Persistency in High-Cost Health Care Claims: “It’s Where the Spending Is, Stupid”

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 accounts 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.

Key Findings:

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.

Figure 12 Figure 16 Figu Figu Figu Figu re re re re10 5 3 1 Figure 15 Characteristics in 2017, Within Patterns of Health Spending in 2017, Within Patterns of A Pe ve Pr rc ra Leng entage ege miu Copay th of m of Inc T Pe r me ime ea rs s nt on i en T s and C s W Aop mith o 10 oi n g nsura Priv Pe Em rc ate p ent nce lo He yof Spendi e fo alth rsr a W Ph In ith sura y 1ng sic 0 nce o ian From r M Under Offi ore ce Health Spending in 2 017, Within Patterns of High-Cost Claims From 2013–2017 w A R Fi H Se c Sa om m he g e o v m ur ong e fe w t p p rhe e rle a e r l7, C r he te m is he c e an E nc su S ha ns e xp t a a 20 e r iv ns e te a s ut c e cs ta p ta m a or c e r e rtov e rr e ions y is c ploy e e e sh t Out x ic r nt a a ow s s of m ga -e of ine e c n in im p c w -r a ou P ila d s it toc i h hig e nt Fi in t rand I nt k g ting e o s b ur his t the e Ma hos for e s 8. ing r txim ns c udy. e 84 ost The in t gur u ood p -m sh e They in he fir e , rc a st b r c e rty s onsu ing. op nt c Ty olum A of 10 c p ddre lude Ult m e spe e p n co of im res ha r nd a a c Cn e s e tnt ov ing, e nt s ve ly a e xa ins Lar , for r a g highe b m g one e tina e a the ge w ,ll 20 e t fiv r tion o sa e oo - p 14 C n 30 e m r e laim fa y – p m e f th 2020 le ra , ium a ra m nd s st es ot s e , p ................................ a ? 40 low e udie ns he r c p e e in 201 re nt d s rr- .ha c c aSixt e ost gnt v ee 3 for - y of of sin p -ha thr sp t he rtr e ing e he io e nding se r p 5.8 m he re e e.......................... rnr sea a c e lt rolle e nt h cov rill pc rion p e h of es r sent (te B hose e rre a a ot e op g cd - h e ed le b y w 9 e High-Cost Claims From 2013–2017 Paul Fronstin is Director of the Health Re High sea -C rco h s atnd CE la duc im as tion FrPo rog mr a2 m 0 1 at3 t– he 2 0 Em 1p 7loyee Benefit Research Institute Persistency in High-Cost Health Care Claims: “It’s Where the AV ge isit Em 2013 65 A p Enrol mong lo –20 ye17 e led s W ,and orke W ino a High rDistr rs ke rin Ea ib Priv -De uti rnidu on ate ngctibl s of T -Se , an ctor e otal S dHe Inalth Es flpend atabli tio Plan nin ,shme 1g 9 (HD 8 in 8 – nts 20 HP) 2019 17 W or i ithn 6 4 Figure 13 Ten of the 17 conditions are given a weight of one. Seven of the 17 conditions receive a weight of between two and six. G w t high le he old e ar d ir e s t -b c out a e ost o b rg l- e ov p of e e ctla e tro - si p ra im us follow oc st l.,a e e k2017) nt nt e of ts, t ly (fr he OOP in t om he .a lt he c h ca )20 ha m t13 op rar axim e – c 10 t2017. se eum r r is p vte ic .ic r e c The s of Thos s, w ent p ne of hic e e op xt a c h d la c le four cim ount r iv w ae it nt cs up h p ing olu s, a e m frs w ins or si ns st ur t e he d ell a a n iv nc tide highe s high e 59 tphe r -st p e c m e os sa spe rium ctm e c nt nding p la s a le im of int nd s, a t hose o w m e nd spe a re k in t e d nding m s c iff ost he eov re lik e tnc co rae a p e tlg e s b y 10 e g t or o l e e pie tss re w e s in 201 r a e c ac e eff h th n nt or t hose t dhr e a3, w ir b e le e O w .OP or itho h (EBRI). M. Christopher Roebuck is president and CEO of RxEconomics, LLC. This Issue Brief was written with assistance Cost-sharing will have limited effectiv Ne evne er iss n To in c p 10% hanging In Top 1 the0% way indiv In Top 1 idua 0%ls wit Inh la Top 1 rg 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 a m the ra exim fir pest rum si c four st olu , ew nt m hi y ly n con e c a h arnd c s, w ould ttaee ini m r b e ng pe or a no g tae he rs 50 ily m m or high e – e a 64 ns tha -, c for c ost n om $ indiv c 7,1 pla aim r50 eidua d a p nt w es. it ls r h p The in t e 30 rshe on p ne e b rxt in 201 c ot e sect nt tom a7 ( ion d m 90 ong Fi p ge e ur s r those c c ee r ibe 7) nt . s t of ne For he tvhe e ins rd he in t attaa a nc he lt in m h ca e , top aor m r e10 e ong spe d p e te tnding a he ril. ce nt 5 p The .d e P is rsect e tcr re ibut si nt st ion e of ion ntly 7 e frm om ploy the er s a Insnd tituins te’s r ure ersea s wrill ch a nend ed t eo dit consi orial st dera ff ots. heArny w avyie s i wn w s expr hich th esseedy in t can e hisnga repg or e thig are h -tc hose ost cof laim the ant as. ut hor One s a op nd tion sh ould is to Spending by Type of Health Care Service, Within Patterns of Prior work has defined high-cCom ost claorbid imantsities as tho A se m in on the g to Diabet p 10 pe ics rcent in T of op hea lth 10 P care erce spent nding (Long et al., 2017) Spending Within Patterns of High-Cost Categories Average Copaym F en ig t ure 9Average Coinsurance 73% E Our mp fin loy 60d e % $3 ings ha r0 s could v er eim duc plic e a spe tion nding s for b the y e e lim ffeina ctiv ting enespousa ss of the l c ov Caedrill ag ae c .t a W xe or found any for tha m t 33 of a p etr acx th enta of t w those ould c pa ep r si the ste 25 nt exc % lylus in ion Ander2 son, G 0% 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, a follow the nd p top he ing ula fa high prtr ion a e right - sent cost c -s our ha c ount cla nd im ing fin ca olum nt dfo in s w g rn cont s. 56 e rThe e p a ea ls rini c la o est ng nt m uc sect of the h mor tion in ot m ae l sp a ens clik lude e nding e for lys a indiv to , d b bis ee idua c ttw us he esi ls espouse on n 60 a in t of he t he nd of top k 70 t he e 1 p y p p ie e m olic rrc p ce e lic y nt nt hold a trof ions eae spe crhe .for W nding d et p he ublic found .ir C OO le pa tolic P ha r ly m ty , .a 32 t xim hose pe um rc in e , nt not be ascribed to the officers, trustees, or other sponsors of EBRI, Employee Benefit Research Institute-Education and Fi reg qur uir ee 9, orSa enc mp our le a M ge ea a ns ny , one Hea lt ch C onsi ond derit eion d as, 201 large 3c ................................ ase to meet with a case ................................ manageH r io grh t -C o o us st eC w ................................ aha teg t o arrie e s becoming know .. 11 n (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) Octob er 2 70 4 %, 2019 • No. 493 Sample Means, Health Conditions, 2013 $26.81 of thee m top ploy 10 Unit m pee e nt rd c- e St bnt aased tof es I che la s So im alta h b nt Diff s w ene ere e fit rnt es t tFr he o om r e spouse d Ot uche P er eus r m of C ie um ount tof he Inche rp r eie a olic a ss." lt esh ca yhold Hera e W lt e ser r h Af o, rkc ev om r ic fa Ea e ir p rs. ns a in r22 g W e s d e I, n cw no. found reit ah o se 3 (Ma s nly tha 20 y t /Jun O a v tp e ra e ae ny r ll c In 20 e fnt p la03 toint i oa n)m : in t ong 89– im 105. those e, a nd $26.50 t a Ph.D., he nd highe 70– R 80 of r x spe tpEco hose ernding cenomics nt in t of he grtoup hose top , s L 10 w LC in t e p r he e e rm cte op or nte 1 p of likc e ela ly rcim e to nt ab nt of es a old spe ll efiv ndi r, e fe ng y m era aele ra s w , che ae nd d re tt he t he he ir p spouse OOP olicy hold m a of xim etrhe or um pspouse .olic For yh told hose of etrhe , rc e om a pc olic hin payg rhold e tdhe w e ir it r .h 50 18 % % 16.7% Never in Top In Top 10% In Top 10% In Top 10% a Re s c sea onc rcie h Fund rge ser(v Eic Be RI s.- E ARF) s ad , v or oc ta he teir s, c sta aff se s. N maena ithe gerr s o EBRI r c onc nor ie Er BgRI es- E he RF lob lp pab tie ient s o s rna tavkiga es p teosit the ions $25.89 hea on lth ca spe rc ei fic sy st polic em yso t hat 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 ne W e vhe r e ra the in t fivr e he o -r y e tno op art p e 10 e mp r iod ploy er,c ehe e rs nt a ulti lt of h ca ma cla te rim ely a c s ost nt up s. s p o N w rt ot er a e long Me conc d ic ae ft are nt er r b a tu he te yd - in A a Cm p Aro ong ppaoss s a ae l d rw e , la ilsom l td iv ee p ely e e nd sm m $24.77 p oaloy n ll p oe the e rs a rcr efacto nnounc ntagrs e of a es d tw he the e llp y a op nd wula e the ret ion g o oing v.e Ira n ll 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 They OOP m wa exim r only e sl um ight 16 , c ly pos e le rtc-ss e sh nt lik a rae ing m lyong tis o in la bte hose ernr ge olle ne pa vd r e Hy trin he ine pe in t rte ffhe ns a elt c io h p tt niv op ela 10 in ns c p ha w eit rnging c h hig ent of h d be cha e ladim v uc ior a tible nt bs. es, e c aus ite he pra he tiea nt lts no h reim long bureseme r 51% havnt e 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 ca arte e g for or iindiv es iduals with 16$2 % 5 $23.77 43.7% B rot-G 45old % berg, Zarek C., Amitabh Chandra, Benjamin R. 14H .7a %ndel, $23.34 and Jonathan T. Kolstad. "What Does a Deductible Do? 50% Age Total Health Care Costs Percentile impact of the health bene 18.6% fits plan that they offer. For instanc$22.82 e, it can be argued that at least a portion of employer savings 20 Da to 17 dt rop , a 6010 % spousa p in 201 ercel c nt 7 ov ................................ of etrhe ag e p.op Uula nite tion a d Parccceoun l S ................................ etrevd ic e for m 70 ay p ha ervcee nt re c................................ of eivhe eda lt the h ca mrost e spe attnding entio ................................ .n a Att le the ast t im one e -w ha he lf n it of ................. ta he nnounc se 20% ed 13 18.9% 18.6% inc arre ant nge ive m teo ntlim s (it H RA thesir ) or us e he of althe h-a sa lth ca vings 18.5% re -a fo ccro fin unt a nc (Hia SA l r)e -e aligib sonsle . Thi hea s is lth p a lp ahe ns.nom enon known as moral hazard. The data Never in Top In Top 10% In Top 10% In Top 10% Totalcomorbidities. This advocate a18.3% lso helps patients avoid duplicative or w$a 1st ,8e 3ful 7 care as m $12 uc ,7h a 07s possible $.3 2 P,r7im 78ary care $65,855 18.0% 20.5% 46% 20.2% The 17.4% Impact of Cost-Sharing on Health Care Prices, Quantities, and Spending 45% D 20.1% ynamics." The 20.1%Quarterly Journal 14% Total 0 – 89th 90th – 94th 39.4% 95th – 98th 99th – 100th Lower/Upper Respiratory Disease/Infection 19.8% 27% may be offset by provider cost shifting back to employers as a result ®of lower reimbursement rates from individuals formerly Pe I it indiv s d nte • r idua r c o is s duc ion to e One ist ls re U t -a te ion n hir cd he lin e m dr d c ina of 1 not 3y indiv te i only he n idua a lt tHigh h b he lsir e p ne e dr esi fit dst uc s for -eC tnt ible ost l y spouse in t (whe he He n th s w top ho e a 10 y w ha l p t e 15% d e rh e rone c Care Claims: e eligib nt ) of ble ut c for la als im o ca 4% ov tnt he es ha rir a g OO e d td P hia rm oug ba e xim t 2% “ h th es. 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The d1 y1na $21.53 .2% mics of how Medicare buy-in proposals may otherwise aff 1ect H a In ow m Fi ini e gv 1 ur m 2 e $2 % e r um t, 0 op 9, p r of io w 10 r e $1 rp sh ee 2,00 sea r ow cer nt 0 c the h ha in he of pce s la r ac c im lt onc eh ca nt ant a lude g s f re e or of d spe 5tfiv tha he nding e t e non ynt e air in 201 r-e s w , or sa 51 k m 7 a ing p pe le nd rspouse c w ent ha ith va d of a s spe t rhose m ious ed nd ia he w n tot m it ah d or lth condit e aia l sp tb ha ee tn w e nd s a io or ns of lsko ing $2 in 201 ha 3,50 spouse d hy 3. 0p on Ietr s on is the e ns aa ls ion he lt o h ca a d ,lt is ah ca p r nd e la ya re e bd out by Where the Sp 13–17 ending Is, Stupid,’” EBRI Issue Brief, no. 493 10% (Employee Bene 4% fit Research Ins 3% titute, Octob 2% er 24, 2019). ( In cop the y50 r ight semi % © na Tr l puv apeen He r “It’a s The lth Ana Prly icte ic s, St s, all r upid ight : W s r hy eser The ved U)nit for ed 20 St13 ate –s I 201 s So 7. 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Individuals were excluded if they reaF che igdu are ge 7 65 before the end of 2017, if they were born after the 25% 6.1% Peripheral vascular disease 6.1% 29% 30% Chronic Obstructive Pulmonary Di 9.2% sease 0.3% 0.2% 5.5% 1% 1% 3% 22.5% 18% 35–49 24% 29% 25% 24% Pe ripheral vascular disease • Not only 27% did individuals persistently in the top 10 percent 0. 3 of %claimants spe 6 2% nd more on hea4% lth care than those 5% all copy 6% right and other applicable notices contained therein, and you may cite or quote small portions of the report Specialist physician $151 $422 26% $848 $1,112 a re nd sponsibilit heart dis y efor ase cov are e rinc ing lude emd p.loy Ov ee es w rall,ho 17w ce ond re p itrions evious culy rr ecnt ov ly e rceom d aps a ris espouse the CC und I. Th er ea not inde he x ris p sh lan ow as m n ator the e a t nd op m oor f th e e Deyo, R. A., D. C. Cherkin, and M. A. Ciol. "Adapting a Clinical Comorbidity Index for Use with ICD-9-CM Admini 10 4.s % 4t % rative b polic eginn ym ing akeof rs ne 2013 ed, tor o rif t eflect hey on wew reha otthe Am rw eis ric ea unt ns raarc ee g ae btle ting aftfor er t t he he b ire g grinn eating er he of a2013 lth sp(eending .g., job . They c change ould , d e cp onc ende lude nt: It’s Statutory Out-of-Pocket Maximum, 4.1% Cerebrovascular disease 7.7% 1% 0.4% 3% 4% 8% Figure 14, Comorbidit 19 ie .3s A % mong Diabetics in Top 10 Percent of Health Spending, 2013–2017 ................................... 16 30% 3.8% 2.5% 3.9% 3.6% 20% Cerebrovas te cm ula 50–64 pr or da isre ily as in t e he top 10 percent and those never 30% in the top 10 p47% ercent, the dist 59% ribution of spe 63% nding varied as provided that you do so verbatim and with proper citation. Any us 0.e 4 % beyond the sc2% ope of the foregoing 4% requires EBRI 5% ’s Cost-sharing 17.4% may continue to 6.6% play a role even if high-cost claimants reach their maximum OOP. Before becoming a e ta m bp leloy a4% long er Ss a ch izw d op op it hh it ren t t ia/B s v his ip a ne ol rious arw , Dep a c p rom e psrsoa ion pone c , h. An xnt iety s. , M C oo leda Di rly sord , ters hose in the higher spending categories were more likely to have Outpa tient Serv D icaets abases." Journal of C 2.lin 1%ical Epidemiology 45, no. 6 (June 19 17% $840 92): 613–619. $5,724 $13,073 $18,792 the pric$1 es, st 0 upid.” 22% 2.6% Dst em ate us nt ia change, death). After imposing these criteria, 5.8 million policyholders and dependents remained, each with five 0.01% 0.01% 0.02% 0.04% 0.1% by Type of Coverage, 2014–2020* 2.1% 2.4% A T A G L A N C E 5.2% well. Outpatient services, such as diagnostic services, accounted for 46 percent of total health care spending I prm iorpli express cations perm is for sion. MFor edica perm ris esi B ons, p uy-le In ase Pcront opo acts Eals BRI at perm 21% issions@ebri.org. Dhigh eme- nctost ia 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% v Fiagrur ious e 15 15 % he , aH lt 4.5% e h condit alth Spe ions nding . Th in 2017 e CCI r, aW ng itehin d fr P om att e 0.1 a rns of mon Hig gh t-hose Cost in t Clahe im s bFr otom tom 20 89 1 3 p– e2 rc 01 ent 7 ................................ of health spending to ....... 1.7 17 20% 20% DC iah gro no ns ic ti c obstructive pulmonary disease 6% 18% 5% $444 11% $1,768 13% $3,625 15%$4,361 y ears of 20 2% %eligibility. 18% 19% 2014 2015 2016 2017 2018 2019 2020 20% Non-Traumatic Joint Disorders $18,000 16% th 25.5% E In o lixha rdus ere for tro , a A td hose ., dC re . ss St ne e la v ine regre rin t , cala n he id m L s, e t. op P a m 10 lm p loy e pre.e r " c rC e s w nt lin.ill ic P ane rl C esc ela drss ipti to ifion fcoc atus d ions rugs on Soft d ais ccw eount a ase re e p (d C re C for vS) ent ." 2 ion a 620 p1 e3 rnd c.e nt ca of re tm otaanl he ageam lth ca ent25.2% . rOur e Se W Ther hil vee e r a tis l he M ase e c dor ic pa olla atrie e r nt b yuy s m tha -in p a t ya p r rop e pa lie c osa h th s tls o e e w irm e m rpeloy a int xim errod u am tuc t e OOP e m dp in t t, s t the he o ir m 11 a pna r6 ior g e C e ong xpe hearrlt e ie h ca ss nc . e Se r e w n. it spe h Dc n eost d bing bi-e s : ha St “H r a23.9% ing b igh enow -ahe nda (lt e D ng h--MI caost g )e a m c nd la ent im Re t aools in p nt . s Brare ian Ca hm roong nic o tbhose structin t ive he pu lm top on 1 p ary e dris ce ent as, esuggesting that those in the top 1 per2c3e .6nt % 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 Availabili % ty: This report is available on the int20.3% ernet 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 on speindiv nding idua , and ls w offic ith p e evris siit st s t ent o ly p rla im ra gr ey ccla aim re s phy are sic aia cns ase and in pspe oint c.ia One lists a -ha cc lf of ountte he d m for ha 18 d hy pep rc ee rtnt ens . I $ion a n cont 16,300nd raone st, - 17.6% I w g n e he ne the rr ea semi t l ma he sp y na e tr l p nding ans apla e tris e “ , I to tst ’s The t upid heir.” c P a G rr ic e ee ne d s, St e ra cis lly upid ions , 20 : onc W pehy re c e tThe nt he y of U re tnit he ace h th p dop Ste ula air t em ts I ion a as So xim cum count Diff OOP esr efor nt , p F 80 ot rom e p nt e ia r Ot clly ehe nt he r of C lping ount tota trl sp he ies,” m ending tUw o ta ek E o en . Higgins (D-NY) both introduced proposals to expand eligibility to Medicare to individuals ages 50 and older who are not Pe cond ptic it uion lcers. When looking at C 15.9% CI 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 ha -2% da d mia ong bet e those s, and in t one he- ha top lf of 10 tp he erir c espe nt for nding all fiv waes a ye sa soc rs, p iatreeds cw ripti ith p on red sc rugs riptia on ccount drugs e.d A for foc 52 us p on ercp ernt ev of enttion otal he may a lth Reinha 5% rdt and his co-authors concluded: “The United States spent considerably more on health care than any other he y long eta lt eeh ca ligib r to le rree for a se ch it r v the ic.e The s. Y prog eus rta e e m m of . p These -loy fin 1.1% e ar nc s offe p ia rop l re r osa w he als rad lt w s for h p ere la e a ns ng ls o ta ha g initng t rin la od in he uc rg ed ea lt p in t hy art he b look a e 11 ha5 vior nd C ong p fe rior el re tthe ss o . b sa T ehe cm om e H t ing igg o pins a la n e high prnr op -c olle osa oste l s claimant Md Thi ild ia lg s st ivnosed er udy w dise w asit aes c h ca ond ncuc er t(e22 d tp he roug rcent h th ), d eia Eb BeRI te s (1 Cent 8 p er efo r0 cr.e 1 R nt % e)sea , and rch o chr n He onic 0.05 a % o ltb h B stre uc ne tifit ves I p 0.nnov ulm 3%ona ation (E ry disB eRI a1% se C (R CH OP BID ), ) w (15 ith th 1%e 10% 8% $14,700 Pe Fip gtur ic e u lc 17 er, Health Spending on Diagnostics and Outpatient Surgery in 2017, Within Patterns of High-Cost Claims From 0.1% 0.4% 1% 1% Medical supp Me lied s,ic daerv eic P ea st,ie ant nds." dura He ba lelt m h Af edifa ca irl se q 38 u 4% i, p S m no. a em n1 (Ja t plenua Mre y a 20 n19 s,) : 210 01 7$32 – 3114. $14 $281 ,300 $800 $1,508 th Renal Disease 13% reduce spending on not just hypertension and diabetes in the long term but on other conditions as well since care spending, outpatient services accounted for 29 6% percent, and office visits accounted for 3 percent. Dw c m ia ount he b ae yt t e he ars ls y r, (w o w tim he ithe hp y o t a r he acw rte ric t h m high ao re u ea t d su cus e or c m e e isr p dions s, l ip c a m etr iod o acn ft ae se p )rrit a indiv a te or us a idua es a rs, or ls p e r r e lo cae w cnt h th us ag ee e rir s of of mG a he D xim P a.lt um A h ca t tOOP he re sa se . m rve ic teim s e ev , e m n w osthil m ee t aasu rgre ets of ing high aggre us ga etre s will int fun rd od ing uce su dp in t porhe t of 11 2% the 5 follow Congring ess or could ganiz ha atv ions e p: otA eon ntia Hlly e 5% w im ittp , a Bclue ted C erm oss p 4% loy Blue me nt Shie -ba ld sed Ass 15% he ocaia ltth b ion, ene ICfit UB s g 16% A, iv JP en th Mor eg an 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 a 2002 nd d 20 ia 03 bet20 es a 04 re 20 oft 05en a 2006 ssoc 20ia 07 ted20 w 08 ith o 20t09 her 20 dis 10eases. 2011 In th 2012e sh 2013 ort t 20 e14 rm, 20 em 15ploy 20e 16rs w 20ill 17 ne 20 ed 18 to work Hut em iliiza plet0% g ion s ia or uc p 20 a h a 07 raps p leghy ia 20 si 08 cian vi20 sit 09 s per c 20 ap 10ita and 2011 hospit 0.1 a 20 % l d 12ays pe 20 r 13 ca 0p .0it 2a % 20 w14 ere below 2015 0 .2 the % OE 20C 16D med 0 20 ia .4 17 n %…U.S. 2018 2% ha spe Cha vc e se, ifi the c iMe ty b r of igg cetre he , st Milli le ba gm n isg a la n, for tivP e fiz t h la e engua rb , uc and k g.e P Of cour . hRMA At the.se, tim 2% high e, the us p erro s a posa re t l inc he m lude ostd c la ha ngua llenging ge t ha pop t w ula ould tion to a have d ad llow ress ed . employers (33 percent), 1% respiratory disease or infections (30 percent), dyslipide $m 12,ia 70 0( 28 percent), back problems (24 percent), and Fronstin, Paul, and M. Chr Cais nc top er (he Non-M r Roe etasb tauc tic or M k. "eta The stati C cost ) of Spousa 10% l Health 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 spending 4% for those in t 11% he top 10 perc26% ent one or two y33% ears Network management is crucial when it comes to addressing high-cost claimants. Employers and insurers will need to Raw diit ath th ion te hir e ra C he o pv y ae ltre h p d la Sp ns o uasnd e other partners to implement car 16% e engagement$0 25% programs tha$175 t29% help individua 32% ls$298 navigate the $262 R enal disease 0.4% 0% 1% 2% 6% policym 0% akers need to reflect on what Americans are getting for their grT ea otta erl he He aa ltlh sp th Ce anding re Co . s They c ts Perould cen ti clonc e 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 rIn ce: pati pFe ien gu rct Hos re e nt 11 pi ia n tal m httong ps://w t whose E w me .cdc rge .go in t ncvy/nc he Depa hs /d top rata tme /10 nh nt is /p ea err lyc re elnt ea Offi s e/ tchr e ins V e ur20 is eits or 18 1four 1.pdf y an ed a OF r utp is b gu ati re ut en 3 ti S only n ervic 15 es percent Pre sa cm ripong tion Drug those s in the Hemiplegia or paraplegia continuously evaluate which health care providers are in their ne 0t.w 04 or %k to ensure 0 tha .3% t patients have 1% access to the m 2% ost CanceE r m (np oloy n-m er es ha tasta vte ic b oe r e m n tr e thtay sing tatict)o manage health care costs for decades. Attempted cost-control measures include health care system so that they get the right Osteo ca ar rte hrit in t is he 2% right sett 10% ing 1% and avoid waste 4% ful care as muc 8% h as possible. 22% Other outpatie C no t v se ere rvd ic e Cshildren/Other Dependents 41% $252 17% $1,12% 921 10% $4,531 $7,395 t int her od pruc icees, st d dur upid ing .”t he 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. topS ou 10 rc e: pe Erm cpl eoy ntee in a Benll fiv efit Res e ea ye ra ch I rs. ns ti Thi tute s es su timg ate ge sst bas t sed ha ont ad one mini-sttr im atie ve e en vre olnt lms t ent ha and t cindiv laims idua data. ls recover from, such as knee M Re o eff d ne a icra l ie a dtint e c som /e s a p es rv b ov e e ina re ide t liion o vre sr id nif p sor ea la ds e n d e r to e si m gini n/c m os ize t- sh the ar ing amoun chatnge of 0.s t w 03 aha % ste t ful aff e he cta how lt0 h ca .01 m % re uc ut h p ilize atd ie.nt E 0m s p .1% pa loy y e out rs a of nd poc ins 0.2 kur % ete for rs m he ay a ltah lso 1% 0.3% 1% 4% 7% Tabl Long, e Pe o tef r e C t o ant l. Ee ffe nt ctiv s 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, drov e more of the spending for those temporarily in the top 10 percent than those AIDS c Ther onsi c e d a e is re r a ne ser cw or v ic olla ae nd s a r y end m tha eot rtg he a ing prp lie st prrs t ov ucide o tur era m l c aprloy r ha ang nge ere a m s t tteeo nt mts su p he ts0 d c .t1 o h e% liv m as high e arna y of ge-he phe ea r0 a fo lt .lt 0 h ca rh ca 2 m %arnc r ee e m spe ne ore tnw d gor ing 0 e.n k 3e s, a : % r“aH llcigh yc. oun Y -he ett, a ain m b ltle h 2% - c cost ost are y ce la aim rs ants 1% are While there are many factors to consider, to the degree individuals ages 50–64 with employment-based health benefits CFin ancedings r (non-m e o ta n Pe static r os r is mette asnc tatiy c) in Spending 1% 6% 12% 10% IntroductW ion ash ................................ ington, DC: National Ac ................................ ademy of Medicine, ................................ 2017. .......................................................... 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 Chronp ic e r C si ost ne dnt itily on in t anhe d Se top le c10 te d p e CrC ce S* nt . Similar findings emerged for outpatient surgery and diagnostics. whersi enc the e 19 sp88 ending , the c isost , st of upid pr.” ov G ideing nerhe ally a, lt20 h b p ee ne rcfit ent s t 0% o of etm he p loy pop 10e %ula es a tion a nd t 2he 0c % cir ount dep s efor 3nd 0% e 80 nt s ha perc 4s inc e 0% nt of reatsed ot5a 0l s %mp or ending e tha 60n % on or swit gacniz hea dt ions to the , a nd Med dic ire ac re t cpont rogrraacm ting. , the 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 m $7,3il 50 lion enrollees follow 0.e 0d 1 % from 2013–2017 0.1%in this study 0.w 4% ere part of the1% $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 Qua he Using alt n, h ca U cH la n . im d re e et s d r se a 1l. r 3 av" tic a C e od fr s. om ing Yet 20 $A 6e lgo ,617 m 00p r it on loy hm e 5.8 s for rs offe m ill Dion ind re fin heing alth p ivC idua om lans or ls 19% b tw ha idit itth e ie in la s in I mp rloy ge C D m p 21% -a e 9 rnt - tC look a -M baa sed nd nd I he Cfe D a 6% e lt -10 l h b the A ed ne sa mfit m ini s, w e s tt5% ro ae tp iv found la en e Danr ta tolle ha ." 5% tMe e20 s d 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 2 41 OH th ye pr en rto en n-s sip oe ncialty drug spending from medical claims $56 $223 $652 $1,235 Ult imately, employers and insurers will need to provide 10% good informat8% ion around the21% se programs. W 26% ithout educationa 33% l PPO/POS 56% 61% 66% 66% w Fihe nding tphe ers on rc C e the nt ar e y P inc e 42 arrrsi e e , st a no. high se enc in w 11 yus in Sp (eo N rrs, ov k e e m e rnding m od eb ae e rnin r r ................................ a 2 tg 00 es a us 5)nd e : r11 s, or a 316 0 – lo 113 pw er us c 9. ee nt rs of ................................ incrhe ease alth ca in inf re la se tion (Fi rvice ................................ s e gur ve e n w 1). hil Tod e a ta yr, gp erte ing m ....................... ium high s for us ers will12 55 per p ce ent r $c 6e ,0 of nt 00 tof het p ot op al he ulataion a lt 7h sp cc eount nding ed . Thi fors fin 84 p de ing rcea nt lone of tm ota ay l he caa us lte h sp emepnding loyers t , 10 o su pep rc pe or nt t a of Me the d ic pa op reula buy tion a -in pcrcop ount osa el, d 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% e fforts, 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, 70 hav p ee trhe cent bigg of e spe st b nding ang for , 5 p th ee rc b euc nt ka . cOf cour counted se, for high 56 p us erecre s nt are of tspe he m nding ost c , ha and llenging 1 perc p eop nt ula acctoun ion to a ted for ddr e 28 ss .p e rcent of especially if tH he Ry A are able to pay premiums on behalf of those 19% opting out of 17% employment- 15% based covera15% ge for Medicare. H pe ow rce C nt a n Em only p one loy eor rs a tw nd o yIe ns ar ur s, 4 ers A ped rc de re nt ss w Learreg e in t Cla he im top s? ................................ 10 percent three or four ................................ years, and only 2 p........................ ercent were in the 19 18–24 6% 7% 4% 4% 3% Sc hizophrenia/bipolar, depression, anxiety, mood Hypertension 2 Whaley, Christophe W 20 r orke M., 17 L, ars n Vu, W ith in N High in Priv ee Pa rajate -Sood tter Cost -Se ns , Mic ctor Claim of haeHigh l E. Es ants Ctabli he -Cost rne in shme w 9% , Fo L Claim ea llnne o nts With w M is From 20 ng etc aY 21% lfe, ea a De arnd A 13 du tee – ctibl v2017 Me 32% hr e, otra. "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 re n $spe 4 o ,0f 0c 0 Sp tiv een ly d, in in 200 g 9. Despite the efforts to manage expenditures through a combination of cost-sharing and spending (Figure 6). HSA-eligible health plan 11% 9% 7% 7% ditsop ord 10 ers percent each of the five years. Therapy, Digital Coaching, Condition Management, Medical De6% cision 5% 14% 16% 51% 17% Implica 25–34 tions Patie for nt s To the C Sw adit ill ca h: I c Ta mx p ................................ act Of A Rewards Prog 11% ................................ ram On Choic 10% e Of Prov ................................ ider13% s, Prices, And 12% Uti............................ lization." H 6% ealth 19 DThi yslis st pid 7% eudy e mia xamines the concentration of health spending 2002 a– m2018 ong 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 doe Nevs it er in T ap op 1 pe0% ar thaIn t Top 1 emp0% loyers ha 11% In Top 1 ve fa 0%iled a Int Top 1 cont 21% 0% rolling spending 31% 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 w bye ll a 2.1 p s peerrcsi est nte ( nc Wyha in lety ho ese t al. e,xpe 2019) ndit.ur Fi ena s ov nce iarl in a fiv cee nt -y iveeas r m pe aryiod be . The nee dd ea dt at o on inc us reea se of h pe aa tie lth ca nt enga re se ge rv m ice ent s, he in t ahe lth ir use of Sc C ho iznc o cp ov 35–49 hlus re ern aia g ion /e b ia pnd o lar, c a dre ep?re 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 ck pod rob dls of emsgoing 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 RH he eu am lth ca a50–64 toidr e a rt spe hritnding is and tre ends latedt o dis be ea c sonc e entrated: about 25% a quarter of indiv 23%iduals wer38% e in the top d 40% ecile of spending 47% in at percent 6% of individuals who were in the bottom 90 per0 ce .4nt % of spending 5%0. 2 m % oved into 12% the 1% top 10 perc23% ent 4% the following 26% y 3% ear 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 e E m mp ploy loym ere s a ntr -e b atsed aking henot alth b ice. ene A rfit ec s w entho suc rould vey found be follow thate d a for mor te he foc ent usir ee d 20 str13 at– e20 gy 17 on phigh eriod -c.ost health care claims ranked Figure 6 M N le ulot a tip st lonly e $3 one s ,50 c l0 e d y ro id es aindiv ir s, whil idua e tls hr p ee er-si qua sternt telrys in t wehe re ne top ve 10 r in t pehe rc 0e .t 2 nt o % p of de cc la ile im . a Ant m 0s spe .ong 02% tnd hose mor ev ee on r0 26% i.n th 2he %aelt th ca op d re e ctile ha 1% , n th about ose 1 in 5 w 7% as R(hFi eg um ura et o11 id )a.rt Only hritis 3 p ande re rcle ant te dm dov iseead s e 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 Re ferences ...........................................................................................................................................................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% $3,02% 69 4% t te he mrp eor only arily one in t or he ttw op o y 10 ea p rs, erc 4 p ent e racnd entt hose were ne in t ve he r in t tophe d etc op ile 10 thr p ee er c or e nt four (Fi y ge ur ae rs, a 15)nd , the only dis 2 p tribut ercion o ent w f spe ere in t nding he v top arie d percent of spending. M ultiple25 s% clerosis 24% 0.01% 0.1% 1% 6% Male 49% 50% 38% 39% 44% Specialist ph*yA s E s ix 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% K Ie m y pli Fi 5% nding cats: ions for the Cadillac Tax $2,871 Ther chara ec w tee ris ret ic sls of ight indi diffv eidua rencls e s b who y ta yp re e not of p jla us n. t high Only- c22 os tp c elracim ent ant of s tb hose ut pein t rsist he e nt top ly high 10 26% p-ecrost cent c la of im ca lant im s ais nt ne s a ell de fiv d efor ye ars Lower/$3 up ,00 pe 0r respiratory disease/infection 11% 10% 20% 22% 30% a d Es w e ndno cile e ll. tin a e s Out ................................ ll p fiv ae tie ynt ea ser rs. v The ices, suc 2 per ................................ h a cent s d of iag the nost pop ic ser ulav tion p ice ................................ s, a erc si cst ount ente lyd in t forhe ne taop r................................ ly d one ecile -h a of lf (4 spe 6 p nding erce a nt ............................. c) c ount of tot ed a l he for a 19 lth ca r22 e 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% w The eree e xc nr isolle e ta dx o in a n hig n HRA h-c ost or H eSA mp-loy eligib mele nt he -ba ased lth p he lan, alt h p whe la rns ea s (a 30 ka p te he rc e Cnt ad of illatchose tax) ne is v ae p r rin t ovis he ion in top 10 the p 20 erc 10 ent P a w tie ernt e AOv e stm he m prloy a a/ll, th C eO rs a PD e nd 5.8 m , ac he uta e illlt b ion h p ronindiv la ch ns itis itd o ua de lst e erxa mine mine wd h a in t t khis inds o study 2% f seus rvic ed e s a $38 b nd ill int 2% ion in ervent he ions alth ca mig 5% rht e in 201 be helpful to im 7. The 6% 2 pp ele rcm ent ent of . t8% he p spe erc nding ent of for tot ta hose l spene nding ver in t in 20 he17 top . I n cont 10 per rc ae st nt , t( he Fig 73 ur ep e 16 rc). e nt Pr e of sctrhe ipti p on opd ula rugs tion w accho ount we ed re for ne v 2e 6r p in t erche ent t op of d tot ec aile l he in alth $2,491 • TwentT yarge peted rce Snt pec of ialty the Pha p rma op cula y Man tion a agemen cctount (e.g., S ed ite-of for -C 84 are, percent 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 iaP h g y rn ot ro os ie dtc ic d tion a isorde nd rs Affordable Care Act (ACA). When the ACA passed in 2010, th 24%e Cadillac tax, a 14% nondeductible 11% 40 percent 7% enrolle $2,50 d in suc 0 h a plan. Thi Inde s m pena den y t indic Specia altty e P thha arma t tche y) re is2% some degree of 2% pla $2,322 n selection rela 6% ted to high 7% deductibles and 6% population in the top 10 percent of spending every year between 2013 and 2017 accounted for 19 percent of total spe c are nding spe 2 4% 0%nding from, 2013 wher– e20 as 17 offic acec ount visits t edo for pr im only ary 20 ca p re e rp chy ent si c of ians spe anding nd spe in cia 2017. lists a ccounted 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% e exc xpe isc et e ta dx im usep of ose he d aon lth ca ther e p or ser tion o vices. f he In o altth cov her w eor rad gs, t e chose osts tw ha ho t eexc xpe eec dts $10 to us,200 e he a for lth si cngle are ser cov vic ereas d ge is ap nd rop $2 or7,50 tiona 0 for tely Surg spe Fig eur ry nding e 1, P in 201 remium 7. IIn cont ncreases rast A , m the ong 73 E p m ep rc lo ey nt e rof s Wi the th 10 o popula r Mor tion w e E ho mpw loy ere e 6% e ne s, Wor ver in t kerhe Ea trop 10% nin 10 gs ,p a end rce Int nfl of ation, spe 7%nding from 3% Policyholder 47% 46% 57% 58% 55% among those in the top 10 percent for all five years, prescripti $1,975 on drugs accounted for 52 percent of total health care percent accounteIm d pl for eme 28 nt Hi p gh er -T coe uc nt h Co of nc spe ierge nding or Nav . igation 21% Percentage Who Nb 2 ee rvne oufit s s. sy s W te e ma d lsio soe rd xa ers mine persistency in spending over a five-year period. Examining the concentration of health $2,000 2% 1% 6% 10% 20% Tfa hym roily id dcio so vrd ere ars ge, was scheduled to take effect in 2018. It has since been delayed twice and is currently scheduled to Our a rSee e m fin Fi or d ge ings ha ure 1988 likse 6. ly– 4 v t2 o e a 01 nd self im 9 p 6. ................................ -or sele 5 tin ant chtt t im int psp o :lic /he /w at w aion lt wh p .s for kffla .ons ................................ rg p /ublic w reitph mor o rt p-olic see cy tio .c om Our n/ephb rre es he su - 2% ................................ 2019 ns lts su iv-es g e cc g ov tio est en r -a t6 ha g-e wt. 4% o t H rk ao xin ew r-................................ e g av nd e he r-, e atmp lt hose h b loy e 7% e ne in t r-fit che os, suc ntrib top ution ............. h a 10 s s-7% for- 6 2013–2017 accounted for only 20 percent of spending $1,761 in 2017. ChemotE hm era ploy pyers have not limited their efforts to patient cost-sh 3% aring when it 0% comes to mana 2% ging 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% Ospe steo nding arthri ta isnd the persistency of such spending is as important in evaluating the efficacy of the movement to higher 1% 1% 4% 7% 10% p p t thr a re ekroug e miums c ee 15 nt ff h th % eof c/t e cin 202 la Cim ada Im illnt 2. a plc e s m me A tt a nt x, w a tha y Hi gh b t ill e -p P oint b erfor be et tin la m , ean trhe coff fina e N r gpe etwo or pta ion o rnc r kt s or A ia ine lly f he cff c e ou in t c a nta tlt iv he h cov bl ee Care H inSA r ee r-d a eg uc ligib eing cost lea he s t gga ha re ltg h p t aetx e la c n us e eb e de s $11 of ca u he se ,200 alt of h ca t he for r e low si se ngle e rv r ic st c ea ov s. tut eEror v ae g yn if e OOP and En docrine disorders 14% have adopted various types of insurance and delivery system1% s, which now inc2% lude health maint 3% enance $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 Healt $1,351 h Care Initiatives for 2020 ................................................................................ 6 Non-tra $1 u,50 ma 0tic joint disorders 4% 3% 13% $1,696 17% 18% cost-sharing through deductibles, copayments, and coinsurance as a way to manage use of health care services and Not surprisingly, the characteristics of the persistently high-cost claimant group, defined as being in the top 10 percent m t $3 Ia npa a xin 0,15 xim tg ie um he 0 for nt aser , ltw h b fa v hi ic m c ee h ma ily ne s a fit ccov s r c yount e te e rd a m g uc e p ed e e w rs t for ill dhe iff b 27 e e c r e om su pnc eb rp e c je re s in p e c nt he t tof o ns la tiv spe he n ch e ne tnding aoic ss x. e of . for cov those eragein t , the he pto op pula 10t ion th percea ntt a one ccoun or tts for wo y e m aost rs a he nda lt 22 h care $1,232 N3 ervou or sg sa yniz stea m tions diso ( rd He MOs) rs , exclusive provider organizations (EPOs), preferred provider organizations (PPOs), point- one year, while 73 percent were never in the top 10 perc1% ent. Among the 4% 27 percent who 10% were ever in the14% top Enrollees Spending Person Person Person $1,541 Maximum* Dial yH sDH is Ps are health plans $1,143 with deductibles of at least $1,350 for individual cov 0% erage and $2,700 0% for family covera 1% ge 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 p spe erc nding ent a m wong ill not those be su in t bje he ct ttop o c 10 ost - psh era cr eing nt tfor hre a e si org nif four ica ynt ea sh rs b arut e of only the 15 ir c p ost ers. ce nt Our a m $1,353 fin ong dings ha those vin t e im he p lic top at ions 10 p for erc ent 2% Eliminate Out-of-Network Coverage for Select Services of-servic $958 e (POS) plans, accountable care organizations (ACOs), patie 11% nt-centered medical homes (PCMHs), Figure 3, 10 Pe p rc ee rc nt ea nt g, e21 of p Pe errc sons ent w W eit re h P in t rivhe at et op He 10 alt h I pens rce unt ra nc only e Und one e ror A g tw e o 65 y eEanr rs, 4 olle 10%d p ein a rce nt H igh we-rD e ein t duc he tible top H 10 ea ltph P ercla ent n 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 A The s expe ta 10 x w % cte ad s inc , indiv lude idua d in t ls in t he h Ae C A top to 10 m ip tiga ercte ent a gof ains cla t im the ant ris s ing in acll fiv ost e of yhe eaa r $1,167 s w lth ca ere r em aor nd e tlik o e gly ene to ra ha tev e ta c x r ere ta vin he enuea tlt o h pay 20 Ca 18 lc, ula the ting pe w rche ent the ag r ea n of ind indi iviv didua ual re ls aw che ith p d the riva ir te OOP ins ur ma axi nc mu e w m ho frow m er ce la ims enr olle data d is in a con mp HD licH aP te inc d brye the ased fact from tha 17 t 1) .4 p OOP erc ent in t he top 10 percent of claimants (those who were in the top 10 p$1,123 ercent either one or two years or three or four in a Med T ll fiv ic ya pree e ob yfe uy H ae r -s. in p al tThi h rPl op s su aosa n gls ge a st s w s te ha ll.t W one e found -time etv ha ent t indiv s thaidua t indivi ls ad gua es 50 ls re –c 64 ove ar c cfr ount om, for suc a h a dis s k prne op eo a rtnd iona hip te rsh epala re c eof me hi nt gh s, - private health insurance exchanges, Centers of Excellence (COEs), high-performance networks, limited thr (He 5% D eH or P) fou or rin a yea C rs, a onsu 56% nd me only r-D ir 2 p ecteerd ce $ H nt 4e 1 a ,w 5 lte 0 h P r0e la in t n (C heD t $1,025 H op $ P6 )1 , 50 p ,20 3107 e 5rc –e 20 nt18 ea ................................ ch o $2f th 3,00 e0 five years. ............................ 60–70% 7 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% ma t c for o ond 46 xi ot mum it .0 p he ion r e s t p e rrc sov ha tima ent is n th ions ( te Fiose sg w ur in t e e in t re he 3 no ). he A Fu t CtpA op r ro .t he v The 10 id re , p d d t e he e fo rd cr uc or emo nt y tible b s le t ess hin p s ha e toha d p v le cn fiv ea in p bp eo in e eur n inc g y e sta a he r mp rs. e he a le H sia ,ow ng lt 2) h e e m ind ve xc or riv ,lus e id w g ua hil ion r ene ls e c r te a hose ast n lly s on p raein t yg no a the r he d thing le a tss op ss um o of 10 utw p of p the ion t e p rtc o he e cha nt kre som tt a , w ll fiv bhe eeco n a ene us the e is y years) had character Im ispl tic eme s li nt P keoi t nt- hose of-Salin t e Rehe bate tsop in Pha 10$869 r mac peryc Be ent nef for its all five years studied. For instance, persistently high-cost 7% d cost rive c m laim ore a nt of s.t he Ov sp era ell, th nding e yf or ac c those ount tfor em 55 por p ae rily rce in t nt of het ot top al he 10 a plt eh sp rcent e nding than th . Thi ose s fin ped rsi ing stea nlone tly in t ma he y c top aus 10 e e p m ep rc loy ent er .s t o networks, capitation, and value-based payments. They have also adopted disease mana 7% gement 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 Presca of y rire e pa t t ihe rre os looke nc D a eiv b ru ili ing gts y d p of si re m w vila eor ntiv rk teo e rs t tshose eo rve icxc ein t slude , a he nd t the 3) op us v 10 aelue p oe f of rocut ee nt -m of p t-hr ne loy e tw m e o e or rk nt four s -b erv ased ic ye es a he ro sft ,a e tlt 26% he n h cov dyo w ese e no r re a g t m e c uc ofu rom h mor nt 18% to ta wxa e a rd lik ble the e ly inc tin o om -ne ha etw 31% v w eo itv rk hout a rOOP ious lim it, 52% e Finr gur olle e d 4, in Av ae n HD rageH A Pnnu . Am al Em ong p indiv loyeidua e-Only ls w a itnd h aFa dm edily uc D tible educ , tthe ible a, ve Arm ag oe ng de W dor uckte ible rs in P incrre iv aa sed te- Se from ctor $4 Est 46 a b to lis$1 hm ,84 ent 6 s fW rom ith claimants were much more likely to be at least 50 years old. Sixty-three percent of those in the top 10 percent of • The 5.8 million ind $573 ividuals examined in this study used $38 billion in health care in 2017. The 2 percent of the su Thi ps is pw or e ta lln ls ae o Me ss b or d pic rn og a er r e out a b m uy s, t by -in p e the lem r op fin ed osa dic ings o ine l, e , spe on n o -c si ut ia te p lly a a tnd if t ient he ne su ya rr a-g rsi e et re a y b he a le nd a tlt o p h cl p oss ay ini ibly b pcrs, a emyium nd the c s on onc find ie b ings o regha e lf of se n d rvic ia those egs. nost op ictsing (Fig out ur eof 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. Therefore, we give a range of estimates for whether someone 6% reached their OOP maximum. 2002 he w or alt ke h condit tro s p 20 re 1fe 8 a ions r m ad ong t dha itiona n th those l he osew a in t lt ith insu h e he m tp op rloy anc 10 ee e -p b only e erne ce fit c nt ov s ove only erag rone ec a (Fi sh or g ur w ta w eg o 4 e ). s (a y eA and r nd s (it ot Fi inc g he ur r re e for a13 sed m ).s of fr One om t a fin xa $9d b 58 ing le tco tom ha $3p t,3 e st ns 92 ands a a tion) mout ong ; ais nd those the Pre cs la cim ripa tio nt ns a daru ll D gfiv e sdp e uc e n yte d ible ia nrgs, a , fro 20 s w m 02 p– e h20 ll a arm 18 s a59 c ................................ y c ple ar im cesnt of those in t ................................ he top 10 perc 23% ent thr................................ ee or four 15% years, were 3% ......................... age 26% s 50–64, 7 43% employmp eop nt- ula batsed ion in cov the era tg op e for 10 Me perdcic ea nt re of . spending every year between 2013 and 2017 accounted for 19 percent of $0 HRA 10% 10% 9% 9% 9% b lae rc ga eW us phe e er n it of cent t his caom g e p e rof e s fe tindiv o rep nc re idua esc , r the ipti ls y in t on arhe d e r“ ug ov top e b re 10 -ne ins p fit ur es, e re cd e.” nt m p Onc of loy ce e la rw im s us or ant kua es e rlly s e a a it cd h ye he op r tha a a r v w for eit h m h d eula aia lth cov rbye taend s (3 e rus a3 p ge e a e or rp c se h ea nt e rm )a . a nThe c inc y brre e ene a su se fit lts in the * Clinw icit ah fa l Clas m siily fic ac tio ov ne Sry asg te em . C (C op CS a)y c m lae snt sifs ha ied inv de iv id bu eae lsn inc into r 2e 8a 5 si mng utua als w ly execll. lu sThe ive an adv c elr in aig ca el lyc op hom ay om gee nnt eo ufor s c aa te n o gorff ieic s.e M vo is re it in inc forr m ea atsed ion c an be Spe c 5om cialp tya 0% d re ru dg s w s itp h e30 ndi n pg e r fro cem nt m ae m dong ical ctlhose aims never in the top 10 percent (Figur 1% e 12). Persistent 2% ly high-cost cla3% imants were 7% tota20 l sp 02ending 2003 in 201 2004 7. 20 I 05 n cont 2006 rast20 , t 07 he 73 2008 perc 20 e09 nt of 20t10 he p 20 op 11ulat 20 ion w 12 ho 2013wer 20 e14 nev20 er15 in th 20e 16 top20 10 17 pe 20 rc 18 ent 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 Me ovnt e t oa Ful nd l-Re Coins placeur mea nnc t Hie g hfor -De da u cP tibhy le P si la cnian 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). ® fr c su Hom ow om ggp m e c $1 rst a a H ena n e he SA 5.38 a g ns st m -e er iv rp lin 200 ong ig loy e to ine blne e e c ss r or s h g 2 t e of ot rre a eo ia spond llt ta h he $2 tte ion p ir 6. p la r c 81 n ic b tov o e e tin 201 e tw d he ris a eg e c se oun n d e,8 ( fin tihe tad Fi s a bings? g e the nd ur tes a e or r 5 e Fi yn ). b rd is a s C t t ot ,e toin he s. rhe 6% e y g su Fi r a tna he r he ra dnc lly le a n lt ss ,e us h condit e rof m e a t p m e w loy s for or 6% ha e ions et r he s ha e offic m .a p lt Av loy h ca e m e v ong teis o rrit s d e d 4% s in ind e se o, cide rc iv v trhe ic idua e b a ey e sed s t tsh ls w ha e ould in t m e 4% n th n p or he e re ur e m y tc op c od og ot ha he 10 e niz si st ng r e ly w p 4% e , is tha rb e cut e tw nt could si ost of nc-e 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 ecinding alty dru fr gom sp e2013 nding – 20 from 17 m ae cd count ical ce la dim for s only 20 percent of spending 3% in 2017. 2% 2% 2% sharing arrang Us eers me W nts ho M tha oved t e Int mp o Top 1 loyers 0% i us n te he to ma Us na ers g W e h us o M e ov of edhe Inta ol Top 5 th ca% i ren t se he Fol rvice los wi a nnd g Us s ers pe W nd ho M ingov . Be ed s Int id oe Top 1 s de% i duc n ttib he Fol lesl,o wing 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 ha c sh laa v im reing he .a W nt a lt m or s for h insu a ky e r b s ove fiv er e a ine nc yre ff - ea ins e rfr cstom ur , iv51 e e a in a bp n insu eecra d cus d er nt e r ea ss he of nc ing e a those ltch insu a om lap rw g ait e r ny a h d p nc o aia rnd et ion o b pe r pt ea e m y s a f he ing ium lsa o p s a lt rha e h ca rm e d ium not hy re p s t cinc e ost ro te lude s. tns ha C ion td onsu c in t o , m and m a pxa a eny r ab b e le out ng o rinc a self g one om em -ins -ee q , nt ua ur w hil r ting hr teer oug tout of heh tir -hose of cost -poc -wk ite h t coins So ur ura cnc e: e E Sour m rep c q le: o uir yMedi ee es p B cal el n a Ex e n p fpendit it R ae rt ur sic e e a ipa Panel rch nt I n s t Sur sto ivtey up t e a Ins y e ur sa tanc i m pe a e r tC e com s e nt b ponen aa sg ee dt (o of MEP n t ahe d Sm -IC) ic nha .istr ra gte iv,e out enr- oof llm -p en oc t k an ed t p cla ay im m se d nt ats for a. coinsurance will claim*a B nt as a sedll ofiv n a e syu eba sre s w t ofe in re d iv tihe duDi aspouse lag s n w os itti hc s d of atat he on O polic OP y m hold axim eu rm , 0% c som . pare 10 d% with o20 nly % 20 pS e 30 urger rc %ent y am 40ong % those 50%never60 in % the Source e:mp Emloy ploe yrs ee us Bee n e cfo it sR t- es sha earing rch In in stita u tnu e emb stim ea r to es f d ba iffe sed re ont n aw dm ay in si sto tra e tiv ng e e an gre o llw mo erk nt e ars nd, cslo aim me stime datas . by varying the use of deductibles, © 2019, Employee Benefit Research Institute –Education and Research Fund. All rights reserved. Note: Data not collected in 2007. he • altThe h pla cha n, rw ahic cteh e ristss ics of entia the lly m pe era si ns st e tn ha tly t thigh he e-m co pst loy ce la ri m acatnt s a g s it roup s ow wn insu ere diff reerr e ant nd fr bom ear s t the he c ha finra anc cte iarl r istis icks of of the d inc spe sh iaarb nding ree ing atse e s a m w on a ls it yo h o he bh ea ff a e d ic ltff h ca e re e c v spir tis iv rit ee a c ser tin a or ost y vs ic dd .d e is rs d e ess aoe se ing s not (27 da y p a -eto ut rc-om ednt ay a ) , tus ib ca a elly c of k e phe nj rob oy alt le h ca tm he s (2 sa re 6 p m se ere v tra ic cx p e ent s,r )e b ,fe ut arnd/or e itnc we ill . c not A onne s a a rd cetdsu iv re elt ss , tis w tshe or ue kb e d ulk ris s a e a of rse e he (24 alt h top N 10 ot ep : e HrM c Se O ou nt = rc h e: of ea Elc m th la pl m oy im a ee a in nt B te en s. nef 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. c Fi og pur aye me 6, nts Dis , t arnd ibut co ion o insura f He nce a.l tS h Sp omee nding of the, oA the mong r wa I yndivi s in w dhic uals h c w oit sh Em t-sharing ploy is m e us nt e- dB inc ased lud e H e tie alt re h C d cov o-p ea ra yg me e, nts Cont foinu r he ous alth Source: National Business Group on Health, https://www.businessgrouphealth.org/pub/?id=6B0FADBD-0570-B014-6775-E3C8413D3233 PcO la Sim =ps r oinatt o he f sre trha vice n sim ; HRA p= ly h e paa lty hing reim pb re urm se ium men s. t arrangement; HSA=health savings account. spe theor nding izedp top tha o ula p t ris etfe ion ne not r high only ve er r a -in t p brov ehe m e ium d top ed uc c1o0 p tm ible perre s b che ent ut ns . a iv Ils ndivi eo ca ov b de ov ua ra e ls g out e te w m -it of ph or -p low a oc rily k ce ost in t t m -he sh axim a trop ing um 10 s. ov p I ete r r rlow c ae isnt e es t rof -p he rcela m qim ue ium ast nt , ion a s ha less s t d o percent), among other less prevalent conditions (Figure 14). c are providers, tiered co-payments for prescription drugs, value-based insurance design, and reference pricing. Enrollment in 2017 .................................................................................................................................. 8 e e e e e e e e e e e e e e e A e e e e e e eb b b b b b b b b b b b b b b b b b b b b b rr r r r r r r r r r r r r r r r r r r r r re i. i. i. i. i. i. i. i. i. i. i. i. i. i. i. i. i. i. i. i. i. i.s o o o o o o o o o o o o o o o o o o o o o oe r r r r r r r r r r r r r r r r r r r r r rg g g g g g g g g g g g g g g g g g g g g g a rIIIIIIIIIIIIIIIIIIIIIIc s s s s s s s s s s s s s s s s s s s s s sh s s s s s s s s s s s s s s s s s s s s s s u u u u u u u u u u u u u u u u u u u u u u re e e e e e e e e e e e e e e e e e e e e e ep B B B B B B B B B B B B B B B B B B B B B B or r r r r r r r r r r r r r r r r r r r r rrief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief ief t fr o• • • • • • • • • • • • • • • • • • • • • •m O O O O O O O O O O O O O O O O O O O O O O th c c c c c c c c c c c c c c c c c c c c c ce tttttttttttttttttttttto o o o o o o o o o o o o o o o o o o o o o E b b b b b b b b b b b b b b b b b b b b b be e e e e e e e e e e e e e e e e e e e e e Br r r r r r r r r r r r r r r r r r r r r rR 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2I4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 E ,,,,,,,,,,,,,,,,,,,,,, d 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2u 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0c 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1a 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9t ion • • • • • • • • • • • • • • • • • • • • • • N N N N N N N N N N N N N N N N N N N N N N a o o o o o o o o o o o o o o o o o o o o o on ...................... d 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 R3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 e search Fund © 2019 Employee Benefit Research Institute 21 11 19 20 22 13 23 15 16 18 12 14 17 10 2 7 4 6 9 3 5 8