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. 2014 Jan 15;4(1):mmrr.004.01.b01.
doi: 10.5600/mmrr.004.01.b01. eCollection 2014.

Medicare-Medicaid eligible beneficiaries and potentially avoidable hospitalizations

Misha Segal  1 , Eric Rollins  1 , Kevin Hodges  1 , Michelle Roozeboom  2
Affiliations

Medicare-Medicaid eligible beneficiaries and potentially avoidable hospitalizations

Misha Segal et al. Medicare Medicaid Res Rev. .

Abstract

Objective: Potentially avoidable hospitalizations have been identified by experts as leading to poor health outcomes and costly care. Potentially avoidable hospitalizations are particularly common among full-benefit dual eligible beneficiaries. This paper examines potentially avoidable hospitalizations rates by setting, state, and medical condition, and the average cost of these events.

Methods: This analysis identifies potentially avoidable hospitalizations using diagnosis codes identified by an expert panel. Settings of care are determined using a timeline file, which assigns an individual to a specific setting on a particular day.

Population/data source: The analysis uses several different datasets from the Chronic Conditions Data Warehouse. The study population includes fee-for-service beneficiaries who were eligible for both Medicare and full Medicaid benefits for at least one month during the calendar year. The study years are 2007 to 2009.

Results: In 2009, among our study population, 26 percent of hospitalizations were potentially avoidable; and the rate was 133 per 1,000 person-years. Potentially avoidable hospitalizations were much more likely for those beneficiaries who were in institutions--16 percent of beneficiaries in our study population were in an institution, yet comprised 45 percent of all potentially avoidable hospitalizations. The range in rates across the states was considerable, with more than a threefold difference across states. Five conditions were responsible for nearly 80 percent of potentially avoidable hospitalizations. From 2007 to 2009, the national and state rates were fairly consistent.

Discussion: This analysis indicates that the potentially avoidable hospitalization rate among MME beneficiaries was consistently high from 2007 to 2009. This bears monitoring in the future to see if the Centers for Medicare & Medicaid Services' various initiatives have led to a reduction in rates.

Keywords: Dual Eligibles MMEs; Medicaid; Medicare; Potentially avoidable hospitalizations; patient safety (measurement); quality metrics; quality of care; readmissions.

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Figures

Exhibit 1.
Exhibit 1.. 2009 Potentially Avoidable Hospitalizations Rates, by Setting of Care
Exhibit 2.
Exhibit 2.. Percent of Potentially Avoidable Hospitalizations (PAH) and Associated Spending
Exhibit 3.
Exhibit 3.. Potentially Avoidable Hospitalization (PAH) Rates by State for 2009.
Exhibit 4.
Exhibit 4.. Highly Prevalent Conditions Associated with Potentially Avoidable Hospitalizations in 2009
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References

    1. Carter MW. Factors associated with ambulatory care—sensitive hospitalizations among nursing home residents. Journal of Aging and Health. 2003;15(2):295–331. doi: 10.1177/0898264303015002001. - DOI - PubMed
    1. Centers for Medicare & Medicaid Services. Data Analysis Brief: Medicare-Medicaid Dual Enrollment from 2006 through 2011. 2013a Retrieved from: http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-....
    1. Centers for Medicare & Medicaid Services. Geographic Variation Database. [Online Data Resource] 2013b Retrieved from http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trend....
    1. Centers for Medicare & Medicaid Services. Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. 2013c Retrieved from http://www.innovations.cms.gov/initiatives/rahnfr/index.html.
    1. Centers for Medicare & Medicaid Services. Hospital Compare [Online Comparison Tool] 2013d Retrieved from http://www.medicare.gov/hospitalcompare.

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