Assesses hospital inpatient and observation stay utilization among adult commercial and Medicare health plan members. Health plans report observed rates of hospital use and expected rates of hospital use that take the member’s health history into account. The observed rate and expected rate is used to calculate a calibrated observed-to-expected ratio that assesses whether plans had more, the same or less readmissions than expected, while accounting for incremental improvements across all plans over time. The observed-to-expected ratio is multiplied by the hospitalization rate across all health plans to produce a risk-standardized rate which allows for national comparison.
WHY IT MATTERS
Hospital utilization is a driver of health care expenditures and puts patients at risk for adverse events. Inpatient admission costs accounted for 21% of total Medicare benefit payments in 2017 and 1 in 25 hospitalized individuals are affected by a health care-associated infection.1,2 Older patients are particularly at increased risk for delirium, falls and depressed psycho-physiologic functioning while hospitalized.3,4 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 |
|---|---|---|---|---|
| 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
- Kaiser Family Foundation. An Overview of Medicare. Retrieved December 2, 2019, from The Henry J. Kaiser Family Foundation website: https://www.kff.org/medicare/issue-brief/an-overview-of-medicare/
- 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.