Post-Acute Care Episodes Expanded Analytic File

In previous work, RTI has examined PAC episodes initiating with an acute hospitalization. However, as ASPE and CMS begin to consider alternatives to silo-based payments, it is necessary to also consider service use that occurs without the presence of an acute hospitalization, so-called "community entrants." For example, beneficiaries may enter home health services without having an acute hospital stay. In this work RTI has also constructed episodes that begin with HHA, IRF, and LTCH. The purpose of the community entrant analysis is to provide a baseline understanding of the characteristics of beneficiaries who enter care without an acute hospital stay. Table 1 summarizes the services that initiate episodes in our analyses.

Table 1. Initiating Events for Post-Acute Care Episodes

Episode Initiating Event	Initiating Claim Type
1. Acute hospital-initiated episode	Acute hospital
2. Community entrant episode	Home Health (HHA) Inpatient Rehabilitation Hospital (IRF) Long-Term-Care Hospital (LTCH)

RTI's past work constructing PAC episodes (Gage et al., 2009; Morley et al., 2009) required a 60-day clean period for an acute hospitalization to initiate an episode of care. This clean period was defined as the absence of acute hospital and PAC services (HHA, LTCH, IRF, and skilled nursing facility [SNF]). In the current work, RTI has replaced the 60-day clean period with a 30-day clean period. The decision to reduce the clean period to 30 days was based on earlier work with ASPE looking at time-based episode definitions. This decrease in the required gap in services prior to initiating an episode is likely to result in inclusion of a broader range of beneficiaries who may be in and out of acute and Post-Acute care.

Figure 1. Analytic Samples: Longitudinal Cohort and Cross Section

    

• Analytic Sample 1: Longitudinal Cohort—The longitudinal cohort sample consists of a 30 percent sample of beneficiaries with an initiating event in an acute hospital or in home health in 2006 plus 100 percent of beneficiaries with an initiating event in LTCH or IRF in 2006. To construct the cohort sample, RTI selected the first initiating event in 2006 per beneficiary and then constructed a file of all claims following the initiating event for 2006, 2007, and 2008 for these beneficiaries. This file contains two calendar years of data for each beneficiary in the cohort.
• Analytic Sample 2: Cross Section—The cross-sectional samples consist of a 30 percent sample of beneficiaries with an initiating event in an acute hospital or in home health plus 100 percent of beneficiaries with an initiating event in LTCH or IRF in 2006, 2007, and 2008. RTI constructed the first episode per year for these beneficiaries to compare changes in utilization patterns over the 3-year study period.

Figure 2. Fixed-Length versus Variable-Length Episodes

    

Figure 2 is a schematic of the difference between fixed-length and variable-length episodes. Fixed-length episodes include claims within 30 days of discharge from an initiating event. Variable-length length episodes include claims following discharge from an initiating event prior to a 30 day gap in acute or PAC service use.

Figure 3. Defining Endpoints of Fixed-Length Episodes

    

Physician claims were also examined as part of this analysis though only acute and PAC claims were used to define initiating events and episode endpoints. Physician claims with dates of service falling between the admission date on an initiating event and the last date of episode were identified from the Medicare Carrier claims using physician specialty codes and the dollars associated with these services were included in episode payment analyses.

In summary, episodes were constructed on the following dimensions:

1. Episode definition
    
   1. 30-day fixed length
   2. 30-day variable length
2. Initiating event
    
   1. Acute hospital
   2. HHA
   3. IRF
   4. LTCH
3. Alternative methods of handling the end of fixed episodes
    
   1. Any claim initiating
   2. Prorated
4. Alternative episode end point of an acute hospitalization.

Based on these dimensions, the total number of episodes examined in this work includes the 15 episode definitions shown in Table 2. Using these definitions, RTI examined episode patterns, use of PAC services, and payments for both the acute hospital-initiated and the community entrant episodes.

Table 2. Episode Definitions

Initiating Event	Fixed or Variable Length	Episode End Point
Acute hospitalization	Fixed	Any Claim Starting Within 30 Days After Hospital Discharge
Acute hospitalization	Fixed	Any Claim Starting Within 30 Days After Hospital Discharge, Excluding Acute Hospital Readmissions
Acute hospitalization	Fixed	30-Day Fixed Period Following Hospital Discharge (prorated)
Acute hospitalization	Fixed	30-Day Fixed Period Following Hospital Discharge (prorated), Excluding Acute Hospital Readmissions
Acute hospitalization	Variable	30-Day Variable-Length Episode
Acute hospitalization	Variable	30-Day Variable-Length Episode Excluding Acute Hospital Readmissions
HHA	Fixed	Any Claim Starting Within 30 days After Discharge from Initiating Event
HHA	Variable	30-Day Variable-Length Episode
HHA	Variable	30-Day Variable-Length Episode Excluding Acute Hospitalizations
IRF	Fixed	Any Claim Starting Within 30 days After Discharge from Initiating Event
IRF	Variable	30-Day Variable-Length Episode
IRF	Variable	30-Day Variable-Length Episode Excluding Acute Hospitalizations
LTCH	Fixed	Any Claim Starting Within 30 days After Discharge from Initiating Event
LTCH	Variable	30-Day Variable-Length Episode
LTCH	Variable	30-Day Variable-Length Episode Excluding Acute Hospitalizations

Table 3. Top 10 MS-DRGs for Acute Hospital-Initiated Episodes for Beneficiaries Discharged to PAC

Rank 2008	Rank 2007	Rank 2006	MS-DRG	N 2008	Percent 2008	Cumulative Percent 2008
Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM143).
1	1	1	470: Major joint replacement or reattachment of lower extremity w/o MCC	90,434	13.7	13.7
2	2	2	065: Intracranial hemorrhage or cerebral infarction w CC	13,992	2.1	15.8
3	4	4	481: Hip & femur procedures except major joint w CC	13,704	2.1	17.9
4	3	3	194: Simple pneumonia & pleurisy w CC	13,064	2.0	19.9
5	5	5	690: Kidney & urinary tract infections w/o MCC	12,954	2.0	21.9
6	7	11	641: Nutritional & misc metabolic disorders w/o MCC	9,755	1.5	23.3
7	6	6	299: Peripheral vascular disorders w MCC	9,752	1.5	24.8
8	9	7	292: Heart failure & shock w CC	8,602	1.3	26.1
9	15	17	291: Heart failure & shock w MCC	8,561	1.3	27.4
10	12	14	552: Medical back problems w/o MCC	8,113	1.2	28.6

The proportion of beneficiaries with acute hospital-initiated episodes discharged to each site of PAC is shown in Table 4. The percentage of beneficiaries discharged to each PAC setting is similar across the 3 years of data, with the largest proportion of beneficiaries discharged to SNF (42.2 percent in 2008) and HHA (37.4 percent in 2008) and a smaller proportion discharged to LTCH (1.7 percent in 2008), IRF (8.6 percent in 2008), and therapy services (10.1 percent in 2008). These results indicate that there has been a slight decrease in the percentage of beneficiaries discharged to IRF and a slight increase in the percentage discharged to SNF over the period 2006-2008. This change is of particular note when looking at specific MS-DRGs. For example, 17.9 percent of beneficiaries in MS-DRG 470, "major joint replacement" were discharged to IRF in 2006, and this decreased to 12.2 percent of beneficiaries in this MS-DRG in 2008. The decrease is likely a result of the phase-in of the 60 percent rule in the IRF payment system—a rule that requires 60 percent of a provider's admissions meet certain classification criteria in order for the provider to be eligible for IRF payment.

Table 4. First Site of PAC, Acute Hospital-Initiated Episodes, Overall and for Top 5 MS-DRGs by Volume of PAC Users, 2006-2008

MS-DRG	N	% Discharged to PAC	% Discharged to LTCH	% Discharged to IRF	% Discharged to SNF	% Discharged to HHA	% Discharged to Therapy
Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM143, M3MM156).
All MS-DRGs 2008	659,549	38.7	1.7	8.6	42.2	37.4	10.1
470: Major joint replacement or reattachment of lower extremity w/o MCC	90,434	94.2	0.1	12.2	37.4	37.4	12.9
065: Intracranial hemorrhage or cerebral infarction w CC	13,992	75.0	1.2	37.0	36.8	17.3	7.7
481: Hip & femur procedures except major joint w CC	13,704	95.4	0.4	22.1	68.0	7.7	1.8
194: Simple pneumonia & pleurisy w CC	13,604	36.3	0.9	1.7	51.1	37.8	8.5
690: Kidney & urinary tract infections w/o MCC	12,954	43.9	0.4	1.7	58.3	28.9	10.7
All MS-DRGs 2007	661,958	37.9	1.7	8.9	42.2	37.1	10.0
470: Major joint replacement or reattachment of lower extremity w/o MCC	91,259	93.9	0.1	14.2	37.1	36.2	12.4
065: Intracranial hemorrhage or cerebral infarction w CC	14,433	75.1	1.3	36.7	38.1	16.4	7.4
481: Hip & femur procedures except major joint w CC	13,558	95.0	0.7	23.1	66.8	7.7	1.8
194: Simple pneumonia & pleurisy w CC	15,044	36.1	1.2	1.5	50.7	38.8	7.8
690: Kidney & urinary tract infections w/o MCC	13,704	43.9	0.4	1.8	59.8	28.0	10.1
All MS-DRGs 2006	667,784	37.1	1.8	9.7	42.1	36.4	9.9
470: Major joint replacement or reattachment of lower extremity w/o MCC	91,621	94.0	0.2	17.9	36.2	33.7	12.0
065: Intracranial hemorrhage or cerebral infarction w CC	15,459	74.7	1.6	35.5	39.0	16.3	7.5
481: Hip & femur procedures except major joint w CC	13,846	94.8	0.8	23.1	66.8	7.3	1.9
194: Simple pneumonia & pleurisy w CC	16,638	35.7	1.2	1.7	51.6	38.3	7.3
690: Kidney & urinary tract infections w/o MCC	13,724	43.3	0.5	1.8	60.8	27.3	9.7

Table 5 displays the top 30 episode patterns for beneficiaries with acute hospital-initiated episodes. Each letter in the sequence represents a type of service: A = acute hospital, S = SNF, H = HHA, I = IRF, L = LTCH, O = hospital outpatient therapy, and T = independent therapist. Note that a single letter may represent one claim or multiple claims of the same type. This episode pattern analysis was conducted on the 30-day variable-length episode definition to provide an understanding of the complete clinical trajectory of service use related to an index event. Analysis of episode patterns for beneficiaries with acute hospital-initiated episodes indicate that as expected, acute to HHA (AH) and acute to SNF (AS) are the most common episode patterns (36.8 percent of all PAC episodes in 2008), and that the top 30 episode patterns account for over 82 percent of all episode patterns for beneficiaries discharged to PAC. Given that a small proportion of beneficiaries use LTCH nationally, there is only one episode pattern in that top 30 that includes LTCH. The episode pattern acute to LTCH (AL) is the 26^th most common episode pattern, and it is common to 0.5 percent of beneficiaries with acute hospital-initiated episodes.

Table 5. Episode Patterns: Acute Hospital-Initiated Episodes, 2008

Rank	Episode Pattern	N	Percent	Cumulative Percent
Note: Episode pattern is based on a 30-day variable episode definition. Each letter indicates a type of service use, but a single letter may represent one claim or multiple claims of the same type of service. A = acute hospital, S = SNF, H = HHA, I= IRF, L= LTCH, O = outpatient department therapy, T = independent therapist. Source: RTI analysis of 2008 Medicare claims (M3MM157).
1	AH	150,850	22.9	22.9
2	AS	91,928	13.9	36.8
3	ASH	56,661	8.6	45.4
4	AO	34,141	5.2	50.6
5	AHA	24,512	3.7	54.3
6	AT	18,485	2.8	57.1
7	ASO	17,931	2.7	59.8
8	AIH	14,900	2.3	62.1
9	ASAS	14,687	2.2	64.3
10	AHO	14,655	2.2	66.5
11	AHT	14,467	2.2	68.7
12	ASA	13,841	2.1	70.8
13	AHAH	8,839	1.3	72.2
14	ASHO	6,632	1.0	73.2
15	ASHT	6,115	0.9	74.1
16	AIO	5,961	0.9	75.0
17	ASHA	5,221	0.8	75.8
18	AI	4,902	0.7	76.5
19	ASASH	4,446	0.7	77.2
20	AST	4,282	0.6	77.8
21	ASASA	3,453	0.5	78.4
22	ASASAS	3,353	0.5	78.9
23	AIHO	3,158	0.5	79.4
24	ASASO	3,135	0.5	79.8
25	AHAS	3,071	0.5	80.3
26	AL	3,004	0.5	80.8
27	AHAHA	2,488	0.4	81.1
28	AOA	2,482	0.4	81.5
29	AISH	2,337	0.4	81.9
30	AHASH	2,290	0.3	82.2

Summary statistics looking at index, PAC, and total episode payments, by episode definition are presented in Tables 6 to 9. Mean payments were calculated using three different methods—payments per service use, payments per PAC user, and payments per hospital discharge—to demonstrate the differences in mean payments across different beneficiary samples. These different calculations are described below.

• Payments per service user indicate the mean Medicare payments for those beneficiaries who use the specific PAC service (average payments per SNF admission for those who had an SNF admission).
• Payments per PAC user indicate the mean Medicare payments across all beneficiaries who use any PAC, regardless of whether or not they use a specific PAC service.
• Payments per hospital discharge indicate the mean Medicare payments across all beneficiaries with an index acute hospital stay, regardless of whether they use a PAC service. Note that the per-hospital discharge calculations include rehospitalizations and a small amount of subsequent service use for beneficiaries not discharged to PAC from their acute hospital initiating event.

As also demonstrated in earlier work, episode length and payments differ significantly by episode definition. For example, in 2008, the mean PAC payment per PAC user under the longest episode definition, the 30-day variable-length episode definition, was $17,236 in 2008 compared with $10,651 under the episode definition that includes any claim initiating within 30 days after hospital discharge (Table 6). Payments per discharge, as opposed to payments per PAC user, depend on the proportion of beneficiaries discharged to PAC. Among beneficiaries with acute hospital-initiated episodes in 2008, 38.7 percent were discharged to PAC and the mean PAC payment per hospital discharge was $8,384 under the 30-day variable-length episode definition. Table 7 displays episode summary statistics for the top five MS-DRGs by volume of PAC users to demonstrate the differences in PAC utilization by MS-DRG and to demonstrate the differences in the per-PAC-user and per-discharge calculations by MS-DRG given differences in the proportion of beneficiaries discharged to PAC by MS-DRG. For example, for MS-DRG 470, the mean PAC payment per discharge and the mean payment per PAC user were very similar across episode definitions ($9,593 versus $10,067 for the 30-day variable episode) because 94.2 percent of beneficiaries in this MS-DRG are discharged to PAC. In contrast, only 36.3 percent of beneficiaries in MS-DRG 194 are discharged to PAC, and therefore there are significant differences in the per-PAC-user and per-hospital-discharge calculations for PAC payments ($7,072 versus $14,892 for the 30-day variable episode). In addition to summary statistics for PAC users, Table 8 also shows the mean length of stay associated with each of the episode definitions in each of the 3 years of data. In general, the patterns in episode length are consistent with the patterns we observe for payment, with significant variation in the PAC and total episode length depending on whether we look at a shorter fixed-length definition or a longer variable-length definition. These patterns were consistent across the 3 years of data examined.

Table 6. Episode Summary Statistics: Acute Hospital-Initiated Episodes, 2006-2008

Episode Definition	Mean Index Acute Hospital Payment Per Discharge1	Mean Index Acute Hospital Physician Payment Per Discharge1,2	Mean PAC Payment Per Discharge1,3	Mean Episode Payment Per Discharge1,4	Mean Index Acute Hospital Payment Per PAC User1,5	Mean Index Acute Hospital Physician Payment Per PAC User2,5	Mean PAC Payment Per PAC User3,5	Mean Episode Payment Per PAC User5,5
Index acute hospitalizations are defined as hospital admissions following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Note that per-hospital discharge calculations include use of acute and Post-Acute care services for beneficiaries who do not meet the criteria of PAC user (use of PAC services following discharge from an index acute hospitalization). This includes acute hospital readmissions for non-PAC users. Physician payment is defined as separately billable Part B physician services rendered during the index acute hospital stay. Post-Acute care includes Medicare payments for SNF, IRF, LTCH, HHA, and therapy. Note that acute hospital readmissions are also included in PAC payments for episode definitions A, C, and E. Episode payment includes the index acute hospital stay, PAC, physician services during the index acute hospital stay and during the PAC episode. PAC users are defined as beneficiaries discharged to SNF, IRF, LTCH, HHA, or therapy following discharge from an index acute hospitalization. An index acute hospitalization is defined as a hospital admission following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM143, M3MM149, M3MM216, M3MM237).
2008 (N=659,549)
A. 30-Day Variable Episode	$8,531	$1,172	$8,384	$18,847	$10,572	$1,524	$17,236	$30,827
B. 30-Day Variable Episode Excluding Acute Hospital Readmissions	$8,531	$1,172	$3,511	$13,472	$10,572	$1,524	$9,075	$21,926
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge	$8,531	$1,172	$5,252	$15,355	$10,572	$1,524	$10,651	$23,499
D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions	$8,531	$1,172	$3,157	$13,048	$10,572	$1,524	$8,165	$20,838
E. 30-Day Fixed Following Hospital Discharge (prorated)	$8,531	$1,172	$3,845	$13,948	$10,572	$1,524	$7,564	$20,412
F. 30-Day Fixed Following Hospital Discharge Excluding Acute Hospital Readmissions (prorated)	$8,531	$1,172	$2,221	$12,113	$10,572	$1,524	$5,745	$18,418
2007 (N=661,958)
A. 30-Day Variable Episode	$8,205	$1,161	$7,725	$17,807	$10,062	$1,524	$16,145	$29,156
B. 30-Day Variable Episode Excluding Acute Hospital Readmissions	$8,205	$1,161	$3,259	$12,865	$10,062	$1,524	$8,596	$20,904
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge	$8,205	$1,161	$4,905	$14,656	$10,062	$1,524	$10,100	$22,416
D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions	$8,205	$1,161	$2,945	$12,489	$10,062	$1,524	$7,772	$19,918
E. 30-Day Fixed Following Hospital Discharge (prorated)	$8,205	$1,161	$3,612	$13,363	$10,062	$1,524	$7,217	$19,533
F. 30-Day Fixed Following Hospital Discharge Excluding Acute Hospital Readmissions (prorated)	$8,205	$1,161	$2,088	$11,632	$10,062	$1,524	$5,510	$17,656
2006 (N=667,784)
A. 30-Day Variable Episode	$7,941	$1,127	$7,208	$16,953	$9,644	$1,482	$15,236	$27,720
B. 30-Day Variable Episode Excluding Acute Hospital Readmissions	$7,941	$1,127	$3,045	$12,339	$9,644	$1,482	$8,200	$20,015
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge	$7,941	$1,127	$4,617	$14,052	$9,644	$1,482	$9,604	$21,426
D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions	$7,941	$1,127	$2,754	$11,991	$9,644	$1,482	$7,422	$19,086
E. 30-Day Fixed Following Hospital Discharge (prorated)	$7,941	$1,127	$3,425	$12,860	$9,644	$1,482	$6,909	$18,731
F. 30-Day Fixed Following Hospital Discharge Excluding Acute Hospital Readmissions (prorated)	$7,941	$1,127	$1,967	$11,203	$9,644	$1,482	$5,300	$16,964

Table 7. Episode Summary Statistics: Acute Hospital-Initiated Episodes, by MS-DRG for Top 5 MS-DRGs by Volume of PAC Users, 2008

Episode Definition	Mean Index Acute Hospital Payment Per Discharge1	Mean Index Acute Hospital Physician Payment Per Discharge1,2	Mean PAC Payment Per Discharge1,3	Mean Episode Payment Per Discharge1,4	Mean Index Acute Hospital Payment Per PAC User1,5	Mean Index Acute Hospital Physician Payment Per PAC User2,5	Mean PAC Payment Per PAC User3,5	Mean Episode Payment Per PAC User4,5
Index acute hospitalizations are defined as hospital admissions following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Note that per-hospital discharge calculations include use of acute and Post-Acute care services for beneficiaries who do not meet the criteria of PAC user (use of PAC services following discharge from an index acute hospitalization). This includes acute hospital readmissions for non-PAC users. Physician payment is defined as separately billable Part B physician services rendered during the index acute hospital stay. Post-Acute care includes Medicare payments for SNF, IRF, LTCH, HHA, and therapy. Note that acute hospital readmissions are also included in PAC payments for episode definitions A, C, and E. Episode payment includes the index acute hospital stay, PAC, physician services during the index acute hospital stay and during the PAC episode. PAC users are defined as beneficiaries discharged to SNF, IRF, LTCH, HHA, or therapy following discharge from an index acute hospitalization. An index acute hospitalization is defined as a hospital admission following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Source: RTI analysis of 2008 Medicare claims (M3MM143, M3MM149, M3MM237).
A. 30-day Variable Episode
470: Major joint replacement or reattachment of lower extremity w/o MCC	$11,079	$1,484	$9,593	$22,802	$11,120	$1,505	$10,067	$23,365
065: Intracranial hemorrhage or cerebral infarction w CC	$6,392	$979	$21,822	$30,587	$6,401	$1,038	$28,034	$37,217
481: Hip & femur procedures except major joint w CC	$10,295	$1,734	$24,434	$37,817	$10,296	$1,750	$25,465	$38,918
194: Simple pneumonia & pleurisy w CC	$5,347	$631	$7,072	$13,681	$5,471	$749	$14,892	$22,291
690: Kidney & urinary tract infections w/o MCC	$3,989	$513	$8,727	$13,859	$4,090	$586	$16,943	$22,712
B. 30-Day Variable Episode Excluding Acute Hospital Readmissions
470: Major joint replacement or reattachment of lower extremity w/o MCC	$11,079	$1,484	$7,093	$20,079	$11,120	$1,505	$7,527	$20,601
065: Intracranial hemorrhage or cerebral infarction w CC	$6,392	$979	$13,849	$21,974	$6,401	$1,038	$18,460	$26,904
481: Hip & femur procedures except major joint w CC	$10,295	$1,734	$16,900	$29,687	$10,296	$1,750	$17,719	$30,559
194: Simple pneumonia & pleurisy w CC	$5,347	$631	$2,710	$8,895	$5,471	$749	$7,458	$14,246
690: Kidney & urinary tract infections w/o MCC	$3,989	$513	$4,092	$8,814	$4,090	$586	$9,316	$14,494
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge
470: Major joint replacement or reattachment of lower extremity w/o MCC	$11,079	$1,484	$7,335	$20,238	$11,120	$1,505	$7,701	$20,679
065: Intracranial hemorrhage or cerebral infarction w CC	$6,392	$979	$14,812	$22,960	$6,401	$1,038	$19,086	$27,484
481: Hip & femur procedures except major joint w CC	$10,295	$1,734	$17,664	$30,413	$10,296	$1,750	$18,402	$31,193
194: Simple pneumonia & pleurisy w CC	$5,347	$631	$4,385	$10,711	$5,471	$749	$9,163	$15,977
690: Kidney & urinary tract infections w/o MCC	$3,989	$513	$5,418	$10,247	$4,090	$586	$10,453	$15,642
D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions
470: Major joint replacement or reattachment of lower extremity w/o MCC	$11,079	$1,484	$6,437	$19,279	$11,120	$1,505	$6,831	$19,753
065: Intracranial hemorrhage or cerebral infarction w CC	$6,392	$979	$12,239	$20,191	$6,401	$1,038	$16,314	$24,528
481: Hip & femur procedures except major joint w CC	$10,295	$1,734	$15,168	$27,749	$10,296	$1,750	$15,903	$28,528
194: Simple pneumonia & pleurisy w CC	$5,347	$631	$2,490	$8,631	$5,471	$749	$6,858	$13,527
690: Kidney & urinary tract infections w/o MCC	$3,989	$513	$3,684	$8,352	$4,090	$586	$8,400	$13,456
E. 30-Day Fixed Following Hospital Discharge (prorated)
470: Major joint replacement or reattachment of lower extremity w/o MCC	$11,079	$1,484	$5,893	$18,796	$11,120	$1,505	$6,182	$19,160
065: Intracranial hemorrhage or cerebral infarction w CC	$6,392	$979	$10,520	$18,667	$6,401	$1,038	$13,496	$21,894
481: Hip & femur procedures except major joint w CC	$10,295	$1,734	$11,567	$24,316	$10,296	$1,750	$12,047	$24,838
194: Simple pneumonia & pleurisy w CC	$5,347	$631	$3,112	$9,438	$5,471	$749	$6,235	$13,049
690: Kidney & urinary tract infections w/o MCC	$3,989	$513	$3,615	$8,444	$4,090	$586	$6,749	$11,938
F. 30-Day Fixed Following Hospital Discharge Excluding Acute Hospital Readmissions (prorated)
470: Major joint replacement or reattachment of lower extremity w/o MCC	$11,079	$1,484	$5,173	$18,016	$11,120	$1,505	$5,490	$18,412
065: Intracranial hemorrhage or cerebral infarction w CC	$6,392	$979	$8,672	$16,624	$6,401	$1,038	$11,559	$19,773
481: Hip & femur procedures except major joint w CC	$10,295	$1,734	$9,955	$22,536	$10,296	$1,750	$10,437	$23,062
194: Simple pneumonia & pleurisy w CC	$5,347	$631	$1,664	$7,805	$5,471	$749	$4,583	$11,252
690: Kidney & urinary tract infections w/o MCC	$3,989	$513	$2,353	$7,021	$4,090	$586	$5,364	$10,420

Table 8. Episode Length of Stay: Acute Hospital-Initiated Episodes, 2006-2008

Episode Definition	N	Percent of Beneficiaries Discharged to PAC1	Mean Index Acute Hospital LOS2 (days)	Mean Index Acute Hospital Payment2	Mean PAC LOS3 (days)	Mean PAC Payment4	Mean Episode LOS5 (days)	Mean Episode Payment5
PAC users are defined as beneficiaries discharged to SNF, IRF, LTCH, HHA, or therapy following discharge from an index acute hospitalization. An index acute hospitalization is defined as a hospital admission following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Post-Acute care length of stay is defined as the difference between the admission date on the first PAC episode claim and the discharge date on the last PAC episode claim. Note that for some beneficiaries there may be a gap in service use between the discharge date on the index acute hospital claim and the admission date on the first PAC episode claim. Post-Acute care includes Medicare payments for SNF, IRF, LTCH, HHA, and therapy. Note that acute hospital readmissions are also included in PAC payments for episode definitions A, C, and E. Episode length of stay is the difference between the admission date on the index acute hospital claim and the last episode claim. Episode payment includes the index acute hospital stay, PAC, physician services during the index acute hospital stay and during the PAC episode. Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM143, M3MM149, M3MM237).
2008
A. 30-Day Variable Episode	659,549	38.7	6.2	$10,572	79.1	$17,236	87.3	$30,827
B. 30-Day Variable Episode Excluding Acute Hospital Readmissions	659,549	38.7	6.2	$10,572	56.4	$9,075	64.6	$21,926
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge	659,549	38.7	6.2	$10,572	40.6	$10,651	48.8	$23,499
D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions	659,549	38.7	6.2	$10,572	37.4	$8,165	45.6	$20,838
E. 30-Day Fixed Following Hospital Discharge (prorated)	659,549	38.7	6.2	$10,572	25.0	$7,564	33.2	$20,412
F. 30-Day Fixed Following Hospital Discharge Excluding Acute Hospital Readmissions (prorated)	659,549	38.7	6.2	$10,572	22.7	$5,745	30.9	$18,418
2007
A. 30-Day Variable Episode	661,958	37.9	6.3	$10,062	77.9	$16,145	86.2	$29,156
B. 30-Day Variable Episode Excluding Acute Hospital Readmissions	661,958	37.9	6.3	$10,062	55.8	$8,596	64.0	$20,904
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge	661,958	37.9	6.3	$10,062	41.2	$10,100	49.5	$22,416
D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions	661,958	37.9	6.3	$10,062	38.0	$7,772	46.2	$19,918
E. 30-Day Fixed Following Hospital Discharge (prorated)	661,958	37.9	6.3	$10,062	24.9	$7,217	33.2	$19,533
F. 30-Day Fixed Following Hospital Discharge Excluding Acute Hospital Readmissions (prorated)	661,958	37.9	6.3	$10,062	22.6	$5,510	30.9	$17,656
2006
A. 30-Day Variable Episode	667,784	37.1	6.4	$9,644	75.4	$15,236	83.8	$27,720
B. 30-Day Variable Episode Excluding Acute Hospital Readmissions	667,784	37.1	6.4	$9,644	53.2	$8,200	61.5	$20,015
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge	667,784	37.1	6.4	$9,644	39.2	$9,604	47.6	$21,426
D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions	667,784	37.1	6.4	$9,644	36.1	$7,422	44.5	$19,086
E. 30-Day Fixed Following Hospital Discharge (prorated)	667,784	37.1	6.4	$9,644	24.7	$6,909	33.1	$18,731
F. 30-Day Fixed Following Hospital Discharge Excluding Acute Hospital Readmissions (prorated)	667,784	37.1	6.4	$9,644	22.4	$5,300	30.8	$16,964

The percentage of beneficiaries using specific PAC services also varies by episode definition as shown in Table 9 In this table, we report the percentage of beneficiaries using each type of service, the mean claim length of stay, mean payment per service user, mean payment per PAC user, and mean payment per hospital discharge for each of the six episode definitions examined. The results indicate that the percentage of beneficiaries using HHA and SNF services increases under longer episode definitions because these services may be used directly after discharge from an acute hospitalization or later in an episode of care such as following an LTCH or IRF admission. Use of LTCH and IRF services is less sensitive to episode definitions because these services most often occur directly following an acute hospitalization. Table 8 also demonstrates the differences in acute hospital readmission during an episode-by-episode definition. Under the episode definition including any claim starting within 30 days after hospital discharge, 14.8 percent of beneficiaries had a readmission during an episode, but this increases to 28.6 percent under a 30-day variable-length episode definition again indicating differences in service use and policy implications for different episode definitions.

Table 9. Service-Specific Episode Summary Statistics, Acute Hospital-Initiated Episodes, 2008

Service Use (N = 659,549)	A. 30-Day Variable Episode	B. 30-Day Variable Episode Excluding Acute Hospital Readmissions	C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge	D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions	E. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge (prorated)	F. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions (prorated)
"Per service user" indicates mean Medicare payments for those beneficiaries who use the specific PAC service. "Payments per PAC user" indicate the mean Medicare payments across all beneficiaries who use any PAC, regardless of whether or not they use a specific PAC service. "Payments per hospital discharge" indicate the mean Medicare payments across all beneficiaries with an index acute hospitalization, regardless of whether they use a PAC service. Note that per-hospital discharge calculations include acute hospital readmissions and a small amount of subsequent service use for beneficiaries not discharged to PAC from their acute hospital initiating event. Note that 13.3 percent of non-PAC users had an acute hospital readmission under episode definition A, and 13.2 percent had an acute hospital readmission under episode definition C and E. Source: RTI analysis of 2008 Medicare claims (M3MM143, M3MM149, M3MM215).
HHA
Percent with Claim	60.7	57.1	52.2	51.3	52.2	51.3
Mean Visits	25.6	20.1	15.8	15.7	6.8	6.6
Mean Claim Length (days)	60.4	47.5	35.3	35.1	19.9	18.6
Mean Payment Per Service User1	$4,230	$3,429	$2,786	$2,768	$1,339	$1,304
Mean Payment Per PAC User2	$2,566	$1,958	$1,455	$1,420	$699	$669
Mean Payment Per Hospital Discharge3	$1,079	$759	$590	$549	$278	$259
SNF
Percent with Claim	48.2	44.5	45.3	44.2	45.3	44.2
Mean LOS (days)	39.3	30.3	32.3	29.4	19.8	18.9
Mean Payment Per Service User1	$13,646	$10,743	$11,476	$10,518	$7,495	$7,169
Mean Payment Per PAC User2	$6,575	$4,781	$5,204	$4,644	$3,399	$3,165
Mean Payment Per Hospital Discharge3	$2,703	$1,849	$2,085	$1,796	$1,348	$1,224
IRF
Percent with Claim	9.7	8.9	9.0	8.8	9.0	8.8
Mean LOS (days)	14.3	13.0	13.5	12.9	12.9	12.5
Mean Payment Per Service User1	$17,518	$15,922	$16,504	$15,825	$15,919	$15,378
Mean Payment Per PAC User2	$1,707	$1,410	$1,489	$1,387	$1,436	$1,348
Mean Payment Per Hospital Discharge3	$706	$545	$601	$536	$573	$521
LTCH
Percent with Claim	2.6	1.8	2.0	1.8	2.0	1.8
Mean LOS (days)	31.5	27.3	27.4	27.0	20.8	21.3
Mean Payment Per Service User1	$38,932	$35,069	$35,203	$34,861	$27,406	$28,144
Mean Payment Per PAC User2	$1,011	$634	$691	$621	$538	$501
Mean Payment Per Hospital Discharge3	$444	$245	$283	$240	$215	$194
Outpatient Department Therapy
Percent with Claim	20.3	17.0	11.5	11.4	11.5	11.4
Mean Payment Per Service User1	$1,410	$1,137	$628	$620	$363	$359
Mean Payment Per PAC User2	$286	$193	$72	$70	$42	$41
Mean Payment Per Hospital Discharge3	$117	$75	$29	$27	$16	$16
Independent Therapist
Percent with Claim	9.6	8.9	6.3	6.2	6.3	6.2
Mean Payment Per Service User1	$1,209	$1,125	$358	$358	$331	$330
Mean Payment Per PAC User2	$116	$100	$22	$22	$21	$20
Mean Payment Per Hospital Discharge3	$46	$39	$9	$9	$8	$8
Acute Hospital Readmission
Percent with Claim	28.3	—	14.8	—	14.8	—
Mean LOS (days)	11.3	—	7.4	—	6.0	—
Mean Payment Per Service User1	$17,561	—	$11,594	—	$9,652	—
Mean Payment Per PAC User2	$4,976	—	$1,718	—	$1,430	—
Mean Payment Per Hospital Discharge3	$3,288	—	$1,655	—	$1,407	—

The per-service-user, per-PAC-user, and per-hospital-discharge calculations highlight the sensitivity of these calculations to the episode definition selected and the population over which payments are averaged. This is demonstrated most clearly by examining the LTCH utilization. Under the episode definition including any claim starting within 30 days after hospital discharge, mean payment per beneficiary using LTCH is $35,203. When calculated per PAC user, the mean payment is $691, and when calculated per hospital discharge, the payment is $283. These sharp differences indicate the importance of understanding service use patterns in thinking about episode-based payment. This includes consideration of issues related to geography and provider supply in areas of the country with access to LTCHs compared with those without LTCHs in their area.

Physician service use is another topic of interest to episode bundling discussions. Use of physician services in the week prior to the episode initiating event, during the initiating event, and during the episode is presented in Table 10. To reveal more about differences in use prior to the start of an episode for different types of cases (for example, medical versus surgical), these data are presented both overall and for the top five MS-DRGs by volume of PAC users. Overall, 49.9 percent of beneficiaries with acute hospital-initiated episodes had at least one physician claim in the week prior to the start of an episode, although this finding varied from 34.5 percent for beneficiaries in MS-DRG 481, "hip & femur procedures," to 54.2 percent for beneficiaries in MS-DRG 470, "major joint replacement or reattachment of lower extremity." Total episode payments for physician services were higher for beneficiaries receiving surgical procedures and for beneficiaries with stroke compared with beneficiaries being treated for pneumonia or kidney and urinary tract infections.

Table 10. Physician Service Use, Acute Hospital-Initiated Episodes, by MS-DRG for Top 5 MS-DRGs by Volume of PAC Users, 2008

MS-DRG	7 Days Prior to Index Acute Hospitalization1	Index Acute Hospitalization1	A. 30-Day Variable Episode	B. 30-Day Variable Episode Excluding Acute Hospital Readmissions	C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge	D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions	E. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge (prorated)	F. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions (prorated)
An "index acute hospitalization" is defined as a hospital admission following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Seven days prior to index acute hospitalization does not define the start of the episode. "Per service user" indicates mean Medicare payments for those beneficiaries who use physician services. "Payments per PAC user" indicate the mean Medicare payments across all beneficiaries who use any PAC, regardless of whether or not they use physician services. "Payments per hospital discharge" indicate the mean Medicare payments across all beneficiaries with an index acute hospital stay, regardless of whether they use a PAC service. Physician claims with dates of service falling between the admission date on an index acute hospitalization and the last date of episode were identified from the Medicare Carrier claims using physician specialty codes and the dollars associated with these services were included in episode payment calculations. Source: RTI analysis of 2008 Medicare claims (M3MM216).
All MS-DRGs
Percent with Claim	49.9	98.6	98.9	98.9	98.9	98.8	98.9	98.8
Mean Payment Per Service User2	$207	$1,546	$3,052	$2,305	$2,302	$2,125	$2,302	$2,125
Mean Payment Per PAC User3	$103	$1,524	$3,019	$2,279	$2,275	$2,101	$2,275	$2,101
Mean Payment Per Hospital Discharge4	$107	$1,137	$1,931	$1,430	$1,572	$1,360	$1,572	$1,360
470: Major joint replacement or reattachment of lower extremity w/o MCC
Percent with Claim	54.2	98.9	99.0	99.7	99.0	99.0	99.0	99.0
Mean Payment Per Service User2	$156	$1,522	$2,200	$1,974	$1,877	$1,820	$3,104	$1,820
Mean Payment Per PAC User3	$85	$1,505	$2,178	$1,954	$1,858	$1,801	$1,858	$1,801
Mean Payment Per Hospital Discharge4	$83	$1,484	$2,130	$1,906	$1,824	$1,763	$1,824	$1,763
065: Intracranial hemorrhage or cerebral infarction w CC
Percent with Claim	37.0	98.2	98.4	98.4	98.4	98.3	98.4	98.3
Mean Payment Per Service User2	$217	$1,057	$2,827	$2,077	$2,030	$1,843	$2,030	$1,843
Mean Payment Per PAC User3	$80	$1,038	$2,782	$2,043	$1,997	$1,812	$1,997	$1,812
Mean Payment Per Hospital Discharge4	$81	$979	$2,373	$1,733	$1,756	$1,560	$1,756	$1,560
481: Hip & femur procedures except major joint w CC
Percent with Claim	34.5	98.8	99.0	99.0	98.9	98.9	98.9	98.9
Mean Payment Per Service User2	$181	$1,770	$3,189	$2,571	$2,522	$2,354	$2,522	$2,354
Mean Payment Per PAC User3	$62	$1,750	$3,157	$2,545	$2,496	$2,329	$2,496	$2,329
Mean Payment Per Hospital Discharge4	$62	$1,734	$3,089	$2,492	$2,455	$2,287	$2,455	$2,287
194: Simple pneumonia & pleurisy w CC
Percent with Claim	45.0	99.1	99.3	99.2	99.2	99.2	99.2	99.2
Mean Payment Per Service User2	$178	$756	$1,942	$1,328	$1,353	$1,207	$1,353	$1,207
Mean Payment Per PAC User3	$80	$749	$1,928	$1,318	$1,343	$1,198	$1,343	$1,198
Mean Payment Per Hospital Discharge4	$85	$631	$1,262	$838	$979	$794	$654	$794
690: Kidney & urinary tract infections w/o MCC
Percent with Claim	43.0	98.9	99.1	99.1	99.1	99.1	99.1	99.1
Mean Payment Per Service User2	$167	$593	$1,694	$1,098	$1,109	$975	$1,109	$975
Mean Payment Per PAC User3	$72	$586	$1,679	$1,864	$1,099	$966	$1,099	$966
Mean Payment Per Hospital Discharge4	$82	$513	$1,143	$734	$840	$679	$840	$679

Table 11. Top 10 Condition Groupings: HHA-Initiated Episodes, 2006-2008

Rank 2008	Rank 2007	Rank 2006	Condition Grouping	N 2008	Percent 2008	Cumulative Percent 2008
Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM204).
1	1	1	Other, Medical	57,849	24.48	24.5
2	2	2	Orthopedic, Minor Medical	40,669	17.21	41.7
3	3	3	Neurologic, Medical	33,344	14.11	55.8
4	6	6	Cardiovascular, General	21,438	9.07	64.9
5	4	4	Integumentary, Medical	20,783	8.79	73.7
6	5	5	Endocrine, Medical	19,050	8.06	81.7
7	7	7	Cardiovascular, Cardiac Medical	9,429	3.99	85.7
8	8	8	Kidney & Urinary, Medical	6,909	2.92	88.6
9	10	11	Respiratory, COPD	6,075	2.57	91.2
10	9	9	Cardiovascular, Vascular Medical	5,522	2.34	93.5

In addition to looking at HHA episodes by condition grouping, RTI also examined the top 10 ICD-9 codes in the first position on HHA claims for beneficiaries with acute hospital-initiated episodes discharged to HHA and for beneficiaries with HHA-initiated episodes (Table 12) as well as the HHRG coded on HHA claims for these two groups of beneficiaries (Table 13). The results of these analyses indicate that the most common ICD-9 code for beneficiaries initiating care in an acute hospital was V54.81 "Aftercare following joint replacement" (11.5 percent) while the most common ICD-9 code for the HHA-initiated beneficiaries was V57.1 "Other physical therapy" (10.3 percent). In general, the top ICD-9 codes for the acute initiated episodes were for aftercare related to surgery whereas the top ICD-9 codes for the HHA-initiated episodes were for more chronic conditions such as hypertension, congestive heart failure, diabetes, and Alzheimer's. The top ten ICD-9 codes accounted for 43.6 percent of all episodes for beneficiaries initiating care in an acute hospital and discharged to HHA and 35.1 percent of all HHA-initiated episodes. The HHRG analysis also indicated some differences in these two populations. Based on the top 10 HHRGs in each group of beneficiaries, a higher proportion of beneficiaries initiating an episode in an acute hospital and discharged to HHA were in higher case-mix weight HHRGs indicating higher clinical severity, functional severity, and service severity compared to beneficiaries with HHA-initiated episodes. One of the top ten HHRGs for HHA-initiated episodes included 14-19 therapies while all others included 0-13 therapies. These results suggest a lower intensity, but chronic patient in the HHA-initiated episodes.

Table 12. Top 10 ICD-9 Codes (Primary) Coded on HHA Claims, Acute Hospital-Initiated Episodes for Beneficiaries Discharged to HHA and HHA-Initiated Episodes, 2008

Rank	ICD-9 Code	N	Percent	Cumulative Percent
Source: RTI analysis of 2008 Medicare claims (M3MM256).
Acute Hospital-Initiated Episodes, Beneficiaries Discharged to HHA
1	V54.81: Aftercare following joint replacement	28,244	11.5	11.5
2	V57.1: Other physical therapy	14,552	5.9	17.4
3	428.0: Congestive heart failure, unspecified	13,116	5.3	22.7
4	V58.73: Aftercare following surgery of the circulatory system, NEC	12,439	5.0	27.7
5	486: Pneumonia, organism unspecified	7,841	3.2	30.9
6	491.21: Obstructive chronic bronchitis with (acute) exacerbation	7,252	2.9	33.8
7	V58.42: Aftercare following surgery for neoplasm	7,108	2.9	36.7
8	V58.78: Aftercare following surgery of the musculoskeletal system, NEC	6,388	2.6	39.3
9	V58.75: Aftercare following surgery of the teeth, oral cavity and digestive system	5,449	2.2	41.5
10	401.9: Essential hypertension, unspecified	5,224	2.1	43.6
HHA-Initiated Episodes
1	V57.1: Other physical therapy	24,218	10.3	10.3
2	401.9: Essential hypertension, unspecified	14,399	6.1	16.3
3	781.2: Abnormality of gait	9,312	3.9	20.3
4	250.00: Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled	8,534	3.6	23.9
5	428.0: Congestive heart failure, unspecified	5,652	2.4	26.3
6	250.02: Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled	5,388	2.3	28.6
7	728.87: Muscle weakness (generalized)	5,388	2.3	30.8
8	331.0: Alzheimer's disease	3,715	1.6	32.4
9	V57.89: Other specified rehabilitation procedure, Other (multiple training or therapy)	3,244	1.4	33.8
10	332.0: Paralysis agitans (Parkinson's disease)	3,119	1.3	35.1

Table 13. Top 10 HHRGs Coded on HHA Claims, Acute Hospital-Initiated Episodes for Beneficiaries Discharged to HHA and HHA-Initiated Episodes, 2008

Rank	HHRG	Case Mix Weight	N	Percent	Cumulative Percent
Source: RTI analysis of 2008 Medicare claims (M3MM257, M3MM258).
Acute Hospital-Initiated Episodes, Beneficiaries Discharged to HHA
1	1CGK: Early Episode, 0-13 therapies, Clinical Severity Level 3, Functional Severity Level 2,Service Severity Level 1	0.9896	24,521	9.9	9.9
2	1BFK: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 1,Service Severity Level 1	0.7335	19,884	8.1	18.0
3	1CFK: Early Episode, 0-13 therapies, Clinical Severity Level 3, Functional Severity Level 1,Service Severity Level 1	0.901	19,849	8.0	26.1
4	1BGK: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 2,Service Severity Level 1	0.8221	19,551	7.9	34.0
5	1AFK: Early Episode, 0-13 therapies, Clinical Severity Level 1, Functional Severity Level 1,Service Severity Level 1	0.5827	12,585	5.1	39.1
6	1AGK: Early Episode, 0-13 therapies, Clinical Severity Level 1, Functional Severity Level 2,Service Severity Level 1	0.6713	8,982	3.6	42.7
7	1BGM: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 2,Service Severity Level 3	1.2993	7,938	3.2	45.9
8	1BGP: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 2,Service Severity Level 5	1.69	7,005	2.8	48.8
9	1CHK: Early Episode, 0-13 therapies, Clinical Severity Level 3, Functional Severity Level 3,Service Severity Level 1	1.0733	6,742	2.7	51.5
10	1AGM: Early Episode, 0-13 therapies, Clinical Severity Level 1, Functional Severity Level 2,Service Severity Level 3	1.1485	6,466	2.6	54.1
HHA-Initiated Episodes
1	1CGK: Early Episode, 0-13 therapies, Clinical Severity Level 3, Functional Severity Level 2,Service Severity Level 1	0.9896	25,829	10.9	10.9
2	1CFK: Early Episode, 0-13 therapies, Clinical Severity Level 3, Functional Severity Level 1,Service Severity Level 1	0.901	21,635	9.2	20.1
3	1BFK: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 1,Service Severity Level 1	0.7335	15,057	6.4	26.5
4	1BGK: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 2,Service Severity Level 1	0.8221	14,876	6.3	32.8
5	1CHK: Early Episode, 0-13 therapies, Clinical Severity Level 3, Functional Severity Level 3,Service Severity Level 1	1.0733	11,522	4.9	37.6
6	1AFK: Early Episode, 0-13 therapies, Clinical Severity Level 1, Functional Severity Level 1,Service Severity Level 1	0.5827	10,317	4.4	42.0
7	1AGK: Early Episode, 0-13 therapies, Clinical Severity Level 1, Functional Severity Level 2,Service Severity Level 1	0.6713	6,361	2.7	44.7
8	1BGP: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 2,Service Severity Level 5	1.69	5,119	2.2	46.9
9	2BGK:Early Episode, 14-19 therapies, Clinical Severity Level 2, Functional Severity Level 3,Service Severity Level 1	0.8221	4,894	2.1	48.9
10	1BHK: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 3,Service Severity Level 1	0.9058	4,522	1.9	50.8

In Table 14, episode patterns for beneficiaries initiating care in HHA are shown. Over 70 percent of HHA community entrant beneficiaries have "HHA only" episodes and do not go on to use other PAC services. The second most frequent episode pattern is HHA to acute hospital (HA), which is common to 5.9 percent of the HHA community entrants. To learn more about the difference between HHA community entrants and beneficiaries with acute hospital-initiated episodes discharged to HHA as their first site of PAC, we ran an episode pattern analysis on the second set of beneficiaries as well (Table 15). A smaller proportion of beneficiaries in the acute hospital-initiated group use HHA only (61.2 percent), and a higher proportion of beneficiaries go on to use subsequent services—a pattern more clearly illustrated in the next set of tables.

Table 14. Episode Patterns: HHA-Initiated Episodes, 2008

Rank	Episode Pattern	N	Percent	Cumulative Percent
Note: Episode pattern is based on a 30-day variable episode definition. Each letter indicates a type of service use, but a single letter may represent one claim or multiple claims of the same type of service. A = acute hospital, S = SNF, H = HHA, I = IRF, L = LTCH, O = outpatient department therapy, T = independent therapist. Source: RTI analysis of 2008 Medicare claims (M3MM157).
1	H	165,702	70.1	70.1
2	HA	14,033	5.9	76.1
3	HAH	8,681	3.7	79.7
4	HO	7,130	3.0	82.8
5	HAS	4,336	1.8	84.6
6	HT	4,293	1.8	86.4
7	HASH	3,099	1.3	87.7
8	HAHA	1,682	0.7	88.4
9	HOH	1,544	0.7	89.1
10	HAHAH	1,357	0.6	89.7

Table 15. Episode Patterns: Acute Hospital-Initiated Episodes, Beneficiaries Discharged to HHA, 2008

Rank	Episode Pattern	N	Percent	Cumulative Percent
Note: Episode pattern is based on a 30-day variable episode definition. Each letter indicates a type of service use, but a single letter may represent one claim or multiple claims of the same type of service. A = acute hospital, S = SNF, H = HHA, I = IRF, L = LTCH, O = outpatient department therapy, T = independent therapist. Source: RTI analysis of 2008 Medicare claims (M3MM187).
1	AH	150,850	61.2	61.2
2	AHA	24,512	9.9	71.1
3	AHO	14,655	5.9	77.1
4	AHT	14,467	5.9	82.9
5	AHAH	8,839	3.6	86.5
6	AHAS	3,071	1.2	87.8
7	AHAHA	2,488	1.0	88.8
8	AHASH	2,290	0.9	89.7
9	AHAHAH	1,430	0.6	90.3
10	AHASA	1,060	0.4	90.7

Summary statistics for the HHA-initiated episodes are shown in Table 16 by year and episode definition. The mean number of visits in the initial index HHA claim is 16.8 visits, and this is consistent across the 3 years of data examined. As with the acute hospital-initiated episodes, episode length and payments are sensitive to the episode definition we look at. For example, under Episode Definition C (any claim initiating within 30 days following discharge from the initiating event), the mean episode length of stay is 64.0 days, but this increases to 113.1 days under the longer 30-day variable-length episode definition. Table 17 presents the difference in total HHA utilization for beneficiaries with acute-initiated episodes discharged to HHA and for beneficiaries with HHA-initiated episodes for 2006-2008. Beneficiaries with HHA initiated episodes have a higher number of HHA visits, more claim days in HHA, and higher HHA payments compared to beneficiaries with acute initiated episodes discharged to HHA.

Table 16. Episode Summary Statistics: HHA-Initiated Episodes, 2006-2008

Episode Definition	N	Mean Visits During Initiating Event1	Mean Index Claim Length (days)	Mean Initiating Event Payment1	Mean Episode LOS (days)2	Mean Episode Payment2
1. An "initiating event" is defined as an HHA claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. 2. Episode length of stay is defined as the difference between the admission date on the first episode claim and the discharge date on the last episode claim. Episode payments include Medicare payments for SNF, IRF, LTCH, HHA, and therapy. Note that acute hospitalizations are also included in episode payments for episode definitions A and C. Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM100, M3MM102, M3MM260).
2008
A. 30-Day Variable Episode	236,307	16.8	101.0	$2,779	113.1	$11,736
B. 30-Day Variable Episode Excluding Acute Hospitalization	236,307	16.8	83.7	$2,779	87.9	$4,966
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	236,307	16.8	59.4	$2,779	64.0	$6,446
2007
A. 30-Day Variable Episode	223,915	17.2	96.7	$2,690	108.9	$10,957
B. 30-Day Variable Episode Excluding Acute Hospitalization	223,915	17.2	80.2	$2,690	84.3	$4,773
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	223,915	17.2	57.6	$2,690	62.6	$6,155
2006
A. 30-Day Variable Episode	212,780	16.8	103.5	$2,555	116.0	$11,313
B. 30-Day Variable Episode Excluding Acute Hospitalization	212,780	16.8	82.2	$2,555	86.3	$4,678
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	212,780	16.8	56.4	$2,555	61.3	$5,924

Table 17. HHA Utilization, HHA Initiated Episodes versus Beneficiaries With Acute Hospital-Initiated Episodes Discharged to HHA, 2006-2008

Episode Definition	Mean HHA Visits per HHA Initiated Episode	Mean HHA Claim Length (days) per HHA Initiated Episode	Mean HHA Payment per Episode per HHA Initiated Episode	Mean HHA Visits per Acute Initiated Episode Discharged to HHA	Mean HHA Claim Length (days) per Acute Initiated Episode Discharged to HHA	Mean HHA Payment per Episode per Acute Initiated Episode Discharged to HHA
Visit, claim length, and payments include index event plus subsequent service use in the episode. Source: RTI Analysis of 2006, 2007, and 2008 Medicare Claims (M3MM260, M3MM261).
2008
A. 30 Day Variable Episode	64.7	101.0	$5,776	22.6	57.8	$3,697
B. 30 Day Variable Episode Excluding Acute Hospitalization	57.2	83.7	$4,777	17.9	45.7	$3,030
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	48.2	59.4	$3,675	14.8	34.9	$2,571
2007
A. 30 Day Variable Episode	65.2	96.7	$5,521	22.5	55.9	$3,462
B. 30 Day Variable Episode Excluding Acute Hospitalization	57.6	80.2	$4,597	18.0	44.4	$2,852
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	47.7	57.6	$3,530	14.9	34.5	$2,440
2006
A. 30 Day Variable Episode	68.0	103.5	$5,657	23.4	57.1	$3,416
B. 30 Day Variable Episode Excluding Acute Hospitalization	57.8	82.2	$4,504	18.1	44.0	$2,755
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	46.7	56.4	$3,321	14.8	34.2	$2,343

Table 18 and Table 19 show more clearly the service-specific utilization under different episode definitions for HHA community entrants (Table 18) and for beneficiaries initiating a PAC episode in an acute hospital but discharged to HHA for their first site of PAC (Table 19). In Table 18, we can see that 35.4 percent of beneficiaries with an HHA-initiated episode have more than one HHA claim in their care trajectory under the 30-day variable-length episode. Over 9 percent go on to use SNF, and 23.1 percent have an acute hospitalization under this same episode definition. Among those beneficiaries initiating care in an acute hospital but discharged to HHA as the first setting of PAC, a similar proportion of beneficiaries goes on to use SNF and have an acute hospitalization. Under the same episode definition, 7.3 percent of beneficiaries have an SNF claim and only a slightly higher proportion of beneficiaries have a rehospitalization (25.9 percent). In Table 20, we see the proportion of beneficiaries using physician services in the week prior to the start of an episode and during the episode. A higher proportion of beneficiaries with HHA-initiated episodes have at least one physician claim in the week prior to the start of the episodes, compared with beneficiaries with acute hospital-initiated episodes (57.2 percent and 49.9 percent, respectively).

Table 18. Service-Specific Episode Summary Statistics: HHA-Initiated Episodes, 2008

Service Use (N = 236,307)	A. 30-Day Variable Episode	B. 30-Day Variable Episode Excluding Acute Hospitalization	C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event
Service use for the initiating event is not included in this calculation. HHA use following first claim reported here. Episode definition B excludes acute hospitalizations. Therefore values for acute hospitalization are missing for this episode definition. Source: RTI analysis of 2008 Medicare claims (M3MM143, M3MM215).
HHA (not including initiating event)1
Percent with Claim	35.4	28.2	33.0
Mean Visits	64.0	53.9	18.5
Mean Claim Length (days)	166.4	148.1	51.6
Mean Payment Per Service User	$8,465	$7,096	$2,711
SNF
Percent with Claim	9.3	0.4	5.6
Mean LOS (days)	47.8	40.0	36.3
Mean Payment Per Service User	$16,517	$12,886	$12,863
IRF
Percent with Claim	1.5	0.2	0.8
Mean LOS (days)	16.2	14.2	14.9
Mean Payment Per Service User	$19,238	$15,781	$17,772
LTCH
Percent with Claim	0.8	0.1	0.3
Mean LOS (days)	33.0	33.3	29.0
Mean Payment Per Service User	$38,520	$31,122	$33,213
Outpatient Department Therapy
Percent with Claim	7.4	5.1	4.6
Mean Payment Per Service User	$1,378	$1,141	$657
Independent Therapist
Percent with Claim	3.4	3.0	2.6
Mean Payment Per Service User	$1,234	$1,181	$458
Acute Hospitalization2
Percent with Claim	23.1	—	16.7
Mean LOS (days)	10.7	—	7.3
Mean Payment Per Service User	$15,850	—	$10,563

Table 19. Service-Specific Episode Summary Statistics: Acute Hospital-Initiated Episodes, Beneficiaries Discharged to HHA, 2008

Service Use (N = 246,595)	A. 30-Day Variable Episode	B. 30-Day Variable Episode Excluding Acute Hospitalizations	C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge
By definition, 100 percent of beneficiaries with acute initiated episodes discharged to HHA have at least one HHA claim in their episode. Note that 18.9 percent of beneficiaries in episode definition A, 10.2 percent in episode definition B, and 1.6 percent of beneficiaries in episode definition C have more than one HHA claim in their PAC episode. Episode definition B excludes acute hospitalizations. Therefore values for acute hospitalization are missing for this episode definition. Source: RTI analysis of 2008 Medicare claims (M3MM187).
HHA
Percent with Claim1	100.0	100.0	100.0
Mean Visits	22.6	17.9	14.8
Mean Claim Length (days)	57.8	45.7	34.9
Mean Payment Per Service User	$3,697	$3,030	$2,571
SNF
Percent with Claim	7.3	0.7	2.8
Mean LOS (days)	39.7	30.5	26.4
Mean Payment Per Service User	$14,135	$10,323	$9,679
IRF
Percent with Claim	1.3	0.1	0.4
Mean LOS (days)	15.3	12.9	12.9
Mean Payment Per Service User	$19,184	$15,294	$16,065
LTCH
Percent with Claim	0.8	0.0	0.2
Mean LOS (days)	30.0	25.2	23.8
Mean Payment Per Service User	$35,925	$26,896	$28,227
Outpatient Department Therapy
Percent with Claim	9.3	7.5	4.2
Mean Payment Per Service User	$1,016	$881	$424
Independent Therapist
Percent with Claim	7.5	6.9	4.2
Mean Payment Per Service User	$1,168	$1,124	$299
Acute Hospitalization2
Percent with Claim	25.9	—	14.0
Mean LOS (days)	11.4	—	7.1
Mean Payment Per Service User	$18,205	—	$11,322

Table 20. Physician Service Use, by Condition Grouping and by Episode Definition: HHA-Initiated Episodes, 2008

Condition Grouping	7 Days Prior to Initiating Event1	A. 30-Day Variable Episode	B. 30-Day Variable Episode Excluding Acute Hospitalizations	C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge
An initiating event is defined as an HHA claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Physician claims with dates of service falling between the admission date on an index acute hospitalization and the last date of episode were identified from the Medicare Carrier claims using physician specialty codes and the dollars associated with these services were included in episode payment calculations. Source: RTI analysis of 2008 Medicare claims (M3MM216).
All Condition Groupings
Percent with Claim	57.2	83.0	81.8	82.3
Mean Payment Per Service User	$259	$1,679	$1,018	$960
Other, Medical
Percent with Claim	60.2	78.8	77.5	78.3
Mean Payment Per Service User	$349	$1,367	$842	$875
Orthopedic, Minor Medical
Percent with Claim	58.2	84.0	82.9	83.3
Mean Payment Per Service User	$507	$1,431	$913	$825
Neurologic, Medical
Percent with Claim	51.7	82.6	81.4	81.7
Mean Payment Per Service User	$488	$1,507	$903	$821
Cardiovascular, General
Percent with Claim	54.0	86.7	85.9	85.7
Mean Payment Per Service User	$494	$1,532	$994	$816
Integumentary, Medical
Percent with Claim	57.9	83.0	81.5	82.2
Mean Payment Per Service User	$629	$1,876	$1,024	$1,092

Table 21. Top 10 MS-DRGs for LTCH-Initiated Episodes, 2006-2008

Rank 2008	Rank 2007	Rank 2006	MS-DRG	N 2008	Percent 2008	Cumulative Percent 2008
Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM143).
1	1	1	885: Psychoses	672	13.5	13.5
2	2	2	207: Respiratory system diagnosis w ventilator support 96+ hours	333	6.7	20.2
3	5	6	189: Pulmonary edema & respiratory failure	204	4.1	24.3
4	3	3	593: Skin ulcers w CC	196	3.9	28.3
5	7	7	592: Skin ulcers w MCC	195	3.9	32.2
6	6	8	573: Skin graft &/or debrid for skin ulcer or cellulitis w MCC	158	3.2	35.4
7	4	4	574: Skin graft &/or debrid for skin ulcer or cellulitis w CC	142	2.9	38.3
8	8	5	057: Degenerative nervous system disorders w/o MCC	136	2.7	41.0
9	10	9	299: Peripheral vascular disorders w MCC	103	2.1	43.1
10	13	12	603: Cellulitis w/o MCC	84	1.7	44.8

Table 22. Top 10 MS-DRGs for Acute Hospital-Initiated Episodes, Beneficiaries Discharged to LTCH, 2008

Rank	MS-DRG	N	Percent	Cumulative Percent
Source: RTI analysis of 2008 Medicare claims (M3MM143).
1	207: Respiratory system diagnosis w ventilator support 96+ hours	1,628	14.2	14.2
2	189: Pulmonary edema & respiratory failure	899	7.8	22.1
3	871: Septicemia w/o MV 96+ hours w MCC	519	4.5	26.6
4	949: Aftercare w CC/MCC	401	3.5	30.1
5	177: Respiratory infections & inflammations w MCC	388	3.4	33.5
6	208: Respiratory system diagnosis w ventilator support <96 hours	291	2.5	36.0
7	193: Simple pneumonia & pleurisy w MCC	246	2.1	38.2
8	945: Rehabilitation w CC/MCC	236	2.1	40.2
9	190: Chronic obstructive pulmonary disease w MCC	223	1.9	42.2
10	057: Degenerative nervous system disorders w/o MCC	208	1.8	44.0

Table 23 and Table 24 describe the episode patterns for beneficiaries with LTCH-initiated episodes (Table 23) and beneficiaries with acute hospital-initiated episodes discharged to LTCH as their first site of PAC (Table 24). A higher proportion of beneficiaries used LTCH only in their episode among the community entrant sample (40.3 percent) compared with the acute hospital-initiated sample of beneficiaries discharged to LTCH (26.2 percent). More detail on the episode- and service-specific utilization between these two groups is presented in the next set of tables.

Table 23. Episode Patterns: LTCH-Initiated Episodes, 2008

Rank	Episode Pattern	N	Percent	Cumulative Percent
Note: Episode pattern is based on a 30-day variable episode definition. A = Acute hospital, S = SNF, H = HHA, I = IRF, L = LTCH, O = outpatient department therapy, T = independent therapist Source: RTI analysis of 2008 Medicare claims (M3MM157).
1	L	2,002	40.3	40.3
2	LS	531	10.7	51.0
3	LH	425	8.6	59.6
4	LA	206	4.1	63.7
5	LO	132	2.7	66.4
6	LSO	92	1.9	68.2
7	LSA	90	1.8	70.0
8	LSH	79	1.6	71.6
9	LSAS	78	1.6	73.2
10	LHA	55	1.1	74.3

Table 24. Episode Patterns: Acute Hospital-Initiated Episodes, Beneficiaries Discharged to LTCH 2008

Rank	Episode Pattern	N	Percent	Cumulative Percent
Note: Episode pattern is based on a 30-day variable episode definition. A = Acute hospital, S = SNF, H = HHA, I = IRF, L = LTCH, O = outpatient department therapy, T = independent therapist Source: RTI analysis of 2008 Medicare claims (M3MM187).
1	AL	3,004	26.2	26.2
2	ALH	1,352	11.8	38.0
3	ALS	872	7.6	45.6
4	ALA	643	5.6	51.3
5	ALSH	344	3.0	54.3
6	ALHA	281	2.5	56.7
7	ALSA	264	2.3	59.0
8	ALSAS	205	1.8	60.8
9	ALSO	183	1.6	62.4
10	ALO	158	1.4	63.8

Similar to the acute and HHA-initiated episodes, episode length and payments vary by each of the episode definitions (Table 25). Under episode definition C, any claim initiating within 30 days of discharge, the mean episode length of stay for beneficiaries with LTCH-initiated episodes is 57.8 days. In comparison, under the longer definition A, 30-day variable length, the mean episode length is 101.6 days. In Table 26, the total LTCH utilization per episode is shown for beneficiaries with acute hospital-initiated episodes discharged to LTCH and for beneficiaries with LTCH-initiated episodes. Though there was not much difference in the mean LTCH days per episode, the mean payments were higher for beneficiaries initiated their episodes in an acute hospital indicating that these beneficiaries are in higher weight MS-DRGs.

Table 25. Episode Summary Statistics: LTCH-Initiated Episodes, 2006-2008

Episode Definition	N	Mean Initiating Event LOS (days)1	Mean Initiating Event Payment1	Mean Episode LOS (days) 2	Mean Episode Payment2
An initiating event is defined as an LTCH claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Episode length of stay is defined as the difference between the admission date on the first episode claim and the discharge date on the last episode claim. Episode payments include Medicare payments for SNF, IRF, LTCH, HHA, and therapy. Note that acute hospitalizations are also included in episode payments for episode definitions A and C. Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM143).
2008
A. 30-Day Variable Episode	4,967	26.7	$26,414	101.6	$46,633
B. 30-Day Variable Episode Excluding Acute Hospitalization	4,967	26.7	$26,414	70.9	$33,467
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	4,967	26.7	$26,414	57.8	$36,399
2007
A. 30-Day Variable Episode	4,587	28.0	$26,803	98.0	$45,447
B. 30-Day Variable Episode Excluding Acute Hospitalization	4,587	28.0	$26,803	81.3	$12,751
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	4,587	28.0	$26,803	58.5	$36,209
2006
A. 30-Day Variable Episode	4,821	27.9	$26,679	93.3	$42,851
B. 30-Day Variable Episode Excluding Acute Hospitalization	4,821	27.9	$26,679	65.5	$32,028
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	4,821	27.9	$26,679	55.7	$34,972

Table 26. LTCH Utilization, LTCH Initiated Episodes versus Beneficiaries With Acute Initiated Episodes Discharged to LTCH, 2006-2008

Episode Definition	Mean LTCH Length of Stay (days) per LTCH Initiated Episode	Mean LTCH Payment per Episode per LTCH Initiated Episode	Mean LTCH Length of Stay (days) per Acute Initiated Episode Discharged to LTCH	Mean LTCH Payment per Episode per Acute Initiated Episode Discharged to LTCH
Length of stay and payments include index event plus subsequent service use in the episode. Source: RTI Analysis of 2006, 2007, and 2008 Medicare Claims (M3MM260, M3MM261).
2008
A. 30 Day Variable Episode	32.2	$31,549	31.2	$39,621
B. 30 Day Variable Episode Excluding Acute Hospitalization	28.6	$27,983	27.3	$35,291
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	29.1	$28,484	27.6	$35,784
2007
A. 30 Day Variable Episode	32.8	$31,429	31.5	$38,413
B. 30 Day Variable Episode Excluding Acute Hospitalization	29.4	$28,029	27.8	$34,536
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	29.9	$28,658	28.0	$34,920
2006
A. 30 Day Variable Episode	32.6	$30,998	31.8	$38,286
B. 30 Day Variable Episode Excluding Acute Hospitalization	29.4	$27,896	28.0	$34,526
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	29.9	$28,558	28.3	$34,957

In Table 27 and Table 28, we compare the service-specific utilization in the episode for beneficiaries initiating care in the LTCH (Table 27) to the utilization for beneficiaries who initiate care in an acute hospital-initiated episode and are discharged to LTCH (Table 28). Patterns of service-specific utilization do vary for these two samples, particularly when examining episode definition A, the 30-day variable-length episode. Beneficiaries with acute hospital-initiated episodes discharged to LTCH as their first setting of PAC have a higher proportion of service use of all types compared with the community-initiated entrants. For example, 38.6 percent of beneficiaries with acute hospital-initiated episodes discharged to LTCH used HHA during the episode compared with 24.1 percent among the LTCH community entrants; SNF utilization was 38.5 percent compared with 32.9 percent and acute hospitalizations was 42.7 percent compared with 29.5 percent. The differences in use during episodes between the community entrant and the acute hospital-initiated LTCH user likely reflect the types of cases in each group—the more complex medical conditions versus psychoses and skin cases, as demonstrated in Table 21 and Table 22. Use of physician services during episodes is presented in Table 29. Over 54 percent of beneficiaries with LTCH-initiated episodes have at least one physician claim in the week prior to the initiating event. Payments associated with physician services during LTCH-initiated episodes varied significantly by MS-DRG, with highest payments associated with beneficiaries in MS-DRG 207, "respirator system diagnosis w ventilator support 96+ hours," and MS-DRG 199, "pulmonary edema & respiratory failure," compared with far lower physician service payments for beneficiaries in MS-DRG 885, "psychoses."

Table 27. Service-Specific Episode Summary Statistics: LTCH-Initiated Episodes, 2008

Service Use (N = 4,967)	A. 30-Day Variable Episode	B. 30-Day Variable Episode Excluding Acute Hospitalization	C. 30-Day Fixed: Any Claim Starting Within 30 Days After LTCH Discharge
Service use for the initiating event is not included in this calculation. LTCH use following first claim reported here. Episode definition B excludes acute hospitalizations. Therefore values for acute hospitalization are missing for this episode definition. Source: RTI analysis of 2008 Medicare claims (M3MM143, M3MM213).
HHA
Percent with Claim	24.1	20.1	18.8
Mean Visits	59.1	44.7	22.7
Mean Claim Length (days)	137.4	105.6	48.2
Mean Payment Per Service User	$7,958	$6,014	$3,188
SNF
Percent with Claim	32.9	28.1	29.3
Mean LOS (days)	56.2	43.3	43.0
Mean Payment Per Service User	$16,599	$12,778	$12,861
IRF
Percent with Claim	3.5	2.3	2.6
Mean LOS (days)	18.8	17.8	17.8
Mean Payment Per Service User	$21,804	$20,906	$21,303
LTCH (not including initiating event)1
Percent with Claim	13.3	4.9	6.7
Mean LOS (days)	40.6	37.7	35.2
Mean Payment Per Service User	$38,469	$31,799	$30,881
Outpatient Department Therapy
Percent with Claim	13.5	8.9	6.0
Mean Payment Per Service User	$2,602	$2,120	$1,140
Independent Therapist
Percent with Claim	1.3	1.0	0.7
Mean Payment Per Service User	$1,362	$1,480	$415
Acute Hospitalization2
Percent with Claim	29.5	—	18.6
Mean LOS (days)	14.7	—	9.8
Mean Payment Per Service User	$22,291	—	$15,69

Table 28. Service-Specific Episode Summary Statistics: Acute Hospital-Initiated Episodes, Beneficiaries Discharged to LTCH, 2008

Service Use (N = 11,454)	A. 30-Day Variable Episode	B. 30-Day Variable Episode Excluding Acute Hospitalization	C. 30-Day Fixed: Any Claim Starting Within 30 Days After Acute Hospital Discharge
By definition, 100 percent of beneficiaries with acute initiated episodes discharged to LTCH have at least one LTCH claim in their episode. Note that 10.4 percent of beneficiaries in episode definition A, 0.9 percent in episode definition B, and 1.8 percent of beneficiaries in episode definition C have more than one LTCH claim in their PAC episode. Episode definition B excludes acute hospitalizations. Therefore values for acute hospitalization are missing for this episode definition. Source: RTI analysis of 2008 Medicare claims (M3MM187).
HHA
Percent with Claim	38.6	31.1	17.2
Mean Visits	51.3	36.6	21.6
Mean Claim Length (days)	113.7	81.0	44.9
Mean Payment Per Service User	$7,499	$5,429	$3,325
SNF
Percent with Claim	38.5	30.5	18.0
Mean LOS (days)	57.0	41.7	40.1
Mean Payment Per Service User	$19,550	$14,546	$14,002
IRF
Percent with Claim	8.0	5.9	4.0
Mean LOS (days)	20.0	18.2	17.5
Mean Payment Per Service User	$21,776	$19,890	$19,862
LTCH
Percent with Claim1	100.0	100.0	100.0
Mean LOS (days)	31.2	27.3	27.6
Mean Payment Per Service User	$39,621	$35,291	$35,784
Outpatient Department Therapy
Percent with Claim	14.5	8.2	1.4
Mean Payment Per Service User	$2,467	$1,857	$582
Independent Therapist
Percent with Claim	1.7	1.0	0.1
Mean Payment Per Service User	$1,218	$1,091	$171
Acute Hospitalization2
Percent with Claim	42.7	—	13.7
Mean LOS (days)	16.1	—	10.8
Mean Payment Per Service User	$25,010	—	$19,878

Table 29. Physician Service Use, by MS-DRG and by Episode Definition: LTCH-Initiated Episodes, 2008

MS-DRG	7 Days Prior to Initiating Event1	A. 30-Day Variable Episode	B. 30-Day Variable Episode Excluding Acute Hospital Readmissions	C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge
An initiating event is defined as an LTCH claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Physician claims with dates of service falling between the admission date on an index acute hospitalization and the last date of episode were identified from the Medicare Carrier claims using physician specialty codes and the dollars associated with these services were included in episode payment calculations.
All MS-DRGs
Percent with Claim	54.2	92.8	92.3	92.6
Mean Payment Per Service User	$401	$4,306	$2,908	$3,084
885: Psychoses
Percent with Claim	56.5	96.4	96.4	96.4
Mean Payment Per Service User	$174	$1,718	$1,523	$1,454
207: Respirator system diagnosis w ventilator support 96+ hours
Percent with Claim	42.6	85.3	84.4	85.3
Mean Payment Per Service User	$820	$6,691	$4,638	$5,556
189: Pulmonary edema & respiratory failure
Percent with Claim	48.5	87.3	86.3	86.3
Mean Payment Per Service User	$580	$6,596	$3,624	$4,084
593: Skin ulcers w CC
Percent with Claim	53.6	96.4	95.9	95.9
Mean Payment Per Service User	$217	$3,665	$2,551	$2,559
592: Skin ulcers w MCC
Percent with Claim	50.8	97.9	97.9	97.9
Mean Payment Per Service User	$269	$5,552	$3,432	$3,698

Table 30. Top 10 RICs, IRF-Initiated Episodes, 2006-2008

Rank 2008	Rank 2007	Rank 2006	RIC	N 2008	Percent 2008	Cumulative Percent 2008
Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM155).
1	1	1	RIC 01: Stroke	1,917	16.0	16.0
2	2	2	RIC 06: Neurological Conditions	1,875	15.7	31.7
3	3	4	RIC 09: Other Orthopedic	1,648	13.8	45.5
4	4	3	RIC 20: Miscellaneous	1,427	11.9	57.4
5	5	5	RIC 07: Lower Extremity Fracture	994	8.3	65.7
6	6	6	RIC 08: Lower Extremity Joint Replacement	710	5.9	71.7
7	8	7	RIC 16: Pain Syndrome	445	3.7	75.4
8	9	8	RIC 05: Spinal Cord Dysfunction, Non-Traumatic	441	3.7	79.1
9	7	9	RIC 10: Amputation, Lower Extremity	376	3.1	82.2
10	11	11	RIC 02: Brain Dysfunction, Traumatic	373	3.1	85.4

Table 31. Top 10 RICs, Acute Hospital-Initiated Episodes, Beneficiaries Discharged to IRF, 2008

Rank	RIC	N	Percent	Cumulative Percent
Source: RTI analysis of 2008 Medicare claims (M3MM155).
1	RIC 01: Stroke	12,010	21.3	21.3
2	RIC 07: Lower Extremity Fracture	10,644	18.9	40.1
3	RIC 08: Lower Extremity Joint Replacement	10,516	18.6	58.8
4	RIC 20: Miscellaneous	4,921	8.7	67.5
5	RIC 09: Other Orthopedic	3,463	6.1	73.6
6	RIC 06: Neurological Conditions	3,248	5.8	79.4
7	RIC 14: Cardiac	2,173	3.9	83.2
8	RIC 03: Brain Dysfunction, Non-Traumatic	2,039	3.6	86.8
9	RIC 05: Spinal Cord Dysfunction, Non-Traumatic	2,000	3.5	90.4
10	RIC 02: Brain Dysfunction, Traumatic	1,598	2.8	93.2

As observed in the other types of community entrants, a higher proportion of beneficiaries initiating care in an IRF use only IRF services in their episode (Table 32) compared with beneficiaries initiating their episode in acute hospitals and discharged to IRF as their first setting of PAC (Table 33) (24.3 percent versus 8.7 percent, respectively). A similar proportion of beneficiaries in each sample are discharged to HHA only following their episode, 22.6 percent among community-initiated episodes and 26.4 percent among beneficiaries initiating their episode in an acute hospital.

Table 32. Episode Patterns: IRF-Initiated Episodes, 2008

Rank	Episode Pattern	N	Percent	Cumulative Percent
Note: Episode pattern is based on a 30-day variable episode definition. A = Acute hospital, S = SNF, H = HHA, I = IRF, L = LTCH, O = outpatient department therapy, T = independent therapist. Source: RTI analysis of 2008 Medicare claims (M3MM157).
1	I	2,910	24.3	24.3
2	IH	2,708	22.6	47.0
3	IO	1,220	10.2	57.2
4	IS	594	5.0	62.2
5	ISH	442	3.7	65.9
6	IHO	328	2.7	68.6
7	IT	214	1.8	70.4
8	IA	194	1.6	72.0
9	IHA	164	1.4	73.4
10	ISO	155	1.3	74.7

Table 33. Episode Patterns: Acute Hospital-Initiated Episodes, Beneficiaries Discharged to IRF, 2008

Rank	Episode Pattern	N	Percent	Cumulative Percent
Note: Episode pattern is based on a 30-day variable episode definition. A = Acute hospital, S = SNF, H = HHA, I = IRF, L = LTCH, O = outpatient department therapy, T = independent therapist Source: RTI analysis of 2008 Medicare claims (M3MM187).
1	AIH	14,900	26.4	26.4
2	AIO	5,961	10.6	37.0
3	AI	4,902	8.7	45.6
4	AIHO	3,158	5.6	51.2
5	AISH	2,337	4.1	55.4
6	AIHT	2,268	4.0	59.4
7	AIS	1,826	3.2	62.6
8	AIT	1,775	3.1	65.8
9	AIHA	1,410	2.5	68.3
10	AIA	1,114	2.0	70.3

Table 34 presents the IRF-initiated episode summary statistics per year of analysis and by episode definition. The mean episode length under episode definition C, any claim initiating within 30 days was 47.8 days, but this increased to 92.2 days under the longer 30-day variable-length episode definition. Patterns of use and payment per episode definition were similar across the years of data. In Table 35, the total IRF utilization per episode is shown for beneficiaries with acute hospital-initiated episodes discharged to IRF and for beneficiaries with IRF-initiated episodes. Across the episode definitions and years of data shown here, beneficiaries with IRF-initiated episodes had slightly longer mean episode length of stay, but slightly lower mean episode payments compared to beneficiaries with acute hospital-initiated episodes discharged to IRF.

Table 34. Summary Statistics: IRF-Initiated Episodes, 2006-2008

Episode Definition	N	Mean Initiating Event LOS (days)1	Mean Initiating Event Payment1	Mean Episode LOS (days) 2	Mean Episode Payment2
An initiating event is defined as a IRF claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Episode length of stay is defined as the difference between the admission date on the first episode claim and the discharge date on the last episode claim. Episode payments include Medicare payments for SNF, IRF, LTCH, HHA, and therapy. Note that acute hospitalizations are also included in episode payments for episode definitions A and C. Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM143).
2008
A. 30-Day Variable Episode	11,956	13.0	$13,833	92.2	$27,563
B. 30-Day Variable Episode Excluding Acute Hospitalization	11,956	13.0	$13,833	67.1	$19,349
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	11,956	13.0	$13,833	47.8	$20,932
2007
A. 30-Day Variable Episode	11,564	13.2	$13,836	91.1	$26,734
B. 30-Day Variable Episode Excluding Acute Hospitalization	11,564	13.2	$13,836	66.9	$19,001
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	11,564	13.2	$13,836	48.3	$20,622
2006
A. 30-Day Variable Episode	11,936	13.2	$13,391	89.7	$25,486
B. 30-Day Variable Episode Excluding Acute Hospitalization	11,936	13.2	$13,391	63.5	$18,055
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	11,936	13.2	$13,391	46.4	$19,537

Table 35. IRF Utilization, IRF Initiated Episodes versus Beneficiaries With Acute Initiated Episodes Discharged to IRF, 2006-2008

Episode Definition	Mean IRF Length of Stay (days) per IRF Initiated Episode	Mean IRF Payment per Episode per IRF Initiated Episode	Mean IRF Length of Stay (days) per Acute Initiated Episode Discharged to IRF	Mean IRF Payment per Episode per Acute Initiated Episode Discharged to IRF
Length of stay and payments include index event plus subsequent service use in the episode. Source: RTI Analysis of 2006, 2007, and 2008 Medicare Claims (M3MM260, M3MM261).
2008
A. 30 day Variable Episode	14.4	$15,436	14.1	$17,224
B. 30 Day Variable Episode Excluding Acute Hospitalization	13.3	$14,164	12.9	$15,836
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	13.7	$14,605	13.4	$16,453
2007
A. 30 day Variable Episode	14.5	$15,310	13.9	$16,850
B. 30 Day Variable Episode Excluding Acute Hospitalization	13.5	$14,113	12.8	$15,551
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	13.8	$14,539	13.2	$16,138
2006
A. 30 day Variable Episode	14.4	$14,795	13.5	$15,946
B. 30 Day Variable Episode Excluding Acute Hospitalization	13.4	$13,666	12.5	$14,763
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event	13.8	$14,093	13.0	$15,291

In examining the service-specific utilization for IRF community entrants (Table 36) and for beneficiaries initiating their episodes in an acute hospital and discharged to IRF (Table 37), a higher proportion of beneficiaries with acute hospital-initiated episodes used HHA under the 30-day variable-length episode definition (62.7 percent compared with 48.1 percent) and had an acute hospitalization (29.3 percent compared with 22.9 percent), again demonstrating the likely differences in medical complexity between these two groups of beneficiaries. Physician service use for beneficiaries with IRF-initiated episodes is presented in Table 38. Of beneficiaries with IRF-initiated episodes, 65 percent had at least one physician claim in the week prior to the initiating event, and over 80 percent of beneficiaries with IRF-initiated episodes in RIC 09 (Other Orthopedic) had at least one physician claim prior to the start of the episode.

Table 36. Service-Specific Summary Statistics: IRF-Initiated Episodes, 2008

Service Use (N = 11,956)	A. 30-Day Variable Episode	B. 30-Day Variable Episode Excluding Acute Hospitalization	C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event
Service use for the initiating event is not included in this calculation. IRF use following first claim reported here. Episode definition B excludes acute hospitalizations. Therefore values for acute hospitalization are missing for this episode definition. Source: RTI analysis of 2008 Medicare claims (M3MM143, M3MM213).
HHA
Percent with Claim	48.1	42.6	40.0
Mean Visits	38.2	30.7	21.9
Mean Claim Length (days)	81.5	65.9	41.9
Mean Payment Per Service User	$6,082	$5,007	$3,710
SNF
Percent with Claim	24.1	17.4	20.3
Mean LOS (days)	52.9	44.3	43.5
Mean Payment Per Service User	$17,725	$14,755	$14,683
IRF (not including initiating event)1
Percent with Claim	7.8	2.0	4.4
Mean LOS (days)	17.8	15.9	15.6
Mean Payment Per Service User	$20,537	$16,581	$17,490
LTCH
Percent with Claim	1.5	0.3	0.7
Mean LOS (days)	33.1	32.4	27.5
Mean Payment Per Service User	$34,871	$28,617	$27,173
Outpatient Department Therapy
Percent with Claim	24.3	20.4	15.7
Mean Payment Per Service User	$1,888	$1,544	$770
Independent Therapist
Percent with Claim	5.7	5.0	3.1
Mean Payment Per Service User	$1,370	$1,240	$396
Acute Hospitalization2
Percent with Claim	22.9	—	13.7
Mean LOS (days)	11.5	—	7.8
Mean Payment Per Service User	$16,910	—	$11,314

Table 37. Service-Specific Episode Summary Statistics: Acute Hospital-Initiated Episodes, Beneficiaries Discharged to IRF, 2008

Service Use (N = 56,439)	A. 30-Day Variable Episode	B. 30-Day Variable Episode Excluding Acute Hospitalization	C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge
By definition, 100 percent of beneficiaries with acute initiated episodes discharged to IRF have at least one IRF claim in their episode. Note that 6.6 percent of beneficiaries in episode definition A, 0.5 percent in episode definition B, and 3.6 percent of beneficiaries in episode definition C have more than one IRF claim in their PAC episode. Episode definition B excludes acute hospitalizations. Therefore values for acute hospitalization are missing for this episode definition. Source: RTI analysis of 2008 Medicare claims (M3MM187).
HHA
Percent with Claim	62.7	55.2	49.6
Mean Visits	34.1	27.3	21.0
Mean Claim Length (days)	68.1	53.5	38.0
Mean Payment Per Service User	$5,712	$4,714	$3,777
SNF
Percent with Claim	24.4	16.8	18.8
Mean LOS (days)	51.7	42.1	39.7
Mean Payment Per Service User	$18,287	$15,016	$14,326
IRF
Percent with Claim1	100.0	100.0	100.0
Mean LOS (days)	14.1	12.9	13.4
Mean Payment Per Service User	$17,224	$15,836	$16,453
LTCH
Percent with Claim	1.4	0.2	0.5
Mean LOS (days)	32.6	27.3	28.4
Mean Payment Per Service User	$33,777	$27,479	$30,960
Outpatient Department Therapy
Percent with Claim	28.5	23.7	14.0
Mean Payment Per Service User	$1,769	$1,484	$640
Independent Therapist
Percent with Claim	11.1	9.8	4.9
Mean Payment Per Service User	$1,577	$1,496	$405
Acute Hospitalization2
Percent with Claim	29.3	—	14.7
Mean LOS (days)	11.5	—	7.9
Mean Payment Per Service User	$17,801	—	$12,376

Table 38. Physician Service Use, by RIC and by Episode Definition: IRF-Initiated Episodes, 2008

RIC	7 Days Prior to Initiating Event1	A. 30-Day Variable Episode	B. 30-Day Variable Episode Excluding Acute Hospital Readmissions	C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge
An initiating event is defined as an IRF claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Physician claims with dates of service falling between the admission date on an index acute hospitalization and the last date of episode were identified from the Medicare Carrier claims using physician specialty codes and the dollars associated with these services were included in episode payment calculations. Source: RTI analysis of 2008 Medicare claims (M3MM226).
All RICs
Percent with Claim	65.0	89.5	89.3	89.3
Mean Payment Per Service User	$532	$2,172	$1,385	$1,433
RIC 1: Stroke
Percent with Claim	58.0	86.9	86.6	86.8
Mean Payment Per Service User	$438	$2,400	$1,445	$1,448
RIC 06: Neurological Conditions
Percent with Claim	61.8	94.2	94.0	94.1
Mean Payment Per Service User	$359	$2,237	$1,442	$1,459
RIC 09: Other Orthopedic
Percent with Claim	80.8	95.6	95.3	95.5
Mean Payment Per Service User	$578	$1,990	$1,389	$1,431
RIC 20: Miscellaneous
Percent with Claim	70.5	93.6	93.4	93.5
Mean Payment Per Service User	$411	$2,288	$1,327	$1,481
RIC 07: Lower Extremity Fracture
Percent with Claim	72.7	89.9	89.8	89.7
Mean Payment Per Service User	$719	$2,228	$1,253	$1,292

Table 39. Mortality Analyses, Acute Hospital-Initiated Episodes, 30-Day Variable-Length Episode Definition, 2008

30-Day Variable-Length Episode Definition	Beneficiaries Alive at End of Episode	Beneficiaries Dying During Episode
An "index acute hospitalization" is defined as a hospital admission following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Episode length of stay is defined as the difference between the admission date on the first episode claim and the discharge date on the last episode claim. Episode payments include Medicare payments for the index acute hospitalization, SNF, IRF, LTCH, HHA, therapy, and acute hospital readmissions. Post-Acute care length of stay is defined as the difference between the admission date on the first PAC episode claim and the discharge date on the last PAC episode claim. Note that for some beneficiaries there may be a gap in service use between the discharge date on the index acute hospital claim and the admission date on the first PAC episode claim. PAC payments include Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospital readmissions. "Per service user" indicates mean Medicare payments for those beneficiaries who use the service. Source: RTI analysis of 2008 Medicare claims (M3MM155).
Number of Beneficiaries	608,499	51,050
Percent of Beneficiaries	92.3	7.7
Mean Index Acute Hospital Length of Stay1	5.9	9.0
Mean Index Acute Hospital Payment1	$10,392	$12,712
Mean Episode Length of Stay (days)2	87.5	84.6
Mean Episode Payments2	$26,281	$46,018
Mean PAC Length of Stay (days)3	79.4	74.5
Mean PAC Payments3	$15,888	$33,306
HHA
Percent with Claim	62.8	34.6
Mean Visits Per Service User4	25.3	31.2
Mean Payment Per Service User4	$4,213	$4,599
IRF
Percent with Claim	9.9	7.3
Mean Length of Stay Per Service User (days)4	14.3	15.6
Mean Payment Per Service User4	$17,444	$18,718
LTCH
Percent with Claim	1.9	10.6
Mean Length of Stay Per Service User (days) 4	32.1	30.3
Mean Payment Per Service User4	$38,092	$40,756
SNF
Percent with Claim	45.8	76.0
Mean Length of Stay Per Service User (days) 4	40.2	33.4
Mean Payment Per Service User4	$13,920	$11,676
Outpatient Therapy
Percent with Claim	21.2	9.6
Mean Payment Per Service User4	$1,410	$1,409
Independent Therapist
Percent with Claim	10.3	1.0
Mean Payment Per Service User4	$1,210	$1,083
Acute Hospital Readmission
Percent with Claim	25.0	68.6
Mean Length of Stay Per Service User (days) 4	10.5	14.9
Mean Payment Per Service User4	$15,891	$24,807

Table 40. Mortality Analyses, Acute Hospital-Initiated Episodes, 30-Day Fixed-Length Episode Definition, 2008

30-Day Fixed-Length Episode Definition	Beneficiaries Alive at End of Episode	Beneficiaries Dying During Episode
An "index acute hospitalization" is defined as a hospital admission following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Episode length of stay is defined as the difference between the admission date on the first episode claim and the discharge date on the last episode claim. Episode payments include Medicare payments for the index acute hospitalization, SNF, IRF, LTCH, HHA, therapy, and acute hospital readmissions. Post-Acute care length of stay is defined as the difference between the admission date on the first PAC episode claim and the discharge date on the last PAC episode claim. Note that for some beneficiaries there may be a gap in service use between the discharge date on the index acute hospital claim and the admission date on the first PAC episode claim. PAC payments include Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospital readmissions. "Per service user" indicates mean Medicare payments for those beneficiaries who use the service. Source: RTI analysis of 2008 Medicare claims (M3MM155).
Number of Beneficiaries	630,573	28,976
Percent of Beneficiaries	95.6	4.4
Mean Index Acute Hospital Length of Stay (days)1	6.0	9.3
Mean Index Acute Hospital Payment1	$10,466	$12,889
Mean Episode Length of Stay (days)2	49.2	39.0
Mean Episode Payments2	$20,885	$28,581
Mean PAC Length of Stay (days)3	41.1	29.0
Mean PAC Payments3	$10,420	$15,693
HHA
Percent with Claim	53.7	21.0
Mean Visits Per Service User4	15.9	8.8
Mean Payment Per Service User4	$2,806	$1,720
IRF
Percent with Claim	9.2	4.5
Mean Length of Stay Per Service User (days)4	13.5	10.5
Mean Payment Per Service User4	$16,585	$12,867
LTCH
Percent with Claim	1.7	8.2
Mean Length of Stay Per Service User (days) 4	28.7	21.6
Mean Payment Per Service User4	$36,040	$31,503
SNF
Percent with Claim	44.0	73.8
Mean Length of Stay Per Service User (days) 4	33.3	18.9
Mean Payment Per Service User4	$11,830	$6,879
Outpatient Therapy
Percent with Claim	12.0	2.5
Mean Payment Per Service User4	$630	$376
Independent Therapist
Percent with Claim	6.6	0.2
Mean Payment Per Service User4	$358	$289
Acute Hospital Readmission
Percent with Claim	13.4	45.1
Mean Length of Stay Per Service User (days) 4	7.3	8.1
Mean Payment Per Service User4	$10,963	$15,680

In the mortality analysis of beneficiaries initiating episodes in HHA, 4.5 percent died under the longer 30-day variable-length episode definition (Table 41) and 2.5 percent died under the shorter 30-day fixed episode definition (Table 42). Under the 30-day variable-length episode definition, beneficiaries dying during the episode have a higher number of HHA visits in the index event than those who survive, but under the shorter 30-day fixed definition, beneficiaries who die have fewer visits during their index HHA claim. A higher proportion of beneficiaries dying during an HHA-initiated episode used IRF, LTCH, SNF, and had an acute hospitalization. Under the 30-day variable definition, 82.5 percent of beneficiaries dying during the episode have an acute hospitalization during their episode compared with 20.3 percent of beneficiaries who survive until the end of the episode. Results were similar across the two episode definitions examined.

Table 41. Mortality Analyses, HHA-Initiated Episodes, 30-Day Variable-Length Episode Definition, 2008

30-Day Variable-Length Episode Definition	Beneficiaries Alive at End of Episode	Beneficiaries Dying During Episode
An "initiating event" is defined as an HHA claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Episode length of stay is defined as the difference between the admission date on the first episode claim and the discharge date on the last episode claim. Episode payments include Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospitalizations. Service use for the initiating event is not included in this calculation. Per service user" indicates mean Medicare payments for those beneficiaries who use the service. Source: RTI analysis of 2008 Medicare claims (M3MM155).
Number of Beneficiaries	225,632	10,675
Percent of Beneficiaries	95.5	4.5
Mean Index HHA Visits1	16.8	17.3
Mean Index HHA Payment1	$2,791	$2,529
Mean Episode Length of Stay (days)2	112.0	135.6
Mean Episode Payments2	$10,685	$33,951
HHA (not including initiating event)3
Percent with Claim	34.9	45.9
Mean Visits Per Service User4	64.4	58.1
Mean Payment Per Service User4	$8,530	$7,423
IRF
Percent with Claim	1.4	3.7
Mean Length of Stay Per Service User (days) 4	16.3	15.2
Mean Payment Per Service User4	$19,359	$18,261
LTCH
Percent with Claim	0.6	6.3
Mean Length of Stay Per Service User (days) 4	34.5	30.0
Mean Payment Per Service User4	$38,546	$38,467
SNF
Percent with Claim	8.0	37.1
Mean Length of Stay Per Service User (days) 4	50.6	35.3
Mean Payment Per Service User4	$17,373	$12,614
Outpatient Therapy
Percent with Claim	7.3	8.6
Mean Payment Per Service User4	$1,388	$1,192
Independent Therapist
Percent with Claim	3.5	1.5
Mean Payment Per Service User4	$1,240	$959
Acute Hospitalization
Percent with Claim	20.3	82.5
Mean Length of Stay Per Service User (days) 4	9.8	15.3
Mean Payment Per Service User4	$14,204	$24,397

Table 42. Mortality Analyses, HHA-Initiated Episodes, 30-Day Fixed-Length Episode Definition, 2008

30-Day Fixed-Length Episode Definition1	Beneficiaries Alive at End of Episode	Beneficiaries Dying During Episode
An "initiating event" is defined as an HHA claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Episode length of stay is defined as the difference between the admission date on the first episode claim and the discharge date on the last episode claim. Episode payments include Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospitalizations. Service use for the initiating event is not included in this calculation. Per service user" indicates mean Medicare payments for those beneficiaries who use the service. Source: RTI analysis of 2008 Medicare claims (M3MM155).
Number of Beneficiaries	230,357	5,950
Percent of Beneficiaries	97.5	2.5
Mean Index HHA Visits1	16.9	12.8
Mean Index HHA Payment1	$2,796	$2,144
Mean Episode Length of Stay (days)2	64.4	50.3
Mean Episode Payments2	$6,173	$17,008
HHA (not including initiating event)3
Percent with Claim	33.5	16.2
Mean Visits Per Service User4	18.6	9.5
Mean Payment Per Service User4	$2,723	$1,709
IRF
Percent with Claim	0.8	1.4
Mean Length of Stay Per Service User (days)4	15.0	12.0
Mean Payment Per Service User4	$17,875	$15,496
LTCH
Percent with Claim	0.2	2.5
Mean Length of Stay Per Service User (days)4	29.7	26.4
Mean Payment Per Service User4	$33,346	$32,695
SNF
Percent with Claim	5.1	24.2
Mean Length of Stay Per Service User (days)4	38.3	20.3
Mean Payment Per Service User4	$13,530	$7,368
Outpatient Therapy
Percent with Claim	4.6	3.8
Mean Payment Per Service User4	$661	$454
Independent Therapist
Percent with Claim	2.7	0.4
Mean Payment Per Service User4	$459	$390
Acute Hospitalization
Percent with Claim	15.2	73.8
Mean Length of Stay Per Service User (days)4	7.0	9.8
Mean Payment Per Service User4	$9,888	$15,951

Analysis of the LTCH-initiated episode revealed that 17.8 percent of LTCH community entrants die before the end of the episode under the 30-day variable-length definition (Table 43). This percentage decreases to 13.5 under the shorter 30-day fixed definition (Table 44). Mean index LTCH length of stay is similar across those who die and those who survive, but under the 30-day variable-length episode the total episode length of stay is much shorter for beneficiaries who die during the episode (68.2 days compared with 108.8 days). A higher proportion of beneficiaries who survive through the end of the episode use subsequent PAC and have acute hospitalization during the episode. Of those that survive until the end of the episode under the 30-day variable length definition, 26.8 percent of beneficiaries who survive have an acute hospitalization compared with 42.0 percent of those who die. Similar results were found in looking at the shorter episode definition; however, the proportion of beneficiaries using each service was lower.

Table 43. Mortality Analyses, LTCH-Initiated Episodes, 30-Day Variable-Length Episode, 2008

30-Day Variable-Length Episode Definition	Beneficiaries Alive at End of Episode	Beneficiaries Dying During Episode
An "initiating event" is defined as an LTCH claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Episode length of stay is defined as the difference between the admission date on the first episode claim and the discharge date on the last episode claim. Episode payments include Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospitalizations. Per service user" indicates mean Medicare payments for those beneficiaries who use the service. Service use for the initiating event is not included in this calculation. Source: RTI analysis of 2008 Medicare claims (M3MM155).
Number of Beneficiaries	4,083	884
Percent of Beneficiaries	82.2	17.8
Mean Index LTCH Length of Stay (days)1	26.5	27.9
Mean Index LTCH Hospital Payment1	$24,850	$33,638
Mean Episode Length of Stay (days)2	108.8	68.2
Mean Episode Payments2	$44,387	$57,006
HHA
Percent with Claim	26.8	11.4
Mean Visits Per Service User3	59.9	50.2
Mean Payment Per Service User3	$8,088	$6,556
IRF
Percent with Claim	3.8	2.3
Mean Length of Stay Per Service User (days)3	18.5	21.2
Mean Payment Per Service User3	$21,436	$24,642
LTCH (not including initiating event)4
Percent with Claim	12.5	17.1
Mean Length of Stay Per Service User (days)3	41.4	38.1
Mean Payment Per Service User3	$37,122	$43,034
SNF
Percent with Claim	33.4	30.7
Mean Length of Stay Per Service User (days)3	60.1	36.5
Mean Payment Per Service User3	$17,544	$11,850
Outpatient Therapy
Percent with Claim	15.3	5.4
Mean Payment Per Service User3	$2,633	$2,200
Independent Therapist
Percent with Claim	1.6	0.2
Mean Payment Per Service User3	$1,400	$110
Acute Hospitalization
Percent with Claim	26.8	42.0
Mean Length of Stay Per Service User (days) 3	14.6	14.9
Mean Payment Per Service User3	$20,996	$26,110

Table 44. Mortality Analyses, LTCH-Initiated Episodes, 30-Day Fixed-Length Episode Definition, 2008

30-Day Fixed-Length Episode Definition	Beneficiaries Alive at End of Episode	Beneficiaries Dying During Episode
An "initiating event" is defined as an LTCH claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Episode length of stay is defined as the difference between the admission date on the first episode claim and the discharge date on the last episode claim. Episode payments include Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospitalizations. Per service user" indicates mean Medicare payments for those beneficiaries who use the service. Service use for the initiating event is not included in this calculation. Source: RTI analysis of 2008 Medicare claims (M3MM155).
Number of Beneficiaries	4,295	672
Percent of Beneficiaries	86.5	13.5
Mean Index LTCH Length of Stay (days)1	26.6	27.5
Mean Index LTCH Hospital Payment1	$25,363	$33,130
Mean Episode Length of Stay (days)2	60.9	38.1
Mean Episode Payments2	$35,565	$41,728
HHA
Percent with Claim	21.0	4.2
Mean Visits Per Service User3	23.1	9.7
Mean Payment Per Service User3	$3,226	$1,974
IRF
Percent with Claim	2.9	0.7
Mean Length of Stay Per Service User (days)3	17.8	17.6
Mean Payment Per Service User3	$21,422	$18,300
LTCH (not including initiating event)4
Percent with Claim	6.9	5.7
Mean Length of Stay Per Service User (days)3	35.1	36.3
Mean Payment Per Service User3	$30,095	$36,978
SNF
Percent with Claim	31.1	17.7
Mean Length of Stay Per Service User (days)3	45.3	17.7
Mean Payment Per Service User3	$13,446	$6,289
Outpatient Therapy
Percent with Claim	6.8	0.7
Mean Payment Per Service User3	$1,150	$568
Independent Therapist
Percent with Claim	0.8	0.1
Mean Payment Per Service User3	$425	$114
Acute Hospitalization
Percent with Claim	17.5	25.6
Mean Length of Stay Per Service User (days)3	10.0	8.6
Mean Payment Per Service User3	$14,662	$20,203

A much smaller proportion of beneficiaries with IRF-initiated episodes die during their episode, likely because beneficiaries in IRFs must be willing to participate in 3 hours of therapy per day. In looking at the 30-day variable-length episode definition, 3.9 percent of beneficiaries die (Table 45) and this decreases to 2.0 percent when looking at the shorter episode definition (Table 46). A higher proportion of beneficiaries with IRF-initiated episodes who die during their episode have more than one IRF claim in their episode, use SNF or LTCH, or have an acute hospitalization compared with those who survive. A higher proportion of beneficiaries surviving until the end of their episode use HHA and therapy services, and these patterns are consistent across the longer and shorter episode definitions.

Table 45. Mortality Analyses, IRF-Initiated Episodes, 30-Day Variable-Length Episode Definition, 2008

30-Day Variable-Length Episode Definition	Beneficiaries Alive at End of Episode	Beneficiaries Dying During Episode
An "initiating event" is defined as an IRF claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Episode length of stay is defined as the difference between the admission date on the first episode claim and the discharge date on the last episode claim. Episode payments include Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospitalizations. Per service user" indicates mean Medicare payments for those beneficiaries who use the service. Service use for the initiating event is not included in this calculation. Source: RTI analysis of 2008 Medicare claims (M3MM155).
Number of Beneficiaries	11,485	471
Percent of Beneficiaries	96.1	3.9
Mean Index IRF Length of Stay (days)1	13.0	12.5
Mean Index IRF Payment1	$13,833	$13,837
Mean Episode Length of Stay (days)2	92.0	98.2
Mean Episode Payments2	$26,538	$52,539
HHA
Percent with Claim	48.5	38.6
Mean Visits Per Service User3	38.0	45.9
Mean Payment Per Service User3	$6,072	$6,396
IRF (not including initiating event)4
Percent with Claim	7.4	18.3
Mean Length of Stay Per Service User (days)3	18.0	15.7
Mean Payment Per Service User3	$20,674	$19,188
LTCH
Percent with Claim	1.2	7.9
Mean Length of Stay Per Service User (days)3	34.6	27.0
Mean Payment Per Service User3	$36,222	$29,687
SNF
Percent with Claim	22.7	57.7
Mean Length of Stay Per Service User (days)3	54.3	39.5
Mean Payment Per Service User3	$18,161	$13,544
Outpatient Therapy
Percent with Claim	24.8	12.1
Mean Payment Per Service User3	$1,898	$1,411
Independent Therapist
Percent with Claim	23.3	2.1
Mean Payment Per Service User3	$1,369	$1,441
Acute Hospitalization
Percent with Claim	20.7	76.6
Mean Length of Stay Per Service User (days)3	10.6	17.6
Mean Payment Per Service User3	$15,043	$29,189

Table 46. Mortality Analyses, IRF-Initiated Episodes, 30-Day Fixed-Length Episode Definition, 2008

30-Day Fixed-Length Episode Definition1	Beneficiaries Alive at End of Episode	Beneficiaries Dying During Episode
An "initiating event" is defined as an IRF claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Episode length of stay is defined as the difference between the admission date on the first episode claim and the discharge date on the last episode claim. Episode payments include Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospitalizations. Per service user" indicates mean Medicare payments for those beneficiaries who use the service. Service use for the initiating event is not included in this calculation. Source: RTI analysis of 2008 Medicare claims (M3MM155).
Number of Beneficiaries	11,716	240
Percent of Beneficiaries	98.0	2.0
Mean Index IRF Length of Stay (days)1	13.0	11.9
Mean Index IRF Payment1	$13,843	$13,324
Mean Episode Length of Stay (days)2	48.1	36.0
Mean Episode Payments2	$20,747	$29,965
HHA
Percent with Claim	40.5	18.3
Mean Visits Per Service User3	21.9	17.8
Mean Payment Per Service User3	$3,718	$2,918
IRF (not including initiating event)4
Percent with Claim	4.3	8.8
Mean Length of Stay Per Service User (days) 3	15.9	10.1
Mean Payment Per Service User3	$17,741	$11,416
LTCH
Percent with Claim	0.6	2.9
Mean Length of Stay Per Service User (days) 3	28.9	13.6
Mean Payment Per Service User3	$28,630	$11,976
SNF
Percent with Claim	19.8	42.9
Mean Length of Stay Per Service User (days) 3	44.5	21.5
Mean Payment Per Service User3	$14,991	$7,749
Outpatient Therapy
Percent with Claim	15.9	2.5
Mean Payment Per Service User3	$772	$173
Independent Therapist
Percent with Claim	3.2	0.0
Mean Payment Per Service User3	$396
Acute Hospitalization
Percent with Claim	12.8	59.2
Mean Length of Stay Per Service User (days) 3	7.7	8.6
Mean Payment Per Service User3	$10,555	$19,314

The mortality analyses conducted here provide important information on the proportion of beneficiaries who die under each type of initiated episode and the episode payment associated with these beneficiaries. Given the finding that episode payments are substantially higher for beneficiaries who die in an episode, these results demonstrate the important implications of mortality status on total episode utilization and payments.

Table 47. Standardized Post-Acute Care Payments for Acute Hospital-Initiated Episodes, by State, 2008, Episode Definition 30-Day Fixed: Any Claim Starting Within 30 Days

State	Number of PAC Users1	Percent of Beneficiaries Discharged to PAC 2(%)	Mean PAC Payment Per Discharge3 ($)	CV4	Mean PAC Payment Per PAC User5 ($)	CV4	Mean PAC LOS Per PAC User6 (days)	CV4
PAC users are defined as beneficiaries discharged to SNF, IRF, LTCH, HHA, or therapy following discharge from an index acute hospitalization. Percentage of beneficiaries discharged to PAC is calculated as the proportion of PAC user of beneficiaries with an index acute hospitalization. An index acute hospitalization is defined as a hospital admission following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Post-Acute care includes Medicare payments for SNF, IRF, LTCH, HHA, therapy and acute hospital readmission. Note that per-hospital discharge calculations include use of acute and Post-Acute care services for beneficiaries who do not meet the criteria of PAC user (use of PAC services following discharge from an index acute hospitalization). This includes acute hospital readmissions for non-PAC users. Coefficient of variation (CV) is the ratio of the standard deviation to the mean. Post-Acute care includes Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospital readmission. Per-PAC user calculations include only beneficiaries discharged to PAC. Post-Acute care length of stay is defined as the difference between the admission date on the first PAC episode claim and the discharge date on the last PAC episode claim. Note that for some beneficiaries there may be a gap in service use between the discharge date on the index acute hospital claim and the admission date on the first PAC episode claim. Source: RTI analysis of 2008 Medicare claims (M3MM200).
Top 5 States for Mean PAC Payment Per PAC User
LA	9,160	35.2	$6,291	2.2	$14,864	1.3	48.7	0.6
TX	41,438	38.3	$6,453	2.0	$14,387	1.2	47.2	0.6
NV	3,853	37.3	$6,355	2.1	$14,359	1.2	39.6	0.6
IN	17,038	37.9	$6,362	2.0	$14,282	1.2	42.2	0.7
OH	29,900	40.2	$6,161	2.0	$12,982	1.2	40.5	0.7
Middle 10 States for Mean PAC Payment Per PAC User
CO	7,266	39.7	$5,418	2.1	$11,571	1.3	37.4	0.7
FL	49,482	43.0	$5,772	1.9	$11,536	1.2	39.9	0.6
NM	2,683	32.1	$4,528	2.2	$11,463	1.2	42.2	0.6
AL	11,617	31.2	$4,442	2.3	$11,457	1.2	45.0	0.6
GA	15,553	32.3	$4,645	2.3	$11,430	1.3	42.2	0.7
MO	16,991	37.2	$5,220	2.1	$11,429	1.3	39.6	0.8
MI	25,376	39.3	$5,306	2.1	$11,293	1.3	41.0	0.7
DE	2,757	42.7	$5,614	1.9	$11,189	1.2	36.7	0.6
NH	3,796	47.3	$4,528	2.2	$11,161	1.3	42.3	0.7
AZ	8,563	30.6	$4,376	2.3	$11,097	1.2	33.8	0.6
Bottom 5 States for Mean PAC Payment Per PAC User
OR	4,578	33.2	$3,838	2.1	$8,925	1.2	35.7	0.6
SD	2,294	35.3	$3,853	2.4	$8,747	1.5	34.0	0.9
MT	2,215	31.9	$3,525	2.4	$8,429	1.4	35.5	0.8
IA	8,498	36.2	$3,787	2.2	$8,092	1.3	32.8	0.8
AK	491	21.7	$2,626	3.1	$7,395	1.8	33.8	0.7

By displaying the mean PAC payment per PAC user and the mean PAC payment per discharge, we can see the effect of using different denominators over which to calculate mean payments at the state level. Comparing both calculations highlights the impact of the percentage of beneficiaries discharged to PAC as well as the use per PAC user. In Figure 4 these differences are shown graphically for 10 states. The states shown here represent two from the top 5 in terms of mean PAC payment per PAC user (Texas and Ohio), three from the middle 10 (Florida, Michigan, and New Hampshire), and 2 from the bottom five (Oregon and Montana). In addition to these 7, we also chose to include Massachusetts, California, and New York in this figure because of their population size and the differences in supply and practice patterns that they represent. The figure displays both the mean payment per PAC user and the mean payment per discharge in these 10 states. By presenting both of these numbers in the same graph, we can see that though Texas has the highest mean PAC payment per PAC user of the states shown here, and Massachusetts has a higher mean payment per discharge due to the higher proportion of beneficiaries in Massachusetts discharged to PAC (50.5%). The dotted lines across the figure represent the mean payment per PAC user based on the mean and median nationally. The national mean and median are shown here to provide benchmarks for comparing state payments to national payments. Six of the 10 states shown here have mean payments per PAC user lower than the national average, and four states have higher mean payments per PAC user than the national average. Differences in provider supply and practice patterns are clearly an important consideration in developing an episode-based payment.

Figure 4. Benchmarking Analysis: Mean PAC Episode Payment Per PAC User, and Per Discharge for Acute Initiated Episodes, By State, Episode Definition 30-day Fixed Any Claim Starting Within 30 Days, 2008

    

Figure 4 is a bar chart reporting the mean PAC payment per discharge and the mean PAC payment per PAC User by state for beneficiaries under the episode definition 30-Day Fixed: Any Claim Starting within 30 Days in 2008. Data for Texas, Ohio, Massachusetts, California, Florida, Michigan, New Hampshire, New York, Oregon, and Montana are shown here. The mean and median national payment per PAC user are also reported to allow for an understanding of how the states compare to each other and how they compare to the nation overall.

Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM200).

Although the state-level PAC episode analysis reveals important differences across geographic areas, the CBSA-level analysis highlights additional variation within states and across metropolitan areas. Table 48 contains PAC episode descriptives for acute hospital-initiated episodes for the top 20 CBSAs in terms of the number of PAC users. Although New York, Illinois, California, Philadelphia, and Massachusetts were not among the top states in mean PAC payment per PAC user, metropolitan areas within these states are at the top in terms of the numbers of beneficiaries using PAC services. Three CBSAs in Texas are among the top 20 nationally, including Houston, Dallas, and rural Texas. In looking at these three CBSA areas alone, we see differences in use patterns within Texas. Although 38.3 percent of beneficiaries are discharged to PAC in Texas overall, 37.0 percent were discharged to PAC in Houston, 38.1 percent in rural Texas, and 41.0 percent in Dallas. There is significant variation in mean PAC payment per PAC user among the CBSAs shown here, with Houston having the highest (and fifth highest across all CBSAs) at $16,188 and Baltimore having the lowest at $10,124.

Table 48. Standardized Post-Acute Care Payments for Acute Hospital-Initiated Episodes, by CBSA, 2008, Episode Definition of 30-Day Fixed: Any Claim Starting Within 30 Days

Top 20 CBSAs by Volume of PAC Users	Number of PAC Users1	Percent of Beneficiaries Discharged to PAC2 (%)	Mean PAC Payment Per Discharge3 ($)	CV4	Mean PAC Payment Per PAC User5 ($)	CV4	Mean PAC LOS Per PAC User6 (days)	CV4
PAC users are defined as beneficiaries discharged to SNF, IRF, LTCH, HHA, or therapy following discharge from an index acute hospitalization. Percentage of beneficiaries discharged to PAC is calculated as the proportion of PAC user of beneficiaries with an index acute hospitalization. An index acute hospitalization is defined as a hospital admission following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Post-Acute care includes Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospital readmission. Note that per-hospital discharge calculations include use of acute and Post-Acute care services for beneficiaries who do not meet the criteria of PAC user (use of PAC services following discharge from an index acute hospitalization). This includes acute hospital readmissions for non-PAC users. Coefficient of variation (CV) is the ratio of the standard deviation to the mean. Post-Acute care includes Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospital readmission. Per-PAC user calculations include only beneficiaries discharged to PAC. Post-Acute care length of stay is defined as the difference between the admission date on the first PAC episode claim and the discharge date on the last PAC episode claim. Note that for some beneficiaries there may be a gap in service use between the discharge date on the index acute hospital claim and the admission date on the first PAC episode claim. Source: RTI analysis of 2008 Medicare claims (M3MM200).
New York-White Plains-Wayne, NY-NJ	23,031	43.1	$5,998	1.7	$11,687	1.1	39.7	0.6
Chicago-Naperville-Joliet, IL	19,111	41.3	$6,105	1.9	$12,354	1.1	41.9	0.6
Los Angeles-Long Beach-Santa Ana, CA	13,403	42.8	$6,682	1.9	$13,320	1.2	43.5	0.6
Philadelphia, PA	9,986	45.6	$5,709	1.9	$10,755	1.2	38.2	0.7
Nassau-Suffolk, NY	9,023	43.2	$5,459	1.7	$10,757	1.0	37.8	0.6
Boston-Quincy, MA	8,151	49.7	$6,735	1.8	$11,881	1.2	43.5	0.6
St. Louis, MO-IL	7,953	39.3	$5,373	2.1	$11,174	1.3	39.5	0.7
Tampa-St. Petersburg-Clearwater, FL	7,546	44.4	$6,119	1.9	$11,995	1.2	39.7	0.6
Houston-Sugar Land-Baytown, TX	7,544	37.0	$7,072	2.1	$16,188	1.2	45.6	0.6
Edison, NJ	7,213	47.4	$6,676	1.7	$12,396	1.0	38.1	0.6
Cleveland-Elyria-Mentor, OH	6,817	41.7	$6,417	1.8	$13,096	1.1	40.5	0.6
Warren-Troy-Farmington-Hills, MI	6,777	40.8	$5,591	2.0	$11,543	1.2	41.7	0.6
Baltimore-Towson, MD	6,652	33.0	$4,377	2.0	$10,124	1.1	34.2	0.6
Atlanta-Sandy Springs-Marietta, GA	6,343	33.6	$4,943	2.3	$11,818	1.3	43.9	0.6
Washington-Arlington-Alexandria DC-VA	6,279	37.6	$4,979	2.0	$10,794	1.2	36.7	0.7
Rural NC	6,003	33.5	$4,641	2.1	$11,083	1.2	41.6	0.7
Newark-Union, NJ-PA	5,836	44.0	$6,518	1.8	$12,904	1.0	39.8	0.6
Dallas-Plano-Irving, TX	5,779	41.0	$6,927	1.9	$14,685	1.1	46.6	0.6
Pittsburgh, PA	5,360	47.0	$6,696	1.9	$12,362	1.2	39.2	0.6
Rural TX	5,128	38.1	$5,743	2.1	$12,789	1.2	48.3	0.6

In addition to the geographic analysis for acute hospital-initiated episodes, we also performed geographic analysis for HHA-initiated episodes. Because of the small numbers of beneficiaries with LTCH- and IRF-initiated episodes at the state and CBSA levels, geographic analyses for these types of episodes are not presented here. Table 49 shows the mean PAC payment per user for the top 5 states, the middle 10 states, and the bottom 5 states. The states with the highest payments per HHA-initiated episode are Indiana and Tennessee, and the states with the lowest payments are Vermont and Oregon. Although there is variation in the PAC episode payment across states, there is also significant variation in the number of beneficiaries with HHA-initiated episodes in each of the states shown in Table 49 with Texas, California, and Michigan among the top. To reveal more about the geographic areas with the highest volume of these types of cases, Table 50 presents the top 20 CBSAs in terms of the number of HHA-initiated episodes. Although Chicago and Los Angeles have the highest volume of HHA community-initiated episodes, these types of episodes are also common to several different metropolitan areas in Texas and Florida as well as rural areas of Texas, Mississippi, Oklahoma, and North Carolina.

Table 49. Standardized Post-Acute Care Payments for HHA-Initiated Episodes, by State, 2008, Episode Definition of 30-Day Fixed: Any Claim Starting Within 30 Days

State	N	Mean Episode Payment1 ($)	CV2	Mean Episode LOS1 (days)	CV2
1. Episode length of stay is defined as the difference between the admission date on the first episode claim and the discharge date on the last episode claim. Episode payments include Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospitalizations. 2. Coefficient of variation (CV) is the ratio of the standard deviation to the mean. Source: RTI analysis of 2008 Medicare claims (M3MM200).
Top 5 States for Mean Episode Payment Per User
IN	3,904	$7,732	1.6	66.3	0.6
TN	6,354	$7,656	1.4	76.1	0.5
WV	962	$7,376	1.5	65.2	0.6
CT	3,441	$7,333	1.4	56.9	0.7
WY	186	$7,320	1.5	60.7	0.6
Middle 10 States for Mean Episode Payment Per User
GA	6,706	$6,565	1.5	66.4	0.6
NV	1,779	$6,519	1.6	62.0	0.6
NC	6,650	$6,479	1.5	57.4	0.7
NE	840	$6,461	1.4	53.8	0.7
TX	23,528	$6,451	1.3	86.6	0.4
DE	449	$6,441	1.3	52.0	0.7
MO	4,311	$6,413	1.5	55.5	0.7
VA	5,366	$6,412	1.4	57.8	0.7
WI	1,840	$6,403	1.3	52.6	0.7
MI	14,321	$6,385	1.4	64.7	0.6
Bottom 5 States for Mean Episode Payment Per User
CA	19,251	$5,690	1.4	55.1	0.7
SD	236	$5,621	1.4	42.5	0.8
MT	400	$5,603	1.2	48.8	0.7
VT	739	$5,580	1.3	59.2	0.7
OR	1,733	$5,239	1.3	49.7	0.7

Table 50. Standardized Post-Acute Care Payments for HHA-Initiated Episodes, by CBSA, 2008, Episode Definition of 30-Day Fixed: Any Claim Starting Within 30 Days

CBSA	Number of PAC Users	Mean PAC Payment Per PAC User ($)	CV	Mean PAC LOS Per PAC User (days)	CV
Source: RTI Analysis of 2008 Medicare Claims (M3MM200).
Chicago-Naperville-Joliet, IL	11,599	$6,000	1.8	83.7	0.4
Los Angeles-Long Beach-Santa Ana, CA	9,124	$5,562	1.7	62.9	0.5
Warren-Troy-Farmington-Hills, MI	7,303	$6,158	1.5	67.6	0.5
New York-White Plains-Wayne, NY-NJ	6,447	$6,042	1.6	51.3	0.6
Miami-Miami Beach-Kendall, FL	5,261	$4,836	1.6	57.7	0.5
Tampa-St. Petersburg-Clearwater, FL	5,005	$6,081	1.6	53.3	0.6
West Palm Beach-Boca Raton-Boynton FL	4,311	$5,752	1.6	53.2	0.6
Houston-Sugar Land-Baytown, TX	4,297	$6,410	1.6	87.9	0.4
Dallas-Plano-Irving, TX	3,885	$6,376	1.8	88.3	0.3
Ft Lauderdale-Pompano Beach-Deerfield	3,136	$5,548	1.7	56.5	0.6
Rural TX	3,098	$6,316	1.5	88.8	0.4
Atlanta-Sandy Springs-Marietta, GA	2,956	$6,518	1.7	68.0	0.5
Philadelphia, PA	2,632	$6,261	1.6	57.8	0.6
McAllen-Edinburg-Mission, TX	2,549	$5,475	1.5	92.1	0.3
Rural MS	2,415	$7,398	1.8	86.9	0.4
Detroit-Livonia-Dearborn, MI	2,408	$6,587	1.7	67.6	0.6
St. Louis, MO-IL	2,274	$6,421	1.5	57.2	0.6
Jacksonville, FL	2,019	$6,182	1.6	62.7	0.5
Rural OK	1,926	$7,134	1.7	89.2	0.4
Rural NC	1,893	$6,858	1.6	61.9	0.6

Figure 5. Percentage of Beneficiaries with an Acute or PAC Claim Following Discharge From Initiating Event, by Type of Initiating Event

   

Figure 5 reports the percentage of beneficiaries with at least one acute or PAC claim following discharge from an initiating event, by initiating event, for each of the twenty-four 30-day windows included in the longitudinal cohort analysis.

Note: All initiating events occurred in 2006. Twenty-four 30-day windows were constructed following discharge from the initiating event to follow service use for 2 years.
Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM197).

While Figure 5 provides information on the percentage of beneficiaries using different services following discharge from an initiating event, Figure 6 provides information on the payment associated with that service use by type of initiating event. Payments are presented per PAC user, so the denominator is constant across each window and includes all beneficiaries with an initiating event. Mean payments per PAC user are highest for beneficiaries with acute hospital-initiated episodes in the first 30 days following discharge from the initiating event, but for the remainder of the analysis period, beneficiaries with LTCH-initiated episodes have the highest payments per PAC user. Although beneficiaries with HHA-initiated episodes had the highest proportion of beneficiaries with at least one acute or PAC claim after 90 days (as seen in Figure 5), the payments associated with this use are low and likely indicative of ongoing HHA and therapy services.

Figure 6. Mean Acute and PAC Payments Per PAC User Following Discharge From Initiating Event, by Type of Initiating Event

   

Figure 6 reports the mean acute and PAC payments per PAC User following discharge from an initiating event, by initiating event, for each of the twenty-four 30-day windows included in the longitudinal cohort analysis.

Note: All initiating events occurred in 2006. Twenty-four 30-day windows were constructed following discharge from the initiating event to follow service use for 2 years.
Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM197).

For beneficiaries with acute hospital-initiated episodes, Figure 7 and Figure 8 provide more detail on the percentage of beneficiaries with a claim by service type and the mean payments per PAC user by service type. Although physician service use is not included in Figure 5 or Figure 6, these services were included in Figure 7 and Figure 8 to demonstrate the high proportion of physician service use following discharge from an acute hospital-initiated episode and the continued use of these services over the 2-year period. In looking specifically at PAC services, HHA and SNF service use is relatively high compared with other PAC services in the first 90 days following discharge from an acute hospitalization. While 10 percent of beneficiaries use IRF in the first 30 days after discharge, this percentage decreases to less than 1 percent for the remainder of the analysis period. The proportion of beneficiaries with an acute hospitalization is highest in the first 90 days following discharge from the index hospitalization and then decreases for the remainder of the analysis period. After day 90, use of HHA and acute hospitalization are most common among beneficiaries with acute hospital-initiated episodes. The payments per PAC user shown in Figure 8 reveal that the payments per PAC user for SNF are highest up until day 60, but the payments per PAC user for acute hospitalizations are highest for the remainder of the analysis period. Although a high proportion of beneficiaries use physician services in each window, the payments associated with these services are very low.

Figure 7. Percentage of Beneficiaries with an Acute, PAC, or Physician Claim Following Discharge From an Acute Initiating Event, by Type of Claim

    

Figure 7 reports the percentage of beneficiaries with at least one acute, PAC, or physician claim following discharge from a acute hospital-initiating event, by type of claim (HHA, IRF, LTCH, SNF, readmission, hospital outpatient therapy, independent therapy and physician services) for each of the twenty-four 30-day windows included in the longitudinal cohort analysis.

Note: All initiating events occurred in 2006. Twenty-four 30-day windows were constructed following discharge from the initiating event to follow service use for 2 years.
Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM181).

Figure 8. Mean Acute, PAC, and Physician Payments Per User PAC User Following Discharge From an Acute Hospital-Initiated Event, by Type of Claim

    

Figure 8 reports the mean acute, PAC, and physician payments per PAC Users following discharge from an acute hospital-initiating event, by type of claim (HHA, IRF, LTCH, SNF, readmission, hospital outpatient therapy, independent therapy and physician services) for each of the twenty-four 30-day windows included in the longitudinal cohort analysis.

Note: All initiating events occurred in 2006. Twenty-four 30-day windows were constructed following discharge from the initiating event to follow service use for 2 years.
Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM181).

To learn more about the differences in use patterns over a 2-year period for beneficiaries with different diagnoses in their acute initiating event, we looked at the mean acute and PAC payments for beneficiaries in the top five MS-DRGs in terms of volume of discharges to PAC (Figure 9). Beneficiaries in MS-DRG 065, "Intracranial hemorrhage or cerebral infarction w CC," and beneficiaries in MS-DRG 481, "Hip & femur procedures except major joint w CC," had the highest payments per PAC user for the first 90 days following discharge from the index acute hospitalization. Payments per PAC user for beneficiaries in MS-DRG 470 decreased at the fastest rate and were lowest among the top five MS-DRGs starting at 30 days following discharge from the index hospitalization.

Figure 9. Mean Acute and PAC Payments Per PAC User Following Discharge From an Acute Initiating Event, by MS-DRG

    

Figure 9 reports the mean acute and PAC payments per PAC User following discharge from an acute hospital- initiating event, by MS-DRG, for each of the twenty-four 30-day windows included in the longitudinal cohort analysis. Five MS-DRGs are shown here including MS-DRG 470 "Major joint replacement or reattachment of lower extremity w/o MCC"; MS-DRG 194 "Simple pneumonia & pleurisy w CC; MS-DRG 065 "Intracranial hemorrhage or cerebral infarction w CC; MS-DRG 690 "Kidney & urinary tract infections w/o MCC'; and MS-DRG 481 "Hip & femur procedures except major join w CC."

Note: All initiating events occurred in 2006. Twenty-four 30-day windows were constructed following discharge from the initiating event to follow service use for 2 years.
Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM181).