Erschienen in:
03.12.2018 | Original Research
Subgroups of High-Cost Medicare Advantage Patients: an Observational Study
verfasst von:
Brian W. Powers, MD, MBA, Jiali Yan, MS, Jingsan Zhu, MS, MBA, Kristin A. Linn, PhD, Sachin H. Jain, MD, MBA, Jennifer L. Kowalski, MS, Amol S. Navathe, MD, PhD
Erschienen in:
Journal of General Internal Medicine
|
Ausgabe 2/2019
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Abstract
Background
There is a growing focus on improving the quality and value of health care delivery for high-cost patients. Compared to fee-for-service Medicare, less is known about the clinical composition of high-cost Medicare Advantage populations.
Objective
To describe a high-cost Medicare Advantage population and identify clinically and operationally significant subgroups of patients.
Design
We used a density-based clustering algorithm to group high-cost patients (top 10% of spending) according to 161 distinct demographic, clinical, and claims-based variables. We then examined rates of utilization, spending, and mortality among subgroups.
Participants
Sixty-one thousand five hundred forty-six Medicare Advantage beneficiaries.
Main Measures
Spending, utilization, and mortality.
Key Results
High-cost patients (n = 6154) accounted for 55% of total spending. High-cost patients were more likely to be younger, male, and have higher rates of comorbid illnesses. We identified ten subgroups of high-cost patients: acute exacerbations of chronic disease (mixed); end-stage renal disease (ESRD); recurrent gastrointestinal bleed (GIB); orthopedic trauma (trauma); vascular disease (vascular); surgical infections and other complications (complications); cirrhosis with hepatitis C (liver); ESRD with increased medical and behavioral comorbidity (ESRD+); cancer with high-cost imaging and radiation therapy (oncology); and neurologic disorders (neurologic). The average number of inpatient days ranged from 3.25 (oncology) to 26.09 (trauma). Preventable spending (as a percentage of total spending) ranged from 0.8% (oncology) to 9.5% (complications) and the percentage of spending attributable to prescription medications ranged from 7.9% (trauma and oncology) to 77.0% (liver). The percentage of patients who were persistently high-cost ranged from 11.8% (trauma) to 100.0% (ESRD+). One-year mortality ranged from 0.0% (liver) to 25.8% (ESRD+).
Conclusions
We identified clinically distinct subgroups of patients within a heterogeneous high-cost Medicare Advantage population using cluster analysis. These subgroups, defined by condition-specific profiles and illness trajectories, had markedly different patterns of utilization, spending, and mortality, holding important implications for clinical strategy.