A small share of individuals account for a disproportionate amount of total health care use and spending, according to a new EBRI report.

These high-cost claimants typically have complex and intensive medical needs, often related to chronic conditions. However, the definitions of high-cost claimants vary, commonly relying on spending thresholds or percentile cutoffs.

The study focused on individuals with employment-based health benefits between 2018 and 2022 who had multiple medical conditions. Researchers examined trends in the share of enrollees exceeding various annual health care spending thresholds and spending patterns. Among the key findings in the report:

  • One percent of enrollees accounted for 29% of spending, which was found in the first fact sheet in the series. Although the average spending for this group was $206,000 per person and median spending was $150,000, everyone in this group used at least $96,000 in health care services.
  • The share of enrollees spending $100,000 or more annually remained stable, increasing slightly from 0.92% in 2018 to 0.94% in 2022.
  • Approximately 0.20% of enrollees spent $250,000 or more per year throughout the 2018 to 2022 period.
  • The share of people spending $500,000 or $1 million or more annually remained consistent across the years.
  • The proportion spending $2 million or more increased modestly from 0.0012% in 2018 to 0.0014% in 2022, peaking at 0.0016% in 2020, possibly because of COVID-19.
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In 2022, individuals with health care costs of $100,000 or more were most frequently diagnosed with heart disease, nervous system disorders, respiratory conditions, musculoskeletal disorders and hypertension. The prevalence of these conditions remained mostly stable between 2018 and 2022.

“These findings highlight the persistent concentration of health care spending among a small share of enrollees in employment-based health plans,” the report concluded. “Despite some year-to-year variation, the proportion of individuals exceeding high spending thresholds has remained relatively stable over time, and those with the highest costs continue to be predominantly affected by chronic conditions.

“Understanding the characteristics and health burdens of high-cost claimants is essential for employers, insurers and policymakers aiming to design targeted strategies for care management, cost containment and improved health outcomes.”

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