High-Cost Users of Medical Care

Cost characteristics of hospital patients were analyzed in 2238 medical records randomly selected from 42,880 discharges in six contrasting hospital populations in the year 1976. Total hospital billings were concentrated on a few patients. On average, the high-cost 13 per cent of patients consumed as many resources as the low-cost 87 per cent. Repeated hospitalizations for the same disease were more characteristic of the expensive patients than were single cost-intensive stays, "intensive care," or prolonged single hospitalizations. Potentially harmful personal habits (e.g., drinking and smoking) were indicated in the records of high-cost patients substantially more often than in those of low-cost patients. Unexpected complications during treatment were five times more frequent in the high-cost group. Public policy programs for health insurance or cost control should include provisions based on the special characteristics of high-cost patients. (N Engl J Med. 1980; 302:996–1002.) A MAJOR portion of medical resources in the United States is consumed by a small fraction of patients. 1 This fact, most recently documented by Schroeder, 2 raises important issues of cost distribution, predictability, preventability, equity in treatment, and ultimate health status of the high-cost users of medical care. This study develops a profile of these high-cost patients through a review of 2238 patient records in six contrasting hospital populations. The special modes of usage, diagnostic and prognostic characteristics, and other factors that contribute to high-cost utilization (e.g., unhealthy habits or unexpected complications during treatment) should be defined and understood in order . . .