Legal / Ethics

The most expensive one percent: A case study

There is a lot of talk today about the cost of Medicare and Medicaid—and about reducing the benefit. Policymakers and caregivers alike undoubtedly would find it helpful to examine the patterns of spending on health care throughout the United States. Healthcare expenses in the United States rose from $1,106 per person in 1980 ($255 billion overall) to $6,280 per person in 2004 ($1.9 trillion overall) to $8,402 per person in 2012. And government statisticians estimate that health costs will reach $13,100 per person in 2018, accounting for $1 out of every $5 spent in the economy.

However, as we all know, healthcare spending is not distributed evenly across individuals, or even segments of the population, specific diseases, or payers. The top five most costly medical conditions in terms of health care expenditures were for treatment of heart disease, trauma-related disorders, cancer, mental disorders, and chronic obstructive pulmonary disease (COPD)/asthma. In addition:

  • Five percent of the population accounts for almost half (49%) of total healthcare expenses.
  • The 15 most expensive health conditions account for 44% of total health care expenses.
  • Patients with multiple chronic conditions cost up to seven times as much as patients with only one chronic condition.

Consider, for example, Ann Smith* who is 66 years old and has had multiple sclerosis since she was 18. She sees half a dozen physicians, takes 21 prescribed medications, and is typically in and out of the hospital twice a year. We begin Ann’s case study at a nursing home in Massachusetts. Here is the short version of what happened:

Feb. 11 – Smith’s personal care attendant (PCA) drives her to a hospital because Smith is having trouble talking and hearing. She is admitted for IV rehydration.

Feb. 15 – Smith is discharged to a nursing home where she shares a bedroom with another woman. She is now weaker than when she was at home, and needs help standing, dressing, and taking care of other daily activities.

March 3 – Smith returns to the hospital. At the nursing home, she tried to call 411 to get a phone number, but dialed 911 by mistake. She seems flustered and disoriented as she talks to the police, so she’s returned to the hospital for a mental health evaluation.


March 6 – Smith is readmitted to the nursing home where she continues her rehabilitation. She is moved by the kindness of the staff and loves the food, but is anxious to get back to her own home.

March 21 – Smith develops a urinary tract infection and becomes agitated, which her doctor attributes to too many changes of place and medications, so she is admitted to a hospital again.

March 26 – She is discharged to the nursing home again, but develops cellulitis in one hand. The infection spreads up her arm.

March 28 – Smith is readmitted to the hospital for treatment of cellulitis. She is overwhelmed again, her anxiety flares, and she’s transferred to the mental health unit.

April 6 – She is again discharged to a nursing home, and the nurses begin to doubt whether she can live independently at home, with some help. But Smith wants to go home…

… but there are several issues. She has been in and out of this nursing home and several hospitals for the last 2 months. She was admitted to the hospital from home because she was severely dehydrated; simply put, she wasn’t getting enough to drink. Now, after three separate hospital stays, repeated recoveries and $56,171 in bills, Smith is cleared to go home, but before she can go, her nurses want to make sure the seemingly small problems that triggered her long, expensive medical journey won’t happen again.

Smith’s 93-year-old mother, her only living relative, after a long struggle with her conscience, finally called and told the nurses why Smith wasn’t getting enough to drink: She was letting her PCAs work hours that were convenient for them, but not for her. Smith usually wakes up around 6 a.m., but her PCA wasn’t arriving until 10 a.m. Moreover, another PCA, the one who comes on weekends, wasn’t arriving at Smith’s home until 4 p.m. So from 6 am to 10 am during the week—and 6 am to 4 pm on weekends—she had no one to help her get to the bathroom or to get something to eat or drink; she also experienced multiple falls during these periods. However, Smith relates well to the PCAs and relies on them for emotional support.

If you were Ann Smith’s nurse case manager, what would you do? Please respond, and I will be happy to have a dialogue with you. To start the discussion, consider: What ethical issues are involved? What care issues? What social issues? And then, always paramount, what are the practical issues? I hope we can have a fruitful professional exchange!

*Name has been changed.

Leah Curtin, RN, ScD (h), FAAN, is Executive Editor, Professional Outreach for American Nurse Today. An internationally recognized nurse leader, ethicist, speaker, and consultant, she is a strong advocate for both the nursing profession and high-quality patient care. Currently she is Clinical Professor of Nursing at the University of Cincinnati College of Nursing and Health. For over 20 years, she was the Editor-in-Chief of Nursing Management. In 2007, she was appointed to the Standards and Appeals Board of DNV Healthcare, a new Medicare accrediting authority. Dr. Curtin can be reached at LCurtin@healthcommedia.com.

Selected references

Kane J. Health costs: How the U.S. compares with other countries. PBS Newshour. Oct. 22, 2012. http://www.pbs.org/newshour/rundown/2012/10/health-costs-how-the-us-compares-with-other-countries.html. Accessed Feb. 5, 2013.

Health care costs to top $8,000 per person. CBSNews. Feb. 24, 2009. http://www.cbsnews.com/2100-204_162-4824163.html Accessed Feb. 5, 2013.

Medical Expenditure Panel Survey. The Concentration of Health Care Expenditures and Related Expenses for Costly Medical Conditions, 2009. Feb. 16, 2012. http://meps.ahrq.gov/mepsweb/data_stats/Pub_ProdResults_Details.jsp?pt=Statistical+Brief&opt=2&id=1042 Accessed Feb. 5, 2013.

Bebinger M. A checkup on one of America’s most expensive patients. 90.9wbur. http://www.wbur.org/2012/08/24/most-expensive-patient-budget. Accessed Feb. 5, 2013.

6 thoughts on “The most expensive one percent: A case study”

  1. Mary says:

    This woman needs an advocate to keep her from being eploited by her caregivers!

  2. Leah Curtin says:

    I appreciate the feedback from each of you. From what I understand, this patient was completely dependent before this hospitalization, and the hope is that with help, she could remain at home. However, I do think that some small percentage of people need to be in an institution because she not only needs the physical care, but also lacks judgment. I hope she is able to make it at home with help…but I do not thik so. If/when I find out, I will share what actually happened.

  3. Amy says:

    My first thought was WOW! Several inappropriate hospitalizations as well as hospitalizations following quality issues.

    Overall it does not seem practical to send her home unless she has 24 hour PCA coverage. Looking at the hospitalizations that occurred related to quality issues, home care would be most affordable for the individual and the system

  4. Elaine says:

    I would visit pt everyday for a week in her home to really understand what’s going on. If needed, I would ask the PCA’s to change their schedules and I would see if there are any other resources to help pt – church volunteers and/or more hrs of paid staff. If this does not improve the pt’s situation, I would encourage pt to do assisted living.

  5. Anonymous says:

    How independent was Smith, prior to the Feb. 11th admisssion? She was retained in the NH due to ADLs, which may have been performed by the PCA prior to admission. An OT could have provided adaptations to provide food and fluids available at bedside. Many chronically ill become fearful of offending care givers, lest they be maltreated or abandoned. Many unknown things to consider. Sounds like poor pt managment leading to prolonged admissions with poor outcomes.

  6. revrnjan says:

    This case is unfortunately experienced by vulnerable populations much too frequently.The healthcare issues include case loads that are too large for effective oversight, and health care workers that are not fully prepared or qualified to identify signs of illness or decompensation.I also wonder about workers who are not fulfilling their job expectations, yet are charging the payor systems as if they are. The vulnerable need dedicated caregivers to provide even basic provisions of food and water.

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