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High-Cost Patients

By September 8, 2016Commentary

A new issue brief from the Commonwealth Fund describes the high-cost patient population and the types of health services they use.   (Commonwealth Brief)   A high-need, high-cost patient, according to the authors, is one with three or more chronic diseases and functional limitation in ability to care for themselves or perform a routine daily task.  Data from the MEP surveys from 2009 to 2011 were used in compiling the brief.  About 5% of the US population over age 18, or 12 million people, met this definition.  Compared to other adults, this group is older–more than half were over age 65, more likely to be female–two-thirds were, nearly 75% were white non-Hispanic, less educated, had lower incomes and more likely to be in self-reported poor or fair health.  Only 4% of this group was uninsured, with most having Medicare, Medicaid or both.  The average annual health spending on this population of high-need patients was over $21,000; four times more than the average for all US adults and almost three times as much as for adults with three or more chronic diseases but no functional limitations.  And these people had high out-of-pocket spending, despite their lower income, with an average of $1669 versus $702 for all adults.

This high-need, high-cost group, as would be expected with the higher spending, uses certain services at a much greater rate as well.  This includes triple the number of hospitalizations and emergency room visits compared to the general population.  This group had 535 hospital discharges per thousand, while adults with chronic disease but no limitations had 147 and across all adults the number was 107.  But even in the high-need group there is significant variance; 68% had no hospitalizations, while 5% were hospitalized three or more times in a year.  ER visits showed a similar pattern, with 65% having no ER use and 3% visiting four or more times a year.  Total physician visits averaged 9.6 in this population, compared to 6 for the no functional limits adults and 3.6 for all adults.  Home care use was dramatically greater–an average of 26 days a year, versus less than 2 for the general adult group.  Among the high-need group, the subset with the greatest spending tended to persist as high-spenders from year-to-year.  The most important thing to be gleaned from this research is the significance of identifying functional limitations.  Their presence is a strong indicator of high-spending and helps narrow a population down to those patients who are most likely to benefit from care management interventions.

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