Patient-centered care categorization of U.S. health care expenditures

Use of the Population Grouping Methodology of the Canadian Institute for Health Information to predict high-cost health system users in Ontario

BACKGROUND

Prior research has consistently shown that the heaviest users account for a disproportionate share of health care costs. As such, predicting high-cost users may be a precondition for cost containment. We evaluated the ability of a new health risk predictive modelling tool, which was developed by the Canadian Institute for Health Information (CIHI), to identify future high-cost cases.

METHODS

We ran the CIHI model using administrative health care data for Ontario (fiscal years 2014/15 and 2015/16) to predict the risk, for each individual in the study population, of being a high-cost user 1 year in the future. We also estimated actual costs for the prediction period. We evaluated model performance for selected percentiles of cost based on the discrimination and calibration of the model.

RESULTS

A total of 11 684 427 individuals were included in the analysis. Overall, 10% of this population had annual costs exceeding $3050 per person in fiscal year 2016/17, accounting for 71.6% of total expenditures; 5% had costs above $6374 (58.2% of total expenditures); and 1% exceeded $22 995 (30.5% of total expenditures). Model performance increased with higher cost thresholds. The c-statistic was 0.78 (reasonable), 0.81 (strong) and 0.86 (very strong) at the 10%, 5% and 1% cost thresholds, respectively.

INTERPRETATION

The CIHI Population Grouping Methodology was designed to predict the average user of health care services, yet performed adequately for predicting high-cost users. Although we recommend the development of a purpose-designed tool to improve model performance, the existing CIHI Population Grouping Methodology may be used - as is or in concert with additional information - for many applications requiring prediction of future high-cost users.

Regional variation in cost of neonatal intensive care for extremely preterm infants

Background

Regional variation in cost of neonatal intensive care for extremely preterm infant is not documented. We sought to evaluate regional variation that may lead to benchmarking and cost saving.

Methods

An analysis of a Canadian national costing data from the payor perspective. We included all liveborn 23–28-week preterm infants in 2011–2015. We calculated variation in costs between provinces using non-parametric tests and a generalized linear model to evaluate cost variation after adjustment for gestational age, survival, and length of stay.

Results

We analysed 6932 infant records. The median total cost for all infants was $66,668 (Inter-Quartile Range (IQR): $4920–$125,551). Medians for the regions varied more than two-fold and ranged from $48,144 in Ontario to $122,526 in Saskatchewan. Median cost for infants who survived the first 3 days of life was $91,000 (IQR: $56,500–$188,757). Median daily cost for all infants was $1940 (IQR: $1518–$2619). Regional variation was significant after adjusting for survival more than 3 days, length of stay, gestational age, and year (pseudo-R² = 0.9, p < 0.01). Applying the model on the second lowest-cost region to the rest of the regions resulted in a total savings of $71,768,361(95%CI: $65,527,634–$81,129,451) over the 5-year period ($14,353,672 annually), or over 11% savings for the total program cost of $643,837,303 over the study period.

Conclusion

Costs of neonatal intensive care are high. There is large regional variation that persists after adjustment for length of stay and survival. Our results can be used for benchmarking and as a target for focused cost optimization, savings, and investment in healthcare.

Chronic Diseases in High-Cost Users of Hospital, Primary Care, and Prescription Medication in the Capital Region of Denmark

BACKGROUND

A small proportion of patients account for the majority of health care costs. This group is often referred to as high-cost users (HCU). A frequently described characteristic of HCU is chronic disease. Yet, there is a gap in understanding the economic burden of chronic diseases associated with HCU to different types of health care services.

OBJECTIVE

To analyze which frequent chronic diseases have the strongest association with HCU overall, and HCU in hospital, primary care, and prescription medication.

DESIGN

This is a register-based observational study on Danish health service costs for various diseases in different medical settings.

PARTICIPANTS

A total of 1,350,677 individuals aged ≥ 18 years living in the Capital Region of Denmark by 1 January 2012 were included.

MAIN MEASURES

Chronic diseases, costs, and sociodemographic data were extracted from the nationwide registers, including data from hospitals, primary care, and medicine consumption. These information were merged on an individual level.

KEY RESULTS

Cancer, mental disorders except depression, and heart diseases have the strongest association with HCU overall. Mental disorders except depression were in the three diseases most prevalent in HCU in all the three health care services.

CONCLUSIONS

Our results show that the chronic diseases that have the strongest association with HCU differ between different types of health care services. Our findings may be helpful in informing future policies about health care organization and may guide to different prevention, treatment, and rehabilitation strategies that could lessen the burden in the hospital.

Who Are the High-Cost Users? A Method for Person-Centred Attribution of Health Care Spending

Objective

To develop person-centered episodes of care (PCE) for community-dwelling individuals in the top fifth percentile of Ontario health care expenditures in order to: (1) describe the main clinical groupings for spending; and (2) identify patterns of spending by health sector (e.g. acute care, home care, physician billings) within and across PCE.

Data sources

Data were drawn from population-based administrative databases for all publicly funded health care in Ontario, Canada in 2010/11.

Study design

This study is a retrospective cohort study.

Data collection/extraction methods

A total of 587,982 community-dwelling individuals were identified among those accounting for the top 5% of provincial health care expenditures between April 1, 2010 and March 31, 2011. PCE were defined as starting with an acute care admission and persisting through subsequent care settings and providers until individuals were without health system contact for 30 days. PCE were classified according to the clinical grouping for the initial admission. PCE and non-PCE costs were calculated and compared to provide a comprehensive measurement of total health system costs for the year.

Principal findings

Among this community cohort, 697,059 PCE accounted for nearly 70% ($11,815.3 million (CAD)) of total annual publicly-funded expenditures on high-cost community-dwelling individuals. The most common clinical groupings to start a PCE were Acute Planned Surgical (35.2%), Acute Unplanned Medical (21.0%) and Post-Admission Events (10.8%). Median PCE costs ranged from $3,865 (IQR = $1,712-$10,919) for Acute Planned Surgical to $20,687 ($12,207-$39,579) for Post-Admission Events. Inpatient acute ($8,194.5 million) and inpatient rehabilitation ($434.6 million) health sectors accounted for the largest proportions of allocated PCE spending over the year.

Conclusions

Our study provides a novel methodological approach to categorize high-cost health system users into meaningful person-centered episodes. This approach helps to explain how costs are attributable within individuals across sectors and has applications in episode-based payment formulas and quality monitoring.

Cost trajectories for cancer patients

BACKGROUND

Health care spending is known to be highly skewed, with a small subset of the population consuming a disproportionate amount of health care resources. Patients with cancer are high-cost users because of high incremental health care costs for treatment and the growing prevalence of cancer. The objectives of the present study included characterizing cancer-patient trajectories by cost, and identifying the patient and health system characteristics associated with high health system costs after cancer treatment.

METHODS

This retrospective cohort study identified Ontario adults newly diagnosed with cancer between 1 April 2009 and 30 September 2010. Costs of health care use before, during, and after cancer episodes were used to develop trajectories of care. Descriptive analyses examined differences between the trajectories in terms of clinical and health system characteristics, and a logistic regression approach identified predictors of being a high-cost user after a cancer episode.

RESULTS

Ten trajectories were developed based on whether patients were high- or low-cost users before and after their cancer episode. The most common trajectory represented patients who were low-cost in the year before cancer, survived treatment, and continued to be low-cost in the year after cancer (31.4%); stage ii cancer of the male genital system was the most common diagnosis within that trajectory. Regression analyses identified increases in age and in multimorbidity and low continuity of care as the strongest predictors of high-cost status after cancer.

CONCLUSIONS

Findings highlight an opportunity to proactively identify patients who might transition to high-cost status after cancer treatment and to remediate that transition.

Systematic literature review of the costs of pregnancy in the US

BACKGROUND

The cost of pregnancy is increasing over time despite the decline in pregnancy rates.

OBJECTIVE

To fully elucidate and evaluate the cost drivers of pregnancy in the US for payers, a systematic review was conducted to understand the main cost components and primary factors that contribute to the direct costs of pregnancy, pregnancy-related complications and unintended pregnancy among women of childbearing age (15-44 years).

DATA SOURCES

We performed electronic searches in the PubMed database from January 2000 to December 2012, and major women's health and pharmacoeconomics conference proceedings from 2011 to 2012.

STUDY SELECTION

The systematic review is comprised of studies that reported pregnancy, pregnancy-related complications, unplanned pregnancy, and pregnancy-induced monetary costs. The review excluded narrative reports, systematic reviews, model-derived cost of pregnancy papers, non-US-based studies, and reports based solely on expert opinions.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two reviewers independently applied the inclusion criteria and assessed the quality of the data collected. Disagreements between reviewers were resolved by consensus or by arbitration through a third party, with reference to the original sources. We collected information on the study design and outcomes for each included study. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines in designing, performing, and reporting of the systematic review.

RESULTS

We identified 40 studies from electronic and handsearching methods. We classified studies based on the primary research topic focusing on the overall cost of pregnancy (N = 10), cost of pregnancy-related complications (N = 26), cost of unintended pregnancy (N = 2), cost of planned pregnancy (N = 1), or cost of pregnancy by facilities (N = 1). In the quality assessment, randomized, non-randomized, and retrospective database studies had low to moderate risk of bias. We determined primary cost drivers based on the highest cost reported in each study. The identified cost drivers were inpatient care, pregnancy delivery, multiple births, complicated cesarean sections, high-risk pregnancy, preterm birth, low birth weight, complications due to conditions such as hypertension, diabetes, anemia, and cancer, and in vitro fertilization. In 2008, the overall mean cost per hospital stay for pregnancy-related incidence ranged from $3,306 to $9,234 in 2012 dollars. The mean cost of pregnancy-related complications that led to preterm birth was as high as $326,953 for an infant born at 25 weeks. It is estimated that over 50 % of live births were unintended in the US. The difference in the cost of unintended pregnancy and intended pregnancy was approximately $536 million.

LIMITATIONS

One limitation of the systematic review was the exclusion of model-based cost studies which were excluded because of the high level of variation and heterogeneity across sources of reported cost. Another limitation of the review is that the cost of pregnancy perspective is restricted to the US.

CONCLUSION

Preventing pregnancy-related complications and reducing unintended pregnancies may lower the overall economic burden of pregnancy on the US health care system.

Hypertension-associated expenditures for medication among US adults

BACKGROUND

We sought to estimate how much the presence of hypertension adds to annual per capita and total expenditures for medication among US adults.

METHODS

The sample included 21,782 civilian noninstitutionalized adults aged ≥ 18 years who participated in the 2007 Medical Expenditure Panel Survey. Hypertension was defined as having a diagnosis of high blood pressure (except during pregnancy) or taking a blood pressure medication. We used a 2-part model to examine all-cause medication expenditure associated with hypertension.

RESULTS

The prevalence of hypertension was 32.2%. Overall, 66.7% of adults purchased prescribed medications, with this proportion higher among hypertensive (93.0%) than normotensive (54.4%) adults (P < 0.001). Hypertensive adults were more likely to have medication expenditures than were normotensive adults (odds ratio (OR) = 6.42; P < 0.001). Among hypertensive adults, those aged ≥ 45 years were more likely to incur medication expenditure than those aged 18-44 years (OR = 3.00, P < 0.001 for those aged 45-64 years; OR = 5.95, P < 0.001 for those aged ≥ 65 years), whereas women were 2.91 times as likely as men to have medication spending (P < 0.001). Hispanics were less likely than non-Hispanic whites to have such spending (OR = 0.51; P < 0.001). Among those purchasing medications, the average cost was $1,510 higher among hypertensive persons ($2,337) than normotensive persons ($827). Hypertension-associated expenditures for medication were estimated at $68 billion in the US civilian non-institutionalized population in 2007.

CONCLUSIONS

The presence of hypertension among US adults is associated with an increase of all-cause expenditures for medication, with this increase varying across groups by age and sex.

Person-centeredness in home- and community-based long-term care: current challenges and new directions

Person-centered care (PCC) has demonstrated to be a viable and preferred model of providing health and institutionalized long-term care services. However, the concept of PCC has not been fully extended to home- and community-based long-term care services (HCBS) for older adults with chronic conditions. This review highlights the need for PCC in HCBS and suggests that social workers may play a role in overcoming cultural and structural barriers to extending PCC to HCBS that include: the fragmentation of the industry, financial structures, regulation of services, and paternalism in policy and practice. Recommendations for practice, policy, and research are provided.

Characteristics of primary care office visits to nurse practitioners, physician assistants and physicians in United States Veterans Health Administration facilities, 2005 to 2010: a retrospective cross-sectional analysis

BACKGROUND

Primary care, an essential determinant of health system equity, efficiency, and effectiveness, is threatened by inadequate supply and distribution of the provider workforce. The Veterans Health Administration (VHA) has been a frontrunner in the use of nurse practitioners (NPs) and physician assistants (PAs). Evaluation of the roles and impact of NPs and PAs in the VHA is critical to ensuring optimal care for veterans and may inform best practices for use of PAs and NPs in other settings around the world. The purpose of this study was to characterize the use of NPs and PAs in VHA primary care and to examine whether their patients and patient care activities were, on average, less medically complex than those of physicians.

METHODS

This is a retrospective cross-sectional analysis of administrative data from VHA primary care encounters between 2005 and 2010. Patient and patient encounter characteristics were compared across provider types (PA, NP, and physician).

RESULTS

NPs and PAs attend about 30% of all VHA primary care encounters. NPs, PAs, and physicians fill similar roles in VHA primary care, but patients of PAs and NPs are slightly less complex than those of physicians, and PAs attend a higher proportion of visits for the purpose of determining eligibility for benefits.

CONCLUSIONS

This study demonstrates that a highly successful nationwide primary care system relies on NPs and PAs to provide over one quarter of primary care visits, and that these visits are similar to those of physicians with regard to patient and encounter characteristics. These findings can inform health workforce solutions to physician shortages in the USA and around the world. Future research should compare the quality and costs associated with various combinations of providers and allocations of patient care work, and should elucidate the approaches that maximize quality and efficiency.