Potentially Preventable Spending Among High-Cost Medicare Patients: Implications for Healthcare Delivery.
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ABSTRACT: Background
High-cost patients account for a disproportionate share of healthcare spending. The proportion and distribution of potentially preventable spending among subgroups of high-cost patients are largely unknown.Objective
To examine the distribution of potentially preventable spending among high-cost Medicare patients overall and potentially preventable spending associated with each high-cost category.Design
A cross-sectional study. We merged Medicare claims and social determinants of health data to group patients into high-cost categories and quantify potentially preventable spending.Patients
A total of 556,053 Medicare fee-for-service and dual-eligible beneficiaries with at least one healthcare encounter in the New York metropolitan area in 2014.Main measures
High-cost patients were mapped into 10 non-mutually exclusive categories. The primary outcome was episodic spending associated with preventable ED visits, preventable hospitalizations, and unplanned 30-day readmissions.Key results
Overall, potentially preventable spending accounted for 10.4% of overall spending in 2014. Preventable spending accounted for 13.3% of total spending among high-cost patients and 4.9% among non-high-cost patients (P < 0.001). Among high-cost patients, 44.0% experienced at least one potentially preventable encounter compared with 11.4% of non-high-cost patients (P < 0.001), and high-cost patients accounted for 71.5% of total preventable spending. High-cost patients had on average $11,502 in potentially preventable spending-more than 20 times more than non-high-cost patients ($510). High-cost patients in the seriously ill, frail, or serious mental illness categories accounted for the highest proportion of potentially preventable spending overall, while end-stage renal disease, serious illness, and opioid use disorder were associated with the highest preventable spending per patient.Conclusion
Potentially preventable spending was concentrated among high-cost patients who were seriously ill, frail, or had a serious mental illness. Interventions targeting these subgroups may be helpful for reducing preventable utilization.
SUBMITTER: Khullar D
PROVIDER: S-EPMC7573047 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Few comparisons exist of the quality of primary care provided by nurse practitioners (NPs) versus physicians.Patients with a diagnosis of diabetes in 2007-2010 (n=345,819) who received all primary care from NPs or from generalist physicians in a given year were selected from a national sample of Medicare beneficiaries. We compared the rate of potentially preventable hospitalizations among patients who received primary care from NPs versus generalist physicians. Various statistical methods-including multivariable analysis, inverse probability weighting of propensity score, nonpooling propensity score adjustment and matching, and instrumental variable (IV) analysis-were used to control for differences in patient characteristics between the 2 groups.Patients who received all of their primary care from NPs or from physicians differed by age, sex, race/ethnicity, socioeconomic status, residential area, and number of provider visits in the previous year. Nonpooling propensity score matching substantially reduced the differences, but neither IV approach satisfactorily reduced the differences. In multivariable analyses, receipt of primary care from an NP was associated with a decreased risk of hospitalization for potentially preventable conditions (OR: 0.90; 95% CI, 0.87-0.93). Similar results were found using conditional logistic regression models with propensity methods. We found smaller reductions in our analyses of "other hospitalizations" (OR: 0.96; 95% CI, 0.95-0.98). Both IV analyses showed associations between NP care and lower potentially preventable hospitalizations, but only 1 result was statistically significant.Using potentially preventable hospitalizations as a quality indicator, primary care provided by NPs was at least comparable with that provided by generalist physicians.
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Project description:BackgroundThere 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.ObjectiveTo describe a high-cost Medicare Advantage population and identify clinically and operationally significant subgroups of patients.DesignWe 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.ParticipantsSixty-one thousand five hundred forty-six Medicare Advantage beneficiaries.Main measuresSpending, utilization, and mortality.Key resultsHigh-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+).ConclusionsWe 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.
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