Examining Post Acute Care Relationships in an Integrated Hospital System. 3.3 Diagnosis Related Groups by Hospital and Post-Acute Care Setting

Table 3-6 presents the 20 most common acute hospital DRGS in 2006 (for beneficiaries who go on to PAC as well as beneficiaries not using PAC). For each DRG, Table 3-6 shows the total number of hospital discharges, the percent of all hospital discharges that each DRG accounts for, the average Medicare payment for index acute hospital stays with this DRG, and the percent of beneficiaries in the DRG that go on to use PAC services. The most common type of acute hospital discharge is DRG 544: Major Joint Replacement or Reattachment of Lower Extremity. This DRG represents over 5.0 percent of all hospital discharges in 2006, and 87.0 percent of beneficiaries is this DRG go on to use PAC services. The next two most common acute hospital DRGs are DRG 089: Simple Pneumonia and DRG 127: Heart Failure and Shock. While these two DRGs account for high numbers of acute hospital discharges, they are much less likely to use PAC; only one-third of each of these cases is discharged to PAC. Still, as shown on Table 3-7, these DRGs rank 3^rd and 4^th in terms of the highest volume of discharges among beneficiaries using PAC services. Despite the fact that only one-third of beneficiaries in these two DRGs go on to use PAC following hospital discharge, the high volume of these DRGs in the acute hospital leads to their high proportion in the PAC population. Two DRGs that are most common in acute hospital discharges but that are not likely to use PAC services are DRG 143: Chest Pain and DRG 588: Percutaneous Cardiovascular Procedure, with less than 10.0 percent and 5.0 percent, respectively use PAC. Although DRG 544 is the most common DRG for hospital discharges, it is not the most costly. DRG 148: Major Small & Large Bowel Procedures represents only 1.0 percent of all hospital discharges, yet the average acute index admission payment for is $19,713, the highest among the 20 most common acute hospital DRGs. Almost half these cases (46.4 percent of live hospital discharges)

Table 3-7 presents the 20 most common acute hospital DRGs discharged to PAC by volume and the percent of beneficiaries discharged to each first site of care for each DRG. Note the overlap between Tables 3-6 and 3-7, in that 15 of the top 20 DRGs for all hospital discharges are among the top 20 DRGs discharged to PAC. DRG 545: Revision of Hip or Knee Replacement and DRG 236: Fractures of Hip and Pelvis are two DRGs for which over 80% of all discharges go on to use PAC services but are not among the 20 most common DRGs for all acute hospital discharges.

The goal of Table 3-7 is to show how patients with the same index acute hospital DRG may be discharged to multiple settings, although the distribution of discharges by type of setting may differ by whether the case is primarily medical or rehabilitation-oriented. The DRG from the index acute admission, rather than the diagnosis on the post-acute care claim, was used in order to standardize the analysis of post-acute episodes. Note that the 2006 DRG designations are presented here.

Of the 35.2 percent of beneficiaries in our episode file with an index acute hospital discharge who go on to use PAC, the most common DRG is 544 Major Joint & Limb Reattachment Procedures of Lower Extremity (typically hip or knee replacement procedures). Over 87.0 percent of beneficiaries in this DRG go on to use PAC. These rehabilitation patients are admitted to a range of settings following discharge from the acute hospital. In this DRG, 19.4 percent are discharged to IRFs, 37.3 percent are discharged to SNFs, and 35.7 percent are discharged to HHAs. In our analyses of the 2005 episode data, DRGs 209 and 544 were coded separately, and in 2006 both of these DRGs were combined. The proportion of beneficiaries in this DRG discharged to IRF decreased from 2005 to 2006. In 2005, 25.7 percent of beneficiaries in DRG 209 were discharged to IRF (23.2 percent of beneficiaries in DRG 544). In 2006, 19.4 percent of beneficiaries in DRG 544 were discharged to IRF. This decrease is likely due to increased compliance with statutory requirements that at least a minimum percentage of an inpatient rehabilitation facility's (60.0 percent of admissions, as of July 2006) patient population require treatment for at least one of thirteen conditions.

The thirteen conditions meeting the statutory requirements include hip fractures, but do not include knee replacements. Therefore, beneficiaries with knee replacements are more likely to be discharged to the other PAC settings, especially SNFs as IRFs try to maintain compliance with the 60.0 percent rule and maintain inpatient rehabilitation facility status and payments under the IRF prospective payment system.

The second most common DRG among PAC users is DRG 014 Specific Cerebrovascular Disorders except TIA. Over 58.0 percent of beneficiaries discharged from an acute hospital stay in this DRG go on to use PAC services. These beneficiaries are most frequently discharged from the hospital to SNFs (35.6 percent) or IRFs (34.4 percent), and a smaller proportion are discharged to HHAs (19.7 percent). Beneficiaries in DRG 089 Simple Pneumonia are less likely to use any PAC services (33.6 percent), and when they are discharged to PAC, they are typically discharged to less intense settings of care such as SNF (47.3 percent) or HHA (37.4 percent). In general, the majority of PAC cases are discharged to SNFs or HHAs but, as shown in Table 3-7, IRF services make up a substantial share of services used for certain DRGs, such as DRG 014, DRG 210 Hip and Femur Procedures Except Major Joint, DRG 236 Fractures of Hip & Pelvis, and DRG 545 Revision of Hip or Knee Replacement. These results clearly indicate that the first site of PAC varies by DRG.

While patients may be discharged to different settings, the relative frequency of that type of case within each setting may vary. Table 3-8 illustrates the relative ranking within each site of care for the top 20 index acute hospital DRGs by volume among beneficiaries discharged to PAC. As noted above, DRG 544 was the most common DRG with 15,261 admissions in 2006. This high volume DRG was also the most common admission to IRF, SNF, HHA, and hospital outpatient therapy settings, and ranked 9^th for beneficiaries discharged to LTCHs.

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