A Small Group of Care Decisions Drives a Disproportionate Share of Benefits Spend.

Health spending isn’t spread evenly. KFF’s analysis of 2023 federal survey data found that 5% of the U.S. population accounted for nearly half of all health spending and the lower-spending half of the population accounted for just 3%.

For anyone managing a benefits budget, that shape matters. It means the budget isn’t driven by everyday use. It’s driven by a relatively small number of high-cost events.

The decisions behind the numbers

Many of those events are fueled by decisions, and a handful of categories come up again and again: elective surgery, advanced imaging, and infusion therapy. They have two things in common. They’re expensive, and they’re usually plannable. A member typically knows in advance that something is coming up before the care happens. 

That gap between knowing and acting is where the opportunity sits. When care can be planned, a member can weigh options. When the member can weigh options, where the member goes becomes a real choice.

Same care, different setting

Take imaging for example. The Health Care Cost Institute (HCCI) found that imaging made up 24% of hospital outpatient visits and 17% of hospital outpatient spending among people with employer-sponsored insurance in 2022. It’s one of the most common services in the outpatient setting, and one of the costliest. 

It’s also one where the setting matters. HCCI found that imaging prices at hospital outpatient departments ran two to four times higher than at physician offices. For the most complex category it studied, the average was $1,416 in a hospital outpatient department versus $387 in an office. When that’s multiplied across several dozen members (or more), the consequences of those choices become clear. 

Same scan. Different setting. A very different price for the member and for the plan.

Remember the member from last week, searching for a knee MRI? She didn’t know the care setting was a choice, and nothing in front of her suggested it. She isn’t an outlier. Most members don’t realize that where they get care is something they can decide.

What if help came before the decision? 

Think about what changes if a plan could identify members heading toward these decisions earlier, before they’ve picked where to go. The conversation would happen while the choice is still open, not after it’s made.

Whether that’s worth pursuing depends on whether it can be done honestly. That’s the real question underneath the idea, and it’s where most claims about “predictive” benefits fall apart.

What it takes to identify these decisions earlier

No single source shows the whole picture. Claims record care a member has already received: a diagnosis, an imaging study, a specialty medication. That history can likely point to what’s next. It’s complete and authoritative, but it arrives after the fact. 

What claims can’t show is what the member says she needs. When she searches for a procedure in the HealthJoy app or asks JOY, our virtual care assistant, about what she’s dealing with, she’s telling us what she’s looking for in her own words, often before she has chosen anywhere to go to receive care. HealthJoy holds both under one member identity, so each source fills in what the other can’t see. 

We call what comes out of this a signal. It’s not a diagnosis and it’s not a statement about what any one person will do. It’s a way of identifying earlier that a member may be heading toward a decision, so help can reach her while there’s still a choice to make. That information exists to serve the member’s own experience. 

Not every behavior carries the same weight. In our recent poll, we asked which behavior tells you the least about whether a member is heading toward high-cost care. The answer was a visit to a primary care doctor. Nearly everyone sees one, so a visit on its own says very little. Behaviors that point to a specific need, like searching for a procedure, asking about a specialist, or starting a specialty medication, say far more.

Back to the original question

If a small group of decisions drives a disproportionate share of benefits spend, the pivotal moment isn’t found in what those decisions ultimately cost. It’s whether a member receives help while the choice is still open.