OptumLabs at UnitedHealth Group, Minneapolis, MN, USA.
Department of Health Services, Policy, and Practice, Brown University, Providence, RI, USA.
J Gen Intern Med. 2022 Jun;37(8):1853-1861. doi: 10.1007/s11606-021-06912-4. Epub 2021 Jun 7.
Most healthcare costs are concentrated in a small proportion of individuals with complex social, medical, behavioral, and clinical needs that are poorly met by a fee-for-service healthcare system. Efforts to reduce cost in the top decile have shown limited effectiveness. Understanding patient subgroups within the top decile is a first step toward designing more effective and targeted interventions.
Segment the top decile based on spending and clinical characteristics and examine the temporal movement of individuals in and out of the top decile.
Retrospective claims data analysis.
UnitedHealthcare Medicare Advantage (MA) enrollees (N = 1,504,091) continuously enrolled from 2016 to 2019.
Medical (physician, inpatient, outpatient) and pharmacy claims for services submitted for third-party reimbursement under Medicare Advantage, available as International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and National Drug Codes (NDC) claims.
The top decile was segmented into three distinct subgroups characterized by different drivers of cost: (1) Catastrophic: acute events (acute myocardial infarction and hip/pelvic fracture), (2) persistent: medications, and (3) semi-persistent chronic conditions and frailty indicators. These groups show different patterns of spending across time. Each year, 79% of the catastrophic group dropped out of the top decile. In contrast, 68-70% of the persistent group and 36-37% of the semi-persistent group remained in the top decile year over year. These groups also show different 1-year mortality rates, which are highest among semi-persistent members at 17.5-18.5%, compared to 12% and 13-14% for catastrophic and persistent members, respectively.
The top decile consists of subgroups with different needs and spending patterns. Interventions to reduce utilization and expenditures may show more effectiveness if they account for the different characteristics and care needs of these subgroups.
大多数医疗保健费用集中在一小部分社会、医疗、行为和临床需求复杂的人群中，而按服务收费的医疗保健系统无法很好地满足这些人群的需求。减少前十分位数人群的成本的努力收效甚微。了解前十分位数人群中的患者亚组是设计更有效和有针对性的干预措施的第一步。
根据支出和临床特征对前十分位数进行细分，并考察个体在前十分位数内和外的流动情况。
回顾性索赔数据分析。
2016 年至 2019 年连续参保的 UnitedHealthcare Medicare Advantage（MA）参保者（N=1,504,091）。
医疗保险优势计划下第三方报销的医疗（医生、住院、门诊）和药房服务的医疗（医生、住院、门诊）和药房索赔，可通过国际疾病分类、第十次修订版、临床修正（ICD-10-CM）和国家药品代码（NDC）索赔获得。
前十分位数分为三个不同的亚组，其成本驱动因素不同：（1）灾难性：急性事件（急性心肌梗死和髋/骨盆骨折）；（2）持续性：药物；（3）半持续性慢性疾病和虚弱指标。这些组在不同时间显示出不同的支出模式。每年，灾难性组有 79%退出前十分位数。相比之下，持续性组有 68-70%，半持续性组有 36-37%，每年都在前十分位数中。这些组还显示出不同的 1 年死亡率，其中半持续性成员的死亡率最高，为 17.5-18.5%，而灾难性和持续性成员的死亡率分别为 12%和 13-14%。
前十分位数由具有不同需求和支出模式的亚组组成。如果干预措施考虑到这些亚组的不同特征和护理需求，那么减少利用和支出的干预措施可能会更有效。
