A Thank You to Members: This study was conducted through the EBRI Center for Research on Health Benefits Comorbidities Are Common: Innovation (EBRI CRHBI), with the funding support of the following organizations: Aon, Blue Cross Blue Shield Association, Johnson & Johnson, JP Morgan Chase, and PhRMA. • Heart disease and at least one other condition was the most common combination of comorbidities. Figure 2 Forty-two percent of the top spenders had heart disease and at least one of the other four conditions, Percentage of Enrollees with Heart Disease and Mental Health September 11, 2025, #545 The Employee Benefit Research Institute is a private, nonpartisan, and nonprofit research institute based in accounting for 42 percent of total spending. Average spending was $208,000. Comorbidities and Their Share of Total Spending, 2022 Washington, D.C., that focuses on health, savings, retirement, and economic security issues. EBRI does not lobby and does not take policy positions. The work of EBRI is made possible by funding from its members and • Mental health conditions and at least one other condition were the least common combination of Share of Enrollees Percentage of Total sponsors, which include a broad range of public and private organizations. For more information, visit comorbidities examined in this analysis. Twenty-one percent of the top spenders had heart disease and at Spending Among Employment-Based Health Plan Percentage of Diagnosed With Median Spending Average Spending Spending Accounted www.ebri.org. least one other condition, accounting for 20 percent of total spending. Average spending was $199,000. It Enrollees Heart Disease and per Person per Person for by Enrollee With is worth repeating that mental health conditions were one of the top five most common medical Enrollees With the Most Common Health Conditions Another Condition the Condition ### conditions. 1% 42% $149,000 $208,000 42% The use of health care services — and the spending associated with those services — is far from evenly 5% 37% $55,000 $86,000 40% distributed across the population. It has long been known that a small portion of the population accounts for a 10% 33% $32,000 $57,000 38% disproportionately large share of health care spending. 20% 29% $17,000 $37,000 36% Share of Enrollees Percentage of Total Y et, employers often offer health plans that look and feel largely the same to enrollees regardless of the extent to Percentage of Diagnosed With Median Spending Average Spending Spending Accounted which they use health care services, despite differences in health status, health conditions, and underlying health Enrollees Mental Health and per Person per Person for by Enrollee With care needs. Another Condition the Condition 1% 21% $146,000 $199,000 20.1% Figure 1 High users — often referred to as high-cost claimants, the costliest patients, or top spenders in the health system 5% 21% $51,000 $80,000 20.4% Prevalence of Common Medical Conditions and Associated — are commonly individuals with significant, intensive, and complex medical needs. These individuals usually 10% 20% $30,000 $52,000 20.1% Spending Across High-Cost Claimant Tiers, 2022 r equire ongoing or intensive care for one or more medical conditions. However, there is no agreed-upon definition 20% 18% $16,000 $32,000 19.6% for a high-cost claimant. Various definitions typically rely on annual health care spending thresholds or percentile- ® Share of Enrollees Diagnosed With at Source: EBRI estimates using 2022 Merative™ MarketScan Commercial Database. based cutoffs. Least One of the Following: Skin Note: ICD-10 codes were used to identify enrollees being treated for the various medical conditions. Claims data, while a valuable Percentage of Median Spending Average Spending Percentage of Total Disorders, Respiratory Conditions, source of information for health care research, often undercounts the true prevalence of health conditions due to factors like Enrollees per Person per Person Spending This is the second in a series of EBRI Fast Facts related to the concentration of health care spending. In this Fast undiagnosed cases, coding limitations, patient access issues, and a lack of detailed clinical information. Average spending for Musculoskeletal Conditions, Mental Fact, we examine health care spending among individuals in employment-based health plans with the top medical enrollees by condition includes spending on other health conditions. Health Conditions, or Heart Disease conditions. For simplicity, we chose to show data for enrollees with heart disease and another health condition separately from those who had 1% 87% $149,000 $205,000 87% mental health conditions alongside another health condition. These represented the highest and lowest shares of enrollees. The 5% 87% $52,000 $81,000 87% findings from the other health conditions are available upon request. The health care claims of 13.1 million individuals with employment-based health benefits in 2022 were examined 10% 85% $29,000 $52,000 86% ® using the MarketScan Commercial Database. It contains information on inpatient, outpatient, and pharmacy 20% 84% $15,000 $31,000 85% claims for workers and their dependents. ® Source: EBRI estimates using 2022 Merative™ MarketScan Commercial Database. Note: ICD-10 codes were used to identify enrollees being treated for the various medical conditions. Claims data, while a valuable source of information Key Findings: for health care research, often undercounts the true prevalence of health conditions due to factors like undiagnosed cases, coding limitations, patient This EBRI Fast Fact illuminates the significant concentration of health care spending within employment-based access issues, and a lack of detailed clinical information. Average spending reflects total health care expenditures, not just those related to the listed condition. health plans, revealing that a disproportionately small segment of the population drives the vast majority of costs. • Most High-Cost Claimants Have One of Five Conditions: Over 80 percent of the highest health care The analysis of 2022 claims data for 13.1 million individuals clearly demonstrates that over 80 percent of the spenders in employment-based health plans had at least one of five common medical conditions: skin highest spenders had at least one of five common medical conditions, with the top 1 percent alone accounting for disorders, respiratory conditions, musculoskeletal conditions, mental health conditions, or heart disease. 87 percent of total spending. While heart disease combined with other conditions represented the most common and costly comorbidity, the findings underscore the critical link between common conditions and high health care • Top 1 Percent Drive Spending: Among the top 1 percent of spenders, nearly nine out of 10 (87 percent) utilization. This insight suggests that employers, who often offer uniform health plans, may need to consider more had one or more of these five common conditions. This group alone also accounted for 87 percent of total tailored approaches to address the complex needs and associated costs of their high-cost claimants, 1 spending, averaging $205,000 per person and $149,000 for median spending. acknowledging the limitations of claims data in fully capturing health prevalence. • • C The omT orb op 5 P idity M ercent att, 1 ers 0 Per : A sce igni ntf,i ca and nt sh 20 Per are of ce tnt F op spen olloder w Sim s had ilar m Pa ultit pl ter e m n:edi For caex l cam ondi plte, ion in t s — he top 20 percent of spenders, 84 percent had one or more of the five conditions we examined, accounting for 86 particularly combinations involving heart disease, respiratory conditions, and mental health conditions — percent of total spending. Average spending was $31,000. which substantially contributed to overall health care spending. It is worth noting this analysis primarily Data and Methods focused on the patterns of one condition alongside at least one of the others to illustrate the general issue of comorbidities. The analysis was not a full examination of all possible comorbidity combinations. ® 1 We analyzed the Merative™ MarketScan Commercial Database, which contains pharmacy and medical Comparing median and mean findings is essential, especially in health care spending data. Because spending data are often Employers could benefit from a more tailored analysis of the specific combinations most prevalent in claims data on a sample of 13.1 million enrollees in a non-capitated employment-based health plan in 2022. highly skewed, the mean can be heavily influenced by a small number of high-cost individuals, overstating the experience of their own populations. most e The st nrollees. udy co The hor me t i dian ncl,uded by coin ndi trast, vidua prol vs un ides a der clea age re r65, r pictu er si e d oifng i whn a at al lty U pical .S. g peog erso rn aph actu ic r ally eg i son pen s, a ds nd — enr mak ol inlg ed it in essential for designing effective health policies. a variety of plan types. Using relevant ICD-10 codes from claims, we derived health condition indicators. © 2025, Employee Benefit Research Institute, 901 D St. SW, Suite 802, Washington, DC 20024, 202/659-0670 | ebri.org 2 3 4