5 Chronic Diseases Plague High Spending Group Health Plan Members

Group health insurance plan members with high healthcare spending often have one or more of the same five chronic diseases, according to a fast facts sheet from the EBRI Center for Research on Health Benefits Innovation (EBRI CRHBI).

The study covered healthcare claims from 8.6 million group insurance health plan members using 2021 data from the Merative MarketScan Commercial Database. Members were 65 years of age or younger and the health plans covered a variety of types.

Five conditions were very common among the group health insurance plan members with the highest healthcare spending: heart disease, respiratory conditions, musculoskeletal conditions, nervous system conditions, and skin disorders. A couple of these are among the most expensive chronic diseases in the US. They are also some of the most common comorbidities.

Eight out of ten members had one or more of these conditions. One percent of members contributed 91 percent of all group health plan spending.

In the top one percent of healthcare spenders in group health plans, the average spending amount was $200,000. More than nine out of ten had one or more of the five, previously mentioned chronic diseases.

Researchers found that 50 percent of the top one percent of spenders had a combination of heart disease with at least one of the four other conditions and 50 percent had a nervous system condition and at least one of the four other conditions. Additionally, 46 percent had a respiratory condition, 39 percent had a musculoskeletal condition, and 32 percent had a skin disorder.

The second tier of members—the top two to five percent of spenders—spent on average $80,000 on healthcare. Just shy of nine out of ten enrollees had one or more of the top five chronic diseases. One of the most common conditions in this group was heart disease.

The top six to ten percent of healthcare spenders spent $50,000 on average. Nervous system conditions were common for this group.

The final tier—11 to 20 percent of the healthcare spenders—spent $30,000 on average and represented 87 percent of healthcare spending among group health insurance plan enrollees. A third of this group had a heart disease plus one or more of the four other conditions and three out of ten had at least a musculoskeletal condition.

These results underscore the prevalence and financial impact of chronic diseases among group health plan members. The research joins a host of studies that seek to identify spending and prevalence trends and that can be useful for payers seeking to manage members’ costs.

The pervasiveness of chronic diseases combined with price increases has created a strained financial environment for health insurers and members alike. At the beginning of 2023, experts predicted that this duo would drive a more significant uptake of value-based care solutions among healthcare stakeholders.

Apart from value-based care, payers have utilized at-home chronic disease solutions to help members manage their conditions and their costs. For example, Blue Cross Blue Shield of Massachusetts launched its Nudge Unit to deliver messages to both members and their providers in order to support timely, effective chronic disease management.

Despite the presence of the solutions, the financial situation remains dire. Employers and health insurers have been braced for the steep ascent in healthcare prices for the last couple of years in the wake of the coronavirus pandemic.