Determinants of Cost Recovery of High-Need and High-Cost Patients? Evidence From Indonesian Hospitals

Background High-need, high-cost inpatient cases represent a small proportion of hospital admissions yet account for a disproportionately large share of hospital expenditures. Understanding the factors that influence hospitals’ ability to recover costs from these cases is essential for improving financial performance and supporting sustainable healthcare financing. This study investigates how patient profile, patient care characteristics, and treatment-related factors shape the cost recovery rate of high-need, high-cost inpatient cases in Indonesian hospitals. Methods The study analyzed 121,482 inpatient cases from two public and two private hospitals between 2017 and 2020. All cases were covered under the National Health Insurance scheme. The analysis focused on the highest twenty-five percent of inpatient cases based on cost, representing approximately sixty percent of total inpatient expenditure. Cost recovery rate was defined as the ratio of reimbursement fee to hospital claim for each inpatient case. Multiple regression and decision tree analyses were used to identify factors associated with variations in cost recovery. Results Patient characteristics such as age and sex showed limited influence on cost recovery. In contrast, several patient care characteristics and treatment-related factors demonstrated substantial effects. Discharge type, severity level, and medical intervention category emerged as the most influential determinants of cost recovery among high-need, high-cost patients. Length of stay, care class, and use of intensive care also contributed to explaining variation but to a lesser extent. Conclusions The findings indicate that cost recovery is driven primarily by treatment complexity and patient care characteristics rather than patient demographic factors. Hospitals may enhance cost recovery for high-need, high-cost cases by strengthening discharge management, improving claim documentation for complex interventions, and standardizing care processes through structured clinical pathways. These measures can help improve financial performance while supporting more efficient resource allocation for patients requiring intensive services.