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High-cost patients in a fee-for-service medical plan. The case for earlier intervention
Insights
High-cost patients are often older individuals or young women, while very high-cost patients include older men and infants. Identifying high-cost patients with chronic conditions can help prevent future very high-cost cases.
Area of Science:
- Health Economics
- Medical Care Utilization
- Patient Demographics
Background:
- Understanding patient cost variation is crucial for healthcare management.
- Fee-for-service models present unique challenges in cost containment.
- Identifying high-cost patient subgroups informs resource allocation.
Purpose of the Study:
- To characterize high-cost and very high-cost patients within a large bank's fee-for-service plan.
- To analyze demographic and utilization patterns of these patient groups.
- To explore longitudinal trends and identify predictors of high healthcare costs.
Main Methods:
- Analysis of patient demographics, medical plan expenses, and service utilization over one and four years.
- Comparison of patient groups based on annual healthcare expenditures ($5,000-$25,000 and ≥$25,000).
- Longitudinal analysis to track patient cost trajectories.
Main Results:
- High-cost patients were older individuals and women aged 20-39. Very high-cost patients were older men and infants.
- Very high-cost patients had significantly higher hospital days and physician visits compared to high-cost patients.
- High-cost patients utilized substantially more resources than low-cost patients.
Conclusions:
- Most high-cost patients experience temporary high expenses, but a subset with chronic conditions may become very high-cost.
- Targeted case management for high-risk high-cost patients can potentially mitigate future very high-cost cases.
- Demographic and utilization patterns offer insights into managing healthcare costs in fee-for-service plans.
Abstract:
This article describes the high-cost and very high-cost patients in the fee-for-service medical plan of one of the nation's largest banks in terms of their demographics and medical plan expenses and utilization, within a single year and during a period of 4 consecutive years. High-cost patients ($5,000-25,000 annually) were dominated by older persons and women 20 to 39 years, while the very high-cost patients (at least $25,000) tended to be older men and infants of both genders. Very high-cost patients used 5 to 7 times more hospital patient days and visited with a physician on an outpatient basis twice as often as high-cost patients. In turn, the high-cost patients experienced 37 to 50 times as many patient days and twice as many outpatient visits as patients whose annual expenses were below $5,000. Longitudinal analyses suggested that while most of the high-cost patients are typically low-cost patients or nonusers of services who experience high-cost time spans, some of them suffer from more serious chronic health problems and are apt to become very high-cost patients. Focusing case-management interventions on this small subgroup of high-cost patients may prevent some very high-cost cases in the future.