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Dramatic rise in spending shows costly comeback from heart attack

Medicare spends more on nursing home stays, medical equipment for heart attack patients

ANN ARBOR, Mich. – Medicare spending to treat heart attack patients rose by 16.5 percent between 1998-2008, an increase driven primarily by costs incurred weeks after patients left the hospital.

The bulk of the higher spending was on skilled nursing facilities, hospice, home health care, durable medical equipment such as wheelchairs, and outpatient care, according to an analysis led by the University of Michigan Frankel Cardiovascular Center.

The study published online today ahead of print in the Journal of the American Medical Association Internal Medicine is the first to account for how Medicare spent its money over the past decade to help older Americans recover from heart attacks.

Researchers at the U-M and the Dartmouth Institute for Health Policy & Clinical Practice examined spending in the way Medicare categorizes payments:  the first month after a hospitalization for heart attack and one month to one year after the hospitalization. Of the total increase in expenses, 25.6 percent was for care within 30 days of the date of hospitalization and 74.4 percent was for care one month to one year after hospitalization. 

Medicare spending per patient increased by $1,560 within the first 30 days after hospitalization and rose by $4,535 within 31 to 365 days.

Where costs increased for post 30-day care:

  • Home health, hospice and medical equipment: 23 percent
  • Skilled nursing home: 17 percent
  • Inpatient (hospital) care:13 percent
  • Outpatient care:11 percent
  • Doctor appointments:10 percent

Patients who suffer a heart attack are routinely hospitalized, and Medicare packages payments to hospitals and physicians to cover the first 30 days of care.

Donald Likosky, Ph.D.
Donald Likosky, Ph.D.

“In some respects, this bundled payment has worked to limit the overall cost of caring for patients who have a heart attack. It turns out, however, that over the last decade, much of the cost increase is actually attributed to care beyond the 30 days,” says lead study author and health outcomes researcher Donald Likosky, Ph.D., associate professor of cardiac surgery at the University of Michigan Medical School. “The current payment model, because it is defined by a 30-day window, has not addressed the predominant source of healthcare spending for this patient population.

“Our findings suggest policy makers should extend the current bundled payment, or develop episode-based payments for heart attack care,” he says. 

The substantial increase in spending has occurred even as hospitalizations for heart attacks have fallen and more people have less invasive procedures to treat their symptoms, including more angioplasty instead of open heart surgery. These advances in strategies have shortened hospital stays by one day.

Authors adjusted for differences in prices, comorbidities, and inflation. These adjustments are important considering the 212,329 Medicare patients hospitalized for heart attack in 2008 were older and sicker than those hospitalized in the previous decade.

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Additional Authors: Brahmajee K. Nallamothu, M.D., M.P.H., of the University of Michigan and Veterans Administration Ann Arbor Healthcare System; William B. Borden, M.D., Cornell University; and Weiping Zhou, David J. Malenka, M.D., and Jonathan S. Skinner of Dartmouth College. 

Reference: “Growth in Medicare Expenditures for Patients with Acute Myocardial Infarction,” Journal of the American Medical Association Internal Medicine, Sept. 23, 2013.

Funding: The study was conducted under Data Use Agreement 54913 between the Center for Medicare & Medicaid Services with Dartmouth College and with a grant from the National Institute on Aging.  

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