Small population, large expense: Managing high-cost claimants

One percent of employees account for almost 30% of an employer’s medical spend.1 These are employees and family members with chronic conditions, special needs, and those who’ve faced a catastrophic situation, or have a rare or difficult to diagnose medical issues.

They generate the highest number of medical claims for employers today and present complex health care needs that call for a whole person approach to managing costs, with an eye on strong outcomes and member engagement.

Solutions that address chronic conditions before they get worse or manage chronic conditions may help employers more effectively manage their long-term cost trend. Anchored by digital technology and high-touch advocacy, UnitedHealthcare provides employees and their families support designed to help them find and choose effective options for care.

“When all the pieces are working together in this holistic approach, it’s like a symphony orchestra,” says Dr. Gerald Hautman, Chief Medical Officer with UnitedHealthcare National Accounts. “If you take out one piece, it just doesn’t sound right. That’s why it’s so important to assemble the right team around the employee, and ensure the team is working together for a common purpose, as defined by the employee.”

3 key takeaways on managing complex care needs

  1. 30% of an employer’s medical spend is related to employees dealing with complex conditions.
  2. Due to the high costs associated with complex care, employers are searching for ways to predict and manage these cases among their employee populations.
  3. Efficient and effective care is a combination of technology and personalized advocacy designed to help improve outcomes and lower costs.

A comprehensive approach for complex care needs

For people with complex care needs, such as those with multiple conditions or have experienced a life-changing injury or diagnosis, their needs may be different than the average plan member. They are likely to use the health care system more, and each visit may be more complicated and cost more. 

On average, those with complex care needs are likely to:

  • Generate 5 times more claims2
  • Have hospital stays that are 10 times longer3
  • Use out-of-network providers 11 times more4

For families of children with special needs and adults with complex care needs, UnitedHealthcare provides personal advocates who serve as single points of contact for all aspects of the health care system. Both the Complex Care Concierge program and Special Needs Initiative are similarly designed to help employees and their family members: 

  • Find specialty providers
  • Manage claims and preauthorization issues
  • Connect to community resources

These advocates focus on listening empathetically to understand, drawing on data-driven insights to anticipate needs and finding solutions that often surpass expectations. Employees and their families may feel more supported and confident in their ability to make informed health decisions, which may lead to improved outcomes and lower costs. In fact, the Special Needs Initiative has demonstrated medical cost savings of $1,500 per child, per year.5 

“They [advocates] know the smallest details of a member’s care plan, which helps them proactively direct and problem solve on the member’s behalf. This may reduce waste and improve the member experience,” Hautman says.

Personal Health Support also finds potentially high-cost claimants

Research shows that employees may make less-than-optimal health care choices that have a direct impact on their health — and increase the cost of health care for everyone. What’s more, underlying health conditions and the ability to manage health effectively may be impacted by co-occurring behavioral health conditions. 

These statistics bring the issue into focus:

  • 1 in 4 U.S. adults had 2 or more chronic conditions
  • About 14% of members had comorbid medical and behavioral health conditions in the average population7
  • Claims costs are 2x higher for those with comorbid medical and behavioral health conditions compared to those without comorbid conditions — accounting for 28% of the average total population’s cost of care8

These statistics show that about 1/7 of the average group population accounts for 1/3 of total health care costs.9 If left untreated, behavioral conditions can make recovering from or managing a medical condition more difficult. This can result in suboptimal outcomes and avoidable medical costs.

UnitedHealthcare has the resources and expertise to help employees change for the better. Through Personal Health Support, a multi-channel, proactive engagement solution, is designed to help employees address their health needs and reduce health care costs.

Consider this example of how Personal Health Support reaches out to employees and connects them to effective resources for managing multiple aspects of health. Maria is experiencing abnormal uterine bleeding and her doctor is recommending an MRI.

This outlines a sample journey for an employee dealing with various heart conditions. It details the interactions she has with her nurse and physician as part of the support provided through the UnitedHealthcare Heart Failure disease management program.

The cost of catastrophic care

Effective management of chronic and comorbid conditions may help prevent some employees and their family members from moving into the “catastrophic” category. Of course, not all situations can be predicted or prevented. People could still be in auto accidents, and otherwise perfectly healthy individuals could still sometimes get cancer or other life-changing diseases.

Catastrophic cases continue to rise in cost and complexity and employers are seeking effective ways to predict and manage these cases. Compared to non-catastrophic cases, or those under $100,000, UnitedHealthcare has seen:

  • More money spent on out-of-network care.    
  • 7% of outpatient spend was out of network and 5% of inpatient spend was out of network.10
  • Less spent on care delivered by UnitedHealth Premium® program providers (Tier 1).
  • 24% of the costs for outpatient care occurred at Premium program facilities; 39% of inpatient spend.11
  • More costs associated with outpatient care and pharmacy – with specialty medications accounting for 6% of total cost for catastrophic cases.12

This data has led UnitedHealthcare to develop a 3-pronged approach for Catastrophic Care Management:

Claims management and reporting: Behind-the-scenes work to help to manage costs includes analyzing cost-trend analysis from early intervention and providing real-time reporting to clients to allow for stop loss. Trends and catastrophic cases are also reviewed possibly identifying the need for larger initiatives that should be reviewed or implemented.

Employee/family support: Catastrophic situations are emotional, making the rational elements of care management difficult for employees and their families. Here, an integrated, collaborative clinical team seamlessly supports the employee in areas such as legal assistance, care placement, care monitoring and rehabilitation. 

Data and insights: UnitedHealthcare identifies complex conditions early to build a plan for the employee focused on the right medication, lifestyle, care and provider.

“People need to hear from a physician or caregiver they trust,” Hautman says. “That’s why it’s so important to connect patients to the right providers and to give those providers access to the tools and data they need to make the best treatment recommendations. Employers and insurers should be doing everything they can to use Centers of Excellence and UnitedHealth Premium providers to guide care.”

For more information related to managing populations dealing with chronic or complex conditions, reach out to your broker, consultant or UnitedHealthcare representative.

Controlling costs through payment integrity

Payment integrity solutions combat provider charge issues and optimize claim-payment processing to reduce expenses.

Specialty medications call for specialized cost-control strategies

Integrated medical and pharmacy data, appropriate site of care and customized techniques may help manage the costs for specialty prescriptions.

Footnotes

  1. 2019 UnitedHealthcare National Accounts book of business data.
  2. UnitedHealthcare Commercial book of business 10/2019-09/2020 comparing non-eligible families vs. eligible families.
  3. UnitedHealthcare commercial book of business 10/2019-09/2020 comparing non-eligible families vs. eligible families.
  4. UnitedHealthcare commercial book of business 10/2019-09/2020 comparing non-eligible families vs. eligible families.
  5.  Special Needs Initiative: An integrated strategy to help simplify a complex journey. UnitedHealthcare press release, Aug. 28, 2020. Available: uhc.com/employer/news/midsized-business/member-story--navigating-a-challenging--complex-journey. 
  6. Centers for Disease Control and Prevention. Multiple Chronic Conditions. August 2018.
  7. Azocar F, Bargman EP, Smolskis JM, Groat TD. Enhanced methodology for estimating integrated medical-behavioral costs. Optum® internal report. January 2017.
  8. Ibid.
  9. Ibid.
  10. UnitedHealthcare analysis of high-cost claimants, 2011–2016.
  11. Ibid.
  12. UnitedHealthcare. Internal analysis of fully insured clients with both medical and pharmacy benefits. Fiscal year 2017.

Disclaimer

Tier 1 providers may be subject to change, visit myuhc.com® for the most current information or call the number on your health plan ID card.

The UnitedHealth Premium® designation program is a resource for informational purposes only. Designations are displayed in UnitedHealthcare online physician directories at myuhc.com®. You should always visit myuhc.com for the most current information. Premium designations are a guide to choosing a physician and may be used as one of many factors you consider when choosing a physician. If you already have a physician, you may also wish to confer with him or her for advice on selecting other physicians. You should also discuss designations with a physician before choosing him or her. Physician evaluations have a risk of error and should not be the sole basis for selecting a physician. Please visit myuhc.com for detailed program information and methodologies.

Disease Management programs and services may vary on a location-by-location basis and are subject to change with written notice. UnitedHealthcare does not guarantee availability of programs in all service areas and provider participation may vary. Certain items may be excluded from coverage and other requirements or restrictions may apply. If you select a new provider or are assigned to a provider who does not participate in the Disease Management program, your participation in the program will be terminated. Self-Funded or Self-Insured Plans (ASO) covered persons may have an additional premium cost. Please check with your employer.