Segmenting high-cost Medicare patients into potentially actionable cohorts
Segmenting high-cost Medicare patients into potentially actionable cohorts
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DOI：
10.1016/j.hjdsi.2016.11.002
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发表时间：
2017-03-01
影响因子：
2.5
通讯作者：
Jha, Ashish K.
中科院分区：
文献类型：
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作者：
Joynt, Karen E.;Figueroa, Jose F.;Jha, Ashish K.
背景：医疗服务提供者承担着越来越多的医疗支出责任，先前的研究表明，医疗支出集中在一小部分患者身上。使用简单的方法将这些患者划分为临床有意义的亚组，可能是一种有用和可获得的策略，可以针对干预措施来控制成本。方法：使用2011年（基线年，用于确定合并症和亚组）和2012年（支出年）的医疗保险按服务收费索赔，我们使用基本人口统计学和合并症将受益人分为6个队列，根据专家意见和咨询定义：65岁以下残疾/ESRD，体弱老年人，严重复杂慢性，轻微复杂慢性，简单慢性和相对健康。我们将花费最高的10%的患者视为“高成本”患者。“结果：611,245名受益人是高成本；这些患者较少是白人（76.2%对80.9%），更多是双重资格（37.0%对18.3%）。按类别划分，体弱多病患者最可能是高成本患者（46.2%），其次是65岁以下患者（14.3%）和主要复杂慢性患者（11.1%）；在其他队列中，只有不到5%的受益人在支出年度是高成本的。体弱多病的长者（70,196元）及65岁以下残疾/终末期肾病（71,210元）的高成本组别的开支最高；身体虚弱的高成本组的支出主要由住院（23,704美元）和急性后护理（24,080美元）驱动，而65岁以下的残疾/终末期肾病患者的D部分支出更多（23,003美元）。结论：简单的标准可以将医疗保险受益人划分为具有临床意义的不同消费概况的亚组。含义：在交付系统改革下，当供应商寻求减少支出时，针对体弱或残疾患者的干预措施可能具有特别高的价值。
Background: Providers are assuming growing responsibility for healthcare spending, and prior studies have shown that spending is concentrated in a small proportion of patients. Using simple methods to segment these patients into clinically meaningful subgroups may be a useful and accessible strategy for targeting interventions to control costs.Methods: Using Medicare fee-for-service claims from 2011 (baseline year, used to determine comorbidities and subgroups) and 2012 (spending year), we used basic demographics and comorbidities to group beneficiaries into 6 cohorts, defined by expert opinion and consultation: under-65 disabled/ESRD, frail elderly, major complex chronic, minor complex chronic, simple chronic, and relatively healthy. We considered patients in the highest 10% of spending to be "high-cost."Results: 611,245 beneficiaries were high-cost; these patients were less often white (76.2% versus 80.9%) and more often dually-eligible (37.0% versus 18.3%). By segment, frail patients were the most likely (46.2%) to be high-cost followed by the under-65 (14.3%) and major complex chronic groups (11.1%); fewer than 5% of the beneficiaries in the other cohorts were high-cost in the spending year. The frail elderly ($ 70,196) and under-65 disabled/ESRD ($ 71,210) high-cost groups had the highest spending; spending in the frail high-cost group was driven by inpatient ($ 23,704) and post-acute care ($ 24,080), while the under 65-disabled/ESRD spent more through part D costs ($ 23,003).Conclusions: Simple criteria can segment Medicare beneficiaries into clinically meaningful subgroups with different spending profiles. Implications: Under delivery system reform, interventions that focus on frail or disabled patients may have particularly high value as providers seek to reduce spending.