What to measure
Evidence before assumptions.
- Complex-case engagement
- Episode cost
- Second-opinion use
- Clinical outcome indicators
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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
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.
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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 ScoreEmployer Benefits IQ resource
High-Cost Care Playbook
A printable Employer Benefits IQ worksheet for defining the decision, evidence, accountable owner and review cadence.
Author perspective
By Corry Hull, REBC, CSFS — Author, The High Performance Health Plan and Founder, Employer Benefits IQ.
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