High‐Need Phenotypes in Medicare Beneficiaries: Drivers of Variation in Utilization and Outcomes

Keeney, Tamra; Bélanger, Emmanuelle; Jones, Richard N.; Joyce, Nina R.; Meyers, David J.; Mor, Vincent

doi:10.1111/jgs.16146

Cited by 20 publications

(19 citation statements)

References 16 publications

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“…This may be relevant because we found evidence of frailty across all segments-5% of those relatively healthy, 12% of minor complex and 21% of major complex. Also consistent with prior work, we found that HNHC Mexican American older adults have functional limitations and a combination of multiple chronic conditions [3,6,34].…”

Section: Plos Onesupporting

confidence: 91%

Healthcare utilization and costs among high-need and frail Mexican American Medicare beneficiaries

et al. 2022

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Objectives To examine Medicare health care spending and health services utilization among high-need population segments in older Mexican Americans, and to examine the association of frailty on health care spending and utilization. Methods Retrospective cohort study of the innovative linkage of Medicare data with the Hispanic Established Populations for the Epidemiologic Study of the Elderly (H-EPESE) were used. There were 863 participants, which contributed 1,629 person years of information. Frailty, cognition, and social risk factors were identified from the H-EPESE, and chronic conditions were identified from the Medicare file. The Cost and Use file was used to calculate four categories of Medicare spending on: hospital services, physician services, post-acute care services, and other services. Generalized estimating equations (GEE) with a log link gamma distribution and first order autoregressive, correlation matrix was used to estimate cost ratios (CR) of population segments, and GEE with a logit link binomial distribution was applied to estimate odds ratios (OR) of healthcare use. Results Participants in the major complex chronic illness segment who were also pre-frail or frail had higher total costs and utilization compared to the healthy segment. The CR for total Medicare spending was 3.05 (95% CI, 2.48–3.75). Similarly, this group had higher odds of being classified in the high-cost category 5.86 (95% CI, 3.35–10.25), nursing home care utilization 11.32 (95% CI, 3.88–33.02), hospitalizations 4.12 (95% CI, 2.88–5.90) and emergency room admissions 4.24 (95% CI, 3.04–5.91). Discussion Our findings highlight that frailty assessment is an important consideration when identifying high-need and high-cost patients.

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Section: Plos Onesupporting

confidence: 91%

Healthcare utilization and costs among high-need and frail Mexican American Medicare beneficiaries

et al. 2022

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“…HNHC patients also have unmet needs either with their medical care (i.e., difficulty obtaining medication), ADLs (i.e., lack of needed support with bathing or feeding), or other needs related to obtaining housing or nutritional food 15,34 . Patients with unmet needs are more likely to have acute exacerbations of ongoing medical or behavioral conditions and frequent hospitalizations and ED use 10,15,34 . HNHC patients also have high rates of psychosocial factors such as isolation and mental illness which are found to worsen medical conditions and lead to higher health service use and mortality rates 15,35,36 …”

Section: Resultsmentioning

confidence: 99%

“…While HNHC patients are often referred to as the 5% of the population who account for the majority of overall US health care costs, significant heterogeneity exists in the definition of HNHC patients with regard to age, comorbidities, disability, and social needs 1,10 . Additionally, many common characteristics used to describe HNHC patients are implied rather than explicitly stated which can further exacerbate challenges in identifying this population and developing sustainable interventions 1 .…”

Section: Introductionmentioning

confidence: 99%

High‐need high‐cost patients: A Concept Analysis

Bilazarian

2020

Nursing Forum

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High‐need high‐cost (HNHC) patients are variously defined in the literature as the small subset of the population who account for the majority of US health care costs. Lack of consensus on the defining attributes of HNHC patients has challenged the effectiveness of interventions aimed to improve disease management and reduce costs. Guided by the Walker and Avant method of concept analysis, a literature review of 2 databases (PubMed and CINAHL) was conducted. Three main subgroups of HNHC patients were identified: adults with multiple chronic conditions and functional disability, the frail elderly, and patients under 65 years old with a disability or behavioral health condition. HNHC patients are categorized by a feedback loop of acute‐on‐chronic health conditions, preventable health service utilization, and fragmented care. Antecedents that predispose becoming a HNHC patient include challenges accessing timely care, low socioeconomic status, unmet support, and social factors such as isolation and inadequate.

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“…Persons with ADRD have high costs and high needs. 1 Among persons who die with dementia, average Medicare spending in the last 5 years of life is $287,038, exceeding end-of-life spending for other leading causes of death. 2 ADRD patients and their families often experience burdensome and costly interventions at the end of life that may be of limited benefit and not aligned with patients' preferences.…”

Section: Introductionmentioning

confidence: 99%

Dying with dementia in Medicare Advantage, Accountable Care Organizations, or traditional Medicare

Teno

Keohane

Mitchell

et al. 2021

J American Geriatrics Society

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Background/Objective: Medicare Advantage (MA) and Accountable Care Organizations (ACOs) operate under incentives to reduce burdensome and costly care at the end of life. We compared end-of-life care for persons with dementia who are in MA, ACOs, or traditional Medicare (TM). Design, Setting, and Participants: Retrospective study of decedents with dementia enrolled in MA, attributed to an ACO, or in TM. Decedents had a nursing home stay between 91 and 180 days prior to death, two or more functional impairments, and mild to severe cognitive impairment. Measurements: Hospitalization, invasive mechanical ventilation (IMV) use, and in-hospital death in the last 30 days of life reported in Medicare billing. Results: Among 370,094 persons with dementia, 93,801 (25.4%) were in MA (mean age [SD], 86.9 [7.7], 67.6% female), 39,586 (10.7%) were ACO attributed (mean age [SD], 87.2 [7.6], 67.3% female), and 236,707 (63.9%) were in TM (mean age [SD], 87.0 [7.8], 67.6% female). The proportion hospitalized in the last 30 days of life was higher among TM enrollees (27.9%) and those ACO attributed (28.1%) than among MA enrollees (20.5%, p ≤ 0.001). After adjustment for socio-demographics, cognitive and functional impairments, comorbidities, and Hospital Referral Region, adjusted odds of hospitalization in the 30 days prior to death was 0.72 (95% confidence interval [CI] 0.70-0.74) among MA enrollees and 1.05 (95% CI 1.02-1.09) among those attributed to ACOs relative to TM enrollees. Relative to TM, the adjusted odds of death in the hospital were 0.78 (95% CI 0.75-0.81) among MA enrollees and 1.02 (95% CI 0.96-1.08) for ACO participants. Dementia decedents in MA had a lower likelihood of IMV use (adjusted odds ratio 0.80, 95% CI 0.75-0.85) compared to TM. Conclusions: Among decedents with dementia, MA enrollees but not decedents in ACOs experienced less costly and potentially burdensome care compared with those with TM. Policy changes are needed for ACOs. See related editorial by Ankuda et al. in this issue.

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High‐Need Phenotypes in Medicare Beneficiaries: Drivers of Variation in Utilization and Outcomes

Cited by 20 publications

References 16 publications

Healthcare utilization and costs among high-need and frail Mexican American Medicare beneficiaries

Healthcare utilization and costs among high-need and frail Mexican American Medicare beneficiaries

High‐need high‐cost patients: A Concept Analysis

Dying with dementia in Medicare Advantage, Accountable Care Organizations, or traditional Medicare

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