Preventable ED visits by top spenders are a small proportion of Medicare costs

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1. The top 10% of patients of Medicare beneficiaries account for 70% of the Medicare program’s total spending. 

2. Approximately 41.0% of costs associated with ED visits and hospitalizations by the group of top spending Medicare beneficiaries were deemed preventable in this study, which represents only a small percentage (10%) of overall costs of Medicare.  

Evidence Rating Level: 2 (Good) 

Study Rundown: Seventy percent of the acute care costs utilized by the 2010 Medicare population were from the 10% of patients in the highest cost cohort, and about 10% of those costs were thought to have preventable causes. However, the major drivers of inpatient spending for the highest-cost patients included sepsis, stroke, MI, cancer and major orthopaedic procedures. This suggests that enhanced outpatient management for preventable causes of ED visits and hospitalizations may not necessarily have a particularly large impact on cost reduction. This could explain some of the relatively poor outcomes in current cost control efforts that focus on preventing ED visits and hospitalizations. Furthermore, the study findings underscore the need for transformations in the approach towards management of chronic disease patients to reduce costs overall.

While the study notes that better outpatient care may not necessarilyallow for a significant reduction in total costs, it must be noted that the root cause of many of these so-called non-preventable emergent events may, in fact, be preventable when one considers the cumulative effect of years of poor preventive self care. Moving forward, it will remain crucial to engage patients in their own health care between clinical visits. An interesting approach that should be explored will be the use of personalized, data-driven modalities that can be monitored in the home by the care team.

Click to read the study, published today in JAMA

Click to read an accompanying editorial, published today in JAMA

Relevant Reading: Preventable Hospitalization Among Elderly Medicare Beneficiaries With Type 2 Diabetes

In-Depth [retrospective cohort study]: From 2009-2010 a sample of 1,114,469 patients were reviewed using MedPAR and 5% Medicare outpatient and carrier records. A computer algorithm separated visits into 4 separate categories: non-emergent, emergent/primary care treatable, emergent/ED care-preventable, and emergent/ED care-non-preventable. Tthe high cost patient cohort (10% of sample) was associated with 73.0% of acute care spending in 2010. Within this cohort 42.6% ED visits were said to be preventable by the algorithm.  The most common preventable admissions were for congestive heart failure, bacterial pneumonia, and COPD. Common non-preventable hospitalizations were caused by orthopaedic conditions, ischemic heart disease and cancer. The non-preventable group of diagnoses was associated with the highest overall costs.

By Mike Hoaglin and Rif Rahman

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