Identifying Consistent High-cost Users in a Health Plan

BACKGROUND: High-cost users in a period may not incur high-cost utilization in the next period. Consistent high-cost users (CHUs) may be better targets for cost-saving interventions. OBJECTIVES: To compare the characteristics of CHUs (patients with plan-specific top 20% medical costs in all 4 half-year periods across 2008 and 2009) and point high-cost users (PHUs) (top users in 2008 alone), and to build claims-based models to identify CHUs. RESEARCH DESIGN: This is a retrospective cohort study. Logistic regression was used to predict being CHUs. Independent variables were derived from 2007 claims; 5 models with different sets of independent variables (prior costs, medications, diagnoses, medications and diagnoses, medications and diagnoses and prior costs) were constructed. SUBJECTS: Three-year continuous enrollees aged from 18 to 62 years old from a large administrative database with $100 or more yearly costs (N=1,721,992). MEASURES: Correlation, overlap, and characteristics of top risk scorers derived from 5 CHUs models were presented. C-statistics, sensitivity, and positive predictive value were calculated. RESULTS: CHUs were characterized by having increasing total and pharmacy costs over 2007-2009, and more baseline chronic and psychosocial conditions than PHUs. Individuals' risk scores derived from CHUs models were moderately correlated (∼0.6). The medication-only model performed better than the diagnosis-only model and the prior-cost model. CONCLUSIONS: Five models identified different individuals as potential CHUs. The recurrent medication utilization and a high prevalence of chronic and psychosocial conditions are important in differentiating CHUs from PHUs. For cost-saving interventions with long-term impacts or focusing on medication, CHUs may be better targets.