Abstract
ObjectiveA small proportion of the population accounts for the majority of healthcare costs. Mental health and addiction (MHA) patients are consistently high-cost. We aimed to delineate factors amenable to public health action that may reduce high-cost use among a cohort of MHA clients in Saskatoon, Saskatchewan.MethodsWe conducted a population-based retrospective cohort study. Administrative health data from fiscal years (FY) 2009–2015, linked at the individual level, were analyzed (n = 129,932). The outcome of interest was ≥ 90th percentile of costs for each year under study (‘persistent high-cost use’). Descriptive analyses were followed by logistic regression modelling; the latter excluded long-term care residents.ResultsThe average healthcare cost among study cohort members in FY 2009 was ~ $2300; for high-cost users it was ~ $19,000. Individuals with unstable housing and hospitalization(s) had increased risk of persistent high-cost use; both of these effects were more pronounced as comorbidities increased. Patients with schizophrenia, particularly those under 50 years old, had increased probability of persistent high-cost use. The probability of persistent high-cost use decreased with good connection to a primary care provider; this effect was more pronounced as the number of mental health conditions increased.ConclusionDespite constituting only 5% of the study cohort, persistent high-cost MHA clients (n = 6455) accounted for ~ 35% of total costs. Efforts to reduce high-cost use should focus on reduction of multimorbidity, connection to a primary care provider (particularly for those with more than one MHA), young patients with schizophrenia, and adequately addressing housing stability.
Highlights
Evidence has long demonstrated that a small proportion of the population (< 10%) accounts for the majority (50–70%) of total healthcare spending (Densen et al 1959): individuals commonly referred to as ‘high-cost users’
Three Canadian studies have focused on patients with high costs and mental health and addiction (MHA) issues. de Oliveira et al demonstrated that high-cost MHA patients incur 30% more healthcare costs per capita compared to high-cost users with no mental health conditions; a subsequent study demonstrated that MHA highcost patients (‘MHA high-cost’ patients defined as individuals for whom MHA services accounted for ≥ 50% of their total healthcare costs) had healthcare costs 40% higher than those with no MHA-related costs
Physicians paid on a fee-forservice basis submit billing claims to the provincial health ministry; a single diagnosis using a three-digit International Classification of Diseases (ICD)-9 code is recorded on each claim
Summary
Evidence has long demonstrated that a small proportion of the population (< 10%) accounts for the majority (50–70%) of total healthcare spending (Densen et al 1959): individuals commonly referred to as ‘high-cost users’. As early as 1988, Taube et al demonstrated that individuals with mental disorders comprised 9% of high-cost users in 1 year (i.e., those with ≥ 25 visits), but accounted for nearly half (49.2%) of total outpatient expense (Taube et al 1988). Hunter et al (2015) found that nearly half of high-cost users had a mental health condition (Hunter et al 2015). De Oliveira et al demonstrated that high-cost MHA patients incur 30% more healthcare costs per capita compared to high-cost users with no mental health conditions (de Oliveira et al 2016b); a subsequent study demonstrated that MHA highcost patients (‘MHA high-cost’ patients defined as individuals for whom MHA services accounted for ≥ 50% of their total healthcare costs) had healthcare costs 40% higher than those with no MHA-related costs (de Oliveira et al 2017a). Using a combination of mood, substance use, psychotic and anxiety disorders as the definition of mental illness, Hensel et al found that rates of mental illness were 39.3% in the top 1% costliest users (compared to 21.3% in the lowest cost group) (Hensel et al 2016)
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