Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
The Pediatric Physicians' Organization at Children's, Boston Children's Hospital, Boston, Massachusetts.
JAMA Pediatr. 2015 Oct;169(10):e152682. doi: 10.1001/jamapediatrics.2015.2682. Epub 2015 Oct 5.
Accountable care payment models aim to reduce total direct medical expenses for high-cost patients through improved quality of care and preventive health services. Little is known about health care expenditures of privately insured adolescents, especially those who incur high costs.
To assess health care expenditures for high-cost adolescents and to describe the patient characteristics associated with high medical costs.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort analysis was conducted of data from January 1 to December 31, 2012, of 13,103 privately insured adolescents aged 13 to 21 years (mean [SD] age, 16.3 [2.4] years; 6764 [51.6%] males) at 82 independent pediatric primary care practices in Massachusetts. Analysis was conducted from April 1, 2014, to April 1, 2015.
We compared demographic (age, sex, median income by zip code) and clinical (obesity, behavioral health problem, complex chronic condition) characteristics between high-cost (top 1%) and non-high-cost adolescents. We assigned high-cost adolescents to clinical categories using software from the Agency for Healthcare Research and Quality to describe clinically relevant patterns of spending.
Total direct medical expenses were $41.2 million for the entire cohort and a median $1167 per patient. A total of 132 (1.0%) patients with the highest costs accounted for 23.6% of expenses of the cohort, with a median $52,577 per patient. Mental health disorders were the most common diagnosis in high-cost patients; 78 (59.1%) of these patients had at least 1 behavioral health diagnosis. Pharmacy costs accounted for 28.4% of total direct medical expenses of high-cost patients; primary care accounted for 1.0%. Characteristics associated with being a high-cost patient included having 1 complex chronic condition (relative risk [RR], 6.5; 95% CI, 4.7-9.0), having 2 or more complex chronic conditions (RR, 23.5; 95% CI, 14.2-39.1), having any behavioral health diagnosis (RR, 3.6; 95% CI, 2.6-5.1), and obesity (RR, 2.0; 95% CI, 1.3-3.0).
Total direct medical expenses for privately insured high-cost adolescents are associated with medical complexity, mental health conditions, and obesity. Cost reduction strategies in similar populations should be tailored to these cost drivers.
问责制医疗支付模式旨在通过改善医疗服务质量和预防保健服务来降低高成本患者的总直接医疗费用。对于私人保险青少年的医疗保健支出知之甚少，尤其是那些产生高额费用的患者。
评估高成本青少年的医疗保健支出，并描述与高医疗费用相关的患者特征。
设计、设置和参与者：对 2012 年 1 月 1 日至 12 月 31 日马萨诸塞州 82 家独立儿科初级保健机构中 13103 名 13 至 21 岁（平均[SD]年龄 16.3[2.4]岁；6764[51.6%]男性）的 13103 名私人保险青少年的数据进行了回顾性队列分析。分析于 2014 年 4 月 1 日至 2015 年 4 月 1 日进行。
我们比较了高成本（前 1%）和非高成本青少年的人口统计学（年龄、性别、按邮政编码划分的中位数收入）和临床特征（肥胖、行为健康问题、复杂慢性疾病）。我们使用医疗保健研究和质量局的软件将高成本青少年分配到临床类别，以描述具有临床相关性的支出模式。
整个队列的总直接医疗费用为 4120 万美元，每位患者的中位数为 1167 美元。共有 132 名（1.0%）费用最高的患者占队列费用的 23.6%，每位患者的中位数为 52577 美元。精神健康障碍是高成本患者最常见的诊断；其中 78 名（59.1%）患者至少有 1 项行为健康诊断。药房费用占高成本患者总直接医疗费用的 28.4%；初级保健占 1.0%。作为高成本患者的特征包括存在 1 种复杂的慢性疾病（相对风险[RR]，6.5；95%CI，4.7-9.0）、存在 2 种或更多种复杂的慢性疾病（RR，23.5；95%CI，14.2-39.1）、存在任何行为健康诊断（RR，3.6；95%CI，2.6-5.1）和肥胖（RR，2.0；95%CI，1.3-3.0）。
私人保险高成本青少年的总直接医疗费用与医疗复杂性、心理健康状况和肥胖有关。在类似人群中，降低成本的策略应针对这些成本驱动因素进行调整。
