Benchmarking commercial healthcare claims data

Commercial healthcare claims datasets represent a sample of the US population that is biased along socioeconomic/demographic lines; depending on the target population of interest, results derived from these datasets may not generalize. Rigorous comparisons of claims-derived results to ground-truth data that quantify this bias are lacking.

(1) To quantify the extent and variation of the bias associated with commercial healthcare claims data with respect to different target populations; (2) To evaluate how socioeconomic/demographic factors may explain the magnitude of the bias.

This is a retrospective observational study. Healthcare claims data come from the Merative^™ MarketScan^® Commercial Database; reference data for comparison come from the State Inpatient Databases (SID) and the US Census. We considered three target populations, aged 18-64 years: (1) all Americans; (2) Americans with health insurance; (3) Americans with commercial health insurance.

We analyzed inpatient discharge records of patients aged 18-64 years, occurring between 01/01/2019 to 12/31/2019 in five states: California, Iowa, Maryland, Massachusetts, and New Jersey.

We estimated rates of the 250 most common inpatient procedures, using claims data and using reference data for each target population, and we compared the two estimates.

The average rate of inpatient discharges per 100 person-years was 5.39 in the claims data (95% CI: [5.37, 5.40]) and 7.003 (95% CI: [7.002, 7.004]) in the reference data for all Americans, corresponding to a 23.1% underestimate from claims. We found large variation in the extent of relative bias across inpatient procedures, including 22.8% of procedures that were underestimated by more than a factor of 2. There was a significant relationship between socioeconomic/demographic factors and the magnitude of bias: procedures that disproportionately occur in disadvantaged neighborhoods were more underestimated in claims data (R ² 51.6%, p < 0.001). When the target population was restricted to commercially insured Americans, the bias decreased substantially (3.2% of procedures were biased by more than factor of 2), but some variation across procedures remained.

Naïve use of healthcare claims data to derive estimates for the underlying US population can be severely biased. The extent of bias is at least partially explained by neighborhood-level socioeconomic factors.