A In 2 Tha 022, nk ind You ivi to du als with Members health : This stu care co dy was con sts of $10 du 0,0 cte 00 d o thr more rough twere he EBRI Center most frequen fotly r Resea diagnosed with rch on Hea lth heart Benefits di Insea novation se, nerv (E ou BRI CRH s systemBI), disord with ers, respi the fund ratory ing suppo condirt of th tions, musculo e following o skeletal rgan di izatio sorders ns: , Aon and , Bl hype ue rtensio Cross Blue S n (Figure 2 hield ). Th Association e prevalence o , Johnso f thn ese & Jo cohn ndson itions , JP rem Mor ain gan ed Ch mostly ase, an stable d Ph between RMA. 2018 and 2022. October 2, 2025, #546 The Employee Benefit Research Institute is a private, nonpartisan, and nonprofit research institute based in Washington, D.C., that focuses on health, savings, retirement, and economic security issues. EBRI does not lobby and does not take policy positions. The work of EBRI is made possible by funding from its members and Figure 2 spo nsors, which include a broad range of public and private organizations. For more information, visit Changes in Medical Condition Prevalence Among www .ebri.org. Health Care Spending Trends and Medical Condition Enrollees Spending $100,000 or More Prevalence in 2022 Prevalence in 2018 Prevalence Among Top Health Care Users 53% Heart Disease 55% 47% Nervous System Disorders 47% This is the third in a series of EBRI Fast Facts related to the uneven distribution of health care spending. Health 44% Respiratory Conditions care use and spending are highly concentrated, with a small share of individuals accounting for a disproportionate 43% 37% Muskuloskeletal Conditions amount of total costs. These “high-cost claimants” typically have complex and intensive medical needs, often 39% 35% related to chronic conditions. However, the definitions of high-cost claimants vary, commonly relying on Hypertension 38% 31% spending thresholds or percentile cutoffs. Skin Disorders 30% 31% Cancer 33% This Fast Fact examines two issues in employment-based health plans: (1) trends in the share of enrollees 28% Endocrine Disease 28% exceeding various annual health care spending thresholds and (2) spending patterns among individuals with 25% Mental Health Conditions multiple medical conditions. 23% 23% Diabetes 24% 23% The health care claim Othe s o r f 13.1 to 20.1 million individuals with employment-based health benefits between 2018 22% ® 19% and 2022 were examined using the MarketScan Commercial databases. They contain information on inpatient, Infectious Disease 21% outpatient, and pharmacy claims for workers and 16% their dependents. Kidney Disease 17% 10% Cerebrovascular Disease 11% Key Findings: 4% Pneumonia 6% 3% Connective Tissue Disease 3% • Very few enrollees account for the majority of health care spending among individuals with employment- 0% 10% 20% 30% 40% 50% 60% based health benefits. In the first Fast Fact in this series, we found that 1 percent of enrollees accounted ® Sourc fo e:r 2 EBR 9 percent o I estimates usingf sp 2018end and 20 ing. 22 M era Wh tiveile th Marke average sp etScan Commerciend al Datin abas g e.for this group was $206,000 per person and Note: ICD-10 codes were used to identify enrollees being treated for the various medical conditions. Claims data, while a valuable source of information for health care median spending was $150,000, everyone in this group used at least $96,000 in health care services. research, often undercount the true prevalence of health conditions due to factors like undiagnosed cases, coding limitations, patient access issues, and a lack of • The share of enrollees spending $100,000 or more annually remained stable, increasing slightly from 0.92 percent in 2018 to 0.94 percent in 2022. • Approximately 0.20 percent of enrollees spent $250,000 or more per year throughout the 2018–2022 period. Summary • The shares spending $500,000 or $1 million or more annually remained consistent across years. • The proportion spending $2 million or more increased modestly from 0.0012 percent in 2018 to 0.0014 These findings highlight the persistent concentration of health care spending among a small share of enrollees in percent in 2022, peaking at 0.0016 in 2020 — possibly due to COVID-19. employment-based health plans. Despite some year-to-year variation, the proportion of individuals exceeding high spending thresholds has remained relatively stable over time, and those with the highest costs continue to be Figure 1 predominantly affected by chronic conditions. Understanding the characteristics and health burdens of high-cost Share of Enrollees Exceeding Health Care Spending Levels, 2018–2022 claimants is essential for employers, insurers, and policymakers aiming to design targeted strategies for care Share With Spending management, cost containment, and improved health outcomes. $100,000 $250,000 $500,000 $1 Million $2 Million at Or Above… Sample Size in 2022 122,937 26,153 6,164 1,122 177 Data and Methods 2018 0.92% 0.19% 0.05% 0.009% 0.0012% 2019 0.88% 0.18% 0.04% 0.008% 0.0012% ® We analyzed the Merative™ MarketScan Commercial Database, which contains pharmacy and medical 2020 0.90% 0.20% 0.05% 0.010% 0.0016% claims data on a sample of 13.1 million enrollees in a non-capitated employment-based health plan in 2022. 2021 0.99% 0.21% 0.05% 0.010% 0.0015% The study cohort included individuals under age 65, residing in all U.S. geographic regions, and enrolled in 2022 0.94% 0.20% 0.05% 0.009% 0.0014% a variety of plan types. Using relevant ICD-10 codes from claim ® s, we derived health condition indicators. Source: EBRI estimates using 2018–2022 Merative™ MarketScan Commercial Database. Note: Amounts are in real 2022 dollars. © 2025, Employee Benefit Research Institute, 901 D St. SW, Suite 802, Washington, DC 20024, 202/659-0670 | ebri.org 2 3