Holistic Clinical Prevention: Leveraging Integrated Data to Predict the Top 5% for Intervention

By Justin Schaneman, MS

Vice President, Data Analytics
HCMS Group

By Rene Sims, MSN

Vice President, Clinical Services
HCMS Group

Many employers receive an annual report from health plans listing high-cost claims. And most find themselves looking in the rear-view mirror wondering what they could have done to prevent such costly episodes or at least reduce their impact.

This impact goes far beyond the rising costs of healthcare; the study found that the top 5% of cases drove over 50% of overall spending when absenteeism, disability, and workers’ compensation were included. Fortunately, it is possible to leverage integrated data to predict which individuals are headed toward this top 5%, allowing employers to offer uniquely targeted clinical prevention.

The stakes are high and rising. The HCMS Group’s Research Reference Database, covering 3.8 million members, revealed that the number of cases costing at least $100,000 a year has climbed 16% since 2015 and now averages 5 per 1,000 members. Cases costing $500,000 or more a year have increased 22% over the same time period. These rate increases affect employers of all sizes and from all industries. The database includes employees who had no claims, rounding out the picture of the employee population.

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