Preventable admissions have limited impact on spending

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Efficiency drives health care improvements

Even though avoiding some emergency department use and hospital admissions might not save much money – and certainly not enough to declare victory in controlling health spending – preventing such use when possible would be of substantial benefit to patients, both those who would otherwise use these services and those who have their care delayed because of overburdened emergency department and hospital resources. Even with no cost savings, reducing preventable use of high-intensity and capacity-constrained care would enhance efficiency. Improvements to quality are not always substantial cost savers but still may be worthwhile.

Dr. Aaron E. Carroll and Dr. Austin B. Frakt made their remarks in an accompanying editorial. Dr. Carroll is director of the Center for Health Policy and Professionalism Research at Indiana University School of Medicine. Dr. Frakt is an associate professor of health policy and management at Boston University School of Public Health. Neither author reported any conflicts of interest.



Preventable emergency department visits and hospitalizations account for only a small portion of spending on high-cost Medicare patients, and strategies to control costs for these patients should be expanded to include efforts to reduce costs per episode of ED visits and hospitalizations, according to a study published in JAMA.

Most inpatient spending for high-cost Medicare patients is due to cancer, myocardial infarction, sepsis, and stroke, as well as orthopedic procedures such as hip replacement and spine surgery.

"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," stated Dr. Karen E. Joynt of Brigham and Women’s Hospital, Boston, and her colleagues.

Dr. Karen E. Joynt

The authors examined data from more than 1.1 million Medicare fee-for-service patients aged 65 years and older. They defined patients whose health care costs were in the highest decile in 2010 as high-cost patients; those with health care costs in the top decile for both 2010 and 2009 were categorized as persistently high-cost patients (JAMA 2013;309:2572-8).

Patients in the high-cost Medicare group were, on average, older than Medicare patients overall (78 vs. 77 years), and they were more likely to have chronic health conditions, including congestive heart failure (44% vs. 11%), diabetes (44% vs. 27%), and lung disease (38% vs. 13%). In addition, the high-cost patients were more likely to be male (45% vs. 42%) and African-American (9% vs. 7%).

To examine costs of preventable ED visits and hospitalizations, the authors used validated Agency for Healthcare Research and Quality (AHRQ) prevention quality algorithms. They concluded that high-cost Medicare patients accounted for 79% of overall inpatient costs of Medicare patients. In addition, the researchers discovered that 43% of ED visits by high-cost Medicare patients were considered preventable, compared with 44% of ED visits by the rest of the Medicare population. These preventable ED visits constituted 41% of ED costs for high-cost Medicare patients and 43% of ED costs for all other Medicare patients. Among the persistently high-cost patients, proportions of preventable ED spending and inpatient spending (43% and 14%, respectively) were comparable to those of high-cost patients.

Only 10% of hospital admissions for high-cost Medicare patients were due to preventable causes, compared with 17% of hospitalizations for the non–high-cost population. When the researchers combined costs of ED visits and hospitalizations, they concluded that only 10% of the costs for high-cost patients were categorized as preventable. The rest of the costs were due to what the authors described as "catastrophic events," such as myocardial infarction, sepsis, and stroke, as well as cancer, hip replacement, and spine surgery.

"Strategies [that are] focused on enhanced outpatient management of chronic disease, while critically important, may not be focused on the biggest and most expensive problems plaguing Medicare’s high-cost patients," the authors concluded.

These findings may explain why programs to improve outpatient services for patients with complex medical conditions have failed to reduce health care costs, the authors noted. "While disease management may yield cost savings, even a substantial reduction in these preventable hospitalizations is unlikely to have a large effect on overall spending levels within this cohort."

The authors also examined regional variability of health care spending for preventable acute care. They looked at costs for preventable acute care spending in various hospital referral regions (HRRs). They discovered that HRRs with the lowest supply of primary care physicians had average preventable acute care costs of $1,954 per capita, while HRRs with the highest supply of primary care physicians had average preventable acute care costs of $2,186 per capita. It was unclear whether this difference was due to a greater demand for ED visits and hospitalizations in areas with an ample supply of primary care physicians, or whether the greater supply of primary care physicians was a result of a sicker population of patients driving increased physician availability, Dr. Joynt and her colleagues stated.

They concluded that clinical leaders at health care systems may need to focus both on reducing preventable admissions and on lowering hospital costs for episodes of catastrophic and acute care in order to achieve meaningful savings in health care costs.

The Rx Foundation and the West Wireless Foundation funded the study. One coauthor, Dr. Atul A. Gawande, reported receiving income for teaching and lecturing on health care quality and safety topics, as well as earning royalties on books, other publications, and a documentary on health care system quality and performance. None of the other authors reported any conflicts of interest.

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