Temporal Patterns of High-Spend Subgroups Can Inform Service Strategy for Medicare Advantage Enrollees.

Journal of General Internal Medicine
Samuel J AmodeoDavid J Cook

Abstract

Most healthcare costs are concentrated in a small proportion of individuals with complex social, medical, behavioral, and clinical needs that are poorly met by a fee-for-service healthcare system. Efforts to reduce cost in the top decile have shown limited effectiveness. Understanding patient subgroups within the top decile is a first step toward designing more effective and targeted interventions. Segment the top decile based on spending and clinical characteristics and examine the temporal movement of individuals in and out of the top decile. Retrospective claims data analysis. UnitedHealthcare Medicare Advantage (MA) enrollees (N = 1,504,091) continuously enrolled from 2016 to 2019. Medical (physician, inpatient, outpatient) and pharmacy claims for services submitted for third-party reimbursement under Medicare Advantage, available as International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and National Drug Codes (NDC) claims. The top decile was segmented into three distinct subgroups characterized by different drivers of cost: (1) Catastrophic: acute events (acute myocardial infarction and hip/pelvic fracture), (2) persistent: medications, and (3) semi-persistent chronic conditions and fr...Continue Reading

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