Frail elderly account for majority of potentially preventable Medicare spending

Among the many steps needed to provide high-value care for every high-need, high-cost older adult are a faster shift toward value-based health care; new data collection, analysis, and treatment planning; and new models for payment and patient assignment, an editorial stated.


Among subpopulations of high-cost Medicare beneficiaries, frail elderly patients account for the majority of potentially preventable spending, according to a new study.

Researchers used a 20% sample of Medicare fee-for-service claims from 2012 to examine the proportion of total spending that was potentially preventable in high-cost subpopulations. Beneficiaries were considered “high cost” if they were in the highest 10% of total standardized individual spending. Six subpopulations were defined: nonelderly disabled, frail elderly, major complex chronic, minor complex chronic, simple chronic, and relatively healthy. Costs for avoidable ED visits were added to costs for inpatient and associated 30-day post-acute costs for ambulatory care-sensitive conditions to arrive at potentially preventable spending. The researchers then compared the amount and proportion of spending that was potentially preventable across high-cost subpopulations and by ambulatory care-sensitive condition. Results were published online Oct. 17 by Annals of Internal Medicine.

A total of 6,112,450 Medicare beneficiaries were included in the study. Overall, 17.9% were assigned to the nonelderly disabled group, 8.6% were assigned to the frail elderly group, 18.0% were assigned to the major complex chronic group, 27.8% were assigned to the minor complex chronic group, 18.0% were assigned to the simple chronic group, and 9.7% were assigned to the relatively healthy group. In the study year, 2012, 4.8% of Medicare spending was considered potentially preventable. High-cost frail elderly patients made up 4% of the Medicare population but accounted for 43.9% of overall potentially preventable spending ($6,593 per person), while high-cost elderly disabled persons and persons with major complex chronic conditions accounted for 14.8% ($3,421 per person) and 11.2% ($3,327), respectively. Potentially preventable spending in the frail elderly group was most commonly related to acute care visits for heart failure, bacterial pneumonia, long-term complications of diabetes, and dehydration.

The authors noted that although potentially preventable acute care episodes were defined by using well-established algorithms, some admissions may not have been truly preventable. In addition, they pointed out that their 30-day time frame may have missed some preventable spending and that presence of chronic disease may have been underestimated, among other limitations. However, they concluded that potentially preventable spending varies widely across Medicare subpopulations and that frail elderly patients accounted for the majority of potentially modifiable costs. “Therefore, as we continue to move toward value-based frameworks, interventions that focus on frail elderly patients may be particularly valuable,” the authors wrote.

An accompanying editorial said that many steps will be needed to provide high-value care for every high-need, high-cost older adult, including a faster shift toward value-based health care; new data collection, analysis, and treatment planning; and new models for payment and patient assignment. “This all needs to happen as our health system addresses the critical challenges of lack of universal access to health care, underinvestment in primary care, administrative inefficiency, and disparities in delivery of care,” the editorialists wrote. Studies like the current one “can help point the way to ‘coolable’ hot spots,” they noted. “The onus is now on organizations and systems to shift culture and learn to implement the care and contracting methods used by their ‘coolest’ peers.”