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High Cost of Heart Failure for the Medicare Population
San Diego—The high prevalence of heart failure (HF), particularly among Medicare beneficiaries, places a heavy burden on the US healthcare system in terms of morbidity, mortality, and cost. About 10 in 1000 persons >65 years of age have HF, and it is expected that the incidence of this disease will increase to 8 million by 2030 from 5.1 million in 2012. The cost of managing this disease is substantial, with total direct medical costs estimated at $20.9 billion in 2012 and expected to increase by 2030 to $53.1 billion.
What is behind these numbers? Barry H. Greenberg, MD, Professor of Medicine, University of California, San Diego, La Jolla, CA, led a science and innovation theater at AMCP that looked into the “evidence behind the evidence” in the management of HF. Kathryn V. Fitch, RN, Principal and Healthcare Management Consultant, Milliman, Inc., New York, NY, dug further into the evidence by presenting more data from an actuarial cost analysis on the high cost of HF for the Medicare population. The event was sponsored by Novartis Pharmaceuticals Corporation.
“HF is the inability of the heart to supply enough blood for the body’s metabolic needs,” said Dr. Greenberg, adding that HF can either be systolic (in which contraction of the heart is impaired) or diastolic (in which the ability of the heart to relax normally is impaired).
The need for good management of the disease is highlighted by the increased mortality risk. Among Medicare beneficiaries, the mortality rate in those with HF is 22% compared with 6% in the total Medicare fee-for-service (FFS) population and 4% in the Medicare FFS population without HF.
Dr. Greenberg highlighted that the risk of all-cause mortality increases with each hospital readmission, citing data showing a mortality rate of 3% to 4% at first hospital admission, 10% at 30-day readmission, 22% at 1-year readmission, and 42% at 5 years.
He also cited data showing the rates of readmission, with 27% of patients readmitted 30 days after first-time hospitalization and jumping to 66% to 68% at 1 year after first-time hospitalization. The cost on the healthcare system is substantial, with 80% of all monies spent on HF are for HF-related hospitalizations, he said.
Ms. Fitch discussed data from an actuarial cost analysis. The analysis used the Medicare 5% sample 2012 data as an index year to identify HF beneficiaries. All patients identified with HF had at least one outpatient, non-acute inpatient, or emergency department claim code with a HF ICD-9 code.
The analysis showed that although the prevalence of HF among Medicare FFS beneficiaries is only 11%, these beneficiaries constitute 34% of the total Medicare spend, she said.
“This disease is a huge cost driver,” she said, adding that the high costs are related to the burden of comorbidities. Compared to 21% of patients without HF who have ≥3 comorbidities, 76% of patients with HF have ≥3 comorbidities. The analysis found that beneficiaries without HF with the same number of comorbidities as beneficiaries with HF had significantly lower allowed per month per member (PMPM) medical costs.
The type of chronic comorbid condition that a patient with HF has also affects allowed PMPM medical costs, with particularly higher costs for depression. For example, the analysis found that the allowed PMPM for diabetes was $4216 whereas the PMPM for depression was $6117.
Ms. Fitch also highlighted the high mortality rate among Medicare FFS beneficiaries, saying that the mortal- ity rate is 5 times that of the mortality rate of non-HF beneficiaries. Among institutionalized patients, the morality rate increases to 34.7%.
Given the high cost of heart failure, that payers and providers both should focus care management efforts on patients with HF.—Mary Beth Nierengarten
