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The data on commercial risk opportunities (and where the research goes next)

    The health care industry is struggling to move on value-based care, and many wonder what the future will look like. But while progress is slow, Medicare is moving toward risk. Commercial risk is the wild card. Because of this, the future of commercial risk will decide if the industry lives in a hybrid state forever or realigns around a new cost and quality standard.

    After examining the barriers and possibilities in commercial risk qualitatively, we dug into the top opportunities in claims data. Below is our initial analysis.

    The future of value-based care

    Medicare and Medicaid risk is progressing (slowly) — but commercial risk will determine whether the industry tips toward a new cost and quality standard.


    What we did

    Our team analyzed a robust database of commercial claims with nationwide coverage.

    Within the data set, we focused on professional (non-facility) claims to identify the outpatient and ambulatory sub-service lines with the highest spending for commercial patients under age 65 in CY 2019.

    Our team identified the primary procedure or service performed on each claim and attributed that claim to the corresponding sub-service line. We used average, price-normalized commercial rates reported at the claim level as a proxy for cost and spending.

    What stood out to us
    • Surprisingly not on the list: Chronic conditions, surgeries, and prescriptions
    • Evergreen commercial opportunities: ED E&M, delivery, and MRIs
    • Emerging opportunities: Chemotherapy
    • Costs we’d expect to increase if well-managed: Office/OP E&M, immunizations, and genetic and biomarker testing

    Parting thoughts

    There’s another important consideration for determining which opportunities are worth pursuing: the time horizon for savings.

    Due to employee turnover and employers switching health plans, the window for reducing costs in commercial is shorter than Medicare. We’re still investigating this, but early analysis indicates that the biggest opportunities for cost savings are in episodes of care that can be completed before commercial patients switch health plans.

    Commercial risk is the key to industry-wide value-based care, but it’s still an open question. As we dig deeper into this data set, we’re focused on opportunities to inflect cost and improve value. Do you have thoughts on this subject? Reach out to us at

    More commercial claims analysis:

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