Potentially Avoidable Hospitalizations Remain Consistently High for Dual Eligibles

A CMS study revealed that, compared to past research, the number of potentially avoidable hospitalizations for individuals who are beneficiaries of both Medicare and Medicaid was consistently high in the observed period between 2007 and 2009. In 2009, 26 percent of the dual eligible beneficiaries, or Medicare and Medicaid beneficiaries (MMEs) investigated experienced potentially avoidable hospital stays. The CMS analysis recognized notable differences in percentages of MMEs with potentially avoidable stays when comparing the setting of the MMEs, noting that institutionalized beneficiaries exhibited the highest rates, and across states, as CMS highlighted a threefold difference between states with the lowest and highest rates. CMS also identified five conditions that were mostly responsible for the potentially avoidable hospitalizations among MMEs. The average costs to Medicare and Medicaid for potentially avoidable hospitalizations for 2009 was $2.3 million, with Medicare bearing 96 percent of those costs; 93 percent of that amount was derived from Medicare Part A and the rest from Medicare Part B.


MMEs constitute approximately 20 percent of the entire population of Medicare beneficiaries. In 2009, 7.1 million of the total 9.3 million MMEs received full benefits for a period of one month or more from Medicare and Medicaid. The MME population has been found to experience both more hospitalizations in general and more potentially avoidable hospitalizations than the non-MME Medicare beneficiaries. Specifically, 2009 data indicates that 26 percent of MMEs have experienced at least one hospital stay, and nine percent have had at least one stay that was potentially avoidable, while 20 percent of non-MME beneficiaries have been reported to have at least one hospitalization and only four percent have experienced a potentially avoidable one.


Although only 16 percent of the study population were institutionalized MMEs, those beneficiaries comprised more than 25 percent of total hospitalizations and approximately 45 percent of all the stays that were found to be potentially avoidable. Of the institutionalized MMEs, 90 percent were in nursing homes; of those patients, the rate of potentially avoidable hospitalizations for those in a skilled nursing facility (SNF) was 690 per 1,000 person-years, while for the rest of the nursing home residents the rate was 285 per 1,000 persons-years.


Comparing the state with the lowest rate of potentially avoidable hospitalizations—Utah at a rate of 59 per 1,000 person-years—with the state maintaining the highest rate—Mississippi at a rate of 197 per 1,000 person-years—a threefold difference is revealed. However, the study’s authors note that the analysis did not control for differences in patients’ health statuses or other demographics across states that may have contributed to the wide range in rates.

Medical Condition

Five conditions were identified as responsible for 80 percent of the potentially avoidable hospitalizations of MMEs: congestive heart failure; COPD/asthma; urinary tract infections; pneumonia; and dehydration. Pneumonia was the mostly likely cause for institutionalized MMEs, as it was the cause of the potentially avoidable hospital stays in 30 percent of the cases.