6 solutions to address high-cost claimants

Paper money in a spiral

While it is clear that high-cost claimants make up a large share of healthcare spending, there are also some promising ways to tackle the issue, according to a new report from the American Health Policy Institute.

Because they are not hampered by a slow political apparatus, employers have led the way with innovative solutions to the problem, it says. Both the public and private sectors would do well to embrace the following ideas:

  1. Engage beneficiaries to be active plan participants, such as offering individual education sessions to explain plan options in detail
  2. Implement wellness programs that target those with chronic diseases, adequately inform participants of their progress and have metrics to allow for evaluation of return on investment
  3. Mine health data to target select chronic conditions and design proactive solutions that cut costs while ensuring individuals get needed care
  4. Develop HIPAA-compliant predictive biometric screening profiles, and create a culture of health at the workplace by offering healthy eating options and onsite fitness centers
  5. Use provider-led, payer-led or purchaser-led care management programs that incorporate care teams to address individuals’ medical, behavioral and psychosocial needs
  6. Draw upon state innovation waivers and Medicaid waivers, which allow the public sector to experiment with provisions such as implementing managed care programs, charging small premiums and using healthy behavior incentives to reduce premiums and/or co-payments

The AHPI defines a high-cost claimant as an individual who costs $50,000 or more annually. The group’s analysis of 26 large employers’ claims data found that the average high-cost claimant costs $122,382 each year, or 29.3 times as much as the average member. Though they represent just 1.2 percent of all members, high-cost claimants make up 31 percent of total healthcare spending for the surveyed employers.

Cancer treatments, heart disease, live birth and perinatal conditions and blood infections are among the costliest claims, the report says, adding that 53 percent of healthcare spending for high-cost claimants is for chronic conditions, while 47 percent is for acute conditions.

These high-need individuals are also expensive for public healthcare programs, the report notes, citing a Leavitt Partners analysis of 2013 Medicare fee-for-service claims data that found the average high-cost claimant costs $105,004 each year, or 12.8 times as much as the average member.

- here’s the report