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Healthc (Amst). 2017 Mar;5(1-2):62-67. doi: 10.1016/j.hjdsi.2016.11.002. Epub 2016 Dec 1.

Segmenting high-cost Medicare patients into potentially actionable cohorts.

Author information

1
Harvard School of Public Health, Department of Health Policy and Management, United States; Brigham and Women's Hospital, Department of Medicine, Division of Cardiovascular Medicine, United States.
2
Harvard School of Public Health, Department of Health Policy and Management, United States; Brigham and Women's Hospital, Department of Medicine, Division of General Internal Medicine, United States.
3
Harvard Medical School, Department of Health Care Policy, United States.
4
Harvard School of Public Health, Department of Biostatistics, United States.
5
Harvard School of Public Health, Department of Health Policy and Management, United States; Veterans Affairs Boston Healthcare System, United States. Electronic address: ajha@hsph.harvard.edu.

Abstract

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.

LEVEL OF EVIDENCE:

IV.

KEYWORDS:

Complex populations; Disease management; Frailty; High-cost; Medicare; Segmentation

PMID:
27914968
DOI:
10.1016/j.hjdsi.2016.11.002
[Indexed for MEDLINE]

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