Assesses acute inpatient and observation stay discharges among adult commercial and Medicare health plan members. Health plans report observed and expected rates of hospital use that consider a member’s health history. The rates are used to calculate a calibrated observed-to-expected (O/E) ratio that assesses whether plans had more, the same or fewer hospitalizations than expected, accounting for incremental improvements across all plans over time. The O/E ratio is multiplied by the hospitalization rate across all health plans to produce a risk-standardized rate that allows national comparison.
WHY IT MATTERS
In 2019, 5.9% of people had had a hospital stay in the past year.1 Hospital care accounts for 31% of health spending in the U.S.2 A study found that inpatient admission costs account for 21% of total Medicare benefit payments.3 Hospital and inpatient hospitalizations put patients at risk for adverse events and prolonged inpatient stays.4,5 One in 25 hospitalized individuals are affected by a health care-associated infection.6 Older patients are particularly at increased risk for delirium, falls and depressed psycho-physiologic functioning while hospitalized.7,8 Some hospitalizations can be avoided with improved access to care, timely delivery of care and appropriate care coordination.
Results – National Averages
Acute Hospital Utilization Rate - Medicine
| Measure Year | Commerical HMO | Commercial PPO | Medicare HMO | Medicare PPO |
|---|---|---|---|---|
| 2021 | 24 | 23.1 | 132.4 | 113.9 |
| 2020 | 22.6 | 21.4 | 130.0 | 113.3 |
Acute Hospital Utilization Rate - Total Acute
| Measure Year | Commerical HMO | Commercial PPO | Medicare HMO | Medicare PPO |
|---|---|---|---|---|
| 2022 | 30.6 | 31.3 | 166.1 | 156.7 |
| 2021 | 37.3 | 37 | 181.7 | 166 |
| 2020 | 36.8 | 36.1 | 179.5 | 169.8 |
| 2019 | 43.1 | 42.0 | § | § |
| 2018 | 42.0 | 41.8 | 186.0 | 200.4 |
§ Not available due to CMS suspension of data reporting during COVID-19 pandemic.
This State of Healthcare Quality Report classifies health plans differently than NCQA’s Quality Compass. HMO corresponds to All LOBs (excluding PPO and EPO) within Quality Compass. PPO corresponds to PPO and EPO within Quality Compass.
Figures do not account for changes in the underlying measure that could break trending. Contact Information Products via my.ncqa.org for analysis that accounts for trend breaks.
References
- Centers for Disease Control and Prevention. 2021. Hospitalization—Health, United States. National Center for Health Statistics. https://www.cdc.gov/nchs/hus/topics/hospitalization.htm
- California Heath Care Foundation. 2021. “Health Care Costs 101, 2021: US Spending Growth Outpaces Economy.” California Health Care Almanac.
https://www.chcf.org/wp-content/uploads/2021/06/HealthCareCostsAlmanac2021.pdf - Kaiser Family Foundation. An Overview of Medicare. https://www.kff.org/medicare/issue-brief/an-overview-of-medicare/
- Covinsky, K.E., E. Pierluissi, & C.B. Johnston. 2011. “Hospitalization-Associated Disability.” JAMA: The Journal of the American Medical Association 306(16), 1782–
- Schimmel, E. 2003. “The Hazards of Hospitalization.” Quality and Safety in Health Care 12(1), 58–63.
- Magill, S.S., J.R. Edwards, W. Bamberg, et al. 2014. “Multistate Point-Prevalence Survey of Health Care–Associated Infections.” New England Journal of Medicine 370:1198–208.
- Gillick, M.R., N.A. Serrell & L.S. Gillick. 1982. “Adverse Consequences of Hospitalization in the Elderly.” Social Science & Medicine 16(10), 1033–8.
- Lang, V.J., N.S. Clark, et al. 2008. “Hazards of Hospitalization: Hospitalists and Geriatricians Educating Medical Students About Delirium and Falls in Geriatric Inpatients.” Gerontology & Geriatrics Education 28(4): 94–104.