Protect Your Health Plan From the Nation’s Top Killer

The Centers for Disease Control and Prevention (CDC) reports that heart disease costs the U.S. more than $400 billion each year. That includes the cost for health services, medication and lost productivity.

Heart disease is consistently in the top 10 list of most costly claims. Typically, claims for an employee or a dependent with heart disease cost their plan more than $50,000 a year.

Heart Disease Claims Are Infrequent but Expensive

According to the Sun Life High-Cost Claims Report, high claimants such as these make up less than 2% of claims. However, they represent more than 18% of all stop-loss claims reimbursements for self-insured plans.

Heart disease also contributes disproportionately to the number of office visits and emergency room visits each year. The CDC says 6.7% of all visits to a physician and 5.9% of all emergency department visits are related to heart disease.

The total cost of heart disease is projected to reach $1.1 trillion by 2035. And $748.7 billion of that will represent the direct cost of care.

How to Protect Your Plan

Case management programs are one of the best ways to control the costs associated with heart disease. These personalized, high-touch programs first identify employees with chronic conditions that contribute to the disease. They then connect them with the right providers and resources to coordinate treatment plans. This form of intervention can motivate employees to prevent recurring conditions, which in turn lowers costs for health plans.

Patient navigators also work with employees to connect them to the resources they need and act as advocates. They can help explain health care and disability benefits. They can also recommend assistance for dealing with the emotional impacts of serious illnesses like congestive heart failure.

You may also want to:

• Encourage employees and their dependents to take advantage of preventive care benefits. Annual physicals, lab tests and screenings all help identify risk factors for heart disease.

• Educate employees about the benefits of managing chronic illnesses like high blood pressure and high cholesterol. Encourage them to regularly follow up with their primary care physician and take medication as directed.

• Cover the cost of second opinions. These visits can identify alternative treatment options and may provide access to more cost-effective care from a different provider.

• Provide wellness options that encourage healthy lifestyles, including exercise programs, access to a nutritionist, mental health support and more. Be sure to invite dependents to participate as well.

• Implement commercial claims reviews to evaluate all high-dollar claims and ensure appropriate billing. This review allows you to examine not just an itemized bill but also medical records and associated claim forms. A complete evaluation may result in adjusted payments.

You can also take a strategic approach.

• Evaluate health care claims and prescription drug data to determine what health risks are most prevalent. This includes analyzing employee demographic data as well as the number of:

  • Doctor visits

  • Inpatient days

  • Outpatient visits

• Conduct biometric screenings to identify any undetected risk factors that lead to heart disease. This would include testing for:

  • Diabetes

  • High blood pressure

  • High cholesterol

All of this data will help you not only identify health issues within your employee population but also establish a potential cost for ongoing care.

Talk to your broker or benefits adviser if you would like more information about creating a plan to address the cost of heart disease before it becomes a problem. They can help you identify at-risk employees and carve out a wellness plan to help them manage their health. They can also help you put stop-loss coverage in place to protect your plan from large claims.

This content is for informational purposes only and not for the purpose of providing professional, financial, medical or legal advice. You should contact your licensed professional to obtain advice with respect to any particular issue or problem.

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