The first analysis of public healthcare expenditure (Análisis poblacional del gasto en servicios sanitarios en Cataluña (España): ¿qué y quién consume más recursos? / Population-based analysis of the healthcare expenditure in Catalonia (Spain): what and who consumes more resources?), from which this article has been written, is based on the microdata of use generated by users of the public healthcare system in Catalonia. The study reveals that more than half of the health budget was allocated to medical care for only 5% of the population. Specifically, 51% of the budget that the Catalan Ministry of Health dedicates to caring for 7.5 million people was allocated to some 375,000 users, with an average expenditure per person of almost 10,000 euros. Within this minority of users, 1% of the population consumed 23% of the resources (22,852 euros per person). The aforementioned study is based on data from 2014 and shows great variability in individual expenditure according to medical needs. Among 95% of the population to which 49% of healthcare administration expenditure was allocated, it is worth noting that half of the Catalan population was responsible for 3.6% of total healthcare expenditure, with an average of 71 euros per person.

The main item of healthcare expenditure was dedicated to hospital care, accounting for 27.7% of the total budget, followed by primary care, with 22.7%. This was followed by expenditure on drugs, with 17.5% of resources, hospital pharmacy outpatient dispensing (9.5%), outpatient consultations (7.8%) and emergencies (5.0%). The remaining areas (day hospitals, social healthcare, mental health, dialysis, non-urgent healthcare transport, minor outpatient surgery, home breathing therapy, outpatient rehabilitation and home hospitalisation) together represented less than 10% of the budget.

This distribution displays no significant changes over time with regard to the known preponderance of hospital, primary and pharmaceutical care. But it does highlight the growing importance of spending on hospital pharmacy outpatient dispensing, which has grown exponentially in recent years.

The average healthcare expenditure of women and men increases with age. The highest value is between 80 and 84 years of age, during which time men require an average of 3,387 euros per person per year and the women an average of 2,723 euros. At the other extreme, the period of lowest use of healthcare services is between 15 and 19 years for women and between 20 and 24 years for men. Average expenditure is always higher for men than for women, except for women aged between 15 and 39, coinciding with their childbearing age.
 

The highest total expenditure is dedicated to the population aged between 40 and 79, coinciding with the largest population groups and similarly higher for men than for women. With regard to the latter, the exceptions are women of childbearing age and those aged between 80 and 89, given the fact that they outnumber men during this period of life. These differences in expenditure by gender can be explained by a greater use of healthcare services by men because of the pathologies they suffer, but also by a bias towards greater intensity in healthcare for men, as scientific literature has already shown (Ruiz Cantero, 2009).

An analysis of healthcare use and expenditure in Catalonia in 2014 also demonstrated that the type of use of the public healthcare system varies with age. In younger age groups, the greatest expenditure is related to primary care (especially in women) and emergencies. As age increases, spending on hospital care (always higher in men than in women, except, once more, during the childbearing age of women) and expenditure on drugs becomes greater.

Expenditure on hospital care – the highest in relation to the total budget – is more prominent in men up to 14 years of age than in women. At this stage, coinciding with their childbearing age, it is women who require a greater consumption of hospital resources. The situation is later reversed and men are again the users of more resources, especially after the age of 70. In contrast, expenditure on drugs is higher for men up to the age of 39 and for women from the age of 40 onwards.

The average expenditure needed to treat an illness ranges from 2,854 euros for severe depression to 8,097 euros for the infection of the human immunodeficiency virus (HIV). But the most expensive treatments do not generate the highest overall costs. With the second lowest unit cost (3,149 euros), diabetes represents the highest total expenditure (1,763 million euros) because of its high prevalence. In contrast, HIV represents one of the lowest expenditure, despite the fact that it is the most expensive treatment. A very similar situation can be observed with regard to cancer: the unit cost of its treatment is high, but overall expenditure is not because it affects a relatively small number of people. In total terms, the most costly diseases after diabetes are chronic obstructive pulmonary disease (COPD), chronic renal failure and heart failure.
 

The number of chronic diseases is a major determining factor in the use of healthcare services and, consequently, of healthcare expenditure (Monterde et al., 2016; Coderch et al., 2014). Twenty-two per cent of the population suffers from a chronic disease, which means an annual health expenditure of 413 euros per person. However, the need for resources is gradually increasing as chronic diseases accumulate: expenditure increases to 2,413 euros with five of these diseases (which would affect 5.4% of the population), to 9,626 euros with ten (0.2% of the population) and to 18,780 euros with thirteen (0.02% of the population).

Determining the population distribution of health expenditure helps to identify which groups of patients have a higher level of needs, which diseases are more intensive in terms of health expenditure and which items represent a greater proportion of expenditure. This knowledge is therefore an extremely useful tool for planning healthcare services and prioritising healthcare policies. It is therefore of great interest to identify the characteristics of the 5% of the population that originates most healthcare expenditure (age, sex, number of chronic diseases, pathologies, proximity to death, etc.) and to prioritise healthcare or social policy interventions in this group.

This article also opens up the possibility to further analyse specific diseases and repeat this with data from studies conducted before and after this publication. In this way, it will be possible to determine what impact the appearance of new diagnostic and therapeutic techniques will have on healthcare expenditure, as well as producing estimates of future expenditure.

This article has been adapted from thi study:

VELA, E., CLÈRIES, VELLA, V.A., ADROHER, C. and GARCÍA-ALTÉS, A. (2017): Análisis poblacional del gasto en servicios sanitarios en Cataluña (España): ¿qué y quién consume más recursos?
 

More bibliographic references:

CODERCH, J.; I. SÁNCHEZ-PÉREZ, and P. IBERN, et al. (2014): "Predicción del riesgo individual de alto coste sanitario para la identificación de pacientes crónicos complejos". Gaceta Sanitaria, 28(4):292-300.

MONTERDE, D.; E. VELA, and M. CLÈRIES (2016): "Los grupos de morbilidad ajustados: nuevo agrupador de morbilidad poblacional de utilidad en el ámbito de la atención primaria". Atención Primaria, 48(10):674-682.

RUIZ CANTERO, M. T. (2009): Sesgos de género en la atención sanitaria, Serie Nueva Salud Pública, 4, Granada: Escuela Andaluza de Salud Pública.

WAMMES, J. J. G.; P. J. VAN DER WEES, et al. (2018): "Systematic review of high-cost patients’ characteristics and healthcare utilisation", BMJ Open, 8(9), DOI: 10.1136/bmjopen-2018-023113.