Turn a high-cost care Score priority into a complex-case review action

A low high-cost care score signals that the plan may be reacting to expensive claims after they occur instead of guiding complex care before decisions become fixed. A handful of serious conditions, planned procedures or specialty referrals can shape a large share of annual spend. The employer’s responsibility is not to practice medicine; it is to ensure the plan has an accountable process for supporting members through consequential care decisions.

The High Performance Health Plan approach begins with early visibility and clear roles. Leaders need to know how a complex case is identified, who reaches out to the member, what clinical resources are available and how options such as centers of excellence, second opinions, site-of-care alternatives and care navigation are considered. Without a defined process, the plan defaults to the most familiar path rather than the best-supported one.

For the next 90 days, create a complex-case review for one high-impact care category. Select a category with meaningful cost, variation or member disruption—such as cancer care, musculoskeletal surgery, infusion therapy or advanced imaging. Map the identification trigger, member outreach sequence, clinical decision support, vendor handoffs and the escalation path when timely support is not available.

Set a practical review cadence with the responsible partners. Examine whether cases were identified early, whether members accepted support, which care choices were made and what barriers appeared. Ask the vendors to explain how they measure quality, experience and financial impact—not simply utilization reduction. Record the lessons, open issues and the accountable owner for each follow-up item.

This Roadmap action creates a repeatable management routine: identify a complex case early, give the member a clear path to clinically appropriate support and learn from every handoff. As the process matures, the employer can broaden it to additional conditions and connect it to primary care, navigation and provider strategy. Better high-cost care management is not a single vendor decision; it is a disciplined way to guide people through the moments that matter most.