High-Cost Claims | Employer Health Plans
For a plan of 10,000 members costing the employer sponsor $50 million: 300 people account for $28 million. Understanding who is high cost this year, and who will be high cost next year will help shape critical medical cost strategies.
High medical cost solutions for a working family population warrant targeted strategies. The concentration of expenses for this year’s medical costs is found claimants spending more than $25,000/year. Condition-specific solutions are often required for back surgeries, cancers, neonatal care, extended substance abuse treatment, auto-immune disorders, and complications of hospitalization.
The cost profile for every single high-cost claimant is significant. Employers need to understand what medical conditions, what cost overages and types of medical procedures are driving recent high-cost claim experience.
Employers should prioritize based on two basic criteria: what conditions are prevalent and growing for their high cost claimant cohort, and; what conditions might a carve-out point solutions deliver the greatest results.
There are a growing number of categories where high-cost claimant management and intervention can make significant improvements. Care management, cost management, value-based approaches and negotiated cost solutions should be considered.
This infographic from Wellmark's Blue@Work spotlights the tremendous burden of high cost claims.
SunLife's Annual Stop Loss Report has provided the industry an almanac of high cost conditions that employer plan sponsors need to proactively address.