A 6 minute read
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December 12, 2019

What are all-payer claims?

All-payer claims – also referred to as “patient claims” or “claims analytics” – are patient medical claims that contain vital, detailed information about population health and treatment plans, and can indicate clinicians with the highest procedure volumes.


Medical and Rx claims come from patient visit documentation at a hospital, physician group, or other care facility. Claims include diagnosis, procedure, and treatment data – allowing your team to identify gaps in care and find new intervention opportunities.

Claims analytics can give you a complete view of the care landscape, and help you ensure you fully understand your clients and prospects. All-payer claims, specifically, come from private and commercial insurers, including the Centers for Medicare and Medicaid Services (CMS). Below, we’ve compiled some of the ways you can use patient claims to revitalize your sales and marketing efforts.

1. Find your target market

How do you find the patients that could benefit most from your drug or treatment? Where are the physicians serving these populations? What is the best way to gauge the size of this market? Before picking up the phone, your team must answer these questions while planning your go-to-market strategy.

Claims analytics can help you understand how big your ideal market is through diagnosis and procedure information. By using an all-payer claims database (APCD), you can further segment this information by region, provider, and provider type. You can even layer other key intelligence – including comorbidities and demographic information – to garner deep insights about more specific patient populations.

For example, your organization developed a drug or treatment for patients with Alzheimer’s. You can leverage ICD codes and DRGs to determine the base volume of patients with that diagnosis, organized by year, initial diagnosis site, and geography. Then you can use ICD, CPT, or HCPCS codes to find patients who have undergone procedures related to their Alzheimer’s treatment – and, again, organize this information by procedure volume, point of care, health system, and other filters.

Tracing referral patterns is another way your organization can use patient claims analytics to target providers. By pinpointing the clinicians and care centers patients are referred to most often, you can effectively customize your messaging based on the clinical, quality, and financial performance of distinct providers.

Diabetes referral patterns from New York Presbyterian Hospital

diabetes-referral

Fig 1 Image taken from Definitive Healthcare’s DHC Visuals Hospital’s platform, featuring outbound referral volume for patients with diabetes. Data is from CY 2018.

2. Maximize your value proposition

As a pharmaceutical or biotechnology company, your goal is to provide value to your clients – in the form of patient-centric drugs and treatments that lower overall care costs and improve quality performance. Communicating the return on investment (ROI) of your biologic is no easy feat, and you need to know how best to market your product in the most direct manner possible.

In a few words: what does your therapy help achieve?

Once you have an audience with your point of contact, you need to earn their trust quickly to move the conversation forward. Use clear, demonstrable benefits wherever possible—including hard numbers and statistics, i.e. “improves cardiovascular function by 15 percent in 90 days.”

Some questions to ask while crafting your value prop include:

  • Does your drug reduce certain risks?
  • Does your drug pose fewer side effects than your competitor’s?
  • Is your drug fast-acting?
  • Have you demonstrated improved patient adherence?

Your value proposition should contain 4 distinct components: a headline, short descriptive paragraph, key features (in bulleted form), and a visual aid (like a graph or chart). The key here is to give your prospective clients the most compelling information about your therapy up front, so they’re compelled to return for a deeper conversation later. Be prepared to alter your value prop slightly depending on who you’re speaking with – the Chief Financial Officer, for instance, has different priorities than the Chief Nursing Officer.

3. Map patient journeys

What is a patient journey, and how can tracking it give you a competitive advantage?

Patient journey refers to the series of care provisions for a single episode of care, from the initial entry point through final discharge. This includes a patient’s first appointment with a clinician, subsequent encounters with specialists before or after diagnosis, and all following treatments – whether at a hospital, outpatient surgery center, hospice, or other point of care – until final discharge.

Each touchpoint is an opportunity for your organization to introduce your drug or treatment and thereby displace competitors. By tracing patient care routes—and the point at which most patients receive a diagnosis—you can gain a comprehensive understanding of when your treatment would be most effective. This is especially true in cases where patients are misdiagnosed or live without diagnosis for an extended period of time.

Using claims analytics, you can answer vital questions such as:

  • What treatment(s) your patient population is receiving pre-diagnosis
  • Where patients receive care before diagnosis
  • How long it takes before patients receive the proper diagnosis
  • Where patients are referred post-diagnosis
  • How patients manage their conditions, and the associated comorbidities

Alternatively, you could discover which physicians are misdiagnosing patients that end up receiving the diagnosis you’re looking for. Many illnesses share common symptoms, and the length of time spent waiting for the right diagnosis can compromise the effectiveness of proper treatments. Reducing the time spent searching for the right diagnosis can increase drug adherence, improve patient outcomes, and reduce care costs – giving you a solid foothold in the market.

Hospital to long-term care facility referrals by DRG volume

ltc-referrals

Fig 2 Image taken from Definitive Healthcare’s DHC Visuals Platform on hospital referral analytics. Data from CY 2018.

4. Find key opinion leaders

Once you’ve pinpointed the physicians diagnosing high volumes of your target population, you can leverage their experience to improve your sales strategy. Physician leaders and key opinion leaders can act as influencers and consultants, using their expertise to guide your sales strategy.

Key opinion leaders (KOLs) are often clinicians with deep knowledge of their field as well as the wider healthcare industry, including clinical trials and other technological developments. KOLs are most often involved in the later stages of drug development to assist with product branding, campaign messaging, and final go-to-market strategy – but you don’t have to wait that long to utilize them as a resource.

You can engage with a key opinion leader at multiple points during drug or treatment development, including:

  • Research and discovery
  • Clinical trials
  • Regulations and approval
  • Post-approval and distribution

The right KOLs can help you with everything from identifying research areas to conducting the research itself, offering insights on clinical trial design, providing information on the effectiveness of your therapy, publishing papers that name your biologic, and much more.

Physician leaders, in contrast with KOLs, serve more as beta testers and internal influencers at hospitals and other care centers. These clinicians directly impact decision-making at a hospital, and must juggle providing holistic, patient-centered care alongside business and financial interests. With a physician influencer on your side, you can improve the odds that your therapy is adopted.

Key opinion leader profile

physician-profile

Fig 3 Image taken from a physician profile within Definitive Healthcare’s Physicians platform. The featured data includes clinical activity level, prescription activity level, propensity to prescribe brand name drugs, and key opinion leader specialty area.

5. Displace your competitors

Competitor displacement is much easier to carry out in theory than in practice. Clinicians are less likely to consider new treatment options if they already have access to effective therapies, but this change is possible.

Using claims analytics, you can discover which therapies are most popular by specialty, region, or clinician and track these trends over time. This insight allows your team to compare the usage rate and success of biosimilars—which helps you forecast against your competitors. You can also use all-payer claims to understand shifts in market share and isolate market erosion by region, specialty, and diagnosis so you can fill those gaps.

In every patient claim, we capture:

  • At least one diagnosis
  • Procedure and treatment information (including which drugs were administered)
  • Some patient demographic information
  • Rendering physician and care facility

These data points can help you identify where biosimilars are being administered and prescribed in the treatment process, and help you pitch your therapy accordingly. You can also see which drugs have fallen out of favor to ensure that your product doesn’t share any of the adverse effects.

Learn More

Looking for more information on how to expand your market share and improve medication adherence? With access to Definitive Healthcare’s all-payer claims database (APCD), your team can leverage insights and analytics necessary to create and act on an efficient, targeted selling strategy. Using all-payor claims through Definitive Healthcare, you can:

  • Determine target population size and location
  • Analyze physician referral patterns
  • Customize sales and marketing messaging

Watch our on-demand webinar, How Pharma and Biotech Firms Apply Data-Driven Strategies to Sell into Healthcare. In this webinar, you’ll be given detailed instructions (including actual examples from our clients) on how your Biotechnology or Pharmaceutical company can use claims analytics to:

  • Pinpoint your ideal patient population
  • Improve and customize your messaging
  • Discover where patients are seeking care and receiving diagnoses
  • Find physician leaders and key opinion leaders
  • Undercut your competitors

Click the link below to revitalize your sales and marketing strategy.

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