What Contributes Most to High Health Care Costs? Health Care Spending in High Resource Patients

J Manag Care Spec Pharm. 2016 Feb;22(2):102-9. doi: 10.18553/jmcp.2016.22.2.102.


Background: U.S. health care spending nearly doubled in the decade from 2000-2010. Although the pace of increase has moderated recently, the rate of growth of health care costs is expected to be higher than the growth in the economy for the near future. Previous studies have estimated that 5% of patients account for half of all health care costs, while the top 1% of spenders account for over 27% of costs. The distribution of health care expenditures by type of service and the prevalence of particular health conditions for these patients is not clear, and is likely to differ from the overall population.

Objective: To examine health care spending patterns and what contributes to costs for the top 5% of managed health care users based on total expenditures.

Methods: This retrospective observational study employed a large administrative claims database analysis of health care claims of managed care enrollees across the full age and care spectrum. Direct health care expenditures were compared during calendar year 2011 by place of service (outpatient, inpatient, and pharmacy), payer type (commercially insured, Medicare Advantage, and Medicaid managed care), and therapy area between the full population and high resource patients (HRP).

Results: The mean total expenditure per HRP during calendar year 2011 was $43,104 versus $3,955 per patient for the full population. Treatment of back disorders and osteoarthritis contributed the largest share of expenditures in both HRP and the full study population, while chronic renal failure, heart disease, and some oncology treatments accounted for disproportionately higher expenditures in HRP. The share of overall expenditures attributed to inpatient services was significantly higher for HRP (40.0%) compared with the full population (24.6%), while the share of expenditures attributed to pharmacy (HRP = 18.1%, full = 21.4%) and outpatient services (HRP = 41.9%, full = 54.1%) was reduced. This pattern was observed across payer type. While the use of physician-administered pharmaceuticals was slightly higher in HRP, their use did not alter this spending pattern.

Conclusions: Overall, expenditures in the HRP population are more than 10-fold higher compared with the full population. Managed care pharmacy can benefit from understanding what contributes to these higher costs, and managed care directors should consider an appropriately balanced assessment of the share of total spend by service and therapeutic category in HRP when devising drug usage and related cost-management strategies.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Ambulatory Care / economics
  • Cost of Illness*
  • Delivery of Health Care / economics*
  • Female
  • Health Care Costs*
  • Health Expenditures*
  • Health Resources
  • Humans
  • Insurance Claim Review / economics
  • Male
  • Managed Care Programs / economics
  • Medicaid / economics
  • Middle Aged
  • Prevalence
  • Retrospective Studies
  • United States
  • Young Adult