Outpatient care coordination does not significantly reduce hospitalizations among high-cost Medicare patients, researchers say. Instead 90% of inpatient spending for those patients was "for treatment of conditions that you wouldn't think would be preventable by outpatient management."
Aggressive preventive care efforts in outpatient settings have little effect on spiraling hospital costs in the most expensive patients, says a surprising Harvard study. Rather, hospital payments must be reduced for certain procedures if the campaign to lower healthcare costs has any chance of success.
"The big ticket items (in hospital care) are not for the diabetics who comes in for a couple of days to get their blood sugar controlled," says Karen Joynt, MD, of the Harvard School of Public Health and the report's principal author.
"It's someone coming in for bypass surgery or back surgery, or someone coming in with sepsis. It's the 65-year-old who comes in with a huge heart attack or a 70-year-old with a hemorrhagic stroke, who needs a 30-day hospitalization and rehabilitation," she says. "We found that the problem is just so much more complex than (can be managed) with outpatient care."
Joynt's co-authors in the paper, published in the Journal of the American Medical Association include Atul Gawande, MD, associate professor at Harvard Medical School, whose 2011 article in the New Yorker, The Hot Spotters, suggested that better care in outpatient settings such as clinics, and physician champions for high-cost patients, can reduce expensive hospitalizations among the system's most costly patients.
Confirmation of that article, Joynt says, was what she and her co- investigators in this study expected to find.
"But instead, what we found was that 90% of inpatient spending for patients in the high-cost group [of Medicare patients] was for treatment of conditions that you wouldn't think would be preventable by outpatient management, at least in the near term."
For example, she explains, at the top of the list of the most expensive types of care among high-cost patients are orthopedic procedures like joint replacement and spine surgery, which account for about $300 million a year to the Medicare program, followed by ischemic heart disease, then cancer and chemotherapy, rehabilitation, sepsis, gastrointestinal tract infections and GI disorders, arrhythmia, device and procedural complications, and stroke or intracranial hemorrhage, none of which is really preventable through outpatient interventions, the authors said.
The most expensive preventable reason for hospitalization among high-cost patients, congestive heart failure, accounted for about $75 million, followed by bacterial pneumonia and chronic obstructive pulmonary disease, at less than $50 million each.
"Just having a nurse take better care of the outpatient medicines for patients (at risk of stroke or heart attack, for example) in the short term is not going to make any population-based differences in people having strokes or heart attacks," she says.
The authors drew their conclusions after looking at costs of inpatient and outpatient services for Medicare beneficiaries from 2009 and 2010. They identified the most expensive 10% and then detailed what types of emergency and inpatient services made up their high-priced Medicare bills. They then dissected which conditions and services might have been prevented through better outpatient management.
The 10% of patients who had the highest costs accounted for 79% of inpatient costs but only 9.6% were attributable to preventable hospitalizations, while 16.8% of costs within the non-high-cost group were due to preventable hospitalizations. Among the cohort of the most expensive Medicare beneficiaries, 10% were older. They were more likely to be male and more likely to be black.
Joynt is quick to point out that she doesn't think the study should prompt clinicians to abandon hospital, clinic, or physician-based prevention programs.
"We don't in any way want to imply that outpatient care coordination isn't the right thing to do, or isn't extremely valuable," she says. "But it is to say that if we're really going to bend the cost curve, we have to make the per episode cost lower. We can't just rely on reducing the number of episodes."
As the population ages, and more people receive health coverage through Medicare, "we don't want people to be getting fewer knee replacements. We're going to have more people aging, and they are going to have heart attacks and strokes and heart valve surgery."
She suggests that one way to do that might be through payment models such as bundling of episodes of care and accountable care organizations.
"If you're bundling care for, say, valve surgery, and a hospital knows it will get $25,000 for that surgery, they're going to try to find a way to drop the cost so they get a margin on it. And that's pressure on them to reengineer specific items of care.
"Hospitals are going to start innovating how they're going to streamline and improve their processes of care to make it less expensive. And the same goes for knee and hip replacement, where the prices for these things have gone way, way up, but it's not totally clear that the quality is any better."
True, she acknowledges, some patients receive unnecessary care, such as surgery that may be no more effective than medical management with physical therapy. The Choosing Wisely campaign attempts to make patients think carefully about whether a particular procedure will accomplish their treatment goals, weighing the potential for adverse consequences and harm.
But that may be largely offset by the fact that more patients will need that care as they age.
In an accompanying editorial, Aaron Carroll, MD, and Austin Frakt, PhD, of Indian University School of Medicine and the VA Boston Healthcare System, called Joynt's results "sobering," because they "confirmed what many know to be true—that 10% of the Medicare population accounts for about 70% of the program's spending."
However, that such a small amount of this spending, 9.6%, "is certainly nothing to ignore, yet even saving the entire amount (which is unlikely) is not the panacea some might have hoped," they wrote. "Increasing outpatient services may not be a mechanism for reducing spending."
The article was released one day prior to JAMA's usual publication date to coincide with Joynt's presentation of the paper at the annual research meeting of AcademyHealth in Baltimore.