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The most expensive patients

A surprisingly tiny number of patients have medical needs that could bankrupt Medicare.
Dr. Brian Goldman · CBC ·

The Canadian Institute for Health Information pegs health care costs at $220 billion a year and rising. Politicians and experts are looking for ways to trim spending.  Here's a clue: a new study published in the Canadian Medical Association Journal (CMAJ) shows just how few patients it takes to put Medicare at risk.

The system spends modest amounts of money on the vast majority of us – but vast sums of money on a small number of patients.  That's the main conclusion of a study of Ontarians eligible for publicly funded health care between 2009 and 2011.  Total health care spending was $42 billion a year, with $30 billion a year spent on individual patients.  A small fraction of patients – five per cent of Ontario's population – accounted for two thirds of health spending.  Just one per cent of Ontarians accounted for a third – at a cost of $45,000 per patient per year.  By comparison, on average, Canada spends $6000 per person per year on health care. 

Adults and especially seniors with severe chronic illnesses accounted for a lot of the spending.  They include patients with heart failure, chronic obstructive pulmonary disease or COPD, as well as pneumonia and kidney infections.  As an ER physician, I've seen a lot of patients lately with end stage cancer admitted to hospital for palliative care, and that was a major cost driver in the Ontario study.  That's adults.  On a per patient basis, kids cost more than adults in health care, with the top one per cent accounting for 38% of costs. The main reasons why kids get hospitalized include prematurity and low birth weight, acute respiratory conditions like bronchiolitis, cancer chemotherapy, and depression.

This is an Ontario study, but the conclusions apply to the rest of Canada absolutely. Several major studies over the years have shown that the top five per cent of patients in terms of cost consume two thirds of hospital and nursing home costs, occupy nearly two thirds of acute care hospital beds, and account for 85 per cent of home care costs.  The results are similar to studies in the US, and other developed nations.

The big reason why caring for the top five per cent is so expensive is that they get admitted to hospital.  That's true for adults and kids.  Hospital care is the most expensive type of health care.  The authors of the study in CMAJ believe that at least some of the five per cent get admitted to hospital because they don't get adequate home care. Improving that could prevent hospitalization and save a lot of money.  The patients that make up the five per cent have illnesses that are vastly different from one another; each will have a different fix. 

The study looked at how much money is spent on the five per cent.  It didn't look at how well the dollars are spent.  I have no doubt that some of it is an out of and out waste of money.  And some of it is spent on care that is futile in the sense that no amount of health care will restore the patient to a decent quality of life.  For instance, it has been said that we spend more on health care in the last two years of a patient's life than in all the years prior to that.  

If we get better at identifying what health care is futile, we could save patients harm and save the system a lot of money.