Foundation Models to Unlock Real-World Evidence from Nationwide Medical Claims

arXiv:2605.02740v3 Announce Type: replace Abstract: Real-world data increasingly inform regulatory and clinical decisions. Administrative claims, among their major sources, continuously track care and its cost across providers throughout enrollment, yet remain largely unexplored for healthcare foundation models. Here we present ReClaim, a family of generative foundation models built on 43.8 billion claims records from more than 200 million enrollees in the MarketScan Research Databases. ReClaim learns diagnoses, procedures, medications and expenditure jointly through pre-training from scratch, then specializes for downstream prediction tasks through post-training, with a training cutoff at the end of 2022. In predicting more than 1,000 diseases, ReClaim achieved a mean ROC-AUC of 0.769, outperforming disease-specific gradient-boosted models (0.663) and a transformer-based baseline (0.694), and retained this advantage when generalizing to two independent cross-domain electronic health record datasets. ReClaim also outperformed gradient-boosted models in forecasting next-year expenditure and in identifying high-need, high-cost enrollees. ReClaim maintained its advantage in disease prediction and expenditure forecasting on post-cutoff data (2023-2024). Beyond prediction, ReClaim representations used as covariates resulted in improved effect estimates compared with algorithm-derived covariates, when benchmarked against results expected from randomized controlled trials. Together, these results establish nationwide insurance claims as a scalable substrate for healthcare foundation models supporting disease prediction, expenditure forecasting and confounding adjustment in real-world evidence studies. Code is available at https://github.com/BIDS-Xu-Lab/ReClaim.