Post-Acute
The need for good, affordable care has never been greater
Conventional wisdom has it that a very small percentage of Medicare patients account for a very large part of the Medicare budget. With funding from The Commonwealth Fund, a group of researchers tried to put a finer point on that wisdom by defining who these high-cost, high-usage subpopulations are, and how much “preventable spending” they account for.
Perhaps not surprisingly, they are primarily what the researchers categorize as the “frail elderly.”
Beneficiaries in the highest 10 percent of total standardized individual spending were defined as “high-cost” patients, using a 20 percent sample of Medicare fee-for-service claims from 2012.
Researchers calculated potentially preventable spending by summing costs for avoidable emergency department visits plus inpatient and associated 30-day post-acute costs for ambulatory-care–sensitive conditions (ACSCs). They compared the amount and proportion of potentially preventable spending across the high-cost subpopulations and by individual ACSCs.
The researchers found that in 2012:
- 8 percent of Medicare spending was potentially preventable, of which 73.8 percent was incurred by high-cost patients.
- Despite making up only 4 percent of the Medicare population, high-cost, frail elderly persons accounted for 43.9 percent of total potentially preventable spending ($6,593 per person).
- High-cost nonelderly disabled persons accounted for 14.8 percent of potentially preventable spending ($3,421 per person).
- The major complex chronic group accounted for 11.2 percent ($3,327 per person) of potentially preventable spending.
Frail elderly persons accounted for most spending related to admissions for urinary tract infections, dehydration, heart failure, and bacterial pneumonia.
Which site of care?
The researchers examined potentially preventable hospitalizations and emergency-department visits, and associated costs. Using federal government data, they examined potentially preventable hospitalizations related to specific conditions, such as heart failure, diabetes, hypertension and asthma, “for which good outpatient care can likely prevent the need for hospitalization.”
On average, frail elderly persons accounted for the most potentially preventable inpatient spending for nearly all individual ambulatory-care-sensitive conditions. Much of the preventable inpatient spending in this group was related to acute care visits for:
- Heart failure ($451 per person).
- Bacterial pneumonia ($355 per person).
- Urinary tract infections ($289 per person).
- Diabetes long-term complications ($152 per person).
- Dehydration ($121 per person).
The nonelderly disabled group accounted for the most potentially preventable spending for admissions related to diabetes short-term complications.
“These findings highlight the need to understand and mitigate the health consequences of frailty, especially as the U.S. population ages and frailty becomes more prevalent,” the researchers write. “Given the high concentration of potentially modifiable spending among frail elderly persons, interventions that target this population may lead to disproportionate reductions in healthcare costs.
“Our work suggests that simple interventions in the outpatient setting, such as close management of heart failure and prevention of urinary tract infections, may substantially reduce unnecessary spending.”
Editor’s note: The study appeared in the Oct. 17, 2017, edition of Annals of Internal Medicine. The authors are Jose Figueroa, M.D., MPH, and Ashish Jha, M.D., MPH, from the Harvard T.H. Chan School of Public Health; Karen Joynt Maddox, M.D., MPH, Washington University School of Medicine; and Nancy Beaulieu, PhD, and Robert Wild, MS, PH, from Harvard Medical School.