West Health Institute, 10350 N Torrey Pines Rd, La Jolla, CA, 92037, USA.
Institute for Accountable Care and Brandeis University, 415 South St. MS 035, Waltham, MA, 02453, USA.
BMC Health Serv Res. 2023 Sep 14;23(1):992. doi: 10.1186/s12913-023-09957-9.
To test the accuracy of a segmentation approach using claims data to predict Medicare beneficiaries most likely to be hospitalized in a subsequent year.
This article uses a 100-percent sample of Medicare beneficiaries from 2017 to 2018. This analysis is designed to illustrate the actuarial limitations of person-centered risk segmentation by looking at the number and rate of hospitalizations for progressively narrower segments of heart failure patients and a national fee-for-service comparison group. Cohorts are defined using 2017 data and then 2018 hospitalization rates are shown graphically.
As the segments get narrower, the 2018 hospitalization rates increased, but the percentage of total Medicare FFS hospitalizations accounted for went down. In all three segments and the total Medicare FFS population, more than half of all patients did not have a hospitalization in 2018.
With the difficulty of identifying future high utilizing beneficiaries, health systems should consider the addition of clinician input and 'light touch' monitoring activities to improve the prediction of high-need, high-cost cohorts. It may also be beneficial to develop systemic strategies to manage utilization and steer beneficiaries to efficient providers rather than targeting individual patients.
为了测试一种使用索赔数据预测 Medicare 受益人在随后一年住院可能性的分割方法的准确性。
本文使用了 2017 年至 2018 年 Medicare 受益人的 100%样本。本分析旨在通过观察心力衰竭患者的住院率和全国按服务收费比较组中越来越窄的分段患者数量和住院率，来展示以个人为中心的风险分割的精算局限性。使用 2017 年的数据定义队列，然后以图形方式显示 2018 年的住院率。
随着分段变窄，2018 年的住院率增加，但 Medicare FFS 总住院率的比例下降。在所有三个分段和 Medicare FFS 人群中，超过一半的患者在 2018 年没有住院。
由于难以确定未来高利用的受益人，医疗系统应考虑增加临床医生的投入和“轻触”监测活动，以提高对高需求、高成本群体的预测。开发系统策略来管理利用率并引导受益人到高效的提供者，而不是针对个别患者，可能也会有所帮助。
