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  • Writer's pictureAli Panjwani

Predicting the Seemingly Unpredictable: Anticipating High-Cost Health Claims

Healthcare costs have emerged as a significant stress factor for self-funded employers, with high-cost health claims representing a substantial challenge. According to the Sun Life Catastrophic Report 2023, a staggering 20% of employers experienced at least one member with over $1 million in claims over a four-year period (Sun Life, 2023). As healthcare services and drug therapies become more advanced and costly, HR benefits professionals and consultants are navigating a sea of financial and emotional stresses, seeking innovative approaches to predict and manage these expenses effectively.

Enter AI—specifically, patient journey analytics from Merit Medicine, a pioneer in the field of health tech. By harnessing the predictive power of our comprehensive data and AI capabilities, Merit Medicine provides a beacon of hope in this turbulent landscape.

Understanding the Challenge

Forward-thinking benefits professionals know that the numbers in the Sun Life report transcend just simple numerical values.They represent the unpredictability and volatility that beleaguer employers and HR departments nationwide every day. In the past four years, we have seen a 45% increase in the number of million-dollar claims, from 109 claims per million covered members to 158, highlighting the urgent need for HR teams to anticipate and plan for these events (Sun Life, 2023) .

The emotional toll on HR professionals managing benefits is often overshadowed. Yet, the responsibility of maintaining a balance between providing quality care and managing costs weighs heavily on their shoulders. The strategy is not just a financial consideration; it's a matter of employee wellbeing and corporate health.

Introducing the Solution: AI and Patient Journey Analytics

Merit Medicine's AI-driven patient journey prediction platform stands at the forefront of innovation. We are more than a technology solution; we are a strategic partner for HR professionals, designed to anticipate high-cost medical events. Our longitudinal dataset includes millions of patients' histories, allowing a refined forecast of potential high-cost medical spending and specialty drug use critical for risk management and budgeting.

The Power of Prediction

Predictive analytics can translate into actionable intelligence, affording HR benefits professionals a clear view into the future of their healthcare expenses. Armed with this information, they can make well-informed decisions about budget allocations, employee coverage, and stop-loss insurance.

The utilization of Merit Medicine's platform shows that accurate forecasting isn't just a concept—it's an achievable advantage. Empowering employers with the ability to predict their high-risk and soon-to-be high-risk patients might cost in the next 12-18 months is a game-changer, potentially saving a company millions in premium spend and preventing insufficient budgeting for such events.

Implementing AI in Healthcare Risk Management

For HR benefits professionals and consultants, the pathway to incorporating AI-driven solutions like Merit Medicine involves several considerations. Essential among them are:

  • Evaluating and selecting the right partner

  • Ensuring privacy and security when handling sensitive healthcare data

  • Crafting clear communication strategies to explain value to employers and impact on employees

The journey to integration may seem daunting, but the benefits—both financial and human—make it a worthwhile venture.

Embracing the Future of Healthcare

As the landscape of healthcare continues to evolve, so too must our strategies for managing costs. For HR professionals, the adoption of responsible AI-driven solutions represents a proactive approach to a typically reactive circumstance.

Merit Medicine invites you to consider the future—a future where rising healthcare costs are not only anticipated but strategically managed. In this era of tech-enabled foresight, HR leaders have an unprecedented opportunity to mitigate risks and uphold the wellbeing of both their companies and employees. As the report posits and Merit Medicine demonstrates, the improbable task of predicting the unpredictable is not just plausible. It’s here.

For more information about Merit Medicine and our expert application of AI in transforming healthcare spending, please join the waitlist.

Adapt, anticipate, and take control. The future of healthcare is precision-guided and empowered by advanced analytics.

Sun Life. (2023). Sun Life Catastrophic Report (2023 Edition). Retrieved from


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