High-Cost Claims
Overview
High-cost claims have become the single fastest growing issue for employers in the last several years and have been highlighted as the “most significant threat to employer-sponsored healthcare.” Since 2016, the number of health plan members with claims $3M+ has doubled, heightening sustainability concerns.
Mitigating High-Cost Claims
Addressing a Rapidly Escalating Challenge
The management of high-costs claims is diverse and complex with various stakeholders increasingly conflicted and less motivated to work with self-insured plan sponsors. Market solutions exist in some areas but are unevenly deployed.
The National Alliance is amplifying the employer/purchaser voice through collective action and creating momentum through its high-cost claims initiative. It brings together coalitions and employers from across the country to address emerging issues and challenges.
High-Cost Claims Resources
Cancer treatments, heart disease, live birth and perinatal conditions, and blood infections are among the costliest claims, while 53% of healthcare spending for high-cost claims is for chronic conditions, and 47% is for acute conditions, according to the American Health Policy Institute. Learn more and take action with these resources.
Understanding Cell and Gene Therapy and its Impact on the Workforce
This two-part Action Brief series covers the basics of the fast-growing field of life-changing, life-saving — and costly — cell and gene therapies (CGTs). Learn to navigate the challenges and strategize about how best to provide equitable, affordable access to CGTs.
Employers Beware: Alternative Funding Programs Require Careful Review to Avoid Negative Consequences
As healthcare costs increase, employers and other plan sponsors continue to explore strategies to better manage pharmaceutical costs. Given that prescription drug spending accounts for 18% of all healthcare spending,
such strategies focus on the specialty medications that account for a significant share of that spending. One approach is the use of alternative funding programs (AFPs). AFPs have been gaining traction with employers by marketing strategies that shift the entire financial burden of high-cost specialty medications away from the employer, primarily by directing covered employees to manufacturers’ patient assistance programs (PAPs). This practice comes with risks.
New Directions to Better Manage High-Cost Claims
Rethinking how Employers Address High-cost Claims
Mitigating High-Cost Claims
Mitigating High-Cost Claims: A Closer Look at Hemophilia
Healthcare Affordability
Coalitions In Action
Membership in the National Alliance is a catalyst for state and regional coalitions and their employer/purchaser members to advance key initiatives. Together, they leverage their collective influence to drive health, equity and value.
Nevada Business Group on Health
The Nevada Business Group on Health plays a leading role nationally to keep healthcare expenses down and improve workforce health through better management of high-cost claims. More than 77% of US employers with 500 or more employees say helping these claimants manage their care was important or very important, according to an analysis by Mercer.
HealthCareTN (HCTN)
Advances in medical technology, including cell and gene therapies, along with ACA requirements that remove annual and lifetime maximums, have driven an increase in both the number of claimants exceeding traditional thresholds, and the amount spent for average high-cost cases. HCTN and its leading employers are focused on developing a framework for understanding, preventing and addressing high-cost claims.
