High-cost claimants: Strategies to reduce employer health care costs

shutterstock-609134795.jpg

American health care is expensive — in fact, health care spending in the exceeded $5 trillion in 2024 and is expected to grow to $8.6 trillion by 2033. But when it comes down to it, health care costs center on a small percentage of high-needs members. High-cost claimants, or those whose claims cost $50,000 or more per year, remain the largest driver of health care expenses.

Only 1.2 percent of members are high-cost claimants but cost 29 times more than non-high-cost claimant members. High-cost claimants cost $122,382 on average annually. 47 percent of high-cost claimants have acute conditions and 53 percent have chronic conditions.

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).

Employer 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.

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.

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.

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.

Working together to support high-cost claimants

As health care needs become more complex and costs continue to rise, Wellmark Blue Cross and Blue Shield takes a proactive approach to connecting employees with the support they need. Using advanced claims analysis and clinical review, Wellmark can identify employees who may benefit from additional guidance and care coordination before health challenges become more difficult to manage.

Once identified, employees are connected with Wellmark's Case Management team of registered nurses and licensed social workers. These clinicians partner with your employees to understand their health care needs, coordinate services, explain coverage, connect them to appropriate resources and help create a care plan that supports their long-term health goals.

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.

Questions? Please contact your authorized Wellmark representative, or email us at blueatwork@wellmark.com to learn more.