Research Article: A challenge to all. A primer on inter-country differences of high-need, high-cost patients

Date Published: June 19, 2019

Publisher: Public Library of Science

Author(s): Marit A. C. Tanke, Yevgeniy Feyman, Enrique Bernal-Delgado, Sarah R. Deeny, Yuichi Imanaka, Patrick Jeurissen, Laura Lange, Alexander Pimperl, Noriko Sasaki, Michael Schull, Joost J. G. Wammes, Walter P. Wodchis, Gregg S. Meyer, Rosa Maria Urbanos Garrido.


Across countries, a small group of patients accounts for the majority of health care spending. These patients are more likely than other patients to experience problems with quality and safety in their care, suggesting that efforts targeting efficiency and quality among this population might have significant payoffs for health systems. Better understanding of similarities and differences in patient characteristics and health care use in different countries may ultimately inform further efforts to improve care for HNHC patients in these health systems.

We conducted a cross-sectional descriptive study using one year of patient-level data on high-cost patients in seven high-income OECD member countries. Countries were selected based on availability of detailed information (large enough samples of claims, administrative, and survey data of high-cost patients). We studied concentration of spending among high-cost patients, characteristics of high-cost patients, and per capita spending on high-cost patients.

Cost-concentration of the top 5% of patients varied across countries, from 41% in Japan to 60% in Canada, driven primarily by variation in the top 1% of spenders. In general, high-cost patients were more likely to be female (57.7% on average), had a significant number of multi-morbidities (up to on average 10 major diagnostic categories (ICD chapters), and had a lower socioeconomic status. Characteristics of high-cost patients varied as well: median age ranged from 62 in the Netherlands to 75 in Germany and the difference in socioeconomic status is particularly stark in the US. Lastly, utilization, particularly for inpatient care, varied with an average number of inpatient days ranging from 6.6 nights (US) to 97.7 nights in Japan.

In this descriptive study, there is substantial variation in the cost concentration, characteristics, and per capita spending on high-cost patient populations across high-income countries. Differences in the way that health systems are structured likely explains some of this variation, which suggests the potential of cross-system learning opportunities. Our findings highlight the need for further studies including comparable performance metrics and institutional analysis.

Partial Text

Health care spending is concentrated among a relatively small number of high-cost patients [1]. These patients face the most pressing medical needs and typically suffer poor clinical outcomes [2–4]. It has been suggested that improved care for this population could increase efficiency and improve overall quality within health systems [5].

The lead author (the manuscript’s guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; no important aspects of the study have been omitted; and any discrepancies from the study as originally planned (and, if relevant, registered) have been explained.




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