High-cost claimants big factor in healthcare spending

So-called “high-cost claimants” may be the key to controlling healthcare spending.

According to the American Health Policy Institute, commercially insured high-cost claimants represent nearly a third of all healthcare spending even though they are only 1.2 percent of commercial health insurance enrollees. Nevertheless, their spending is outsized: Their costs average $122,382 per year--29.3 times as much as other members on average. Such claimants are fighting cancer, heart disease, blood infections or are the result of complicated births.

Despite being older than commercially insured patients or disabled, Medicare's high-cost claimants also consume large amounts of financial resources. The cost of their care is $105,044 annually and cost 12.8 times more than the average Medicare enrollee. About 3.4 percent of Medicare fee-for-service enrollees fall into this category, according to the study--nearly triple the proportion of the commercially insured population.

Such patients have always been big drivers of healthcare spending. "Frequent fliers” in hospital emergency departments can cost the facilities huge sums--and often result in uncompensated care. And care for cancer patients often leads to huge bills, even for patients who have insurance.

“Both the federal government and the private sector need to take a careful look at high-cost claimants. Employers, for their part, are developing innovative approaches to high cost claimants and are in a unique position to establish programs that address this group,” said AHPI CEO Tevi Troy in a statement. These new approaches, coupled with the slowness of our political system to respond to cost challenges, make it probable that employers will be nimbler and faster in developing innovative programs to address high cost claimants.”

The study suggested ways reduce costs, including the use of data mining, more aggressive wellness programs and the use of more Medicaid Innovation waivers.

- read the AHPI study (.pdf)
check out the statement (.pdf)

High cost of cancer treatments puts patients deeply into debt