Figure 1 Figure 2 Spending on Health Care Services, by Health Care Spending Levels, 2022 Spending on Outpatient Services, by Health Care Spending Levels, 2022 Figure 3 Spending on Prescription Drugs, by Health Care Spending Levels, 2022 Under $50,000 $100,000 $250,000 $500,000 $1 Million $2 Million Under $50,000 $100,000 $250,000 $500,000 $1 Million $2 Million Total Total $50,000 or More or More or More or More or More or More October 23, 2025, #547 $50,000 or More or More or More or More or More or More Under $50,000 $100,000 $250,000 $500,000 $1 Million $2 Million Total Inpatient $50,000 or More or More or More or More or More or More Primary Care 18% 9% 29% 33% 37% 42% 49% 58% 7% 10% 2% 2% 2% 1% 1% 1% Services Physician Visits Retail Outpatient 25% 22% 28% 25% 19% 13% 10% 6% Specialist Visits 20% 27% 11% 10% 8% 7% 4% 4% Pharmacy 51% 67% 31% 26% 23% 21% 23% 20% Services Unlocking Health Benefits: Where Employer Specialty Mental Health 7% 4% 2% 5% 12%2% 16%1% 22%1% 24%1% 18% 1% 17% 0% Prescription Prov M id ee dri c V ait siio ts ns 31% 24% 41% 41% 41% 37% 29% 22% High-Cost Spending Often Goes Drugs ® Source: EBRI estimates using 2022 Merative™ MarketScan Commercial Database. ® Physical Therapy & Source: EBRI estimates using 2022 Merative™ MarketScan Commercial Database. 1% 2% 0% 0% 0% 0% 0% 0% Chiropractor Visits This is the fourth in a series of EBRI Fast Facts related to the uneven distribution of health care spending. Health Percentages may sum to more than 100 percent due to rounding. care use and spending are highly concentrated, with a small share of individuals accounting for a disproportionate Emergency 7% 10% 3% 2% 1% 1% 1% 0% amount of total costs. These “high-cost claimants” typically have complex and intensive medical needs, often Department Visits related to chronic conditions. However, the definitions of high-cost claimants vary, commonly relying on In summary, for individuals with lower overall health care expenditures, a larger share of their prescription drug Key Findin Urgs f gentor Ca r Out e Vis p itati s ent Spen 1% ding 1% 0% 0% 0% 0% 0% 0% spending thresholds or percentile cutoffs. spending is on retail pharmacy-dispensed medications. However, as total health care spending increases, there’s a Lab Services 5% 7% 2% 2% 2% 2% 2% 1% clea r shift, with specialty medications consuming a larger proportion of prescription drug spending. This shift • Specialist visits accounted for the largest share of outpatient spending. Overall, spending on specialist This Fast Fact examines the composition of spending in employment-based health plans. It looks at how spending starts with individuals with $250,000 or more in total spending, where we see that specialty medications X-rays, CT Scans, visits accounted for about 40 percent of outpatient spending and 20 percent of total spending (Figure 2). on inpatient services, outpatient services, and prescription drugs varies by overall level of spending. It also 3% 5% 2% 1% 1% 1% 0% 0% or MRIs acc ounted for 22 percent of total spending, while retail pharmacy-dispensed drugs accounted for 19 percent of • Primary care physician visits and emergency department visits each represented 7 percent of total examines the composition within outpatient services and prescription drugs. total spending. spending. Other Outpatient 4% 0% 9% 8% 8% 9% 14% 12% Services • Lab services made up 5 percent of total spending, followed by mental health provider visits and other The health care claims of 13.1 million individuals with employment-based health benefits in 2022 were examined ® Summary ® outpatient services at 4 percent each. using the Mar SouketS rce: EB can RI es tComm imates uercia sing 20 l d 22 at Me abases rative™ .M Th arkey etSccon an tain Com m in efo rcia rlma Dattio aban seon . inpatient, outpatient, and pharmacy claims fo • X r wo -rayrk s, CT ers and scan th s,eir d or M epend RIs; ents. physica l therapy/chiropractor visits; and urgent care visits constituted smaller For employers navigating the ever-increasing complexity of providing health benefits, this analysis underscores a proportions of total spending (3 percent, 1 percent, and 1 percent, respectively). critical fact: Health care spending is highly concentrated among a small segment of individuals. Crucially, the Key Findings: compo Key Fi sitio ndin n of gs f thor at spen Prescripti ding dram on Dru aticalg Spending ly shifts as spen ding escalates. While traditional outpatient services T rends Across Health Care Spending Levels for Outpatient Services dominate lower spending tiers, inpatient services are the top driver of spending among enrollees using the most • Overall, 18 percent was spent on inpatient services, 51 percent on outpatient services, and 31 percent on W health e grou care ped . T pr o esc effectively ription drug manag spend e ben ing efin its sp to two end catego and ensu ries: retail p re sustainab harmac le ofy ferings, emplo -dispensed dru yers must gs, whichtake a d are eeper • Primary care physician visits; specialist visits; mental health provider visits; physical therapy/chiropractor prescription drugs (Figure 1). di adju ve i di nt cate o the d th data an rough d thmov e phe bey armacy b ond broad enefit,- and brush sp strategies. ecialty medication Understand s, which ing an are d strategically adjudicated th add rou ress gh th ing e me the un dical ique visits; emergency department visits; urgent care visits; lab services; and X-rays, CT scans, or MRIs all • Inpatient Services: As health care spending increased, the proportion allocated to inpatient services and plan. o ften complex needs of high-cost claimants is no longer merely beneficial, but essential for optimizing health showed a consistent pattern: They represented a significantly higher percentage of overall spending for significantly rose. For enrollees with under $50,000 in spending, inpatient services represented only 9 plan performance and safeguarding financial stability. enrollees with under $50,000 in total health care spending. As overall health care spending increased, percent of their total health care expenditure. This jumped to 58 percent for those with $2 million or more • Retail pharmacy-dispensed drugs constituted the majority of overall prescription drug spending at 25 their proportional share generally decreased. in spending. Data and Methods percent of total spen ding (Figure 3). • For instance, specialist visits accounted for 27 percent of total spending for those under $50,000 but only • Outpatient Services: Conversely, outpatient services accounted for a decreasing share of health care • Specialty medications accounted for a smaller proportion at 7 percent. 4 percent for those with $1 million or more in spending. spending as total spending increased. They made up 67 percent of spending for enrollees under the ® We analyzed the Merative™ MarketScan Commercial Database, which contains pharmacy and medical • Similarly, emergency department visits were 10 percent of total spending for the lowest-spending group $50,000 threshold, but this dropped to 20 percent for those with $2 million or more in spending. claims data on a sample of 13.1 million enrollees in a non-capitated employment-based health plan in 2022. Trends Across Health Care Spending Levels for Prescription Drugs but dropped to 0–1 percent for the higher spending tiers. • Prescription Drugs: For enrollees with under $50,000 in total health care spending, prescription drugs The study cohort included individuals under age 65, residing in all U.S. geographic regions, and enrolled in • Some services, like physical therapy/chiropractor visits and urgent care visits, became negligible (less constituted 24 percent of their expenditure. This percentage rose to 41 percent for those spending $50,000 a variety of plan types. Using relevant ICD-10 codes from claims, we derived health condition indicators. • The proportion of total spending on retail pharmacy drugs generally decreased as total health care th oran mor 0.5 e, $ percent 100,000 ) at h orig m her s ore, an pen d di $2 ng 50,000 levels. o r more. Beyond these thresholds, the proportion began to spending levels increased. It was highest for enrollees with $50,000 or more in spending (28 percent), decline. For those with $500,000 or more in spending, it dropped to 37 percent, then to 29 percent for A Thank thY en steadi ou to Members ly decline : d Th fro is stu m 25 dy percent was con for ducte those sp d throug end h ing the EBRI Center $100,000 or mor foe r Resea to a lorw o ch o f 6 n Hea percent lth Benefits for The “other outpatient services” category stands in stark contrast to the others. It accounted for 0.3 percent of those spending $1 million or more, and finally to 22 percent for the highest spending group, those Innovation (EBRI CRHBI), with the funding support of the following organizations: Aon, Blue Cross Blue Shield those with $2 million or more in spending. This suggests that for individuals with high overall health care spending spen amo di ng ng enr $2 ol m lees illio with n or u mnd ore er $5 . 0,000 in health care spending. However, its share increased substantially Association expend , Joh itu nso res, p n & Jo harmac hnson y-, di JP spen Mor sed d ganru Ch gs ase ma , an de up d Ph a s RMA. maller r elative portion of their total drug costs. as overall spending rose, reaching 9 percent for those with $50,000 to $500,000 or more in spending, then peaking • In stark contrast, the proportion of spending on specialty medications showed a substantial increasing at 14 percent for those spending $1 million or more before slightly decreasing to 12 percent for those with $2 In essence, prescription drug spending as a proportion of total health care spending peaked in the middle-to-higher The Employee Benefit Research Institute is a private, nonpartisan, and nonprofit research institute based in trend with higher health care spending levels, up to a certain point. It started very low at 2 percent for m spen illio din ng or tiers more (fro in sp m $5 end 0,ing. 000 Th to $25 is sug 0,000 gests th ) anat as in d then d di evi crea dus als in ed fo cur r th sig e very nificantly highes hi t-gh spen er to ding tal hea enrollees. Th lth care cos is ts, a Washington, D.C., that focuses on health, savings, retirement, and economic security issues. EBRI does not lobby 1 those spending under $50,000. It then rose through the middle spending tiers, reaching its peak at 24 larger portion of their outpatient spending is attributed to services not falling into the specific categories listed. reflects that in the highest spending categories, other health care services (like inpatient care, as observed and does not take policy positions. The work of EBRI is made possible by funding from its members and percent for those spending $500,000 or more. It decreased to 18 percent for those with $1 million or more previously) became significantly more dominant in the overall expenditure. sponsors, which include a broad range of public and private organizations. For more information, visit in spending and to 17 percent for those with $2 million or more. This indicates that as total health care www 1 .ebri.org. spending increased, a larger proportion of that spending was directed toward specialty medications. High The Outpatient Services Table contains encounters and claims for services that were rendered in a doctor’s office, hospital users of health care are typically individuals with significant, intensive, and complex medical needs, often outpatient facility, emergency room, or other outpatient facility. A small percentage of claims in this table may represent requiring ongoing or intensive care for chronic conditions. inpatient services, because the claim was not incorporated into an inpatient admission (e.g., no room and board charge was found). These claims generally have an “inpatient” Place of Service (STDPLAC) code. © 2025, Employee Benefit Research Institute, 901 D St. SW, Suite 802, Washington, DC 20024, 202/659-0670 | ebri.org 2 3 4