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Most pricey Medicare patient care may be unpreventable

By Andrew M. Seaman

NEW YORK (Reuters Health) - Treating the costliest Medicare patients in doctors' offices instead of emergency rooms or hospitals whenever possible may not save as much money as originally hoped, according to a new study.

After analyzing recent data on more than one million Medicare patients, researchers found that only about a tenth of the money spent on the program's most expensive patients was for care that could be provided without a trip to the hospital.

"I think it's a more complicated problem than we thought," said Dr. Karen Joynt, the study's lead author, from Brigham and Women's Hospital in Boston.

"I'm not saying we shouldn't try taking care of these patients as outpatients… but if we only do that as the intervention to control healthcare costs, we will not have maximum impact," she added.

Previous research has found that the majority of spending by Medicare - the U.S. government's health insurance for the elderly and disabled - is concentrated among a small portion of patients.

Policymakers had hoped that programs aimed at treating some of these patients' conditions in doctors' offices would reduce the amount of money the program spent on costly emergency room visits and inpatient hospital care, but Joynt told Reuters Health that hasn't happened.

"It got us thinking, ‘What is really going on in this group?'" she said.

For the new study, the researchers used data on emergency room and hospital care from 2009 and 2010 for a 5 percent sample of all Medicare patients - roughly 1.1 million people. Then, using computer models, they estimated how many hospital and emergency room charges could possibly be prevented with outpatient care.

Joynt and her colleagues found the top 10 percent of Medicare's costliest patients were responsible for 73 percent of the $91.7 billion the program spent in 2010.

Those heavy users of expensive healthcare were responsible for about 33 percent of all emergency room costs and 79 percent of all hospital stay costs.

After running the data through computer models that determine whether ER visits and hospital stays are needed, about 43 percent of ER visits and 16 percent of hospital stays were considered treatable without a hospital.

The most common preventable hospital stays among those patients were for heart failure, bacterial pneumonia and chronic obstructive pulmonary disease, the researchers report in the Journal of the American Medical Association.

Overall, only about 10 percent of all hospital care for the pricey patients was potentially preventable - about $6.7 billion.

"There is not as much to be saved in this area as we once thought," said Dr. Aaron Carroll, who wrote an editorial accompanying the new study.

Carroll, who is director of the Center for Health Policy and Professionalism Research at Indiana University School of Medicine in Indianapolis, said $6.7 billion is still a lot of money but controlling healthcare spending will take more than one approach.

"This idea that we could come up with an easy target and save a ton of money is missing the boat," he said.

Joynt agreed.

"I think it just points out that we need a multipronged approach to address costs. Just addressing outpatient care and care coordination is not going to cut it," she said, adding that the cost of hospital stays also needs to be reduced.

"There are some things on that list that you're just not going to prevent - like hip and knee replacements… So there are just some places that we need to make cheaper," she said.

SOURCE: http://bit.ly/11BNqsF and http://bit.ly/16v2h8p The Journal of the American Medical Association, online June 24, 2013.

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