1.Public Law 109-432, See Section 1833(t) of the Social Security Act. (December 20, 2006).
2.The data file that RAND obtained from CMS for analysis contained 2005 utilization data and 2007 payment rates. Thus all financial analyses contained in this report apply 2007 payment rates against 2005 utilization experience, and as such cannot be directly mapped to the actual spending numbers that occurred in 2005 using the 2005 payment rates.
3.RAND applied 2007 payment rates to the 2005 frequency data to produce estimates of spending by types of services/procedures. The estimates shown do not reflect true spending that occurred in 2005 as a function of applying 2005 payment rates, so cannot be directly mapped to final spending figures for care provided in the hospital outpatient setting.
4.The service mix index is calculated as the sum of the relative weights of all OPPS services divided by the volume of all services. The concept is similar to the case mix index for inpatient services.
5.Public Law 108-173, December 8, 2003.
6.Section 5001(a), Public Law 109-171, February 8, 2006.
7.Public Law 109-432, See Section 1833(t) of the Social Security Act. (December 20, 2006).
8.The Final OPPS Rule is scheduled to be released November 1, 2007.
9.A subsection d hospital is one located in one of the fifty States or the District of Columbia other than the following: a psychiatric hospital; a rehabilitation hospital; a hospital whose inpatients are predominantly individuals under 18 years of age; a hospital which has lengthy average inpatient lengths of stay (e.g. greater than 25 days); a cancer center
10.International Classification of Disease Version 9.0, Clinical Modification. CMS provided RAND with ICD-9-CM codes aggregated to the fourth of five possible digits. RAND and CMS agreed that this level of detail would provide sufficient specificity in most cases without overwhelming the analysis with the granularity of the five digit level.
11.APCs are categories of outpatient services that are clustered based on similar resources use as well as clinical similarities. OPPS pays a set amount for each APC. The services within each APC are represented by HCPCS codes, which refers to the Healthcare Common Procedure Coding System, a standardized coding system for describing the specific items and services provided in the delivery of health care. These codes are used by Medicare, Medicaid, and other health insurance programs to process claims. The American Medical Association’s (AMA) Current Procedural Terminology (CPT) codes are part of the HCPCS.
12.Based on the analytic file that RAND obtained from CMS, which contained 2005 utilization data and 2007 payment rates, RAND’s spending estimates provided in the tables in this report apply 2007 payment rates to the 2005 utilization data.
13.Not all drugs administered in the HOPS are separately billed under OPPS; drugs under $50 are bundled with the infusion APCs and HCPCS codes. Our analyses of the most costly drugs do not include those drugs that are not separately billed under OPPS.
14.With the exception of transfusion medicine and anatomic pathology, laboratory services are paid under Medicare by the Clinical Laboratory Fee Schedule (CLFS), irrespective of the venue in which they are provided.
15.DME is billed to a separate fee schedule which was not included in the data RAND analyzed.
16.Analyses also did not include APCs with a status indicator of “P”-partial hospitalization or “Q” packaged services subject to separate payment under OPPS, which are both very low frequency services and do not contribute significantly to either the volume or cost of services provided under OPPS.
A list with the groupings of ICD-9-CM utilized for the analyses is available upon request.
17.A list with the groupings of ICD-9-CM utilized for the analyses is available upon request.
18.The subjective classification of diagnoses determines which diagnoses are identified as most frequent. Other approaches to the classification may alter the specific diagnoses that rise to the top.
19.RAND applied 2007 APC payment rates to the 2005 utilization data. The estimates of spending by category assume that the volume and distribution of visits and services/procedures did not substantially change over the two-year period. Note: the estimates shown cannot be mapped to actual 2005 spending figures which are based on 2005 APC payment rates
20.The visit and services/procedure volumes presented in Table 3.1 reflect 2005 data, the most current frequency data that were made available to RAND. RAND applied the 2007 APC payment rates to the 2005 frequency data based on the data obtained from CMS; thus spending estimates shown in this report will not map to final published spending for 2005 based on 2005 payment rates. Drugs/biologicals are excluded from this table because RAND did not have access to complete payment data for these services. Also hospital outpatient expenses not covered under OPPS (e.g., clinical laboratory services) are also not included in this tally.
21.E&M visits were identified using the status indicator V (i.e., the status indicator associated with APC codes that indicate clinic or emergency department visits). Services/procedures were identified with the status indicators S, T or X (i.e., the status indicators associated with APC codes that indicate significant procedures and ancillary services).
22.The data presented in Table 3.1 do not account for all hospital outpatient setting claims, as some hospital outpatient setting services may be entirely procedural and, therefore, not accompanied by a separately identifiable E&M code.
23.Table 3.2 was constructed using 2005 Medicare facility data for services paid through the hospital outpatient prospective payment system (OPPS). Emergency department data were analyzed separately (Table 3.3) from data reflecting care provided in the HOPS. Given the focus on tests and procedures rather than clinic visits, analyses were restricted to APCs with a Status Indicator of S, T or X. The most common diagnoses codes were identified for each of the most frequent APCs. A clinical expert identified the related specialty for the APCs.
24.Table 3.3 was constructed using 2005 Medicare facility data for services paid through the hospital outpatient prospective payment system (OPPS). HOPS data were analyzed separately (Table 3.2) from data reflecting care provided in the ED. Given the focus on tests and procedures rather than clinic visits, analyses were restricted to APCs with a Status Indicator of S, T or X. The most common diagnoses codes were identified for each of the most frequent APCs. A clinical expert identified the related specialty for the APCs.
25.As noted previously, the data file provided to RAND by CMS contained 2007 payment data and 2005 utilization data. The estimates shown here do not reflect actual spending in 2005 as 2005 payment data were not available in the analysis file, thus the estimates provided here cannot be mapped directly to final actual spending in 2005 for Hospital Outpatient Setting care.
26.The expenditure data presented in Table 3.4 reflect APC payment rates for 2007. Based on the data supplied to RAND by CMS, we applied the 2007 payment rates to the 2005 utilization data to provide estimates of spending by type of services. Note: the estimates shown in Table 3.4 cannot be mapped to actual 2005 spending figures which are based on 2005 payment rates.
27.The expenditure data presented in Table 3.5 reflects APC payment rates for 2007. Based on the data supplied to RAND by CMS, we applied the 2007 payment rates to the 2005 utilization data to provide estimates of spending by type of services. Note: the estimates shown in Table 3.4 cannot be mapped to actual 2005 spending figures which are based on 2005 payment rates.
28.Only drugs and biologicals exceeding $50 are separately billable; less-expensive drugs are incorporated into the drug infusion OPPS payments. Consequently this list only represents a subset of the entire spectrum of these treatments that patients receive
29.The NCCN is a not-for-profit alliance of 21 cancer centers that develops evidence-based treatment guidelines for most cancers. The organization has collaborated with ASCO and the Commission on Cancer in the development of cancer measures.
30.The CAHPS Clinician and Group Survey asks patients about their experiences with physicians and their staff in primary and specialty care settings; the Hospital CAHPS survey addresses patient experiences in the inpatient setting.
31.The SCIP is a national quality partnership of organizations working to improving surgical care by significantly reducing surgical complications. The group is focused on four target areas including infection, adverse cardiac events, deep vein thrombosis, and post operative pneumonia.
32.The ASC Quality Collaboration is an 18 member private-public collaboration with representation from CMS, the Joint Commission, the Federated Ambulatory Surgery Association, the American College of Surgeons and others.
33.This table reflects measures that are publicly available.
34.Some hematology diagnoses are also relevant to the oncology/neoplasia subcategory. Anemia includes anemia of chronic disease and other unspecified anemias. Polycythemia vera is the most common red cell condition and unspecified thrombocytopenia is the most frequent platelet condition.
35.General symptoms include presenting complaints that usually have a broad differential diagnosis such as malaise, fever, sleep disturbances, dizziness, headache, swelling, and myalgia.
36.Some measures are included in more than one category such as chemotherapy measures (included in counts for chemotherapy and breast) and radiotherapy (included in radiotherapy, breast and urology).
37.All surgical oncology is included in the oncology/neoplasia category.
38.Includes urinary frequency, retention, incontinence.
39.Health literacy is defined in Healthy People 2010 as: "The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions".
40.Health numeracy is defined as: The degree to which individuals have the capacity to access, process, interpret, communicate, and act on numerical, quantitative, graphical, biostatistical, and probabilistic health information needed to make effective health decisions.
41.For diabetes codes, fifth digits having the following values are translated as follows: 0 = type II or unspecified, not stated as uncontrolled; 1=type I, not stated as uncontrolled; 2=type II or unspecified, uncontrolled; and 3=type I, uncontrolled.