The Critical Role of Claims Data in Employer Health Spending Decisions

In the complex landscape of healthcare spending, employers often find themselves navigating a maze of costs, strategies, and regulations. A recent survey by the National Alliance of Healthcare Purchaser Coalitions sheds light on a crucial finding: the actions employers take regarding health spending are not solely driven by escalating costs. Instead, **access to claims data** emerges as a pivotal factor influencing their decision-making processes. This article explores how the visibility of claims data affects employer strategies, the implications for various stakeholders, and what employers can do to leverage this information for better health outcomes and cost management.

The Pulse of the Purchaser Survey Findings

The 2026 Pulse of the Purchaser survey, which gathered insights from 408 employers engaged with healthcare purchaser coalitions, reveals a significant correlation between the access to claims data and the implementation of various health strategies. Employers with **full access to their medical claims data** averaged 11.9 healthcare strategies, compared to only 7.9 strategies utilized by those with limited or no access. This stark difference underscores the critical need for employers to not only have access to data but to fully utilize it in shaping their health spending decisions.

Understanding the Data Access Gap

Despite the apparent advantages of having claims data, the survey indicates that around **75% of employers** store their claims data with health plans or third-party administrators (TPAs). Alarmingly, this group reported the lowest rate of complete claims access, with only **59.2%** achieving full visibility of their medical claims. In contrast, employers utilizing independent data warehouses reported a much higher success rate. Approximately **85.9%** of these employers experienced complete access to medical claims, highlighting the importance of storage methods in determining access levels.

The Relationship Between Costs and Strategy Adoption

Interestingly, the survey found that employers expecting steep cost increases were not more likely to adopt new purchasing strategies. Those anticipating **9% or more cost increases** were just as likely as their peers to implement the 26 strategies tracked in the survey. This suggests that while cost pressures are a significant concern, they do not automatically translate into proactive measures unless employers have the data to inform their decisions.

Access Versus Utilization

The gap between having access to claims data and utilizing it effectively is notable. For instance, while **65.3%** of survey respondents reported having complete medical claim-level access, only **58.6%** indicated they had the ability to audit their own files. This discrepancy raises questions about the usability of the data that employers do have access to, particularly when it comes to holding vendors accountable and ensuring financial integrity.

Why Size Matters: Employer Data Utilization

The survey results also revealed significant differences in how employers of varying sizes utilize health data. Larger employers, particularly those with **10,000 or more employees**, were found to leverage claims data for a broader range of purposes. For example, **68.8%** of larger employers used claims data to assess plan financial integrity, whereas only **32.1%** of small employers (under 1,000 employees) did the same. This trend continues across various functions including vendor performance management and benchmarking, which saw participation rates of **67.2%** and **78.1%** among larger employers respectively, compared to much lower figures for smaller organizations.

Identifying Opportunities for Smaller Employers

The survey highlights a specific opportunity for brokers working with smaller plan sponsors. Small employers frequently use claims data for basic cost analysis but often lack the resources or expertise to delve deeper into financial integrity assessments, benchmarking, or vendor accountability. This presents brokers with a unique chance to add value by guiding small employers in establishing the necessary infrastructure to collect and analyze claims data effectively.

Regulatory Changes and Future Implications

Recent regulatory changes also play a role in shaping how employers approach health spending. The Consolidated Appropriations Act of 2026, signed into law in February, extends disclosure requirements beyond pharmacy benefit managers (PBMs) to include TPAs and other plan service providers. A proposed rule from the Department of Labor aims to ensure that PBMs and TPAs provide comprehensive disclosures when contracting with self-funded group health plans. This could empower employers by granting them greater visibility into their health spending, potentially leading to more informed decision-making.

Strategic Recommendations for Employers

To navigate the complexities surrounding health spending and claims data, employers should consider the following strategies:

• Invest in Data Infrastructure: Establish or upgrade data collection and storage systems to ensure easy access to complete claims data.
• Engage Third-Party Data Warehouses: Consider using independent data warehouses to enhance claims visibility and usability.
• Utilize Data for Vendor Accountability: Leverage claims data to evaluate vendor performance, negotiate contracts, and ensure financial integrity.
• Stay Informed on Regulatory Changes: Keep abreast of new regulations that may impact data access and utilization, ensuring compliance while maximizing benefits.

Key Takeaways

• Access to claims data significantly influences the health spending strategies employers adopt.
• Employers with full claims access utilize more strategies than those with limited access.
• Size matters; larger employers are more likely to leverage claims data for comprehensive health management.
• Regulatory changes may provide employers with improved access to vital claims information.
• Brokers can help small employers maximize their health spending strategies through enhanced data infrastructure.

Frequently Asked Questions

How can employers improve their access to claims data?

To enhance access to claims data, employers should evaluate their current data storage arrangements. Transitioning to independent data warehouses can significantly improve visibility and usability. Additionally, fostering relationships with TPAs that prioritize transparency in data sharing can also be beneficial. Employers should ensure that data is not only accessible but also presented in a usable format that allows for effective analysis.

What are the main barriers to utilizing claims data for small employers?

Small employers often face barriers such as limited staff capacity and lack of resources to effectively analyze claims data. Unlike larger organizations, smaller employers may not have dedicated teams for data analysis, making it challenging to leverage insights for strategic decision-making. Brokers can play a vital role in providing the necessary support and tools to help small employers overcome these hurdles.

How do regulatory changes affect employer health spending strategies?

Regulatory changes, particularly those related to data transparency, can significantly impact how employers manage their health spending. The expanded disclosure requirements for TPAs and PBMs mean that employers may gain increased access to critical claims data, allowing them to make more informed decisions regarding vendor performance and plan management. Staying informed about these changes is crucial for employers looking to optimize their healthcare spending.

What strategies can employers use to hold vendors accountable?

Employers can employ various strategies to hold vendors accountable, including utilizing claims data for performance benchmarking, conducting regular audits, and negotiating contracts based on transparent data insights. By establishing clear metrics for evaluating vendor performance and ensuring that contracts include provisions for accountability, employers can create a more competitive environment that promotes cost-effective and quality healthcare solutions.