Better preventive care may not be enough to control costs in Medicare patients, according to a new study.
Most U.S. health care spending is due to a small proportion of patients, but it is not known how much of the spending in this group is related to preventable services. Researchers sought to answer that question by using standard 5% Medicare files to determine standardized costs of inpatient and outpatient services for individual patients across 2009 and 2010. Patients in the top cost decile for 2010 were considered high-cost patients, and those in the top cost decile for 2009 and 2010 were considered persistently high-cost patients. In all, 1,114,469 Medicare fee-for-service beneficiaries 65 years of age or older were included. The study's main outcome measure was the proportions of acute care emergency department (ED) visits and acute hospitalizations that were considered preventable in high-cost patients. The results were published online June 24 by JAMA.
Patients in the high-cost group were older and had more comorbid conditions than patients who weren’t considered high-cost. They were also more likely to be men and more likely to be black. Approximately 33% of total ED costs in 2010 were due to high-cost patients, and of these, 41% were considered potentially preventable compared with 42.6% of ED costs in the non-high-cost group. For inpatient costs, 79% were due to high-cost patients, and of these, 9.6% were related to preventable hospitalizations compared with 16.8% of costs in the non-high-cost group. In the persistently high-cost group, 43.3% of ED costs and 13.5% of inpatient costs were considered preventable. Geographic regions with more primary care physicians and more specialist physicians also had higher preventable spending among high-cost patients.
The authors concluded that although more than 70% of Medicare acute care spending in 2009 and 2010 involved high-cost patients, only approximately 10% of these expenditures appeared to be preventable. They also noted that because a higher number of primary care physicians and specialists in a region was associated with more spending among high-cost patients, spending may not be reduced by improved access to primary care alone. "Our findings suggest that a complementary approach to saving money on acute care services for high-cost patients may be to additionally focus on reducing per-episode costs for high-cost disease entities through clinical innovation and care delivery redesign," the authors wrote.