Policymakers may want to target the late post-acute period in patient care if they really want to rein in healthcare spending. A study published online Sept. 23 in JAMA Internal Medicine attributed three-quarters of Medicare beneficiaries’ acute MI expenditures to days 31 through 365.

Many bundled payment initiatives and Medicare’s readmission penalty program for acute MI, heart failure and pneumonia use a 30-day cutoff, reasoning that outcomes during the first 30 days after the index admission best reflect the quality of care given to a patient. Donald S. Likosky, PhD, of the cardiac surgery department at the University of Michigan in Ann Arbor, and colleagues looked beyond that timeframe to assess costs within the first year of care.

For their study, they compared expenditures from 1998-1999 and 2008 for Medicare patients who were admitted for acute MI. They used a random sample of 20 percent of beneficiaries for each period and followed them for one year after hospitalization. Unadjusted expenditures were calculated in 2008 dollars.

Likosky found a 19.2 percent decline in the incidence of acute MI between the two periods. Patients in the 2008 sample were older, sicker and had more comorbidities, with the exception of ischemic heart disease and cerebrovascular disease.      

The overall case fatality rate dropped from 36 percent to 31.7 percent over the decade, with 30-day mortality rates falling from 18.6 percent to 15.3 percent and 31- to 365-day rates dipping from 22.3 percent to 20.2 percent. Thirty-day readmission rates failed to budge appreciably, though, while the mean cost per readmission rose 9.8 percent over the decade.

Overall expenditures per patient increased 16.5 percent, or $6,094 per patient. Spending per patient rose by 7.5 percent in the first 30 days and by 28 percent between days 31 and 365. Almost 75 percent of spending occurred between 31 to 365 days after admission.

Likosky and colleagues noted that the cost increases were not due to price hikes or technology expenses but rather “increased use of home health agencies, hospices, durable medical equipment, skilled nursing facilities, and inpatient services,” they observed. “Although the first 30 days after admission are the focus of many bundled payment initiatives, care after the initial admission is still very much ‘fee for service,’ with greater intensity of care per patient rewarded with increased Medicare reimbursements.”

The findings suggest that policies should expand their focus beyond 30 days or even 90 days to contain growth in expenditures, according to Likosky and colleagues, a recommendation that was seconded by Ashish K. Jha, MD, MPH, in an editorial.

Jha, of Harvard School of Public Health in Boston, pointed out that shifts in practice such as a greater use of PCI over CABG between 1998 and 2008 and improvements in mortality should translate into cost savings. “Although readmission rates in the late period remained stable, the spending per readmission went up—with little evidence that patients benefited,” he wrote.

Jha emphasized the need for an investment in quality measures that extend beyond early post-acute care. “Without real investments in measuring the quality and health impact of services in the late period of post-acute care, important coverage decisions will continue to be made in a vacuum: cover everything and further strain the federal budget, or arbitrarily deny specific services and be accused of rationing.”