Healthcare generates unimaginable amounts of data. The World Economic Forum has reported that a single hospital can generate 50 petabytes of data each year; that’s enough to fill 11 million standard DVDs. Unfortunately, 97% of that data never gets used, robbing clinicians and health plans of valuable, even vital, information about patients.

It doesn’t have to be that way. Consider the example of two fictitious, but representative, 70-year-old twins, Maria and Rosita. Both have multiple chronic conditions, as do most of their peers, and both have recently joined new Medicare Advantage plans.

But there, the similarities end:

• Maria’s plan knows nothing about her health history until April, when she goes to the doctor for a checkup and routine labs. That means it can’t assign her a care coordinator or enroll her in a diabetes-management program for a third of the year.
• Rosita’s plan has access to two years of her lab results through Quest Member Insights. By February 1, it has already assigned her a care coordinator and begun sending her educational materials about managing her conditions.

In an age of capitation and value-based care, health plans must work harder than ever to offer tailored support to higher-risk members with chronic conditions. That can be hard to do when you don’t know anything about your members’ health history at enrollment. Since up to a third of consumers change health plans each year, health plans are potentially in the dark about millions of commercial, Medicare and marketplace plan members.

“Health plan members sometimes feel like they’re ‘nothing but a number,’” said Kirk Loveless, Health Plan Executive Director of Healthcare Analytics and Solutions at Quest Diagnostics. “The truth is that health plans often don’t have access to the data to provide care that’s personalized to the member’s health status.”

A window into a patient’s health

Lab results, which inform roughly 70% of healthcare decisions, offer a good window into a patient’s health history. Unfortunately, it can take months for the data to start flowing.

Quest Diagnostics data show that members typically complete their first lab test about 83 days after their effective date of eligibility. But it takes even longer for health plans to access clinical information because claims must be submitted and adjudicated before the clinical data can be ingested into their systems.

That’s where Quest Member Insights pre-enrollment data comes in. As the leading diagnostic company in the nation, Quest Diagnostics holds data on more than 90% of insured lives. That includes more than 76.1 billion lab test results that span 15-plus years. On average, the company has 111 lab test results per individual over a two-year period. By accessing that data, health plans like Rosita’s can get a head start on providing better, more targeted guidance.

A wealth of advantages

When health plans access — and act on — pre-enrollment lab data, members benefit in several ways:

• They can get early support in managing their conditions and risk factors.
• Gaps in care can be identified and filled in.
• The personalized care they receive can help reduce their long-term healthcare costs and improve their quality of life.

Health plans benefit as well:

• Healthcare costs can decrease over time as members become healthier.
• Pre-enrollment data can identify any unrecorded health conditions and inform disease diagnostic codes to better reflect hierarchical condition category coding (HCC) and risk adjusted factor (RAF) scores. This can lead to more appropriate payments for member healthcare coverage.
• Closing gaps in care for new members can lead to improved HEDIS® measure scores and STAR ratings.
• An improved member experience can lead to higher CAHPS® scores.

“Health plans are more successful when their members are more successful,” Loveless said. “What’s more, a member who is satisfied with their health plan is more likely to renew, reducing churn and allowing the plan to benefit from the investment it has made in care coordination and disease-management programs.”

To learn more about how Quest Diagnostics data solutions and services can help your health plan gain a clearer understanding of its new members’ health, visit Quest Diagnostics® | HAS Pre-enrollment Data 2025.