Dataset Information

Identifying Patients with Persistent Preventable Utilization Offers an Opportunity to Reduce Unnecessary Spending.

ABSTRACT:

Background

Improving care for high-cost patients is increasingly important for improving the value of healthcare. Most prior research has focused on identifying patients with high costs, but the extent to which these costs are potentially preventable remains unclear.

Objective

To identify patients with persistent preventable utilization and compare their characteristics with high-cost patients.

Design

Descriptive analysis using Medicare claims data from 2013 to 2014.

Participants

Medicare fee-for-service and dual-eligible beneficiaries (N = 515,689) from the New York metropolitan area who were continuously enrolled in Medicare Parts A and B in 2013 and 2014.

Main measures

The primary analysis focuses on patients with persistent preventable utilization (at least one preventable emergency department visit, hospitalization, or 30-day readmission in both 2013 and 2014) and high-cost patients in 2014 (top 10% of total annual spending). We compared demographic, medical, behavioral, and social characteristics and total and preventable healthcare utilization between these two groups.

Key results

Patients with persistent preventable utilization accounted for 4.8% of the overall patient population, 13.4% of overall costs, but 46.2% of preventable costs among all Medicare patients. Compared with high-cost patients, patients with persistent preventable utilization had lower median healthcare costs ($33,383 vs. $56,552), but their median potentially preventable costs were seven times higher ($7151 vs. $928). We also found that 1.9% of patients could be categorized in both the persistent preventable utilization group and the high-cost group. This subset of patients had the highest median Medicare costs and preventable costs and represented over 30% of total preventable spending and 9.4% of overall costs among all Medicare patients.

Conclusion

Designing and targeting interventions for patients with persistent preventable utilization may offer an important opportunity to reduce unnecessary utilization and promote high-value care.

SUBMITTER: Zhang Y

PROVIDER: S-EPMC7728931 | biostudies-literature | 2020 Dec

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Identifying Patients with Persistent Preventable Utilization Offers an Opportunity to Reduce Unnecessary Spending.

Zhang Yongkang Y Khullar Dhruv D Wu Yiyuan Y Casalino Lawrence P LP Kaushal Rainu R

Journal of general internal medicine 20200727 12

<h4>Background</h4>Improving care for high-cost patients is increasingly important for improving the value of healthcare. Most prior research has focused on identifying patients with high costs, but the extent to which these costs are potentially preventable remains unclear.<h4>Objective</h4>To identify patients with persistent preventable utilization and compare their characteristics with high-cost patients.<h4>Design</h4>Descriptive analysis using Medicare claims data from 2013 to 2014.<h4>Par ...[more]

PMID: 32720238

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Project description:ImportanceRising prescription medication costs under Medicaid have led to increased procedural prescription denials by health plans. The effect of unresolved denials on chronic condition exacerbation and subsequent acute care utilization remains unclear.ObjectiveTo examine whether procedural prescription denials are associated with increased net spending through downstream acute care utilization among Medicaid patients not obtaining prescribed medication following a denial.Design, setting, and participantsThis cross-sectional study used Medicaid claims data from 2022 to 2023 for patients at inpatient, outpatient, and pharmacy sites of care across 2 states (Virginia and Washington) and 2 independent health plans. Patients with at least 1 prescription denial in the study period (January 1 through July 31, 2023) were matched to those without denials in a given medication class, based on demographics, health plan data, chronic condition history, and health care utilization. Rates of and spending for physiologically related acute care visits in the 60 days following a medication fill or denial were compared for the study period.Main outcomes and measuresThe main outcomes were all-cause acute care utilization and total medical spending (in 2023 US dollars per member per year [PMPY]) for principal diagnoses physiologically related to each medication class, in the 60 days following a medication fill or denial. Sensitivity analyses were performed to check for spurious associations or unmeasured confounders.ResultsThe 19 725 patients in this study had a median age of 41 (IQR, 29-55) years, and most (60.7%) were female. Patients had a mean (SD) of 3.3 (16.1) comorbidities, 1.0 (2.6) all-cause acute care visits, and 5.6 (7.8) primary care visits during the baseline period. Patients experiencing specific procedural prescription denials had a higher risk of physiologically related emergency department visits and hospitalizations compared with those without a denial in the subsequent 60 days (adjusted odds ratio, 1.40 [95% CI, 1.03-1.88] minimum vs 1.75 [95% CI, 1.39-2.20] maximum for exposure and control groups across the 7 medication classes with significant differences). Denials in 6 medication classes were associated with net total medical spending increases, ranging from $624 (95% CI, $435-$813) to $3016 (95% CI, $1483-$4550) in additional expense PMPY after accounting for both prescription and medical costs attributed to denials.Conclusions and relevanceThe findings of this cross-sectional study suggest that although procedural prescription denials aimed to curb immediate drug costs, some denials prompted heightened acute care utilization and costs that outweighed the short-term prescription budget savings. Health plans should incorporate this potential unintended consequence when shaping prescription coverage policies. Future research should systematically review all medication classes across plans nationally.

Dataset Information

Identifying Patients with Persistent Preventable Utilization Offers an Opportunity to Reduce Unnecessary Spending.

Background

Objective

Design

Participants

Main measures

Key results

Conclusion

Publications

Identifying Patients with Persistent Preventable Utilization Offers an Opportunity to Reduce Unnecessary Spending.

Similar Datasets

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