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Why A Third of Employers Can't Access Medical Claims Data and What It Means

Update Navigating the Data Dilemma: Why Medical Claims Access Matters A recent survey conducted by the National Alliance of Healthcare Purchaser Coalitions highlights a pressing issue in the healthcare landscape: one-third of employers are struggling to access their medical claims data from health vendors, including pharmacy benefit managers (PBMs) and insurers. This lack of access is more than just a minor inconvenience; it poses a significant barrier to employers’ abilities to manage healthcare costs effectively. The Implications of Limited Data Access on Healthcare Costs Employers who can access their claims data are in a better position to implement proactive cost-control strategies, such as conducting audits of their PBM contracts and leveraging innovative payment models like direct contracting with providers. The ability to analyze healthcare utilization patterns allows employers to make informed decisions, improve healthcare outcomes, and combat soaring costs. In fact, survey results revealed that 99% of employers believe that high drug prices, rising hospital fees, and costly claims are the most significant threats to their affordability. Who Struggles the Most? Size Matters Interestingly, data access largely correlates with company size. The survey found that 74% of employers with more than 50,000 employees reported having full access to their claims data, compared to only 52% of those with fewer than 1,000 employees. This disparity raises concerns about equity and highlights a systemic issue where larger employers can leverage their resources to negotiate better terms with vendors. Changing Landscapes: The Shift Towards Transparency The survey also underscored a notable trend: many employers are reconsidering their partnerships with the industry’s top three PBMs—CVS Caremark, Express Scripts, and Optum Rx—opting instead for transparent vendors. This shift is partly driven by dissatisfaction with hospital consolidations, as 60% of employers expressed skepticism about their impact on cost and quality. Such sentiments reflect a broader demand for transparency and accountability in the healthcare sector. Conclusion: A Call for Action As employers navigate these challenges, it’s clear that access to medical claims data is not just a technical requirement; it’s a strategic necessity. Employers must advocate for reforms leading to increased data access and transparency, ensuring they can manage healthcare costs effectively while improving the quality of care for their employees. The current state of healthcare demands proactive solutions, as echoed by National Alliance’s president, Shawn Gremminger, who aptly termed the situation a “dumpster fire” for those unwilling to challenge the status quo. Employers should band together to push for policy changes that enhance data accessibility and promote fair pricing within healthcare.