High-cost patients in a fee-for-service medical plan. The case for earlier intervention

Med Care. 1990 Feb;28(2):112-23. doi: 10.1097/00005650-199002000-00002.


This article describes the high-cost and very high-cost patients in the fee-for-service medical plan of one of the nation's largest banks in terms of their demographics and medical plan expenses and utilization, within a single year and during a period of 4 consecutive years. High-cost patients ($5,000-25,000 annually) were dominated by older persons and women 20 to 39 years, while the very high-cost patients (at least $25,000) tended to be older men and infants of both genders. Very high-cost patients used 5 to 7 times more hospital patient days and visited with a physician on an outpatient basis twice as often as high-cost patients. In turn, the high-cost patients experienced 37 to 50 times as many patient days and twice as many outpatient visits as patients whose annual expenses were below $5,000. Longitudinal analyses suggested that while most of the high-cost patients are typically low-cost patients or nonusers of services who experience high-cost time spans, some of them suffer from more serious chronic health problems and are apt to become very high-cost patients. Focusing case-management interventions on this small subgroup of high-cost patients may prevent some very high-cost cases in the future.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Age Factors
  • California
  • Catastrophic Illness / economics*
  • Child
  • Child, Preschool
  • Fees, Medical*
  • Female
  • Health Benefit Plans, Employee / statistics & numerical data*
  • Health Expenditures / statistics & numerical data*
  • Hospitalization / statistics & numerical data
  • Humans
  • Infant
  • Infant, Newborn
  • Insurance, Health / statistics & numerical data*
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Office Visits / statistics & numerical data
  • Sex Factors