2026 Projected PEPY Claim Spend
What's Your Strategy – Right Now?
Discover How Nuvana is Mitigating High-Cost Claims to Reduce Renewal Volatility and Premium Increases
Core Method: Identify risk early using technology, then route employees to the right care pathway before a condition escalates into a six-figure claim. This is NOT retroactive claim analysis.
Executive Summary & Business Problem
Renewal increases are primarily driven by a small subset of high-cost claims. This proposal reduces claim frequency and severity in the three highest-impact buckets by identifying risk early and guiding employees into the right care pathway - before costs escalate.
Healthcare premium increases are not random
They are a lagging indicator of concentrated, high-cost claims and the volatility those claims create at renewal.
Key cost concentration realities
The Cost Burden of MSK + Cardiovascular + Metabolic + Mental Health Conditions
Musculoskeletal, cardiovascular, and mental health conditions represent three of the largest contributors to U.S. healthcare spending, creating a massive opportunity for innovative care delivery models that can bend the cost curve while improving patient outcomes. (2,3,4)
$681B - MSK Annual Cost
Total U.S. spending on musculoskeletal disorders, driven by imaging, surgeries, and opioid prescriptions
$418B - Cardiovascular Cost
Annual cardiovascular disease burden including medical care and lost productivity
$280B - Mental Health Cost
Annual U.S. spending on mental health and substance use disorders including treatment and lost productivity
$1,379B - Combined Costs
Total addressable opportunity for integrated MSK, cardiovascular, metabolic and mental health care solutions
Annual Cost of Health Conditions (5). (Total Dollars is Billions)
(5)
Proposed Solution
A claims mitigation strategy focused on three main cost drivers, enabled by early risk identification and tiered care pathways.
Strategy overview
Identify risk early
Utilize technology to detect rising-risk employees in MSK, metabolic disease, and chronic mental health before escalation.
Route to the right care pathway
Provide low, medium, and high intensity pathways with rapid escalation and employee choice.
Reduce high-cost claims and volatility
Fewer avoidable high-cost events means lower renewal pressure and a stronger renewal narrative.
Care Pathway Model
Low Risk (Self-guided)
Evidence-based self-guided care always provided first.
Medium Risk (Virtual consult)
Virtual consults & telehealth available for immediate access.
High Risk (Near-site/in-person)
Near-site or in-person evaluation with seemless scheduling.
Employee choice & immediate access
Fast clinical escalation when needed
Clear governance & reporting
Meets Privacy & security review standards
Care Pathways
Each focus area uses the same tiered model. Employees have access to all three tiers at all times, and can select their pathway. Automated Clinical escalation is triggered for care navigation when risk is higher or symptoms persist.
MSK Care Pathway
Provider: Health Coach, and/or Physical Therapist (PT)
Low risk (Self-guided)
Self-guided pathway with condition-based education and exercises matched to the reported MSK condition.
Medium risk (Virtual consult)
Virtual PT consult for assessment, coaching, and progression planning; triage and escalation guidance as appropriate.
High risk (Near-site / in-person evaluation)
Near-site or in-person PT evaluation for higher-risk cases or preference; coordinated plan of care and escalation only when clinically indicated.
Chronic Mental Health Care Pathway
Provider: Health Coach and/or Mental Health Provider
Low risk (Self-guided)
Self-guided pathway with structured education, coping tools, and check-ins to support early needs and reduce barriers to care.
Medium risk (Virtual consult)
Virtual consult with a mental health provider for assessment and care planning; early intervention to reduce crisis escalation.
High risk (Near-site / in-person evaluation)
Near-site or in-person evaluation with a mental health provider for higher acuity, complexity, or preference; coordinated follow-up.
Metabolic Care Pathway
Provider: Health Coach and/or Primary Care Provider
Low risk (Self-guided)
Self-guided pathway with education, habit-building tools, and check-ins aligned to metabolic risk (weight, blood pressure, glucose risk).
Medium risk (Virtual consult)
Virtual consult with a primary care provider for assessment and care planning; coordination for screening and follow-up as appropriate.
High risk (Near-site / in-person evaluation)
Near-site or in-person primary care evaluation for higher-risk profiles or complexity; ongoing management to reduce complication trajectory.
Pathway intent
This pathway is designed to intervene early, provide immediate self-guided options, improve care continuity, and reduce the probability of expensive downstream events (complications, hospital utilization, and disability risk).
Success signals include earlier primary care touchpoints, improved adherence to follow-up, and reduced avoidable acute utilization where measurable.
Implementation, Measurement, and Governance
Implementation plan
Phase 1 (Weeks 1-6): Launch and risk identification
Enterprise security and privacy review; communications rollout; risk identification workflows live for all three buckets.
Phase 2 (Weeks 6-12): Activate pathways
Scheduling SLAs; escalation logic; monthly reporting begins (leading indicators).
Phase 3 (Months 3-12): Optimize and prepare renewal narrative
Targeted engagement; performance optimization; renewal-ready reporting package for broker and carrier discussions.
Measurement and reporting
Leading indicators (30-90 days)
Engagement by bucket, pathway selection (low/medium/high), time-to-first-touch, and adherence signals.
Lagging indicators (6-12 months)
High-cost claim events (e.g., $50k+ / $100k+), MSK leakage signals, ER utilization trends (as available), and productivity proxies if tracked.
Decision and next steps
Approve a 180-day pilot or enterprise rollout focused on MSK, CV, metabolic disease, and chronic mental health.
Confirm data access level (none / limited / de-identified claims) to quantify ROI and support a carrier-defensible renewal narrative.
Launch communications with a simple message: identify risk early, choose your pathway, escalate when needed.
References
- PolitiFact (2012). Does 20% of the population use 80% of health care? https://www.politifact.com/factchecks/2012/feb/23/alan-bates/does-20-percent-population-really-use-80-health-ca/
- Peterson-KFF Health System Tracker. Health expenditures vary across the population. https://www.healthsystemtracker.org/chart-collection/health-expenditures-vary-across-population/
- Hinge Health. State of MSK Care Report. https://www.hingehealth.com/for-organizations/state-of-msk-report-2026/
- UHC (2025). https://www.uhc.com/employer/news-strategies/musculoskeletal-conditions-drive-spend?utm_source=chatgpt.com
- Gaskin DJ et al. — The Economic Costs of Pain in the United States (National Academies of Sciences)
$18,500+