Articles | June 21, 2023

Using Data Analytics to Understand High-Cost Participants

High-cost health plan participants — those whose total medical and drug costs exceed $100,000 — are driving healthcare spending. Typically, they represent less than 1 percent of all participants, but account for about 30 percent of total spending, a share that’s steadily increasing.

Managing cost for high-cost participants and predicting future costs presents a unique challenge because this spending is extremely volatile. Fortunately, from a cost-management perspective, not all high-cost events are unpredictable “lightning strikes.”

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In fact, most high-cost participants have received treatment for one or more chronic conditions and many have steadily progressed along a line of increasing comorbidities, until their health status declined to the point where they required high-cost care. The more plan sponsors understand these characteristics and cost drivers, the better they can align interventions and apply viable management strategies to reduce or mitigate costs.

In an article recently published in the Second Quarter 2023 issue of Benefits Quarterly, we leverage a large, diverse dataset to provide insight into the following:

  • Who high-cost participants are today
  • Who may become high-cost participants
  • What strategies may be available to help prevent or mitigate costs, improve population health and reduce volatility within plan budgets

We look at both high-cost claims (between $100,000 and $1.0 million) and ultra-high-cost claims of $1.0 million and above both before and during the COVID-19 pandemic.

More than half of all high-cost claimants analyzed had one or more of these underlying chronic conditions: diabetes, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease and hypertension. Each of these conditions has well-established lifestyle components, which means there is potential to improve long-term health and manage the risk with a combination of physician-guided lifestyle habits and sound, often less acute medical treatment.

While physical conditions dominate the discussion on high-cost claimants, there is an increasingly common mental health comorbidity among high-cost participants. Approximately 56 percent of high-cost claimants have a diagnosed mental health condition, compared with a rate of 37 percent among non-high-cost claimants. There is also a correlation between mental health and the risk of having a catastrophic event and/or suboptimal recovery after a catastrophic event.

Having a data-driven strategy is important since it provides answers to key questions and gives plan sponsors the information needed to focus their cost-management strategies and evaluate the success of the initiatives they implement.

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Download the article here, with permission from the International Society of Certified Employee Benefit Specialists, the publishers of Benefits Quarterly.

Interested in learning how your data on high-cost participants can help you manage healthcare costs?

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