High-Cost Patients and Preventable Spending: A Population-Based Study

Abstract

Background: Although high-cost (HC) patients make up a small proportion of patients, they account for most health system costs. However, little is known about HC patients with cancer or whether some of their care could potentially be prevented. This analysis sought to characterize HC patients with cancer and quantify the costs of preventable acute care (emergency department visits and inpatient hospitalizations). Methods: This analysis examined a population-based sample of all HC patients in Ontario in 2013. HC patients were defined as those above the 90th percentile of the cost distribution; all other patients were defined as non–high-cost (NHC). Patients with cancer were identified through the Ontario Cancer Registry. Sociodemographic and clinical characteristics were examined and the costs of preventable acute care for both groups by category of visit/condition were estimated using validated algorithms. Results: Compared with NHC patients with cancer (n=369,422), HC patients with cancer (n=187,770) were older (mean age 70 vs 65 years), more likely to live in low-income neighborhoods (19% vs 16%), sicker, and more likely to live in long-term care homes (8% vs 0%). Although most patients from both cohorts tended to be diagnosed with breast, prostate, or colorectal cancer, those with multiple myeloma or pancreatic or liver cancers were overrepresented among the HC group. Moreover, HC patients were more likely to have advanced cancer at diagnosis and be in the initial or terminal phase of treatment compared with NHC patients. Among HC patients with cancer, 9% of spending stemmed from potentially preventable/avoidable acute care, whereas for NHC patients, this spending was approximately 30%. Conclusions: HC patients with cancer are a unique subpopulation. Given the type of care they receive, there seems to be limited scope to prevent acute care spending among this patient group. To reduce costs, other strategies, such as making hospital care more efficient and generating less costly encounters involving chemotherapy, should be explored.

Divergent Patterns in Care Utilization and Financial Distress between Patients with Blood Cancers and Solid Tumors: A National Health Interview Survey Study, 2014–2020

“…Examining the difference between blood cancers and solid tumors specifically, existing studies have demonstrated that the clinical course, treatment options, and overall morbidity and mortality among the two types of cancers are fundamentally different [ 26 , 27 , 28 , 29 , 30 , 31 ]. These differences have significant implications for the financial toxicity experienced by patients and survivors.…”

“…We found that respondents with blood cancers reported increased medical utilization and distress over the medical costs of healthcare and paying medical bills compared to those with solid tumors. The high costs associated with providing care to patients with blood cancers are well documented [ 23 , 26 , 28 , 39 ]. Our study corroborates these findings, as respondents with blood cancers reported a higher level of medical care utilization, especially in the domains of length and frequency of hospitalizations, as well as the number of outpatient visits.…”

“…Second, patients with blood cancers and solid tumors are not the same. Although blood cancers only comprise approximately 10% of all cancers [ 25 ], significant differences exist in the clinical course, treatment options, and overall morbidity and mortality between blood cancers and solid tumors [ 26 , 27 , 28 , 29 , 30 , 31 ]. NHIS distinguishes between blood cancer and solid tumors in patient-reported cancer diagnoses, and comparisons can be made between reported medical care utilization with financial barriers and distress in each group.…”

Comparison of claims from high–drug cost beneficiaries in Ontario, Canada, and Australia: a cross-sectional analysis

“…6 Higher costs have also been associated with clustering in overall health care expenditures. [7][8][9][10][11][12] It is unclear to what extent the overall growth in drug expenditure is driven by this same occurrence.Canada is currently the only high-income country with a universal health insurance system that does not provide universal coverage of prescription drugs, 13 in contrast to Australia, which has a publicly funded Pharmaceutical Benefits Scheme (PBS). Recently, there has been increasing pressure to establish a national drug coverage program in Canada, similar to Australia's PBS.…”

“…6 Higher costs have also been associated with clustering in overall health care expenditures. [7][8][9][10][11][12] It is unclear to what extent the overall growth in drug expenditure is driven by this same occurrence.…”