What to measure
Evidence before assumptions.
- Complex-case engagement
- Episode cost
- Second-opinion use
- Clinical outcome indicators
← The Framework
Component 07
High-Cost Care & Clinical Strategy
Do employees have a better pathway when healthcare becomes expensive or complex?
Clear definition
High-cost care and clinical strategy creates intentional pathways for the relatively small number of episodes and members that can drive a disproportionate share of plan spending.
Common mistakes
What weakens performance.
- Relying on a PPO alone for complex-care decisions
- Starting support only after a major claim is paid
- Using cost as the only definition of success
High-performance practices
Build a deliberate approach.
01
Build pathways for cancer, surgery, musculoskeletal care and specialty medications
02
Use centers of excellence and second opinions when clinically appropriate
03
Coordinate advocacy, clinical support and benefits design
Definitive employer guide
High-cost care is defined by both cost and complexity. A small number of episodes can shape a plan’s financial results and an employee’s experience, making early identification and thoughtful support essential.
The goal is not blunt cost containment. It is a better pathway to appropriate care, informed choices and accountable clinical support before decisions become urgent.
Why high-cost care requires a strategy
Complex episodes often involve fragmented information, variable quality and time-sensitive decisions. A passive PPO model rarely provides the coordination needed at the critical moment.
The practical question is not whether a vendor offers this capability. It is whether the plan team has a clear owner, decision standard and review cadence that turns information into action for employees and the organization.
Finding the episodes that matter
Analyze emerging and historical spend by condition, provider, site of care and member journey. Pair financial data with clinical insight rather than relying on catastrophic claims lists alone.
The practical question is not whether a vendor offers this capability. It is whether the plan team has a clear owner, decision standard and review cadence that turns information into action for employees and the organization.
Centers of excellence and second opinions
These options can help when used for defined clinical situations and supported by a member-centered referral path. Their value should be measured through quality, experience and total episode cost.
The practical question is not whether a vendor offers this capability. It is whether the plan team has a clear owner, decision standard and review cadence that turns information into action for employees and the organization.
Care navigation and clinical support
Employees need a visible route to expert help before a major procedure or specialty treatment is selected. Navigation, advocacy and benefit design must work together.
The practical question is not whether a vendor offers this capability. It is whether the plan team has a clear owner, decision standard and review cadence that turns information into action for employees and the organization.
Measuring value beyond savings
Track appropriateness, access, outcomes, avoidable complications and member experience alongside financial results.
The practical question is not whether a vendor offers this capability. It is whether the plan team has a clear owner, decision standard and review cadence that turns information into action for employees and the organization.
Five metrics every employer should monitor
High-cost episode concentration
Track this measure monthly or quarterly, compare it with prior periods, and connect variance to a named decision or accountable owner.
Second-opinion engagement
Track this measure monthly or quarterly, compare it with prior periods, and connect variance to a named decision or accountable owner.
Site-of-care variation
Track this measure monthly or quarterly, compare it with prior periods, and connect variance to a named decision or accountable owner.
Total episode cost
Track this measure monthly or quarterly, compare it with prior periods, and connect variance to a named decision or accountable owner.
Member experience and outcomes
Track this measure monthly or quarterly, compare it with prior periods, and connect variance to a named decision or accountable owner.
Maturity progression
Crawl. Walk. Run. Sprint.
Crawl
Establish baseline data, assign ownership and document the immediate decision gaps.
Walk
Create a recurring review cadence and use evidence to challenge vendor assumptions.
Run
Integrate the work into benefit design, contracting and employee-facing pathways.
Sprint
Continuously test results, refine incentives and share clear performance accountability.
Ten questions to ask
- 01Which conditions and episodes drive material spend?
- 02When does the plan identify an emerging complex case?
- 03How can employees access an independent second opinion?
- 04What clinical criteria guide centers of excellence?
- 05Are site-of-care choices evaluated?
- 06Who coordinates navigation and benefit coverage?
- 07How do we measure clinical quality?
- 08How do we prevent surprise bills and disruption?
- 09What vendor incentives affect recommendations?
- 10Which pathway should be improved in the next 90 days?
What good looks like
Managed, not merely renewed.
A high-performing approach is transparent, actively governed and connected to employee experience. It gives leaders a repeatable way to test assumptions, make tradeoffs and improve outcomes over time.
Related 
- High-Cost Care Playbook
- Complex-Care Case Review Guide
- Health Plan Score Priorities Brief
Frequently asked questions
Where should an employer begin?
Start with the plan data, contract language and governance process already in place. Identify the decisions that lack evidence, then establish a focused 90-day diagnostic work plan.
Is this only relevant at renewal?
No. Renewal is an outcome of year-round management. The highest-value work happens before terms are presented, while there is time to analyze, negotiate and design a better approach.
Sources & references
Evidence that supports the work.
This guide combines the Framework methodology with primary government guidance and independent health-policy research. Sources are included for further review and are not legal, tax or clinical advice.
- Reviewed / updated
- Framework component
- High-Cost Care & Clinical Strategy
- Book connection
- Chapters 21–23
- Author
- Corry Hull, REBC®, CSFS® — Vice President of Employee Benefits, BHC Insurance; Health Rosetta Advanced Advisor; author of The High Performance Health Plan.
U.S. Department of Labor — Employee Benefits Security Administration↗Centers for Medicare & Medicaid Services — Transparency in Coverage↗U.S. Department of Health & Human Services — No Surprises Act↗Internal Revenue Service — Publication 15-B↗KFF — Employer Health Benefits Survey↗RAND — Hospital Prices Paid by Private Health Plans↗
Book connection
Chapters 21–23: Managing complex care
Chapters 21–23
The clinical-strategy chapters help leaders focus on the episodes that disproportionately shape plan cost and experience.
Explore the bookHealth Plan Score connection
High-Cost Care & Clinical Strategy
Are complex cases supported with defined pathways, expert guidance and outcome measures?
A lower score points to a focused review of high-cost episodes and available clinical support pathways.
Take the Health Plan ScoreDecision-support documents
Put the strategy to work.
resourceHigh-Cost Care Playbook
A printable Employer Benefits IQ worksheet for defining the decision, evidence, accountable owner and review cadence.
Author perspective
Corry Hull, REBC®, CSFS® — Vice President of Employee Benefits Consulting at BHC Insurance, Health Rosetta Advanced Advisor, author of The High Performance Health Plan, founder of Employer Benefits IQ, 2026 Health Rosetta Rosie Award recipient, public speaker and employee benefits strategist.
Explore the Health Plan ScorePut the methodology to work
Apply the HPHP methodology with .
Employer Benefits IQ is the practical application platform for employers who want to use education, tools, data, vendor intelligence and decision support in real-world benefits decisions.
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