EP471: High-Cost Claimants in 2025 and Beyond—What Is Really Expensive Not to Know? With Christine Hale, MD, MBA

Recently on Relentless Health Value, we've been tinkering around with a few recurring themes — recurring through lines — that are just true about American healthcare these days. In this episode, host Stacey Richter speaks with Dr. Christine Hale about high-cost claimants and the implications for healthcare plans in 2025 and beyond. They discuss the importance of trust in patient care, the financial incentives behind patient steering, and the critical role of timely and comprehensive data analysis. Dr. Hale emphasizes the need for an integrated approach to medical and pharmacy claims data to avoid expensive consequences and improve patient outcomes, and shares strategies for plan sponsors to manage high-cost claimants through evidence-based care, appropriate treatment settings, and creative problem-solving — all while underlining the importance of patient engagement and satisfaction.

WHAT YOU'LL LEARN

✅ How the definition of a high-cost claimant is changing — and why buy-and-bill pharmaceuticals are becoming one of the most expensive line items plan sponsors don't see coming

✅ What plan sponsors are getting wrong about high-cost claimant management, and why integrating medical and pharmacy claims data is the prerequisite for catching problems before they become expensive

✅ Why starting small — rather than trying to overhaul everything about high-cost claimant management at once — is the more effective and sustainable path for most plan sponsors

✅ The concrete steps employers should take to improve high-cost claimant spend: evidence-based care pathways, appropriate treatment settings, and creative problem-solving grounded in trust and patient engagement

✅ Why relationships and trust between patients and care teams are not a soft add-on but a precondition for steering high-cost claimants toward the right care at the right time

WHY THIS MATTERS

High-cost claimants are a small share of any plan's population but an outsized share of its spend, and the mechanisms driving those costs — buy-and-bill pharmaceutical markups, fragmented data, and misaligned steering incentives — are largely invisible to plan sponsors until the bill arrives. Dr. Hale's message is that this is manageable: with integrated data, evidence-based protocols, and a willingness to start small, plan sponsors can meaningfully bend the high-cost claimant curve without waiting for a systemic fix.

MENTIONED IN THIS EPISODE

EP462 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps

EP468 with Matt McQuide: Apple Podcasts | Spotify | Other Apps

EP371 with Erik Davis and Autumn Yongchu: Apple Podcasts | Spotify | Other Apps

EP467 with Stacey Richter: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

05:22 What is a high-cost claimant, and how is the definition changing?

07:42 Why buy-and-bill pharmaceuticals can be so costly for plan sponsors.

10:19 What are plan sponsors getting wrong about this situation?

11:28 What do you need as an employer to understand your plan data fully?

17:35 What are plan sponsors currently doing that they should not being doing?

19:54 Why starting small is important.

25:37 What are the steps employers should take to improve their high-cost claimant spend?