Healthcare utilization and costs among high-need and frail Mexican American Medicare beneficiaries

Objectives To examine Medicare health care spending and health services utilization among high-need population segments in older Mexican Americans, and to examine the association of frailty on health care spending and utilization. Methods Retrospective cohort study of the innovative linkage of Medicare data with the Hispanic Established Populations for the Epidemiologic Study of the Elderly (H-EPESE) were used. There were 863 participants, which contributed 1,629 person years of information. Frailty, cognition, and social risk factors were identified from the H-EPESE, and chronic conditions were identified from the Medicare file. The Cost and Use file was used to calculate four categories of Medicare spending on: hospital services, physician services, post-acute care services, and other services. Generalized estimating equations (GEE) with a log link gamma distribution and first order autoregressive, correlation matrix was used to estimate cost ratios (CR) of population segments, and GEE with a logit link binomial distribution was applied to estimate odds ratios (OR) of healthcare use. Results Participants in the major complex chronic illness segment who were also pre-frail or frail had higher total costs and utilization compared to the healthy segment. The CR for total Medicare spending was 3.05 (95% CI, 2.48–3.75). Similarly, this group had higher odds of being classified in the high-cost category 5.86 (95% CI, 3.35–10.25), nursing home care utilization 11.32 (95% CI, 3.88–33.02), hospitalizations 4.12 (95% CI, 2.88–5.90) and emergency room admissions 4.24 (95% CI, 3.04–5.91). Discussion Our findings highlight that frailty assessment is an important consideration when identifying high-need and high-cost patients.

Venous-Thromboembolism Is Associated with Increased Healthcare Utilization in Elderly Patients with Diffuse Large B Cell Lymphoma

INTRODUCTION: Lymphoma is associated with a high risk of venous-thromboembolism (VTE); we have previously shown that elderly patients with diffuse large B cell lymphoma (DLBCL) have a 6.7-fold higher risk of VTE compared to control population without a history of cancer. Given this high risk, we sought to examine the impact of VTE on healthcare utilization using Surveillance, Epidemiology, and End Results Registry (SEER) data linked with Medicare. METHODS: We identified 5,537 Medicare beneficiaries diagnosed with DLBCL at age ≥66 years between 2011 and 2015, with at least 1 year of coverage prior to diagnosis, and initiation of chemotherapy within 1 year post-diagnosis. We ascertained pre-existing comorbidities for the 1 year prior to DLBCL diagnosis. Patients were followed from DLBCL diagnosis until 1 year after cancer diagnosis, or until death, loss of continuous Part A or Part B coverage, blood or marrow transplantation, or end of study (12/31/2016), whichever came first. VTE diagnosis was based on ICD 9 and ICD 10 codes for events including deep vein thrombosis (DVT) and pulmonary embolism (PE). Hospitalizations and Outpatient Visits: Total number of hospitalizations and outpatient visits were compared in DLBCL patients with and without VTE for 1 year after cancer diagnosis, using multivariable negative binomial regression, offset for person-months and adjusting for age at diagnosis, race/ethnicity, stage at diagnosis and number of pre-DLBCL comorbidities (0, 1, 2+). Predicted counts for hospitalizations and outpatient visits were estimated from the multivariable models. Healthcare Spending: Total inpatient and outpatient Medicare spending and spending per visit was estimated from multivariable quantile regression, offset for person-months contributed and adjusting for age at diagnosis, race/ethnicity, stage at diagnosis, and pre-DLBCL comorbidities (0, 1, 2+). RESULTS: Overall, 462 (8.3%) patients developed VTE within 1 year of diagnosis of DLBCL and 244 patients had a VTE history before lymphoma diagnosis. Patients with VTE after DLBCL diagnosis had increased number of hospitalizations compared to those without VTE at the 3, 6 and 12 month time points in the first year after cancer diagnosis (Table 1). The median number of hospitalizations in patients with VTE was 2 compared to 1 in those without VTE at 3 months (p<0.0001). Increased hospitalizations continued until 1 year after lymphoma diagnosis; median number of hospitalizations was 3 in those with VTE compared to 2 in those without VTE at 1 year (p<0.0001). This lead to $51,285 in Medicare spending for hospitalizations in those with VTE compared to $37,065 in those without VTE (excess Medicare spending of $14,220 in those with VTE) in the first year after DLBCL diagnosis (p<0.001). We found no difference in the cost per visit; the excess costs were due to increased number of hospitalizations. The excess hospitalizations in those with VTE compared to those without VTE were primarily related to admissions for cardiovascular problems that included PE and/or DVT (14% vs 5%, respectively; p<0.001). Patients with VTE also had increased outpatient visits in the first year (Table 2). Median number of outpatient visits was 17 in those with VTE compared to 14 in those without VTE at 1 year (p<0.001). Medicare spending for outpatient visits in patients with a VTE diagnosis after DLBCL was $13,851 in the first year compared to $5,863 in those without VTE ($7,988 excess in those with VTE, p<0.001). Similar to hospitalizations, there was no difference in the cost per outpatient visit and the excess costs were due to increased number of visits. Increased outpatient healthcare utilization was also noted in patients who had a history of VTE prior to DLBCL diagnosis compared to those without VTE (median number of outpatient visits: 18 vs 14, p<0.001). CONCLUSION: In conclusion, elderly patients with DLBCL and VTE (diagnosed both before and after DLBCL diagnosis) have substantially higher healthcare utilization compared to those without VTE, resulting from both increased hospitalizations and outpatient visits in the first year after cancer diagnosis; these translate into higher Medicare spending. These findings identify a need for thromboprophylaxis in high risk patients after DLBCL diagnosis and future studies should assess cost-benefit analysis with thromboprophylaxis. Figure 1 Figure 1. Disclosures Gangaraju: Alexion: Consultancy; Sanofi Genzyme: Consultancy.

1416. Medicare Spending on Urinary Tract Infections: A Retrospective Database Analysis

Background Medical visits for UTIs represent 1%-6% of all healthcare visits (~7 million visits) and are estimated to cost the United States (US) healthcare system at least &1.6 billion annually. UTIs are associated with significant morbidity; particularly among the elderly, where UTIs are most prevalent. Little is known about the specific costs to Medicare of UTI; here, we seek to examine overall Medicare spending on UTI. Methods We conducted a retrospective multicenter cohort study of the Medicare fee-for-service (FFS) data. Patients were included for analysis if the following criteria were met: (1) enrolled in Medicare FFS from January 1, 2016 through December 31, 2019, (2) not enrolled in Medicare Advantage during that time period, (3) did not have any UTI diagnoses in 2016, and (4) enrolled in Medicare Part D. Individuals were categorized as having uncomplicated UTI (uUTI), complicated UTI (cUTI), or those who first had a uUTI that progressed to a cUTI (uUTI to cUTI). Medicare spending in the 12 months post-diagnosis was calculated, and patients were stratified by home- or institutionally-based (eg, nursing home, long-term care facility, etc.). Results 2,330,123 patients were included for analysis; 92% were home-based, 8% were institutionally-based. Mean Charlson Comorbidity Index (CCI) across all patients was 2.16. In the 12 months after initial diagnosis, average Medicare spend was &33,984, &9,941 of which was UTI-related. Annual UTI-related costs were approximated &9,000 for home-based vs. &21,444 for institutionally-based patients. Mean drug spend per patient on antibiotics was &872. Broadly, uUTI patients were least expensive, followed by cUTI patients, with uUTI to cUTI patients being most expensive. Higher costs for were observed for institutionally-based patients, largely due to more frequent acute hospitalizations and more Part A-paid skilled nursing stays. Conclusion UTI-related spending represents approximately one-third of total annual Medicare spend for patients diagnosed with a UTI. Given average Medicare spending of approximately &12,000 per person in 2019, UTI is associated with substantially increased per patient cost and represents a significant source of spending for Medicare. Disclosures Kate Sulham, MPH, Spero Therapeutics (Consultant) Eric Hammelman, MBA, AbbVie Pharmaceuticals (Consultant)Edwards Lifesciences (Consultant)Genentech (Consultant)Spero Therapeutics (Consultant)Vertex Pharmaceuticals (Consultant)

Traditional Medicare Spending on Inpatient Episodes as Hospitalizations Decline

OBJECTIVE: To describe Medicare inpatient episode spending trends between 2009 and 2017 as inpatient use declined among traditional Medicare beneficiaries. METHODS: Inpatient episodes included claims for all traditional Medicare inpatient, outpatient, and Part D services provided during the 30 days prehospitalization, the inpatient stay, and the 90 subsequent days. We describe the mean number of episodes per 1000 beneficiaries, mean episode-related spending per beneficiary, and mean spending per episode for all beneficiaries and for specific populations and types of episodes. Spending measures are reported with and without adjustment for payment rate increases over the study period. RESULTS: The number of inpatient-initiated episodes per 1000 beneficiaries declined by 18.2% between 2009 and 2017 from 326 to 267. After adjusting for payment rate increases, Medicare spending per beneficiary on episode-related care declined by 8.9%, although spending per episode increased by 11.4% over this period. Between 2009 and 2017, all subgroups defined by age, sex, race, or Medicaid status experienced declines in inpatient use accompanied by decreased overall episode-related spending per beneficiary and increased spending per episode. Larger declines in the number of episodes per 1000 beneficiaries were seen among episodes that began with a planned admission (28.8%) or involved no use of post–acute care services (23.9%). When comparing admissions according to medical diagnosis, the largest decline occurred for episodes initiated by a hospitalization for a cardiac or circulatory condition (31.8%). CONCLUSION: Medicare inpatient episodes per beneficiary decreased, but spending decreases due to declining volume were offset by increased spending per episode.

Associations between Hospital Quality Outcomes and Medicare Spending per Beneficiary in the USA

The cost of healthcare in the United States has increased over time. However, patient health outcomes have not trended with spending. There is a need to better comprehend the association between healthcare costs in the United States and hospital quality outcomes. Medicare spending per beneficiary (MSPB), a homogeneous metric across providers, can be used to evaluate the association between episodic Medicare spending and quality of care. Fifteen inpatient outcome measures were selected from Hospital Compare data among all (n = 4758) facilities and transformed to quintiles to ensure comparability across measures and to reduce the influence of outliers on the analysis. Both univariate and multiresponse multinomial ordered probit regression models were utilized across outcome domains to quantify associations between outcomes and spending. We found that MSPB was not associated with quality of care in most cases, adding evidence of a lack of outcome accountability among Medicare-funded facilities. Furthermore, worse outcomes were found to be associated with increased spending for some metrics. Policies are needed to align quality of care outcomes with the increasing costs of U.S. healthcare.