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Potentially Avoidable Hospitalizations of Dually Eligible Medicare and Medicaid Beneficiaries from Nursing Facility and Home‐ and Community‐Based Services Waiver Programs
Author(s) -
Walsh Edith G.,
Wiener Joshua M.,
Haber Susan,
Bragg Arnold,
Freiman Marc,
Ouslander Joseph G.
Publication year - 2012
Publication title -
journal of the american geriatrics society
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.992
H-Index - 232
eISSN - 1532-5415
pISSN - 0002-8614
DOI - 10.1111/j.1532-5415.2012.03920.x
Subject(s) - waiver , medicaid , medicine , population , emergency medicine , pneumonia , psychological intervention , skilled nursing facility , family medicine , environmental health , nursing , health care , political science , law , economics , economic growth
Objectives Beneficiaries dually eligible for M edicare and M edicaid are of increasing interest because of their clinical complexity and high costs. The objective of this study was to examine the incidence, costs, and factors associated with potentially avoidable hospitalizations ( PAH ) in this population. Design Retrospective study of hospitalizations. Setting Hospitalizations from nursing facilities ( NF ) including M edicare and M edicaid‐covered stays, and M edicaid H ome and C ommunity‐ B ased S ervices ( HCBS ) waiver programs. Participants Dually eligible individuals who received Medicare skilled nursing facility ( SNF ) or Medicaid NF services or HCBS waiver services in 2005. Interventions None. Measurements Potentially avoidable hospitalizations were defined by an expert panel that identified conditions and associated D iagnostic R elated G roups ( DRG s) which can often be prevented or safely and effectively managed without hospitalization. Results More than one‐third of the population was hospitalized at least once, totaling almost 1 million hospitalizations. The admitting DRG for 382,846 (39%) admissions were identified as PAH . PAH rates varied considerably among states, and blacks had a higher rate and costs for PAH than whites. Five conditions (pneumonia, congestive heart failure, urinary tract infections, dehydration, and chronic obstructive pulmonary disease/asthma) were responsible for 78% of the PAH . The total M edicare costs for these hospitalizations were $3 billion, but only $463 million for M edicaid. A sensitivity analysis, assuming that 20%–60% of these hospitalizations could be prevented, revealed that between 77,000 and 260,000 hospitalizations and between $625 million and $1.9 billion in expenditures could be avoided annually in this population. Conclusion Potentially avoidable hospitalizations are common and costly in the dually eligible population. New initiatives are needed to reduce PAH in this population as they are costly and can adversely affect function and quality of life.