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The highest cost patients account for a disproportionately large share of American healthcare costs and are increasingly the focus of research and policy efforts to stem the rapid growth of these costs. These patients tend to be medically complex and frail, but we know little about how such characteristics influence healthcare spending from the perspectives of the patients and their caregivers. Therefore, we examined five of the highest cost patients at an academic medical center in a case series. We interviewed the patients, their family members, and their clinicians and analyzed their claims data and medical charts to explore how patient and health system characteristics influenced their health costs. We found that their complex medical issues, physical disability/frailty, and mental illness/substance use seemed to be linked with increased costs, while their socioeconomic status, social network, activation, and trust in clinicians and the health system appeared to increase or decrease costs depending on context. In these patients’ narratives, trust seemed to modify the interaction between patient activation and cost. Our observations raise questions about whether factors mediating costs in high-cost patients may be more heterogenous than previously described and if patient trust and activation may be important, potentially modifiable drivers of these costs. Our case series illustrates the challenges of unilateral policies to address high cost patients and the need for targeted approaches.

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Patients must make sense of increasingly complex information to navigate their health and the health care system, with limited opportunity to do so in clinical settings. Patient education videos may help to communicate key information, but they are often impersonal and cumbersome to produce or update with new evidence. To address these limitations, a program was developed to facilitate local video creation to deliver targeted information to patients.

ObjectiveTo characterize racial differences in receipt of low value care (services that provide little to no benefit yet have potential for harm) among older Medicare beneficiaries overall and within health systems in the United States.DesignRetrospective cohort studySetting100% Medicare fee-for-service administrative data (2016–18).ParticipantsBlack and White Medicare patients aged 65 or older as of 2016 and attributed to 595 health systems in the United States.Main outcome measuresReceipt of 40 low value services among Black and White patients, with and without adjustment for patient age, sex, and previous healthcare use. Additional models included health system fixed effects to assess racial differences within health systems and separately, racial composition of the health system’s population to assess the relative contributions of individual patient race and health system racial composition to low value care receipt.ResultsThe cohort included 9 833 304 patients (6.8% Black; 57.9% female). Of 40 low value services examined, Black patients had higher adjusted receipt of nine services and lower receipt of 20 services than White patients. Specifically, Black patients were more likely to receive low value acute diagnostic tests, including imaging for uncomplicated headache (6.9% v3.2%) and head computed tomography scans for dizziness (3.1% v1.9%). White patients had higher rates of low value screening tests and treatments, including preoperative laboratory tests (10.3% v6.5%), prostate specific antigen tests (31.0% v25.7%), and antibiotics for upper respiratory infections (36.6% v32.7%; all P<0.001). Secondary analyses showed that these differences persisted within given health systems and were not explained by Black and White patients receiving care from different systems.ConclusionsBlack patients were more likely to receive low value acute diagnostic tests and White patients were more likely to receive low value screening tests and treatments. Differences were generally small and were largely due to differential care within health systems. These patterns suggest potential individual, interpersonal, and structural factors that researchers, policy makers, and health system leaders might investigate and address to improve care quality and equity.