Abstract
BackgroundHealth care spending is overwhelmingly concentrated within a very small proportion of the population, referred to as the high-cost users (HCU). To date, research on HCU has been limited in scope, focusing mostly on those characteristics available through administrative databases, which have been largely clinical in nature, or have relied on ecological measures of socio-demographics. This study links population health surveys to administrative data, allowing for the investigation of a broad range of individual-level characteristics and provides a more thorough characterization of community-dwelling HCU across demographic, social, behavioral and clinical characteristics.MethodsWe linked three cycles of the Canadian Community Health Survey (CCHS) to medical claim data for the years 2003–2008 for Ontario, Canada. Participants were ranked according to gradients of cost (Top 1%, Top 2-5%, Top 6-50% and Bottom 50%) and multinomial logistic regression was used to investigate a wide range of factors, including health behaviors and socio-demographics, likely associated with HCU status.ResultsUsing a total sample of 91,223 adults (18 and older), we found that HCU status was strongly associated with being older, having multiple chronic conditions, and reporting poorer self-perceived health. Specifically, in the fully-adjusted model, poor self-rated health (vs. good) was associated with a 26-fold increase in odds of becoming a Top 1% HCU (vs. Bottom 50% user) [95% CI: (18.9, 36.9)]. Further, HCU tended to be of lower socio-economic status, former daily smokers, physically inactive, current non-drinkers, and obese.ConclusionsThe results of this study have provided valuable insights into the broader characteristics of community-dwelling HCU, including unique demographic and behavioral characteristics. Additionally, strong associations with self-reported clinical variables, such as self-rated general and mental health, highlight the importance of the patient perspective for HCU. These findings have the potential to inform policies for health care and public health, particularly in light of increasing decision-maker attention in the sustainability of the health care system, improving patient outcomes and, more generally, in order to achieve the common goal of improving population health outcomes.
Highlights
Health care spending is overwhelmingly concentrated within a very small proportion of the population, referred to as the high-cost users (HCU)
It is well known that health care spending is overwhelmingly concentrated; a very small proportion of the population consumes the majority of costs
All Ontario residents are covered by a single payer insurance system referred to as the Ontario Health Insurance Plan (OHIP) and all related health care utilization is tracked in the health administrative data
Summary
Health care spending is overwhelmingly concentrated within a very small proportion of the population, referred to as the high-cost users (HCU). It is well known that health care spending is overwhelmingly concentrated; a very small proportion of the population consumes the majority of costs. In 2007/08, the top 1% of health care users in Ontario accounted for one-third of health care spending; the lower 50% of users, on the other hand, consumed a mere 1% of total expenditures [1] This is not a phenomenon specific to Ontario, nor is it one isolated within Canada’s universal health care system. Research has overwhelmingly focused on improving patient outcomes through better case management and strategies to reduce health care spending.
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