Abstract 17306: The Most Expensive Patients in the Hospital
Introduction: In the Medicare population, 1% of the patients is responsible for 15% of spending. There are two patterns typical of highest-cost patients: those who cycle in and out of the hospital with preventable conditions, and those who have a single catastrophic event. While a great deal of focus has been placed on the former, much less is known about the latter. We do know that a large proportion of these most-expensive patients receive prolonged mechanical ventilation (PMV).
Methods/Results: We used national Medicare data to explore diagnoses, procedures, and costs associated with these most-expensive patients. There were 91,054 hospitalizations for Medicare patients with a DRG containing PMV in 2010. The majority of PMV patients were admitted emergently (71.9%); an additional 16.7% were admitted urgently. Elective admissions represented 9.5%, and trauma accounted for 1.8%. Median length of stay was 16 days, and the median stay in the intensive care unit was 11 days. Procedures were performed in the majority of these patients, and clinical outcomes were exceedingly poor (table). The financial costs associated with this group of patients were high. The average total hospitalization charge was $227,917; the maximum charge was over $9 million. The mean Medicare payment for PMV patients in 2010 was $61,995, with a maximum of $1.3 million. This was largely through the set DRG price (mean $59,491), though outlier payments (mean $5,957, maximum $1.2 million) and patient-paid coinsurance (mean $835, maximum $88,644) played a significant role as well.
Conclusions: A small group of Medicare beneficiaries undergoing PMV have extremely high costs and poor outcomes. This shared clinical pathway suggests that there is room for improvement, both in terms of identifying these patients early during hospitalization to prevent progression to PMV, as well as in terms of clinical innovation to improve care within the intensive care unit for those who are already ventilated.
Author Disclosures: K.E. Joynt: None. M. Makar: None. A. Gawande: None. D. Cutler: None. Z. Obermeyer: None.
- © 2014 by American Heart Association, Inc.