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Managing High Cost Claimants is Employers’ Top Health Strategy

July 20, 2018
The sickest 6% of an employer’s population represents 47% of the total allowed medical and pharmacy spend.

Over the next five years, the top health benefits strategy that U.S. employers are looking at is how to “managing and monitoring high-cost claimants,” according to a new study from Mercer.

More than three quarters (77%) of U.S.employers with 500 or more employees said this strategy was “very important” or “important. (These findings come from a recent analysis of responses to the Mercer National Survey of Employer-Sponsored Health Plans, 2017.) 

A study of carrier claims data from Mercer Health Advantage, a program offered through select insurance carriers that features high-intensity care management for the sickest employees, revealed a rapidly growing percentage of claims classified as “high cost” by the participating carriers. 

Generally, a relatively small number of plan members drive a large majority of the cost. According to Mercer’s database containing approximately1.6 million members, on average the sickest 6% of an employer’s population represents 47% of the total allowed medical and pharmacy spend. High touch, nurse-centered care coordination can often produce the best possible health outcomes and as cost-efficiently as possible.

The important difference between standard health advocacy programs and high-intensity care management programs is that the care manager works directly with the care team as well as the patient and family, stays in contact after discharge to provide support, and provides a supportive role in improving compliance with treatment plans.

"There are ways employers can improve the experience of employees and family members dealing with serious conditions while also mitigating cost." said Mercer’s Jean Moore, senior director, Health Specialty PracticesThis can be done by helping to ensure that patients are receiving the right care, delivered in the right place at the right time.” 

Some examples of patient success stories include:

A patient in a car accident spent months in a hospital and then a rehabilitation facility to recover from severe injuries. The patient’s nurse care manager kept in contact with the providers and the family to ensure that the patient progressed through the proper course of care and had a full understanding of his treatment and health status. The nurse also helped him apply for disability and set up care and durable medical equipment in the home when he was discharged. Careful monitoring and follow-up ensured a smooth transition from facility to home and prepared the patient and his family on what to know or avoid to prevent relapse or readmission. 

For an older patient having a hospital admission for hip replacement, the care manager spoke with the member prior to admission to set expectations regarding the surgery and recovery. Once home, the nurse spoke with the patient and her daughter about pain management, proper medication dosage, helped schedule follow-up appointments and arranged for physical therapy to begin at home.  

Another patient credits his nurse care manager with saving his life by convincing him that his chest pain (the onset of a heart attack) warranted a trip to the emergency room for immediate care. 

About the Author

EHS Today Staff

EHS Today's editorial staff includes:

Dave Blanchard, Editor-in-Chief: During his career Dave has led the editorial management of many of Endeavor Business Media's best-known brands, including IndustryWeekEHS Today, Material Handling & LogisticsLogistics Today, Supply Chain Technology News, and Business Finance. In addition, he serves as senior content director of the annual Safety Leadership Conference. With over 30 years of B2B media experience, Dave literally wrote the book on supply chain management, Supply Chain Management Best Practices (John Wiley & Sons, 2021), which has been translated into several languages and is currently in its third edition. He is a frequent speaker and moderator at major trade shows and conferences, and has won numerous awards for writing and editing. He is a voting member of the jury of the Logistics Hall of Fame, and is a graduate of Northern Illinois University.

Adrienne Selko, Senior Editor: In addition to her roles with EHS Today and the Safety Leadership Conference, Adrienne is also a senior editor at IndustryWeek and has written about many topics, with her current focus on workforce development strategies. She is also a senior editor at Material Handling & Logistics. Previously she was in corporate communications at a medical manufacturing company as well as a large regional bank. She is the author of Do I Have to Wear Garlic Around My Neck?, which made the Cleveland Plain Dealer's best sellers list.

Nicole Stempak, Managing Editor:  Nicole Stempak is managing editor of EHS Today and conference content manager of the Safety Leadership Conference.

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