Little is known about whether potentially preventable spending is concentrated among a subset of high-cost Medicare beneficiaries.

To determine the proportion of total spending that is potentially preventable across distinct subpopulations of high-cost Medicare beneficiaries.

Beneficiaries in the highest 10% of total standardized individual spending were defined as “high-cost” patients, using a 20% sample of Medicare fee-for-service claims from 2012. The following 6 subpopulations were defined using a claims-based algorithm: nonelderly disabled, frail elderly, major complex chronic, minor complex chronic, simple chronic, and relatively healthy. Potentially preventable spending was calculated by summing costs for avoidable emergency department visits using the Billings algorithm plus inpatient and associated 30-day postacute costs for ambulatory care–sensitive conditions (ACSCs). The amount and proportion of potentially preventable spending were then compared across the high-cost subpopulations and by individual ACSCs.

Medicare.

6 112 450 Medicare beneficiaries.

Proportion of spending deemed potentially preventable.

In 2012, 4.8% of Medicare spending was potentially preventable, of which 73.8% was incurred by high-cost patients. Despite making up only 4% of the Medicare population, high-cost frail elderly persons accounted for 43.9% of total potentially preventable spending ($6593 per person). High-cost nonelderly disabled persons accounted for 14.8% of potentially preventable spending ($3421 per person) and the major complex chronic group for 11.2% ($3327 per person). Frail elderly persons accounted for most spending related to admissions for urinary tract infections, dehydration, heart failure, and bacterial pneumonia.

Potential misclassification in the identification of preventable spending and lack of detailed clinical data in administrative claims.

Potentially preventable spending varied across Medicare subpopulations, with the majority concentrated among frail elderly persons.

The Commonwealth Fund.

关于潜在的可预防支出是否集中在一部分高成本的医疗保险受益人中，我们知之甚少。

确定高成本医疗保险受益人的不同亚群中可能可预防的总支出比例。

使用 2012 年医疗保险按服务收费的 20% 样本，将标准化个人支出总额中最高 10% 的受益人定义为“高成本”患者。使用基于索赔的算法定义了以下 6 个亚群：非老年残疾、年老体弱、大杂慢性、小杂慢性、单纯慢性、相对健康。潜在可预防支出的计算方法是使用比林斯算法将可避免的急诊科就诊的成本加上住院和相关的 30 天门诊护理敏感疾病 (ACSC) 的急性后成本相加。然后在高成本亚群和各个 ACSC 之间比较潜在可预防支出的数量和比例。

医疗保险。

6 112 450 名医疗保险受益人。

被认为可以预防的支出比例。

2012 年，4.8% 的医疗保险支出是可以预防的，其中 73.8% 是由高成本患者承担的。尽管仅占医疗保险人口的 4%，但高成本的体弱老年人占潜在可预防支出总额的 43.9%（每人 6593 美元）。高成本非老年残疾人占潜在可预防支出的 14.8%（每人 3421 美元），主要复杂慢性群体占 11.2%（每人 3327 美元）。体弱的老年人占与尿路感染、脱水、心力衰竭和细菌性肺炎入院相关的大部分支出。

识别可预防支出方面的潜在错误分类和行政索赔中缺乏详细的临床数据。

潜在的可预防支出因医疗保险亚群而异，其中大多数集中在体弱的老年人中。

联邦基金。