The 6 most common data searches by payors, underwriters, and actuaries

Financial and risk management professionals play a critical role in ensuring that care remains accessible, affordable, and sustainable. Among these professionals are payors, underwriters, and actuaries, each of whom relies on data-driven insights to manage risk, set pricing, and design effective health plans.

But what types of data are most valuable to them? And how do they use these insights to make informed decisions?

Here are the six most common types of healthcare, patient, demographic, and market data sought by payors, underwriters, and actuaries to do their jobs effectively.

Medical claims data & utilization trends

Medical claims data is one of the most valuable resources in healthcare analytics. It’s the raw record of patient encounters: Services rendered, costs incurred, diagnoses, and procedures. Payors, underwriters, and actuaries use this data to understand how care is delivered, where the money is going, and what risks are emerging.

For payors, claims data is key to managing utilization and controlling costs. It allows them to track how often specific procedures are performed, which providers are driving the highest costs, and where there may be opportunities to steer care toward more efficient options. Utilization patterns can inform decisions around benefit design, provider contracting, and care management programs.

Underwriters rely on this data to assess the risk level of individuals or groups applying for coverage. Historical claims patterns can reveal the presence of chronic conditions, high-cost treatments, or trends in emergency department use—all which factor into pricing decisions and coverage terms.

Actuaries take a broader view, using claims data to build predictive models that forecast future costs. These models account for utilization trends, demographic shifts, and emerging risk factors. The goal: Ensure that premiums are set at sustainable levels while maintaining profitability.

With the Atlas All-Payor Claims dataset, you can access the insights you need to shape the future strategy of your organization. Our claims datasets deliver market-level searches for diagnosis, procedures, and prescriptions at the inpatient and outpatient levels, enabling you to dig into overarching trends and comprehensively understand the treatment of your target population.

Provider performance metrics

The unfortunate truth of the healthcare industry is that not all patients receive the same quality of care. And for payors, underwriters, and actuaries, understanding provider performance is critical to assessing and managing clinical and financial risks. Metrics like complication rates and hospital readmissions, both of which you can find in our PhysicianView product, serve as indicators of care quality, efficiency, and potential cost impact.

Payors use provider performance data to guide network design, negotiate reimbursement rates, and implement value-based care initiatives. High complication or readmission rates can signal inefficiencies or gaps in care coordination, driving up costs. Conversely, providers with strong outcomes may be candidates for preferred network status or alternative payment models that reward quality over volume.

Underwriters may examine this data when evaluating the overall risk associated with employer-sponsored plans or specific provider networks. If a population primarily accesses care through lower-performing providers, that can influence pricing decisions and risk projections.

Actuaries incorporate provider performance into their models to better predict future claims. High complication or readmission rates can skew cost forecasts, especially in regions or populations heavily reliant on certain facilities or physician groups. Adjusting for provider variability helps refine assumptions and improve the accuracy of financial models.

Facility performance metrics

Hospitals, whether they belong to a health system or IDN or are independently operated, can vary widely in financial stability, efficiency, and risk exposure. Understanding how these facilities operate, who they serve, and how they perform is essential for risk management professionals.

Payors use facility-level data to assess the overall value of including a facility in their network. Unsurprisingly, hospitals with strong financials and efficient operations tend to deliver care with fewer delays, better outcomes, and more predictable costs—key factors in network management and rate negotiations. A hospital with a heavy reliance on government payors (Medicare, Medicaid, etc.,) may face financial strain, while those with a balanced payor mix often have more operational flexibility.

Underwriters consider facility data when assessing group health plans tied to certain regions or provider networks. Hospitals with high operational risks—such as frequent penalties for readmissions, low patient volume, or staffing shortages—can signal elevated risk and influence underwriting decisions.

Actuaries factor facility performance into cost modeling and trend forecasting. Operational issues at hospitals can drive up claims in certain regions or for specific services. Additionally, shifts in payor mix or service capacity can affect access and utilization, changing the cost dynamics for health plans.

You can access deeper intelligence about hospitals and health systems with our HospitalView product.

Demographic data

Healthcare needs and costs are heavily influenced by who the patients are. Demographic data gives payors, underwriters, and actuaries the context they need to evaluate population risk, forecast utilization, and make strategic decisions around coverage and pricing.

Payors rely on demographic insights to design health plans tailored to specific populations. For example, an area with an aging population may require expanded access to chronic disease management and long-term care services. In contrast, younger populations might prioritize mental health services or maternity care. Demographic data also informs marketing strategies and helps payors anticipate shifts in enrollment.

Underwriters use demographics to assess the baseline risk of insuring individuals or groups. Key factors like age, gender, and geography directly impact the likelihood of claims. Social determinants of health—such as income, education, housing stability, and access to care—also play a role, offering a fuller picture of potential healthcare needs and costs.

Actuaries integrate demographic data into predictive models that estimate future healthcare spending. Trends like urbanization, migration, and income disparity can alter care utilization patterns. Accurate demographic modeling allows actuaries to project costs at both the individual and population level, ensuring that premiums are aligned with expected risk.

As healthcare shifts toward more personalized and value-based care models, these insights are becoming even more valuable for managing risk and ensuring equitable access to care.

Drug and medical device pricing data

Prescription drugs and medical devices are among the fastest-growing cost drivers in healthcare and appropriately pricing them plays a central role in financial planning. Stakeholders need this data to make informed, forward-looking decisions that manage costs and risk without compromising patient care.

Payors use drug and device pricing data to make critical decisions about formulary design, prior authorization policies, and rebate negotiations. By understanding and tracking the real-world cost of implantable devices or specialty drugs, payors can balance access with affordability.

Underwriters need visibility into drug and device spending to assess the financial risk of insuring individuals or employer groups. A population with a high rate of utilization for specialty drugs, for example, poses a greater financial risk, influencing premium calculations and plan design.

Actuaries analyze long-term trends in pharmaceutical and device costs to forecast their impact on total claims. They evaluate how emerging therapies could shift spending patterns, estimate uptake rates, and factor this into premium rate-setting and reserve calculations.

Emerging healthcare trends

Whether it’s the rise of telehealth, the spread of value-based care, the growing popularity of urgent care clinics and ambulatory surgery centers, or the nationwide staffing shortage, the healthcare landscape is constantly changing. More importantly, these trends shape how, where, and what kind of care is delivered, so it’s critical for payors, underwriters, and actuaries to understand (and stay ahead of) emerging trends so they can perform their jobs effectively.

Payors track these trends to adjust benefits, reimbursement models, and provider contracts. For example, the rapid adoption of telehealth forced many payors to revise coverage policies and evaluate its long-term cost-effectiveness. In value-based care models, where providers are paid based on outcomes rather than volume, payors need data on performance metrics, risk-sharing arrangements, and patient engagement.

Underwriters are paying close attention to the increase in mental health service utilization. Behavioral health claims have risen sharply, especially post-pandemic, changing the risk profile of certain populations. There’s also heightened focus on social determinants of health. Underwriters now consider factors like housing instability or food insecurity, which correlate with higher healthcare utilization and costs.

Actuaries are modeling the long-term cost impact of chronic disease trends, such as rising rates of diabetes and obesity among younger populations. These shifts affect long-term claims projections and insurance pricing. Another focus: Climate-related health risks. Actuaries are beginning to account for the financial impact of events like heatwaves or natural disasters, which can lead to spikes in hospitalizations and affect healthcare infrastructure.

Learn more

Data drives every decision in healthcare finance and risk management. With access to accurate, relevant, up-to-date data, stakeholders can give themselves the competitive advantage they need to do their jobs effectively.

At Definitive Healthcare, we deliver the data and analytics healthcare professionals need to make smarter, faster decisions. Our solutions offer deep insights into claims, provider and facility performance, market dynamics, and more—helping you stay ahead of the trends and create more effective strategies.

Want to get hands on with any of the products we discussed in this article or get a deep dive into our data? Start a free trial with Definitive Healthcare today.