Insurers' focus: The top 1% of health spenders

Companies shift strategies as they prepare for reform law

Topics: Care Coordination, Methodologies, Performance Improvement, Reimbursement, Finance

February 29, 2012

Insurers are expected to more closely monitor the heaviest users of health care—partly by pressuring providers—as they aim to curb costs before new federal health reforms take effect in 2014, the New York Times reports.

Under the overhaul, insurers no longer will be permitted to deny coverage to individuals with pre-existing conditions or put lifetime limits on coverage. As a result, health insurers are expected to look for ways to control costs for expensive customers.

According to a recent study, 1% of patients account for more than 25% of private insurance health spending, and their medical bills average about $100,000 annually.

Many insurance executives say their companies already are developing programs targeting such patients. For example, health insurers often work with self-insured employers to manage employees' health conditions, the Times reports.

Meanwhile, some insurers also are experimenting with strategies to identify more costly patients and those who could develop serious complications. For example, HealthPartners' health plan in some instances assigns high-risk patients a case manager—who monitors the patient's health post discharge—and a social worker, who assists with medication costs.

According to the Times, insurers also are experimenting with quality-based payment models. For example, Cigna plans to pay physicians higher rates to coordinate care and is looking at ways for physicians to share savings generated by helping patients avoid hospital visits (Abelson, Times, 2/27).

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Rating: | kenneth olshansky | February 29, 2012

Targeting high cost patients and providing education and case managers are essential but until there are carrots and sticks for patients to take responsibility for their own health,then in my opinion, nothing will change. Insurance policies must be designed so those patients with, especially, "controllable risk factors" (e.g. obesity,type II diabetes,high blood pressure, etc.) meet certain obligations to keep their premiums down.