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Segmenting High-Cost Claimants: Unveiling Insights for Strategic Healthcare Management

Unlock insights into high-cost claimants and optimize your population health strategies with segmented analysis. Dive into cost categories and understand the demographic makeup driving healthcare spending trends.

High-Cost Claimants: Unveiling Insights from Segmented Analysis

"When looking at high-cost claimants, we decided to divide them into cost buckets, or categories. We did this partially because we know not everyone uses the same definition for high-cost claimants. We also did this because we thought there might be more information we could extract from our analysis by segmenting the high-cost population.

Looking at our charts, in both the bar and the donut charts, the blue includes members in 2022 with total plan paid between $50,000 - $99,000. Yellow represents the same for a$100k - $249K. Orange includes members with plan paid between $250K - $500K, and green represents members with total plan paid of over $500K. Looking at the chart on the left, it's not too surprising that the percentage of members who fall into each of these cost categories has gone up over the last few years, which is consistent with the general trend of increasing costs. The donut chart on the right shows the cost contribution of each of the high cost categories to overall costs, it also includes the members with less than $50,000 in spend in purple.

Here we can see the outsize impact on total spending of the high-cost members, particularly for members with annual spend above $250K, these members represent less than 1 in 500, but they contributed 14% to total cost." - Janet Young, M.D., Clinical Advisor

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"As mentioned the earlier, establish your baseline. It's really imperative to understand the demographic makeup of your population, what conditions are driving the spend at various thresholds, and how many remain high cost claimants from year to year. You can use this information to develop your ongoing strategies related to the services that drive the high-cost claims within those various categories.

Whether that's cancer, for example, or other chronic conditions, we suggest that you continue to promote your regular screening exams. Thinking about some of the newer technology that's out there to identify early or more rare cancers, utilizing COEs to help ensure high quality care, or second opinion services to ensure that members are on the right treatment paths.

And then lastly, knowing the facility cost. We saw where even within the highest categories from a cancer perspective, the facility costs were what were driving that threshold, so understanding and using price transparency tools can be useful here as well." - Jennifer Jones, Vice President, Strategic Partnerships & Population Health Practice Leader

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