A high-cost claim is a care-pathway decision

High-cost claims often arrive as urgent financial events, but they begin as care-pathway decisions. When an employer scores low in high-cost care and clinical strategy, the practical question is not simply how to contain the next large claim. It is whether employees can find the right support, provider and course of care early enough to improve both the experience and the economics.

Use the Diagnose phase to understand the patterns behind major spend. Review recurring conditions, sites of care, referral patterns, specialty medications and the member journeys connected to costly episodes. This creates a clearer view of where the plan is reacting and where earlier intervention could change the decision path.

In the Design phase, define how clinical support, navigation, second opinions and centers of excellence should work together. Evaluate each program by its ability to help a person make a more informed choice at the moment it matters, not by the promise of an isolated vendor solution.

Finally, make high-cost-care strategy a recurring Roadmap conversation. Set a leadership review cadence, agree on the measures that indicate access and outcomes, and document the decisions that follow. The result is a plan that is more prepared to guide care before a complex claim becomes the only signal leadership sees.