ObjectivesTo investigate the characteristics and healthcare utilisation of high-cost patients and to compare high-cost patients across payers and countries.DesignSystematic review.Data sourcesPubMed and Embase databases were searched until 30 October 2017.Eligibility criteria and outcomesOur final search was built on three themes: ‘high-cost’, ‘patients’, and ‘cost’ and ‘cost analysis’. We included articles that reported characteristics and utilisation of the top-X% (eg, top-5% and top-10%) patients of costs of a given population. Analyses were limited to studies that covered a broad range of services, across the continuum of care. Andersen’s behavioural model was used to categorise characteristics and determinants into predisposing, enabling and need characteristics.ResultsThe studies pointed to a high prevalence of multiple (chronic) conditions to explain high-cost patients’ utilisation. Besides, we found a high prevalence of mental illness across all studies and a prevalence higher than 30% in US Medicaid and total population studies. Furthermore, we found that high costs were associated with increasing age but that still more than halve of high-cost patients were younger than 65 years. High costs were associated with higher incomes in the USA but with lower incomes elsewhere. Preventable spending was estimated at maximally 10% of spending. The top-10%, top-5% and top-1% high-cost patients accounted for respectively 68%, 55% and 24% of costs within a given year. Spending persistency varied between 24% and 48%. Finally, we found that no more than 30% of high-cost patients are in their last year of life.ConclusionsHigh-cost patients make up the sickest and most complex populations, and their high utilisation is primarily explained by high levels of chronic and mental illness. High-cost patients are diverse populations and vary across payer types and countries. Tailored interventions are needed to meet the needs of high-cost patients and to avoid waste of scarce resources.

Developing and distributing a safe and effective SARS-CoV-2 (COVID-19) vaccine has garnered immense global interest. Less than a year after COVID-19 was declared a pandemic, several vaccine candidates had received emergency use authorization across a range of countries. Despite this scientific breakthrough, the journey from vaccine discovery to global herd immunity against COVID-19 continues to present significant policy challenges that require a collaborative, global response. We offer a framework for understanding remaining and new policy challenges for successful global vaccine campaigns against COVID-19 as well as potential solutions to address them. Decision-makers must be aware of these challenges and strategize solutions that can be implemented at scale. These include challenges around maintaining R&D incentives, running clinical trials, authorizations, post-market surveillance, manufacturing and supply, global dissemination, allocation, uptake, and clinical system adaption. Alongside these challenges, financial and ethical concerns must also be addressed.

As of 2015 a major reform in LTC is taking place in the Netherlands. An important objective of the reform is to reign in expenditure growth to safeguard the fiscal sustainability of LTC. Other objectives are to improve the quality of LTC by making it more client-tailored. The reform consists of four interrelated pillars: a normative reorientation, a shift from residential to non-residential care, decentralization of non-residential care and expenditure cuts. The article gives a brief overview of these pillars and their underlying assumptions. Furthermore, attention is paid to the political decision-making process and the politics of implementation and evaluation. Perceptions of the effects of the reform so far widely differ: positive views alternate with critical views. Though the reform is radical in various aspects, LTC care will remain a largely publicly funded provision. A statutory health insurance scheme will remain in place to cover residential care. The role of municipalities in publicly funded non-residential care is significantly upgraded. The final section contains a few policy lessons.