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Growth in Medicare Expenditures for Patients With Acute Myocardial Infarction: A Comparison of 1998 Through 1999 and 2008
Study Questions:
What are the trends in expenditures from 1998-1999 and 2008 for Medicare beneficiaries hospitalized for acute myocardial infarction (AMI)?
Methods:
This was a cross-sectional analysis of a random 20% sample of fee-for-service Medicare beneficiaries admitted with AMI from 1998-1999 (n = 105,074), and a 100% sample for 2008 (n = 212,329). The main outcomes measures were per-beneficiary expenditures standardized for price and adjusted for risk and inflation. Expenditures were measured across four periods: overall (index admission to 1 year), index (within the index admission), early (postindex admission to 30 days), and late (31-365 days).
Results:
Compared with the subjects from 1998-1999, those in 2008 were older and had more comorbidities, but slightly less ischemic heart disease and cerebrovascular disease. Although there was a 19.2% decline in the rate of hospitalizations for AMI, overall expenditures per patient increased by 16.5% (absolute difference, $6,094). Of the total risk-adjusted increase in expenditures, 25.6% occurred within 30 days (22.0% attributed to the index admission), and 74.4% happened 31-365 days after the index admission. Spending per beneficiary within 30 days increased by $1,560 (7.5%), and spending between 31 and 365 days increased by $4,535 (28.0%). Expenditures for skilled nursing facilities, hospice, home health agency, durable medical equipment, and outpatient care nearly doubled 31-365 days after admission. Mortality within 1 year declined from 36.0% in 1998-1999 to 31.7% in 2008; of the decline, 3.3% was in the 30 days following admission, and 1.0% was in days 31-365.
Conclusions:
The authors concluded that between 1998 and 2008, Medicare expenditures per patient with an AMI substantially increased, with approximately three-fourths of the increase in expenditures occurring 31-365 days after the date of hospital admission.
Perspective:
This study suggests that although Medicare bundles payments 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. Although services in the late period of care explained approximately three-fourths of the cost growth, they accounted for only approximately one-fourth of the gains in mortality. This growth in the use of health care services 31-365 days after an AMI challenges efforts to control costs. Refocusing on services following early post-acute services may include extending bundled payments, redoubling efforts to encourage accountable care organizations, and measuring the value of services following post-acute care. Measuring value may be hard work because understanding of the appropriateness and value of services following early post-acute care is so rudimentary, but will be critical to delivering optimal and cost-effective therapy.
Keywords: Home Care Agencies, Risk, Myocardial Infarction, Myocardial Ischemia, Hospice Care, Cross-Sectional Studies, Cardiovascular Diseases, Durable Medical Equipment, Skilled Nursing Facilities, Medicare, United States
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