milliman Principal and Consulting Actuary. The Milliman MedInsight Risk Adjustment Platform offers several key benefits: - **Unified health records** from all major national networks and direct APIs to ensure no critical information is missed. - **Claims-medical record integration** to bridge the gap between claims and medical records, streamlining workflows, improving documentation accuracy and enhancing response tracking. - **Seamless system integration** with existing systems and workflows to enable easy storage, retrieval, and future access to queries and reports. - **Enhanced coding compliance** to identify isolated errors versus systemic provider issues to ensure accurate coding and targeted training. - **Proactive care identification** to quickly pinpoint beneficiaries who may benefit from additional care (e.g., in-home care visits) to improve Star ratings and health outcomes. - **Detailed insights into provider quality, financial performance, and risk levels** down to the individual NPI, powered by the [Milliman MedInsight ACO Builder](https://medinsight.com/healthcare-data-analytics-software/analytic-products/aco-builder/) and [Milliman Medicare Advantage Network Intelligence (MANI)](https://www.milliman.com/en/products/mani), along with quarterly lagged Medicare national data. - **Peer comparison tools** that leverage our ability to access comprehensive Centers for Medicare and Medicaid Services (CMS) data to gain a competitive edge. The new Milliman MedInsight Risk Adjustment Platform provides easy implementation as well as integration with current workflows, along with support from clinical coders and clinicians to ensure quick market impact. “The Risk Adjustment Platform enables us to fully achieve our vision of tackling the complexities and coordination challenges between providers and patients,” said Marcos Dachary, Chief Market Strategist of Milliman MedInsight Payer Solutions. “The combination of MedInsight’s actionable intelligence and data enrichment platform with clinical and documentation workflows will create a comprehensive solution that is truly unique and unmatched in the market. This marks a significant step forward in helping customers meet regulatory requirements and enhancing the quality of care they provide to their patients.” MedInsight will be showcasing its Risk Adjustment Platform at the upcoming RISE National 2025 Conference in San Antonio, Texas. Visit MedInsight at Booth 201 or [online](https://medinsight.com/healthcare-data-analytics-resources/events/rise-national-2025/) for more information. ## About Milliman MedInsight Founded in 1998, Milliman MedInsight® is a leading provider of healthcare data and analytics, trusted by over 300 payers, providers/ACOs, employers, and government agencies worldwide. Our comprehensive suite of analytics and data solutions empowers organizations to leverage healthcare data for informed decision-making and improved clinical and financial outcomes. With deep industry expertise and advanced technology, we deliver actionable insights into healthcare utilization, costs, quality, and performance. From risk management to value-based care, Milliman MedInsight empowers stakeholders to navigate the complexities of the healthcare landscape and achieve sustainable success. [Download the press release.](https://medinsight.com/wp-content/uploads/2025/03/new-risk-adjustment-platform-press-release-2025.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healthcare-data-analytics-contact/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Healthcare Data Analytics [Skip to the content](https://medinsight.com/#content) Previous ### [Milliman MedInsight ACO clients achieve $658 million in savings for the 2024 Medicare Shared Savings Program. Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-aco-clients-achieve-658-million-in-savings-outperforming-national-averages-in-the-2024-medicare-shared-savings-program/) ### [Milliman MedInsight wins 2025 Best in KLAS for Data Analytics Platform (Payer). Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-wins-2025-best-in-klas-for-data-analytics-platform-payer/) ### [Milliman MedInsight celebrates 25+ years of trusted data and insights. Learn more](https://medinsight.com/healthcare-data-analytics-about/25th-anniversary/) ### [Milliman MedInsight ACO clients achieve $658 million in savings for the 2024 Medicare Shared Savings Program. Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-aco-clients-achieve-658-million-in-savings-outperforming-national-averages-in-the-2024-medicare-shared-savings-program/) ### [Milliman MedInsight wins 2025 Best in KLAS for Data Analytics Platform (Payer). Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-wins-2025-best-in-klas-for-data-analytics-platform-payer/) ### [Milliman MedInsight celebrates 25+ years of trusted data and insights. Learn more](https://medinsight.com/healthcare-data-analytics-about/25th-anniversary/) ### [Milliman MedInsight ACO clients achieve $658 million in savings for the 2024 Medicare Shared Savings Program. Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-aco-clients-achieve-658-million-in-savings-outperforming-national-averages-in-the-2024-medicare-shared-savings-program/) Next # Healthcare data analytics software for health plans and ACOs ### Unlock the power of your data: MedInsight advanced analytics and contextualized insights empower healthcare payers, providers, purchasers, and consultants. ![MedInsight Healthcare Data Analytics](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/08/homepage-graphic-2025-v2.png) ## MedInsight is trusted by: ![Southeastern Health Partners Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/07/southeastern-partners-logo-300x86.png) ![Community Health Plan of Washington Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/02/community-health-plan-wa-300x118.png) ![SSM Health Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/01/ssm-health-logo.png) ![Hartford Healthcare Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/01/hartford-healthcare-logo.png) ![Altais Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/01/altais-logo.png) ![AultCare Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/01/aultcare-logo.png) ![Virginia Health Information Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/virginia-health-logo.png) ![Genesys PHO Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/genesys-pho-logo.png) ![Atrio Health Plans Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/07/atrio-health-plans-logo-300x138.png) ![Care New England Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/care-new-england-logo.png) ![DMBA Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/dmba-logo.png) ![Quartz Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/quartz-logo.png) ![Washington Health Alliance Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/washington-health-alliance-300x150.png) ![Bon Secours Mercy Health Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/07/bs-mercy-health-300x150.png) ![Sharp Health Plan Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/11/sharp-health-plan-logo-300x192.png) ![Jefferson Health Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/11/jefferson-health-logo-300x150.png) ![Independent Health](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/11/independent-health-logo.png) ![Advanced Health logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/11/advanced-health-logo.png) ![CalPERS Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/11/calpers-logo.png) ![Delaware Valley ACO Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/07/delaware-valley-aco-logo-300x150.png) ## Who MedInsight serves ![Payers]() ### Payers Gain a new competitive advantage by aggregating and benchmarking claims, clinical, lab, and third-party data to reduce costs, hospital re-admissions, and improve overall patient care [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/payer/) ![ACOs]() ### ACOs Extend your analytics capability without hiring by aggregating and normalizing patient claims and clinical data to identify care gaps, reduce network leakage, and minimize financial risks [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/) ![Employers]() ### Employers Understand your healthcare spend and gain insights for improving the quality of your benefits package to better serve and improve the health at-risk and all employee needs [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ![State Government]() ### State government Proactively monitor key healthcare trends to ensure that reimbursement rates are set appropriately and managed Medicaid plans are performing with a powerful analytics platform [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ## MedInsight platforms ![MedInsight VBC]() #### MedInsight ### Value-based Care Extend your analytics capability to identify care delivery, cost savings, and financial risk reduction opportunities with the MedInsight VBC Platform. [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/) ![MedInsight Payer]() #### MedInsight ### Payer Harness payer-focused capabilities such as benchmarking cost and utilization metrics, population health management, employer group reporting, and more. [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/payer/) ![MedInsight Risk Adjustment]() #### MedInsight ### Risk Adjustment Improve clinical documentation and coding, risk scoring, and quality outcomes with an integrated, comprehensive, enterprise solution for risk management. [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/risk-adjustment/) ## MedInsight platform overview video Trust your data and accurately price risk with MedInsight: relied on by over 300 payers and ACOs since 1997 to aggregate and enrich claims data with county-level benchmarks, risk adjusters, and groupers—all peer-reviewed as part of the MedInsight Data Confidence Model. Your data will be refreshed in days instead of weeks every month so you can identify insights that lead to improved health outcomes, lower cost, and reduced financial risk. [Let's talk](https://medinsight.com/healthcare-data-analytics-contact/) ## MedInsight components ![Insights]() ### Insights Identify quality of care improvements, savings opportunities, and ways to lower financial risk – and visually communicate them to stakeholders through the MedInsight reporting interface. ![Analytics]() ### Analytics Perform advanced, custom analysis on claims data that is aggregated across payers, enriched with groupers and metrics, and run through the MedInsight Data Confidence Model. ## MedInsight applications [![Contracts]()\\ \\ **Contracts** \\ \\ View financial performance across contracts so you can analyze the likelihood of success by contract, set individual contract targets, and track performance over the year.](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/contracts/) [![AI]()\\ \\ **AI** \\ \\ Apply artificial intelligence (AI) and machine learning (ML) models to your data for better insights, faster; you can also access our Emerging Experience dataset via AI.](https://medinsight.com/healthcare-data-analytics-software/applications/data-science-portal/) [![Group Reporting]()\\ \\ **Group reporting** \\ \\ Show your plan’s value by sharing detailed account and group reporting with employers and third-parties to enable better decisions and increase plan renewals.](https://medinsight.com/healthcare-data-analytics-software/applications/employer-group-insights-egi/) ## MedInsight analytics products ### Performance Benchmarking Suite MedInsight Performance Benchmarking Suite empowers organizations to compare their performance against Milliman’s highly respected benchmarks. With comprehensive metrics and key performance indicators, organizations gain a clear understanding of their strengths, weaknesses, and areas for improvement. [Learn more](https://medinsight.com/healthcare-data-analytics-software/analytic-products/performance-benchmarking-suite/) ### Risk Adjustment Suite MedInsight Risk Adjustment Suite offers advanced algorithms and predictive modeling capabilities that optimize coding accuracy, identify documentation gaps, and ensure appropriate reimbursement. [Learn more](https://medinsight.com/healthcare-data-analytics-software/analytic-products/risk-adjustment-suite/) ### Clinical Suite MedInsight Clinical Suite offers revolutionizes healthcare delivery by empowering organizations with advanced clinical analytics and decision support capabilities. This comprehensive suite enhances clinical decision-making, improves patient outcomes, and drives operational efficiency. [Learn more](https://medinsight.com/healthcare-data-analytics-software/analytic-products/clinical-suite/) ### Identify how to unlock insights from your data [Get an analytics assessment](https://medinsight.com/healthcare-data-analytics-assessment/) ## Testimonials “In partnering with MedInsight, we’ve been able to go deeper to put in custom strategies and formulas that have put us into a very high percentage of attribution identification. That’s huge when you are trying to go into a practice and develop change at point of care.” CEO, Southeastern Health Partners “When we work with other vendors, the tool doesn’t deliver what the presentation and demo showed. It takes more configuration and customization to get what you need. With MedInsight, you know what you’re getting on the front end: Milliman’s intellectual property in the development of tools. They know how to look at health information, medical claims, and health related work. They have stuff out-of-the-box that meets our teams’ needs and we’re not left empty handed.” VP, Enterprise Business Intelligence “I love the folks at MedInsight. I love collaborating with them. I love all that they bring to the table.” IT Consultant, Southeastern Health Partners “We’ve been using MedInsight for four years and it’s been a positive experience. The prior vendor experience was very frustrating in that they had a lot of trouble dealing with data, specifically normalizing the data. Milliman was able to come in and in six months, complete what this previous vendor couldn’t do in the space of 2 ½ to three years.” Director, Claims, Utilization & Trend Analysis “The team is fantastic. There’s a lot of transparency. We have a good working relationship. I get the support I need, which is really nice. **That data we get is very clean.** We can quickly aggregate and get at insights within the portal.” Analytics Director “Getting MedInsight data normalization provides us with the cleanest data, which has been a huge benefit and relief. **We haven’t found anyone else that can do it.** We need the benchmarking and all, but everything else is just icing on the cake.” VP, Healthcare Analytics and IT “HCG grouper allows us to pull Medicare data in the prescribed CMS format. It saves us significant labor every year. We just run our data through it, and it does what it needs to. Same for our other pricing …  we use MedInsight data for all of it because of the way it organizes data into neat spaces and it’s easy for us to use. We also launched Medicare Repricer on our commercial data. We make contracting decisions with providers based on that Repricer data, so we _know_ it’s saved us money to get our business on reference-based pricing rather than percentage billed.” Actuarial Department “It’s very easy to use, intuitive. When we have questions, there’s the reference library or we can go to our team at MedInsight for more in-depth questions.” VP, Healthcare Provider “They’ve helped us develop an education program for our analytics and executive community that’s been awesome. When we have technical or actuarial issues with groupers and software, we get immediate feedback. I don’t think of the tool, software, or suite. I think of the people support that sit behind it.” Director, Population Health Analytics “I spend a lot of time in MedInsight daily. I pull a bit of everything, depending on who’s asking. It’s super user-friendly and very easy to use. If you’re teaching someone else how to use it, you’re spending less time training and more time getting data out of there.” Data Analyst “We have three different claims payments – commercial, Medicare Advantage, and data from CMS for Medicare shared savings – and MedInsight aggregates all three of those data sources, normalizes them and makes it a uniform system where we can look at everything together on a similar basis. I don’t have to pull data out of this system or that system. The portal is understandable, intuitive, and easy to use.” SVP, Healthcare Analytics “As crazy as it sounds, we’re still evolving in our use of MedInsight after 10 years. There’s a lot of it we’re still trying to learn because our use of it has broadened, now spanning underwriting, sales, business development, actuarial, and finance. It’s a tool that’s used widely across the organization.” Chief Operations Officer “We’re under 50 people, so MedInsight is replacing 20–30 people that it would take to procure 250,000 beneficiaries and insurance claims on a regular basis while updating all of the benchmarks and creating new analyses. Utilizing MedInsight has made my organization extremely more efficient. It’s a partnership; they’re going to walk and talk with you throughout your business cases and really understand your business needs.” Director of Population Health Information Technology “First stop I go to for any request that comes to me: Can I get it from MedInsight? Because that’s the easiest way. It’s definitely the most comprehensive source for us. The things we can do now with a click of a button in MedInsight are just amazing – the financial link, the chronic condition, risk scoring, and benchmarking. We’ve customized everything, including the sales portal and attribution reporting.” Actuarial Director “We get our money’s worth from MedInsight, and I know there is even more that we have yet to flesh out.” Manager, Finance “MedInsight is highly engaged when it comes to training.” Director, Training “Our primary contact from MedInsight is on top of things for us. They have been a good ally for us throughout our relationship.” Manager, Analytics “MedInsight has been able to tailor things to our needs. The data mart enables us to integrate with our data warehouse, and we also like the integrity of the data.” VP Analytics “We really enjoy all aspects of MedInsight: Query Express, HCGs, and the Waste Calculator. MedInsight has great analytical groupers.” CEO & President “When I compare my options, MedInsight is my preferred data source simply because it is better than other vendors or what we have internally.” Director, Analytics [See more client testimonials](https://medinsight.com/healthcare-data-analytics-resources/client-testimonials/) ![Best in KLAS Payer Analytics]() ## Best in KLAS for the sixth year MedInsight’s platform for healthcare analytics and data warehousing was recognized as the Best in Payer Data Analytics Platforms in the 2025 Best in KLAS: Software and Services report. Best in KLAS awards are determined following extensive evaluations and conversations with thousands of healthcare providers. [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ## Blogs ### Transforming value-based care performance with the MedInsight VBC Platform Value-based care (VBC) shifts the focus from the quantity of healthcare services delivered to the quality and effectiveness of care provided. In this model, providers... [Read more](https://medinsight.com/healthcare-data-analytics-resources/blog/transforming-value-based-care-performance-with-the-medinsight-vbc-platform/) ### Precision is key: How payers can unlock strategic insights from claims and clinical data integration Today, payers face mounting pressure to deliver better outcomes, control the cost of care, and  manage financial risk. Meeting these goals requires more than access... [Read more](https://medinsight.com/healthcare-data-analytics-resources/blog/precision-is-key-how-payers-can-unlock-strategic-insights-from-claims-and-clinical-data-integration/) ### How healthcare payers can grow their analytic capabilities while staying vigilant against data breach threats Increasingly scalable, flexible, interoperable, cloud-based platforms supporting sophisticated analytic capabilities have created wide-ranging opportunities and profound insights for healthcare organizations, from improvements in quality of... [Read more](https://medinsight.com/healthcare-data-analytics-resources/blog/how-healthcare-payers-can-grow-their-analytic-capabilities-while-staying-vigilant-against-data-breach-threats/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Healthcare Data Analytics [Skip to the content](https://medinsight.com/#content) Previous ### [Milliman MedInsight ACO clients achieve $658 million in savings for the 2024 Medicare Shared Savings Program. Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-aco-clients-achieve-658-million-in-savings-outperforming-national-averages-in-the-2024-medicare-shared-savings-program/) ### [Milliman MedInsight wins 2025 Best in KLAS for Data Analytics Platform (Payer). Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-wins-2025-best-in-klas-for-data-analytics-platform-payer/) ### [Milliman MedInsight celebrates 25+ years of trusted data and insights. Learn more](https://medinsight.com/healthcare-data-analytics-about/25th-anniversary/) ### [Milliman MedInsight ACO clients achieve $658 million in savings for the 2024 Medicare Shared Savings Program. Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-aco-clients-achieve-658-million-in-savings-outperforming-national-averages-in-the-2024-medicare-shared-savings-program/) ### [Milliman MedInsight wins 2025 Best in KLAS for Data Analytics Platform (Payer). Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-wins-2025-best-in-klas-for-data-analytics-platform-payer/) ### [Milliman MedInsight celebrates 25+ years of trusted data and insights. Learn more](https://medinsight.com/healthcare-data-analytics-about/25th-anniversary/) ### [Milliman MedInsight ACO clients achieve $658 million in savings for the 2024 Medicare Shared Savings Program. Learn more](https://medinsight.com/healthcare-data-analytics-about/press-releases/milliman-medinsight-aco-clients-achieve-658-million-in-savings-outperforming-national-averages-in-the-2024-medicare-shared-savings-program/) Next # Healthcare data analytics software for health plans and ACOs ### Unlock the power of your data: MedInsight advanced analytics and contextualized insights empower healthcare payers, providers, purchasers, and consultants. ![MedInsight Healthcare Data Analytics](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/08/homepage-graphic-2025-v2.png) ## MedInsight is trusted by: ![Southeastern Health Partners Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/07/southeastern-partners-logo-300x86.png) ![Community Health Plan of Washington Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/02/community-health-plan-wa-300x118.png) ![SSM Health Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/01/ssm-health-logo.png) ![Hartford Healthcare Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/01/hartford-healthcare-logo.png) ![Altais Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/01/altais-logo.png) ![AultCare Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2024/01/aultcare-logo.png) ![Virginia Health Information Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/virginia-health-logo.png) ![Genesys PHO Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/genesys-pho-logo.png) ![Atrio Health Plans Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/07/atrio-health-plans-logo-300x138.png) ![Care New England Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/care-new-england-logo.png) ![DMBA Logo](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/12/dmba-logo.png) ![Quartz Logo]() ![Washington Health Alliance Logo]() ![Bon Secours Mercy Health Logo]() ![Sharp Health Plan Logo]() ![Jefferson Health Logo]() ![Independent Health]() ![Advanced Health logo]() ![CalPERS Logo]() ![Delaware Valley ACO Logo]() ## Who MedInsight serves ![Payers]() ### Payers Gain a new competitive advantage by aggregating and benchmarking claims, clinical, lab, and third-party data to reduce costs, hospital re-admissions, and improve overall patient care [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/payer/) ![ACOs]() ### ACOs Extend your analytics capability without hiring by aggregating and normalizing patient claims and clinical data to identify care gaps, reduce network leakage, and minimize financial risks [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/) ![Employers]() ### Employers Understand your healthcare spend and gain insights for improving the quality of your benefits package to better serve and improve the health at-risk and all employee needs [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ![State Government]() ### State government Proactively monitor key healthcare trends to ensure that reimbursement rates are set appropriately and managed Medicaid plans are performing with a powerful analytics platform [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ## MedInsight platforms ![MedInsight VBC]() #### MedInsight ### Value-based Care Extend your analytics capability to identify care delivery, cost savings, and financial risk reduction opportunities with the MedInsight VBC Platform. [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/) ![MedInsight Payer]() #### MedInsight ### Payer Harness payer-focused capabilities such as benchmarking cost and utilization metrics, population health management, employer group reporting, and more. [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/payer/) ![MedInsight Risk Adjustment]() #### MedInsight ### Risk Adjustment Improve clinical documentation and coding, risk scoring, and quality outcomes with an integrated, comprehensive, enterprise solution for risk management. [Learn more](https://medinsight.com/healthcare-data-analytics-software/platform/risk-adjustment/) ## MedInsight platform overview video Trust your data and accurately price risk with MedInsight: relied on by over 300 payers and ACOs since 1997 to aggregate and enrich claims data with county-level benchmarks, risk adjusters, and groupers—all peer-reviewed as part of the MedInsight Data Confidence Model. Your data will be refreshed in days instead of weeks every month so you can identify insights that lead to improved health outcomes, lower cost, and reduced financial risk. [Let's talk](https://medinsight.com/healthcare-data-analytics-contact/) ## MedInsight components ![Insights]() ### Insights Identify quality of care improvements, savings opportunities, and ways to lower financial risk – and visually communicate them to stakeholders through the MedInsight reporting interface. ![Analytics]() ### Analytics Perform advanced, custom analysis on claims data that is aggregated across payers, enriched with groupers and metrics, and run through the MedInsight Data Confidence Model. ## MedInsight applications [![Contracts]()\\ \\ **Contracts** \\ \\ View financial performance across contracts so you can analyze the likelihood of success by contract, set individual contract targets, and track performance over the year.](https://medinsight.com/healthcare-data-analytics-software/platform/provider-aco-value-based-care-vbc/contracts/) [![AI]()\\ \\ **AI** \\ \\ Apply artificial intelligence (AI) and machine learning (ML) models to your data for better insights, faster; you can also access our Emerging Experience dataset via AI.](https://medinsight.com/healthcare-data-analytics-software/applications/data-science-portal/) [![Group Reporting]()\\ \\ **Group reporting** \\ \\ Show your plan’s value by sharing detailed account and group reporting with employers and third-parties to enable better decisions and increase plan renewals.](https://medinsight.com/healthcare-data-analytics-software/applications/employer-group-insights-egi/) ## MedInsight analytics products ### Performance Benchmarking Suite MedInsight Performance Benchmarking Suite empowers organizations to compare their performance against Milliman’s highly respected benchmarks. With comprehensive metrics and key performance indicators, organizations gain a clear understanding of their strengths, weaknesses, and areas for improvement. [Learn more](https://medinsight.com/healthcare-data-analytics-software/analytic-products/performance-benchmarking-suite/) ### Risk Adjustment Suite MedInsight Risk Adjustment Suite offers advanced algorithms and predictive modeling capabilities that optimize coding accuracy, identify documentation gaps, and ensure appropriate reimbursement. [Learn more](https://medinsight.com/healthcare-data-analytics-software/analytic-products/risk-adjustment-suite/) ### Clinical Suite MedInsight Clinical Suite offers revolutionizes healthcare delivery by empowering organizations with advanced clinical analytics and decision support capabilities. This comprehensive suite enhances clinical decision-making, improves patient outcomes, and drives operational efficiency. [Learn more](https://medinsight.com/healthcare-data-analytics-software/analytic-products/clinical-suite/) ### Identify how to unlock insights from your data [Get an analytics assessment](https://medinsight.com/healthcare-data-analytics-assessment/) ## Testimonials “In partnering with MedInsight, we’ve been able to go deeper to put in custom strategies and formulas that have put us into a very high percentage of attribution identification. That’s huge when you are trying to go into a practice and develop change at point of care.” CEO, Southeastern Health Partners “When we work with other vendors, the tool doesn’t deliver what the presentation and demo showed. It takes more configuration and customization to get what you need. With MedInsight, you know what you’re getting on the front end: Milliman’s intellectual property in the development of tools. They know how to look at health information, medical claims, and health related work. They have stuff out-of-the-box that meets our teams’ needs and we’re not left empty handed.” VP, Enterprise Business Intelligence “I love the folks at MedInsight. I love collaborating with them. I love all that they bring to the table.” IT Consultant, Southeastern Health Partners “We’ve been using MedInsight for four years and it’s been a positive experience. The prior vendor experience was very frustrating in that they had a lot of trouble dealing with data, specifically normalizing the data. Milliman was able to come in and in six months, complete what this previous vendor couldn’t do in the space of 2 ½ to three years.” Director, Claims, Utilization & Trend Analysis “The team is fantastic. There’s a lot of transparency. We have a good working relationship. I get the support I need, which is really nice. **That data we get is very clean.** We can quickly aggregate and get at insights within the portal.” Analytics Director “Getting MedInsight data normalization provides us with the cleanest data, which has been a huge benefit and relief. **We haven’t found anyone else that can do it.** We need the benchmarking and all, but everything else is just icing on the cake.” VP, Healthcare Analytics and IT “HCG grouper allows us to pull Medicare data in the prescribed CMS format. It saves us significant labor every year. We just run our data through it, and it does what it needs to. Same for our other pricing …  we use MedInsight data for all of it because of the way it organizes data into neat spaces and it’s easy for us to use. We also launched Medicare Repricer on our commercial data. We make contracting decisions with providers based on that Repricer data, so we _know_ it’s saved us money to get our business on reference-based pricing rather than percentage billed.” Actuarial Department “It’s very easy to use, intuitive. When we have questions, there’s the reference library or we can go to our team at MedInsight for more in-depth questions.” VP, Healthcare Provider “They’ve helped us develop an education program for our analytics and executive community that’s been awesome. When we have technical or actuarial issues with groupers and software, we get immediate feedback. I don’t think of the tool, software, or suite. I think of the people support that sit behind it.” Director, Population Health Analytics “I spend a lot of time in MedInsight daily. I pull a bit of everything, depending on who’s asking. It’s super user-friendly and very easy to use. If you’re teaching someone else how to use it, you’re spending less time training and more time getting data out of there.” Data Analyst “We have three different claims payments – commercial, Medicare Advantage, and data from CMS for Medicare shared savings – and MedInsight aggregates all three of those data sources, normalizes them and makes it a uniform system where we can look at everything together on a similar basis. I don’t have to pull data out of this system or that system. The portal is understandable, intuitive, and easy to use.” SVP, Healthcare Analytics “As crazy as it sounds, we’re still evolving in our use of MedInsight after 10 years. There’s a lot of it we’re still trying to learn because our use of it has broadened, now spanning underwriting, sales, business development, actuarial, and finance. It’s a tool that’s used widely across the organization.” Chief Operations Officer “We’re under 50 people, so MedInsight is replacing 20–30 people that it would take to procure 250,000 beneficiaries and insurance claims on a regular basis while updating all of the benchmarks and creating new analyses. Utilizing MedInsight has made my organization extremely more efficient. It’s a partnership; they’re going to walk and talk with you throughout your business cases and really understand your business needs.” Director of Population Health Information Technology “First stop I go to for any request that comes to me: Can I get it from MedInsight? Because that’s the easiest way. It’s definitely the most comprehensive source for us. The things we can do now with a click of a button in MedInsight are just amazing – the financial link, the chronic condition, risk scoring, and benchmarking. We’ve customized everything, including the sales portal and attribution reporting.” Actuarial Director “We get our money’s worth from MedInsight, and I know there is even more that we have yet to flesh out.” Manager, Finance “MedInsight is highly engaged when it comes to training.” Director, Training “Our primary contact from MedInsight is on top of things for us. They have been a good ally for us throughout our relationship.” Manager, Analytics “MedInsight has been able to tailor things to our needs. The data mart enables us to integrate with our data warehouse, and we also like the integrity of the data.” VP Analytics “We really enjoy all aspects of MedInsight: Query Express, HCGs, and the Waste Calculator. MedInsight has great analytical groupers.” CEO & President “When I compare my options, MedInsight is my preferred data source simply because it is better than other vendors or what we have internally.” Director, Analytics [See more client testimonials](https://medinsight.com/healthcare-data-analytics-resources/client-testimonials/) ![Best in KLAS Payer Analytics]() ## Best in KLAS for the sixth year MedInsight’s platform for healthcare analytics and data warehousing was recognized as the Best in Payer Data Analytics Platforms in the 2025 Best in KLAS: Software and Services report. Best in KLAS awards are determined following extensive evaluations and conversations with thousands of healthcare providers. [Learn more](https://medinsight.com/healthcare-data-analytics-contact/) ## Blogs ### Transforming value-based care performance with the MedInsight VBC Platform Value-based care (VBC) shifts the focus from the quantity of healthcare services delivered to the quality and effectiveness of care provided. In this model, providers... [Read more](https://medinsight.com/healthcare-data-analytics-resources/blog/transforming-value-based-care-performance-with-the-medinsight-vbc-platform/) ### Precision is key: How payers can unlock strategic insights from claims and clinical data integration Today, payers face mounting pressure to deliver better outcomes, control the cost of care, and  manage financial risk. Meeting these goals requires more than access... [Read more](https://medinsight.com/healthcare-data-analytics-resources/blog/precision-is-key-how-payers-can-unlock-strategic-insights-from-claims-and-clinical-data-integration/) ### How healthcare payers can grow their analytic capabilities while staying vigilant against data breach threats Increasingly scalable, flexible, interoperable, cloud-based platforms supporting sophisticated analytic capabilities have created wide-ranging opportunities and profound insights for healthcare organizations, from improvements in quality of... [Read more](https://medinsight.com/healthcare-data-analytics-resources/blog/how-healthcare-payers-can-grow-their-analytic-capabilities-while-staying-vigilant-against-data-breach-threats/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Healthcare Data Analytics Blog [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/#content) #### Blogs # Healthcare data analytics blog [![Medical consultation](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/10/medical-consultation.jpg)](https://medinsight.com/healthcare-data-analytics-resources/blog/transforming-value-based-care-performance-with-the-medinsight-vbc-platform/) [Healthcare Data Analytics Blog\\ **Transforming value-based care performance with the MedInsight VBC Platform**](https://medinsight.com/healthcare-data-analytics-resources/blog/transforming-value-based-care-performance-with-the-medinsight-vbc-platform/) [Value-based care (VBC) shifts the focus from the quantity of healthcare services delivered to the quality and effectiveness of care provided. In this model, providers are rewarded for improving patient outcomes, enhancing care efficiency, and refining resource use. This shift matters because it aligns incentives with what truly benefits patients: better health, the right amount](https://medinsight.com/healthcare-data-analytics-resources/blog/transforming-value-based-care-performance-with-the-medinsight-vbc-platform/) [… Transforming value-based care performance with the MedInsight VBC Platform](https://medinsight.com/healthcare-data-analytics-resources/blog/transforming-value-based-care-performance-with-the-medinsight-vbc-platform/) [Read the blog](https://medinsight.com/healthcare-data-analytics-resources/blog/transforming-value-based-care-performance-with-the-medinsight-vbc-platform/) [![Working woman](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/10/vbc-analytics-payers.jpg)](https://medinsight.com/healthcare-data-analytics-resources/blog/precision-is-key-how-payers-can-unlock-strategic-insights-from-claims-and-clinical-data-integration/) [Healthcare Data Analytics Blog\\ **Precision is key: How payers can unlock strategic insights from claims and clinical data integration**](https://medinsight.com/healthcare-data-analytics-resources/blog/precision-is-key-how-payers-can-unlock-strategic-insights-from-claims-and-clinical-data-integration/) [Today, payers face mounting pressure to deliver better outcomes, control the cost of care, and  manage financial risk. Meeting these goals requires more than access to raw data—it demands actionable insights that support strategic, cost-effective decision-making. This is where the integration of clinical and claims data becomes transformative. By bridging the gap between clinical records](https://medinsight.com/healthcare-data-analytics-resources/blog/precision-is-key-how-payers-can-unlock-strategic-insights-from-claims-and-clinical-data-integration/) [… Precision is key: How payers can unlock strategic insights from claims and clinical data integration](https://medinsight.com/healthcare-data-analytics-resources/blog/precision-is-key-how-payers-can-unlock-strategic-insights-from-claims-and-clinical-data-integration/) [Read the blog](https://medinsight.com/healthcare-data-analytics-resources/blog/precision-is-key-how-payers-can-unlock-strategic-insights-from-claims-and-clinical-data-integration/) [![Woman at library](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/10/woman-at-library.jpg)](https://medinsight.com/healthcare-data-analytics-resources/blog/how-healthcare-payers-can-grow-their-analytic-capabilities-while-staying-vigilant-against-data-breach-threats/) [Healthcare Data Analytics Blog\\ **How healthcare payers can grow their analytic capabilities while staying vigilant against data breach threats**](https://medinsight.com/healthcare-data-analytics-resources/blog/how-healthcare-payers-can-grow-their-analytic-capabilities-while-staying-vigilant-against-data-breach-threats/) [Increasingly scalable, flexible, interoperable, cloud-based platforms supporting sophisticated analytic capabilities have created wide-ranging opportunities and profound insights for healthcare organizations, from improvements in quality of care to cost-saving efficiencies. But the sensitive health care data underlying such promising developments can also leave payer organizations at risk. Healthcare payers handle large volumes of sensitive patient information,](https://medinsight.com/healthcare-data-analytics-resources/blog/how-healthcare-payers-can-grow-their-analytic-capabilities-while-staying-vigilant-against-data-breach-threats/) [… How healthcare payers can grow their analytic capabilities while staying vigilant against data breach threats](https://medinsight.com/healthcare-data-analytics-resources/blog/how-healthcare-payers-can-grow-their-analytic-capabilities-while-staying-vigilant-against-data-breach-threats/) [Read the blog](https://medinsight.com/healthcare-data-analytics-resources/blog/how-healthcare-payers-can-grow-their-analytic-capabilities-while-staying-vigilant-against-data-breach-threats/) [![Two doctors talking](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/10/doctors-consulting.jpg)](https://medinsight.com/healthcare-data-analytics-resources/blog/optimizing-outcomes-leveraging-analytics-for-provider-performance-in-value-based-care/) [Healthcare Data Analytics Blog\\ **Optimizing outcomes: Leveraging analytics for provider performance in value-based care**](https://medinsight.com/healthcare-data-analytics-resources/blog/optimizing-outcomes-leveraging-analytics-for-provider-performance-in-value-based-care/) [In a recent webinar discussion, Milliman MedInsight and Genesys PHO explored how healthcare organizations can use performance analytics to strengthen value-based care (VBC) initiatives. The panel included Francesca Hammerstrom, General Manager of Value-Based Care at Milliman MedInsight; Dr. Christopher Kodama, Chief Medical Officer at Milliman MedInsight; Samantha Lewis, Director of Healthcare Business and Population Health](https://medinsight.com/healthcare-data-analytics-resources/blog/optimizing-outcomes-leveraging-analytics-for-provider-performance-in-value-based-care/) [… Optimizing outcomes: Leveraging analytics for provider performance in value-based care](https://medinsight.com/healthcare-data-analytics-resources/blog/optimizing-outcomes-leveraging-analytics-for-provider-performance-in-value-based-care/) [Read the blog](https://medinsight.com/healthcare-data-analytics-resources/blog/optimizing-outcomes-leveraging-analytics-for-provider-performance-in-value-based-care/) [![Generative AI webinar](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/generative-ai-webinar.jpg)](https://medinsight.com/healthcare-data-analytics-resources/blog/charting-new-frontiers-with-generative-ai-a-medinsight-journey/) [Healthcare Data Analytics Blog\\ **Charting new frontiers with generative AI: A MedInsight journey**](https://medinsight.com/healthcare-data-analytics-resources/blog/charting-new-frontiers-with-generative-ai-a-medinsight-journey/) [In recent years, generative artificial intelligence (Gen AI) has progressed far beyond being an industry buzzword—it’s now a driving force reshaping how organizations collect, analyze, and utilize data for optimizing patient care and organizational strategy. The transformative potential of Gen AI, particularly in the realm of healthcare analytics, cannot be overstated. As healthcare organizations grapple](https://medinsight.com/healthcare-data-analytics-resources/blog/charting-new-frontiers-with-generative-ai-a-medinsight-journey/) [… Charting new frontiers with generative AI: A MedInsight journey](https://medinsight.com/healthcare-data-analytics-resources/blog/charting-new-frontiers-with-generative-ai-a-medinsight-journey/) [Read the blog](https://medinsight.com/healthcare-data-analytics-resources/blog/charting-new-frontiers-with-generative-ai-a-medinsight-journey/) [![Pharmacy](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/pharmacy-cost-management.jpg)](https://medinsight.com/healthcare-data-analytics-resources/blog/advancing-pharmacy-management-the-impact-of-biologics-biosimilars-glp-1s-and-data-driven-insights/) [Healthcare Data Analytics Blog\\ **Advancing pharmacy management: The impact of biologics, biosimilars, GLP-1s, and data-driven insights**](https://medinsight.com/healthcare-data-analytics-resources/blog/advancing-pharmacy-management-the-impact-of-biologics-biosimilars-glp-1s-and-data-driven-insights/) [Healthcare costs continue to climb with the average per-person expense rising 6.7%—from $7,378 in 2024 to $7,871 in 2025. This increase is being driven primarily by two categories: pharmacy and outpatient facility care. Pharmacy costs alone grew by 9.7%, while outpatient facility care costs have risen by 8.5%. Collectively, these service areas are responsible for](https://medinsight.com/healthcare-data-analytics-resources/blog/advancing-pharmacy-management-the-impact-of-biologics-biosimilars-glp-1s-and-data-driven-insights/) [… Advancing pharmacy management: The impact of biologics, biosimilars, GLP-1s, and data-driven insights](https://medinsight.com/healthcare-data-analytics-resources/blog/advancing-pharmacy-management-the-impact-of-biologics-biosimilars-glp-1s-and-data-driven-insights/) [Read the blog](https://medinsight.com/healthcare-data-analytics-resources/blog/advancing-pharmacy-management-the-impact-of-biologics-biosimilars-glp-1s-and-data-driven-insights/) Load More ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Asthma Medication Economics [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/clinical-economics-of-asthma-controller-medication-adherence-outcomes/#content) # Clinical Economics of Asthma Controller Medication: Adherence & Outcomes By Sudhanshu Bansal 4 April 2018 Print / PDF Share ![]() ## Share this page Copied Clinical Economics of Asthma Controller Medication: Adherence & Outcomes Sudhanshu Bansal ## Practical Analytic Approaches to Healthcare Challenges Asthma is a lifelong disease. In addition to limiting a person’s quality of life, medically it is also associated with significant healthcare utilization and costs.\[i\] According to a survey in 2015, there were 5.9 million physician office visits and 2.0 million Emergency Department visits in the US because of asthma.\[ii\] \[iii\] The Centers for Disease Control and Prevention (CDC) estimated that in 2007 asthma alone cost the U.S. about $56 billion in medical costs, lost school and work days, and early deaths. Good adherence to long-term asthma controller medications, defined as 50% or greater, has been shown to be associated with reduced acute asthma exacerbations in patients with persistent asthma and is one of the key outcome measurements for programs focused on improving persistent asthma management. Despite these facts, actual adherence is only about 30 to 40%.\[iv\] \[v\] One likely barrier to achieving higher asthma controller medication adherence is cost. Generic medications, which are usually less expensive than branded medications, were found to have better overall adherence rates.\[vi\] To explore asthma controller medication adherence rates, treatment outcomes, and any potential association with branded or generic drugs, Milliman conducted a focused analysis using MedInsight’s healthcare analytic platform on a large database containing claims for over 3.9 million Medicaid, Medicare Advantage and commercial members. We compared the incidence of acute asthma exacerbations and status asthmaticus events among asthma patients (defined as having intermittent or persistent asthma) who were exclusively on branded asthma controller medications to patients who were exclusively on generic asthma controller medications. We also researched the proportion of generic and branded asthma controller medications and utilization patterns in patients that achieved a high adherence rate. We defined our goal for high adherence as 80% or greater for the proportion of days covered (PDC) with asthma controller medications for patients under treatment for more than three months. Findings: Asthmatic patients were prescribed 52 types of asthma long-term controller medication drug compositions within the study period. This compares with a total of 69 drug compositions considered to be asthma long-term controller medications (HEDIS AMR-A table).\[vii\] Forty-two out of the 52 prescribed compositions were branded compositions. Twenty-two percent of asthma patients using generic controller medications exclusively had high adherence rates (80% or higher) compared with 14% of asthma patients who were using branded controller medications exclusively. Asthma patients using generic controller medications exclusively had much lower rates for acute exacerbations and status asthmaticus (34%) than asthma patients using branded controller medications exclusively (62%). Both groups had high adherence rates of over 80%. ![Comparison]() We also found that patients using generic controller medications exclusively and having adherence rates greater than 80% had 24% lower Emergency Department visits and 32% lower inpatient admissions per thousand member months compared with patients using branded controller medications exclusively. ![Comparison]() Our observations were based on limited administrative claims data; however, the results are in line with the analysis presented by association for accessible medicines depicting higher compliance among patients on generic drugs and other studies.vi While potential reasons for this finding such as demographic differences or formulary composition were not investigated, the most likely reason for this observation is differences in asthma severity between the population using generic controller medications and the population using branded controller medications. ## References: \[i\] American Academy of Allergy, Asthma and Immunology. Allergy and Asthma Drug Guide. \[ii\] Centers for Disease Control and Prevention. National Center for Health Statistics. Last updated: March, 2017. Available at: [https://www.cdc.gov/nchs/fastats/asthma.htm](https://www.cdc.gov/nchs/fastats/asthma.htm). \[iii\] National Ambulatory Medical Care Survey: 2015 State and National Summary Tables. Available at: [https://www.cdc.gov/nchs/data/ahcd/namcs\_summary/2015\_namcs\_web\_tables.pdf](https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2015_namcs_web_tables.pdf) \[iv\] Asthma Controller Medication Adherence, Risk of Exacerbation, and Use of Rescue Agents Among Texas Medicaid Patients with Persistent Asthma. Published: 2015. \[v\] Mika J. Mäkelä, Vibeke Backer, Morten Hedegaard, Kjell Larsson, Adherence to inhaled therapies, health outcomes and costs in patients with asthma and COPD, Respiratory Medicine, Volume 107, Issue 10, 2013, pages 1481–1490, ISSN 0954-6111. Available at: [https://dx.doi.org/10.1016/j.rmed.2013.04.005](https://dx.doi.org/10.1016/j.rmed.2013.04.005). \[vi\] Generic Drug Access & Savings in the U.S. Association for Accessible Medicines (AAM). 2017 Report. Available at: [https://www.accessiblemeds.org/sites/default/files/2017-07/2017-AAM-Access-Savings-Report-2017-web2.pdf](https://www.accessiblemeds.org/sites/default/files/2017-07/2017-AAM-Access-Savings-Report-2017-web2.pdf). \[vii\] HEDIS 2017 Volume 2 NDC Code List. Available at: [https://www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2017/hedis-2017-ndc-license/hedis-2017-final-ndc-lists](https://www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2017/hedis-2017-ndc-license/hedis-2017-final-ndc-lists). [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Healthcare Waste Twitter Chat [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/harvard-medical-school-vbid-health-medinsight-twitter-chat-on-healthcare-waste/#content) # Harvard Medical School, VBID Health & MedInsight Twitter Chat on Healthcare Waste By Milliman MedInsight 6 August 2018 Print / PDF Share ![]() ## Share this page Copied Harvard Medical School, VBID Health & MedInsight Twitter Chat on Healthcare Waste Milliman MedInsight ## Practical Analytic Approaches to Healthcare Challenges Last week on Twitter, we hosted a Twitter chat with [Milliman](https://twitter.com/millimanhealth) about healthcare waste in the industry. > Are you ready to discuss ways that the U.S. [#healthcare](https://twitter.com/hashtag/healthcare?src=hash&ref_src=twsrc%5Etfw) industry can curb unnecessary spending? Tune into the [#healthwaste](https://twitter.com/hashtag/healthwaste?src=hash&ref_src=twsrc%5Etfw) chat today. [pic.twitter.com/VJoa9nbukq](https://t.co/VJoa9nbukq) > > — Milliman, Inc. (@millimanhealth) [August 2, 2018](https://twitter.com/millimanhealth/status/1025010897608237057?ref_src=twsrc%5Etfw) [MedInsight’s](https://twitter.com/MedInsight) [Rich Moyer](https://twitter.com/RichCMoyer) and [Marcos Dachary](https://twitter.com/MarcosDachary) were joined by Harvard Medical School’s [Dr. Michael Chernew](https://twitter.com/Michael_Chernew) and VBID Health’s [Dr. Mark Fendrick](https://twitter.com/UM_VBID) to answer questions posed by Milliman. Other healthcare professionals joined the discussion asking questions and offering ideas using the hashtag #healthwaste. > Please welcome our guests [@RichCMoyer](https://twitter.com/RichCMoyer?ref_src=twsrc%5Etfw), [@MarcosDachary](https://twitter.com/MarcosDachary?ref_src=twsrc%5Etfw), [@Michael\_Chernew](https://twitter.com/Michael_Chernew?ref_src=twsrc%5Etfw), and [@FendrickVBID](https://twitter.com/FendrickVBID?ref_src=twsrc%5Etfw). [#healthwaste](https://twitter.com/hashtag/healthwaste?src=hash&ref_src=twsrc%5Etfw) [pic.twitter.com/rA1benzDyr](https://t.co/rA1benzDyr) > > — Milliman, Inc. (@millimanhealth) [August 2, 2018](https://twitter.com/millimanhealth/status/1025064936974647296?ref_src=twsrc%5Etfw) This was the first time Rich Moyer or Marcos Dachary had ever participated in an event like this. And over the course of an hour, we saw a rich discussion about healthcare waste developing. This was a great opportunity for others in the industry to be able to ask questions directly to the healthcare experts on this panel. > A1. We simply cannot afford to have health care spending grow as fast as it has. Prices are a huge issue, but wasteful use also important. We need to reduce use of low value services while increasing access to high value services. [#healthwaste](https://twitter.com/hashtag/healthwaste?src=hash&ref_src=twsrc%5Etfw) [https://t.co/oR3wHvl4nC](https://t.co/oR3wHvl4nC) > > — Michael Chernew (@Michael\_Chernew) [August 2, 2018](https://twitter.com/Michael_Chernew/status/1025067029181722626?ref_src=twsrc%5Etfw) > A3 Identifying waste is getting easier thanks to efforts from [https://t.co/ZaILsgWkAB](https://t.co/ZaILsgWkAB) [#healthwaste](https://twitter.com/hashtag/healthwaste?src=hash&ref_src=twsrc%5Etfw) [https://t.co/C4up8eieqh](https://t.co/C4up8eieqh) > > — Marcos Dachary (@MarcosDachary) [August 2, 2018](https://twitter.com/MarcosDachary/status/1025069902284111880?ref_src=twsrc%5Etfw) > And we need to turn Choosing Wisely recommendations into analytics to help quantify the efforts [#healthwaste](https://twitter.com/hashtag/healthwaste?src=hash&ref_src=twsrc%5Etfw) > > — Marcos Dachary (@MarcosDachary) [August 2, 2018](https://twitter.com/MarcosDachary/status/1025070495237120006?ref_src=twsrc%5Etfw) > A3. Agree with [@MarcosDachary](https://twitter.com/MarcosDachary?ref_src=twsrc%5Etfw). Washington Health Alliance did just that to identify $millions in [#healthwaste](https://twitter.com/hashtag/healthwaste?src=hash&ref_src=twsrc%5Etfw). [https://t.co/N63IgX9lGg](https://t.co/N63IgX9lGg) [@WAHealthCheckup](https://twitter.com/WAHealthCheckup?ref_src=twsrc%5Etfw) > > — UM V-BID Center (@UM\_VBID) [August 2, 2018](https://twitter.com/UM_VBID/status/1025071388372226048?ref_src=twsrc%5Etfw) > There are many demand and supply side levers to reduce [#healthwaste](https://twitter.com/hashtag/healthwaste?src=hash&ref_src=twsrc%5Etfw). Better to use synergistically. [pic.twitter.com/RBmEpwCCQL](https://t.co/RBmEpwCCQL) > > — UM V-BID Center (@UM\_VBID) [August 2, 2018](https://twitter.com/UM_VBID/status/1025070128415887360?ref_src=twsrc%5Etfw) > A5. Graphical description of [#clinicalnuance](https://twitter.com/hashtag/clinicalnuance?src=hash&ref_src=twsrc%5Etfw). A critical concept needed to reduce [#healthwaste](https://twitter.com/hashtag/healthwaste?src=hash&ref_src=twsrc%5Etfw) [https://t.co/EPFND2PPo8](https://t.co/EPFND2PPo8) > > — UM V-BID Center (@UM\_VBID) [August 2, 2018](https://twitter.com/UM_VBID/status/1025073145500323840?ref_src=twsrc%5Etfw) > A6 – we’ve been talking about unnecessary services, but large price variation is another one [#healthwaste](https://twitter.com/hashtag/healthwaste?src=hash&ref_src=twsrc%5Etfw) > > — Rich Moyer (@RichCMoyer) [August 2, 2018](https://twitter.com/RichCMoyer/status/1025074183301222401?ref_src=twsrc%5Etfw) > A6. Agreed. [#healthwaste](https://twitter.com/hashtag/healthwaste?src=hash&ref_src=twsrc%5Etfw). Main point is if we can’t control spending by lowering growth in prices and wasteful use, we will have problems that extend well beyond the healthcare system and likely dramatic changes (for better or worse). I hope we are moving in right direction. [https://t.co/NZ9kgMj1e8](https://t.co/NZ9kgMj1e8) > > — Michael Chernew (@Michael\_Chernew) [August 2, 2018](https://twitter.com/Michael_Chernew/status/1025075869461753856?ref_src=twsrc%5Etfw) If our #healthwaste Twitter chat interested you, be sure to check out [Milliman’s Critical Point podcast on healthcare waste](https://www.milliman.com/insight/2018/Critical-Point-podcast--Episode-1-Healthcare-waste/) to hear more from Marcos Dachary and MedInsight’s Dr. David Mirkin. > Thanks to our guests [@RichCMoyer](https://twitter.com/RichCMoyer?ref_src=twsrc%5Etfw), [@MarcosDachary](https://twitter.com/MarcosDachary?ref_src=twsrc%5Etfw), [@Michael\_Chernew](https://twitter.com/Michael_Chernew?ref_src=twsrc%5Etfw), and [@FendrickVBID](https://twitter.com/FendrickVBID?ref_src=twsrc%5Etfw) for sharing their perspectives. [#healthwaste](https://twitter.com/hashtag/healthwaste?src=hash&ref_src=twsrc%5Etfw) > > — Milliman, Inc. (@millimanhealth) [August 2, 2018](https://twitter.com/millimanhealth/status/1025078276971159554?ref_src=twsrc%5Etfw) > Want more on [#healthwaste](https://twitter.com/hashtag/healthwaste?src=hash&ref_src=twsrc%5Etfw) from [@MarcosDachary](https://twitter.com/MarcosDachary?ref_src=twsrc%5Etfw)? Check out the [@millimanhealth](https://twitter.com/millimanhealth?ref_src=twsrc%5Etfw) podcast Critical Point to hear him and MedInsight’s Dr. David Mirkin discuss [#healthcare](https://twitter.com/hashtag/healthcare?src=hash&ref_src=twsrc%5Etfw) [#waste](https://twitter.com/hashtag/waste?src=hash&ref_src=twsrc%5Etfw) in depth: [https://t.co/RBKXI5zG4m](https://t.co/RBKXI5zG4m) > > — Milliman MedInsight (@MedInsight) [August 2, 2018](https://twitter.com/MedInsight/status/1025070005682094082?ref_src=twsrc%5Etfw) We had a great time discussing healthcare waste with the community and look forward to doing another Twitter chat on a new topic in the future! [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Healthcare Waste Discussion [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/healthcare-waste-a-conversation-with-dr-mark-fendrick/#content) # Healthcare Waste: A Conversation with Dr. Mark Fendrick By Milliman MedInsight 14 June 2018 Print / PDF Share ![]() ## Share this page Copied Healthcare Waste: A Conversation with Dr. Mark Fendrick Milliman MedInsight ## Practical Analytic Approaches to Healthcare Challenges Dr. Mark Fendrick conceptualized and coined the term _Value-Based Insurance Design_ and is the director of the Value-Based Insurance Design Center (VBID) at the University of Michigan. His research focuses on how clinical payment and consumer engagement initiatives impact access to care, quality of care, and healthcare costs. He has authored over 250 articles and book chapters and has received numerous awards for the creation and implementation of value-based insurance design. He spoke with Milliman MedInsight about healthcare waste and his work with the MedInsight Health Waste Calculator. **Question: You spent your career trying to improve access to high-value care. Why have you gotten into the low-value care arena?** Well, it turns out that most of the services that people consider high value – I like to say the things I beg my patients to do – while they improve individual and population health, they tend to add to overall healthcare costs. Often in modest ways, sometimes in high ways. So given that most public and private payers are very concerned about the rate of healthcare cost growth, it has been incumbent upon us who have been pushing payers to use more of high-value care to identify potential opportunities to reduce spending on those services that don’t make Americans any healthier to allow us some head room to buy more of those high-value services that are currently underutilized. Early Value-Based Insurance Design, or VBID, just included reductions in consumer out of pocket costs for high-value services. As people used them more often costs went up. Now we’re trying to identify those low-value services, make them more difficult for people to access, take advantage of those immediate and substantial savings, and hopefully have much of those savings be put back into services that improve Americans’ health. **Question: Where do you think a payer should start when thinking about low-value care?** Low-value care is a little bit tricky in the fact that when you start removing certain services or making it more difficult to access certain services there is going to be special interest and concern, whether it be on the provider side or on the patient side. So we decided to get a number of stakeholders from across the country together and identify services that were easy to find in claims that were almost always low-value when they were used, and that if we got rid of them no one would really mind. We wanted these to be below the radar, or as I like to say fruit below the ground. This national multi-stakeholder Task Force on Low-Value Care selected five commonly overused services ready for action for purchasers to identify and eliminate. They include: diagnostic testing and imaging prior to low-risk surgery, population based vitamin D screening, prostate specific antigen testing for men over the age of 65, imaging in the first six weeks after muscular-skeleto back pain injury, and the use of branded drugs when a chemically identical generic was available. It’s our hope that tools like the Health Waste Calculator can help payers identify these and many other services. Services that if they were successfully removed would pretty much not be noticed and would allow payers millions, if not billions, of dollars to spend on those high-value services that are currently out of reach for many people in America. To read more about our conversation with Dr. Fendrick [click here](https://www2.medinsight.milliman.com/l/353101/2018-06-04/98nl1w). [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Health Waste Calculator [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/medinsight-health-waste-calculator-featured-in-health-affairs-third-most-read-article-of-2017/#content) # MedInsight Health Waste Calculator Featured in Health Affairs’ Third Most-Read Article of 2017 By Milliman MedInsight 27 February 2018 Print / PDF Share ![]() ## Share this page Copied MedInsight Health Waste Calculator Featured in Health Affairs’ Third Most-Read Article of 2017 Milliman MedInsight ## Practical Analytic Approaches to Healthcare Challenges Milliman’s MedInsight Health Waste Calculator – a leading analytic platform that provides actionable data around healthcare quality, efficiency, and effectiveness – was featured in _Health Affairs_’ third most-read article of 2017! The article, [“Low-Cost, High-Volume Health Services Contribute The Most To Unnecessary Health Spending,”](https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0385) highlights the Commonwealth of Virginia’s use of the MedInsight Health Waste Calculator, which found more than $586 million in unnecessary costs in the Virginia All-Payer Claims Database. Every year the healthcare industry wastes an estimated $750 billion.\[1\] Milliman created the MedInsight Health Waste Calculator to root out low-value, wasteful services to help significantly reduce healthcare waste for payers, providers, APCDs, and other healthcare systems. The Virginia Center for Health Innovation (VCHI), Virginia Health Information (VHI), and Value-Based Insurance Design (VBID) Health partnered with MedInsight to support Virginia’s statewide initiatives to identify and reduce low value, unnecessary medical tests and procedures in their healthcare systems. VCHI brought together Virginia’s leading health providers, payers, and employer groups to root out low-value care. Working with the VHI team, they used the MedInsight Health Waste Calculator to aid their measurement, monitoring, and reporting on services that provide no net health benefit. The _Health Affairs_ article outlines the forty-four low-value health services analyzed in the 2014 data, why they were so costly, and how the MedInsight Health Waste Calculator identified them. To read full press release or download the full article [click here](https://www2.medinsight.milliman.com/Health_Affairs_Press_Release). \[1\] Institute of Medicine, [Best Care at Lower Cost: The Path to Continuously Learning Health Care in America](https://www.nationalacademies.org/hmd/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx). National Academies Press, 2013. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Overused Eye Imaging [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/overused-ophthalmology-imaging-more-may-not-be-better/#content) # Overused Ophthalmology Imaging: More May Not Be Better By Lalit Baveja and Shivangi Sharma 21 February 2018 Print / PDF Share ![]() ## Share this page Copied Overused Ophthalmology Imaging: More May Not Be Better Lalit Baveja and Shivangi Sharma ## Practical Analytic Approaches to Healthcare Challenges Globally, policy makers and payers are focusing on services that are regarded medically unnecessary and do not yield useful results. In the United States, these are referred to as low- or no-value services and are considered wasteful. A significant percentage of the services considered wasteful are medical imaging when done without appropriate indications. Inappropriate use of imaging services contributes to unjustifiable healthcare costs and may lead to irrelevant incidental findings, exposing individuals to unnecessary radiation doses.1 We set out to research wasteful eye imaging services because there is very limited literature or analytical research in this area. According to the American Academy of Ophthalmology Preferred Practice Pattern® guidelines, in the absence of symptoms or significant pathology, a comprehensive history and physical examination should suffice and imaging is not indicated. Advanced eye imaging (optical coherence tomography, visual field testing, fundus photography, or eye photography) should be reserved for malignant neoplasms of the eye, retinal detachments, and injury to eye, optic nerves, or optic chiasm.2 Similar views are advocated by Choosing Wisely® from the American Academy of Ophthalmology, which states: “Don’t routinely order imaging tests for patients without symptoms or signs of significant eye disease in the absence of symptoms or signs of significant disease pathology.”3 We used Milliman MedInsight’s Health Waste Calculator (HWC) to identify wasteful eye imaging services. The HWC ‘Imaging Tests for Eye Disease’ measure identifies eye imaging as wasteful unless the patient has symptoms or signs of significant eye disease such as neoplasms of the eye, choroidal detachment, optic atrophy, glaucoma, diabetic retinopathy, macular degeneration, etc., where imaging is considered medically necessary. We calculated the HWC ‘Imaging Tests for Eye Disease’ measure for one of our clients, a commercial health plan with approximately 2,091,517 members, using claim data from calendar year 2015. As shown in Figure 1, 67% of eye imaging services measured were wasteful and cost nearly $8,198,169. **Figure 1: Pattern of Eye Imaging Services** | Service Type | Number of Services | Percentage of Services | Aggregate Allowed Amount | Percentage of Allowed Amount | | --- | --- | --- | --- | --- | | Total Eye Imaging | 157,308 | 100% | $12,736,798 | 100% | | Necessary Eye Imaging | 51,888 | 33% | $4,538,629 | 34% | | Wasteful Eye Imaging | 105,420 | 67% | $8,198,169 | 66% | **Figure 2: Percentage Distribution of Wasteful Eye Imaging** ![test]() Figure 2 profiles the distribution of the various advance eye imaging modalities that have been identified as wasteful. For each modality, the figure identifies the percentage of services that are wasteful and the corresponding percentage of wasteful total allowed dollars. Optical computed tomography has the highest rate of wasteful services and wasteful costs in the eye imaging service waste category. Analysis highlighted that it was performed for an array of inappropriate diagnoses including but not limited to headache, dizziness, and routine eye exam visits. This supports the proposition that eye imaging is being overused and is often done inappropriately in the absence of significant underlying disease pathology. Another interesting finding revealed that 41.9% of members with wasteful services had a repeat service for eye imaging in a year, which was also determined wasteful. It is important to note that claim data alone allows only an approximate identification of wasteful eye imaging. Even so, we were able to confirm a high prevalence of wasteful eye imaging for our client that allowed them to target potentially avoidable utilization and costs. 1 Sorenson C, Drummond M, Bhuiyan Khan B. Medical technology as a key driver of rising health expenditure: Disentangling the relationship. ClinicoEconomics and Outcomes Research, 2013:5 223–234. 2 American Academy of Ophthalmology Preferred Practice Patterns Committee. Preferred Practice Pattern Guidelines. Comprehensive Adult Medical Eye Evaluation. Ophthalmology. January 2016. Volume 123, Issue 1, Pages P209–P236. 3 American Association Ophthalmology. Choosing Wisely. Five things physicians and patients should question. February 21, 2013. Accessed at https://www.choosingwisely.org/clinician-lists/american-academy-ophthalmology-routine-imaging-for-patients-without-symptoms-or-signs-of-eye-disease/ [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Pharmacy Prescription Insights [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/pharmacy-prescription-is-it-generic-enough/#content) # Pharmacy Prescription: Is It Generic Enough? By Sudhanshu Bansal and Sumeet Vashishta 18 April 2018 Print / PDF Share ![]() ## Share this page Copied Pharmacy Prescription: Is It Generic Enough? Sudhanshu Bansal and Sumeet Vashishta ## Practical Analytic Approaches to Healthcare Challenges Prescription drugs comprise the third-largest component of U.S. national health expenditures, behind only hospital care and physician services, according to the Centers for Medicare and Medicaid Services.\[i\] According to the QuintilesIMS Institute, invoiced sales of prescription drugs amounted to $450 billion in 2016, representing 13.4 percent of all U.S. health spending. Prices for prescription drugs in the U.S. are far higher than they are in other industrialized countries. In 2014, on an invoice price basis, the U.S. spent $1,327 per capita on prescription drugs, as compared to non-U.S. members of the Organisation for Economic Co-operation and Development, which had a median per capita drug spending of $489.\[ii\] Generic drugs represent an effective and affordable method to decrease pharmacy costs. Generic drugs have saved the U.S. healthcare system $1.67 trillion in the last decade, generating $253 billion in savings in 2016 alone.\[iii\] To explore the extent of generic drug usage in pharmacy prescriptions we conducted a focused analysis using drug categories in one of MedInsight’s client databases. Key findings of this analysis were: - The proportion of generic prescriptions dispensed has increased consistently over the last 7 years, accounting for 89% of total prescription events in 2016. - Generic prescriptions account for only 27% of total prescription costs. - Branded drug prescription events decreased by 48% between 2010 to 2016, - Branded spending increased by 42% over that same period. Our observations were based on our analysis of a single customer’s data, however the results are in line with the analysis presented by the Generic Pharmaceutical Association (GPhA) for 2015.\[iv\] ![generic-vs-brand drugs]() We further analyzed the prescription events and prescription costs for the top 5 drug categories in terms of total cost in the year 2016. The key observations were: - All five categories were found to be directly or indirectly related to a chronic condition. - In four out of five categories, the generic prescription rate was greater than 50%. - The exception was anti-asthmatic drugs. These were prescribed largely in the form of branded drugs (78%) with a generic prescription rate of only 22% percent. - More than 90% of the total prescription costs were attributable to branded drugs in all top five drug categories. ![drugs-category-by-cost]() The analysis confirmed market perception and published trend of increasing generic prescription rates despite the bulk of pharmacy expense still driven by the expensive branded drugs. \[i\] Centers for Medicare and Medicaid Services. National Health Expenditures 2015 Highlights. Available at: [https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf](https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf) \[ii\] Avik Roy,2017. A Market-Based Plan for Affordable Prescription Drugs. Available at: [https://freopp.org/a-market-based-plan-for-affordable-prescription-drugs-931e31024e08](https://freopp.org/a-market-based-plan-for-affordable-prescription-drugs-931e31024e08) \[iii\] Association for Accessible Medicines. 2017 Generic Drug Access and Savings in the U.S. Report. Available at: [https://www.accessiblemeds.org/resources/blog/2017-generic-drug-access-and-savings-us-report](https://www.accessiblemeds.org/resources/blog/2017-generic-drug-access-and-savings-us-report) \[iv\] Generic Pharmaceutical Association, 2015. Generic Drug Savings In The U.S. Seventh Annual Edition:2015. Available at: [https://www.gphaonline.org/media/wysiwyg/PDF/GPhA\_Savings\_Report\_2015.pdf](https://www.gphaonline.org/media/wysiwyg/PDF/GPhA_Savings_Report_2015.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Pre-operative Testing Insights [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/pre-operative-laboratory-testing-for-low-risk-surgeries/#content) # Pre-operative Laboratory Testing for Low Risk Surgeries By Leena Laloo and Urvashi Sood 3 January 2018 Print / PDF Share ![]() ## Share this page Copied Pre-operative Laboratory Testing for Low Risk Surgeries Leena Laloo and Urvashi Sood ## Practical Analytic Approaches to Healthcare Challenges Routinely performing pre-operative testing is a common practice prior to surgery. The American Society of Anesthesiologists (ASA) Task Force defines routine tests as those done in the absence of any specific clinical indication or purpose (i.e. tests intended to discover a disease or disorder in an asymptomatic patient).1 Routine pre-operative testing typically consists of a panel of blood and urine tests, chest X-rays and electrocardiogram. The purpose is to identify any condition that would add risk to the surgery, and to adjust perioperative anesthetic care to mitigate surgical risk or even postpone or cancel surgery.\[1\] Although pre-operative testing has long been a common practice there is little or no evidence that supports any benefit for “routine testing” before low risk surgery.\[2\] Unnecessary pre-operative testing may cause a patient to be subjected to increased cost of surgical care, false positive, or borderline results that lead to further follow-up investigations.2 Follow-up investigations due to false positive results can cause unnecessary psychological and economic burdens, postponement of surgery, and even morbidity and mortality.2 In a cost effectiveness study by the Agency for Healthcare Research and Quality (AHRQ), it was found that routine pre-operative investigations resulted in a delay or cancellation of the planned surgery in about 2% of cases, some changes to anesthetic management in up to 11% of cases, or resulted in a change in surgical procedure in under 1% of cases.2 The components of preoperative laboratory testing considered in this blog were metabolic, general health, and electrolyte panel; urinalysis; blood glucose; serum albumin, creatinine, potassium, and sodium; bilirubin; complete blood count (CBC), hemoglobin, bleeding time, prothrombin time; alanine aminotransferase (ALT) and aspartate aminotransferase (AST). To study the practice pattern of this pre-operative laboratory testing in low risk surgery cases we used the MedInsight Health Waste Calculator’s evidence-based algorithm which includes the Choosing Wisely guidelines for identifying unnecessary testing for low risk surgical procedures. The analysis was conducted on claims from a large Midwestern commercial health plan for the year 2015. Low-risk surgeries considered in this study include various endoscopic and laparoscopic surgeries, minor gynecology, orthopedic, ophthalmology, and urological procedures including superficial surgeries. We identified 84 percent of pre-operative laboratory testing services associated with low risk surgical procedures as wasteful, meaning that only 16 percent were necessary (Figure 1). The total aggregate allowed cost for pre-operative laboratory testing was $80,445,931, of which wasteful laboratory testing associated with low risk surgical procedures accounted for $1,471,672, which is 2% of the total cost for pre-operative laboratory testing. These results show that wasteful pre-operative laboratory investigations add significant costs for patients and payers. ![pre-operative]() On further analysis of wasteful laboratory testing services, the top five wasteful pre-operative tests based on total cost were comprehensive metabolic panel, complete CBC, general health panel, urinalysis, hemoglobin (Hb) and prothrombin time (PT). Collectively these five common pre-operative lab tests contributed to 92% of the total wasteful laboratory testing. The profiling of these top five pre-operative tests is shown in Figure 2. ![Wasteful-pre-operative-lab-testing]() It is important to note that claims data alone is not sufficient to identify wasteful services with absolute certainty. However, even with conservative estimates, these findings confirm that a significant percentage of pre-operative laboratory testing done for low risk surgeries are wasteful. \[1\] Apfelbaum JL, Connis RT, Nickinovich DG et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012 Mar; 116(3):522–38. \[2\] Balk EM, Earley A, Hadar N, Shah N, Trikalinos TA. Benefits and Harms of Routine Preoperative Testing: Comparative Effectiveness. Comparative Effectiveness Review No. 130. (Prepared by Brown Evidence-based Practice Center under Contract No. 290-2012-0012-I.) AHRQ Publication No. 14-EHC009-EF. Rockville, MD: Agency for Healthcare Research and Quality; January 2014 [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Reducing Healthcare Waste [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/reducing-healthcare-waste-a-three-pronged-approach/#content) # Reducing Healthcare Waste: A Three Pronged Approach By Dr. Anikia Nelson and Mark Leaman 6 February 2018 Print / PDF Share ![]() ## Share this page Copied Reducing Healthcare Waste: A Three Pronged Approach Dr. Anikia Nelson and Mark Leaman ## Practical Analytic Approaches to Healthcare Challenges Experts and stakeholders across the industry agree that there is an immediate need to reduce wasteful healthcare spending in the US. A 2012 Institute of Medicine report estimated that one third of US healthcare spending, or $750 billion is wasted annually ( [Washington Post, September 2012](https://www.washingtonpost.com/news/wonk/wp/2012/09/07/we-spend-750-billion-on-unnecessary-health-care-two-charts-explain-why/?utm_term=.723cac882adb)). Of that amount, $210 billion is spent on unnecessary services attributable to overtreatment. Overtreatment can result from a number of varying factors. However, regardless of the underlying reasons, the end result is that patients are exposed to treatments and tests that do not result in optimal care and outcomes. In other words, these are healthcare services we shouldn’t be paying for regardless of the cost. More alarming than the huge amounts of money spent on overtreatment, is that many of these tests and treatments and their downstream effects can be harmful to patients. There are many stakeholders motivated to reduce healthcare waste. Regardless of whether you’re a payer or a provider, the fundamental steps to actually reduce healthcare waste are similar: - Identify and quantify wasteful services; - Implement strategies to reduce utilization of unnecessary services; and - Track and evaluate the success of waste reduction strategies and adjust efforts accordingly. To identify and quantify wasteful services, Milliman and VBID Health collaboratively developed a tool called the _MedInsight Health Waste Calculator_. The _MedInsight Health Waste Calculator_ categorizes claims data using logic based on national initiatives such as Choosing Wisely, to quantify services that research has proven add no value in specific clinically nuanced scenarios. These wasteful services are flagged at the claim line level allowing the Health Waste Calculator to quantify utilization and costs associated with wasteful services. With over 400 clinical measures in the development pipeline, the latest version of the MedInsight Health Waste Calculator has 42 measures to quantify waste related to about 60 Choosing Wisely measures from claims data. Quantifying waste allows organizations to prioritize which services to target with waste reduction strategies by aligning internal priorities with metrics on waste prevalence and cost, and factors such as risk of member harm. There are a number of high profile initiatives and collaborative partnerships aimed at identifying specific wasteful or unnecessary medical services. Two of the most prominent of these collaborative initiatives are Choosing Wisely and the US Preventative Services Task Force (USPSTF). One example of a service that is potentially unnecessary is cardiac imaging in certain situations. Specifically, the American College of Cardiology identified as unnecessary stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of members where there are no cardiac symptoms or no high risk markers present. As noted on the Choosing Wisely website, “asymptomatic, low risk patients account for up to 45 percent of unnecessary screening.” ( [Choosing Wisely, American College of Cardiology](https://www.choosingwisely.org/clinician-lists/american-college-cardiology-stress-cardiac-testing-or-advanced-non-invasive-imaging-in-routine-evaluations/)) A more common and familiar category of services that has generated a lot of publicity over the years has been unnecessary prescription of antibiotics for non-bacterial infections. Among the harmful consequences of these services are increased antimicrobial resistance causing severe infections, complications, and longer hospital stays. ( [Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4232501/)) Once wasteful services have been identified within a population, the obvious question is, what can be done to reduce these unnecessary services. Organizations can leverage several different strategies to address and reduce wasteful services. Strategies are generally centered on one or more levers such as analytics and reporting, education and promotion, claim adjudication, provider network management, medical management, purchasing criteria, and/or benefit design. Strategies will vary based on cost and resources available to implement, and how much they disrupt the healthcare delivery and payment cycle. One of the _MedInsight Health Waste Calculator’s_ earliest clients used the tool’s output to mature their waste reduction strategies and has realized significant savings by reducing wasteful services. By utilizing practice consultants in each of their accountable care organizations and embarking on member awareness campaigns among other interventions, this payer has reduced per member per month costs on ten waste measures ranging from 1.6% savings on unnecessary imaging for uncomplicated rhinosinusitis to 30.2% savings on unnecessary cervical cancer screening in women aged 13 to 20. Less disruptive strategies, such as member awareness campaigns, will likely have the least amount of impact on reducing wasteful services. Initiating utilization management requirements for potential wasteful services can be costly and disruptive, but would have a high impact on reducing wasteful services. Quantifying unnecessary services in a population can provide guidance on where to focus an organization’s often limited resources. By categorizing identified waste into high volume, low cost services versus high cost, low volume services an organization can better predict expected savings against the cost of various intervention strategies. This article describes analysis of 44 wasteful health services in the Virginia All Payer Claims Database, which revealed that low-cost, high-volume services contributed the most to unnecessary health spending (Mafi, et al., 2017). Regardless of the strategy, the ultimate objective of reducing wasteful services is to change the behavior of the providers who are ordering the potentially unnecessary services. With this key concept in mind, a group of researchers conducted a study to identify a framework that would be most favorable towards changing physicians’ behavior to reduce low-value care (Parchman, M.L., Healthcare (2016), [https://dx.doi.org/10.1016/j.hjdsi.2016.10.005](https://dx.doi.org/10.1016/j.hjdsi.2016.10.005)). The researchers conducted interviews with an eight-member stakeholder advisory committee that included patients, providers and health care leaders. Among their findings, the research group found that providers were most inclined to change their behavior when wasteful services were presented as not only wasteful, but also harmful or potentially harmful to their patients. The overall framework that the researchers found to be most effective in creating the culture for change included: - Prioritize addressing low-value care; - Build a culture of trust, innovation and improvement; - Establish a shared language and purpose; and - Commit resources to measurements Once a strategy has been implemented, the final step is to track and evaluate the effectiveness of the intervention strategy. The same tools and methods used to identify the wasteful or unnecessary services should be used to track these same services over time to determine if there has been an actual reduction in the services that were targeted for intervention. In closing, there is no debate that measurement of waste is critical for any serious approach to reduce unnecessary healthcare services. Integral to a three-pronged approach to reduce wasteful and unnecessary services is identifying, quantifying and then tracking the wasteful services over time. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Machine Learning Tools Overview [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/society-of-actuaries-podcast-machine-learning-tools-overview/#content) # Society of Actuaries Podcast: Machine Learning Tools Overview By Milliman MedInsight 21 May 2018 Print / PDF Share ![]() ## Share this page Copied Society of Actuaries Podcast: Machine Learning Tools Overview Milliman MedInsight ## Practical Analytic Approaches to Healthcare Challenges Machine learning is a hot topic in healthcare analytics today. Shea Parkes and Anders Larson, two of Milliman’s machine learning experts, started a podcast focusing on the subject for the Society of Actuaries (SOA) in 2015. The latest episode was posted May 1, 2018 and is called “Machine Learning Tools Overview.” In the episode, they discuss the range of tools available to help implement machine learning. “Tools are anything that helps you get the job done. You should do some planning, you should talk some stuff out. But at a certain point, especially with machine learning, someone is going to need to interface with a computer and get something done.” Shea and Anders discuss a range of tools for machine learning, drilling deeper on Graphical User Interface (GUI) modeling tools such as RapidMiner and KNIME. Many of the prior sessions focused on the concepts and theory, only hinting at specific tools and implementations. This episode kicks off a whole new series that will focus on languages, libraries, frameworks, and cloud providers. [Click here](https://www.soa.org/prof-dev/podcasts/predictive-analytics-podcasts/) to listen to the latest podcast! Previous episodes include a 12 part series on machine learning from an actuarial perspective. The episodes start with fundamental concepts, then move on to many of the common machine learning algorithms. Shea Parkes has been in many different roles in his time at Milliman. Now as a Principal he helps lead PRM Analytics with products that focus on Accountable Care and other Organizations. He also participates in many volunteering opportunities with the Society of Actuaries (SOA), mostly within the SOA’s Predictive Analytics and Futurism division. He served on the council of that division for a term and participated in planning many webinars, conference sessions, and newsletter articles. Anders Larson is a consulting actuary with the Milliman Indianapolis office. He provides actuarial consulting services to commercial and Medicaid health plans, self-funded groups, and provider organizations. All the episodes of the podcast can be found on the [official SOA page here](https://www.soa.org/prof-dev/podcasts/predictive-analytics-podcasts/) and you can find it on iTunes! If you would like to learn more about the podcast and or request topics for discussion email Shea Parkes at [shea.parkes@milliman.com](mailto:shea.parkes@milliman.com). [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Anesthesia in Colonoscopy [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/study-results-on-anesthesia-in-screening-colonoscopy/#content) # Study Results on Anesthesia in Screening Colonoscopy By Arushi Khurana and Sudhanshu Bansal and Sumeet Vashishta 27 June 2018 Print / PDF Share ![]() ## Share this page Copied Study Results on Anesthesia in Screening Colonoscopy Arushi Khurana, Sudhanshu Bansal and Sumeet Vashishta ## Practical Analytic Approaches to Healthcare Challenges The U.S. Preventive Services Task Force recommends colorectal cancer screening for men and women aged 50–75.\[i\] For colorectal cancer (CRC) screening, colonoscopy has been accepted as the most effective method, with the adenoma detection rate (ADR) remaining one of the most important measures of a quality colonoscopy. Factors shown to affect adenoma and polyp detection rates (PDR) include: use of sedation along with other factors like adequacy of bowel preparation, cecal intubation rate, withdrawal time, image enhancements, and the performing endoscopist.\[ii\] Traditionally, conscious (moderate) sedation (CS) using midazolam and an opioid has been used in screening colonoscopies. Until recent Medicare reimbursement changes, for most colonoscopy procedures CS has been considered an inherent part of the procedure, not to be reported and billed separately except for the situation when moderate sedation is provided by a second physician in a facility setting. However over the past decade, newer anesthesia options have become available, and based on a nationwide survey distributed in 2004 to the members of the American College of Gastroenterology, it was found that approximately one quarter of patients now undergo deep sedation with propofol (propofol sedation (PS)).\[iii\] Although Propofol sedation (PS) has led to detection of more advanced polyps, a retrospective analysis of 699 consecutive patients who underwent inpatient screening colonoscopies at one academic inpatient centre found no significant difference between ADR or location of detected adenomas between the CS and PS groups.2 An upward trend in separate anesthesia by anesthesiologist for screening colonoscopy was found in those with higher comorbidity according to a study conducted on National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database.3 To get an insight into how frequently separate anesthesia services are used in screening colonoscopy, and the associated comorbidities of the patient, we performed an analysis on Commercial plan members aged 50-75 years using a MedInsight data for year 2012. We identified the number of comorbidities the patient had, using diagnosis codes for the conditions used in a similar study.\[iv\] A comorbidity is assigned only when the member had at least two claims 30 days apart with the corresponding diagnosis code in the two years preceding colonoscopy. A total of 25,055 screening colonoscopies were performed in the year 2012 with the following characteristics. ![Screening_Colonoscopies_Graph]() Separate anesthesia was given in 3,465 (13.83%) of screening colonoscopies with a breakdown by comorbidity count and gender as given below: ![Screening_Colonoscopies_with_Separate_Anesthesia_Graph]() Out of all screening colonoscopies performed under separate anesthesia (3,465) a staggering 62.11% (2,152) had no associated comorbidities and the additional costs for anesthesia services alone in such cases amounted to $ 796,134. Although separate anesthesia for screening colonoscopies does not improve the ADR and most of the times has not been covered by the insurance plan, it is associated with increased patient satisfaction and reduced pain levels. As a result it has been increasingly used for screening colonoscopy. The Centers for Medicare and Medicaid Services, as a provision of the Affordable Care Act revised the definition of “colorectal cancer screening tests” beginning January 1, 2017 to include anesthesia that is separately furnished in conjunction with screening colonoscopies.\[i\] It will be interesting to look at the utilization and financial impact of this ruling on commercial and Medicare payers in the near future. \[i\] United States Preventive Services Task Force. Recommendations for colorectal cancer screening, 2008. Available at: [https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/colorectal-cancer-screening2#tab](https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/colorectal-cancer-screening2#tab) \[ii\] Nakshabendi R, Berry AC, Munoz JC, John BK. Choice of sedation and its impact on adenoma detection rate in screening colonoscopies. Annals of Gastroenterology : Quarterly Publication of the Hellenic Society of Gastroenterology. 2016;29(1):50-55. Available at: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4700847/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4700847/) \[iii\] Khiani VS, Soulos P, Gancayco J, Gross CP. Anesthesiologist Involvement in Screening Colonoscopy: Temporal Trends and Cost Implications in the Medicare Population. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2012;10(1):58-64.e1. doi:10.1016/j.cgh.2011.07.005. Available at: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3214600/#R6](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3214600/#R6) \[iv\] Comorbidity Measures for Use with Administrative Data Author(s): Anne Elixhauser, Claudia Steiner, D. Robert Harris and Rosanna M. Coffey Source: Medical Care, Vol. 36, No. 1 (Jan., 1998), pp. 8-27. \[v\] Federal Register, The daily Journal of the United States Government. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015. Available at: [https://www.federalregister.gov/articles/2014/11/13/2014-26183/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory](https://www.federalregister.gov/articles/2014/11/13/2014-26183/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Opioid Prescription Trends [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/study-results-on-claims-data-can-it-be-used-to-understand-opioid-prescription-trends/#content) # Study Results on Claims Data: Can It Be Used To Understand Opioid Prescription Trends? By Christine Castle and Rahul Ekbote 18 June 2018 Print / PDF Share ![]() ## Share this page Copied Study Results on Claims Data: Can It Be Used To Understand Opioid Prescription Trends? Christine Castle and Rahul Ekbote ## Practical Analytic Approaches to Healthcare Challenges Since 2000, the rate of deaths from drug overdoses has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (i.e. opioid pain relievers and heroin).1 In fact, almost 40% of all opioid overdose deaths involved a prescription opioid.2 In addition to the loss of life, opioid overdoses have resulted in an estimated $504 billion in economic cost during 2015.3 Historically, opioid addiction was an issue discussed in the context of illegal drugs such as heroin and other synthetic opioids. However, in the last few years this issue has expanded into the realm of prescription opioids and become a nationwide crisis that can no longer be ignored. The key question for policy makers and other health care stakeholders is, “What can we do to mitigate this crisis?” The solution needs to address patient behaviors that lead to overdoses and the prescription of unnecessary opioids by healthcare professionals. There isn’t a single right answer that will address both of these underlying issues regarding patient behavior and unnecessary prescriptions. Each and every stakeholder including policy makers, payers, providers, patients, family members, and others (e.g., law enforcement) have a role to play in the solution. Data analytics can be a key resource in understanding and responding to this crisis. For example, the analysis of claims can help payers and providers gain an in-depth understanding of the utilization patterns of prescribed opioids. Specifically, claims data for prescription opioids should be analyzed across three dimensions: 1. **Providers:** What are the key characteristics of providers who are potentially overprescribing opioids and who are these providers? 2. **Prescriptions:** What is the trend and utilization pattern including potential unnecessary use of opioid prescriptions in a given population? 3. **Members:** What do we understand about the medical condition(s) and other key characteristics of individuals who are prescribed opioids with a specific focus on members/patients potentially receiving unnecessary opioid prescriptions? ![Opioid]() We used the Milliman MedInsight platform to analyze sample prescription claims from 2012 to 2016 to demonstrate the analyses for answering these critical questions. The claims data was analyzed at an aggregated population level as well as at the individual member, provider, and claim level. Exploratory analyses were conducted within a plan population to: - Determine if the overprescribing of opioids is concentrated and isolated within a specific geographic region or network. - Understand spikes or changes in prescribing rates for specific opioids over time. - Identify specific providers prescribing opioids at a higher than average prescription rate. - Identify at-risk members and providers for proactive outreach and education. - Evaluate the appropriateness of utilization given the use of pain management in selected co-morbidities. The outcomes from the exploratory analyses were used to guide the in-depth evaluation and identify potential members and providers for targeted outreach. Table 1. Opioid Prescribing Trends by Line of Business ![Opioid_Table]() One of the first places to start on the path to understanding opioid misuse is to track the ongoing utilization pattern for members across different lines of business (e.g., Medicare, Medicaid) over time as illustrated in Table 1. When a health plan has multiple lines of business, it is crucial to understand if the problem is occurring at an aggregate plan level, or within a specific line of business. Using a normalized metric such as scripts per thousand members provides an effective baseline metrics for comparison rather than simply comparing the sheer volume of opioid prescriptions. These baseline metrics can be further stratified by geographic region, product type (e.g., HMO, PPO), or even isolated by specific types of prescription opioids. We stratified the sample data set by lines of business and determined that the majority of the opioid scripts were being written within the Medicare population. Table 2. Medicare – Top Prescribed Opioids in 2017 ![Opioid_Table_2]() From here, we investigated the opioid prescriptions for the Medicare population to understand what types of opioids were being prescribed. Table 2 on the left shows that the majority of the opioids being prescribed within the sample Medicare population were short-acting opioids such as oxycodone/acetaminophen and hydrocodone/acetaminophen. We also analyzed the prescription rate over time to determine if there was a change in prescribing patterns associated with these two types of opioid medications. We found that the prescribing rate for hydrocodone/acetaminophen increased 133% over the last four years. This information can be useful for care managers as they think through mitigation strategies associated with different types of prescription opioids. The ability to analyze the prescription claims data from such different dimensions helps to hone in on a member population to be targeted for intervention. Once a baseline understanding of opioid use is established, it is critical to identify sub-populations for effective targeting. It is not only important to identify the members who are receiving these prescriptions, but also understand why and how they are receiving them. A detailed member level drill down is essential to understand the underlying conditions and diagnoses related to opioid use. Moreover, the member and claim level details also provide insights regarding the providers prescribing these opioids. These findings are helpful to understand if members received multiple opioid prescriptions from more than one provider. Within our sample dataset, we isolated a member’s opioid prescriptions in 2016. We were then able to analyze the total prescriptions they had per month, and how many distinct providers wrote opioid prescriptions in that month. If a plan has a large proportion of members who are receiving opioid prescriptions from more than one provider, they can develop mitigation strategies such as a pharmacy lock-in policy, which “locks-in” members to specific providers in order to monitor and reduce unnecessary distribution. The ability to conduct such detailed analyses helps develop a deep understanding of prescription opioid misuse which is essential to design an appropriate response. In order to battle the ongoing crisis, payers and providers can utilize their claims data and sophisticated analytics to pinpoint areas for interventions. For further information please contact [rahul.ekbote@milliman.com](mailto:rahul.ekbote@milliman.com) or [christine.castle@milliman.com](mailto:christine.castle@milliman.com) (1)Accessed on February 8th 2018 from the website of CDC ( [https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm](https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm)) (2) Accessed on February 8th 2018 from the website of CDC ( [https://www.cdc.gov/drugoverdose/data/overdose.html](https://www.cdc.gov/drugoverdose/data/overdose.html)) (3) Accessed on February 8th 2018\. ‘The Underestimated Cost of the Opioid Crisis’ by the Council of Economic Advisers – November 2017 [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Effectiveness of Annual Physicals [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/study-results-on-the-effectiveness-of-annual-physicals/#content) # Study Results on the Effectiveness of Annual Physicals By Mary John Shekhar and Sumeet Vashishta 19 July 2018 Print / PDF Share ![]() ## Share this page Copied Study Results on the Effectiveness of Annual Physicals Mary John Shekhar and Sumeet Vashishta ## Practical Analytic Approaches to Healthcare Challenges There has been an ongoing debate in United States (US) on the value of the annual comprehensive physical examination. One school of thought recommends elimination of the annual comprehensive physical exam due to lack of value. Choosing Wisely 2014 states that healthy people often do not need annual comprehensive physicals\[i\], and systematic reviews\[ii\] back this up by finding these examinations do not significantly reduce morbidity or mortality. In addition to the fee for the physician, billions of dollar are spent on potentially unnecessary tests ordered during annual comprehensive physical exams and follow up diagnostics. A second school of thought defends the importance of annual comprehensive physical exams considering these critical to maintain and reaffirm a patient-physician relationship. Arguments have been made to improve the annual comprehensive physical exams instead of eliminating it by using a multidisciplinary team based approach, providing physicians with time for a more personalized in-depth review and a more comprehensive and satisfying overall experience for the patient.\[iii\] We wanted to understand if this ongoing debate has had an impact on the rate of annual physical exams. Using data from a MedInsight client with 12 million members, we reviewed recent trends in annual physical exams\[\*\] over a five (5) year period 2012-2016. We restricted our analysis to healthy members between 18 and 64 years of age who did not have a chronic condition in a given year (defined as being in a non-chronic CCHG (Chronic Conditions Hierarchical Group)). ![Annual_Phsyical_Exam](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/05/Figure_1_Annual_Phsyical_Exam_Visits_Updated.png) ![Annual_Physical_Exam_Visits]() We had the following findings: - About 7 percent of members aged 18-64 years are getting annual physical exams. - Rate of annual physical visits over the five-year period was relatively flat for all age groups; the 51-64 age group had a slightly increasing trend in the rate of annual physical visits. - No substantial difference in annual physical visits was observed between male and female members. Our analysis shows a recent decline in the number of people getting an annual physical examination. The reason for this decline could be the possible harms associated with these health checks such as fear of false positive results, over diagnosis, unwarranted treatment, follow-ups, and adverse emotional stress due to false labelling.2 Some individuals also find it a waste of their productive time waiting for the care; which could have been utilized better elsewhere. We assume these likely factors may be facilitating drop in numbers of annual physical exam visits.\[i\] Systematic review and meta-analysis have also provided evidence that annual physical examination does not reduce morbidity or mortality for any cause, although they increased the number of new diagnoses. Replacing the annual physical examination with a more personalized health review involving more discussion and limited examination would be more acceptable to the patients. This would not only suffice the purpose of preventive health review; but also help in improving the physician-patient relationship.\[ii\] **Limitations** The results and interpretations are solely based on the administrative claim data. **References:** \[\*\] An annual physical exam was identified using procedure codes 99395 and 99396 when reported along with ICD9 diagnosis code V700 or ICD10 diagnosis code Z0000. \[i\] Consumer Reports Health, 2014. Choosing wisely.Health checkups, when you need them and when you don’t. Available at: [https://www.choosingwisely.org/patient-resources/health-checkups/](https://www.choosingwisely.org/patient-resources/health-checkups/) \[ii\] Krogsboll LT, Jorgensen KJ, Gronhoj Larsen C, Gotzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ 2012;345: e7191. Available at: [https://www.bmj.com/content/345/bmj.e7191](https://www.bmj.com/content/345/bmj.e7191) \[iii\] Allan H. Goroll, M.D., 2015. Toward Trusting Therapeutic Relationships — In Favor of the Annual Physical. Available at: [https://www.nejm.org/doi/full/10.1056/NEJMp1508270?query=featured\_home](https://www.nejm.org/doi/full/10.1056/NEJMp1508270?query=featured_home) \[iv\] Mehrotra, Ateev and Prochazka, Allan. Improving Value in Health Care — Against the Annual Physical. New England Journal of Medicine. October 2015; 373:1485-1487. Available at : [https://www.nejm.org/doi/full/10.1056/NEJMp1507485](https://www.nejm.org/doi/full/10.1056/NEJMp1507485) \[v\] Bloomfield HE, Wilt TJ. Evidence Brief: Role of the Annual Comprehensive Physical Examination in the Asymptomatic Adult, VA-ESP Project #09-009; 2011. Available at: [https://www.ncbi.nlm.nih.gov/books/NBK82767/](https://www.ncbi.nlm.nih.gov/books/NBK82767/) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Wasteful Cardiac Testing [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/wasteful-pre-operative-cardiac-testing-prior-to-low-risk-surgery/#content) # Wasteful Pre-Operative Cardiac Testing Prior to Low-Risk Surgery By Lalit Baveja and Shivangi Sharma 30 January 2018 Print / PDF Share ![]() ## Share this page Copied Wasteful Pre-Operative Cardiac Testing Prior to Low-Risk Surgery Lalit Baveja and Shivangi Sharma ## Practical Analytic Approaches to Healthcare Challenges Anesthesiologists perform pre-operative assessment on all patients undergoing surgery in order to identify any disease or risks to the surgery and to plan perioperative anesthetic care to mitigate surgical risk. In patients with known cardiac disease, diagnostic cardiac tests such as stress tests and echocardiograms are sometimes recommended as part of this assessment. A recommendation from the American Society of Anesthesiologists notes that pre-operative cardiac stress testing is only appropriate for identifying extremely high-risk patients, in whom the results would change management prior to surgery, change the decision of the patient to undergo surgery, or change the type of procedure that the surgeon will perform. 1 The American College of Cardiology and American Heart Association recommends that there is no benefit for routine pre-operative cardiac testing in low risk surgery for patients with no cardiac disease. 2 For this reason, Milliman MedInsight’s Health Waste Calculator identifies pre-operative cardiac testing for patients undergoing low- or moderate-risk non-cardiac procedures (e.g., surgery cataract, laparoscopic cholecystectomy, corneal transplant, and removal of tonsils) as wasteful. We applied the Health Wast Calculator pre-operative testing measure for one of our clients, a commercial health plan with approximately 850,000 members, using claims data from calendar year 2012. As shown in Figure 1, 2.2% of the 5,120 pre-operative cardiac testing services were wasteful, at a cost of $88,000. Hence, it is recommended that clinicians perform pre-operative evaluation appropriately and reduce distress among patients. | Service Type | Number of Services | Percentage of Services | Aggregate Allowed Amount | Percentage of Allowed Amount | | --- | --- | --- | --- | --- | | Total Preoperative Cardiac Testing | 5,120 | 100% | $2,513,987 | 100% | | Wasteful Preoperative Cardiac Testing | 112 | 2.19% | $88,041 | 3.50% | Showing 1 to 2 of 2 entries It is important to note that claims data alone allows only an approximate identification of wasteful pre-operative cardiac testing. Even so, we were able to confirm instances of pre-operative testing for our client that could help it potentially avoid healthcare costs in the absence of benefit. For more information on how to identify wasteful services, visit the [MedInsight Health Waste Calculator](https://medinsight.com/insight/health-data-analytics-for-identifying-wasteful-services) web page. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Value of Claims Auditing [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/do-not-overlook-the-value-of-claims-auditing/#content) # Do Not Overlook the Value of Claims Auditing By David Cusick 31 July 2014 Print / PDF Share ![]() ## Share this page Copied Do Not Overlook the Value of Claims Auditing David Cusick **This article was originally published in Employee Benefit News. It was written by both David Cusick and Brian Anderson.** When seeking ways to keep expenses under control, health care plan sponsors may overlook the value of claims auditing. Auditing fees may not be inconsequential, but the fact is that an accurate audit including both pharmacy and medical claims has the potential to pay back the investment many times over. The more members a plan has enrolled and the more complex the plan’s benefit setup, the more likely a plan is to have a greater amount of claims payment errors. Every plan will have claims paid in error. It is often tempting simply to assume claims have been paid with a certain degree of accuracy, and then move on without verifying whether the assumption is correct. Nevertheless, there will always be instances of duplicate billing, wrong or missing discounts and rebates, mistakes in member eligibility, incorrect plan setup, or other problems. Regular audits of medical and pharmacy claims can find these discrepancies, leading to the recovery of overpayments. Even more importantly, audits can identify problems in the way a plan is set up and point the way to eradicating inaccuracies, reducing cost, and preventing waste in the future. Auditing can give plan sponsors vital information for revising and improving contracts with third-party administrators and pharmacy benefit managers, which can lead to significant reductions in costs. Many engagements begin with auditing one plan year, and then extend to multiple plan years based on the results of the first audit. Some plans have implemented processes that include monthly oversight reporting, which provides ongoing auditing and trend metrics. The monthly reporting is set up as an online service so that the reports can be automatically emailed to the health plans and accessed via an encrypted web portal. Auditing is applicable to all types of health care plans, including self-insured plans, Medicaid, Medicare, Taft-Hartley funds, and commercial plans. In our opinion, any organization that is at risk for paying medical or pharmacy claims must consider the value of claims auditing. **What happens during an audit?** Once all the initial preparation has been completed, the process of a good, cost-effective audit usually involves two steps. The first assesses all available claims and eligibility data, including claims adjustments and reversals, using sophisticated electronic testing techniques. Compared to audits done in previous years, it is now possible to examine the entirety of a plan’s data rather than only a sample. The second involves a more hands-on stage with a close examination of the patterns of claims issues identified by the electronic audit. Individual claims are pinpointed for further investigation according to these patterns. A comprehensive claims audit tests at least the following areas: - Eligibility: Is the member eligible for the claim at the time of service? - Financial: - Were the contracted pricing arrangements (or usual and customary limits) applied properly? - Were there any duplicate charges for a procedure or drug? - Have the administrative fee invoices been reconciled? - Have the claims invoices been reconciled? - Plan design: - Is the member cost sharing accurate? - Do the payments exceed plan limits and maximums? - Have other features of the plan design been properly applied? - Are there opportunities for coordination of benefits? - Performance guarantee review: Are the claims processing and other customer services compliant with established performance guarantees as defined in the contractual agreements with the TPA or PBM? For medical claims, they should include outlier physician charges (charges that are significantly higher than usual for a given procedure) and tests that are inconsistent with standards promulgated by the National Correct Coding Initiative of the Centers for Medicare and Medicaid Services, such as code pairs tests (procedures that, according to the NCCI, should not be reported together because one service inherently includes the other or because the two codes are mutually exclusive). For pharmacy claims, an audit examines a number of elements, such as compliance with formulary and/or generic drug provisions, patterns of use including early refills and quantity limits, proper application of clinical edits (e.g., step therapy, prior authorization, drug utilization review, etc.), “reasonableness” of any rebates, and the value associated with the maximum allowable cost list. **Early detection** If feasible, it is a good idea to have claims audited every one or two years. At least as important, however, is the implementation audit. An implementation audit takes place shortly after a plan has been set up. A good time frame is 90 days after beginning work with a new vendor or any substantially new contract. Implementation audits are akin to taking off the training wheels. They help ensure that a plan has been set up correctly and that the plan sponsor is getting all of the benefits it contracted for during the implementation process. They happen after enough time has passed to gain a body of experience data but still soon enough to head off a major course change requiring extensive retroactive corrections. Expect an audit to take three to six months. After that the recovery effort begins, in twofold fashion: recovering any money that the plan may have overpaid, and the equally important work of correcting errors in the system that were identified in the audit. Plan sponsors may engage an overpayment recovery vendor, or choose to handle it in-house. The benefits of proactive auditing for the plan sponsor should be evident: to verify the integrity of vendor contracts and to meet fiduciary responsibilities. As with anything, there is no guarantee an audit will pay for itself every time. But it is not unusual for an audit to have findings about 3% to to 5% of paid claims costs, with recoveries of about 1% to 2%. Today, for many reasons, claims audits are more effective than ever. They can be relied on to uncover something in the working of a plan that can be improved, isolated issues as well as systemic and redundant errors, contractual compliance questions, or basic data entry problems. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Managing Data Supplier Relationships [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/managing-data-supplier-relationships-to-ensure-quality/#content) # Managing Data Supplier Relationships to Ensure Quality By Doug Bates 4 December 2013 Print / PDF Share ![]() ## Share this page Copied Managing Data Supplier Relationships to Ensure Quality Doug Bates Data quality is the foundation of any data warehouse. As the old saying goes “garbage in – garbage out.”  If there are inconsistencies or irregularities in the data loaded into a data warehouse, all analyses based on those data are potentially flawed. Healthcare data are complex, and even data from organizations well experienced in claims administration and data transmission contain errors from time to time. Having processes in place to detect and correct data problems is critical for any healthcare information platform, but even with the best of processes, errors from submitted data result in increased costs and often delay data warehouse updates. Many MedInsight clients are dependent on multiple data supplier partners to provide source data for their healthcare data warehouse. Some are of these clients are self-insured employers requesting data from the organizations who administer their claims. Others are community or business coalitions and some are states building all payer claims databases. As the number of data sources increases, the complexity and potential for error increases. Establishing strong partnerships with all your data suppliers is the one of the best ways support efficient data warehouse updates. Different organizations have different relationships with their data suppliers, so the possible techniques for keeping data suppliers engaged in the success of a data warehouse often vary from one client to a next. Below are some ways to engage data suppliers in the project. - Notify data suppliers as early as possible when considering the implementation of a data warehouse. Ask about any technical or legal constraints that may impact their ability to fully participate. - Clearly define the data elements you will need to support the analyses you plan to produce, but don’t dictate a specific layout. If the data supplier can provide the required data elements in a layout they have already developed for other projects, this will greatly reduce the amount of time they need to produce their initial data submission and reduce the risk of error. - If appropriate, and agreed to by all parties, offer to share information back to the data suppliers. Creating a deliverable of value back to the data suppliers can help keep them interested in the success of the project. - If data are being purchased from the data supplier, or if the submission of data is included as part of a broader service contract, consider adding financial incentives (or penalties) into the contract for data being submitted on time and without error. - Ask the data suppliers to describe the types of data audits they will run on the data prior to submitting files. All organizations are busy. Claims administrators have to focus on many different priorities to meet the needs of their customers, but if data suppliers are fully engaged in a data warehouse initiative, and incorporate data quality processes with each data submission, everyone will save time and money by avoiding rework. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Pediatric Risk Adjustment [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/risk-adjustment-for-pediatric-populations/#content) # Risk Adjustment for Pediatric Populations By Rob Parke 15 November 2013 Print / PDF Share ![](https://medinsight.com/wp-content/uploads/2023/05/cloase-icon-new.png) ## Share this page Copied Risk Adjustment for Pediatric Populations Rob Parke The use of risk adjustment in provider reimbursement arrangements has increased as alternative payment arrangements are becoming more widespread in health insurance. Risk adjustment has been used by Medicare Advantage and managed Medicaid plans to reimburse health plans for the unique risks and populations in their care. More recently, as carriers have transferred utilization risk to providers through alternative payment arrangements, such as global budgets and bundled payments, risk adjustment has been used to reflect a provider’s patient’s severity. However, many risk adjustment methodologies were developed using a standard population representing a combination of adults and children. Adults comprise a larger proportion of the average population, and as a consequence, the disease states recognized in these methodologies were optimized with greater emphasis on adults. Since a chosen risk adjustment methodology should reflect the characteristics of the underlying patient population organizations such as children’s hospitals, pediatric provider groups, and health plans that enroll a large proportion of children, health organizations have begun to question these standard risk adjustment models. These groups argue that there are fundamental differences in clinical profiles, patient mix, treatment options, and patient management needs between the pediatric population and the general population. In a recent Milliman research paper, we built a control model for a standard commercial population and a model optimized for a pediatric population from the Truven Health Analytics MarketScan® \[1\] database using the open source hierarchical condition categories (HCC) \[2\] system to compare results. We limited our focus to New England States \[3\] and developed a concurrent \[4\] risk adjustment model with 184 disease classifications based on the HCC system. The R-Squared value \[5\] in our control model is 58% on the standard population. This is very similar to the reported R-Squared values for many commercially available concurrent risk adjusters \[6\]. However, if we remove the adults from this population, our model’s R-Squared reduces significantly to 45%. To improve upon the control model’s R-Squared of 45% for pediatric-only populations we developed the pediatric-only model through an iterative process using only the pediatric population included in our MarketScan database sample: 1. We began the modeling at the DxGroup level that underlies the HCCs. There are 784 DxGroups in the original HCC classification system. 2. We modeled DxGroups with more than 30 patients separately and left those with less than 30 patients in their original HCCs. 3. We created two-way and three-way disease interactions for inclusion in the model (e.g., diabetes and chronic obstructive pulmonary disorder (COPD) would be included as an additional explanatory variable, in addition to diabetes alone, and COPD alone). We calculated the sample size of each and retained only those that had at least 30 patients in a cell. 4. We regrouped DxGroups and disease interaction terms with statistically insignificant coefficients (at a 5% significance threshold) with the other small-cell DxGroups in the same HCC and recalculated their coefficients (risk weights). 5. We reset the coefficients of DxGroups and disease interaction terms with statistically significant but negative coefficients to zero. Negative coefficients often imply a confounding variable; if left in the model, they will produce spurious relationships among conditions. From a payment perspective, negative coefficients result in reduction in payment for diagnosing or treating a condition, which does not have face validity either. 6. We repeated steps (4) and (5) until all variables left in the model had statistically significant and non-negative coefficients. This resulted in 570 DxGroups/HCC categories. This pediatric risk adjustment model results in an R-Squared of 58% on pediatric populations, which is a significant improvement from the control model’s R-Squared of 45%. This increase in statistical fit will impact the financial results of organizations bearing financial risk for pediatric populations. For example, using the pediatric-only model on children in the data used to develop our model, results in a risk score that is approximately 1.5% higher than the control model developed for a standard population. In alternative payment models which use risk adjustment to distribute payments to providers, models calibrated using a standard population could result in inequitable reimbursement to providers specializing in pediatric populations. As a result, these providers should carefully review the risk models used in any alternative payment arrangement before participation. * * * \[1\] Truven Health Analytics MarketScan® is a large and nationally representative commercial claims database. It is used to develop risk adjustment tools by many vendors of commercial risk adjustment tools. \[2\] The HCCs are used in Medicare Advantage and Part D plans, in the federally administered risk adjustment model for commercial individual and small groups starting in 2014, and in several states’ Medicaid and subsidized insurance programs. The HCCs used in all of these systems have not been calibrated for a pediatric population. \[3\] We only used claims in New England States – Maine, Massachusetts, Connecticut, New Hampshire, Rhode Island, and Vermont for model development. \[4\] A concurrent model uses the current year’s data to risk adjust total cost of care within the year. We chose to develop a concurrent model because many recent global risk contracts retrospectively use risk adjustment at settlement. \[5\] The R-Squared statistic measures the amount of variability a model is capable of explaining in a population and is often used to evaluate the effectiveness of a risk adjustment model. A more accurate model results in a higher R-Squared value. \[6\] See TABLE IV.7 of the 2007 SOA risk adjuster comparison study: [www.soa.org/files/research/projects/risk-assessmentc.pdf](https://www.soa.org/files/research/projects/risk-assessmentc.pdf). [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Low Value Care Task Force [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/task-force-on-low-value-care-fall-convening/#content) # Task Force on Low Value Care: Fall Convening By Dr. Anikia Nelson 19 October 2017 Print / PDF Share ![]() ## Share this page Copied Task Force on Low Value Care: Fall Convening Dr. Anikia Nelson ## Practical Analytic Approaches to Healthcare Challenges The excitement in the room was palpable as 28 attendees descended on the Westin’s Earhart Room in Detroit, Michigan. Stakeholders from across the nation gathered on September 13 with a common goal—to reduce wasteful healthcare services in the United States. Our charge for the day was to prioritize 29 healthcare services that, in particular clinical scenarios, should not be offered even if they are free. These low-value healthcare services account for an estimated $210 billion or 27% of wasteful healthcare spending in the United States.1 The Task Force on Low Value Care narrowed the list to six measures, meant to serve as a starting point to reduce wasteful care. Attendees represented a variety of stakeholders. Policy executives from Pfizer, Sanofi, J&J, and Amgen rubbed elbows with large employers such as Caterpillar, Walmart, GE, Comcast, and Hewlett Packard Enterprise. Employer coalitions from the Midwest and Pacific regions joined representatives from the Mid-America Coalition on Healthcare, the National Coalition on Healthcare, Network Strategic Initiatives, and the Independent Colleges and Universities Benefits Association. States were generously represented with attendees from the State Comptroller of Connecticut, the New York City Mayor’s Office of Labor Relations, and the Virginia Center for Health Innovation, which is embarking on the creation of a Virginia Health Value Dashboard. Health plan representation included epidemiology specialists from Kaiser Permanente Washington and Blue Cross Blue Shield of Massachusetts. The National Patient Advocate Foundation brought the patient perspective to the table, and representatives from MedInsight and VBID Health, collaborators on the MedInsight® Health Waste Calculator, provided insight on measuring and acting on the Task Force’s recommendations. The Task Force used seven key criteria to identify the best services to start with. The first involved considering the potential for patient harm, whether physical, financial, psychological, or due to downstream procedures resulting from over-treatment. Recognizing the need for short-term wins to motivate continued action on this large problem, the Task Force also considered ease of implementation and identified measures where successful examples exist. For example, by requiring providers to select one or more of five evidence-based rationales, a health system in Alberta has seen a 92% reduction in unnecessary vitamin D screening. In order to make a significant impact on the issue, the Task Force also prioritized measures with high unit price, high prevalence, high aggregate spend, and high Waste Index (the proportion of services that are wasteful in each nuanced clinical scenario). Last, but equally as important, the Task Force considered political feasibility, selecting services that affect a variety of conditions in order to minimize consumer and provider backlash. The list of six selected measures will be released in official communications by the Task Force. Five of the six measures are in production, allowing reliable quantification and trending with the MedInsight Health Waste Calculator. 1. Smith, M., Saunders, R., Stuckhardt, L., & McGinnis, J. (2013). _Best Care at Lower Cost: The Path to Continuously Learning Health Care in America._ Washington, DC: The National Academies Press. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Spinal Surgery Overutilization [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/too-many-spinal-surgeries/#content) # Too Many Spinal Surgeries? By Barb Ward 10 July 2014 Print / PDF Share ![]() ## Share this page Copied Too Many Spinal Surgeries? Barb Ward Hospitals have historically relied on surgeries contributing to their top service lines and providing a significant source of revenue generation for hospitals and surgeons. This has, in part, led to the overutilization of surgeries. In the area of spinal surgeries, as noted in the [Modern Healthcare](https://www.modernhealthcare.com/article/20140322/MAGAZINE/303229985/rethinking-spine-care) article from March 24, 2014, the mounting research evidence shows that too many Americans are undergoing unnecessary spinal procedures and experiencing mixed outcomes. According to the Agency for Healthcare Research and Quality, there were more than 465,000 spinal-fusion operations in the U.S. in 2011, compared with 252,400 in 2001. The estimated cost of spinal-fusion procedures was more than $12.8 billion in 2011, according to AHRQ. Hospital costs alone for a spine procedure average $27,568 and total costs can hit six figures for major spinal-fusion procedures, experts say. **Isolating Spinal Surgeries** Spinal surgeries can occur in both inpatient and outpatient settings. Through the use of the Major Diagnostic Categories (MDC), the MDC related to musculoskeletal diseases has the highest cost (as measured by the total allowed amount) _we will focus on the inpatient facility component for these surgeries._ From here, drilling to the individual DRGs within this MDC will present the DRGs on which targeted analysis can be conducted. [![07 10 14 Spinal Surgeries (1)]()](https://medinsight23.wpengine.com/wp-content/uploads/2023/07/07_10_14_Spinal_Surgeries_1.png) There are several types of spinal fusion surgery DRGs but DRG460 has the highest total cost and the highest volume. [![07 10 14 Spinal Surgeries (2)]()](https://medinsight23.wpengine.com/wp-content/uploads/2023/07/07_10_14_Spinal_Surgeries_2.png) **Analytic Drills** There are several options to continue the analysis. Using Milliman Benchmarks validates the opportunity based upon the total cost as well as the cost per admit. While the total allowed amount is higher than the benchmarks, the allowed per admit is significantly higher. [![07 10 14 Spinal Surgeries (3)]()](https://medinsight23.wpengine.com/wp-content/uploads/2023/07/07_10_14_Spinal_Surgeries_3.png) Understanding the elements driving this utilization and associated costs can include a demographic analysis to evaluate the variances within the population. Below, we show the breakout between gender by basic age bands, showing a higher surgical incidence among females across almost all age groups. [![07 10 14 Spinal Surgeries (4)]()](https://medinsight23.wpengine.com/wp-content/uploads/2023/07/07_10_14_Spinal_Surgeries_4.png) Another level of analysis can take a more clinical focus and isolate the types of diagnoses driving these surgeries. The AHRQ Clinical Classification System (CCS) rolls up the detail of the ICD9 diagnoses for efficient drilling for analysis, allowing you to quickly get to detailed diagnosis information. [![07 10 14 Spinal Surgeries (5)]()](https://medinsight23.wpengine.com/wp-content/uploads/2023/07/07_10_14_Spinal_Surgeries_5.png) [![07 10 14 Spinal Surgeries (6)]()](https://medinsight23.wpengine.com/wp-content/uploads/2023/07/07_10_14_Spinal_Surgeries_2.png) Additional analysis could include: - Provider level drills evaluating for specific patterns. This would include a look at what facilities these surgeries are occurring as well the individual surgeons, to compare the cost and utilization at each of these levels. - Assessment of pre-operative activities – Evaluating outpatient modalities focused on non-surgical interventions to determine what activities occurred prior to the decision to perform surgery. With the growing consensus about overutilization of surgery, more organizations are developing centers of care that promote a more coordinated approach to care. These centers offer multiple alternatives to surgery using a variety of treatment modalities and resources in a coordinated manner to reduce or avoid unnecessary surgeries while maintaining good patient outcomes. Being able to analyze and understand the utilization of spinal surgeries is an important component in developing strategies to provide alternatives to surgery to help reduce utilization, curb the costs and better align with changing financial incentives. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Healthcare Waste Analysis [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/utilization-health-waste-in-the-us-healthcare-marketplace/#content) # Utilization Health Waste in the US Healthcare Marketplace By Michael Chernew 11 September 2014 Print / PDF Share ![](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/05/cloase-icon-new.png) ## Share this page Copied Utilization Health Waste in the US Healthcare Marketplace Michael Chernew The American Healthcare system is experiencing rapid change, largely driven by the recognition by both public and private payers that the trajectory of healthcare spending growth must be slowed. Despite the recent slowdown in healthcare spending growth, which many attribute to the recession, efforts to transform benefit design and payment systems are proceeding rapidly. For example, public payers are both cutting payment rates and experimenting with bundled and global payment models. Private payers are adopting similar payment models and developing more sophisticated benefit designs that encourage patients to seek care from low cost and maybe high value providers, and to avoid expensive and maybe low value services. In this environment it is crucial to try to eliminate waste. The new payment models allow providers to share some of the savings if utilization of wasteful services can be curtailed. The challenge of course is identifying which services are wasteful. The fact that waste exists in the healthcare system is widely accepted. Berwick and Hackbarth (2012) estimate there is about 200 billion dollars in waste due to over treatment in the US healthcare system, almost 10% of total spending. But eliminating that waste may be a challenge. Like everything in healthcare, the waste is likely to vary across geography and more importantly, across providers. Identifying which providers to focus on is a challenge. More fundamentally, aggregate measures of waste are not necessarily helpful to providers. Detailed, operational measures that can be applied to provider systems are needed. Fortunately, there has been a recent increase in effort to identify wasteful services. A number of lists exist. Perhaps the most prominent of these efforts is the Choosing Wisely campaign, sponsored by the American Board of Internal Medicine Foundation, challenged specialty societies to identify wasteful practices. Other panels, such as the United States Preventive Services Task Force, have identified services that might be wasteful. Thus clinically meaningful knowledge of what is wasteful exists. Translating the knowledge of what is wasteful into tools that can be applied to identify that waste at the system level is difficult. Claims data is not ideal in many cases to identify waste. Often the measures of waste depend on patient history. Clinical knowledge and IT expertise are needed. Academic efforts to quantify waste using subsets of available measures are just beginning. For example, using a limited number of services, Schwartz et al. (2014) find 0.6% – 2.7% of Medicare spending may be wasteful and between 25% – 40% of beneficiaries have received at least 1 low value. Moreover, they found that there was significant regional variation in spending on low value services, suggesting some providers are more prone to use low value services than others. Finally, different measures of low value services were correlated across regions suggesting that measures of low value services based on a small number of services may be indicative of broader patterns of waste. Commercial tools to quantify practice patterns will be crucial to many cost containment activities. Data can help focus efforts on reducing waste and thereby improve value. Such tools could be used to support payment reform, provider education, tiered benefits or even value based insurance designs.  One way or another spending growth must be contained. Our goal must be to do so in a way that improves value. —————————————- To learn more about identifying and eliminating waste in the healthcare system, join us at our next MedInsight webinar: **Spending Growth, Cost Containment, and Elimination of Waste in the Healthcare System** September 17, 2014, 2:00-3:00 PM ET Although spending growth has slowed recently, pressure to continue to hold the line on spending has increased. Competition in the exchanges, increasing fiscal pressure from employers, and government reduction in payment to health plans all suggest insurers must devise new ways to control spending. For providers, new payment systems such as global and bundled payment models impose economic and clinical accountability in which financial success requires elimination of waste—because greater volume is accompanied by greater cost but not greater revenue. This new environment requires new measurement systems. The MedInsight webinar will focus on policy issues related to spending trends and will present ways to help payers and providers quantify waste in their system. Presenter: **Michael Chernew, PhD, VBID Health, Harvard Medical School** Dr. Chernew is a founding partner of VBID Health, a professor at Harvard Medical School, serves as the Co-Editor of the American Journal for Managed Care, and as Editor of The Journal of Health Economics. He is a member of the Congressional Budget Office’s Panel of Health Advisors as well as a Research Associate of the National Bureau of Economic Research. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) Live chat:Chat with an Expert ![](https://cdn.bizible.com/ipv?_biz_r=&_biz_h=802059049&_biz_u=20774fa211d44785f1ddb056deef30cd&_biz_l=https%3A%2F%2Fmedinsight.com%2Fhealthcare-data-analytics-resources%2Fblog%2Futilization-health-waste-in-the-us-healthcare-marketplace%2F&_biz_t=1760538215253&_biz_i=Utilization%20Health%20Waste%20in%20the%20US%20Healthcare%20%7C%20MedInsight&_biz_n=0&rnd=173342&cdn_o=a&_biz_z=1760538215261)![](https://cdn.bizibly.com/u?_biz_u=20774fa211d44785f1ddb056deef30cd&_biz_l=https%3A%2F%2Fmedinsight.com%2Fhealthcare-data-analytics-resources%2Fblog%2Futilization-health-waste-in-the-us-healthcare-marketplace%2F&_biz_t=1760538215264&_biz_i=Utilization%20Health%20Waste%20in%20the%20US%20Healthcare%20%7C%20MedInsight&rnd=958053&cdn_o=a&_biz_z=1760538215264) ## Healthcare Efficiency Analysis [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/analyzing-healthcare-efficiency-using-medinsights-waste-calculator/#content) # Analyzing Healthcare Efficiency Using MedInsight’s Waste Calculator By Marcos Dachary, Chief Market Strategist and General Manager of Payer Solutions, MedInsight 12 November 2013 Print / PDF Share ![]() ## Share this page Copied Analyzing Healthcare Efficiency Using MedInsight’s Waste Calculator Marcos Dachary, Chief Market Strategist and General Manager of Payer Solutions, MedInsight ### Rationale for Developing the Initial 20 Measures The concepts for the measures for the newest MedInsight product, the Health Waste Calculator, were identified from various publications about avoidable healthcare, medical waste, and Choosing Wisely. The team identified an initial list of 134 measures to develop. The prioritization of the initial 20 waste calculator measures, version 1 and 2 (see Appendix I below), was based on the following criteria: - High prevalence rate or incidence of the wasteful events as reported in different publications - High cost impact due to the wasteful events - Representation of different specialties or clinical conditions - Representation of different types of services – preventive screening tests, diagnostic tests and prescription of drugs - Representation of relevant measures for different age groups (children, adults, elderly or all population) as well as gender specific measures The following examples highlight a summary of evidence that supported the prioritization of these measures in version 1. - Rhinosinusitis related three measures – The prevalence of both acute and chronic rhinosinusitis in a National Health Interview Survey conducted in 2004, found that 14% of people in the US population were diagnosed with sinusitis. Rhinosinusitis accounts for health-care expenditure of more than $3.0 billion per year in the United States.  Despite the fact that CT imaging has moderate sensitivity (76%) and specificity (79%) in diagnosing acute bacterial sinusitis, it is still being ordered.  In another survey data it was found that 81% of adults presenting with acute sinusitis were prescribed antibiotics. Rhinosinusitis is still the fifth leading indication for practitioners to prescribe antimicrobials despite the fact that 70% of patients improve without antibiotics. - Imaging for low back pain – Approximately 15 percent of the U.S. population reports having frequent low back pain. Healthcare cost for back pain includes both direct medical expenses and indirect cost of time lost from work, disability payments and diminished productivity. Additionally, medical care for these individuals cost approximately $35 billion dollars, with imaging driving much of the cost. In the calendar year 2000, Medicare made approximately $55 million in combined technical and professional component payments for 1.36 million claims for conventional radiography of the lumbar spine (For CPT code 72100) and $339 million for 592,000 lumbar spine MR imaging claims. - Pap smear – Pap smear is the most common screening test conducted in women over 21 years of age and in a survey conducted by the National Center for Health Statistics, 93% of American women report having had at least one Pap smear in their lifetime. Among women with no history of abnormal smears, 55% undergo Pap smear screening annually, 17% report a 2-year screening interval, 16% report being screened every 3 years, and 11% are not being screened regularly. Even the very elderly report frequent screening where 38% of women age 75 to 84 and 20% of women age 85 and older reported annual Pap smears. Ideally in women with no history of abnormal smears the U.S. Preventive Services Task Force (USPSTF) recommends screening for cervical cancer in women aged 21 to 65 years with cytology (Pap smear) every 3 years. - Cardiac stress testing – Half of all patients in community practice had 1 or more stress tests within 24 months of coronary revascularization. Of those tested, only 5% required repeat revascularization. From 1993 to 2001, roughly 180,000 cardiac revascularizations, 360,000 catheterizations, and 1 million stress tests and nuclear imaging studies were performed on a 5% national sample of Medicare beneficiaries. As overall rates of stress testing in the US Medicare population doubled from 1993 to 2001, the proportion of tests performed with radionuclide imaging increased from 50% to 80%. The nearly 3-fold absolute rise in US rates of radionuclide imaging suggests that these imaging studies have become the standard of clinical practice without clear evidence to support their routine use in place of exercise tests without radionuclide imaging Further an analysis was conducted on a set of claims data for a small Midwestern HMO health plan to find the average cost and the number of events that were wasteful out of a total of 10,074 enrollees, about 1% of their total costs were classified as wasteful using the first version of this product. A sample of this claim cost analysis is shown in the table below. [![Waste Calc 11.8.13 (1)]()](https://medinsight.com/wp-content/uploads/2023/07/Waste_Calc_11813_1.jpg) [![Waste Calc 11.8.13 (2)]()](https://medinsight.com/wp-content/uploads/2023/07/Waste_Calc_11813_2.jpg) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## PHI and APCDs Overview [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/apcd-protected-health-information-phi/#content) # PHI and APCDs By Al Prysunka 13 December 2013 Print / PDF Share ![]() ## Share this page Copied PHI and APCDs Al Prysunka As more and more states create APCDs, their uses are expanding and evolving. Data generated by APCDs are being used to generate disease, injury, chronic condition, and utilization rates across demographic and geographic settings, as well as by payer type.  States are also contemplating linking administrative claims data with clinical data in order to better assess the quality of health care provider services. In addition, states are moving toward providing greater accessibility to their APCD data through public web sites and/or by subscription through a dedicated portal. In order to fulfill these (and other) proposed uses, capturing and sharing Protected Health Information (PHI) is critical. In order to identify the members as they move across the health care system and to segment the data when necessary, it is essential that a significant amount of PHI data be collected. Ideally, at a minimum, the following data elements should be collected: - Names (last, first, middle initial) - Social Security Number - Contract Number - Date of Birth - Gender - Place of Residence (street address, municipality, zip code, state name) Depending upon the legal constraints found in a particular state, the data elements listed above are collected and processed using different approaches or methodologies.  In some states direct identifiers (e.g. – name, SSN) are hashed by the data submitters using the same algorithm (usually SHA 512) prior to transmission to the data processor via SFTP.  To prevent a data submitter from identifying a member in the data who over time is covered by another plan, the hashed elements are then encrypted (usually Triple DES) prior to being released. In other states direct identifiers are collected and then used to create a non-identifiable master member/patient index (or crosswalk) prior to the data being released. In one state the data submitters send the direct identifiers to a “third party’ vendor, which creates the master index and then returns the index to the data submitters for inclusion in the files provided to the data processing vendor. Once the direct identifiers are collected and converted to an encrypted value or a master member/patient identifier, they are no longer considered to be PHI. However, if these data are released along with the other descriptive member data elements (Date of Birth, Gender, and Place of Residence) which are necessary for the required analyses, the potential exists for the indirect identification of individuals if the APCD data are associated with other information (e.g. – voter registration lists). To prevent this from occurring, both risk mitigation techniques (suppression, generalization, perturbation) and administrative/legal restrictions (data use agreements) must be utilized as the data are released. Given the amount of PHI contained in most APCDs, along with their expanded uses and greater accessibility to the data, careful consideration must be given to managing the release of the data to avoid violating the pertinent sections of the HIPAA privacy rules. The Federal rules associated with Protected Health Information (PHI), 45 CFR Parts 160 and 164 – _Standards for Privacy of Individually Identifiable Health Information_, define three approaches to protect individuals from being associated with their health care data by users of claims and other health care related data. The three approaches are found in §164.514. - The first approach, as described in §164.514 (b) (2) and commonly referred to as the “safe harbor method” allows for the release of health care data associated with individuals, their relatives, employers, or household members as long as all direct identifiers are removed from the data, including all geographic units smaller than a state (except for using the first three digits of the zip code if the population covered is greater than 20,000) and all date fields. As the name implies, this approach provides the lowest risk of an individual and his or her health care data being associated. However, by prohibiting the release of all date related, and most geographic related data, the utility of the APCD to any potential non-government users is greatly diminished. For example, if health plans or employers would like to evaluate utilization rates or readmission rates by hospital service area, it would be impossible without the geographic and date of service data. - The second approach, as described in §164.514 (b)(1) and further defined by the Department of Health and Human Services Office of Civil Rights 2012 _Guidance Regarding Methods for De-identification of Protected Health Information in Accordance with the HIPAA Privacy Rule_, is commonly known as the “expert determination method”.  This approach relies on a person with appropriate experience with statistical and scientific methods related to health care data to evaluate the data being collected and released and then provide recommendations on how to minimize the risk that the information could be used alone or in combination with other data sources to identify an individual. While this approach is potentially less restrictive than the other two approaches and provides greater flexibility to non-state government users of the data, while still providing a high level of risk minimization that an individual and his or her health care data will not be associated, there is also a good deal of uncertainty involved with this approach. If the expert is asked to evaluate a system for releasing the data rather than a specific report or analysis containing member associated data, it may be that the determination will be to follow the safe harbor approach due to the uncertainty of the data content and its presentation to the public.  However, the expert, as part of the risk evaluation, must also to take into consideration whether or not the proposed recommendations regarding de-identification will lead to information loss which may limit the usefulness of the resulting health information in certain circumstances. - The third approach, as described in §164.514 (e) and commonly referred to as the “limited data set”, also prohibits the release of same direct identifiers as listed under the safe harbor approach, but allows the release of geographic units greater than street or postal addresses and all date fields if the data user enters into a data use agreement that specifies how the data are to be used, who specifically can access the data, and requires the user to certify that the data will be protected and not accessed by other parties. Some may view this approach as having the greatest potential for an individual’s health care data to be associated through indirect identification. However, in states where monetary and civil penalties have been established for violating the requirements of a data use agreement, incentives exist to minimize that risk. The benefit of using the limited data set approach is the certainty that is provided to non-government users that the critical data (dates and geographic data) will be available for important analytic proposals as long as the data use agreement is followed, and no data are generated and made available to the public which could lead to an individual and his or her health care data being associated. Before making a decision on the approach taken to release their APCD data, will need to weigh the mandated analytic requirements and expectations of those wanting to use the data against the public’s concern that the release of data is occurring in a manner that prevents the association of individuals with their health care data by unscrupulous individuals. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Telemedicine in California [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/covered-california-leveraging-telemedicine/#content) # Covered California: Leveraging Telemedicine for Network and Quality Management By Susan Philip 20 July 2016 Print / PDF Share ![]() ## Share this page Copied Covered California: Leveraging Telemedicine for Network and Quality Management Susan Philip Healthcare purchasers, including state-based marketplaces, are making a push to move healthcare payments from volume to value and to transform the delivery system to promote quality of care. Covered California is seeking to do this through its contracting health plans and the qualified health plan (QHP) solicitation process. The most recent solicitation lays out key milestones for the 2017 to 2019 plan years. Beginning in 2017, during the annual QHP certification, a contracting plan will be required to “report on its strategies to ensure that contracting Providers are not charging unduly high prices and for what portion of its entire enrolled population it applies each strategy.” Strategies may include various tactics to move toward value-based payments, drive enrollees to high-value providers, and engage enrollees in decision-making and their own health management. Milliman MedInsight® can assist health plans and providers with developing appropriate strategies, identifying analytic requirements, and conducting analysis to support them in their network management, quality management, and transformation efforts. We will be releasing a series of articles on these related topics. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Population Health Data Insights [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/data-needed-to-support-population-health-management/#content) # What Data Is Needed To Support Population Health Management? By Nancy Zoelzer 17 January 2014 Print / PDF Share ![]() ## Share this page Copied What Data Is Needed To Support Population Health Management? Nancy Zoelzer In our series of blog postings on the topic of Population Health Management, we have discussed how to define populations in Analytics for Population Health Management, and we have looked at the types of analytic tools available for analysis of populations in [Identifying Appropriate Metrics for Population Management.](https://medinsight.com/healthcare-data-analytics-blog/identifying-appropriate-metrics-for-population-management/%20target=) Today we will focus on types of data, both traditional and non-traditional, that can assist in the performance of a robust population health analysis. Many healthcare organizations have access to a wealth of data, however this data has not historically been brought together in an organized manner. An emerging concept in data management is “Big Data,” an approach where all data relevant to an individual’s healthcare – including those data that may exist outside an individual organization’s walls – are gathered and linked for analysis. To effectively gather and link these data for population health management, the enterprise data warehouse needs to be flexible enough to accept data from traditional, as well as non-traditional sources. Data sources that can be accessed and linked for robust Population Health analysis include: - Insurance Administration Data (Claims, Pharmacy, Enrollment Data) – Insurance administration data is by far the most commonly used data for analysis. - Clinical Data (Electronic Medical Records, Lab Results, Registries) – Clinical data increases the richness of data available about an individual and a population. This type of data is starting to make its way into the enterprise data warehouse. - Medical Management Data (Health Risk Assessment, Authorization, Disease/Case Management Data) – Most health organizations have medical management data readily available, but most have not yet brought this data into an enterprise database. - Provider Administrative Data (Physician Practice Management, Hospital Billing, Admissions Discharge, and Transfers Data) – Provider administrative data is generally available in a more timely manner, allowing for a nearer to real-time data analysis. - Public Data (State Discharge Datasets, Immunization Registries) – Public data has not typically been accessible in an enterprise data warehouse, yet it can provide additional insight for population health analysis. - Demographic and Social Media Data (Lifestyle, Interest) – With increasing availability, lifestyle and interest data is a largely untapped source of data for population analysis. **Why Incorporate All These Data?** Access to a wide variety of data allows for broader population health analysis which can lead to new and earlier insights to help identify improvements, efficiencies and effectiveness of the healthcare delivery system. A population health management strategy with a robust data warehouse can help answer the question, “Who will benefit from which programs?” For more detailed information click on the box below to receive Milliman’s white paper entitled Population Health Management Concepts. Watch for upcoming blog posts that dive into development of a population analysis for a specific population. Click here to review an earlier posting describing Pediatric population analysis – [Pediatrics Population Health Management.](https://medinsight.com/healthcare-analytics/pediatrics-population-health-management) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Reducing Healthcare Waste [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/eliminating-waste-in-the-healthcare-system/#content) # Eliminating Waste in the Healthcare System By [Mark Fendrick](https://www.linkedin.com/in/mark-fendrick-3673691a/) 24 January 2014 Print / PDF Share ![]() ## Share this page Copied Eliminating Waste in the Healthcare System Mark Fendrick Healthcare spending in the United States far exceeds that in other developed countries and the American health care system is widely recognized as wasteful. The Congressional Budget Office has concluded that up to 30 percent of the healthcare in the U.S. is unnecessary. Such estimates of waste are generally based on aggregate data such as total spending across areas. Connecting such macro based estimates to actual, identifiable waste is a complex task, but necessary if interventions are to be developed to eliminate waste. There is nascent literature documenting aggregate spending on services thought to be wasteful. For example, a 2011 study found that the price tag for 12 commonly overused tests, such as annual electrocardiograms (EKGs) for heart disease and imaging tests for lower-back pain, was about $6.8 billion. Recently medical societies, under the banner of the American Board of Internal Medicine’s _Choosing Wisely_ campaign have begun efforts to identify potentially wasteful services. This initiative builds on more limited, earlier efforts to identify wasteful services, such as designation of some preventive services as harmful by the U.S. Preventive Services Task Force. Identifying waste is complex because the value of any given service depends on the characteristics of the patient to whom it is delivered, such as age, gender and clinical attributes. For example, the U.S. Preventive Services Task Force recommends colorectal cancer screening for individuals over 50-74 years of age, uncertain in those 75-84 and harmful for those 85 years and over. Lists of wasteful services often contain many qualifiers describing the conditions in which delivery of the identified services are wasteful. In other instances, the same service may be clinically appropriate. For some services the conditions are easily observable, such as age. In other cases labeling any given claim as wasteful requires more subjective judgment that stretches the capabilities of administrative claims data. Thus, efforts to quantify waste will be subject to over counting (identifying services as wasteful when in fact they are clinically appropriate) and undercounting (failure to identify waste). Yet given the imperative to improve the efficiency of the health care system, such tools, despite the imprecision, can help guide cost containment efforts. Moreover, not only is removing this waste and unnecessary care from the system a way to reduce costs, it is also an opportunity to improve quality and patient safety. To utilize this opportunity to improve health care quality and enhance patient safety, as well as stem increasing health care costs, VBID Health has collaborated with Milliman to create the Health Waste Calculator—an analytical tool that identifies and quantifies the use of unnecessary or harmful clinical services. The tool employs clinical evidence and the work of national initiatives such as the U.S. Preventive Services Task Force and _Choosing Wisely_ to inform the definitions of wasteful, unnecessary, and even harmful care. The tool utilizes sophisticated algorithms to reduce coding misclassifications. To ensure it captures the latest clinical evidence and scientific findings, the Health Waste Calculator will be updated on a regular basis. The Health Waste Calculator is an important step to arm healthcare payers and purchasers with the tools they need to more effectively and efficiently combine benefit design, payment policy, and educational interventions to improve the quality of care and decrease the cost. _\*Dr. Fendrick, a founding Partner of VBID Health, is Director and co-founder of the University of Michigan Center for Value-Based Insurance Design. He is a Professor in the Department of Internal Medicine and the Department of Health Management and Policy at The University of Michigan. Dr. Fendrick remains clinically active in the practice of general medicine, seeing patients weekly._ [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Quality Encounter Data Submission [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/ensuring-quality-encounter-data-submission-in-medicaid-managed-care-programs/#content) # Tips for Ensuring Quality Encounter Data Submission in Medicaid Managed Care Programs By Andrew Naugle 28 March 2014 Print / PDF Share ![]() ## Share this page Copied Tips for Ensuring Quality Encounter Data Submission in Medicaid Managed Care Programs Andrew Naugle One area of data management within the healthcare industry that is getting new emphasis and interest from regulators is a focus on encounter data. Today, the majority of Americans receiving healthcare services funded through the Medicaid program are enrolled in some form of managed care. Under this scheme, states contract with MCOs that take on responsibility for providing Medicaid services in exchange for a fixed capitation payment. This approach is in contrast to the traditional fee-for-service (FFS) program where providers submit claims directly to the state for payment. It is widely recognized that the FFS approach to provider payment creates perverse incentives for delivery of unnecessary services and uncoordinated care.  Medicaid managed care gets away from this by providing a fixed capitation amount to the Medicaid MCOs, giving them incentives to more effectively manage care.  The MCOs often pass along those same incentives by paying certain providers using capitation as well. Notwithstanding the undesirable incentives that FFS creates, one area where FFS excels is the collection of timely and complete data about the services rendered to each patient and information about the price of those services. Because FFS claims are essentially invoices, this approach offers strong incentives for providers to submit claims in a timely manner (for timely payment) and to ensure those claims are a complete reflection of services rendered (for complete payment). Under capitation, the payment mechanism is decoupled from the data collection process.  In lieu of claims, MCOs must collect encounter data from their providers and then submit that data to the states. Unfortunately, this takes away the direct financial incentives providers have for timely and complete data submission. As a result, many states have struggled to collect credible information about the services delivered under Medicaid managed care. Such data is essential for important activities such as rate setting and program management. Viewing submission of encounter data as an MCO function, many states have implemented strict contractual requirements coupled with tough performance guarantees and financial penalties to motivate MCOs to improve the quality and timeliness of the encounter data they submit. Failure to perform can have significant consequences for MCOs including financial penalties, corrective action plans, bad press, and even contract termination. Based on our experience working with states and MCOs to help improve encounter data quality, we have identified a few things that can help improve the results: 1. **Evangelize the Importance of Encounter Data among Providers.** Once decoupled from the payment process, it can be hard to convince providers of the importance of collecting and reporting encounter data.  Ensuring that these constituents understand the value of encounter data, and are submitting complete and timely information is key for MCOs to meet their contractual obligations to the state. Regardless of how strong the processes are within the MCO to ensure complete and timely submission, if the source information coming from providers is incomplete, what goes to the State will also be incomplete.  In addition to including encounter data requirements in their provider contracts, MCOs should include encounter data as a topic in their provider communication/education plans, and evangelize its importance whenever they can. 2. **Develop Clear Submission Requirements, Definitions, and Data Specifications**. In any situation where data is being submitted to a third party, lack of agreement and understanding of the actual submission requirements, definitions, and data specifications is a set-up for downstream conflicts. Among states, the requirements for submission often vary, and sometimes change during the term of a contract. States and MCOs should engage in a collaborative process to ensure that all parties are working from the same guidance and interpretation of the submission requirements. 3. **Establish an Inter-Disciplinary Team**. Many MCOs view encounter data submission as one department’s responsibility (typically, finance, operations, or information systems). In reality, it takes skilled and knowledgeable resources from throughout the organization to drive a high quality process and result. MCOs should establish an inter-disciplinary team that brings together the experts and makes everyone involved accountable for the outcome. That team may be led by someone from one of those primary departments, but requires support from others. 4. **Implement Automated Data Validation and Reconciliation Processes**. Submitting encounter data typically involves collecting data from multiple sources, transforming it into a new format, and then submitting it to the State. There are many opportunities for errors along the way. To provide an early warning of potential errors and facilitate root cause assessment when errors are identified, MCOs should implement data validation and reconciliation processes that run parallel with the encounter submission preparation process.  Often states will have internal processes they run on the data when they receive it; mirroring these processes can proactively reduce error rates. In addition, where possible, it makes sense to reconcile financial information against financial systems such as the general ledger, not just what’s in the claim system. 5. **Track and Resolve Errors Timely and Completely.**  When submitting encounter data, some errors are unavoidable and thus both MCOs and states must have resources and processes in place to support timely and complete resolution of those errors. Errors can be caused by changes in the way data is collected within the MCO, changes in the state’s internal validation processes, or simply anomalies in the data.  Regardless of the reason, each error should be tracked and resolved to completion. Root causes should also be identified to allow for error prevention. As states have made the transition from FFS to managed Medicaid, the quality of utilization and cost data they receive has eroded. With the majority of Medicaid beneficiaries today receiving healthcare services through managed care plans, this makes it more difficult for states to perform effective oversight of these programs. Multiple encounter data improvement initiatives have emerged as this has become an area of focus for both states and the Federal government. MCOs should expect this scrutiny to continue, but should also recognize that through a systematic approach to managing and reconciling data, and a collaborative posture with their state partners, many of these challenges can be overcome. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Appendicitis Care Analysis [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/episodes-of-care-length-of-stay-appendicitis/#content) # Episodes of Care – Appendicitis By John McBride 20 March 2014 Print / PDF Share ![]() ## Share this page Copied Episodes of Care – Appendicitis John McBride **Evaluating the relationship between episode of care and length of stay in Appendicitis:** In previous posts we have discussed some of the ways episodes of care can be used to compare two different networks and underlying practice patterns. We’d like to dive further on this thread and look at how episodes of care can be used to explore the relationship between cost and length of stay (LOS). **How do Episode Groupers Work?** An episode of care is a summary of care across all care settings for a particular patient’s condition. For example, if patient breaks their wrist after a fall. They would likely go to the emergency room, receive an X-Ray, multiple procedures, and a prescription for the pain. The patient then may require follow up visits with an orthopedist, and physical therapy for rehabilitation. An episode of care combines all of these costs so the true cost of a broken wrist can be assessed. **Adjusting your Population for Severity** One of the features of episode groupers on the market today is the ability to segment condition by severity. Severity generally refers to if the episode has complications and how severe those complications are.  Consider the example below. We have a summary of complete episodes of Appendicitis with two different severity levels. Provider Network 1 handles more cases of higher complexity appendicitis and has a significantly lower average cost per case at both severity levels. [![Episodes of Care (1)](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/07/Episodes_of_Care_1_14.jpg)](https://medinsight.com/wp-content/uploads/2023/07/Episodes_of_Care_1_14.jpg) To better understand the cost drivers of this episode we dug into the inpatient costs and length of stays associated with the Appendicitis episodes.  In the table below we have limited our output to the inpatient hospital claims to investigate the impact of the facility costs on the cost disparity. Provider Network 1 handles the majority of the higher severity stays at a lower cost, but a significantly higher length of stay. However, even the lower severity stays appear to spend almost a full day more in an inpatient facility. The longer lengths of stay are telling that even though there may be lower costs with Provider Network 1 they are utilizing more medical resources to deliver care than Provider Network 2. [![Episodes of Care (2)]()](https://medinsight.com/wp-content/uploads/2023/07/Episodes_of_Care_2.jpg) In this case episode grouping has helped to identify an unexpected relationship between a lower cost per episode provider for appendicitis and a longer length of stay. Length of stay efficiency opportunities appear to exist for Provider Network 1 which could help further reduce the costs of these episodes and the profitability of the provider. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Health Insurance Growth [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/health-insurance-growth-in-india/#content) # Health Insurance Growth in India By Lalit Baveja 4 November 2014 Print / PDF Share ![]() ## Share this page Copied Health Insurance Growth in India Lalit Baveja The health insurance industry in India has come leaps and bounds since the launch of the first Mediclaim policy was enacted in 1986. It is the fastest growing segment of the Indian insurance industry, as evidenced by the fact that it makes up 30.5% of the non-life insurance segment of the Compound Annual Growth Rate since the years 2005-06. This is particularly remarkable when one considers that the non-life insurance sector has shown the highest premium growth rate amongst emerging markets. Before the year 2000, there were only four public sector insurance companies providing health products in India. Currently, there are 26 private companies providing health insurance, including five stand-alone health insurance companies. The health insurance coverage in India is split among central, state, employer, and commercial markets. Various government social schemes since 2003 have led to an enormous boost to the number of people with some form of health insurance coverage in the country. Today, nearly 370 million Indians (29%) have some form of insurance through central or state government, employer based, or private health insurance. Commercial, for-profit insurance is comprised of public and private commercial insurance companies that provide individual or family retail and group medical plans for members. State sponsored health insurance schemes offer protection to the lower income groups, and many government employee based schemes cover government, railways, and defense personnel. [![Indian Health Insurance Overview graphic 1](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/07/Indian_Health_Insurance_Overview_graphic_1.jpg)](https://medinsight.com/wp-content/uploads/2023/07/Indian_Health_Insurance_Overview_graphic_1.jpg) While these numbers show impressive growth in the India healthcare insurance industry, the overall penetration is still low. Of the 29% Indians covered under insurance, 85% are primarily covered through social and state health initiatives. Commercial insurance is only adopted by affluent urban populations and corporate groups, while social health insurance schemes target low-income groups in both urban and rural areas. There is still a huge gap in coverage for people in the working class, lower-middle class, or those living in tier-two or tier-three cities. There is substantial opportunity to improve access to health insurance across all segments and to launch additional comprehensive health benefits for Indians. A few government employee-based programs include inpatient benefits in addition to outpatient benefits at public healthcare facilities or within a tight private provider network. The commercial and social health schemes are primarily annual Mediclaim-type indemnity products with maximum sum assured limits and sub-limits for certain benefits. Group medical policies offered to employers/commercial players offer enhanced benefits (maternity, no pre-existing exclusions) within a maximum sum assured limit. Recently, the main innovations in health insurance products have been a substantial increase in maximum sum assured, the introduction of life-long coverage, improved portability amongst insurers, and a wider range of benefits with accident protection, hospital cash, and critical illness riders. A few health insurers have floated disease-specific insurance coverage (e.g., cancer, cardiac surgery, and, more recently, diabetes), as well as limited outpatient attendance in the individual/family health market. The four existing public sector companies in India continue to lead the market share, but stand-alone health insurance companies and private sector companies are making inroads. The government opened the market in 2000 and allowed a 27% stake for foreign investors that triggered the influx of foreign players into the health insurance market, providing a wider range of choices to the consumer and driving up competition. [![Indian Health Insurance Overview graphic 2]()](https://medinsight.com/wp-content/uploads/2023/07/Indian_Health_Insurance_Overview_graphic_2.jpg) Operationally, however, the expenses for the insurers remain higher than they are in other markets. High incurred claims ratio (ICR) is encountered in a very price-sensitive environment and profitability is limited. In the last financial year, there have been trends of rises in premiums and reduction of claim ratios and profitability by a few non-life companies, as well as one of the stand-alone health insurance companies. The experience is different across individual, family, government, and group medical policy portfolios, as well as across public, private, and stand-alone specialists. Private non-life companies have been controlling claims ratios well, however, they continue to lose out on corporate covers. Public sector companies are showing improvements but still have a long way to go. [![Indian Health Insurance Overview graphic 3]()](https://medinsight.com/wp-content/uploads/2023/07/Indian_Health_Insurance_Overview_graphic_3.jpg) Various factors predict a favorable outlook of the industry in the coming years. The current majority government is expected to bring in stability and catalyze economic growth. A proposed bill to increase the equity share of foreign partners to 49% will invite more foreign players to the health insurance market, which will result in better choices for members, added capability, and more competitive plans. There is interest from a range of foreign insurers who look at India as a major opportunity for growth. The government’s declared mandate to introduce universal health insurance will continue to expand focus to other low- and middle-income groups and will give further impetus to the social health insurance sector. World Bank predicts India to bring in coverage to 50% of its population under some form of health insurance plan by the year 2015. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Healthcare Data Analytics [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/healthcare-data-analytics-for-identifying-wasteful-services/#content) # Health Data Analytics for Identifying Wasteful Services By Nancy Zoelzer 15 September 2014 Print / PDF Share ![]() ## Share this page Copied Health Data Analytics for Identifying Wasteful Services Nancy Zoelzer Eliminating inefficient and unnecessary medical services improves overall healthcare efficiency while reducing costs. In 2009, the Institute of Medicine (IOM) identified $750 billion of wasted spending, with unnecessary services accounting for $210 billion. The Congressional Budget Office has estimated that 30% of medical care in the U.S. is unnecessary care. (Source: Institute of Medicine article “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America”, 2013.) Removing this waste and unnecessary care from the system will reduce costs, and is an opportunity to improve quality and patient safety. [![Waste Calc 09.15.14](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/07/Waste_Calc_091514.png)](https://medinsight.com/wp-content/uploads/2023/07/Waste_Calc_091514.png) There are a number of use cases for analyzing health claims data to find wasteful and likely to be wasteful services. - Quantify necessary vs wasteful services - Identify opportunities for cost savings - Provider profiling and pay for performance risk sharing reporting - Employer Group Reporting to convey the value of health plan services provided to employers In a wasteful services pilot study, Milliman looked at one health plan’s claims data for Medicare and Commercial over a one year period (November 2012 – October 2013). Observations from that study found that 21% of members had at least one wasteful service, 25% of all services provides were wasteful and 2.12% of the total claim cost allowed dollars were wasteful. Further data analysis found that 80% of the wasteful dollars came from only four measures: - Stress cardiac imaging or advanced non-invasive imaging (58% – $8,568,369) - Annual EKGs or cardiac screening (12% – $1,779,260) - Lower back pain image (6% – $940,363) - ED CT Scans for Dizziness (4% – $533,876) To assist in identification of wasteful services, Milliman, along with [VBID Health](https://www.vbidhealth.com/ "VBID Health"), has developed the MedInsight Waste Calculator, which is an analytical tool that provides actionable data to support healthcare quality, efficiency, and effectiveness reporting. The calculator brings together clinical expertise and powerful data analytics—allowing healthcare managers to target and reduce wasteful spending. —————————————- To learn more about identifying and eliminating waste in the healthcare system, join us at our next MedInsight webinar: **Spending Growth, Cost Containment, and Elimination of Waste in the Healthcare System** September 17, 2014, 2:00-3:00 PM ET Although spending growth has slowed recently, pressure to continue to hold the line on spending has increased. Competition in the exchanges, increasing fiscal pressure from employers, and government reduction in payment to health plans all suggest insurers must devise new ways to control spending. For providers, new payment systems such as global and bundled payment models impose economic and clinical accountability in which financial success requires elimination of waste—because greater volume is accompanied by greater cost but not greater revenue. This new environment requires new measurement systems. The MedInsight webinar will focus on policy issues related to spending trends and will present ways to help payers and providers quantify waste in their system. Presenter: **Michael Chernew, PhD, VBID Health, Harvard Medical School** Dr. Chernew is a founding partner of VBID Health, a professor at Harvard Medical School, serves as the Co-Editor of the American Journal for Managed Care, and as Editor of The Journal of Health Economics. He is a member of the Congressional Budget Office’s Panel of Health Advisors as well as a Research Associate of the National Bureau of Economic Research. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Population Health Metrics [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/identifying-appropriate-metrics-for-population-management/#content) # Identifying Appropriate Metrics For Population Management By Nancy Zoelzer 19 December 2013 Print / PDF Share ![]() ## Share this page Copied Identifying Appropriate Metrics For Population Management Nancy Zoelzer For many reasons, including the advent of the Affordable Care Act, Population Health Management is gaining increased attention from healthcare organizations. A population health initiative has the promise to make care proactive, better coordinated and more customized for the population. A previous blog posting – [Analytics for Population Health Management](https://medinsight.com/healthcare-analytics/analytics-for-population-health-management) – outlined how populations are defined and presented a sampling of metrics for measuring performance. In this blog article we dive deeper into the process of identifying the appropriate metrics for population health management. One size does not fit all for population-based analytic methodologies. One reason to look at populations from a variety of perspectives is to analyze trend. What is driving trend? Is it something clinical? Is it geographic disparity? Or network variations? Differing metrics are needed in order to effectively analyze a population. For example, looking at compliance with recommended HbA1c lab testing is appropriate when looking at a population of diabetics, but the same measure is far less meaningful when looking at a population of cancer patients. In identifying the appropriate analytic metrics one should consider the population to be analyzed, as well as the focus of the population analysis initiative. There are several categories of _analytic tools_ for population health management, including measures, service categorization, clinical categorization and risk adjustment. _Measures_ include: - _Primary Prevention Measures –_ Disease avoidance, immunization rates, and wellness program participants. - _Secondary Prevention Measures –_ Early detection and treatment of disease, colon cancer screening, and breast cancer screening. - _Tertiary Prevention Measures –_ Reducing the impact of disease and aspirin use in CHF patients. - _Quaternary Prevention Measures –_ Avoidance of unnecessary or unsafe interventions and avoidance of imaging for low back pain. _Service Categorization_ is a methodology used to analyze resource utilization and cost by service types. Categorization enables the creation of a cost model for population trending, benchmarking, and profiling. Milliman’s Health Cost GuidelinesTM is a widely-used methodology used to organize healthcare claims into service categories. _Clinical Categorization_, such as Milliman’s Chronic Condition Hierarchical Groups, helps organize populations by disease cohorts. _Risk Adjustment_ is a methodology used to assess the overall health of a population or sub-population. Risk adjustment enables comparison across populations by adjusting the health risk of the population. Additionally, individuals within a population can be stratified by risk. There are many risk adjustment methodologies available in the industry, including the Milliman Advanced Risk Adjuster (MARA). _Other Analytic Tools_ include resource efficiency tools (e.g., Dartmouth Atlas, NYU Avoidable ED Visits, and Prometheus), care management tools, and Milliman Global RVUs (a method to measure utilization across all categories of care). For a robust population analysis, _Benchmarks_ are needed in addition to the analytic tools. Benchmarks enable the comparison of actual population cost and utilization with a benchmark. For more detailed information click on the box below to receive Milliman’s white paper entitled _Population Health Management Concepts_. Watch for upcoming blog posts that dive into development of a population analysis for a specific population. Click here to review an earlier posting describing Pediatric population analysis – [Pediatrics Population Health Management](https://medinsight.com/healthcare-analytics/pediatrics-population-health-management). [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Risk Adjustment in Analytics [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/is-risk-adjustment-enough-in-population-analytics/#content) # Is Risk Adjustment Enough in Population Analytics? By Nancy Zoelzer 8 December 2017 Print / PDF Share ![](https://medinsight.com/wp-content/uploads/2023/05/cloase-icon-new.png) ## Share this page Copied Is Risk Adjustment Enough in Population Analytics? Nancy Zoelzer ## Practical Analytic Approaches to Healthcare Challenges Most analysts conducting population health data analysis understand that no two populations are completely the same. Even within a population with similar attributes – people with congestive heart failure, for example – there will be variances in the population subgroups. Many factors contribute to these variances, including age and gender, comorbidities and geographic differences in treatment patterns as well as provider unit pricing and efficiency. Analysis of cost and utilization data, even with the use of “per member per month” and “per 1,000” calculations, does not produce a fully accurate comparison because of variations in risk or severity of the population. For a more “apples to apples” comparison, a common approach is the application of risk or severity adjustment methodologies to the data to normalize utilization and cost across the populations. Risk adjustment methodologies, such as the Milliman Advanced Risk Adjuster (MARA), Optum’s Episode Risk Groups, or Verisk’s DxCGs, are common tools used to risk adjust results to account for the variations in populations’ risk and severity. Consider the example below. Four PCP groups are each treating a population of patients who have Diabetes without Coronary Artery Disease as identified using Milliman’s Chronic Condition Hierarchical Groups. Each medical groups’ population is of varying size and consists of a mix of commercial and Medicare patients. In Figure 1 we see that the total medical and pharmacy Allowed PMPM cost for all services received by the identified patients is highest for Group 3 at $1,063 PMPM. (All services, regardless of diagnosis.) | Figure 1 | | | | --- | --- | --- | | | Medical Member Months | Allowed PMPM | | Group1 | 41,441 | $828 | | Group 2 | 20,975 | $893 | | Group 3 | 6,503 | $1,063 | | Group 4 | 4,869 | $843 | | Total | 73,788 | $868 | Next, using MARA, we take the risk of each population into consideration. As shown in Figure 2, the population attributed to Group 2 has the highest average MARA concurrent risk score at 3.11, and the Group 3 population’s average concurrent risk is slightly lower at 3.06. A higher overall risk score means that the population’s medical conditions are more severe. Adjusting the cost experience for the population severity allows for a more comparable analysis of the cost of the two populations. We see that, even with the risk adjustment, Group 3’s allowed PMPM is well above the other three groups. | Figure 2 | | | | | | --- | --- | --- | --- | --- | | | Medical Member Months | Allowed PMPM | Avg MARA Concurrent Risk | Risk Adj All PMPM | | Group 1 | 41,441 | $828 | 2.97 | $279 | | Group 2 | 20,975 | $893 | 3.11 | $287 | | Group 3 | 6,503 | $1,063 | 3.06 | $348 | | Group 4 | 4,869 | $843 | 2.89 | $291 | | Total | 73,788 | $868 | 3.01 | $288 | Now, if we want to compare the efficiency of resource utilization in the treatment of these similar populations, an additional adjustment is needed to separate out unit cost versus resource use. Milliman’s GlobalRVUs are a unit value system that covers the entire range of healthcare services, including physician, hospital, DME, and pharmacy. In Figure 3 we see that additional calculations have been added to our analysis. The Risk Adjusted RVUs PMPM is the total RVUs (RVUs) for each group’s diabetic population divided by the population’s average MARA concurrent risk score, giving us an overall measure of utilization. Allowed per RVU is the total allowed amount (not adjusted) divided by the total number of RVUs associated with the delivery of services. Utilization Efficiency is calculated as the ratio between the PCP group’s risk adjusted RVUs to the overall average. **Using these data, we see that the main driver of the higher risk-adjusted allowed PMPM is that Group 3’s Utilization Relativity Ratio (based on Risk Adjusted RVU PMPM) is 1.15 or 15% higher than the aggregate for the groups and 19% higher than the next highest group (0.97). We also see that relative price, as measured by Allowed Per RVU, is a relatively small contributor to the difference in risk-adjusted allowed PMPM as the Allowed Per RVU for Group 3 ($45.14) is only 2% higher than the aggregate for the group ($44.39).** | Figure 3 | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | | | Medical Member Months | Allowed PMPM | Avg MARA Concurrent Risk | Risk Adj All PMPM | Allowed per RVU | Risk Adj RVUs PMPM | Utilization Relativity Ratio | | Group 1 | 41,441 | $828 | 2.97 | $279 | $43 | 6.46 | 0.97 | | Group 2 | 20,975 | $893 | 3.11 | $287 | $46 | 6.24 | 0.93 | | Group 3 | 6,503 | $1,063 | 3.06 | $348 | $45 | 7.70 | 1.15 | | Group 4 | 4,869 | $843 | 2.89 | $291 | $46 | 6.30 | 0.94 | | Total | 73,788 | $868 | 3.01 | $288 | $44 | 6.68 | 1.00 | Applying risk adjustment methodologies to cost of care analysis is the approach many analysts use. But is risk adjustment enough? As shown in the example above, leveraging an RVU methodology in conjunction with risk adjustment can provide additional critical insights into variances due to both population severity and provider efficiency. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Identifying Waste in Healthcare [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/medinsight-chosen-to-identify-unnecessary-costs-in-healthcare-delivery/#content) # MedInsight Chosen to Identify Unnecessary Costs and Procedures in Healthcare Delivery By Bridget Watson 20 July 2016 Print / PDF Share ![]() ## Share this page Copied MedInsight Chosen to Identify Unnecessary Costs and Procedures in Healthcare Delivery Bridget Watson ## Practical Analytic Approaches to Healthcare Challenges Milliman announced today that its healthcare tool, the MedInsight® Health Waste Calculator, has been chosen by two state All Payer Claims Databases (APCDs) and a leading Regional Health Improvement Collaborative to aid in their identification of unnecessary costs and procedures in healthcare delivery. The Virginia Center for Health Innovation (VCHI), Oregon Health and Hospitals, and the Washington Health Alliance (WHA) have all licensed the MedInsight Health Waste Calculator to support their statewide initiatives to identify and eliminate waste in their healthcare systems. “In Virginia, an important component of our state health innovation plan is to reduce utilization of low value medical tests and procedures so that we can free up needed resources to advance high value care. Our medical and business communities want to do what they can to better ensure that patients and providers are choosing wisely when it comes to healthcare,” said Beth Bortz, President and CEO of VCHI. The Health Waste Calculator is an analytic tool that is powered by Milliman’s MedInsight software and encapsulates Value-Based Insurance Design (VBID) Health’s market knowledge on wasteful healthcare spending. The tool identifies and quantifies the use of unnecessary or potentially harmful clinical services, including those defined by national initiatives such as the U.S. Preventive Services Task Force and _Choosing Wisely_. Using the Health Waste Calculator, each state will be able to report on countless aspects of healthcare but the typical starting points are reports by county, region, or even health system, using these metrics: - Percentage of individuals exposed to at least one potentially wasteful service. - Percentage of potentially wasteful services in each market, what is called the Waste and Quality indices. - Cost metrics of the waste impact as a baseline for them to work from as they implement strategies to realize greater efficiencies. Mark Fendrick, Director of VBID, stated, “the achievement of Triple Aim in healthcare is to improve quality, enhance patient experience, and lower costs, which requires us to spend more on evidence-based services and less on those that do not produce health. The MedInsight Health Waste Calculator can identify, and potentially reduce, the use of low value services to free up needed resources to reduce important gaps in care.” MedInsight is used by over 300 health plans, employers, at-risk providers/ACOs, state governments, community health coalitions, and third party administrators. For more information about Milliman’s MedInsight products, [click here](https://www.medinsight.milliman.com/). [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Medicaid Population Management [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/medicaid-population-management/#content) # Medicaid Population Management By Rich Moyer 7 February 2014 Print / PDF Share ![]() ## Share this page Copied Medicaid Population Management Rich Moyer In previous blogs, we’ve discussed Population Management concepts and given specific examples of pediatrics, ACO, and clinical populations. In this blog we turn to the Medicaid population. Medicaid has unique characteristics because of the nature of the financing and because of the social demographics of the population served. This population is going through big changes because of Medicaid expansion and the advent of programs that may resemble some of the characteristics of Medicaid, such as subsidized rates through the federal and state exchanges. A key to analyzing this population is to create homogeneous sub-populations. There are several ways to define the sub-populations: - Program – CHIP, TANF/AFDC, ABD (duals), Waiver programs - Type of delivery model – Managed Care and Fee for Service - County – Rates are typically defined at the county level for managed care and care delivery is organized around counties - Special populations – Pregnant women, children, mentally ill There are specific issues that drive the metrics and analysis for Medicaid recipients, including: - High levels of emergency department (ED) use – This population has much higher ED usage rates which often reflect access and socio-demographic issues - Maternity – This population has higher rates of maternity and has wider variability in maternity outcomes - Behavioral Health – Managing behavioral health is a more important component of care - Community Resource Access – Population wellness is much more dependent on additional community resources such as case workers, food banks and social workers It’s important to focus on the key issues that drive the results for the population and to create metrics that reflect these key issues and characteristics. This article first appeared at [Milliman MedInsight](https://medinsight.milliman.com/). [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Inpatient Admission Methodologies [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/methodology-for-identifying-inpatient-admission-events/#content) # Methodology for Identifying Inpatient Admission Events By Sudhanshu Bansal and Sumeet Vashishta 7 September 2016 Print / PDF Share ![]() ## Share this page Copied Methodology for Identifying Inpatient Admission Events Sudhanshu Bansal and Sumeet Vashishta ## Practical Analytic Approaches to Healthcare Challenges Evidence-based measures (EBMs) and many other health insurance data analytics require counts of inpatient admission events and associated costs. There are multiple ways to identify and count inpatient admission events, each of which may produce a different result. As per the California Department of Health Services, the methodologies used to identify and count individual inpatient admission events vary significantly across different organizations, due to unique data structures and availability.[\[i\]](https://medinsight.com/healthcare-data-analytics-resources/blog/methodology-for-identifying-inpatient-admission-events/#_edn1) An inpatient event can be identified by various data points like an inpatient Evaluation and Management (E&M) Current Procedure Terminology (CPT) code; an inpatient Uniform Billing (UB) revenue code; or an inpatient bill type. However, when it comes to utilization or counting of inpatient events, the facility claims that contain inpatient Uniform/Universal Billing form (UUB) revenue codes or inpatient bill types are the most credible, and therefore should be the ones used to identify inpatient admissions. It is important to highlight that an inpatient admission event typically produces more than one claim line, and all of these individual claim lines must be grouped together to constitute the complete inpatient admission event. Various methods are available to do this, with specific advantages and limitations in each method. We have reviewed several of these methods with their potential advantages and shortcomings and have explored the impact of applying these different methods in a representative claims data set. Inpatient claims can come from different types of facilities, including acute hospitals, long-term acute care (LTAC) centers, acute rehabilitation centers, and skilled nursing facilities (SNFs), where there is evidence that the insured stayed overnight.[\[ii\]](https://medinsight.com/healthcare-data-analytics-resources/blog/methodology-for-identifying-inpatient-admission-events/#_edn2) **Methods** **Method 1: All claim lines for a member with same admission date and discharge date constitute a single inpatient admission event when any one of the claim lines have a UB revenue code for inpatient services.** Method 1 accurately identifies an inpatient facility claim line but it fails to account for overlapping dates on claim lines. A single inpatient admission event can have individual claim lines with different admission and discharge dates. This is referred to as “overlapping dates.” Method 1 counts each claim line with a different admission or discharge date as a unique inpatient admission event and calculates the length of stay (LOS) separately for each. **Method 2: Method 1’s logic is used as the first step to identify admission events, followed by a second step grouping all claim lines with overlapping admission and discharge dates into one inpatient admission event.** Method 2 assumes that claim lines with overlapping admission and discharge dates are part of the same continuous stay and counts them as one inpatient admission event. **Method 3: All claim lines for a member with the same admission date and discharge date constitute a single inpatient admission event when any one of the claim lines has either a UB revenue code for inpatient services, or a bill type for inpatient services.** Method 3 casts a wide net to identify inpatient admission events, as it employs more claim types and service codes than Methods 1 or 2. However, similar to Method 1, claim lines with overlapping admissions or discharge dates are not grouped into a single inpatient admissions event. Expanding the data used to identify inpatient admission events increases the probability of having claim lines with overlapping admission or discharge dates. **Method 4: A step to combine claim lines with overlapping admission or discharge dates is added to Method 3.** Method 4 assumes that claim lines with overlapping admission and discharge dates are part of the same continuous stay and counts them as one inpatient admission event. **Method 5: All claim lines for a member with same the claim/encounter ID are grouped into one inpatient admission event when any of the claim lines have a UB revenue code for inpatient services or a bill type for inpatient services.** Method 5 assumes that the claim/encounter identification (ID) remains the same throughout an inpatient admission event, and combines all claim lines with the same claim/encounter ID. This method counts all claim lines with the same claim/encounter ID, even when there is no overlap between admission and discharge dates. **Variation in Results** We applied these different methods for counting inpatient stays on a test database composed primarily of commercial plan members with over 2.6 million lives and 18,551,986 member months for the year 2012 to compare inpatient utilization results for a Healthcare Effectiveness Data and Information Set (HEDIS) EBM: Inpatient Utilization General Hospital/Acute Care (IPU). Results of this comparison are provided in the table in Figure 1. **Figure 1: Comparison of Results Using Different Inpatient Stay Methodologies** [![Figure 1: Comparison of Results Using Different Inpatient Stay Methodologies]()](https://medinsight23.wpengine.com/wp-content/uploads/2023/07/Inpatient_Admissions_Events.png "Figure 1: Comparison of Results Using Different Inpatient Stay Methodologies") Inpatient admission event counts varied up to 25% across the different methodologies. These results clearly confirm that counts of inpatient admission events can vary significantly depending on the methodology used. Average LOS is also influenced considerably by the method used to identify inpatient admission events. The outcomes of this analysis emphasize the importance of using a comprehensive methodology when defining inpatient admissions events. It also highlights the need to know the underlying methodology when comparing results for EBMs, for other inpatient admissions event-related measures between organizations, or for different time periods in order to understand if variations in results may be due to the methodology used to define inpatient admissions event rather than operational or quality differences. [\[i\]](https://medinsight.com/healthcare-data-analytics-resources/blog/methodology-for-identifying-inpatient-admission-events/#_ednref1) California Department of Healthcare Services. Methodology for Identifying Inpatient and Emergency Room Encounters, Appendix A. Retrieved September 7, 2016, from [https://www.dhcs.ca.gov/provgovpart/Documents/Appendix%20A.%20Methods.pdf](https://www.dhcs.ca.gov/provgovpart/Documents/Appendix%20A.%20Methods.pdf) [\[ii\]](https://medinsight.com/healthcare-data-analytics-resources/blog/methodology-for-identifying-inpatient-admission-events/#_ednref2) Health Care Cost Institute (September 2012). Health Care Cost and Utilization Report: 2011: Analytic Methodology. Retrieved September 7, 2016, from [https://www.healthcostinstitute.org/files/HCCI\_HCCUR2011\_Methodology.pdf](https://www.healthcostinstitute.org/files/HCCI_HCCUR2011_Methodology.pdf) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Observation Status Evaluation [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/observation-status-a-practical-approach-to-evaluating-utilization/#content) # Observation Status – A Practical Approach to Evaluating Utilization By David Mirkin 29 October 2013 Print / PDF Share ![]() ## Share this page Copied Observation Status – A Practical Approach to Evaluating Utilization David Mirkin Over the last few years one day hospital stays have been a focal point for medical management efforts to convert these to observation stays. In addition the 2014 Medicare’s Inpatient Prospective Payment System’s final rule on inpatient admission defines an “appropriate” inpatient admission as one that in the judgment of the admitting physician requires a hospital stay of at least two midnights or in medical management terms, a two day length of stay (LOS). Patients not meeting this criteria but needing inpatient hospital care lasting past one midnight but less than two will be classified as observation cases. The combination of these and other factors is leading to an increase in utilization for observation. So is this a positive outcome from a cost management perspective or is it problematic? This is becoming an important question for population management and one that does not have a simple answer. A not uncommon situation is one where the reimbursement levels for inpatient hospital admissions and observation stays are not rationale. By this I mean that observations stays are paid more than if the patient were admitted as a regular inpatient admission. Avoiding an admission through the use of observation may be the right thing to do in this situation from a resource efficiency perspective but may actually cost a payer more than the hospital admission that is being avoided. Regardless, the overall trend is to move patients to observation status when this is appropriate clinically. So how should observation status utilization be measured and what benchmarks should be used to monitor results? If we see an increase in observation utilization is it a desired outcome or should we be concerned? The typical practice of measuring billed units may not be the best approach since observation stays are billed using different units depending on how payer hospital contracts are designed so some observation services may be billed in hourly increments in some settings, in 24 hour increments in others and as a generic per observation episode in others. Our recommendation is to use “observation episodes” as the unit for measuring utilization. An observation episode is measured using the same logic as an inpatient stay, each midnight occurring during an observation stay counts as 1 observation unit with a minimum value of 1 for observation stay not spanning midnight. As examples, an observation stay starting at 4 AM and ending at 8 PM would be 1 observation unit, a stay starting at 4 AM and ending at 1 AM would also be 1 observation unit and finally a stay starting at 4 AM and ending at 1 AM after two midnight would be 2 observation units. This allows us to directly compare observation unit utilization with inpatient hospital utilization and one goal for directing patients towards observation is to reduce inpatient utilization. Now for the question of how do we determine if our rate for observation utilization is positive or a problem we need to address. Since observation is a substitute for short stay hospital admissions we need to look both at observation utilization and short stay hospital utilization.  We recommend combining observation episode with 1 day LOS hospital admissions to produce a combined utilization rate and then comparing this to either a historical target or a benchmark from a source such as Milliman. An example taken from a Milliman analytic tool (MedInsight Guideline Analytics) is shown below. [![Evaluating Utilization 10.25.13]()](https://medinsight.com/wp-content/uploads/2023/07/Evaluating_Utilization_102513.jpg "Evaluating Utilization") Using this example the target utilization is the “combined Obs + 1 Day LOS” or 27.7/1000.  Our actual is 28.3 or a bit higher than we would like. In addition, our 1 Day LOS utilization is higher than the benchmark while our Obs utilization is less meaning we should have opportunity to shift more 1 day admits cases to Obs without causes excess utilization. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Integrating Claims and EHR Data [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/poised-for-breakthrough-integrating-claims-data-and-ehr-data/#content) # Poised for Breakthrough: Integrating Claims Data and EHR Data By Brian Studebaker 4 October 2013 Print / PDF Share ![]() ## Share this page Copied Poised for Breakthrough: Integrating Claims Data and EHR Data Brian Studebaker Up until now, the integration of claims data and EHR data has been an often sought, but seldom realized goal in the healthcare analytics world.  It’s a business intelligence idea with so much potential benefit, and it seems like it just wouldn’t be that hard to do. In reality, unifying these two types of data is enormously complex. To date, there have been too many barriers to sourcing this data, and a clear vision of the true ROI has not really emerged. So why are we poised for a breakthrough now? **The Convergence of Need and Availability** For the first time there are entities that have both access to the data and the interest to leverage it. Accountable Care Organizations (ACOs) need better support in understanding and managing the risk of their populations. Provider-Owned Health Plans (POHPs) must improve the efficiency of medical management in order to survive in the new healthcare market.  With the Accountable Care Act and meaningful use, the penetration of EHR systems is growing, creating electronic data that is accessible and increasingly coded rather than free-form. Rather than admit that integration of this data is a Mount Everest-level task beyond its worth, ACOs and POHPs are now examining the data and data sources to locate the first foot-hold.  They’re finding strengths, weakness and characteristics in the two data types that are complementary. Indeed, the combination of claims data and EHR data will permit advanced analytics at the individual patient and patient population levels that could drive significant improvements in health outcomes and financial performance. [![EHR 10.04.13](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/07/EHR_100413.jpg)](https://medinsight.com/wp-content/uploads/2023/07/EHR_100413.jpg "EHR") **How We Can Get There** Let’s take an “If You Build It, They Will Come” approach, in two phases. Phase 1 starts with a focus on a single EHR system, perhaps one that is chosen as a pilot. The data is loaded from the EHR system and unified with the claims data in a data warehouse. It is transformed, meaning the coding is synchronized so distinct data, duplication and gaps are identified.  Then it is presented in a unified, logical way using dashboards, member profiles and other analytic tools. At this stage, the two data sets are not fully integrated, but value can still be derived from the aggregation and normalization work that have taken place. Phase 2 involves building the data set, then developing/applying advanced analytics such as clinical opportunity identification, development of hybrid risk scores and stratification of better episodes of care. The business intelligence that results could be used in many ways, such as: - to provide greater levels of disease monitoring to ACOs and POHPs, leading to more informed decision-making at the enterprise level - to support clinicians and patients in more informed decision-making during visits, and limiting unnecessary tests or treatments - to guide medical research on disease prevention and treatment Yes, the integration of claims data and EHR data will be messy at first. However, the potential gains for all parties to the healthcare system in our country are enormous. It’s time we pursue them. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Coronary Angiography Overuse [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/potential-overuse-of-coronary-angiography-amongst-asymptomatic-population/#content) # Potential Overuse of Coronary Angiography Amongst Asymptomatic Population By Lalit Baveja and Shivangi Sharma 26 March 2015 Print / PDF Share ![]() ## Share this page Copied Potential Overuse of Coronary Angiography Amongst Asymptomatic Population Lalit Baveja and Shivangi Sharma Coronary angiography is a key diagnostic tool in the management of patients with coronary artery disease. Coronary angiography is used to identify narrowing in coronary arteries and is used for decision support to ascertain the need for revascularization to minimize the risk of myocardial infarction. Various research studies have evaluated trends in the use and results of coronary angiography as key contributory factors to the variations seen in rates for coronary revascularization across the US. For example, a large study by Chan, et al. highlighted that inappropriate revascularization rates ranged from 0% to 55% in different facilities. The use of diagnostic angiography has been advocated in different guidelines to ensure that the revascularization is warranted, however, this approach does not address inappropriate selection of patients for a diagnostic angiography. According to the American Heart Association (AHA), coronary angiography is not recommended in patients who are at low risk according to clinical criteria and who have not undergone prior non-invasive risk testing. Coronary angiography is also not recommended in asymptomatic patients with no evidence of ischemia or non-invasive testing. However, various studies observe that current practice patterns are not consistent with these recommendations _._ Abdallah, et al. in their review of the National CathPCI registry found that, out of 790,601 elective coronary angiographies performed on patients with no history of Coronary artery disease (CAD), approximately 291,586 angiographies were not preceded by any stress test. Amongst these patients with no stress test prior to coronary angiographies, approximately 38.5% did not have symptoms of angina. Other studies have highlighted the variable diagnostic yield of elective diagnostic angiographies. A 2010 Patel et al. study of the cardiovascular national registry found that, in patients without known heart disease who underwent elective invasive angiography, 37.6% had obstructive coronary artery disease. This implies that nearly two-thirds of patients had a negative result for obstructive coronary artery disease. Amongst the group with no obstructive heart disease, 30.0% were noted to have no symptoms, including no angina. False positive findings in inappropriate diagnostic tests can trigger subsequent treatment. Referred to as “diagnostic-therapeutic cascade,” inappropriate angiography in asymptomatic patients increases the likelihood of performing inappropriate coronary artery revascularizations and other associated medical utilization. Bradley, et al. studied 544 hospitals that performed more than 1 million elective coronary angiograms and more than 200,000 elective percutaneous coronary interventions (PCI) between 2009 and 2013, and found that 25.1% of patients were asymptomatic at the time of angiography. The proportion of angiographies performed on asymptomatic patients by individual hospitals ranged from 1% to 73.6%. Hospitals with higher rates of angiography performed on asymptomatic patients also had higher rates of inappropriate PCIs and lower rates of appropriate PCIs. Considering the volume and cost of these procedures, it is important to reinforce appropriate patient selection for coronary angiography. To study the practice pattern of coronary angiography and associated services, we reviewed administrative claims data of a Midwestern US Health plan for the July 2011-June 2012 time period. MedInsight’s Health Waste Calculator tool was used to identify necessary, likely wasteful, and wasteful angiography service units. Angiography services for members who had administrative data evidence for cardiac symptoms or high risk diagnosis (ischemic and coronary heart disease, diabetes, and peripherally artery disease) were assigned as necessary services. The analysis in Table 1 shows that 99% of angiography services (n=11,110) met the necessary criteria, while 1% of services were determined to be either likely wasteful or wasteful (n=95), having no evidence for the presence of any the underlying symptoms or diagnosis that would classify these as necessary. Further analysis highlighted that, amongst the necessary services, 37% were conducted for acute conditions (acute coronary syndrome, angina, and myocardial infarction), while 63% of services were conducted for non-acute conditions. Amongst the inappropriate angiography services, 37% of members received a cardiac stress test prior to the angiography, whereas the remaining 63% of members did not. Due to the absence of clinical data, such as from an Electric Medical Records (EMR) system, we assigned the non-necessary services with a prior stress test as “Likely Wasteful” and the remaining services with no prior stress test as “Wasteful.” **Table 1: Profile of Angiography Services** [![]()](https://medinsight.com/wp-content/uploads/2023/07/Table-1.jpg) To study if members with wasteful angiography had other associated costs of follow-up and cardiac revascularization, we reviewed the utilization experience of members with wasteful angiography services for a period of six months after the wasteful service date. Table 2 summarizes the results of this analysis. We restricted our analysis to utilization for cardiac-related procedures and encounters. We found that cardiac revascularizations (including CABG and PCI) and other cardiac procedures comprised 11% of all cardiac related services, with a combined cost of $217,840 (35% of all allowed cardiac related costs). Follow-up diagnostic angiographies and cardiac imaging comprised another 27% of cardiac related services, with a combined cost of $89,290 (14% of all allowed cardiac related costs). **Table 2: Post-Angiography Utilization by Members with Wasteful Services** [![Post-Angiography Utilization by Members with Wasteful Services]()](https://medinsight.com/wp-content/uploads/2023/07/Table_21.jpg) While the results of this analysis are consistent with the low end of what has been reported for inappropriate coronary angiographies (1% to 73.6%) it raises concern over the need to improve patient selection for coronary angiography. It is important to note that claims data alone is not sufficient to identify wasteful angiography services with absolute certainty. However, even with conservative estimates, these findings confirm the significant resource use and expenses after angiography and the potential medical waste in the subsequent period. Sources Chan et al, Appropriateness of Percutaneous Coronary Intervention JAMA. 2011;306(1):53-61. Available at: [https://jama.jamanetwork.com/article.aspx?articleid=1104058](https://jama.jamanetwork.com/article.aspx?articleid=1104058) Jeffery L Anderason, Jonathan L. Haperin. “Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease”; Journal of the American College of Cardiology. 2012; 60(24):2564-2603. Available at [https://content.onlinejacc.org/article.aspx?articleid=1391403](https://content.onlinejacc.org/article.aspx?articleid=1391403) Mouin S. Abdallah, John A. Spertus. “Symptoms and Angiographic Findings of Patients Undergoing Elective Coronary Angiography Without Prior Stress Testing”; American Journal of Cardiology. Available at [https://www.ajconline.org/article/S0002-9149(14)01112-6/pdf](https://www.ajconline.org/article/S0002-9149(14)01112-6/pdf) Manesh R. Patel, Eric D. Peterson. “Low Diagnostic Yield of Elective Coronary Angiography”; New England Journal of Medicine 2010 March 11; 362(10): 886–895. Available at [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3920593/pdf/nihms540259.pdf](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3920593/pdf/nihms540259.pdf) Bradley SM, Spertus JA. “Patient selection for diagnostic coronary angiography and hospital-level percutaneous coronary intervention appropriateness: insights from the National Cardiovascular Data Registry”; JAMA; 2014;174 (10):1630-1639. Available at [https://archinte.jamanetwork.com/article.aspx?articleid=1898877](https://archinte.jamanetwork.com/article.aspx?articleid=1898877) [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Regional Variation in Syncope [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/regional-variation-in-utilization-syncope/#content) # Regional Variation in Utilization – Syncope By Marcos Dachary, Chief Market Strategist and General Manager of Payer Solutions, MedInsight 23 April 2014 Print / PDF Share ![](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/05/cloase-icon-new.png) ## Share this page Copied Regional Variation in Utilization – Syncope Marcos Dachary, Chief Market Strategist and General Manager of Payer Solutions, MedInsight Area differences in healthcare utilization have been documented since an area variation analysis of tonsillectomy rates was published back in 1938. Besides the research literature, geographic variation in U.S. healthcare also has been documented extensively for the Medicare population in the Dartmouth Atlas. The Institute of Medicine also released a series of reports on geographic variation in healthcare spending in early 2013. General consensus from these studies is that significant regional difference in various health services is observed after adjusting for available patient and payer differences. Regional variation in healthcare utilization is greatest among procedures or diagnoses with variation in standard practices. Syncope, for example, can be treated efficiently on an ambulatory basis or in the inpatient setting up to 1 day. It largely depends on physicians’ preference as to whether to treat a syncope patient outside the hospital or keep the patient overnight. The chart below illustrates the regional difference in Emergency Room and/or Observation Care (“ER/OBS”) utilization and inpatient admissions for syncope between four New York and New Jersey plans and four California plans. Data for all plans are limited to commercial members, and utilization rates are adjusted to reflect standard commercial demographics. Compared to the commercial average (regression line), the four California plans stay at the lower ends of both ER/OBS visits per 1000 and inpatient admission via ER/OBS per 100. On the contrary, the four New York/New Jersey plans not only had a higher than average rates of syncope ER/OBS visits but also admitted a higher percentage of syncope patients via ER/OBS to the inpatient setting. [![Regional Variation in Utilization – Syncope ](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/07/Regional_Variation_in_UtilizationSyncope_041114.jpg)](https://medinsight.com/wp-content/uploads/2023/07/Regional_Variation_in_UtilizationSyncope_041114.jpg) The difference in ER/OBS visits rate between the California plans and the New York/New Jersey plans for syncope perhaps reflects not only where syncope patients seek care in different areas but also the availability of primary care sources in each area.  It may also reflect different patient understandings of the appropriate role of Emergency Department care. However, the difference in the syncope ER/OBS admission ratio (syncope admissions via ER/OBS per 1000 divided by syncope ER/OBS visits per 1000) reflects more on differences physician decision-making. For this condition, physicians in New York/New Jersey admitted ER/OBS syncope patients to the inpatient setting much more often than those in California did (9.6% – 16.6% vs. 6.5% – 8.4%). Even assuming that the same diagnostic work-up takes place in either the inpatient or the outpatient setting, the added cost of accommodating this much higher percentage of patients overnight in the hospital can be substantial. The methodology embedded in the MedInsight Guideline Analytics software solution was used to create the analysis for this article, e.g. the definition of syncope in medical claims data and the means to count admits, observation, and ER cases. ### **\*This article is a guest post, written collaboratively by John Ninomiya, Ph.D, FSA , Director, Epidemiology & Health Services Research, MCG Health and Frances Lee, Ph. D., Senior Clinical Benchmarking Advisor, MCG Health.** [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) Live chat:Chat with an Expert ## Site of Service Savings [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/site-of-service-savings-opportunities/#content) # Site of Service Savings Opportunities By Will Fox 7 August 2014 Print / PDF Share ![]() ## Share this page Copied Site of Service Savings Opportunities Will Fox Most people working in healthcare know that the cost for the same service can vary significantly by setting (e.g. office based vs hospital) and by provider within a setting. The example below illustrates this for a simple surgery with the price doubling in the Ambulatory Surgery Center (ASC) setting and being almost 5 times as much in the hospital setting. [![080714 Site of Service](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/07/080714_Site_of_Service.jpg)](https://medinsight.com/wp-content/uploads/2023/07/080714_Site_of_Service.jpg) The RVUs are higher if the surgery is performed in a facility setting and the unit price is higher in the hospital vs the ASC, these all impact the total cost at the bottom. This illustration uses the average commercial cost in each setting. If you selectively choose the providers to shift from and to, the savings could be much greater. There are savings opportunities due to shifting from the inpatient setting too. A few leading providers are now doing hip replacements in the outpatient setting! Milliman research shows that approximately 15% of commercial costs can be eliminated by site of service shifting (assuming no utilization reductions). For Medicare plans the opportunity is only about 5% due to more synchronized fee schedules (e.g. Lab is paid the same in hospital outpatient setting as in office setting), however, that 5% is still around $45 PMPM so the opportunity is significant. A brief list of the services that we have evaluated the site of service savings opportunities for include: - Outpatient Surgeries moving to ASC or Office - Drugs (office and outpatient based, not prescriptions) - Lab, Imaging, other outpatient services moving to office/free-standing settings - Emergency Room (transition to Urgent care) - Maternity (use of birthing centers and home births) - Inpatient moving to Observation —————————————- To learn more about cost savings opportunities for ACOs and payers, join us at our next MedInsight webinar: **Evaluating ACO Performance and Identifying Savings Opportunities** August 19, 2014, 2:00-3:00 PM ET Accountable care organizations (ACOs) are popping up everywhere and much work is being done to improve outcomes and reduce costs. This informational webinar will focus on sharing actual reports on how to compare ACOs (with drill downs into medical groups, clinics, and PCPs) as well as how to identify and quantify savings opportunities. The session will be helpful to many, including ACOs and payers that are creating analytics to measure performance of medical groups. Presenter: Will Fox, FSA, MAAA, Milliman Principal & Consulting Actuary [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## Healthcare Analytics Trends [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/top-five-analytic-trends/#content) # Top Five Analytic Trends By Andrew Naugle 17 February 2015 Print / PDF Share ![](https://medinsight.com/wp-content/uploads/2023/05/cloase-icon-new.png) ## Share this page Copied Top Five Analytic Trends Andrew Naugle It goes without question that the U.S. health insurance industry is in a state of flux.  Americans are buying individual products through health insurance marketplaces, new insurance carriers have entered the market, and Medicaid has been expanded in 29 states and the District of Columbia. These market changes, in addition to other reform provisions already introduced and others just starting to take hold, have subjected the market to an unprecedented level of change. It is said that insurers like risk but hate uncertainty.  What is for certain today is that the old strategies of accepting good risks and repelling poor risks is no longer a recipe for success.  To thrive in this new environment, health insurers must make smart decisions using data to keep ahead of the competition. Within that context, here are five areas where Milliman clients are using data and analytics in innovative ways to bring some order to the chaos: 1. **Provider Network Optimization.** Despite bending the cost curve, one of the great lessons of the HMO era was that consumers value choice. For years, PPOs competed on network size; employers cared more about network disruption affecting their employees than the cost/volume trade-off. In the face of cost pressures, employers and consumers are now starting to accept that smaller networks may be worth the disruption. To meet this need, plans are deploying sophisticated modeling that combines traditional network access and adequacy measures with reimbursement and quality analytics to develop new “smart” networks. 2. **Value-Based Incentive Programs**. It’s widely accepted that fee-for-service reimbursement rewards volume over value. As a replacement for FFS, many payers are promoting value-based incentive strategies that shift reimbursement from fee schedules to bonus pools that pay additional incentives when quality and/ or cost targets are met. Analytics are key to selecting measures, setting thresholds, and assessing provider performance. They also aid providers trying to operate under these new risk arrangements, identifying gaps in care, and benchmarking peer performance. 3. **New Trend Dynamics**. While predicting the actual numbers requires the proverbial “crystal ball,” the health insurance industry has a reasonably mature understanding of the drivers of health care cost trend. But things are getting more complicated as physician practice patterns change, populations age but live longer, millions of new consumers flood into the individual and Medicaid markets, and burgeoning innovation (e.g., telemedicine/ telehealth, wearables, smartphones, home visits, retail clinics, etc.) disrupts how and where care is provided. Analytics are key to understanding the “trends in trend” in this new world. 4. **Transparency.** The healthcare market has earned a reputation for opaqueness. Consumers are more likely to rely on word-of-mouth when selecting a physician, the price of services depends on who’s paying and has little relationship with the actual cost of services, and information on outcomes and quality is kept locked away from prying eyes. Not so in a post-reform world; consumers can now shop on the basis of price and quality, they can go online and find out how much an appendectomy costs at hospital A or B and which one has a higher success rate, and health plan quality ratings are there for all to see when selecting an exchange plan. Big data and analytics make all of this possible. 5. **Care Management Efficiency.** Gone are the days when health insurers had unlimited funding for care management programs. Today, plans must make judicious use of limited administrative dollars to meet medical loss ratio minimums while still managing complex and catastrophic cases.  Analytics help plans optimize their care management programs, prospectively identifying those members most likely to benefit from care management, and then enrolling them in the right program. With many of their traditional performance management tools neutralized by reform, health insurers have had to get smart about how they leverage data and information: they use analytics to design benefit plans, develop marketing strategies and consumer segmentations, select network providers, develop reimbursement strategies, improve clinical quality, and optimize their remaining cost and quality management tools. In today’s market, how a plan leverages analytics, turning data into actionable information, will make the difference between survival and demise. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png) ## AICU/IOCP Data Insights [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/using-data-in-aicu-iocp-models/#content) # Using Data in AICU/IOCP Models By Patty Jones 11 October 2013 Print / PDF Share ![]() ## Share this page Copied Using Data in AICU/IOCP Models Patty Jones The Patient-Centered Medical Home (PCMH) model emerged in response to the recognized need for more systematic and evidence-based approaches to ensuring access to, and coordinating care for, an entire population. Within that framework an additional focus has developed that recognizes the specific needs of members with chronic and complex conditions. In order to respond to that population, additional models have emerged that focus on proactive identification of chronically ill members using claims-based predictive model scoring as well as clinically based referrals and information. These models are often referred to as Ambulatory Intensive Care Unit (AICU) or Intensive Outpatient Care Program (IOCP). The AICU and IOCP models, now in pilot testing and operation in a number of sites and with different Milliman clients, have the following core design characteristics: - Payer and medical group partnerships that emphasize clinician leadership and active involvement in design and implementation; - Program designs that promote patient-centered process changes and result in enhanced roles for nursing and clinic administrative staff; - Proactive identification of members with chronic or complex illnesses using claims-based risk scoring  tools such as the Milliman Advanced Risk Adjuster (MARA) coupled with clinic and clinician-based identification of candidates for the program; - Clinic-based outreach to members to encourage active engagement; - Personalized care plans that address the specific needs and priorities of the members; and - Recognition of psychosocial barriers to adequate medical care resulting in innovative approaches to removing these barriers. There are a number of good articles written about these initiatives including “Enhancing Quality of Primary Care Using an Ambulatory ICU to Achieve a Patient-Centered Medical Home”  Lewis, Hoyt and Kakoza, Journal of Primary Care & Community Health May 27, 2011 and “American Medical Home Runs” Arnold Milstein and Elizabeth Gilbertson, Health Affairs, 28, no. 5 (2009) pages 1317-1326”. These and other articles provide good information on the results of these programs. Most of these models involve hiring clinic-based case managers or imbedding health plan case managers in clinical sites. Working with the clinical teams and health plans involved in these projects has provided a number of insights into using risk-scoring information in supporting the needs of case managers in these new models. These observations include the following. - Risk scoring data can be interesting but overwhelming to clinical team members – it is best to design reports and portals with early input from the people who will ultimately use it. As fascinating as claims data may be to some of us, these clinicians have an important perspective on what they are likely to use when and how. - Clinical user training can help  them interpret and use risk scoring data  more effectively–focus on the basics and priorities (eg.  the difference between prospective and concurrent scores) and include case studies that lead participants through practice sessions and use of the information. - Clinical insight and patient knowledge is a valuable addition to the use of data – encourage care managers to use risk scoring data to find potential candidates and as a tool for adding a broader clinical, utilization and cost perspective to the information in a medical record. Clinicians and clinical teams can then provide a unique and highly useful perspective on what the information may indicate about a population and what can be done about it. - Managers can use summarized risk scoring data analysis to focus on a reasonable number of cases for review – risk scoring analysis can end up identifying large numbers of candidates. Additional analysis of risk scores can be used to identify a more manageable list of candidates for care management. In the example below a client distribution analysis showed the number of members by risk score level  both concurrently and prospectively for members with a score greater than one. This analysis helped identify patterns and clusters of members by risk score range. Further analysis isolated a smaller population (approximately 7% of the total) with concurrent and prospective scores that remained level or increased. This allowed the management team to focus on new candidates more quickly. **Client Example – Using Population Risk Score Distributions to Identify Care Management Candidates** The AICU and IOCP models, viewed as specialized programs designed to support the needs of chronically ill members, may in fact be good blueprints for all care management programs. The concept of integrating payer and provider data and expertise more directly can be rewarding for care management teams and beneficial to members.Claims analysis and risk scoring tools can be key tools in identifying opportunities and targeting interventions in these models. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series]() ## Measuring Quality in Ambulatory Care [Skip to the content](https://medinsight.com/healthcare-data-analytics-resources/blog/ambulatory-care-measuring-quality-and-the-impact-of-nursing/#content) # Ambulatory Care – Measuring Quality and the Impact of Nursing By Patty Jones 7 March 2014 Print / PDF Share ![]() ## Share this page Copied Ambulatory Care – Measuring Quality and the Impact of Nursing Patty Jones [![Jones Patty](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight23.wpengine.com/wp-content/uploads/2023/07/Jones-Patty.jpg)](https://us.milliman.com/Consultants/?cid=fd8408797f000001003e162d2f96e30b) The shift of medical care from the inpatient to outpatient setting coupled with the emphasis on transformative designed patient-centered medical home models provides measurement challenges and opportunities. The challenges are how to effectively measure quality in this setting given the range of services that are provided—from routine preventive care to complex surgical and invasive procedures. The concurrent opportunity is to measure and promote the role of nurses in providing and leading the care and coordination services that are at the core of ensuring improved patient experiences and outcomes in the outpatient setting. **Table 1: Percentage Share of Inpatient vs. Outpatient Surgeries (1988-2008) \[1\]** [![Ambulatory Care – Measuring Quality and the Impact of Nursing (1)](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2023/07/AmbulatoryCareMeasuringQualityandtheImpactofNursing1.jpg)](https://medinsight.com/wp-content/uploads/2023/07/AmbulatoryCareMeasuringQualityandtheImpactofNursing1.jpg) **Table 2: Trends in Inpatient and Outpatient Utilization (1987-2007) \[2\]** [![Ambulatory Care – Measuring Quality and the Impact of Nursing (2)]()](https://medinsight.com/wp-content/uploads/2023/07/AmbulatoryCareMeasuringQualityandtheImpactofNursing2.jpg) Professional nursing associations have taken notice of these trends and are accelerating the effort to improve on measurement of both quality and nursing impact in the ambulatory setting. In January of this year the American Nurse Association (ANA), American Nurses Credentialing Center (ANCC), and American Nurses Foundation (ANF), hosted the Ambulatory Measurement Summit. This meeting and the work leading up to the Summit involved 40 nursing leaders representing stakeholders in national/specialty nursing organizations, payers with delivery systems, measure developers (including Milliman), delivery systems, and payers. The charge to this group was to come to consensus on five existing measures that warranted further investigation and potential adaptation as an ambulatory nursing measure. Participating in this exercise with this impressive set of nursing leaders representing a wide range of interests I was struck by several observations. - There is a clear need to develop outpatient measures that go beyond preventive and chronic care and address other quality concerns- ambulatory care (especially procedure-based care) involves complex services with risks and consequences that are not well addressed by today’s measures of processes such as immunization and screening rates. - There is a continued opportunity to pilot new measures of coordination – there is clear recognition that the new value to consumers (and opportunity for nursing) will be the ability of the healthcare system to help them successfully move from one service to another and it will take innovative minds to design these measures. - It is hard to measure the impact of nursing independent of other factors – as you examine specific measures it is difficult to claim nursing as the driver of performance in that measure but perhaps this serves to emphasize even more that healthcare involves teams and ultimately identify that nursing remains a key part of that team. At the close of the Summit the attendees reached consensus on five nationally-endorsed measures, as having high relevance to nursing impact: 1. Medication Reconciliation (NQF #0097) 2. Controlling High Blood Pressure (HEDIS Measure) 3. Depression Assessment Conducted (NQF #0518) 4. Pain Assessment and Follow Up (NQF #0420) 5. All-Cause Readmissions (NQF #1768) The next step will be for the ANA and the National Database of Nursing Quality Indicators® will undertake further review of the five consensus measures for possible refinement and testing for use within the ambulatory setting. We will watch this initiative closely as we refine Milliman’s measurement tools to fully reflect the changes underway in the healthcare system, the role of stakeholders such as the nursing profession, and improve the ability to measure the impact of these changes. * * * \[1\] Frakt, Austin. “Inpatient vs. Outpatient Surgeries.” The Incidental Economist, October 2010. [https://theincidentaleconomist.com/wordpress/inpatient-vs-outpatient-surgeries/](https://theincidentaleconomist.com/wordpress/inpatient-vs-outpatient-surgeries/) \[2\] Johnson, Tracy K., “Ambulatory Care Stands Out Under Reform.” Healthcare Financial Management. May 2010. [Contact us to learn more about healthcare data analytics](https://medinsight.com/healhtcare-data-analytics-contact/) ## Explore more tags from this article [medinsight insight](https://medinsight.com/healthcare-data-analytics-resources/blog/tag/medinsight-insight/) ### Join Our Next MedInsight Webinar ## **Register today** to reserve your spot! **Also, access previous webinars** on-demand. [Learn more](https://medinsight.com/healthcare-data-analytics-resources/webinars/) ![Webinar Series](https://cdn-kfldj.nitrocdn.com/KLaVEgPGOfJYDwYBkrgvJblkOAuqkxOb/assets/images/optimized/rev-eca805e/medinsight.com/wp-content/uploads/2025/09/general-webinar-popup.png)