In the seminal paper “It’s The Prices, Stupid: Why The United States Is So Different From Other Countries,” Uwe E. Reinhardt and his co-authors concluded: “The United States spent considerably more on health care than any other country, whether measured per capita or as a percentage of GDP. At the same time, most measures of aggregate utilization such as physician visits per capita and hospital days per capita were below the OECD median…U.S. policymakers need to reflect on what Americans are getting for their greater health spending. They could conclude: It’s the prices, stupid.”
There is a corollary that applies to employer attempts to manage health care spending: “High-health-cost claimants are where the spending is, stupid.” Generally, 20 percent of the population account for 80 percent of total spending on health care services. Yet employers offer health plans that in large part look and feel the same to plan enrollees whether they are high users, moderate users, or low users of health care services even while targeting high users will have the biggest bang for the buck. Of course, high users are the most challenging population to address.
This study examines the concentration of health spending among individuals with employment-based health benefits as well as persistency in those expenditures over a five-year period. The data on use of health care services, health conditions, and spending for this study come from claims on 5.8 million policyholders and dependents with employment-based health benefits who could be followed for the entire 2013–2017 period.
- Twenty percent of the population accounted for 84 percent of total health spending, 10 percent of the population accounted for 70 percent of spending, 5 percent accounted for 56 percent of spending, and 1 percent accounted for 28 percent of spending.
- When it came to persistency in high-cost claims, 27 percent were in the top 10 percent of spending in at least one year, while 73 percent were never in the top 10 percent. Among the 27 percent who were ever in the top 10 percent, 21 percent were in the top 10 percent only one or two years, 4 percent were in the top 10 percent three or four years, and only 2 percent were in the top 10 percent each of the five years.
- The 5.8 million individuals examined in this study used $38 billion in health care in 2017. The 2 percent of the population in the top 10 percent of spending every year between 2013 and 2017 accounted for 19 percent of total spending in 2017. In contrast, the 73 percent of the population who were never in the top 10 percent of spending from 2013–2017 accounted for only 20 percent of spending in 2017.
- The characteristics of the persistently high-cost claimant group were different from the characteristics of the population never in the top 10 percent. Individuals temporarily in the top 10 percent of claimants had characteristics similar to those in the top 10 percent for all five years studied. Sixty-three percent of those persistently in the top 10 percent of claimants, as well as 59 percent of those in the top 10 percent three or four years, were ages 50–64, compared with 30 percent among those never in the top 10 percent. Persistently high-cost claimants were also much more likely to be the spouse of the policyholder. We found that 32 percent of those in the top 10 percent of claimants all five years were the spouse of the policyholder, compared with only 16 percent among those never in the top 10 percent of claimants.
- One-third of individuals persistently in the top 10 percent of claimants had diabetes. Among individuals in the top 10 percent of claimants for five years, 51 percent of those with diabetes also had hypertension, and about one-quarter of those with diabetes also had respiratory disease, back problems, and/or connective tissue disease, among other less prevalent conditions.
- Not only did individuals persistently in the top 10 percent of claimants spend more on health care than those temporarily in the top 10 percent and those never in the top 10 percent, the distribution of spending varied as well. Outpatient services, such as diagnostic services, accounted for 46 percent of total health care spending for those never in the top 10 percent. Prescription drugs accounted for 26 percent of total health care spending, and office visits to primary care physicians and specialists accounted for 18 percent. In contrast, among those in the top 10 percent for all five years, prescription drugs accounted for 52 percent of total health care spending, outpatient services accounted for 29 percent, and office visits accounted for 3 percent.
- Inpatient services accounted for 27 percent of total spending for those in the top 10 percent one or two years and 22 percent among those in the top 10 percent three or four years but only 15 percent among those in the top 10 percent in all five years. This suggests that one-time events that individuals recover from, such as knee and hip replacements, drove more of the spending for those temporarily in the top 10 percent than those persistently in the top 10 percent. Similar findings emerged for outpatient surgery and diagnostics.
EBRI Issue Brief
Oct 24, 2019
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Seven of the 17 conditions receive a weight of between two and six. G hig their were lead oldb hs - cos to o ab er ut g et al overu le t clai - pe of to rs -po fo ist mants .sck ,llow from ently e 2017) et (OOP) of , the ch health in the top . 2013 m c aract are services aximum. – 10 2017. erist peics r cent of Th Thos of , e next whi pe eo ch cl acco pl d aim four er w ives uantin it colu nts h p up i , as well as g ers mns for the nsur ist d ent ance ivi h de hi i gh 59 p gh t ph est r-e emiums cos ercent ssampl pe t claims, nd e and of ing into thos a w mak ere nd spe e ies cov di nd n mo fth fer ing cate se t li ences era top kely ge 1gories i b to reach 0 perc less etwee afford ent n 201 n the thos three abl 3 ir , w e e. Ow or OP ith ho (EBRI). M. Christopher Roebuck is president and CEO of RxEconomics, LLC. This Issue Brief was written with assistance Cost-sharing will have limited effectiven Nevee r is n To s in p 1 chan 0% gin Ing Top 1 the0% way indivi In Top 1 du 0% als with In Top 1 larg 0% e claims use health care. Hence, a Consume Copay r-me Dire nts cteor Coi d He Figure alth nsura 14 Plan nce (CD , 200 HP), 2–2018 2007–2018 Spending Is, Stupid” 80% Distribution of Population Distribution of Spending Figure 8, Sample Means, 2013 .............................................................................................................................. 10 1 or 2 Years 3 or 4 Years All 5 Years Health Conditions in 2017, Within Patterns of High-Cost Claims From 2013–2017 the are pers maximum, first colum ist four entl wh yea ich y and tempo n conta rs coul , we d be inin re ages g no ra the rily h more th 50 me – igh ans for 64, -cos comp an t c $ indivi 7,1 laimants are 50 d wi du pe als i rth . p T n ers 3 he next se 0 the bott on perce in 2017 nt om ction amo 90 (Fi ng d pe gu esc t rce re hos ribe 7). nt of e nev sFor in t the he d er h s in ata in tance, amon ealt the h more tcar op e 10 perc sde pe g tail. th ndi e ent. n 5 T g distr perce he Pers sect ibu n ist io t of tion ently n employers from the 7 In a sn tit d ute’s r insurers esear will ch need to co and editor nsid ial ser taffs. other Any v ways ie ws ex in which press the edy in can e thisng rep age ort hi are those gh-cost c of laima thents au.t hors One and shoul option is to d Spending by Type of Health Care Service, Within Patterns of Prior work has defined high-cCom ost claim orbid ants as ities those in the t Among Diabet op 10 percent of h ics in Top ealth care 10 Perce spen nt ding (Long et al., 2017) Spending Within Patterns of High-Cost Categories Average Copaym F en ig t ure 9Average Coinsurance 73% Our f Employ i60 nd ers % $3 ing 0 cou s have imp ld reduclicatio e spens for t nding by e he ef limi fenating spous ctiveness of th al coverag e Cadillac e. tax We or any found form of that 33 perc a tax ent that of w th oos uld e cap pers the istent e 25x % lclusion y in Anderson, G 20% erard F., Uwe E. Reinhardt, Peter S. Hussey, and Varduhi Petrosyan. "It’s The Prices, Stupid: Why The By Paul Fro 18.6% nstin, Ph.D., Employee Benefit Research Institute and M. Christopher Roebuck, and following the t pop he ufar hig lation prh esents rig -cos ht accounti -t clai han our d mants f co ng fo inlum din w gs. r 5 n er conta 6 Th e percent al e silast nin o much g se o the f ction in tot mo me alr spendin ans for e l cludes ikely in to be t g, a d dib vi isc etw du uss hals i e een ion spouse n 60 of the an the of to d 70 th p key 1e perce pe pol implic rce icyhol nt reac nt of ations de spendin r. hed the f or W p e u fo gbl .ir un ic Clearly, OOP d poli tha maxi cy t .32 thos m percent e um in, not be ascribed to the officers, trustees, or other sponsors of EBRI, Employee Benefit Research Institute-Education and requ Figure 9, ire orS e am ncpl ourage e Mean an s, H yon ee alth cons Con idere dition d as l, 2 arg 013 e cas ................................ e to meet with a cas ................................ e manageH r ior to use gh-Cost C w ................................ ah te at g are becomi ories ng known .. 11 (Figueroa, Zhou, and Jha, 2019). of Health Spending, 2013–2017 Never in Top In Top 10% In Top 10% In Top 10% CDHP (HDHP with Health Savings Account or Health Reimbursement Arrangement) Octobe r 24 70% , 2019 • No. 493 Sample Means, Health Conditions, 2013 $26.81 the of em top pl 10 oy United men pertcent of - States based cl h Is aim ealth So ants Di bff e w nef erent er its e F to re throm e spouse o du Other ce Pr u em C sie f um ountries. th o If h ne p creealth a olicyhold ses" Hea care ser W lth er, co orkAf evices r fairs E mpared arn. in 22 g W s e fou I, n with o cno. 3 ( reasnd es t nly May hat at 2/Ju O 0 perce ve a rne 2003) any ll In fpoin lnt ati among on t: i89 n time, – those 105. an d $26.50 the and Ph. h D 70 ig ., – h RxE 8 er sp of 0 per thos e con nd cent of e i inomi n g grou the those cs, top 10 ps LLC in the were percen mo top re t of 1 p likely to c elaimants rcent o bef older sall pending reach five , femal years e, a were ed nd th the the eir spo poli OOP cy us maxi hol e of der t mum he polic or s.pouse o For yholder, thof se the comp reachi policyhol ng th ared with de eir r. 50 18 % % 16.7% Never in Top In Top 10% In Top 10% In Top 10% as Researc concier h F ge un services d (EBRI.- ERF), As ad vo or their cates staffs. , case m Neither anagers EBRI or c oncierg nor EBRI es- ERF help pati lobbients es or tak navies positions gate the healt $25.89 on h scare pecifi sys c p tem olicy so that 17.1% Percent with Health Condition Within Patterns of High-Cost HDHP (no Health Savings Account or Hea 10% lth Reimburs1 e me ornt 2A Ye rrang ae rs ment) 3 or 4 Years All 5 Years 8 52% $25.04 46.0% ov neve Whether or not emplo er a r in five the -ye top ar p 1e 0 perc riod, yers h ent ea ulti lof th care mately claima cost supp ntss . ort N were ot long after a M conce edicare b ntr ated the uy-in propo ACA amopass ng a sal erelatively d, will s depen ome em small percenta d on o $24.77 ployers ther f an acto nou ge rs as nc oed f wel the they p l an owere pu d the latio goin overall n. In g Figure 10, Length of Time in Top 10 Percent of Spending From 2013–2017 and Distribution of Total Spending 10% $24.31 1 or 2 Years 3 or 4 Years All 5 Years OOP maxim They weronly e su lim, g 1htly le 6 cos perce t-sssnt amon harin likely g to be is i g n thos l e arge nro e nev part lled in er in th Hy ipe ne h rte ealth ff ns ective e t ionop pla1 in ns wi 0 perc chath ng en h ing b it of gh de ehavior claimants ductibl be es, .ca e uith se epati r healt ents h n ro eimb long urs er ement 51% have any proposals. EBRI invites comment on this research. they get the right care in the right setting at the right time. They can help coordinate C care ate f gor or i ie ns dividuals with 16$2 % 5 $23.77 43.7% Brot-G 45old % berg, Zarek C., Amitabh Chandra, Benjamin R1 . 4Handel, .7% $23.34 and Jonathan T. Kolstad. "What Does a Deductible Do? 50% Age Total Health Care Costs Percentile impact of the health benefits 18.6%plan that they offer. 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Dhig emh e- ncos tia t claimant, many will have been part of the majority of individuals who are more sensitive to cost-sharing. 0.02% 0.1% 0.2% 0.4% var Figure 15, ious healt 15% He 4.5% halth cond Spe itions. ndin g in The 2 CCI 017, Withi rangedn from Patter 0.1 ns of amo High ng t-hos Cose t Clai in thms e botto From m20 89 1 percent 3–2017 ................................ of health spending to ....... 1.7 17 20% 20% DC iayears h gro no ns ic t of i c ob eli stru gic bility tive p . ulmonary disease 6% 18% 5% $444 11% $1,768 13% $3,625 15%$4,361 20 2% % 18% 19% 2014 2015 2016 2017 2018 2019 2020 20% Non-Traumatic Joint Disorders $18,000 16% th 25.5% In Elixhau order to ser, for address A., thos C. e n Ste l eve ar iner, ge r i c n and L. P la the ims top 10 , emp almer. p loyer erc "Clini ent s w.ill ne cal Pres Cl ed cription as to sific focus ations drug on Sof s di acco s tea wa unte sre e prev (d CCS) for ention ." 20 26 pe 1 and rc 3.ent care ma of totanl ageme health nt. ca 25.2% re Our Several The Whilre e i th s Med a ese cor ic patients ollary that are buy may r -in pro app ep ach th lies to osals wer eir employ ma e ixi ner attem m tro um OOP, t duced pts to in th heir prior e manage 116 Con ex healt pe grress ience h care . Sen. w spe ith De cos nd bibi ng t-e s :harin Stab “High 23.9% enow g -an heal d eng (th D--MI) cos age and R t claima ment t eools p. nts Bri i are n an Camo hronng ic o tbhos stru e ctiin vethe pu top lmon 1 p ary e drcent iseas, su e ggesting that those in the top 1 perc 23.6% ent wer23.4% e more likely to have multiple R heumatoidM da is le ease 15% 52% 5% 41% 9% 40% 15% 44% 18% 1% 22.2%0.3% 2% 5% 5% 4% Surgery $111 $1,278 $2,218 $2,273 Repo 10 rt % Availability: This report is available on the inte 20.3% rnet at www.ebri.org 0% 19.9% Figure 16, Health Spending in 2017, Within Patterns of High-Cost Claims From 2013–2017 ....................................... 18 $5 findings o spe n ind ndi ing vid,uals w and of ith pers fice visist itsently to primary large care claims ph ar ys e icians a a case ind s n poi pe ncia t. One lists- ac hal counte f of them ha d for 18 percent. d hypertens In $ion 16 ,contr 3 an 00 das one t, - 17.6% ge whe In ne the rral may e s th emina e sp tr elnd p anslat a in pe g r is, e “It’s to stupi the Thd.” ie r care Pric Gees, neral de Stu cision ly, pid: Why 20 s once t percent The U hey r of t e nited States he popu ach their lation ma Is xi account So Dif mum OOP, fere for nt 80 percent po From tentially Other h of el Co t pi ota n untries,” g l th spe em to tak ndi Uwe ng on E. e Higgins (D-NY) both introduced proposals to expand eligibility to Medicare to individuals ages 50 and older who are not Pe conditions ptic ulcer. When looking at CCI 15.9% components, those in the top 1 percent of spending were most likely to have been R heumatoid disease Nervous System Disorders 0.2% 0 14% .1% 1% 1% 1% 0.2% 0.3% 1% $ 4% 15,800 10% Female 48% 59% 60% 56% 14.1% Figure 8 Chemotherapy $0 $272 $1,138 $1,648 $16,000 12.9% Figueroa, José F., Xiner Zhou, and Ashish K. Jha. "Characteristics And Spending Patterns Of Persistently High-Cost 10% th third had -2%amo diab ng etes thos , an e d in on the e- top half 10 of tp heir ercent spend for ing was as all five years sociated , prescription with prescript drugs ion dr accounte ugs.d A for focus 52 pe on rcpr ent eventio of tota n l may hea lth Reinha 5% rdt and his co-authors concluded: “The United States spent considerably more on health care than any other health yet eli longergible care to reac f se orh rvices the it. p The use . Yet rogram. em o pl f The -fi 1 oy .nancia 1% ers se p of ro l fer posals rew health ards for wepl re ans e also ngaging in heal th intr at in oduce largd in e par thy tt look an he 115 behavior d fee Con prior glres the to be s. same to The com Higg ing a pins p lan high ero nrolle -posal costes claimant MThi di ildag ls iv study nos er ded ise w w as it aes h cond cancuct er (2 ed2 p through the ercent), di EB abeRI tesCe (18 nter pefor rc 0en .1 Researc % t), andh c on hronic 0 H .0 ealth Ben 5 % obstructive efits p 0 Innovat .ulmonary 3% ion d (ise EBRI as 1% eCRH (COPD) BI), (1 with 5 1% the 10% 8% $14,700 Pe Fip gture 17, ic ulcer Health Spending on Diagnostics and Outpatient Surgery in 2017, Within Patterns of High-Cost Claims From 0.1% 0.4% 1% 1% Medical supp Medi lies, car dev e icPat es,ie ants nd d ." ura Healt ble m h e Af difairs cal e q 3u 8, 4% ip S m no. a em n 1 (Ja t plenuary Mea 20 n1s 9): 107 , 201$32 – 3114. $14 $281 ,300 $800 $1,508 th Renal Disease 13% reduce sp care sp endingending, on not outp just h ati ype ent rtens services ion and account diabe etes d for in 29 thepe lon rcg e nt, an term b d ut of on ficeot vis he its r cond accounte itions d as for w 3 perc ell sinc en e t. 6% Dwhe country may iabeth t al es er th s , whet (w o imp ith ey oa r her are h ct care with me o igh users uas t d cured ec om isions pl i, moderat pe catr c af ionapi ter s) ta in e or di us via ers du s a als r , or l percenta each ow u th sg ers eir e of of ma GDP. At healt ximum h t care services OOP. he same time, ev mos en wt meas hile tarur geting hi es of aggregat gh users e will introduc funding sup ed ipo n trt of he 115 2% the follo Cong win res gs org could aniz hav ations e pot : Aon entiall He y 5% w im itt, Blu pacted e Cros emplo s 4% Blue yment Sh-ib eld As ased 15% h sociatio ealth ben n, ICU efitBA, JP s 16% givenMor thegan 18% percent) -4%. When it came to other health conditions, individuals in the top 1 percent of spending also had hypertension $13,700 $02013–2017 ........................................................................................................................................... 0% 18 0% 4% Mild live $1 r 4d ,0 is 00 ease 4% 1% 3% 6% 8% Policyholder 43% 57% $13,200 59% 57% Dialysis 3% $0 $29 $462 $1,344 3% hypertension 20 and 02 di 20a 03 betes 2004 are oft 2005en as 2006sociated 2007 20 w 08 ith 20 ot09 her 20 di10 seas 20 es. 11 In 20the 12 short 2013 t 20 er 14 m, employ 2015 20ers 16 wil 2017 l nee 20d 18to work Hutili emizatio ple0% gia n osr uc p 20 a h 07 raas pl eph gia ys 2008 ician visits 2009 per ca 20pit 10 a and 20 h 11osp0ita .120 % l days 12 pe 20 r capi 130.0ta we 2% 2014re belo 20w 15 0 the .2% OECD 2016 medi 0 20 .an 4 17 %…U.S. 20 18 2% s have th Chase, pecific Merc ity of e biger t gest he , Mil b leg liman, an islativ g for t P e fihe buck. lzang er, an uage d P O . hRM At t f cohe urs A. tim e, h 2%e, th igh use e propos rs are al th inc e mo luded lang st challeng uaging e that w populoation to uld hav e add allo ress wed . employers (33 percent), 1% respiratory disease or infections (30 percent), dyslipide $mia 12,70 0( 28 percent), back problems (24 percent), and Fronstin, Paul, and M. Christ Cancopher er (Non-M Reta oe sbu tatic c or M k. "The Cost etastatic) of Spousal H 10%ealth Coverage." EBRI Notes vol. 35, no. 1 D iabetes (with or In w Top 1 ithou 0% A t colm l 5 p Yliec ars ations) In Top 10% 3 or 4 Years In Top 10% 1 or 2 Years Never in Top 10% • Inpatient services accounted for 27 percent of total spen4% ding for those in 11% the top 10 perce 26% nt one or two y33% ears Network management is crucial when it comes to addressing high-cost claimants. Employers and insurers will need to Rawith diatiot nheir the h ra Co p ea v ye lth p red lSp ans an oused other partners to implement care 16% engagement$0 25% programs that $175 29% help individuals 32% $298 navigate the $262 R enal disease 0.4% 0% 1% 2% 6% policymak 0% ers need to reflect on what Americans are getting for their grT eater otal health Health s C pe an rdi e n Cg. osT ts hey Pe could conc rcentile lude: It’s to pay premiums on behalf of eligible individuals if enrollment was the choice of the individual. The Higgins proposal connective tissue disease (24 percent), among other conditions. $12,000 (Employee Benefit Research Institute, January 2014). Source: Mercer, National Survey of Employer-Sponsored Health Plans, and Bureau of Labor Statistics. Source: Medical Expenditure Panel Survey Insurance Component (MEPS-IC). and Sou 22 p rIn ce: paF ti ercen ien gut Hos re 11 t among pi in tal https://w those w E w me .cdc rge i .go nc n vy/nc t he Depa hs/d to rata tme p 10 /nh nt is /pe earrce lyrelnt ea Offi se/ thr ce ins V ee o ur20 isits18 r f 1our 1.pdf years and OF utp igu ati bu re en 3 t on ti S n erly 15 vices percent amon Prescription Drug g thos s e in the Hemiplegia or paraplegia continuous Employ ly ers ev h aluate whic ave been tryin h health g to manage h care provid ealth ers ar car e e incos their networ ts for 0.de 04ca %kde to ensure s. Attempted that 0.3% p cos atitents -contr hav ol m e 1% access easures inc to thlude e m 2% ost Cancer (non-metastatic or me thtastatic) health care system so that they get the righ Ost car teoarte hrit in is th 2% e right sett 10% ing and 1% avoid wasteful 4% care as much as 8% possible. 22% Oth the er oprices, st utpatie C no t v s ue e pi re rv d. d ic” e C shildren/Other Dependents 41% $252 17% $1,12% 921 10% $4,531 $7,395 introduced during the 116 Congress does not include such language and is otherwise silent on the issue. pNote =2htt 01 : ps 9 Data ://w dat w a no w it s .cc dc p ol ro l.go ec jeted v c/nc te id n hs .20 /da 07 ta/n . his/earlyrelease/insur201306.pdf Total 0 – 89th 90th – 94th 95th – 98th 99th – 100th Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. top 10 Source: pe Erc mpl en oyt in ee B a enll five efit Res ye earars ch Ins . ti Thi tute ses stiu mgges ates ba tss that ed on ad one mini-sttr ime e ative en ve rolnts lmen th t an at in d claidi mvid s dauals r ta. ecover from, such as knee M Reff o ed ne a icra l ient a combi dtie s/e s a provi es ve enation rede livrs er of id ni s or pl ea de an se r t des o minimi ign/cos ze t-sthari he amo ng chan unt of ge 0 was .s 0 th 3%at teful healt affect h0 o h c .w 01 are mu % ch p utilizat ed ients . E 0mployers .1pa % y out and of pock insurers 0.2% et for health may also 1% 0.3% 1% 4% 7% T Loabl ng, P e eter of C et al ontents . Effectiv e Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Presc ription $1 D 0,0 ru 00 gs $485 $2,313 $10,144 $34,177 Mild Liver Disea Ns= e5,842,978 N=5,258,680 N=292,149 N=233,719 N=58,430 10% and hip replacements, drove more of the spending for those temporarily in the top 10 percent than those AIDS The cons re care serv id ier s a n cor ew and em ic ollary that es ander ot gi app her ng lies to s provider tructural ch employ arraang ner attem gees to the mentspts such a 0 deliver .to 1% manage s h y of igh-h pe healt ealth rfor 0.0h 2 car mance % care e spe mo networ re nd gi0 e ng .ner ks 3: % , accountabl “High ally. Yet, -heal in th m e 2% -cos care ost t claima years nts1% are While there are many factors to consider, to the degree individuals ages 50–64 with employment-based health benefits CFin ancedings on Persistency r (non-metastatic or metastatic) in Spending Washington, DC: National Academy of Medicine, 2017. 1% 6% 12% 10% Introductio n .......................................................................................................................................................... 5 Prescription drug spending from pharmacy claims $419 $1,896 $8,365 $28,024 Type of Health Plan $8,150 Age $7,900 33 32 41 42 44 Other Chronpe ic rs Co ist nently ditionin the top and Sele 10 ctedpe CrC cent. S* Similar findings emerged for outpatient surgery and diagnostics. wherse ince the 1s988, th pendine g cos is, stupi t of p d.” rov G idi eng h neralealth ly, 20 b pe enef rcent its to 0% o e f tm he popu ployees 10% lat and th ion account 20% eir depe for 3 nd 0 % 8e0 nts percent has incre 40% of tas ota ed 5l 0 % smo pen re than ding on 60% s organiz witched to t ationsh , e and Me di dicare rect con program, th tracting. e average cost of health benefits in the workplace would fall. As noted above, we $8,000 Moderate/severe liver disease About one-quarter (27 percent) of the 5.8$ mil 7,350 lion enrollees followe 0.0d 1% from 2013–201 0.1% 7 in this study0 .wer 4%e part of the 1% $7,150 Specialty drug spending from medical claims $9 $194 $1,126 $4,918 Data ................................................................................................................................................................... 10 HMO/EPO 13% 13% 12% 12% Indicators: $6,850 overall inflation. From 2009 to 2018, health insurance premiums increased 42 percent, compared with a 23 Quan, H. Us health ing cl care Un aims det al e se r data 1. " 3 rvices Co fdi rom . n Yet g 2 $Al 60 em ,go 617 on 00pl rithms oyers 5.8 f of or mfer ill De ion health finin indiv g Comorbi id plu ans als w 19% thd iat in th e ities in m larg pl ICD oy e par men 21% -9-t look an CM and ICD t-based d fee health 6% -1 l the 0 bAdm e same to nefini itss , w trat 5% ep i fo ve Data. lan und that enrolle " 5% M es 20 ed ical found that individuals ages 50–64 account for a disproportionate share of high-cost claimants. Overall, they account for Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. $6,350 cohort in the top 10 percent of spending in at least one year, while three-quarters (73 percent) were never in the top AIDS 0.01% 0.1% 1% 5% Figu Figu Figu Figu re re re re 17 1 4 21 OH th ye pr en rto en n-s sip oe ncialty drug spending from medical claims $56 $223 $652 $1,235 Ultimately, employers and insurers will need to provid10% e good informat8% ion around thes 21% e programs. W 26% ithout educational 33% percent iPP ncrea O/PO se S in worker earnings and a 16 percent inc 56% rease in inflati 61% on (Figure 1). 66% Today, premi 66% ums for whe Findith ngs on Pe er th Care ey 4 are h rs 2, no. istency in igh users 11 (N Sov p , moderat end ember ing ................................ 20 e 0us 5): 1 ers, or l 130–o 113 w us 9.ers ................................ of health care services ................................ even while targeting hi ...................... gh users will 12 55 perce pent of rc $6ent ,000 the of t p ota opl ulation health 7 ac spcounted ending. f Thi ors 84 percent finding alone of t m ota ay caus l health e em spend ployers ing, 1 to sup 0 percent of port a Me the population dicare buy-in accou proposal, nted for 13–17 9% 10% 5% 4% 5% 10 percent (Figure 10). Among the 27 percent who were ever in the top 10 percent, 21 percent were in the top 10 Other Chronic Condition and Selected CCS* Indicators: Dyslipidemia Ave He Pe ra alth Large ge rcentage A Spend nn Empl ual in of Emplo oy g Botto er on s’ Diagno y T m ee op 90 -11% On He Pe stic ly alth rc and Fa s a ent Ca nd of U re 10% mily Ou Inse iti tpatient Surger ativ rs De Wh du es 23% ctibl o B for 202 ec e, am A0 mong ye in 25% 28% eff orts, high-cost claimants will not know about these services and thus will not use them. Financial rewards may also 8 employee-only and family coverage average $7,188 and $20,576, compared with $4,824 and $13,375, have th 70 percent e big og f s est pe b nd an ing g for t , 5 perc he buck. ent accoun Of coted for urse, hi56 per gh usecent of rs are spe the mo ndis ng t challeng , and 1 perc ing pop ent ul acco ation to unted add for ress 28 p . ercen t of especially if th HR ey Aare able to pay premiums on behalf of thos 19% e opting out of 17% employment- 15% based coverage 15% for Medicare. Ho perce w Can nt onl Empl y one oy ers or an two d In year surers s, 4 perce Addres nt sw Lar ere ge in Cth laims e to? p 10 perc ................................ ent three or four ................................ years, and only 2 pe ........................ rcent were in the 19 18–24 6% 7% 4% 4% 3% Sc hizophrenia/bipolar, depression, anxiety, mood Hypertension 2 Whaley, Christopher W 20 M., orke 17 Lan , rs W Vu ith in , Ne High in Priv eraj Pa ate So -tter Cost od, -Se ns Mich ctor Claim of ael High E. Ch Es ants tabli -er Cost new in shme 9% ,Fo Lea Claim llnne o nts With wM is From 20 ng etcalf Y 21% ea e, a De and r At 13 du eev M – ctibl 2017 32% ehrotr e, a. "Paying 35% help get patients more engaged in their health care decisions. A recent study found that paying patients (by sending Implement More Virtual Care Solutions (e.g., Behavioral Health, Physical Distributio res n $4 o pe ,0f 0ctiv 0 Speely, ndi in 2 ng 009. Despite the efforts to manage expenditures through a combination of cost-sharing and spending (Figure 6). HSA-eligible health plan 11% 9% 7% 7% ditop 10 sorderspercent each of the five years. Therapy, Digital Coaching, Condition Management, Medical De6% cision 5% 14% 16% 51% 17% Implications 25–34 Patients for the To Cad Switch: illac T Im ax pact ................................ Of A Rewards Program O 11% ................................ n Choice 10% Of Prov ................................ iders 13% , Prices, And12% Util ........................... ization." Health 6% 19 DThi yslis p study id 7% emia examines the concentration of health spendin 2002 g amo –2018 ng individuals with employment-based health benefits as them a check) who used lower-cost providers reduced the prices paid for health care services subject to the program delivery system changes, why does Neve i r it a n To ppear that p 10% In e Top 1 mplo 0%yers11% h In Top 1 ave failed 0% at In Top 1 control 21% 0% ling spendin 31% g on health 34% Inpatient Hospital Support, Sleep) 1% 27% 22% 15% Sp ondylosis, intervertebral disc disorders, other Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. 1 or 2 Years 3 or 4 Years All 5 Years Affairs 38, no. 3 (March 2019): 440–447. $2,000 wel by 2. l as 1 perce persist ntency in (Whaley thos et al. e expend , 2019) itures . Finaov ncial er a five incent -ye ive ar p s may b eriod. e n Th ee e d deata d to on us increas e oe f h pat ealth ient care enga services gement, h inealth their u se of Sc C honclusio izo cov p35–49 hre erage nia/b and in po lar, care? depre ssion, anxiety, mood disorders30% 29% 33% 35% 33% Employee-Only Coverage Family Coverage Implications for Medicare Buy-In Proposals ................................5% ................................ 10% ................................ 18% ........... 20% 20 ba The od ck prob ds of lems going from a low user to a high user of health care services in any one year were relatively low. Six Emergency $4 D ,00 e0 partment 6% 5% 8% 18% 4% 21% 3% 24% 2% More Focused Strategy on High-Cost Claims 39% 30% Note: HMO=health maintenance organization; EPO=exclusive provider organization; PPO=preferred provider 6% conditions, and spending for this study come from claims on 5.8 million policyholders and dependents with case managers and/or COEs. Sp ondylosis, intervertebral disc disorders, other back problems RHealth car heuma50–64 toid e art sh pri end tis a ing ten nd relads t ted o b dise ea conce se ntrated: about 25% a quarter of i23% ndividuals were 38% in the top d 40% ecile of spendin 47% g in at percent of 6% individuals who were in the bottom 90 percent 0.4% of spen5% din0 g mo .2% ved into th 12% e 1% top 10 perce 23% nt the 4% following year 26% 3% Office Visits organization; POS=point of service; HRA=health reimbursement arrangem 18% ent; HSA=health sa 6% vings account. 4% 3% Conclusion .......................................................................................................................................................... 20 $0 Implement an Engagement Platform That Aggregates Point Solutions and $3,396 $3,392 employment Em ployers are -b taking notic ased health benef e. A rec itsent who surv coey f uld ou be f nd that ollowed a more for the focus entir ee d 2 s013 trat– e2 gy 017 on pe hig rio h- d. cos t health care claims ranked Figure 6 M N least ulot only d tiple one $3 s ,50 cl0 e year ro ids in is, w divid hile uals pers three-qiuarters stently in w the ere nev top er in th 10 perc e 0ent .to 2% p of declaima cile. Am nts 0o .0 spend more ng 2% those eve on r 0in 26% .2 h % th ealt e top h car de eci th le 1% an , athos bout e1 in 5 w 7% as R(hFi egu umra et o 1id 1). art O hnly ritis 3 a percent nd relate dmo disved ease into the top 5 percent of spending, and less than 1 percent moved into the top 1 Self-Only Coverage Other Than Self-Only Coverage 0.1% 1% 2% 8% Pushes Personalized Communications to Employees Primary care physican 10% 2% 1% 1% nd Refe rences .......................................................................................................................................................... 22 2 in a list of top health care initiatives for 2020 among large employers (Figure 2). A better understanding of the Regional enteritis and ulcerative colitis 0.3% 0.1% 1% $3,069 2% 4% temporar there only ilyon ine the or two top 10 years pe, rcent a 4 percent nd t wer hose e nev in the er in th top e t decile op 1thre 0 perc e or en ftour (Fi years gure 15 , a)nd only , the dist 2 perce ribution n t we of spendin re in thg v e top arie d percent of spending. M ultiple25 s% clerosis 24% 0.01% 0.1% 1% 6% Male 49% 50% 38% 39% 44% Spe Key Findi cialist ph*ng yA s E s is x c r p : e ia an qn ud ir Cen ed bters y th of e P E ax tic ee nltl en Prc oe t tec o I tio nn c la ud nd e A Add fforid tia ob na lel Co Cand re iti Ao cns t (A (e.g CA) .,, out-of-pocket (OO8% P) maximums are set 3% by the U.S. Department3% of 2% Imp5% lications for the Cadillac Tax $2,871 charact There were erist sli icsgh oft ind difiv fere idua nce ls swho by typ are e not of pl just an. high Only- 2 cos 2 percent t claimants of t b hos ut e pein rs the istently top 10 percent high 26% -cost c of laima claimants nts is ne al ed l ed five for years Lower/$3 up ,00 pe 0r respiratory disease/infection 11% 10% 20% 22% 30% de as Endnotes w cile ell. in Out all ................................ pa five tient servic years. The 2 es, p such erc ................................ ent as di of ag th ne ospo tic serv pulation p ices, ................................ ers acco istunte ently i d n for the nearly o to................................ p de ne cil-ehal of f s(pe 46 p ndercent) ing ac ............................ counted of total healt for 19 h care 22 Health and Human ServicesCa . O nc O er, Inf P maerti ximliu ty m )s are lower for health-savings-account (HSA)-eligible health plans and are set by the Internal Endnotes Distribution of Health Spending, Among Individuals With Employment-Based R egional enteritis and ulcerative colitis 0.1% 0.5% 2% 5% Outpa tienF t e Se mrv aR ilc e ee ves nue Service. 51% 50%46% 62% $2,640 45% 61% 40% 56% 29% The exc were enro ise tax lled in on an h HRA igh-cos ort HSA employment -eligible h -b ealth plan, ased health wh pereas lans (a 30 ka pe the rc ent Cadi of llac those tax) nev is a p er in th rovision e to ip n 1 the 0 perc 2010 ent Patie were nt AOvera employers sthma/ll, CO th PD a e 5. n , d a 8 c hmill u ealth te ion bro p nind la ch ns to d iiv tisiduals etermi examin ne what ki ed in thi nd s stu s o2% f s dyervices used $38 and int bil2% lion i erventio n heans lth might be care i 5% n 201 help 7.f ul The 2 to 6% impl perce eme nt o nt.f the 8% s pe pe rce ndnt of ing for tot tal hos spe e nev nding in 2017. er in the top In 10 contr percent ast, the 73 (Figur p e e 16 rcent o ). Pres f cri thptio e popul n dration ugs acco who u w nted ere for never 26 i pn e the rcent o top f de totcal ile health in $2,491 • Twenty Targe perce ted Snt of pecial the ty Pha p rma opulat cy Man ion agem acco ent (e unt .g., S ed ite-of for -C84 per are, cent of total health spending, 10 percent of the Figures Lower/upper respiratory diseaH se e /ia nfletc h ti oC n overage, Continuous Enrollment in 2017 9% 15% 25% 22% 26% DT iaProt h g yn ro os iection dt ic disord an ers d Affordable Care Act (ACA). When the ACA passed in 2010, 24% the Cadillac tax, 14% a nondeductibl 11% e 40 percent 7% enrolle $2,50 d in 0 such a plan. TIn his depmay enden i t ndica Specialte ty P that harmather cy) e is2% some degree o2% f plan $2,322 selection r 6% elated to high7% deductibles and 6% population in the top 10 percent of spending every year between 2013 and 2017 accounted for 19 percent of total care sp spend 2 4% i0 ng ending % from, w 2013 hereas –20 17 a officcco e vis unted for its to pri o mary nly 2 care phy 0 percent sicians an of spendi d nsg pecialists in 2017. accou nted for 18 percent. In contrast, 1 $2,220 population accounted for 70 percent of spending, 5 percent accounted for 56 percent of spending, and 1 Co-authored with Gerard F. Anderson, Peter S. Hussey, and Varduhi Petrosyan (Anderson et al., 2003). In this paper, we examine the concentration of health spending among individuals with employment-based health Asthma/COPD, acute bronchitis Endocrine disorders 1% 1% 1% 3%3% 6% 4% 9% 4% excise t expect Figure 1, ed ax im u Pre semium Incr p of osed he on alth the eas care por es Amo services tion of ng Em . h In eapl ot ltoy h her wor cov ers With erads, t ge 10 or cos hos ts e that Mor who e e exc Em xpe ee plct oy ds $10,2 to u ees, Wo se h 00 for ea rker Earni lth c sing are servic le ng cov s, a era nd es ge I di nfl a sproport nd $ ation, 27 ,5 iona 00 tely for Surg spe ery nding in 2017. In contrast, the 73 percent of the population who were n 6%ever in the to 10% p 10 percent of s7% pending from 3% Policyholder 47% 46% 57% 58% 55% among those in the top 10 percent for all five years, prescription $1,975 drugs accounted for 52 percent of total health care percent accounted Im f plor eme28 p nt High ercent o -Touch Cof nc sip erge ending. or Nav igation 21% Percentage Who Nbe 2 ervne oufits. s sy s W te e ma lso diso exami rders ne persistency in spending over a five-year period. Examining the concentration of health $2,000 2% 1% 6% 10% 20% Tfamily cover hyroid disorde ag rse, was scheduled to take effect in 2018. It has since been delayed twice and is currently scheduled to are more Our f See Figures 6. inding l19 ike s8 h l8 y to self ave – 4 an 201 import d 6.5 i 9 ................................ -select ant n https:/ iimpli nto health /w catio ww. ns fo pl kff.ans with org/ r p ................................ ureport blic more p-ol sect icy. compre io Our r n/ehbs esults hensiv - 2% ................................ 2019 s-e ug sectio cov gest era n that -6ge -wo . 4% ta H rker ow xin -................................ ever, t g and he -emplo alth hos be eyer 7% inef n -co tits he ntributio , suc top 10 ............. h as ns -7% for- 6 2013–2017 accounted for only 20 percent of spending $1,761 in 2017. ChemotEm hera plp oy y ers have not limited their efforts to patient cost-s3% haring when0% it comes to manag 2%ing their costs 3% . They 3% spending, outpatient services accounted for 29 percent, and office visits accounted for 3 percent. Covered Spouse 19% 18% 28% 30% 32% Med $1,658 ian Average Minimum Reached Their Out-of- 3% Osspe teo nd art ing an hritis d the persistency of such spending is as important in evaluating the efficacy of the movement to higher 1% 1% 4% 7% 10% premiums/ through pe takrce e ef 15 nt of fect % the cl i C nai 20 adi mants Im 2 llac 2. ple me tax, At t may be nt hat Hi w ghill -poin P b b erfor ett e i t, t m n er of an lhe port ar ce N ge f fina etwo pa ion rnciall rt ineffect ks or A of h y ccou ea in nta lth tive in re he H blec Care ov SA erage -du elicin gi cost bg ag le h sealth plan that gregat excee e us bec e ds $11,2 of ause of healt 00 for si h the car l e oswer n ervices gles coverag tat.utory Even e if OOP and En docrine disorders 14% have adopted various types of insurance and delivery systems 1% , which now inclu 2% de health mainten 3% ance $1,846 4% • When it came to persistency in high-cost claims, 27 percent were in the top 10 percent of spending in at least Medical supplies, devices, and durable medical equipment 2% 2% $1,808 2% 2% Percentage of Percentage of Spending per Spending per 17% Spending per Pocket (OOP) Covered Children/Other OD rga e np ize ati non de s in n S tselect Markets 34% 36% 15% 12% 14% Figure 2, Large Employers’ Top Health $1,351 Care Initiatives for 2020 ................................................................................ 6 Non-tra $1 u,50 ma 0tic joint disorders 4% 3% 13% $1,696 17% 18% cos Not s t-surpri haring singl through d y, the charact educter ibles, co istics of paym the persis ents, an tently d coihi nsgh urance -cost c as laima a way to ma nt group, nag defi e ned as use of bein healt g h in care the service top 10 sp an ercent d $30,150 for family coverage will be subject to the tax. maximum taxing h Inpatient servi ealth , wh be ich ces ne account may fits r ted emp uc ed er diff es the for 27 p erenc compre ercen es in hensiven t of plan sp choice eness din of g . f covera or thosge e i,n th the epo top 10 pulat percen ion that accou t one or nts two fo r mos years and 22 t health care organizations (HMOs), exclusiv $1,232e provider organizations (EPOs), preferred provider organizations (PPOs), point- N3 ervous system disorders one year, while 73 percent were never in the top 10 percent. 1% Among the 27 perc 4% ent who were 10% ever in the14% top Enrollees Spending Person Person Person $1,541 Maximum* Dial yHDHPs a sis re health plans wi $1,143 th deductibles of at least $1,350 for individual covera 0% ge and $2,700 for fa 0% mily coverage 1% in 2019. 2% 3 Connective tissue dis $1,079 ease 11% 5% 3% 14% 19% 24% overall spending: High-deductible health plans (HDHPs) are becoming more and more common. Between 2007 and of claims, were different from the characteristics of the population never in the top 10 percent. Individuals temporarily s pe pe rce ndnt amon ing will not b g thos e es iub n the ject to top 10 cost- pe shari rcen nt g three for a or four signific ant share years but on of tlheir y 15 p cos ercent ts. Our a f mo $1,353 inng din those gs hav in e i the mplica top tions 10 p feor rcent 2% Eliminate Out-of-Network Coverage for Select Services of-service $958 (POS) plans, accountable care organizations (ACOs), patient 11%-centered medical homes (PCMHs), Figure 3, 10 Perc peentag rcent, e 21 perc of Persent ons With were in th Privae te Healt top 10 h pe Insu rcent onl rance Un y one de ror A ge two 65 Enro years, 4 10% lle perce d in a Hi nt w gh ere -Dein ductibl the to e p 10 perc Health Plan ent Osteoarthritis 1% 28% $120,500 $168,500 $1,273 $80,000 70–80% 1% 4% 8% 8% Radiation therapy 0% 1% 1% 0% 4 $1,000 The tax As expect 10%was i ed, innd clud ividu ed in als i the AC n the A top to1 miti 0 perc gatent e agof ainst th claiman e rtising s in al cos l five ye t of health ars $1,167 wer care a e mond re lto g ikely ener to h ate t ave c ax ertain revenue to health pay in 20 Calcul 1 th 8, e th top ating wheth e perc 10 pe entag rce er an nt of e of indivi cl inai div mants dua iduals l reached t (thos withe pwho were rheir OOP maximum from cl ivate insura in t nc he e to who p 1were 0 perc aims data eent nrolle either d is co in an one mpli HDH or cated by two P inc years reas the ed or fa from ct that 1) OO three17 or fo .4 pe urP rce nt $1,123 Medi in all Tcar f yp ivee buy e oyear f He -s ia n .l tThi h pro Pl sposals a su n gges as ts w that ell. W one e f-ou time eve nd that nts in tha divid t in uals age dividuals s 5 re 0–cov 64 er f acco rom unt , such for a d as isp kn roport ee an io d nate shar hip replace e of ments high, - private health insurance exchanges, Centers of Excellence (COEs), high-performance networks, limited (HDHP) or in a Consumer-Directed Health Plan (CDHP), 2007–2018 ............................................................ 7 three 5% or four years, and only 56% 2 percent $41,wer 500e in the top $1,025 $ 10 percent 65,315 each $of 23 the ,000 five years. 60–70% Non-traumatic joint disorders Source: Employee Benefit Research Institute estimates based on administrative enro 3% llment and claims d 9% ata. 14% 15% Other outpatient services $917 14% 15% 14% 11% for other provisions in the ACA. The theory behind capping the health exclusion rests on the assumption that, because to 46 conditions maximum estimates were not .0 perce tha nn t ( thos Figure e in t 3). he t Further, provi op 1ded f 0 perc deor mo du en ctt le ib st peopl les ss than have e in our sample, 2) f be ive en years increas . Ho ing we individuals can mo ver, re genera while tho lly reg spay e in nothing ou ar the dless top 1 of 0 tw of p heth ercent poc er som ket when all feone is ive they years) had characterist Implics eme li nt ke Poi thos nt-of-S e in t ale Reh ba e tetop s in 10 Pha$869 rmac perce y Bent f nefits or all five years studied. For instance, persistently high-cost 7% drive cost claimants more of t . he Overa spending ll, the fo y account r those tem for 55 percent porarily in the of t t ota op l 1 hea 0 perc lth s ent pend than ing.thos This e f per inds in ist g ently i alone m n tay caus he top 10 e em percen ployers t. to networks, capitation, and value-based payments. They have also adopted disease manag 7%ement programs, 7% HMO10% /EPO 70% $23,500 15% $41,30 15% 0 $1 14% 2,000 15% 50–60%14% $714 6% * ClC ino icn an l e Cc l1% a t $5 is vs 00 eif itc is as tio un e S dy is se te a m s e (CCS) classified individuals into 285 mutually exclusive and clinically homogeneous categories. More information can be 3% 10% 19% 22% $652 Prescare re years of ripthe tion l ceivi a ook Dbi rulity o ng p g ed s similar to re f work ventive serv ers those to e ices, and 3) use xclude th in the toe p 10 value of o peof rce ut e nt -m ofpl thr -netw oy ee o ment ork services often does n r f-our based years health cov , they 26%were erag ot mu co e from un ch more t to 18% taxa ward lbl ikely e the in incom to have var -netwo e31% witrk OOP hoiou ut ls imit, 52% Fi enrolle claimants gure 4, d in Av waer er n H e age much DHP. Annu more Am al on E lik mployee g indiv ely to id- u be Only als w at and lieas th a de t 5 Family 0du years cti Dble, the edu old cti . bl S avera ie, Amo xty-thr ge e ng e de Work percent ductiers bl of e i in t nc P hos reas riva e te ed in- the Secto from tor Es p $44 10 perc tablishme 6 to $1 ent ,846 nts of With from • The 5.8 million in $573 dividuals examined in this study used $38 billion in health care in 2017. The 2 percent of the Thi supsport i wel s aln lso a Me ess b p o dricare ro ne grout ams bu b y, tele y -in pr theme f opos indic din al, e ine, gs on s op n o eci -sutpatie ite ally i and f the nt sur near y are -gsery an ite abl he ealth d pos to pay clin sibly pr icsemiums b , a y t ndhe fin co on ncier dings on bege half services o d f ia thos gn . o e so tics ptin (g Fi out gur of e 17 ). 20% $518 84% $12,700 $24,900 $5,400 30–40% found in Elixhauser, Steiner, and Palmer (2013). PPO/PO $446 S 69% 68% 72% 0.40% 72% 72% 5% Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. Implement Direct Primary Care Solutions in Select Markets maximum. workers pr Th efer erefore, w additional e give a health ran insur ge of esti ance b mates f enefits or w over heth cas er someo h wages ne re 6% (and ache oth d their O er forms OP ma of tax xiabl mum. e co mpensation); and Pre health 20 sc0 ri2 ptto i conditi on 2018 da D ruge ons s amo du pecti than nng dbl in t e, g those in the hos fro 20 m e with 0 2 p– h20 arm 1 employ 8 a top c ................................ y c 10 percent laee im-sonly cove onl rag y one e ................................ (Fi or gure two 4 ). ye A ars nd 23% ( it Fi igur ncre ................................ eas 13 e). d from One fin 15% $95 din 8 g that to $3, ......................... 392 amo stands o 26% u ng t is the thos 7 e 43% claimants all five years, as well as 59 percent of those in the top 10 percent three or four years, were 3% ages 50–64, employment popul -bation ased covera in the to gep f1 or M 0 perc edic ent are. of spending every year between 2013 and 2017 accounted for 19 percent of $0 HRA 10% 10% 9% 9% 9% large be caus W percenta hen e ofit this come ge p o ref sf to p eren indivi res ce, t dua crihey are ls in ption d the “ rug be ov top 10 perc er-nef insured. its, emp ent ” O oloyers nc f claima e work usually a nts ers e e ac ith dop h er h year t a f ave w orm it health h di ulary abetes (3 coverag and us 3 per e e a pharm or see cent)a . acy n Th ine b creas reesults nefeit in the * Clinwith family com ical C pare lassd wit ific co atioh verage. n 30 Sys pe tem rce Copay (Cnt a CS) mo c ments lasng sifi those e h d ave indiv been increas nev idualser in th into 285e m ito ng as utp ua1 ll0 perc y well. exclu s ent The a ive a (n Fi dverage g cure linic a 12 l copay ly). h oPe mors ment for ge ist neently h ous c an of ate igh gor- ie cos fice s. t claima M vis ore it i inncr fonts rm eaas w tioed n ere c a n be Spe 5 cialty0% drugs spending from medical claims 1% 2% 3% 7% total 20s 02 pen20 din 03g in 20 20041720 . In 05 co 20 ntras 06 t, the 73 2007 2008 perce 2009 nt of 20 the 10 p 20 op 11ulation 2012 who w 2013 ere nev 2014 20 er15 in the 2016top 10 2017 pe 20 rce 18nt of Given the growth in HDHPs, it is no surprise that they seem to get the most attention when it comes to the various cost- Figure 5, Average Copaym Mo evnt an e to Ful d l-Repl Coiac nsur emen ance t High-D for a educ P tibhy le P sician lan Office Visit Among Workers in Private-Sector Percentage of Bottom 90% of Health Care Percentage of Bottom 90% of 2% Health Care Percentage of Bottom 90% of Health Care found in Elixhauser, Steiner, and Palmer (2013). comprehensiveness of their coverage, the theory is they then us ® e more health care services than they otherwise would s Ho from $ ug w ge manager can s H 15 t SA a e .38 s m -e tro plo li to in gng ib 2 yers n l 00 e cor eg h 2 e otiat res to ra elation ltpon h $26 e p p ld a .81 r n to ice disc be tw ithes n 20 een ounts e 18 findings? d ( iabe Fi and gu tes re an rebates. 5 F). irst d other Coi , re nsurance 6% g Fiardle n health ally, employers ss rates conditi of w6% ha for offic ons t employ have to . Am e vis ong in ers its de 4% do, increase cdi id vid they shou e buals in th etwee d mo 4% n purc ld recog re e mo top hasing d 10 niz este ly, but pe 4% tha rce t nt of since cost - also much more likely to be the spouse of the policyholder. We found that 33 percent of those in the top 10 percent of Source: EBRI analysis of Truven Health Analytics MarketScan Commercial Claims and Encounters Databases. Other non-sp spe ecind altiyng dru from g sp e2013 nding – 2017 from m ae cco dicunted for al claims only 20 percent of spen 3% ding in 2017. 2% 2% 2% sharing arrang Us emen ers Wts tha ho Moved t e Int mplo o Top 1 yers 0% i use n the to man Users age u Who M se ov of hea ed Intol Top 5 th care % in t serv he Fol ices a lowinnd s g Users pending. Who MovBesi ed Intdes de o Top 1% i ductibl n the Fol es, lowing 0% EBRI Issue Brief is registered in the U.S. Patent and Trademark Office. ISSN: 0887 –137X/90 0887 –137X/90 $ .50+.50 Establishments With Copayments or Coinsurance, 2002–2018 .................................................................... 8 Following Year Year Year s have cla haring imants health . W may ork f i or ers nsuran be i five year over neffect ce f -insure ro s, ive m 51 an ins ib n pe ecause address rceurance nt of health ing a l tho compa s insurance e arge portion with ny an diab p d paying prem etes re o miums f al health so ha are care d hypertensio iums to not c ios nclu ts that com .de Cons d ni,n an umer engag ta pa d xab ny about le or self incom one ement -insuri -e, quarter o whi throu nle g out thgh f eir thos - of cos -p e tock -with et claimants coins So urance urce al : E Sl re ou m firp ve c qu le: oyires Medi years ee B p cal ela n E were e n pa xf pe it nd R the e rticipants to iture sea spo P ran chel Iuse o n Ss urv titey pay utf e the Ins euranc a perce st p imolicy e atCom es hold nta b po as ne ge eer, compar nt d o (o ME n f th a Pd Se m -IC) ic nhar .is ed tra ge with tiv, o e eut n ornly - oof llm -20 p poc ent ket payme aercent nd claim among s d nts ata .for coinsura those never i nce n the will * Based on a subset of individuDi alag s n w os itti hc s data on OOP maximum 0% s. 10% 20% S 30 urger % y 40% 50% 60% Source emplo : Emplyers oyee use Ben e co fit st R- esha searing in rch Instita n uteumbe estima r of dif tes basfere ed ont way n admin s to istraenga tive en ge wo rollmerker nt ans, s d clomet aims d imes b ata. y varying the use of deductibles, © 2019, Employee Benefit Research Institute –Education and Research Fund. All rights reserved. Note: Data not collected in 2007. spend health • ing on The charact pla hn, ealth which es ceri are ser stics sentially of vices the does means th pers n ist ot ently h au at t tom he igh atical em -cos plly oy t claima enjoy er acts the nt g as i same tax rou ts ow p wer n insurer a p e r differ eferen ent nd b ce. from t As ears a res the he ch ult fin aract , w anci ork eris al ers risk tics ar of of e the di increase sharing abetes may al with so be e had office ff rectiv espirator visit e cos in addr y d ts. iseas essing e (27 da y pe -to rce -day nt) u , b sack e of p health roblems care (2 services 6 percent) , b , ut and it /wi or connect ll not addive ress tis the sue bu dis lkeas of eh ealth (24 top 10 Notepe : H rc M Sen O ou= rt of ch e: ea Elc m th laimants pl m oya ee in B te en n. ef a n it c Res e o ea rgra ch I niz ns ati ttut ion e ;es EtiP mO ate =s e ba xcs lu ed s ion ve ad prm ov ini id se trr ati o vre ga en nriol zla m tien on t ;an P d P cO lai= mp sr da efe ta. rred provider organization; Source: Employee Benefit Research Institute estimates based on administrative enrollment and claims data. Fi cog pay ure 6, ments Distr , an ib d co ution insura of Heal nce. th Spe Some o ndi f th ng, A e other ways in mong Indiviwhic duals wi h cost th -sha Emring is used inc ployment-Base lude tiered co d Health Cover -pay age, ments f Continuo or health us Source: National Business Group on Health, https://www.businessgrouphealth.org/pub/?id=6B0FADBD-0570-B014-6775-E3C8413D3233 Pclaims OS=po rather int of se trhan vice; s Himp RA= ly he pa altying premi h reimburseum men st. arrangement; HSA=health savings account. s theorize pe pe rce ndnt) ing that d , amo pop to prefer ul ation ng is not only oth h ne er igh ver in ler ess abov -pr prevale the emium com e top dedu nt con 10 cti ble pe pr di rc ehen stions b ent. ut a s ( ive Ilso n Fig di cove ab ur vid eo uals tem rage with 14 ve out ). -of porar - pock lowily cos et maxim in the t-sharing o top ums 10 perc .ver low It raises ent erof t -pre he claima quest mium, less nts ion ha as d to care providers, t iered co-payments for prescription drugs, value-based insurance design, and reference pricing. Enrollment in 2017 .................................................................................................................................. 8 ebri.org ebri.org ebri.org ebri.org ebri.org A res ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org earch repo Is Is Is Is Is Is Is Is Is Is Is Is Is Is Is Is Is Is Is Is Is Iss s s s s s s s s s s s s s s s s s s s s sue B ue B ue B ue B ue B ue B ue B ue B ue B ue B ue B ue B ue B ue B ue B ue B ue B ue B ue B ue B ue B ue Bri ri ri ri ri ri ri ri ri ri ri ri ri ri ri ri ri ri ri ri ri ri rt from the E ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef • • • • • • • • • • • • • • • • • • • • • • O O O O O O O O O O O O O O O O O O O O O Oc c c c c c c c c c c c c c c c c c c c c ctober tober tober tober tober tober tober tober tober tober tober tober tober tober tober tober tober tober tober tober tober tober BRI 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24Educ ,,,,,,,,,,,,,,,,,,,,,, 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • 2019 • ation and R No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 No. 493 es earch Fund © 2019 Employee Benefit Research Institute 21 20 16 23 17 18 14 11 15 19 13 22 10 12 3 5 8 9 7 6 4 2