Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI, USA.
Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, RI, USA.
J Gen Intern Med. 2019 Mar;34(3):405-411. doi: 10.1007/s11606-018-4781-3. Epub 2019 Jan 2.
Developing a definition of what constitutes high need among Medicare beneficiaries using administrative data is an important prerequisite to evaluating value-based payment reforms. While various definitions of high need exist, their predictive validity for different patient outcomes in the following year has not been systematically assessed for both fee-for-service (FFS) and Medicare Advantage (MA) beneficiaries.
To develop a definition of high need using administrative data in 2014 and to examine its predictive validity for patient outcomes in 2015 as compared to alternative definitions for both FFS and MA beneficiaries.
Retrospective cohort study of national Medicare claims and post-acute assessment data.
All Medicare beneficiaries in 2014 who survived until the end of the year (n = 54,717,039).
Two or more complex conditions, 6 or more chronic conditions, acute or post-acute health services utilization, indicators of frailty, complete dependency in mobility or in any activities of daily living in post-acute care assessments, hospitalization, mortality, days in community, Medicare expenditures.
Based on our definition of high-need patients, 13.17% of FFS and 8.85% of MA beneficiaries were identified as high need in 2014. High-need FFS patients had mortality rates 7.1 times higher (16.23% vs. 2.27%) and hospitalization rates 3.4 times higher (40.69 vs. 12.03) in 2015 compared to other beneficiaries. Competing high-need definitions all had good specificity (≥ 0.88). Having 3 or more Hierarchical Chronic Conditions yielded a good positive predictive value for hospitalization, at 0.50, but only identified 19.71% of FFS beneficiaries hospitalized and 28.46% of FFS decedents that year as high need, as opposed to 33.92% and 51.98% for the new definition. Results were similar for MA beneficiaries.
The proposed high-need definition has better sensitivity and yields a sample of almost 5 million FFS and 1.5 million MA beneficiaries, facilitating outcome performance comparisons across health systems.
使用管理数据来定义医疗保险受益人群中的高需求人群是评估基于价值的支付改革的重要前提。虽然存在各种高需求定义，但尚未系统评估其在随后一年中对不同患者结局的预测有效性，无论是对传统的按服务项目付费（fee-for-service，FFS）模式还是医疗保险优势计划（Medicare Advantage，MA）的受益人均未进行评估。
使用管理数据在 2014 年定义高需求人群，并与 FFS 和 MA 受益人的其他替代定义相比，检验其对 2015 年患者结局的预测有效性。
全国性医疗保险索赔和康复后评估数据的回顾性队列研究。
2014 年所有幸存至年底的 Medicare 受益人群（n=54717039）。
两种或两种以上复杂疾病，六种或六种以上慢性疾病，急性或康复后医疗服务利用，脆弱性指标，康复后评估中移动或任何日常生活活动完全依赖，住院，死亡率，社区内天数，医疗保险支出。
根据我们的高需求患者定义，2014 年 FFS 中 13.17%和 MA 中 8.85%的受益人为高需求人群。与其他受益人群相比，高需求 FFS 患者 2015 年的死亡率高 7.1 倍（16.23% vs. 2.27%），住院率高 3.4 倍（40.69 vs. 12.03）。其他高需求定义的特异性均较好（≥0.88）。具有 3 种或更多种等级慢性疾病对住院有较好的阳性预测值，为 0.50，但仅确定了当年 19.71%的 FFS 住院受益人和 28.46%的 FFS 死亡受益人为高需求人群，而新定义则分别为 33.92%和 51.98%。对 MA 受益人的结果相似。
提出的高需求定义具有更好的敏感性，并产生了近 500 万 FFS 和 150 万 MA 受益人的样本，方便了在不同医疗体系中进行医疗结果绩效比较。
