“We’ll Just Use the Claims Data”—and Other Famous Last Words

It’s a phrase we hear a lot in drug policy implementation: “We’ll just use the claims data.” 

In theory, claims data should tell you what was prescribed, what was filled, and how much it cost. In practice, it tells a partial, delayed, and sometimes misleading version of that story. 

What Claims Data Misses

Key gaps? Timing lags, incomplete capture of coupons and rebates, inconsistent coding for indication, and the absence of anything resembling patient context. These aren't just technical details, but structural blind spots that can distort everything from utilization management to policy evaluation. For example, fill rates can be undercounted when third-party specialty pharmacies are involved, or when cost-offset programs mask member cost share. Indication-level pricing analysis? Good luck if you're relying on claims where the ICD-10 codes are either missing or don't differentiate between use cases. 

The Policy Stakes Are Rising

This matters more now than ever. CMS's implementation of the Inflation Reduction Act price negotiation provisions is explicitly tied to metrics like clinical benefit, unmet need, and real-world utilization, yet those metrics can only be interpreted effectively if the underlying data is accurate and comprehensive. Similarly, model participants in ACO REACH and AHEAD are being asked to track pharmacy performance across clinical and financial dimensions. Claims data alone won’t cut it. 

Getting Closer to the Full Picture

The smarter approach? Combine claims with real-time pharmacy data feeds, EHR flags, prior auth outcomes, and structured patient-reported data when you can get it. Even integrating dispensing data from specialty pharmacies or extracting structured data from care management systems can make a material difference. 

From Complexity to Clarity

Through our work, we understand the complexities of linking dispensing data from multiple vendor platforms to a unified quality dashboard, building custom logic for adherence interventions based on diagnosis and therapy class, and validating claims anomalies with case management teams. None of this is easy. But it gets you closer to the actionable truth. 

Proximity Over Perfection

While not perfect, this approach brings us meaningfully closer to the truth, and in drug policy, proximity to the truth is often more valuable than perfection. It enables confident, practical decisions that drive progress.