Identifying Patients with Persistent Preventable Utilization Offers an Opportunity to Reduce Unnecessary Spending

Improving care for high-cost patients is increasingly important for improving the value of healthcare. Most prior research has focused on identifying patients with high costs, but the extent to which these costs are potentially preventable remains unclear.

To identify patients with persistent preventable utilization and compare their characteristics with high-cost patients.

Descriptive analysis using Medicare claims data from 2013 to 2014.

Medicare fee-for-service and dual-eligible beneficiaries (N = 515,689) from the New York metropolitan area who were continuously enrolled in Medicare Parts A and B in 2013 and 2014.

The primary analysis focuses on patients with persistent preventable utilization (at least one preventable emergency department visit, hospitalization, or 30-day readmission in both 2013 and 2014) and high-cost patients in 2014 (top 10% of total annual spending). We compared demographic, medical, behavioral, and social characteristics and total and preventable healthcare utilization between these two groups.

Patients with persistent preventable utilization accounted for 4.8% of the overall patient population, 13.4% of overall costs, but 46.2% of preventable costs among all Medicare patients. Compared with high-cost patients, patients with persistent preventable utilization had lower median healthcare costs ($33,383 vs. $56,552), but their median potentially preventable costs were seven times higher ($7151 vs. $928). We also found that 1.9% of patients could be categorized in both the persistent preventable utilization group and the high-cost group. This subset of patients had the highest median Medicare costs and preventable costs and represented over 30% of total preventable spending and 9.4% of overall costs among all Medicare patients.

Designing and targeting interventions for patients with persistent preventable utilization may offer an important opportunity to reduce unnecessary utilization and promote high-value care.