Figure 1 provides a high-level illustration of the approach used in our analyses. The study population for this work consisted of Medicare FFS beneficiaries who were continuously enrolled in FFS Medicare Part A and Part B for 2004-2006, whose reason for eligibility was their age, and whose primary residence in 2005 was in one of three states: Florida, Oregon, or Texas. As a result of our inclusion criteria, we excluded beneficiaries enrolled in a Medicare Advantage plan for any of the analyses period.
Figure 2 shows the distribution of the nine conditions of interest in 2005 among the continuously enrolled Medicare beneficiaries. Two-thirds had only one of the conditions. Approximately a quarter had two of the conditions, while eight percent had three conditions. Two percent of beneficiaries with any of the conditions had at least four of the conditions, with the maximum being eight of the nine conditions.
Figures 3 shows the average number of episodes related to the conditions experienced by beneficiaries identified as having each of the conditions for ETGs and MEGs, respectively.- With both groupers, there were individuals we identified as having a condition who did not have an episode designated as being related to the condition. This occurred most frequently for congestive heart failure and COPD, where the condition was consistently used as a secondary diagnosis or appeared as a primary diagnosis on claims that did not trigger a new episode, such as durable medical equipment claims. There were instances where individuals with a condition had more than one episode related to the condition; this was most notable with back pain under MEGs. There were five MEG episodes we identified as being related to back pain (Appendix C). There were beneficiaries with back pain that experienced more than 1 of the 5 different episodes we identified as being related to back pain, while other beneficiaries experienced more than 1 of the same type of episode.
Figure 4 shows the average number of episodes related to the conditions experienced by beneficiaries identified as having each of the conditions for ETGs and MEGs, respectively.- With both groupers, there were individuals we identified as having a condition who did not have an episode designated as being related to the condition. This occurred most frequently for congestive heart failure and COPD, where the condition was consistently used as a secondary diagnosis or appeared as a primary diagnosis on claims that did not trigger a new episode, such as durable medical equipment claims. There were instances where individuals with a condition had more than one episode related to the condition; this was most notable with back pain under MEGs. There were five MEG episodes we identified as being related to back pain (Appendix C). There were beneficiaries with back pain that experienced more than 1 of the 5 different episodes we identified as being related to back pain, while other beneficiaries experienced more than 1 of the same type of episode.
Figure 5 (ETGs) shows there is substantial variation in the average total standardized payment per episode across the nine conditions we examined. Episodes for AMI and hip fracture are more expensive on average than episodes for management of low back pain or diabetes.
Figure 6 shows the coefficient of variation (COV), which is the standard deviation in payments divided by the average payment per episode, for ETGs. This measure provides a measure of how much variation there is in standardized payments between episodes related to the same condition. While episodes related to diabetes had the lowest average standardized payments per episode, they had the largest variations in standardized payments suggesting that these episodes may not be homogeneous. To some extent, across these nine conditions, we observe that the COV is inversely related to the average payment. AMI and hip fracture, while having the largest average standardized payments per episode, had lower COV indicating relatively less variation in the costs of episodes, representing more homogeneity in the way these patients are treated.
The observed variation in standardized payments for episodes related to a specific condition could be due to a variety of factors, such as variation in patterns of care, which could be due to undesired variations or heterogeneity in the clinical condition (e.g., severe pneumonia versus mild pneumonia) and random variation.
Figure 7 presents comparable information for the episodes created by MEGs. A similar pattern between average standardized payments and COV is observed overall.
Figure 8 presents comparable information for the episodes created by MEGs. A similar pattern between average standardized payments and COV is observed overall.
Figure 9 shows that related episodes make up a small fraction of all of the episodes experienced by beneficiaries with each of the nine conditions.
Figure 10 shows that, in general, related episodes comprise a greater portion of standardized payments than of total number of episodes. There is also substantial variation across the conditions both in the total standardized payment for care delivered to the beneficiaries and in the potion of payments that are for episodes related to the conditions. For example, for beneficiaries who experience an AMI, the care they received as part of the episodes related to the AMI accounts for approximately 50 percent of their total costs. In contrast, for beneficiaries diagnosed with diabetes, the care they received during their diabetes-related episodes accounts for less then 10 percent of their total costs.
Figures 11 shows comparable information for episodes created by MEGs. The results are substantively similar, so here we only discuss Figures 9 and 10
Figures 12 shows comparable information for episodes created by MEGs. The results are substantively similar, so here we only discuss Figures 9 and 10
Figure 13 shows how we use beneficiaries diagnosed with AMI and the episodes created with ETGs to highlight this complexity and examine beneficiaries who experienced an AMI with the various combinations of vascular disease episodes of care shown.
Figure 14 presents the median number of providers delivering services during episodes related to each of the nine conditions. Providers were categorized as primary care physicians (specialties of family practice, internal medicine, general practice, geriatrics and genecology), specialists (all other physician specialties), and other providers (e.g., physical therapists, dieticians). We present only the information from ETGs as that produced by MEGs was not substantively different.
Figure 15 focuses only on physicians, shows the number of physicians delivering care in a facility (e.g. hospital, nursing home) versus the outpatient setting, which has implications for coordination of care. For ETG episodes related to some conditions, such as breast cancer, COPD, diabetes and low back pain, the majority of physicians are predominantly providing services in outpatient settings. For other conditions, such as AMI and hip fracture, the majority of physicians involved are providing care in facilities.
Figure 16 shows the number of physicians providing services during an episode only provides a partial picture of the potential complexity of an episode. Patients may flow between various health care settings and provider types and Medicare has different performance measurement programs and payment systems for separate settings.
Figure 17 shows the number of settings involved in ETG episodes related to each of the nine clinical conditions of focus.
Figure 18 shows that nearly all (99.2%) patients with an AMI-related episode utilized an acute care hospital, 89 percent utilized the hospital outpatient department (which includes the emergency department), and 74 percent visited a physician office for that episode.- Additionally, approximately 20 percent of patients utilized home health or a skilled nursing facility.- There were three different combinations of settings that each accounted for more than 10 percent of the episodes related to AMI and these three combinations jointly accounted for 67 percent of the AMI-related episodes. The most common combination of settings involved acute care hospitals, hospital outpatient departments and physician office visits (41 percent of episodes). While there are nine clinical measures (listed in Table 12) reported for the hospital facility (and one for physicians in the hospital setting) and five measures for the emergency department, there is only one measure for care delivered in a physician office.- The skilled nursing and home health measures are not condition specific and apply to all patients in those settings.
Figures 19 illustrates the different settings of care that patient with ETG episodes related to AMI, diabetes and hip fracture, respectively, "touch". Comparable information for the other conditions are provided in Appendix E. Also, in Appendix E we report the percentage of episodes related to the nine conditions for both groupers that involve each setting; these tables include DME and outpatient laboratories.
Figures 20 illustrates the different settings of care that patient with ETG episodes related to AMI, diabetes and hip fracture, respectively, "touch". Comparable information for the other conditions are provided in Appendix E. Also, in Appendix E we report the percentage of episodes related to the nine conditions for both groupers that involve each setting; these tables include DME and outpatient laboratories.
Figure 21 shows how standardized payments for ETG episodes related to each of the nine conditions are divided across settings. Comparable information for MEG episodes is presented in the appendices. Substantial variation in the distribution of payments across settings and conditions is evident. For example, the percent of payments for acute inpatient care ranges from approximately six percent for total episode payments for diabetes, low back pain and breast cancer to 80 percent for episodes related to AMI.- Similarly, while physician ambulatory services account for 63 percent of the episode payments for low back pain, they only account for approximately 3 percent of payments for AMI episode. Substantial variation exists for most of the other settings as well.
Figure 22 shows the relationship between the number of settings involved in an episode and the percent of ETG episodes that could be assigned based on the episode professional services payment plurality rule (single provider accounting for at least 30 percent of professional services payments) for AMI, diabetes and hip fracture. While the percent of episodes related to AMI that were able to be attributed to a physician initially increased with the number of settings, there was a substantial drop-off when the episode involved four or more settings. This drop-off was very small, however for diabetes and hip fracture.
Figure 23 shows the average standardized payments per ETG episode by state for each of the nine conditions. As shown, there is substantial variation in the payments per episode, but the pattern by state is not completely consistent. For most conditions, Oregon has lower standardized payments per episode than either Florida or Texas. For some conditions, Florida and Texas have very similar average standardized payments per episode, but Texas has substantially higher payments for bacterial pneumonia, cerebrovascular disease and hip fracture, while Florida has higher average standardized payments for congestive heart failure. These differences could be driven by differences in the number of episodes per beneficiaries in the three states, which could be interpreted as differences in case mix or health of the beneficiaries.
Figure 24 illustrates for hip fracture the state variation in the types of facilities involved in the management of an episode. While approximately 80 percent of episodes related to hip fracture involve an inpatient hospital setting in all three states, there is variation in the use of inpatient rehabilitation facilities (IRFs) and SNFs. Of the three states, Texas has the highest use of IRFs and the lowest use of SNFs, suggesting these two types of facilities are substitutes. Oregon, which has few IRFs, has a much use of SNFs for hip fracture-related episodes.
Figure 25 shows the fraction of care delivered outside the primary state of residence of the beneficiary for each of the nine conditions. This out of state care could be due to beneficiaries residing in a different state for part of the year (e.g., snowbirds), referrals to providers or facilities in a different state, or cross border care when a beneficiary lives close to a state line. There was variation among beneficiaries in the three states in the proportion of ETG episodes that involved providers outside of the beneficiaries"™ primary state of residence, with Oregon having the largest fraction. Contrary to our expectations, Florida does not have the highest rate of out of state care due to snowbirds, but this may be because Florida is not the primary state of residence for these individuals. Overall out-of-state care was received for a minority of episodes "“ less than 20 percent. However, when out of state care was involved, it was often a significant portion of the total standardized payments for the episode, with the average ranging from 43 to 57 percent. Similar results were observed using MEGs.
Figure 26 shows there is in general a consistent relationship between the total number of ETG episodes experienced by a beneficiary and the average standardized payment per episode for episodes related to the condition of focus. The more episodes experienced by a beneficiary, the higher the standardized payments. There was one exception to this pattern for congestive heart failure, which was driven by a very high cost outlier with a small number of episodes.
Figure 27 shows that the greater the total number of ETG episodes experienced by a beneficiary, the more providers that tend to be involved in managing their care for a specific episode. This was largely driven by larger numbers of specialists involved when the beneficiary experiences many episodes. This larger number of providers involved doesn"t necessary translate into greater challenges attributing episodes to physicians, however.
Figure 28 shows the percent of episodes related to AMI, diabetes and hip fracture that could be attributed to a physician using the episode professional services cost plurality rule (single provider accounting for at least 30 percent of professional services costs). While the percent of episodes able to be attributed declined with increasing episodes experience by beneficiaries with AMIs, it actually increased slightly for beneficiaries with diabetes, and remained fairly stable for beneficiaries with hip fractures.
Figure E5 This chart graphic shows that Seventy percent of bacterial pneumonia episodes involved an acute care hospital, 67 percent involved the hospital outpatient department and 52 percent a physician office visit. Additionally, in 34 percent of the episodes, patients utilized a skilled nursing facility, in 11 percent they utilized home health care, and 5 percent of episodes involved a stay in a long term care hospital.- The three most common combinations of settings accounted for 40 percent of the bacterial pneumonia episodes in our sample.- There are eight measures reported for bacterial pneumonia in the acute inpatient setting, no measures reported for the hospital outpatient setting and four measures reported for care in a physician office.- The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.
Figure E6 This chart graphic shows that Breast cancer episodes most often involved the physician office (94 percent) and/or the hospital outpatient department (79 percent).- Twenty one percent of breast cancer episodes involved an acute hospital inpatient stay, 7 percent involved home health, and 3 percent a skilled nursing facility.- The three most common combinations of settings accounted for 81 percent of all breast cancer episodes.- There are only two measures reported to CMS for breast cancer, and they are both applicable to care provided by physicians in an ambulatory setting.- The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.
Figure E7 This chart graphic shows that Breast cancer episodes most often involved the physician office (94 percent) and/or the hospital outpatient department (68 percent).- Only 8 percent of breast cancer episodes involved an acute hospital inpatient stay, 3 percent involved home health, and 2 percent a skilled nursing facility.- The two most common combinations of settings accounted for 80 percent of all breast cancer episodes.- There are only two measures reported to CMS for breast cancer, and they are both applicable to care provided by physicians in an ambulatory setting. The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.
Figure E8 shows that Cerebrovascular episodes most often involved the physician office (75%) and/or the hospital outpatient department (68%).- Sixty one percent of cerbrovascular episodes involved an acute hospital inpatient stay, 20 percent involved home health, and 18 percent a skilled nursing facility.- The three most common combinations of settings accounted for 48 percent of all cerebrovascular episodes.- There are eight stroke measures included in the PQRI, four of which are applicable to physicians in the acute care hospital setting and four of which could be applicable to the physician office setting or the acute care hospital setting.- The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.
Figure E9 shows that Cerebrovascular episodes most often involved the physician office (70%) and/or the hospital outpatient department (45%).- Thirty four percent of cerbrovascular episodes involved an acute hospital inpatient stay, 13 percent involved a skilled nursing facility, 9 percent home health care, and 4 percent an inpatient rehabilitation facility.- The most common combination of settings was the physician ambulatory setting which accounted for 40 percent of all cerebrovascular episodes.- There are eight stroke measures included in the PQRI, four of which are applicable to physicians in the acute care hospital setting and four of which could be applicable to the physician office setting or the acute care hospital setting.- The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.
Figure E10 shows that COPD episodes most often involved the physician office (75%) followed by the hospital outpatient department (59%) and the acute care hospital setting (47%). Additionally, 12 percent of episodes involved a skilled nursing facility or home health care. The three most common combinations of settings accounted for 52 percent of all COPD episodes.- There are currently two COPD measures included in the PQRI for physicians.- The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.
Figure E11 shows that COPD episodes most often involved the physician office (78%) followed by the hospital outpatient department (41%) and the acute care hospital setting (19%). Additionally, 12 percent of episodes involved a skilled nursing facility and 11 percent home health care. The two most common combinations of settings accounted for 56 percent of all COPD episodes.- There are currently two COPD measures included in the PQRI for physicians.- The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.
Figure E12 shows that CHF episodes most often involved the physician office (65%) followed by the hospital outpatient department (57%) and the acute care hospital setting (51%). Additionally, 16 percent of episodes involved a skilled nursing facility, 13 percent home health care, and 4 percent hospice. The three most common combinations of settings accounted for 42 percent of all CHF episodes.- There are currently five measures addressing CHF in the acute care hospital setting and two for physicians.- The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.
Figure E13 shows that CHF episodes most often involved the physician office (74%) followed by the hospital outpatient department (49%) and the acute care hospital setting (26%). Additionally, 16 percent of episodes involved a skilled nursing facility, 9 percent home health care, and 3 percent hospice. The two most common combinations of settings accounted for 49 percent of all CHF episodes.- There are currently five measures addressing CHF in the acute care hospital setting, a 30 day readmission measure (new for 2009) and two for physicians.- The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.
Figure E14 shows that Low back pain episodes most often involved the physician office (91%) followed by the hospital outpatient department (47%) and the acute care hospital setting (12%). Additionally, 8 percent of episodes involved home health care, and 4 percent skilled nursing facilities. The two most common combinations of settings accounted for 70 percent of all low back pain episodes.- There are currently four measures reported to CMS addressing low back pain in the physician office setting and one measure related to imaging appropriateness for the hospital outpatient department.- The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.
Figure E15 shows that Low back pain episodes most often involved the physician office (87%) followed by the hospital outpatient department (30%) and the acute care hospital setting (4%). Additionally, 4 percent of episodes involved home health care, and 3 percent skilled nursing facilities. The two most common combinations of settings accounted for 78 percent of all low back pain episodes.- There are currently four measures reported to CMS addressing low back pain in the physician office setting and one measure related to imaging appropriateness in the hospital outpatient department.- The skilled nursing and home health measures are not condition specific and apply to all patients in these settings.