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Poor Outpatient Care is associated with Costly Hospitalizations that are Preventable

Bowling Green, KY --- Preventable hospitalizations are costly among Medicaid enrollees in comprehensive managed care plans, according to new research from Western Kentucky University.


Many hospitalizations are preventable and consequently a cause for increasing health care costs.

Ambulatory care sensitive conditions (ACSC’s) represent illnesses, such as diabetes and hypertension (high blood pressure), for which good primary care can prevent and/or manage, thereby preventing the need for hospitalization, or for which early intervention can prevent complications or more disease severity.


According to William N. Mkanta, Associate Professor in the Department of Public Health and lead author of the study, “Patients, providers, and systems of care use information on inpatient service utilization on ACSC as a measure of quality for primary care services”. And, if ACSC hospitalizations emerge, it is alarming from both a quality and cost perspective especially among individuals enrolled in managed care plans that are specifically designed to coordinate care and optimize utilization of health care resources, he further said.


 “The focus of many insurance companies is to avert these types of hospitalizations not only for cost containment but also in attempts for continuous quality improvements”, said Neale. R. Chumbler, Dean of the College of Health and Human Services and Professor in the Department of Public Health at Western Kentucky University, the Principal Investigator from which this National Science Foundation study emerged, and co-author of the study.


“Providers and policy makers have to monitor closely care processes occurring in managed care plans among Medicaid recipients to determine ways of reducing the rates of avoidable hospitalizations. Furthermore, the current environment of value-based reimbursement should be exploited to empower both the patients and providers in creating meaningful opportunities for provider teams to offer personalized and comprehensive care to individuals and populations,” Mkanta said on this study that aimed at assessing cost and determine predictors of hospitalizations involving ACSC among Medicaid enrollees in comprehensive managed care plans.

Using a sample of 25,581 Medicaid enrollees who received primary care services in managed care plans in 2009 in 3 large states representing the West, South, and Midwest regions of the United States to create a geographical diversity, Mkanta and his colleagues assessed expenditures for hospitalizations and utilization expenditure differentials to determine factors associated with ACSCs and is one of a select few studies that applied this analytic approach in investigating ACSC hospitalizations in a Medicaid population.


This study found that diabetes was the most frequent ACSC condition, with heart failure being the second most common condition. This study also found that the mean expenditures were higher for hospitalizations in patients with ACSC compared to those without ACSC. Further, a higher proportion of patients admitted with ACSC required advanced treatment or died on admission, according to the study.


Mkanta and his colleagues found that odds of ACSC hospitalizations were 30% higher among Blacks and 25% higher among Hispanics. The results of the study were published in the Volume 3: 1-7 issue of Health Services Research and Managerial Epidemiology.  


Christopher E Johnson, PhD, Professor and Chair of the Department of Health Management and Systems Sciences in the School of Public Health and Information Sciences at the University Louisville stated, “Dr. Mkanta and colleagues’ findings raise important questions about preventable ACSC hospitalizations.” Johnson went on to state, “Does this type of hospitalization avoidance harm patients and reduce quality of care? This study provides key evidence that cost avoidance and quality monitoring systems within the ACSC population may be driving decisions that harm patient health.”


“Our findings suggest there is a proportion of potential cost savings that can be attained from    resources used to care for Medicaid enrollees in comprehensive managed care models,” Mkanta et al. pointed out in the Health Services Research and Managerial Epidemiology article, and further went on to suggest, “at the policy level, our findings reveal potential for support of redesigning further primary care services with the inclusion of important quality provisions to reduce preventable hospitalizations.” Pleased with the value and implications of the findings from the study, Chumbler concluded that “the bottom line is that US health care system needs to be more vigilant in identifying hospitalizations for conditions that should be treatable on an outpatient basis, or that could be less severe if dealt with early and aptly.”   


The full journal article is available here:


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 Last Modified 9/25/14