A Case Study for Health Plan Leaders: Reframing Women’s Health as a Value Strategy
Updated: Sep 3
Women’s Health Is Already a Major Cost Driver. Most Claims Analyses Fail to Show It.
A patient experiences one healthcare journey. A health plan may record that journey as seven unrelated encounters.
Pelvic pain appears in primary care. Heavy bleeding leads to an OB/GYN visit. Fatigue is investigated through endocrinology. Anxiety is treated through behavioral health. Imaging, pharmacy, physical therapy, and an emergency department visit generate their own transactions.
Each claim may look reasonable on its own. Together, they may reveal diagnostic delay, duplicated services, avoidable acute care, and a costly failure to connect the patient with appropriate care.
That distinction matters because health plans generally direct attention and investment toward the categories that appear large enough to affect cost, quality, or risk. If related spending remains scattered across specialties and service lines, a significant business problem can remain invisible even when every transaction is present in the data.
Women’s health offers a powerful example. The opportunity is not emerging because the category suddenly became expensive. It is emerging because a different analytical lens makes its existing cost visible.
Claims data records transactions, not the reason behind them
Claims data is indispensable to healthcare. It shows what was billed, which codes were used, where care occurred, and how much was charged.
But it was designed to adjudicate payment, not explain a patient’s experience or identify the next strategic opportunity. Claims data functions more like a receipt than a diagnosis. A receipt can show where someone spent money and how much, but it cannot explain why the purchase was necessary, what happened before it, or whether it solved the underlying problem.
The same limitation appears in healthcare claims. They capture encounters after they occur but often fail to show the friction between them:
How long a patient waited for an accurate diagnosis
Whether multiple specialists ordered similar tests
Why a patient sought care in the emergency department
Whether a lower-cost site of care was available
Which clinical observations or disease-severity factors never appeared on the claim
Whether anyone was responsible for connecting the encounters into a coherent pathway
This creates two distinct analytical problems. Some opportunities are present in the data but separated across categories. Others depend on clinical reasoning, provider observations, or patient context that claims never captured. Recategorizing claims can address the first problem, but no amount of recategorization can recover information that was never recorded.
A commercially useful analysis must recognize both limitations.
The way spending is categorized determines what executives can see
Health plans and employers routinely assess major cost categories such as musculoskeletal disorders, cardiovascular disease, and diabetes. Women’s health spending, by contrast, is often divided among reproductive care, endocrinology, primary care, behavioral health, imaging, pharmacy, and other specialties.
The result is an analytical blind spot.
Regrouping spending associated with just three conditions—polycystic ovary syndrome, endometriosis, and uterine fibroids—produced a cost category comparable with total medical spending for other musculoskeletal disorders and approximately half the direct healthcare spending attributed to cardiovascular disease in the sources used for the analysis.
That comparison did not include every condition affecting women. It also excluded broader costs such as productivity loss and some fertility-related expenses. The significance was not that a new expense had been discovered. The same claims had always existed. What changed was the unit of analysis.
The conventional view organized claims around the system: specialties, procedures, and service lines. The reframed view organized them around the patient and the conditions shaping her longitudinal journey.
That shift exposed the mechanisms driving cost. Endometriosis can take an average of four to 11 years to diagnose accurately. One cited analysis found that patients with longer diagnostic delays incurred approximately $13,000 to $34,000 more in the five years before diagnosis than patients with shorter delays. Another found that 71.5% of patients with endometriosis had an emergency department visit, compared with 42.2% of matched controls.
Fragmentation also affects where services occur. A laboratory test performed through a hospital system can cost substantially more than the same test at a freestanding facility. When patients move among specialists without effective coordination, repeated labs, imaging, specialty visits, and emergency care can accumulate before anyone addresses the underlying condition.
Fragmented care is therefore more than a patient-experience problem. It is a total-cost-of-care problem.
Finding the cost is only the first step
Making women’s health visible in the data does not automatically produce better care. It gives a health plan a business problem large enough to act on.
The next question is which levers the plan can use. Health plans can change:
Coverage and network design, including which services are covered and who delivers them
Benefit design, including cost sharing, authorization requirements, and utilization controls
Engagement and access, including how members are identified, educated, and directed toward appropriate care
In the case study, the response extended beyond adding a women’s health benefit. It involved redesigning the experience, coverage, care pathway, and operating model around the patient.
The plan explored vendor partnerships that could help triage symptoms, support diagnosis, guide members to appropriate sites of care, and provide help between traditional appointments. Educational campaigns helped women recognize symptoms and find appropriate services. Coverage changes created a way to pay for coordination that otherwise fell between discrete billable encounters.
This last point is fundamental. If no one is paid to connect care, care is likely to remain fragmented.
Reimbursement is often treated as the amount a clinician receives for a service. In practice, it is the financial engine that determines which services are sustainable, what capabilities providers build, where organizations invest, and which options patients can access.
A code alone does not solve the problem. Coding, coverage, and payment must align. A service can have an established code but still lack coverage, adequate payment, an eligible provider, or a practical delivery model. Changing the patient journey may therefore require more than contracting with a vendor. It may require coverage-policy changes, legal review, state-specific considerations, benefit-document updates, and new operating processes.
That complexity explains why the case began as a pilot rather than a system-wide rollout.
A fundable business case starts with the buyer’s data, not the product
The webinar presented a four-step method for turning a fragmented cost pattern into an actionable investment case.
1. Start with the buyer’s data
Show the pattern in the health plan’s population rather than relying exclusively on national prevalence or cost estimates. Lead with the business problem the plan can see in its own claims, not with a description of the product.
This is where many otherwise promising pitches fail. A founder may explain what the solution does without showing why the issue matters to that health plan, in that population, at that moment.
Accessing plan data can be difficult even for internal teams. Radeva noted that one internal claims request took approximately six months. External innovators should make the analytical request as specific as possible by identifying the relevant population, codes, encounters, time period, and cost measures. Public data can support an initial model, but it should be translated into assumptions that resemble the buyer’s population.
2. Quantify the full opportunity
Engagement is not the same as economic value. The business case should estimate total cost of care, identify a credible measurement period, and show where savings could occur.
Health plans increasingly expect evidence within the first six to 12 months. That makes the timing of outcomes part of the value proposition. A solution that may create value over several years still needs a credible near-term validation strategy.
The webinar cited a propensity-matched analysis in which coordinated women’s healthcare was associated with a $3,429 per-member cost reduction over six months. The reported savings came from fewer specialty claims and reduced emergency and inpatient utilization, illustrating the kind of measurable result a plan can evaluate.
3. Connect the cost to the patient journey
Numbers can establish the size of the opportunity, but the journey explains the mechanism.
Map where diagnostic delays, handoffs, duplicated services, inappropriate sites of care, or avoidable acute-care encounters occur. Then show where the proposed solution fits within existing clinical workflows.
Innovators often underestimate this requirement. A new tool cannot simply arrive with a better standalone experience. It must either fit into the existing care pathway or make a persuasive case for changing the coverage, payment, and operating structures that maintain that pathway.
4. Define the action and the proof
Specify what will change, what the change is expected to be worth, and how the result will be measured. Model the first-year impact, the validation approach, and the conditions required to scale.
For an internal health plan leader, this turns an observation into an investment decision. For a founder, it turns a product pitch into a cost-and-quality case that an internal champion can defend.
The strongest opportunities may be hiding between categories
The analytical blind spot exposed in women’s health is not unique to women’s health.
Diabetes, hypertension, and their complications may appear separately across endocrinology, cardiology, and primary care. Musculoskeletal spending can accumulate across physical therapy, pain management, imaging, and orthopedics before it appears as one connected pathway. Behavioral and physical health claims may be separated even when each condition makes the other more expensive. Nutrition-related risk may surface in cardiology and endocrinology data without nutrition ever appearing as a cost category.
The method remains the same: begin with the patient journey, identify the transactions that belong together, quantify the full cost, locate the breakpoints, and define an intervention whose value can be measured.
For healthcare innovators, this changes the central commercialization question. The task is not merely to prove that a solution works. It is to show where the buyer’s current view of the problem is incomplete, how that blind spot creates measurable cost or risk, and what evidence would justify changing the care pathway.
For health plans, the implication is equally direct. If strategic priorities are determined only by categories already visible in standard reporting, investment will continue to follow the structure of the data rather than the needs of the patient.
The data may already contain the opportunity. The first decision is whether to keep analyzing it as a collection of transactions—or reorganize it around the journey the health plan is actually paying for.
About the Speakers
Stacey Mennillo Dieterle, MBA
Head of Go-to-Market for Bloom at Sword Health
Stacey has spent more than 20 years inside the payer system. Her experience spans women’s health strategy, reimbursement, product development, and commercialization, including building a national women’s health platform that delivered a 10X ROI and $2 million in first-year savings. Connect with Stacey on LinkedIn.
Demi Radeva, MSc
Founder and Chief Strategist at Akros Advisory
Demi has more than a decade of experience across Medicaid, Medicare, and Commercial health plans, including leadership roles at UnitedHealthcare and Optum. She now advises HealthTech companies on reimbursement, payer strategy, market access, and commercialization. Connect with Demi on LinkedIn.
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