The high cost of health care in the United States has long been a topic of conversation – and of debate – particularly when examining the drivers of health spending. Just last month, a breakout session at AcademyHealth’s Annual Research Meeting drew crowds of attendees to hear expert perspectives on the topic. There are conflicting opinions of why health care costs are so high in the United States, and as both state and federal governments grapple with how to reign in health care spending, it is necessary to understand the nuanced factors that contribute to high costs.

High-Cost Patients: Who Are They?

Though health care spending is increasing across the board, high-cost patients in particular are an important sub-population to examine. These patients often fall into one of three categories – those with chronic illnesses, those with catastrophic illnesses, and patients receiving end of life care-- and they account for a disproportionately large share of health care costs in the U.S. The cost of their care is influenced by a variety of factors, including more obvious factors like medical issues and physical disability, as well as substance abuse. In addition to these factors, socioeconomic status, social networks and patient attitudes and trust also influence the cost of care.

Ishani Ganguli of Harvard Medical School conducted case studies of five high-cost patients to gain a better understanding of how these factors influence cost. Her findings, published in Healthcare: The Journal of Delivery Science and Innovation, reveal that while medical issues, physical disability and substance abuse were cost drivers – they consistently contributed to higher costs – factors like socioeconomic status, social networks, and patient attitudes were all modifiers – their impact on cost was complex and situational.

Understanding Cost Modifiers

Patient activation, for example, contributed to both increased and decreased costs in the study. For patients with unambiguous medical conditions, high activation contributed to lower costs, while for others it was associated with advocating for higher-priced care. Low activation was generally associated with care fragmentation, and as a result, higher costs. Patient relationships with clinicians also influenced cost. Relationships that lacked trust and collaboration often led to fragmented care, or to patients advocating for care against physician recommendation. Sometimes family members pushed for more aggressive care despite a doctor’s poor prognosis, suggesting a lack of trust in the doctor’s understanding of the patient’s resilience.

Socioeconomic status had a complex influence on cost – patients of higher socioeconomic background were able to invest in personal fitness, medications, and home health aides, which often reduced the need for additional medical care. However, patients of higher socioeconomic status were also more likely to seek care at higher-priced medical institutions.

Overall, the influence of socioeconomic status and patient attitudes on cost of care is complicated and nonlinear, with trust being an important cost modifier. Lack of trust was often due to factors on both the patient and provider side – averse patient experiences with the health care system, low patient activation, poor quality of care, and poor clinician communication are all possible barriers to trust. Trust was a significant determinant in whether individual factors resulted in higher or lower costs. For example, patients with high activation had lower costs if they trusted their clinician, otherwise high activation was associated with higher costs.

Trust: What Are We Missing?

These findings bring nuance to an already complicated area of study. Cost modifiers are not one-way streets, but are complex factors whose impact on cost depends on individual patients and their relationship with their health care provider and the health care system at large. It is not enough to say that high activation, high socioeconomic status patients have lower costs; instead we must examine the specifics of their interactions with their health care providers in order to understand how trust influences their decisions, and how their activation level and socioeconomic status might influence their trust.

The patients interviewed for these case studies were all Caucasian and had health insurance. Race and ethnicity can have a large impact on a person’s trust in their healthcare provider – and as a result, the cost of their care. Given that black and Hispanic patients report higher levels of physician distrust relative to white patients, it is important to broaden these case studies to include other patient populations and their experiences with trust and cost of care.

Given the influence of trust on health care costs, as well as health outcomes, AcademyHealth is excited to support a group of grants funded by the Robert Wood Johnson Foundation that examine how to build trust and mutual respect to support the health care needs of vulnerable populations. These grants will be announced in August 2018.

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