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Member Research and Reports

Member Research and Reports

Brown University School of Public Health │ Identifying High-Need Medicare Beneficiaries at Risk of Dying or Being Hospitalized

It is estimated that 5 percent of the U.S. population accounted for 50 percent of the national healthcare spending in 2012. Identifying exactly who high-need, high-cost patients are, however, remains a significant challenge. While various definitions of high need exist, their predictive validity for different patient outcomes in the following year has not been systematically assessed for both fee-for-service (FFS) and Medicare Advantage (MA) beneficiaries.

This study, by Dr. Emmanuelle Bélanger, assistant professor of health services, policy and practice, and colleagues, aimed to develop a new, comprehensive measure of high need (HN) based on mandatory, claims-based assessments for both FFS and MA beneficiaries, that has strong predictive validity in this population.

[Photo: Dr. Emmanuelle Bélanger]

Authors used administrative data from 2014 to develop a new definition and examined its predictive validity for patient outcomes in 2015 as compared to alternative definitions for both FFS and MA beneficiaries. Based on previous literature, the study’s proposed definition includes having 2 or more complex conditions, 6 or more chronic conditions, acute or post-acute health services utilization, as well as indicators of frailty, or complete dependency in mobility or in any activities of daily living. Based on this definition, 13.17 percent of FFS (4,945,189) and 8.85 percent of MA (1,520,759) beneficiaries were identified as HN in 2014. Their mortality and hospitalization rates were 7 and 3 times higher than non-HN beneficiaries.

Investigators found the proposed definition of HN — which encompasses the complexity of chronic conditions, multi-morbidity, healthcare utilization, and functional impairment — demonstrates better performance than competing HN definitions in predicting hospitalization and mortality for the Medicare population. This makes it useful for triaging and identifying beneficiaries at risk of dying and being hospitalized and facilitating outcome performance comparisons across health systems.

Investigators’ next steps consist in identifying top performing health systems caring for HN beneficiaries and their characteristics, including where they are situated along a continuum of accountability, from unaffiliated hospitals to Accountable Care Organizations. Being able to identify a sufficiently large sample of the HN beneficiaries at risk for hospitalization and mortality is paramount for the instigation of health policies that can have a significant impact on health outcomes and expenditures nationally.

This article was published in the Journal of General Internal Medicine.

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