Navigating the World of High-Cost Healthcare: Effective Strategies and Insights

Janet Young, M.D., Clinical Analytics Advisor at Springbuk and one of the authors of the 2024 Employee Health Trends report, sat down to shed light on hefty healthcare expenses on the Springbuk podcast. 

Need of copy of the 2024 Employee Health Trends Report? Click here to download. 

Through her interview, Janet describes the journey through the world of high-cost claimants, including: 

• The segmentation of high-cost claimants in healthcare and their impact on total spending
• The importance of understanding the variation in health conditions across different cost categories
• Strategies for managing high-cost claims, including early cancer screenings and leveraging Centers of Excellence

Below, you’ll find highlights and takeaways of the conversation. 

Ready to listen to the full episode? Click here.

Defining the Core Challenge

High-cost claimants are members with exorbitant annual claims exceeding a given threshold, typically $50K or $100K. But with medical inflation exceeding 20% annually, these round thresholds fail to capture the expanding group of members driving a rapidly intensifying concentration of costs.

Key Insight: In 2019, claimants above $50K in spend drove under 44% of total costs. By 2022, the same threshold captured only 1.8% of members while accounting for 46.5% of total spend. Frequently revisiting the high-cost claimant definition ensures focus where it's needed most.

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Mitigate On-going High-cost Claimants 

Among members with over $250K in claims, 60% were repeat high-cost claimants from the prior year. Comparatively, only one-third of $50K-$100K claimants were repeat high spenders year-over-year.

‍Key Insight: Preventing chronic high healthcare utilizers from remaining stagnant in astronomical spend brackets requires proactive continuity of care. Navigating patients to the right precision treatments upfront minimizes costly downturns. Monitoring the highest spenders ensures needs aren't falling through cracks. Reducing repeat high-cost claimant rates presents an opportunity to limit volatility.

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Cancer's Growing Catastrophic Costs

While one-off costly events like childbirth or injuries largely drive lower-cost claimants, chronic conditions define the highest spend. Over 70% of conditions for members with spend exceeding $500K are cancer. Comparatively, only 10% of conditions triggering $50K-$100K claims are cancer.

‍Key Insight: Targeting support programs to diagnose cancer earlier and guide patients to evidenced-based precision treatments can help control spiraling expenses in upper claim bands. Identify prevalence of different cancer types to explore patient-support partnerships tailored to your population's needs.

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Getting Ahead of High-Cost Risks

Over 11% of employees with over $500K in claims costs are actually under two years old. A majority are neonatal intensive care unit (NICU) cases stemming from premature births.

‍Key Insight: While unpredictable, some underlying risks can be mitigated. Multiple embryo implantations used in fertility treatments heighten the probability of multi-birth pregnancies and early deliveries. Enhanced prenatal wellness programs also help minimize complications leading to premature delivery.

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Let Data Lead the Way

Rather than broadly shooting in the dark, data illumination guides smarter aim. The members in the highest spend thresholds few shape outcomes for the broader population. Keeping a focus on managing high-cost claimants is key to giving the full team its best shot at winning on cost containment.

If you’d like to discuss analytics solutions tailored to distilling insights on your highest utilizers across thresholds, conditions, demographics, and more, click here to connect with a Springbuk team member. 

Because in health benefits, like sports, game-changing players determine success.

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Need of copy of the 2024 Employee Health Trends Report? ‍

Click here to download and view other resources. 

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