As a leader in human resources or benefits, navigating the challenges of rising health costs can often feel like aiming at a moving target. This dynamic is frequently fueled by a handful of high-cost claimants whose extensive medical needs significantly impact the overall expenditure of health plans:
- High-cost claimants are typically defined as the top 1% of members based on total health plan spending
- The threshold to be considered a high-cost claimant surged 15% from 2019 to 2022 – from $78,815 to over $90,929 per individual
- Despite comprising just 1.2% of the member population, these claimants account for 31% of total medical and pharmacy spend among large employers
While it can feel daunting to strike a balance between optimizing employee care and financial stability, the solution lies in a proactive approach powered by data analytics and targeted care coordination. In this article, we'll discuss ways to thoughtfully address and manage high-cost claims.
Gain clarity through data analysis
The first step in understanding the intricacies of the high-cost claimants in your population is gathering and using accurate data analysis. Intelligent, user-friendly analytic solutions can classify claimants by cost thresholds and conditions, illuminating key drivers:
- For example, a recent report found cancer treatment and neonatal intensive care predominating amongst the top 1% of claimants, while conditions needing surgery or specialty drugs drive lower thresholds
- Data can also show cost breakdowns – e.g. facility fees vs. specialty drugs for cancer treatments
- Demographics within categories may reveal affected populations, helping target supportive programs
- Filtering the data can zero on the conditions or individuals that are driving the most cost
Promote preventive care
Armed with intelligence, employers can launch highly-targeted initiatives to mitigate costs proactively, including:
- Preventive screenings to catch disease early
- Wellness coaching
- Chronic condition management programs
- Health education campaigns tailored to identified risks
For instance, since certain cancers account for high costs, increased screening, smoking cessation support, and health lifestyle promotion could reduce the severity of incidences. Controlling risk factors may also prevent conditions needing surgery.
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