Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA.
JAMA. 2013 Jun 26;309(24):2572-8. doi: 10.1001/jama.2013.7103.
A small proportion of patients account for the majority of US health care spending, and understanding patterns of spending among this cohort is critical to reducing health care costs. The degree to which preventable acute care services account for spending among these patients is largely unknown.
To quantify preventable acute care services among high-cost Medicare patients.
DESIGN, SETTING, AND PARTICIPANTS: We summed standardized costs for each inpatient and outpatient service contained in standard 5% Medicare files from 2009 and 2010 across the year for each patient in our sample, and defined those in the top decile of spending in 2010 as high-cost patients and those in the top decile in both 2009 and 2010 as persistently high-cost patients. We used standard algorithms to identify potentially preventable emergency department (ED) visits and acute care inpatient hospitalizations. A total of 1,114,469 Medicare fee-for-service beneficiaries aged 65 years or older were included.
Proportion of acute care hospital and ED costs deemed preventable among high-cost patients.
The 10% of Medicare patients in the high-cost group were older, more often male, more often black, and had more comorbid illnesses than non-high-cost patients. In 2010, 32.9% (95% CI, 32.9%-32.9%) of total ED costs were incurred by high-cost patients. Based on validated algorithms, 41.0% (95% CI, 40.9%-41.0%) of these costs among high-cost patients were potentially preventable compared with 42.6% (95% CI, 42.6%-42.6%) among non-high-cost patients. High-cost patients accounted for 79.0% (95% CI, 79.0%-79.0%) of inpatient costs, 9.6% (95% CI, 9.6%-9.6%) of which were due to preventable hospitalizations; 16.8% (95% CI, 16.8%-16.8%) of costs within the non-high-cost group were due to preventable hospitalizations. Comparable proportions of ED spending (43.3%; 95% CI, 43.3%-43.3%) and inpatient spending (13.5%; 95% CI, 13.5%-13.5%) were preventable among persistently high-cost patients. Regions with high primary care physician supply had higher preventable spending for high-cost patients.
Among a sample of patients in the top decile of Medicare spending in 2010, only a small percentage of costs appeared to be related to preventable ED visits and hospitalizations. The ability to lower costs for these patients through better outpatient care may be limited.
一小部分患者占据了美国大部分医疗保健支出，了解这部分患者的支出模式对于降低医疗保健成本至关重要。在这些患者中，预防急性护理服务占支出的程度在很大程度上尚不清楚。
量化高成本医疗保险患者的可预防急性护理服务。
设计、设置和参与者：我们对样本中每位患者在 2009 年和 2010 年全年每个住院和门诊服务的标准化成本进行了汇总，并将 2010 年支出最高十分之一的患者定义为高成本患者，将 2009 年和 2010 年均支出最高十分之一的患者定义为持续高成本患者。我们使用标准算法来识别潜在可预防的急诊就诊和急性护理住院治疗。共有 1114469 名年龄在 65 岁或以上的医疗保险按服务收费受益人为研究对象。
高成本患者中被认为可预防的急性护理医院和急诊费用的比例。
高成本组中 10%的医疗保险患者年龄较大，男性居多，黑人居多，合并症较多。2010 年，高成本患者的急诊费用占总急诊费用的 32.9%（95%CI，32.9%-32.9%）。基于经过验证的算法，与非高成本患者的 42.6%（95%CI，42.6%-42.6%）相比，高成本患者中这些费用的 41.0%（95%CI，40.9%-41.0%）是潜在可预防的。高成本患者占住院费用的 79.0%（95%CI，79.0%-79.0%），其中 9.6%（95%CI，9.6%-9.6%）是可预防的住院治疗；非高成本组中 16.8%（95%CI，16.8%-16.8%）的费用是可预防的住院治疗。在持续高成本患者中，急诊就诊（43.3%；95%CI，43.3%-43.3%）和住院治疗（13.5%；95%CI，13.5%-13.5%）的支出比例也相当。在高初级保健医生供应地区，高成本患者的可预防支出更高。
在 2010 年医疗保险支出最高十分之一的患者样本中，只有一小部分费用似乎与可预防的急诊就诊和住院治疗有关。通过更好的门诊护理降低这些患者成本的能力可能有限。
