The Hidden Cost of Delayed Diagnoses

• A high-cost claimant is generally defined as a health plan member whose annual claims exceed $50,000, though many stop-loss carriers and consultants use $100,000 as the threshold for reporting purposes.
• Cancer has been the top driver of employer health care costs for four consecutive years, according to the Business Group on Health.
• A small share of plan members accounts for a disproportionate share of spend: Mercer's analysis of employer claims data found that members with claims above $100,000 made up roughly 1% of the population but drove 34% of total health care spend.
• Research on Medicare beneficiaries found that cancer diagnosed at a later stage can cost up to seven times more to treat than cancer caught early.
• Early diagnosis and a continuous care relationship, not just broader access, are what actually keep these members from turning into catastrophic claims.
• Advanced Primary Care connects prevention, diagnosis, and specialty coordination inside one clinical team, closing gaps that referral-based care management tends to miss.

High-cost claimants are no longer a rare, unpredictable risk that shows up once every few years. For a growing number of self-insured employers, they are the single largest and least controllable line item in the annual budget. A handful of members, often fewer than 1 in 100, can now account for a third or more of total claims spend in a given year.

Chronic care management shouldn't be a bolt-on program run alongside everyday care. Galileo treats it as a core function of Advanced Primary Care itself.  When a clinical team owns a patient's full health picture over time, rather than managing a caseload of already-diagnosed high-risk members, many claims never reach catastrophic status in the first place.

 That distinction, between managing risk after the fact and preventing it from developing, is the difference between a point solution and a genuine employer health care strategy.

What Counts As A High-Cost Claimant?

There is no single federal definition, but the term is most commonly traced to the American Health Policy Institute, which set the threshold at $50,000 or more in annual claims, though stop-loss carriers and benefits consultants often report on the $100,000-and-above population separately.

But the population is small, and the impact is not. Mercer's analysis of employer claims data found that members with claims above $100,000 made up roughly 1% of the population but drove 34% of total health care spend.

The scale of the problem has changed more than the definition. Sun Life's most recent high-cost claims analysis, which reviewed more than 70,000 high-dollar claims across roughly 3,300 self-funded employers, found that claims above $1 million increased 46% in frequency between 2022 and 2026. The costliest single category, blood cancers, averaged $5.45 million per claim in 2025.

For employers, the practical effect is straightforward: a single catastrophic claim can now do more damage to a plan's annual budget than an entire flu season across the rest of the workforce.

Why Chronic Disease, Not Acute Events, Now Drives High-Cost Claims

For years, the classic catastrophic case was someone recovering from a severe accident or an unplanned hospitalization. That is no longer the primary pattern. Chronic and complex conditions, cancer above all, now dominate the claims that push a plan into catastrophic territory.

Cancer has ranked as the top driver of employer health care costs for four straight years, with more than half of large employers naming it their single biggest cost pressure. Musculoskeletal conditions, cardiovascular disease, and diabetes round out the list of conditions employers watch most closely.

A few forces are compounding the trend at once:

• Rising incidence: More employees are being diagnosed with cancer, and at younger ages, than in past years.
• Specialty drug and gene therapy costs: Advanced treatments, including targeted therapy and newer gene therapies, carry price tags that dwarf traditional pharmacy spend.
• Comorbidities: Members managing more than one chronic condition, such as diabetes alongside cardiovascular disease, tend to generate the highest and most persistent claims.
• Delayed diagnosis: Conditions caught later require more intensive, more expensive treatment, and often for longer.

That last point is where an employer's health plan design has the least influence and where its care delivery model has the most.

How Early Diagnosis And Advanced Primary Care Reduce High-Cost Claimants

Plan design can shift where costs land. It has almost no effect on whether a claim becomes catastrophic in the first place. That outcome is determined earlier, often years earlier, by whether a member's condition was caught and managed before it progressed.

The Cost Of Delayed Diagnosis

The financial gap between early and late diagnosis is well documented. A study of Medicare beneficiaries published in the Journal of Medical Economics found that patients diagnosed with cancer at a later stage incurred costs up to seven times higher than those diagnosed early, a pattern that held across cancer types and persisted for years after diagnosis. Separate research using commercial claims data reached a similar conclusion: healthcare costs rise consistently as stage at diagnosis advances, regardless of cancer type.

Stage at diagnosis is not fixed. It is largely a function of whether someone has a care relationship built for early detection, or one that only engages once symptoms are already severe.

Why Continuity, Not Just Access, Matters

Most virtual care models are built for episodic problems: a rash, a sinus infection, a refill. They are not built to notice that a member's blood pressure has been trending upward for eighteen months, or that a family history flags them for earlier cancer screening. That kind of pattern recognition requires a clinical team that sees the same members over time and holds their full record, not a rotating pool of providers handling one-off visits.

This is where an employer's choice of care model becomes a genuine cost-management lever rather than just a benefits perk. A workforce with a continuous care relationship gets more preventive screening, earlier intervention on emerging risk, and fewer surprises that later show up as catastrophic claims.

Where Galileo's Model Fits

Galileo was built around this exact gap. Our clinical teams manage members longitudinally, across everyday concerns, chronic disease management, and preventive care, using a shared record and clinical intelligence tools that flag risk before it escalates. Members in populations with a high burden of chronic conditions see higher engagement with their care team than in typical virtual-first models, because the relationship does not reset with every visit.

That continuity is also why we frame chronic disease management as inseparable from advanced primary care. A care team that only intervenes once a member is already flagged as high-risk has already missed the earlier, cheaper opportunity to change the trajectory.

What Role Does Care Navigation Play In Managing High-Cost Claimants?

Care navigation gets discussed constantly in the benefits industry right now, but the term covers two very different things, and the distinction matters for cost outcomes.

Most care navigation tools on the market are referral-management systems. They track where a member was sent, flag gaps in follow-up, and report back to the employer. That is useful visibility. It is not the same as resolving the underlying clinical need.

Galileo takes a different approach. Rather than layering a tracking tool on top of a fragmented specialist network, our multidisciplinary care team, spanning more than 20 specialties, coordinates care directly. A member managing diabetes and depression, for example, is not routed to two disconnected providers whose records never meet. They are managed by one team working from a single clinical picture, which is how a rising-risk member gets identified and treated before their claims escalate rather than after.

That distinction, between tracking a referral and resolving a need, is the difference between coordination as a software feature and coordination as a property of the care model itself.

A Framework For Spotting Rising Risk Before It Becomes A High-Cost Claim

Benefits leaders do not need a data science team to start identifying rising risk in their population. A few signals reliably show up before a member's claims turn catastrophic:

1. Gaps in preventive screening: Low colonoscopy, mammography, or annual wellness visit completion rates within a population are one of the earliest predictors of later, more expensive diagnoses.
2. Low enrollment in chronic condition programs: A population with known diabetes or hypertension prevalence but low program participation is likely carrying unmanaged risk.
3. High ER and urgent care utilization relative to routine outpatient visits: This pattern often signals members without a consistent care relationship, which correlates with delayed diagnosis.
4. Rising specialty pharmacy trend: A jump in specialty drug utilization, even before a catastrophic claim appears, can be an early warning sign worth investigating with your carrier or vendor.
5. Fragmented vendor data: If your point solutions cannot tell you which members are managing more than one condition, you are likely missing your highest-risk population entirely.

A primary-care-first care model that owns the full clinical picture is built to catch these signals as a matter of course, rather than requiring a separate analytics layer bolted on after the fact.

Traditional Care Management Vs. An Integrated Care Model

The table below compares how each approach typically identifies and manages members at rising risk.

What Employers And Health Plan Stakeholders Can Do Now

Managing this kind of risk is not a single initiative. It is an ongoing discipline that touches plan design, vendor strategy, and care delivery at once. A few starting points for HR and benefits teams:

• Audit your current care model for continuity, not just access. Ask whether members see the same clinical team over time or a different provider with every visit.
• Ask vendors how they define success. A partner focused on catching and resolving conditions early will talk about outcomes and screening rates. A partner focused on utilization management will talk about cost avoidance after the fact.
• Review preventive screening completion, broken out by condition, not just overall wellness visit rates.
• Evaluate stop-loss data alongside clinical data, not in isolation. Claims history tells you what happened. Screening and engagement data tell you what is likely to happen next.
• Consolidate fragmented point solutions where possible. Every additional disconnected vendor is another place a rising-risk member can fall through the cracks.

Rethinking High-Cost Claimants as a Care Problem, Not Just a Cost Problem

Stop-loss coverage will always have a role in protecting a self-insured plan from catastrophic risk. But it manages exposure after the fact. The more durable lever available to employers sits earlier: a care model built to catch conditions before they become catastrophic claims in the first place.

That is the case for treating chronic care management as a function of Advanced Primary Care, not a program running alongside it. Galileo's Advanced Primary Care model brings prevention, diagnosis, and specialty coordination into one clinical team, so fewer members travel the long, expensive road from a missed screening to a million-dollar claim. 

If your population's catastrophic-claims trend is heading the wrong direction, talk to Galileo's employer team about what an integrated care model could look like for your workforce.