Between 1998 and 2008, inflation-adjusted Medicare expenditures for patients with acute myocardial infarction (AMI) increased 16.5 percent per patient despite a 19.2 percent decrease in hospitalization rates. The majority of the increased spending occurred in the 31 to 365 days after the index hospitalization, according to a study published Sept. 23 in JAMA Internal Medicine.

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The study looked at a random 20 percent sample of Medicare beneficiaries from 1998-1999 (n=105,074) and 100 percent sample from 2008 (n=212,329). This represented 0.64 percent and 0.47 percent of all fee-for-service enrollees, respectively, and a 19.2 percent reduction in the incidence of AMI. All patients were at least 65 years old at the index hospitalization and survived for at least one year following hospitalization. Total spending increased from $37,026 to $43,120 per patient, an absolute increase of $6,094 and relative increase of 16.5 percent. Most of the increase (74.4 percent) occurred between days 31 to 365, and was attributed to increased use of home health agencies, hospices, durable medical equipment, skilled nursing facilities and inpatient services. One-year mortality decreased 4.3 percent.

“Our findings suggest that although Medicare’s current bundle payments may include expenditures for patients with AMI within 30 days of the event, they do not contain spending beyond 30 days, which accounted for most of the expenditure growth for such patients from 1998 through 1999 and 2008,” the authors note.

“This growth in the use of health care services 31 to 365 days after an AMI challenges efforts to control costs. A potential approach is to extend bundled or episode-based reimbursements to periods beyond 30 days,” they conclude.

In an accompanying editorial, Ashish K. Jha, MD, MPH, Harvard School of Public Health, Boston, questioned if the additional services that accounted for most of the increased spending provided any benefit. “Absent better evidence about which services are valuable for beneficiaries following early period post-acute care, as well as the specific situations in which they are valuable, it is unclear whether Medicare’s current approach to paying for them is justified,” Jha wrote. “The study … should be a wake-up call for federal policy-makers.”

Keywords: Home Care Agencies, Incidence, Myocardial Infarction, Hospices, Fee-for-Service Plans, Health Expenditures, Durable Medical Equipment, Skilled Nursing Facilities, Inpatients, Medicare, Hospitalization, United States

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