Figure 2 Prevalence of Health Conditions, Average Spending per Person, and Share of Total Spending 1 2022. This raises a question as to what the threshold should be to define someone as a high-cost Among Individuals With Employment-Based Health Coverage, 2022 claimant or high user of health care services. Percentage of Total Average Spending • Spending on Health Care Services Is Highly Skewed: Very few enrollees account for the majority of Share of Chronic Median Spending per Spending Accounted September 4, 2025, #544 Condition per Person for All health care spending among individuals with employment-based health benefits. One percent of enrollees Conditions Sample Person for by Enrollee With Health Care account for 29 percent of spending (Figure 1). While the average spending for this group thei C s o $206, nditio00 n 0 per person and median spending is $150,000, everyone in this group used at least $96,000 in health care Respiratory Disease 44% $3,000 $11,000 43% services. Heart Disease 32% $4,000 $16,000 46% A Small Number of Workers Account for Most Musculoskeletal Disorders 25% $5,000 $16,000 36% o Five percent of enrollees account for 57 percent of spending. The top 10 percent accounted for 71 Skin Disorders 21% $4,000 $14,000 27% Health Costs — Here’s What to Know percent of spending, and the top 20 percent accounted for 84 percent of total health spending. Mental Disorders 19% $5,000 $14,000 24% Nervous System Disorders 18% $8,000 $22,000 37% The use of health care services — and the spending associated with those services — is far from evenly Hypertensio on As mentioned above 18% , 20 percent of the popul $5,000 a tion typically $ a1 c7 c,ount 000 s for 80 percent 29% of total health distributed across the population. It has long been known that a small portion of the population accounts for a Endocrine Disea cse are spending. Anot13% her point of view is $ t8 ha ,0t0 80 0 percent of the $2 0 popu ,000lation accounts 25% for 20 percent disproportionately large share of health care spending, with 20 percent of the population typically accounting for Diabetes 10% $9,000 $22,000 20% of total health care spending, which means that 80 percent of the population uses no or next to no 80 percent of total health care spending. This is generally true among the population with employment-based Infectious Disease 9% $4,000 $17,000 15% health care in any given year. health benefits as well. Other 4% $14,000 $40,000 14% Kidney Disease 3% $10,000 $33,000 11% Figure 1 Yet, employers often offer health plans that look and feel largely the same to enrollees regardless of the extent to Cancer 3% $12,000 $52,000 16% Distribution of Health Spending, Among Individuals which they use health care services, despite differences in health status, health conditions, and underlying health Cerebrovascular Disease 1% $17,000 $50,000 6% With Employment-Based Health Coverage, 2022 care needs. Pneumonia 1% $7,000 $33,000 3% Connective Tissue Disease 1% $10,000 $31,000 2% High users — often referred to as high-cost claimants, the costliest patients, or top spenders in the health system Percentage of Percentage of A ®verage Spending Median Spending Minimum Spending Source: EBRI estimates using 2022 Merative™ MarketScan Commercial Database. — are commonly individuals with significant, intensive, and complex medical needs. These individuals usually Enrollees Spending per Person per Person per Person Note: Chronic conditions sample is enrollees who had at least one of the 16 medical conditions in this figure. It represents 61 percent of all require ongoing or intensive care for chronic conditions. However, there is no agreed-upon definition for a high- enrollees. ICD-10 codes were used to identify the 16 chronic conditions in the data. 1% 29% $206,000 $150,000 $96,000 cost claimant. Various definitions typically rely on annual health care spending thresholds or percentile-based “Endocrine Disease” includes diabetes. 5% 57% $81,000 $51,000 $29,000 cutof Claim fs. s data, while a valuable source of information for health care research, often undercount the true prevalence of health conditions due 10% 71% $51,000 $29,000 $15,000 to factors like undiagnosed cases, coding limitations, patient access issues, and a lack of detailed clinical information. 20% 84% $30,000 $15,000 $6,000 Average spending for enrollees by condition includes spending on other health conditions. In this Fast Fact, we take a closer look at how a small share of workers drives the majority of health care ® Source: EBRI estimates using 2022 Merative™ MarketScan Commercial Database. “Other” includes liver disease, hemiplegia/paraplegia, AIDS, regional enteritis, ulcerative colitis, and dementia. spending in employment-based health plans. This matters to employers, who have spent decades trying to control Columns sum to more than 100 percent because individuals may have more than one condition. rising health care costs. Strategies have included changing plan designs, shifting cost sharing, and exploring new ways to deliver care. Yet, despite these efforts, the cost of providing health benefits has outpaced inflation nearly Chronic Conditions and Comorbidities: Summary e very year since 1988 — a common benchmark for measuring employer success in managing costs. Examining The the c pr onc eva ent lernc atieon ofof chr he oni altch cspe ondi ndi tions ng shoul is reld atgo ive ha ly nd higih n a ha mnd ong wpe ithopl eva e lw ua ho tions useof a lpl ota n ofde he sa igns lth caand re va serrvi ious ces. poi nt This Fast Fact analyzes 2022 health care spending among 13.1 million individuals with employment-based health solutions as a way to manage the use of health care services and overall spending. ® benefits using the MarketScan Commercial Database. The data reveal highly skewed spending, driven largely by • Sixty-one percent of all enrollees in employment-based health plans have at least one of the conditions in individuals with significant chronic and comorbid conditions. Among enrollees, 61 percent had at least one of 16 The health care claims of 13.1 million individuals with employment-based health benefits in 2022 were examined Figure 2. Total spending for these enrollees represented 92 percent of all health care spending in chronic conditions, and this group accounted for 92 percent of all spending. The top three diagnosis codes were ® using the MarketScan Commercial Database. It contains information on inpatient, outpatient, and pharmacy employment-based health plans in 2022. Average spending among this group of enrollees was $10,831 respiratory disease, heart disease, and musculoskeletal disorders. This Fast Fact underscores the complexity of claims for workers and their dependents. per person, while median spending was $2,820. defining high-cost claimants and calls for a nuanced understanding of health care utilization to inform plan design and cost-management strategies. Key Findings: • Among these enrollees, the most common conditions included respiratory disease (44 percent), heart disease (32 percent), and musculoskeletal disorders (25 percent). Other prevalent conditions were skin A Thank You to Members: This study was conducted through the EBRI Center for Research on Health Benefits • The 80/20 Rule Remains: We continue to find that 20 percent of individuals with employment-based disorders (21 percent), mental health disorders (19 percent), nervous system disorders (18 percent), Innovation (EBRI CRHBI), with the funding support of the following organizations: Aon, Blue Cross Blue Shield health benefits account for roughly 80 percent of overall spending (84 percent to be more precise). hypertension (18 percent), endocrine disorders (13 percent), and diabetes (10 percent). Smaller shares had Association, Johnson & Johnson, JP Morgan Chase, and PhRMA. infectious diseases (9 percent), kidney disease (3 percent), cancer (3 percent), cerebrovascular disease (1 o The issue with such a statistic is that it masks nuances in the data. For example, the 20 percent of percent), pneumonia (1 percent), or connective tissue disorders (1 percent). About 4 percent had other The Employee Benefit Research Institute is a private, nonpartisan, and nonprofit research institute based in the population using 80 percent of health spending are not necessarily high users. While their complex conditions such as liver disease, AIDS, or dementia. Washington, D.C., that focuses on health, savings, retirement, and economic security issues. EBRI does not lobby average annual spend is $30,000, because of few very high-cost claimants, median spending for and does not take policy positions. The work of EBRI is made possible by funding from its members and this group is only $15,000, and some people in this group used as little as $6,000 in health care in sponsors, which include a broad range of public and private organizations. For more information, visit www.ebri.org. 1 Comparing median and mean findings is essential, especially in health care spending data. Because spending data are often highly skewed, the mean can be heavily influenced by a small number of high-cost individuals, overstating the experience of ### most enrollees. The median, by contrast, provides a clearer picture of what a typical person actually spends — making it essential for designing effective health policies. © 2025, Employee Benefit Research Institute, 901 D St. SW, Suite 802, Washington, DC 20024, 202/659-0670 | ebri.org 2 3