More than a quarter of public spending on health care comes from 1% of network users. If the cost of hospitalization weighs less and less heavily in the total bill, that related to drugs has more than tripled among these heavy users in nearly 20 years.
This is at least the finding of a study carried out by a team of researchers from HEC Montréal and the School of Management Sciences of UQAM, which traces the evolution of the costs related to public health care in Quebec between 1997 and 2016.
“1% of the highest users of health care alone account for a little more than a quarter of expenditure”, note in their analysis the researchers Nicholas-James Clavet and Julien Navaux, as well as Raquel Fonseca and Pierre-Carl Michaud, all the two holders of the Research Chair in Intergenerational Economic Issues.
This portrait, drawn from unpublished data from the RAMQ and MED-ECHO, a database on diagnoses and the cost of hospital stays in Quebec, shows that the bulk of expenditures related to the health care system stem from a very small proportion of the population.
“The goal is not to judge this, or to say that it is bad. But if we are looking to improve the use of our resources, it is to this share of major users of the health system that we should be interested, ”says one of the authors, Pierre-Carl Michaud.
Since health expenditures are increasing at a sustained rate—5.3% per year on average since 1997—and account for more than half of government expenditures, these researchers estimate that the care required by this group of users must be assessed more closely to see where gains could be made.
This study also reveals that the costs associated with hospitalizations among this “1%” (aged 63 on average) have fallen by 7 percentage points over the past 20 years, despite the aging of the population. Costs related to hospital care in this group fell from 23% to 16% of total health expenditure. In particular because the length of stays has fallen, in 19 years, from 46 to 40 days on average.
Interestingly, hospital expenditures have also fallen by 15 percentage points for the population as a whole, and now eat up only 36% of government health expenditures compared to more than 50% in 1997. And that, even if the average length of stay for all users has hardly changed.
It is the share of drugs in the total bill which has continued to swell for two decades, rising from 16% in 1997 to 28% in 2016 for the population as a whole. Among heavy users, the burden of drug costs has more than tripled.
“We don’t have to say whether it’s desirable or not, but it would be relevant to see if it meets the real needs of these people,” argues one of the co-authors, Julien Navaux. “It would be beneficial to study the cost-effectiveness of these drugs. Among these heavy users, by following the same cohort from year to year, we observed that many of the people [qui reçoivent ces soins et médicaments] are at the end of their life and that 27% die during the year,” adds Pierre-Carl Michaud.
Changing diagnoses
Another of the major findings of this study is the significant change that has occurred in terms of diagnoses related to health expenditures.
In hospitals, costs associated with diseases of the circulatory system (25% among high users) still dominate the total expenditure. But those related to mental health problems have plummeted (from 8 to 2% of diagnoses) in 20 years.
The upheavals in the prevalence of certain diseases and in their treatments are even more visible in the total expenditure related to medicines. Thus, cardiovascular disease, which engulfed 34% of government pharmaceutical expenditure in 1997, now only accounts for 15% of the total. In the famous “1%” club, these expenses have gone from 20% to less than 5% of the total bill.
“This can be explained by the development of better treatments, in particular cardiac surgical interventions”, advances Pierre-Carl Michaud.
On the other hand, the cost associated with anti-cancer agents has jumped, revealing the increasing incidence of cancer in an increasingly older population. Among heavy users, spending on antineoplastic drugs to fight cancer has risen from 3 to 18% of pharmaceutical spending in 20 years.
All in all, the lion’s share of healthcare costs associated with high users still remains a challenge, and is largely due to hospitalizations, which are five times longer than for the rest of the population. The only good news is that despite the aging of the population, which has been accelerating for 20 years, the share of health expenditure associated with the last year of life is experiencing a slight decline, according to another study carried out by the same group. Perhaps a sign that fewer people are dying in hospital, and more in their living environments.