Journal of General Internal Medicine

, Volume 34, Issue 2, pp 218–225 | Cite as

Subgroups of High-Cost Medicare Advantage Patients: an Observational Study

  • Brian W. Powers
  • Jiali Yan
  • Jingsan Zhu
  • Kristin A. Linn
  • Sachin H. Jain
  • Jennifer L. Kowalski
  • Amol S. NavatheEmail author
Original Research



There is a growing focus on improving the quality and value of health care delivery for high-cost patients. Compared to fee-for-service Medicare, less is known about the clinical composition of high-cost Medicare Advantage populations.


To describe a high-cost Medicare Advantage population and identify clinically and operationally significant subgroups of patients.


We used a density-based clustering algorithm to group high-cost patients (top 10% of spending) according to 161 distinct demographic, clinical, and claims-based variables. We then examined rates of utilization, spending, and mortality among subgroups.


Sixty-one thousand five hundred forty-six Medicare Advantage beneficiaries.

Main Measures

Spending, utilization, and mortality.

Key Results

High-cost patients (n = 6154) accounted for 55% of total spending. High-cost patients were more likely to be younger, male, and have higher rates of comorbid illnesses. We identified ten subgroups of high-cost patients: acute exacerbations of chronic disease (mixed); end-stage renal disease (ESRD); recurrent gastrointestinal bleed (GIB); orthopedic trauma (trauma); vascular disease (vascular); surgical infections and other complications (complications); cirrhosis with hepatitis C (liver); ESRD with increased medical and behavioral comorbidity (ESRD+); cancer with high-cost imaging and radiation therapy (oncology); and neurologic disorders (neurologic). The average number of inpatient days ranged from 3.25 (oncology) to 26.09 (trauma). Preventable spending (as a percentage of total spending) ranged from 0.8% (oncology) to 9.5% (complications) and the percentage of spending attributable to prescription medications ranged from 7.9% (trauma and oncology) to 77.0% (liver). The percentage of patients who were persistently high-cost ranged from 11.8% (trauma) to 100.0% (ESRD+). One-year mortality ranged from 0.0% (liver) to 25.8% (ESRD+).


We identified clinically distinct subgroups of patients within a heterogeneous high-cost Medicare Advantage population using cluster analysis. These subgroups, defined by condition-specific profiles and illness trajectories, had markedly different patterns of utilization, spending, and mortality, holding important implications for clinical strategy.


high-cost patients care management medicare advantage 


Prior Presentation(s)

This study was presented, in part, at AcademyHealth; June 25, 2018; Seattle, WA.


This study is supported by a grant from the Anthem Public Policy Institute and, in part, under a grant with the Pennsylvania Department of Health. The Department specifically disclaims responsibility for any analyses, interpretations, or conclusions.

Compliance with Ethical Standards

This study was approved by the Institutional Review Board of the University of Pennsylvania.

Conflict of Interest

Dr. Navathe reports that he has received grant support from Hawaii Medical Service Association and Oscar Health; personal fees from Navvis and Co., Navigant Inc., Lynx Medical, Indegene Inc., and Sutherland Global Services; personal fees and equity from NavaHealth; serves on the board without compensation for Integrated Services, Inc., speaking fees from the Cleveland Clinic, and honoraria from Elsevier Press. Dr. Linn reports that she has received grant support from Hawaii Medical Service Association. Dr. Jain reports employment by Anthem, Inc.; stock ownership in Anthem, Inc., and honoraria from Elsevier Press. Ms. Kowalski reports employment by Anthem, Inc. and stock ownership in Anthem, Inc. and Amazon. Dr. Powers reports employment by Anthem, Inc. All other authors declare no conflicts of interest.

Supplementary material

11606_2018_4759_MOESM1_ESM.docx (107 kb)
ESM 1 (DOCX 106 kb)


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Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Brian W. Powers
    • 1
    • 2
    • 3
    • 4
  • Jiali Yan
    • 5
  • Jingsan Zhu
    • 6
  • Kristin A. Linn
    • 7
  • Sachin H. Jain
    • 3
  • Jennifer L. Kowalski
    • 8
  • Amol S. Navathe
    • 6
    • 9
    Email author
  1. 1.Department of MedicineBrigham and Women’s HospitalBostonUSA
  2. 2.Department of Population MedicineHarvard Medical School/Harvard Pilgrim Health Care InstituteBostonUSA
  3. 3.CareMore Health SystemCerritosUSA
  4. 4.Atrius HealthBostonUSA
  5. 5.Department of MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaUSA
  6. 6.Department of Medical Ethics and Health Policy University of Pennsylvania Perelman School of MedicinePhiladelphiaUSA
  7. 7.Department of Biostatistics, Epidemiology and InformaticsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaUSA
  8. 8.Anthem Public Policy InstituteWashingtonUSA
  9. 9.Corporal Michael J. Cresencz VA Medical CenterPhiladelphiaUSA

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