A report finding that only a small percentage of costs in a sample of high-cost Medicare patients were related to preventable emergency department visits and hospitalizations casts doubt on the ability to lower costs simply through better outpatient care.
The findings indicate that providers may need to focus on methods beyond care coordination and disease management, including clinical innovation and care delivery redesign, in order to reduce costs among patients with chronic conditions, according to a news release Monday about the article for the June 26 issue of the Journal of the American Medical Association (JAMA).
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One persuasive strategy for cost containment has been to target the small proportion or 10 percent of Medicare patients who account for more than half of the healthcare spending in the program. The biggest sources of spending among high-cost beneficiaries are emergency department (ED) visits and inpatient hospitalizations.
Interventions targeting high-cost patients have concentrated on case management and care coordination in order to prevent ED visits and hospitalizations for conditions that providers have thought could improve through high-quality outpatient management programs, the authors said in the article. The authors are: Karen Joynt, MD; Atul Gawande, MD; E. John Orav; and, Ashish Jha, MD.
"However, there are few data on the proportion of inpatient hospitalizations among high-cost patients that are potentially preventable," the authors wrote.
The population sample that the authors researched reflected the national trend, with 10 percent being high-cost Medicare patients. They accounted for 79 percent of inpatient costs in the study. However, within this high-cost group, only 9.6 percent of hospital costs were attributable to preventable hospitalization. The most common reasons for preventable hospitalization in high-cost patients were congestive heart failure, pneumonia and chronic obstructive pulmonary disease (COPD). While spending on the non-high-cost group was much lower overall, more inpatient costs were potentially preventable at 16.8 percent.
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The high-cost group accounted for about 33 percent of ED costs, but only 42.6 percent of the emergency visits were considered preventable, the authors found. The biggest drivers of inpatient spending for these high-cost patients were catastrophic events, including sepsis, stroke and heart attack; cancer; and expensive orthopedic procedures, including spine surgery and hip replacement.
“These findings suggest that strategies focused on enhanced outpatient management of chronic disease, while critically important, may not be focused on the biggest and most expensive problems plaguing Medicare’s high-cost patients,” the authors said. “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 studied costs for 1.1 Medicare fee-for-service beneficiaries from 2009 and 2010 using standard algorithms to identify potentially preventable ED visits and hospitalizations. The Rx Foundation and the West Wireless Foundation funded the study.
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