In recent years, there has been a shift in the pharmaceutical industry with more and more specialty drugs being developed for the treatment of rare diseases and other complex conditions. These therapies are often covered under the medical benefit, making legacy data solutions that rely on the pharmacy benefit insufficient for understanding the patient journey.
To address the gaps in coverage, pharmaceutical companies often work with multiple aggregators to procure additional data. Not only are these sources incompatible, they are largely informed by the same upstream data sources, meaning pharmaceutical companies then have to go through a lengthy process of tokenizing the patient records and crosswalking sources together only to find there’s minimal to no increase in coverage. The lack of transparency to sourcing means clients pay two or three times for effectively the same data.
Even when adding other data types, such as closed payer claims and lab results, clients face compatibility issues, as data owners restrict what can be done to reveal elements (e.g., plan name on a closed claim) around their own sourcing. This leaves pharmaceutical companies with either an inaccurate and incomplete view of the patient journey or at risk of supply disruption if parties are combining elements otherwise restricted.
HealthVerity recently hosted a webinar to introduce taXOnomy, an expansive closed (X) and open (O) claims dataset that provides the transparency and accuracy to fill those gaps. If you missed the webinar, here’s a recap:
Understanding the claims gap
There are different touch points throughout the healthcare system — the pharmacy, healthcare provider, hospital, clinic, lab — and each of these areas capture data on the patient’s healthcare journey. For each of these interactions, a claim is created that is frequently submitted to a clearinghouse that then routes the information to the appropriate insurance company or payer. The clearinghouse provides open claims and payers represent closed claims.
Open claims are provider-centric, capturing only that particular physician’s interaction, and have very short lag times, with HealthVerity receiving data daily. Closed claims are patient-centric, capturing every healthcare interaction in the patient’s healthcare journey that is submitted to insurance, but with long lag times.
A number of clearinghouses commercialize open claims data to aggregators, however, there are a few that do not. The information that is not commercialized is inaccessible as a source of open claims and that is why when you combine data assets from different aggregators, you often end up with the same coverage and do not meaningfully fill the gaps. Additionally, if a patient is seeing multiple healthcare providers that use different clearinghouses, there will be claims coming from different open claims sources, creating potential gaps in the patient journey as well.
As an example, if a patient is seeing two different physicians that use different clearinghouses, with one commercializing the reported data and the other not, you will miss the unreported encounter in open claims. In closed claims, both claims would be submitted to the payer and both encounters would be part of the patient journey.
Expansive, exacting, and efficient closed and open claims
HealthVerity taXOnomy synchronizes closed and open claims in a transparent manner, managing data permissions and usage rights, and leveraging lab results to fill in the gaps. This provides up to a 70% increase in coverage for a more holistic view of each patient’s journey, more net new patients and providers, and broader market reach.
Expansive
The fully interoperable and HIPAA-compliant HealthVerity data ecosystem consists of eight open claim suppliers, one of which is unique to HealthVerity, and four closed claims suppliers, representing the largest collection of closed claims in the industry. This allows taXOnomy to offer expansive coverage of over 324 million patients. The closed claims data and lab results that we incorporate add unique signal to the open claims and provide significant coverage of the medical benefit to support sophisticated commercial strategies.
A snapshot of the patients, National Provider Identifiers (NPIs) and healthcare activities averaged across 2020 - 2023 shows the advantage in diversifying sources in this way:
| Closed claims + open claims + labs | Open claims + labs |
| • Patients - 324 million | • Patients - 275 million |
| • NPIs - 4 million | • NPIs - 3 million |
| • Healthcare activities - 29 billion | • Healthcare activities - 17 billion |
Exacting
As the table above demonstrates, open claims and labs only provide a fraction of the healthcare activities that define the patient journey. By adding closed claims, taXOnomy offers a best-in-class solution that provides up to a 70% increase in coverage of healthcare activities, including more patient, provider and procedure data. This allows pharmaceutical companies to better prioritize outreach with improved decile analyses powered by higher NPI and healthcare activity counts.
With taXOnomy, we can pinpoint providers geographically with a five-digit zip code and patients with a three-digit zip code. This enables precision targeting of patients and providers. The superior coverage informs commercial strategies, allowing pharma companies to accurately communicate and promote to the necessary stakeholders.
Efficient
When you consider this dataset consists of over 324 million patients, the sheer volume of records would be unmanageable, but we have curated the data across closed claims, open claims and lab results into a simplified model. This streamlined model de-duplicates and organizes the data into nine focused tables representing patient, provider and activity insights.
The payer table includes the name of the payer for open claims, providing insights into payer decisions for developing market access strategies. There is also a separate table for LOINC (Logical Observation Identifiers Names and Codes, used as an identifier for lab results), that along with the additional diagnoses and NPIs from the lab data can power triggers and alerts. And as the only data provider to offer lab results from both Labcorp and Quest, which covers 70% of the market, this can add significant signal.
With daily triggering reports and weekly data deliveries for open claims plus lab signal, and monthly data deliveries for our comprehensive, longitudinal view of closed claims, open claims and labs, taXOnomy also offers speed to insight and outreach.
HealthVerity taXOnomy is HIPAA compliant and privacy certified. The privacy certification extends to any data that will be added on in the future. Additionally, it can be licensed under a single contract, with HealthVerity managing the relationship between the suppliers.
With this expansive, exacting and efficient approach, taXOnomy can provide the massive amount of information needed to accurately measure the market and understand healthcare trends with a fully interoperable, transparent and privacy-compliant dataset.
Increase medical benefit coverage
As mentioned earlier, drug development for complex disease states is moving utilization away from retail pharmacy claims to medical claims, making medical benefit data imperative. To demonstrate how taXOnomy provides these insights, we looked at Keytruda, a successful anti-neoplastic drug for oncology. When comparing open claims to closed claims between 2021 - 2023, we see that open claims only provide part of picture, representing only 60% of the total volume of patients taking the drug:
| Medical | 2021 - 2023 |
| Closed claims | 96,000 patients |
| Open claims | 120,000 patients |
| Total | 206,000 patients |
Our unique closed claims add 40% new signal for research and commercial applications.
Increase coverage of diagnoses
When looking at the prevalent chronic condition type 2 diabetes, open claims, again, only tell part of the story. By synchronizing closed claims, we can close the gaps in medical history and provide a robust platform for comorbidity studies and label expansion research. The table below shows where a diagnosis of type 2 diabetes overlaps and is found in both closed and open claims, but closed claims provides 50% more unique diagnoses in just one year:
| Medical | 2023 |
| Closed claims | 269 million diagnoses |
| Also in open claims | 105 million diagnoses |
| Unique to closed claims | 135 million diagnoses |
Increase coverage of providers
Every provider counts, especially for rare diseases like myasthenia gravis where each case is unique and tough to diagnose. Combining closed and open claims increases the count of NPIs needed for precise provider engagement and best-in-class decile analysis. The example below shows providers treating myasthenia gravis that can be found in both closed and open claims and that closed claims provide 50% more unique providers that are not found in open claims. This increase allows you to target the right providers at the right time with greater accuracy.
| Medical | 2023 |
| Closed claims | 15,182 NPIs |
| Also in open claims | 4,684 NPIs |
| Unique to closed claims | 7,601 NPIs |
Increase coverage of healthcare activities
Breast cancer is a complex, multifaceted condition and diagnosis is just the beginning of the breast cancer patient’s journey. There are a number of touch points in a patient’s care that are not limited to one provider or specialist, which means open claims only provide part of the story. The addition of closed claims adds 54% more unique healthcare activities. Closed and open claims provide the foundation for the development of novel screening and treatment approaches and taXOnomy can be seamlessly synchronized with genomic data and electronic medical records to further develop the patient journey.
| Medical | 2023 |
| Closed claims | 9.9 million activities |
| Also in open claims | 3.2 million activities |
| Unique to closed claims | 5.4 million activities |
Next-best action
As these use cases demonstrate, taXOnomy provides an opportunity to inform next-best actions by providing extensive, timely and streamlined insights that allow you to make practical and tactical decisions across the product lifecycle — from R&D with site selection and recruiting patients to enhancing trigger programs and developing commercial strategies.
