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Managing High Cost Claimants is Employers’ Top Health Strategy

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. 



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