How Managing Major Specialties & Patient Outliers Can Cut Costs and Improve Outcomes
If you’re looking to lower healthcare costs while improving employee health outcomes, this may be the most important topic you explore this year.
Let’s talk numbers first:
Roughly 10% or fewer of your health plan members often account for 80% of the total healthcare costs. These high-cost individuals—referred to as patient outliers—are frequently suffering from complex or chronic conditions that fall into major specialty categories such as cancer, heart disease, musculoskeletal issues, or transplant needs.
The kicker? Many of these patients are not the same year after year, making them harder to track without a strategy in place.
Why Managing Outlier Patients Matters
When complex health conditions go unmanaged, both quality and cost of care can vary dramatically. Studies have shown that:
40% of transplants are medically unnecessary
90% of back surgeries are not appropriate or necessary
Community hospitals performing low volumes of complex procedures often see higher complication rates
Our flawed approach to low back pain has led to excessive surgeries and is one of the top drivers of opioid prescriptions
These trends signal the urgent need for a new strategy in benefits planning.
Common Gaps in Traditional Healthcare Systems
Across every major specialty, you’ll find the same recurring issues:
- Lack of evidence-based, patient-specific protocols
- Fragmented care with poor communication between providers
- No system to match patients to high-quality specialists
- Limited access to non-physician resources for ongoing support
- These gaps can be devastating for patients—and expensive for employers.
Proven Strategy: Centers of Excellence (COE)
One of the most powerful solutions gaining traction is the Center of Excellence model. Major employers like Walmart, Lowe’s, and PepsiCo are already using this approach to reduce misdiagnoses and save millions in unnecessary procedures.
These centers specialize in high-volume, complex care with better outcomes and lower complication rates. Here’s the impact they’ve seen:
Misdiagnosis Rates in Traditional Care:
- Cancer: 20%
- Spine surgery: 67%
- Orthopedic surgery: 30%+
- Bypass surgery: 60%
- Stents (regional variance): Up to 50%
- Solid organ transplants: 40%
When employers partner with COEs, they're not only saving money but also reducing pain, unnecessary procedures, and emotional strain on their employees. Plus, it elevates the perceived value of your benefits package.
Major Specialties to Prioritize
Focus on these high-cost areas for the most impact:
- Musculoskeletal Conditions (e.g., back pain, joint issues)
- Cardiometabolic Disorders (e.g., heart disease, diabetes)
- Cancer Care
- Transplants
- Dialysis Treatment
- Specialty Medications
What’s Next?
Employers ready to take control of their healthcare costs are investing in targeted solutions for managing outlier patients and high-cost specialties. The next topic in our series will focus on Transparent Pharmacy Benefits—often the easiest and fastest area to reduce costs due to hidden fees and markups.
Ready to Learn More?
Working with an experienced and transparent advisor can help you implement solutions that directly impact your bottom line. From Centers of Excellence to care navigation and ongoing management support, there are strategies that work—backed by data.