High-Cost Patients in a Fee-for-Service Medical Plan

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.