CLAIMS DEEP DIVE
High-cost claimants increase financial risk
Clinical insights
Increasing healthcare utilization, medical inflation, and the chronic disease burden are pressuring employer health plans. Watch a breakdown of why these trends matter, what’s driving volatility, and how prevention and long-term strategy can help.
Just 1% of members account for 33% of total plan costs
As healthcare costs continue to climb, more members are reaching high-cost claim levels, and the severity of these claims is rising. Leveraging Infolock®, the 2025 High-Cost Claimant Report found that just 1% of members (those with annual claims over $100K) account for 33% of total plan paid. These members face complex health challenges — such as cancer, autoimmune diseases, cardiovascular conditions, and rare disorders — while also balancing workplace and family responsibilities.
HIGH-COST CLAIMANT INCREASES
(2022-2024)
Source: Lockton High-cost Claimant 2025 Report
Key insights:
average annual spend per HCC.
The top 10 claimants in 2024 exceeded $4M each, with the highest reaching $9.15M.
Nearly 80% of HCCs have a specialty drug claim, and many receive infusions in high-cost hospital outpatient settings.
Near-million ($500K+) and million-plus ($1M+) claims have grown more than 40% since 2022. This trend reflects a structural shift in risk exposure for employer plans, driven by specialty drugs, complex conditions, and site-of-care patterns.
Members with HCCs have significantly higher instances of comorbidity burdens.
Where risk lives: Consistent high-cost claim patterns
The top five paid claims categories remain consistent across all HCC thresholds:
- Cancer
- Circulatory system
- Musculoskeletal system and connective tissue
- Dermatologicals
- Analgesics — anti-inflammatory
These patterns highlight growing financial risk exposure for employers, reinforcing the need for earlier detection, targeted navigation, and strategic clinical intervention.
Strategic levers for employers
As severity and volatility rise, employers need to focus on strategic and targeted intervention in key, high-impact areas that address cost and clinical outcomes.
Complex claims intervention
Identifying and intervening in high-cost areas, such as infusion cost optimization, newborn benefits coordination, and pediatric therapy, can lead to savings for employers.
Site-of-care optimization
Hospital outpatient settings account for 55% of medical benefit infusions, the most expensive site of care. Shifting to home or office settings can yield significant savings. Subcutaneous formulations (e.g., Darzalex Faspro) offer alternatives to hospital-based administration.
Precision diagnosis & specialty care access
Early intervention for members with unresolved conditions improves health and cost outcomes, with the Lockton and Mayo Clinic partnership resulting in $98K-$202K savings per patient while removing barriers to specialized care access.
Mental health & chronic disease management
Mental health PMPM costs increased 27% year-over-year, with depression and anxiety affecting nearly one in five high-cost claimants. When mental health conditions occur alongside chronic physical illnesses, they significantly amplify both cost and risk, underscoring the need to integrate mental health into chronic condition management.
Gene therapy monitoring
While utilization of gene therapies remains lower than early market projections, the pipeline continues to expand — necessitating proactive planning for future exposure. For self-funded employers, securing adequate stop loss coverage is critical to mitigate the financial risk of these high-cost treatments.
Cancer prevention & early detection
Cancer is the leading cost driver among HCCs, yet nearly 50% of cancers are still detected at late stages.
Proactive clinical intervention before high risk becomes high cost
Data-driven outreach and proactive clinical engagement help identify and support high-risk members before they become high-cost claimants.
Focus on nutrition
Poor nutrition is a foundational driver of chronic disease and a major contributor to conditions that drive high-cost claims. Diet-related conditions such as type 2 diabetes, hypertension, cardiovascular disease, and obesity are increasingly prevalent among employer populations. Nutrition therapy, delivered by registered dietitians, is an evidence-based intervention that employers can integrate into their benefits strategy to help drive cost savings and improve employee health.
Intervention in action: Lockton Nurse Advocate (LNA)
LNA uses Lockton’s proprietary population health platform, Infolock, to identify members with chronic conditions, gaps in care, or emerging risk factors. Licensed nurses then engage these members through:
- One-on-one health coaching.
- Navigation support for care and benefits.
- Education on treatment options and wellness activities.
- Coordination with wellness vendors for incentive-based programs.
LNA monitors outcomes such as care gap closures, ER avoidance, and reduced medical spend. This early intervention model helps redirect members toward better health trajectories before costs escalate.
