American health care is expensive — in fact, 17.9 percent of the U.S. economy External Site was devoted to it in 2017, and it's projected to increase to 19.6 percent in the next five years. In dollars, that means an estimated $5.4 trillion will be spent in 2024. But when it comes down to it, health care costs center on a small percentage of high-needs members. This group, known as high-cost claimants (or those whose claims cost $50,000 or more per year), remains the largest driver of health care expenses.
High-cost claimants make up about one-third of employer health care spending, though just 1.2 percent of all members are high-cost claimants. High-cost claimants are 29 times the average member cost. High-cost claimants cost $122,382 on average annually. 47 percent of high-cost claimants have acute conditions and 53 percent have chronic conditions.
Source: American Health Policy Institute.
Earlier diagnosis — and the treatment options that come with that — usually means lower cost of care, and preventive services can keep employees and their families in the know health-wise. Encouraging these important, age-specific check-ins is an important front-line offense for identifying emerging conditions, both acute (shorter duration) and chronic (longer duration or even lifelong). But what happens after that?
Strategies for managing high-cost claimants
News of a new diagnosis can be overwhelming, for both the individuals involved and you as an employer. Improving the experience for these employees and their families, while also mitigating unnecessary costs, is likely top-of-mind. Ensuring your employees are getting the right care — at the right place — at the right time is the first step.
Nationally recognized treatment centers.It's smart to encourage all employees and their families to find in-network, nationally designated facilities to guide their diagnosis and treatment. Blue Distinction® Centers, for example, have a proven history of providing quality care and exceptional results.
Proactive identification.Data can be a guiding source for managing high-cost claimants. Through evaluation and modeling, some plans are now able to share the likelihood that a particular person has the potential to become high cost before claims even begin to accrue.
Early intervention.A full-picture view of a member's health is key, and one way to do that is with medical and pharmacy integration. By getting a clear picture into both treatment areas, proper, proactive management for potential high-cost claimants becomes more streamlined. Additionally, engagement and support programs become more personalized, including advanced care planning and coordination.
High-intensity case management.This is a step above traditional care advocacy, where an assigned case manager continually coordinates care both in and out of the hospital, provides discharge planning and post-discharge programs, and assists with adherence to a personalized treatment plan.
Cost management.Payment integrity and proper stewardship of health care dollars remain a large part of managing high-cost claimants. Frequent, expert review, validation and evaluation of treatments and claims provides another check into the effectiveness of care and benefits. For self-funded customers, integrated stop-loss coverage may also be helpful in managing risk for high-cost claimants.
- https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html External Site
- https://www.shrm.org/resourcesandtools/hr-topics/benefits/pages/managing-high-cost-claimants.aspx External Site
- http://www.americanhealthpolicy.org/Content/documents/resources/High_Cost_Claimants.pdf External Site
- https://www.pcpcc.org/2015/08/12/health-care-benefits-cost-increases-hold-steady-2016-national-business-group-health External Site
Working together to support high-cost claimants
Given the ongoing challenge of increasing health care costs, Wellmark Blue Cross and Blue Shield understands the importance of providing proactive support for individuals and their employers. Wellmark can now detect potential and emerging high-cost claimants through in-depth claims analysis and expert review. Once identified, the case management team continues to monitor these individuals and develops personalized action plans strengthened by a unique mix of support programs, resources and outreach.
This comprehensive, end-to-end high-cost claimant approach — including payment policies, payment reviews and proactive reporting — means better management of the health of your employees and your business. Together, we can thoughtfully manage the health and well-being of your employees and their families.
Questions? Please contact your authorized Wellmark representative, or email us at email@example.com Send Email to learn more.
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