The study population consisted of approximately 26 million beneficiaries. As shown in Table 1, the least restrictive heart failure segment (Segment 1) yielded a cohort containing about 3.6 million beneficiaries while the more restrictive segments yielded about 1.8 million and 1.0 million beneficiaries for Segments 2 and 3 respectively. In general, the cohorts were similar in terms of reasons for eligibility, but the 2018 mortality rate was higher for the narrowest cohort (21% for cohort 3) compared to the most inclusive cohort (13% for cohort 1). Average annual 2017 Medicare spending for the narrowest cohort was $46,440 compared with $22,947 for the most inclusive cohort. Performance year spending was generally lower, with 2018 spending averaging $27,037 for the narrowest cohort compared with $18,391 for the most inclusive cohort.
Table 1
Characteristics of Heart Failure Cohorts in 2017
| Segment 1 | Segment 2 | Segment 3 |
Number | 3,639,259 | 1,897,108 | 1,025,745 |
Mean Age | 77 | 78 | 77 |
Sex (Female) | 54% | 53% | 54% |
Eligibility Category | | | |
-Disabled (%) | 25% | 25% | 26% |
-Aged dually eligible for Medicaid and Medicare (%) | 14% | 15% | 15% |
-Aged, non-dual (%) | 61% | 60% | 58% |
ACO Status (%) | 31% | 31% | 32% |
Mortality 2018 (%) | 13% | 17% | 21% |
Mean PMPY 2017 (Truncated) | $22,947 | $30,968 | $46,440 |
Mean PMPY 2018 (Truncated) | $18,391 | $21,689 | $27,037 |
Segment 1
Beneficiaries with at least one ambulatory (Part B) bill or an inpatient (Part A) with a heart failure ICD-10 diagnosis code (see appendix for codes).
Segment 2
Beneficiaries with at least two ambulatory (Part B) heart failure bills 30-days apart or one hospitalization with a primary diagnosis of heart failure.
Segment 3
Beneficiaries with one or more hospitalization with a primary diagnosis of heart failure.
Table 2 shows the 2018 hospital admissions for each heart failure cohort and for the overall study population (labeled All FFS beneficiaries). The study population comprised of 26 million beneficiaries accounted for about 6 million hospitalizations in 2018. The three progressively more restrictive segments contained commensurately smaller proportions of the total hospitalizations. Segment 1, the least restrictive segment, contained about 1.9 million or 30% of the 6 million hospitalizations. Segments 2 and 3 contained about 1.2 million (19%) and 0.8 million (13%) respectively of the 6 million hospitalizations in the study population. Table 2 indicates the degree to which the hospitalization rates are dramatically higher. For example, hospitalization rates in Segment 1 are twice the national average of 240 admissions per 1,000 beneficiaries. Hospitalization rates are nearly 3 and 4 time higher than the national average in Segments 2 and 3 respectively. Finally, as shown in Table 2, 84 percent of beneficiaries in the study sample had zero hospitalizations in 2018, compared with 68 percent, 62 percent and 54 percent respectively in the three heart failure cohorts.
Table 2
Beneficiary counts and outcome measures for all Medicare ACO Assignment-Eligible Beneficiaries and for Three Heart Failure Segments in 2018
2018 Beneficiaries from 2017 Cohort | Number of Beneficiaries | Total Hospital Stays | Hospital Stays per 1,000 Beneficiaries | Number of Beneficiaries with Zero Hospital Stays | Percent Zero Hospital Stays |
All Fee-for-service Beneficiaries | 25,587,927 | 6,138,763 | 240 | 21,531,217 | 84% |
Heart failure segment 1 | 3,160,002 | 1,859,564 | 588 | 2,133,143 | 68% |
Heart failure segment 2 | 1,580,272 | 1,157,220 | 732 | 982,843 | 62% |
Heart failure segment 3 | 810,045 | 795,952 | 983 | 433,912 | 54% |
Segment 1
Beneficiaries with at least one ambulatory (Part B) bill or an inpatient (Part A) with a heart failure ICD-10 diagnosis code (see appendix for codes).
Segment 2
Beneficiaries with at least two ambulatory (Part B) heart failure bills 30-days apart or one hospitalization with a primary diagnosis of heart failure.
Segment 3
Beneficiaries with one or more hospitalization with a primary diagnosis of heart failure.
Figure 1 shows histograms of 2018 counts of hospital utilization for the overall study population and each heart failure cohort including the prevalence of zero 2018 admissions. Overall, the basic shape of the distribution is the same despite the fact the admissions rates are much higher for the progressively more restrictive segments.