Solving the High-Cost Care Problem: Introducing Garner Predictive Outreach

High-cost claims have always posed a challenge to employers, but the problem is getting worse: claimants exceeding $1 million in annual spend increased by 45% between 2022 and 2024, with the sharpest growth concentrated at the highest cost tiers ($2M+). This cost growth has been driven not only by higher prices for medical services, but also increasing incidence of complex diseases and growing utilization of expensive specialty medications. High-cost claims are a problem for employers not only because of their cost, but also because they are difficult to predict. Because only 21% of high-cost claimants persist between years, the vast majority of outsized spend is a moving target, driven by new members each year. Health plans have responded to these challenges with tools like care and utilization management programs, but these programs fail to adequately intervene before members are on an irreversible path towards bad outcomes. 

Identifying and reaching higher-cost claimants has historically run into two barriers:

• Poor quality data. 50% of members who eventually became high-cost claimants showed no previous indicators in existing systems. We estimate that employers have access to both claims data and search behavior for only 1% of members, impeding their ability to properly anticipate who will go on to become high-cost claimants. 
• Low engagement. Even when employers identify future higher-cost claimants, they struggle to reach them in a meaningful way. The average engagement rate for payer-led care management systems intended to reach higher-cost claimants is less than 30%, and 60% of the members they do contact fail to adhere to recommended care plans. 

At Garner, we believe that many high cost medical events have a brief, but meaningful window of intervention—a period of weeks or months where a member is showing preliminary signals through their in-app search behavior, claims history, prescriptions, and diagnoses—but hasn't yet scheduled care. The problem is that by the time traditional benefits tools catch up, that window has closed. Garner's new Predictive Outreach program is built specifically to find that window and conduct a personalized intervention at that critical moment in each member’s care journey. 

Predicting Higher-Cost Claims

Garner's national claims database is built on data from over 320 million patients. Combining this data foundation with our bottom-up approach to provider analytics and our insight into members’ real-time search behavior enables a fundamentally richer approach to predictive, personalized outreach than previously possible. We've built and trained machine learning models across 50 clinical intervention points, from knee and hip replacement to cardiac surgery, high-risk pregnancy, AFib ablation, and diabetic disease progression. Each model analyzes a member's claims history, in-app search behavior, and current providers to determine who is likely to need expensive care in the next three to six months and whether they are currently seeing a provider properly equipped to address their needs. Our deep understanding of provider behavior allows us to triangulate members’ cost trajectories not only based on clinical signals like prescriptions and comorbidities, but also based on factors like how often the specialist that a patient is seeing elects to perform expensive procedures. 

Critically, timing matters as much as identification. Garner’s models target members early in the cost curve, well before their spend escalates. Other tools often intervene too late because their underlying models aren't sensitive enough, and their outreach is generic and impersonal. Our models are designed to flag members at the moment they're most open to switching providers—before a referral is made, before a surgery is scheduled, before the claim is locked in—with a meaningful message that guides members toward high-quality care at the point of greatest impact.

Personalized Outreach at Scale

Once a high-risk member is identified, Garner's Concierge team reaches out by phone or email with messaging tailored to that member's specific clinical situation and where they are in their personal care journey. Some members are brand new to Garner and need an introduction to our product. Some are already seeing a specialist and need a reason to consider switching. Some just need a recommendation. Since launching Garner Predictive Outreach, 76% of the members we’ve contacted agreed that we correctly identified their specific care needs. Personalizing outreach this way has increased employee engagement by 3x compared to generic navigation tools. 

In every case, the goal is the same: connect the member with a Garner Top Provider before high-cost care is delivered elsewhere, driving better outcomes for members and real savings for employers. For employers looking to get ahead of their highest-cost claims, the window to act is earlier than most realize—and Garner is now built to find it.

To learn more, register for our upcoming webinar The Right Member, Moment, and Message: How Personalized Outreach is Changing High-Cost Claims or contact us today at sales@garnerhealth.com. 

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