Catalysts of Cost: Unveiling the Top Drivers of High-Cost Claims in Employer-Sponsored Healthcare Plans

OBJECTIVES: This study explores drivers of high-cost claims (HiCCs), including diagnoses, claim types, and utilization types, from an employer perspective. It aims to provide valuable insights to assist with clinical and financial management in employer-sponsored plans.

METHODS: A retrospective cohort design using a multi-employer claims dataset from Gallagher Benefits Consulting identified employees aged 18 to 65 whose total paid claims in 2021 exceeded $100,000. Diagnosis categories were extracted using CMS Hierarchical Condition Category codes. Descriptive statistics were generated for diagnoses, claim types, and utilization types (e.g., physician services, hospital outpatient, prescription (Rx), and hospital inpatient). The Wilcoxon signed-rank test identified predictors of paid amount differences for the top 10 diagnoses.

RESULTS: In the study period, 16,461 high-cost clients were identified. Medical claims were 5 times more frequent than Rx. The cost averaged $13,638.40 per claim and $244,600.70 per client, with 126 claims per client on average. Physician services had the highest claim frequency, followed by outpatient, Rx and inpatient. Common diagnoses included Diabetes without complications (DM w/out CC), Cardio-Respiratory Failure (CRF), Morbid Obesity (MO), Diabetes with chronic complications (DM w/ CC), and Metastatic Cancer; Acute Myeloid Leukemia (MC/AML). The costliest diagnoses per client were MC/AML, CRF, Bone Metastasis, Lung and other severe cancers, and DM w/ CC. Medical claims were the costliest claim type, and hospital inpatient services had the highest average per-claim cost. The most prevalent diagnoses were DM w/out CC, CRF, MC/AML, MO, and DM w/ CC. Except DM w/out CC and MO, all top 10 diagnoses significantly predicted higher paid amount differences.

CONCLUSIONS: This study unveils critical drivers of HiCCs, emphasizing the disproportionately higher cost and proportion of medical claims. Cancer and diseases linked to metabolic syndrome emerge as major contributors. This warrants future research on cost-effectiveness of preventative measures for high cost diseases, informing their implementation.