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

02/01/2009

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 3rd and 4th 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.

Table 3-6. Top 20 Acute Hospital Discharges, Mean Index Admission Payment, and Percent Using PAC, 2006

Acute Index DRG1 Number of All Hospital Discharges Percent of All Hospital Discharges Mean Acute Index Admission Payment Percent Using PAC
1. NOTE: FY 2006 DRG titles were used in this analysis.
SOURCE: RTI analysis of 2006 Medicare Claims 5% sample.
544: Major Joint Replacement or Reattachment of Lower Extremity 17,475 5.5 $10,504 87.3
089: Simple Pneumonia & Pleurisy Age > 17 w CC 13,911 4.3 $5,069 33.6
127: Heart Failure & Shock 12,165 3.8 $5,229 33.7
088: Chronic Obstructive Pulmonary Disease 9,655 3.0 $4,275 25.3
014: Specific Cerebrovascular Disorders except TIA 8,398 2.6 $6,413 58.1
182: Esophagitis, Gastroent & Misc Digest Disorders Age > 17 w CC 8,071 2.5 $3,967 17.9
143: Chest Pain 6,580 2.1 $2,448 7.8
174:G.I. Hemorrhage w CC 6,448 2.0 $5,201 22.6
558: Percutaneous Cardiovascular Proc w Drug-Eluting Stent 6,025 1.9 $12,587 3.5
320: Kidney & Urinary Tract Infections Age > 17 w CC 5,666 1.8 $4,229 42.3
138: Cardiac Arrhythmia & Conduction Disorders w CC 5,646 1.8 $4,100 21.9
316: Renal Failure 5,106 1.6 $6,823 36.2
416: Septicemia Age > 17 4,981 1.6 $9,165 40.1
296: Nutritional & Misc Metabolic Disorders Age > 17 w CC 4,946 1.5 $3,979 35.5
557: Percutaneous Cardiovasc Proc with Drug Eluting Stent w major cardiovascular diagn 4,081 1.3 $17,055 13.7
210: Hip & Femur Procedures except Major Joint Age > 17 w CC 4,055 1.3 $10,013 87.6
141: Syncope and Collapse 3,605 1.1 $3,647 27.3
524: Transient Eschemia 3,527 1.1 $3,408 25.1
277: Cellulitis Age > 17 w CC 3,110 1.0 $4,394 38.7
148: Major Small & Large Bowel Procedures w CC 3,097 1.0 $19,713 46.4

Table 3-7. First Site of PAC, by Acute Index Admission DRG, Top 20 DRGs by Volume for PAC Users, 2006

Acute Index DRG1 Total Hospital Discharges
for PAC Users
Percent Using PAC2 Percent of Beneficiaries Discharged to Each Setting3
LTCH IRF SNF HHA Outpatient
1. FY 2006 DRG titles were used in this analysis.
2. Indicates the percent of beneficiaries discharged from the acute hospital with this DRG who go on to use PAC.
3. Indicates the percent of PAC users in the DRG discharged to each type of post-acute setting.
SOURCE: RTI analysis of 2006 Medicare Claims 5% sample.
544: Major Joint Replacement or Reattachment of Lower Extremity 15,261 87.3 0.3 19.4 37.3 35.7 7.4
014: Specific Cerebrovascular Disorders Except TIA 4,882 58.1 1.8 34.4 35.6 19.7 8.5
089: Simple Pneumonia & Pleurisy Age >17 w CC 4,675 33.6 1.2 1.8 47.3 37.4 12.2
127: Heart Failure & Shock 4,096 33.7 1.1 1.9 39.1 49.4 8.5
210: Hip & Femur Procedures except Major Joint Age >17 w CC 3,552 87.6 1.1 25.3 63.9 7.1 2.6
088: Chronic Obstructive Pulmonary Disease 2,439 25.3 1.8 2.3 32.4 52.2 11.3
320: Kidney & Urinary Tract Infections Age >17 w CC 2,396 42.3 0.7 2.0 63.6 25.1 8.7
416: Septicemia Age >17 1,996 40.1 3.5 3.0 57.8 26.0 9.8
316: Renal Failure 1,848 36.2 1.5 2.5 53.2 31.9 10.9
296: Nutritional & Misc Metabolic Disorders Age >17 w CC 1,757 35.5 0.7 3.0 53.7 32.5 10.1
243: Medical Back Problems 1,565 52.8 0.7 9.9 52.0 27.9 9.5
174: G.I. Hemorrhage w CC 1,455 22.6 0.7 2.3 48.0 37.9 11.2
182: Esophagitis, Gastroent & Misc Digest Disorders Age >17 w CC 1,445 17.9 0.8 2.8 42.2 41.6 12.7
148: Major Small & Large Bowel Procedures w CC 1,437 46.4 4.2 4.4 38.2 50.3 2.9
079: Respiratory Infections & Inflammations Age >17 w CC 1,370 45.2 2.8 1.9 61.8 25.0 8.5
121: Circulatory Disorders w Ami & Major Comp Disch Alive 1,363 45.8 1.8 4.3 50.6 38.7 4.6
138: Cardiac Arrhythmia & Conduction Disorders w CC 1,234 21.9 0.7 2.4 39.2 47.7 10.1
277: Cellulitis Age >17 w CC 1,205 38.7 1.9 1.5 38.8 46.2 11.6
236: Fractures of Hip & Pelvis 1,064 81.3 0.7 14.7 66.3 12.8 5.6
545: Revision of Hip or Knee Replacement 1,037 83.8 1.2 20.3 34.4 37.9 6.3

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 9th for beneficiaries discharged to LTCHs.

Table 3-8. Acute Index Admission DRGs, Ranking1 by First Site of PAC, 2006

Acute Index Admission DRG2 First Site of PAC
Total PAC Users LTCH IRF SNF HHA Hospital Outpatient Therapy
Rank # % Rank # % Rank # % Rank # % Rank # % Rank # %
1. Indicates the ranking of this DRG by setting. For example, DRG 544 is the 9th most frequent DRG for beneficiaries discharged to LTCH and accounts for 2.2 percent of beneficiaries discharged to this PAC setting.
2. FY 2006 DRG titles were used in this analysis.
SOURCE: RTI analysis of 2006 Medicare Claims 5% sample (MM2Y096).
544: Major Joint Replacement or Reattachment of Lower Extremity 1 15,261 14.0 9 50 2.2 1 2,963 26.4 1 5,684 12.7 1 5,442 13.3 1 1,122 11.3
014: Specific Cerebrovascular Disorders Except TIA 2 4,882 4.5 3 89 4.0 2 1,678 14.9 4 1,738 3.9 5 960 2.3 3 417 4.2
089: Simple Pneumonia & Pleurisy Age >17 w CC 3 4,675 4.3 7 57 2.6 15 84 0.7 3 2,212 4.9 3 1,749 4.3 2 572 5.7
127: Heart Failure & Shock 4 4,096 3.7 10 44 2.0 17 78 0.7 5 1,600 3.6 2 2,024 5.0 4 350 3.5
210: Hip & Femur Procedures except Major Joint Age >17 w CC 5 3,552 3.3 13 38 1.7 3 899 8.0 2 2,269 5.1 33 253 0.6 20 93 0.9
088: Chronic Obstructive Pulmonary Disease 6 2,439 2.2 11 43 1.9 30 56 0.5 12 790 1.8 4 1,274 3.1 5 276 2.8
320: Kidney & Urinary Tract Infections Age >17 w CC 7 2,396 2.2 30 16 0.7 40 48 0.4 6 1,523 3.4 8 601 1.5 6 208 2.1
416: Septicemia Age >17 8 1,996 1.8 4 70 3.1 28 59 0.5 7 1,153 2.6 15 519 1.3 8 195 2.0
316: Renal Failure 9 1,848 1.7 17 27 1.2 41 47 0.4 8 983 2.2 9 589 1.4 7 202 2.0
296: Nutritional & Misc Metabolic Disorders Age >17 w CC 10 1,757 1.6 38 12 0.5 34 53 0.5 9 944 2.1 11 571 1.4 10 177 1.8
243: Medical Back Problems 11 1,565 1.4 41 11 0.5 10 155 1.4 11 813 1.8 17 437 1.1 13 149 1.5
174: G.I. Hemorrhage w CC 12 1,455 1.3 48 10 0.4 50 33 0.3 14 698 1.6 13 551 1.3 11 163 1.6
182: Esophagitis, Gastroent & Misc Digest Disorders Age >17 w CC 13 1,445 1.3 40 11 0.5 45 40 0.4 17 610 1.4 7 601 1.5 9 183 1.8
148: Major Small & Large Bowel Procedures w CC 14 1,437 1.3 6 61 2.7 24 63 0.6 18 549 1.2 6 723 1.8 56 41 0.4
079: Respiratory Infections & Inflammations Age >17 w CC 15 1,370 1.3 12 38 1.7 62 26 0.2 10 846 1.9 26 343 0.8 18 117 1.2
121: Circulatory Disorders w Ami & Major Comp Disch Alive 16 1,363 1.2 18 24 1.1 29 58 0.5 15 690 1.5 14 528 1.3 31 63 0.6
138: Cardiac Arrhythmia & Conduction Disorders w CC 17 1,234 1.1 51 9 0.4 56 29 0.3 19 484 1.1 10 588 1.4 17 124 1.2
277: Cellulitis Age >17 w CC 18 1,205 1.1 19 23 1.0 78 18 0.2 20 467 1.0 12 557 1.4 15 140 1.4
236: Fractures of Hip & Pelvis 19 1,064 1.0 65 7 0.3 9 156 1.4 13 705 1.6 60 136 0.3 34 60 0.6
545: Revision of Hip or Knee Replacement 20 1,037 0.9 39 12 0.5 5 210 1.9 25 357 0.8 21 393 1.0 29 65 0.7
The most common admissions to the IRF setting are for orthopedic procedures (DRGs 544 and 210), and stroke (DRG 014). Although pneumonia is the 3rd most common index acute hospital DRG among beneficiaries discharged to PAC, and also ranks highly among beneficiaries discharged to SNFs (3rd), HHAs (3rd), and hospital outpatient therapy (2nd), pneumonia ranks 15th among beneficiaries discharged to IRF. This result is expected due to the intensive rehabilitation services delivered in IRFs; patients need to be healthy enough to participate in 3 hours/therapy/day, on average. Another notable finding here is the relatively high ranking of DRG 210 Hip & Femur Procedures Except Major Joint Age > 17 w CC, among beneficiaries discharged to IRFs (3rd) and SNFs (2nd) compared to beneficiaries discharged to HHAs (33rd) and hospital outpatient therapy (20th) reflecting the more frequent use of inpatient services following acute hospital discharge for beneficiaries in this DRG. In general, the top 20 DRGs for index acute admissions are common across the PAC settings, except in LTCHs. The top DRGs for discharges to LTCHs are related to ventilator cases, which occur in very small numbers overall. Other common diagnoses in LTCHs are respiratory and medically complex cases, showing skin conditions, renal failure, and other infections and complications.

The most common admissions to the IRF setting are for orthopedic procedures (DRG 544, and DRG 210) as well as stroke (DRG 014). Though pneumonia is the third most common index acute hospital DRG among beneficiaries discharged to PAC, and also ranks highly among beneficiaries discharged to SNF (3rd), HHA (3rd), and hospital outpatient therapy (2nd), pneumonia ranks 15th among beneficiaries discharged to IRF. This result is expected due to the intensive rehabilitation services delivered in IRFs. Another notable finding here is the relatively high ranking of DRG 210 Hip & Femur Procedures Except Major Joint Age > 17 w CC, among beneficiaries discharged to IRF (3rd) and SNF (2nd) compared to beneficiaries discharged to HHA (33rd) and hospital outpatient therapy (20th) reflecting the more frequent use of inpatient services following acute hospital discharge for beneficiaries in this DRG. In general, the top 20 DRGs for index acute admissions are common across the post-acute care settings except in LTCHs. The top DRGs for discharges to LTCHs are related to ventilator cases which occur in very small numbers overall.

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