More than half of all Americans have employer-based health insurance, but most research on high-need, high-cost individuals has focused on Medicare and Medicaid recipients. This resource takes a close look at the population of individuals with complex needs who are privately insured by a large employer in Pennsylvania.
- In a three-year period, the persistent high-user group represented 2.9 percent of the total population, while accounting for 21 percent of total spending.
- Many individuals in this group have multiple chronic conditions, especially hypertension, diabetes, and respiratory illness.
- Individuals with at least two conditions had significantly higher chances of being in the persistent high-user group than individuals with one condition.
- The highest costs for this group were associated with professional services and medication; these individuals also had many more outpatient primary and specialty care visits than any other group.
- Employer-based health insurance plans may be able to lower costs for individuals with complex needs through use of medical homes, nurse telehealth models, community paramedicine, and value-based insurance design.
- What are the characteristics of persistent high users in an employer-based health insurance plan?