Harvard Medical School, Boston, MA, United States; Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States.
Harvard Medical School, Boston, MA, United States; Massachusetts General Physicians Organization, Boston, MA, United States.
Healthc (Amst). 2017 Dec;5(4):204-213. doi: 10.1016/j.hjdsi.2016.12.004. Epub 2016 Dec 27.
The highest cost patients account for a disproportionately large share of American healthcare costs and are increasingly the focus of research and policy efforts to stem the rapid growth of these costs. These patients tend to be medically complex and frail, but we know little about how such characteristics influence healthcare spending from the perspectives of the patients and their caregivers. Therefore, we examined five of the highest cost patients at an academic medical center in a case series. We interviewed the patients, their family members, and their clinicians and analyzed their claims data and medical charts to explore how patient and health system characteristics influenced their health costs. We found that their complex medical issues, physical disability/frailty, and mental illness/substance use seemed to be linked with increased costs, while their socioeconomic status, social network, activation, and trust in clinicians and the health system appeared to increase or decrease costs depending on context. In these patients' narratives, trust seemed to modify the interaction between patient activation and cost. Our observations raise questions about whether factors mediating costs in high-cost patients may be more heterogenous than previously described and if patient trust and activation may be important, potentially modifiable drivers of these costs. Our case series illustrates the challenges of unilateral policies to address high cost patients and the need for targeted approaches.
高费用患者在美国医疗保健费用中占比不成比例，并且越来越成为研究和政策努力的焦点，以遏制这些成本的快速增长。这些患者往往病情复杂且身体虚弱，但我们对这些特征如何从患者及其护理人员的角度影响医疗保健支出知之甚少。因此，我们在一个学术医疗中心对五名高费用患者进行了病例系列研究。我们采访了患者、他们的家属和他们的临床医生，并分析了他们的索赔数据和病历，以探讨患者和医疗系统特征如何影响他们的医疗费用。我们发现，他们复杂的医疗问题、身体残疾/虚弱以及精神疾病/药物滥用似乎与费用增加有关，而他们的社会经济地位、社交网络、积极性以及对临床医生和医疗系统的信任则似乎会根据具体情况增加或减少费用。在这些患者的叙述中，信任似乎改变了患者积极性与费用之间的相互作用。我们的观察结果提出了一些问题，即高费用患者中介费用的因素是否比以前描述的更加多样化，以及患者信任和积极性是否是这些费用的重要潜在可调节驱动因素。我们的病例系列说明了针对高费用患者采取单方面政策的挑战，以及需要采取有针对性的方法。
