Total Direct Medical Expenses and Characteristics of Privately Insured Adolescents Who Incur High Costs

Abstract

IMPORTANCE 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.OBJECTIVES To assess health care expenditures for high-cost adolescents and to describe the patient characteristics associated with high medical costs. DESIGN, SETTING, AND PARTICIPANTSA 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. MAIN OUTCOMES AND MEASURESWe 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.RESULTS 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). CONCLUSIONS AND RELEVANCETotal 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.

Spending on Children’s Personal Health Care in the United States, 1996-2013

“…Several studies have estimated US children’s health care or medical spending by age, but most lack national representativeness, focus on one type of insurance status, or only cover a few years . Moreover, few have split spending across both health condition and type of care . The Health Care Cost Institute has produced 4 annual reports that assess health care spending for children, but their focus was on children who are covered by employer-based insurance.…”

“…[3][4][5][6][7][8][9] Moreover, few have split spending across both health condition and type of care. 3,[10][11][12][13] The Health Care Cost Institute has produced 4 annual reports that assess health care spending for children, but their focus was on children who are covered by employer-based insurance. Thus, the reports excluded children covered by state and federally funded health insurance programs, which have expanded since the introduction of the State Children's Health Insurance Program in 1997.…”

Epidemiology of Children With Multiple Complex Chronic Conditions in a Mixed Urban-Rural US Community

“…1 Children with multiple complex chronic conditions (MCCs) are recognized as a focus population for improvement in health care systems because they constitute a small fraction of our communities yet represent a disproportionate amount of health care costs and mortality. [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] Children with MCCs represented more than onequarter of children in the top 5% of Medicaid spending in 2010. 20 In addition, children who are hospitalized with MCCs have a threefold longer hospital length of stay, 11-fold greater charges, and 15-fold higher inpatient mortality compared with children who are hospitalized without MCCs.…”

“…22,23 Despite the burden of MCCs on children, families, communities, and health care systems, the epidemiological assessment of children with MCCs within a geographically defined pediatric US population has not been previously performed. Although valuable, the extant literature is limited to cohorts derived from databases originating from health care use,* payer source, 4,[7][8][9][10]14,20,[30][31][32][33] death certificates, [34][35][36][37] and national surveys. 38,39 Furthermore, the reported prevalence for chronic disease in children is widely variable (0.2%-44%) because of considerable heterogeneity in study definitions, designs, populations, and conditions.…”

Mental Health Care Use Among Children and Adolescents With High Health Care Costs in Ontario, Canada

“…integrating mental health care professionals into pediatric primary care could prove to be costeffective if hospitalizations can be reduced. 6 Finally, incorporating mental health services into routine care for children with chronic physical illnesses may be associated with improved quality of life and cost savings due to fewer disease exacerbations requiring hospitalization. 7 We used a population-based sample of all children and adolescents with high health care costs in a large Canadian province; previous work has examined specific subpopulations (privately insured, 6 Medicaid insured 4,7 ) or used small samples.…”