Examining Post Acute Care Relationships in an Integrated Hospital System. 3.6.1 Episode Utilization and Payment, by All Patient Refined Diagnosis Related Group and Medicare Severity Diagnosis Related Group

02/01/2009

In Tables 3-13 through 3-15, episode lengths of stay and Medicare payments during PAC episodes are presented for post-acute care users across all DRGs as well as for post-acute care users in DRG 089 and DRG 544. Within these tables, we show the number of beneficiaries with each claim type, the percent using each type of service, the mean length of stay, and the mean Medicare payments. The results are shown overall and then stratified by APR-DRG severity levels 1 through 4 and by MS-DRG severity level (no CCs, with CCs, with MCCs) in Tables 3-16 through 3-18. These tables illustrate different levels of medical severity for hospital discharges overall as well as for different types of cases (pneumonia versus major joint and limb procedures).

For the APR-DRG severity of illness, there are four levels (1-4) which indicate increasing severity. As discussed previously, the MS-DRG severity system stratifies cases by the presence or absence of complicating or comorbid conditions (CCs). Beneficiaries can be classified in up to 3 categories based on the presence of CCs, (although sometimes these categories will be collapsed, as will be discussed for DRG 544). For DRG 089, beneficiaries were classified into 3 categories. The lowest severity level is "No CC," the middle severity level is "CCs," and the highest severity level is "MCCs" (for "major" comorbid or complicating conditions). We must reiterate that the severity-level split for MS-DRGs is DRG-specific and may not have the same meaning across DRGs.

Post-Acute Care Episodes: All DRGs. The average post-acute episode length of stay for all post-acute users in our 2006 episode file was 81.3 days with corresponding average episode payments of over $30,000 (Table 3-13). In looking at the composition of episodes of care for post-acute users, over 60.0 percent of beneficiaries used home health services as part of their episode and nearly 48.0 percent of beneficiaries used skilled nursing facility services. Claims for beneficiaries using LTCH services were associated with the highest payments, but only a small number of beneficiaries used these services as part of their episode (2.9 percent). Looking at patterns of use for beneficiaries using post-acute care by severity level provides more specific information on how services vary by severity level (Table 3-16). When severity is measured using the APR-DRG, the majority of beneficiaries fell in to APR-DRG Level 2 (47.5 percent) and APR-DRG Level 3 (29.8 percent). When using the MS-DRG severity measure, 56.0 percent of beneficiaries were in the lowest severity level.

Table 3-13. Utilization1 and Payment, by Claim Type, for All Post-Acute Users, 2006
All Post-Acute Users (N=109,236) N % with Claim Mean Use Mean Payment

1. Utilization is measured in days for acute, IRF, LTCH, and SNF; visits for HHA, and units of service for hospital outpatient therapy.

SOURCE: RTI analysis of 2006 Medicare Claims 5% sample (MM2Y091).

Total Episode
(Index Admission + Part A + Part B Days)
109,236 - 81.3 $30,028
Index Admission (Days) 109,236 100.0 6.8 $10,297
Home Health (Visits) 65,901 60.3 25.9 $3,916
IRF (Days) 12,819 11.7 13.9 $16,289
LTCH (Days) 3,165 2.9 32.5 $38,559
SNF (SNF) 52,204 47.8 37.3 $11,242
Hospital Outpatient Therapy (Services) 25,007 22.9 43.5 $1,258
Part B Therapy 6,526 6.0 - $286
Part B Services (excluding Part B therapy) 108,145 99.0 - $3,618
Durable Medical Equipment 46,154 42.3 - $687
Hospice 946 0.9 - $2,797
Acute Readmission (Days) 33,302 30.5 11.5 $15,636

 

Table 3-14. Utilization1 and Payment, by Claim Type, for DRG 089 Live Discharges2, 2006
DRG 089: Simple Pneumonia & Pleurisy Age > 17 w CC N = 4,675 N % with Claim Mean Use Mean Payment

1. Utilization is measured in days for acute, IRF, LTCH, and SNF; visits for HHA, and units of service for hospital outpatient therapy.
2. FY 2006 DRG titles were used in this analysis.

SOURCE: RTI analysis of 2006 Medicare Claims 5% sample (MM2Y090).

Total Episode
(Index Admission + Part A + Part B Days)
4,675 - 72.3 $20,476
Index Admission (Days) 4,675 100.0 6.2 $5,161
Home Health (Visits) 2,396 51.3 24.8 $3,629
IRF (Days) 131 2.8 14.6 $17,448
LTCH (Days) 88 1.9 25.1 $30,352
SNF (SNF) 2,516 53.8 35.0 $10,000
Hospital Outpatient Therapy (Services) 923 19.7 30.1 $946
Part B Therapy 150 3.2 - $265
Part B Services (excluding Part B therapy) 4,651 99.5 - $2,447
Durable Medical Equipment 1,893 40.5 - $599
Hospice 54 1.2 - $1,786
Acute Readmission (Days) 1,479 31.6 10.5 $13,023

 

Table 3-15. Utilization1 and Payment, by Claim Type, for DRG 544 Live Discharges2, 2006
DRG 544: Major Joint Replacement or Reattachment of Lower Extremity N = 15,261 N %
with
Claim
Mean
Use
Mean
Payment

1. Utilization is measured in days for acute, IRF, LTCH, and SNF; visits for HHA, and units of service for hospital outpatient therapy.
2. FY 2006 DRG titles were used in this analysis.

SOURCE: RTI analysis of 2006 Medicare Claims 5% sample (MM2Y090).

Total Episode
(Index Admission + Part A + Part B Days)
15,261 - 64.1 $23,985
Index Admission (Days) 15,261 100.0 4.2 $10,532
Home Health (Visits) 10,639 69.7 18.0 $3,562
IRF (Days) 3,082 20.2 10.7 $12,284
LTCH (Days) 99 0.6 26.1 $27,729
SNF (SNF) 6,132 40.2 24.0 $8,260
Hospital Outpatient Therapy (Services) 5,515 36.1 48.0 $1,053
Part B Therapy 639 4.2 - $295
Part B Services (excluding Part B therapy) 15,118 99.1 - $2,628
Durable Medical Equipment 8,467 55.5 - $262
Hospice 28 0.2 - $1,461
Acute Readmission (Days) 2,176 14.3 8.1 $12,952

Post-Acute Care Episodes: DRGs 089 and 544. In looking at beneficiaries in DRGs 089 and DRG 544 overall, there are several important differences in patterns of use (Table 3-14 and Table 3-15). The average episode length of stay for beneficiaries in DRG 089 was 72.3 days compared to 64.1 days for beneficiaries in DRG 544. Though the episode length of day was longer for beneficiaries in DRG 089, the episode payments for these beneficiaries was lower than for beneficiaries in DRG 544 ($20,476 for DRG 089 vs. $23,985 for DRG 544). This difference is likely due to the services received in the inpatient setting. Beneficiaries in DRG 544 are more likely to have received surgical procedures compared to beneficiaries admitted for pneumonia and these procedures are likely reflected in the index acute hospital payments ($5,161 for DRG 089 vs. $10,532 for DRG 544). Use of post-acute services also differed for these beneficiaries. Nearly 70.0 percent of beneficiaries in DRG 544 used home health services in their episodes of post-acute care compared to over 51.0 percent of beneficiaries in DRG 089. A higher proportion of beneficiaries in DRG 089 used SNF services compared to beneficiaries in DRG 544 (53.8 percent vs. 40.2 percent). Beneficiaries in DRG 544 had significantly higher use of IRF services compared to beneficiaries in DRG 089 due as expected give the need for rehabilitative services for beneficiaries recovering from replacement procedures (20.2 percent vs. 2.8 percent).

In Table 3-16 we see that in general, episode lengths of stay and payments rise with increasing severity both when severity is measured using the APR-DRG and when severity is measured using the MS-DRG. For example in looking at episode lengths of stay across all DRGs in the healthiest MS-DRG level, "No CCs", the length of stay was 75.4 days and payments were $26,609 compared to MS-DRG level "MCCs" where length of stay was 91.3 days and payments were $39,587. Patterns of service use within episodes clearly varied by severity level as well. The proportion of beneficiaries using LTCH services increased with increasing severity reflecting the increasing medical complexity of those in the highest severity levels. Similarly, the proportion of beneficiaries using SNF services increased with increasing severity and the proportion of beneficiaries using HHA services decreased with increasing severity indicating the shift from outpatient to inpatient service use for more severely ill beneficiaries.

In the discussion below we look at differences in use and payments for beneficiaries in a medical DRG (DRG 089 Simple Pneumonia & Pleurisy Age > 17 w CC) versus beneficiaries in a rehabilitative DRG (DRG 544 Major Joint and Limb Reattachment Procedures of Lower Extremity).

Post-Acute Care Episodes: DRG 089, By APR-DRG. The majority of beneficiaries with DRG 089 are in APR-DRG severity levels 2 (51.9 percent) or 3 (42.3 percent). Table 3-17 shows that episode length of stay and payments rise with increasing APR-DRG severity. Beneficiaries with APR-DRG severity of illness level 1 had an average of post-acute episode length of stay of 62.4 days and Medicare payments of $15,383. In contrast, those in APR-DRG severity level 4 had episodes averaging 74.2 days and $27,365. These results also show that beneficiaries with pneumonia using LTCH services are more likely to be in the higher APR-DRG levels, level 3 and 4, than patients using other PAC services. For example, 4.4 percent of beneficiaries in severity level 4 had an LTCH admission, compared with less than 1.0 percent in severity group 1. Another finding highlighted in this table is related to the use of home health services, as we found that the percentage of beneficiaries using home health services decreases as APR-DRG severity increases. This result may be due to the increasing likelihood of inpatient service use for beneficiaries of higher severity.

For comparison purposes, Appendix B shows the 2005 results for the mean length of stay and payment, by claim type and APR-DRG, for DRG 089 and DRG 544. While it is useful to compare lengths of stay and rates of utilization across the 2 years, note that episode payments calculated for 2005 did not include DME, hospice, or physician services.

Table 3-16 Utilization1 and Payment, by Claim Type, APR-DRG Severity Index, and MS-DRG Severity Index, All Post-Acute Users, 2006
APR-DRG Severity of Illness Level2,3
  1 (N=16,906) 2 (N=49,614) 3 (N=31,192) 4 (N=6,845)
All Live Discharges
(N = 104,557)
N %
with
Claim
Mean
Use4
Mean
Payment4
N %
with
Claim
Mean
Use4
Mean
Payment4
N %
with
Claim
Mean
Use4
Mean
Payment4
N %
with
Claim
Mean
Use4
Mean
Payment4
Total Episode (Index Admission + Part A + Part B Days) 16,906 16.2* 68.6 $21,349 49,614 47.5* 79.4 $26,053 31,192 29.8* 86.6 $34,156 6,845 6.5* 102.7 $63,807
Index Admission (Days) 16,906 100.0 4.1 $8,016 49,614 100.0 5.4 $8,380 31,192 100.0 8.4 $11,178 6,845 100.0 17.6 $27,542
Home Health (Visits) 11,117 65.8 21.3 $3,471 30,466 61.4 25.6 $3,888 18,100 58.0 27.9 $4,096 3,537 51.7 32.6 $4,560
IRF (Days) 2,059 12.2 11.9 $14,091 5,946 12.0 13.7 $15,978 3,475 11.1 14.8 $17,317 937 13.7 16.6 $19,851
LTCH (Days) 141 0.8 30.1 $28,858 734 1.5 30.5 $32,249 1,196 3.8 30.7 $36,504 968 14.1 36.6 $47,734
SNF (SNF) 5,908 34.9 32.1 $9,988 23,223 46.8 36.9 $11,129 16,802 53.9 38.5 $11,495 3,877 56.6 40.7 $12,500
Hospital Outpatient Therapy (Services) 5,266 31.1 42.9 $1,045 11,817 23.8 45.3 $1,236 5,762 18.5 41.4 $1,422 1,191 17.4 44.0 $1,729
Part B Therapy 907 5.4 - $244 2,795 5.6 - $276 1,986 6.4 - $314 538 7.9 - $295
Part B Services
(excluding Part B therapy)
16,738 99.0 - $2,481 49,158 99.1 - $3,066 30,875 99.0 - $4,267 6,747 98.6 - $7,761
Durable Medical Equipment 7,270 43.0 - $428 20,590 41.5 - $610 13,367 42.9 - $822 3,130 45.7 - $1,163
Hospice 55 0.3 - $2,605 349 0.7 - $2,888 393 1.3 - $2,623 103 1.5 - $2,704
Acute Readmission (Days) 3,268 19.3 9.2 $13,532 13,998 28.2 10.5 $14,403 11,513 36.9 12.3 $16,765 3,066 44.8 14.8 $19,679

 

MS-DRG Severity of Illness Level5
  No CCs (N=61,196) W/CCs (N=26,736) W/MCCs (N=21,304)
All Live Discharges
(N = 109,236)
N %
with
Claim
Mean
Use4
Mean
Payment4
N %
with
Claim
Mean
Use4
Mean
Payment4
N %
with
Claim
Mean
Use4
Mean
Payment4

1. Utilization is measured in days for acute, IRF, LTCH, and SNF; visits for HHA, and units of service for hospital outpatient therapy.
2. APR-DRG-level 1=Minor Severity; 2=Moderate Severity; 3=Major Severity; 4=Extreme Severity.
3. 4.3% of episodes were set to APR-DRG Severity Level=) (ungroupable).
4. Note that mean use and mean payments are calculated per user of each service type.
5. Note that MS-DRG severity levels were assigned to 2006 DRGs. Results may differ in other years of data.
NOTE: *This is a row percent.

SOURCE: RTI analysis of 2006 Medicare Claims 5% sample (PSPA070 part 7).

Total Episode (Index Admission + Part A + Part B Days) 61,196 56.0* 75.4 $26,609 26,736 24.5* 86.7 $30,238 21,304 19.4* 91.3 $39,587
Index Admission (Days) 61,196 100.0 5.3 $9,573 26,736 100.0 7.0 $9,344 21,304 100.0 10.9 $13,573
Home Health (Visits) 38,250 62.5 23.5 $3,735 15,950 59.7 28.9 $4,084 11,701 54.9 29.6 $4,278
IRF (Days) 7,292 11.9 12.5 $14,620 3,109 11.6 15.7 $18,322 2,418 11.3 15.7 $18,710
LTCH (Days) 1,306 2.1 35.5 $46,009 671 2.5 30.1 $32,296 1,188 5.6 30.4 $33,906
SNF (SNF) 26,796 43.8 35.2 $10,758 13,546 50.7 39.5 $11,716 11,862 55.7 39.5 $11,792
Hospital Outpatient Therapy (Services) 15,773 25.8 44.0 $1,110 5,237 19.6 45.8 $1,409 3,997 18.8 38.3 $1,639
Part B Therapy 3,131 5.1 - $265 1,835 6.9 - $303 1,560 7.3 - $307
Part B Services
(excluding Part B therapy)
60,623 99.1 - $2,998 26,467 99.0 - $3,685 21,055 98.8 - $5,318
Durable Medical Equipment 25,967 42.4 - $538 11,098 41.5 - $814 9,089 42.7 - $955
Hospice 383 0.6 - $3,117 281 1.1 - $2,779 282 1.3 - $2,380
Acute Readmission (Days) 15,569 25.4 10.6 $14,739 9,162 34.3 11.5 $15,376 8,571 40.2 13.1 $17,544

 

Table 3-17. Utilization1 and Payment, by Claim Type, APR-DRG Severity Index, and MS-DRG Severity Index, for DRG 089 Live Discharges, 2006
APR-DRG Severity of Illness Level2
DRG   1 (N=153) 2 (N=2,392) 3 (N=1,950) 4 (N=180)
089 Simple Pneumonia & Pleurisy Age >17 w CC (N=4,675) N %
with
Claim
Mean
Use3
Mean
Payment3
N %
with
Claim
Mean
Use3
Mean
Payment3
N %
with
Claim
Mean
Use3
Mean
Payment3
N %
with
Claim
Mean
Use3
Mean
Payment3
  Total Episode (Index Admission + Part A + Part B Days) 153 3.3* 62.4 $15,383 2,392 51.2* 69.4 $18,657 1,950 41.7* 76.6 $22,471 180 3.9* 74.2 $27,365
  Index Admission (Days) 153 100 4.8 $4,978 2,392 100 5.3 $4,970 1,950 100 7.0 $5,263 180 100 10.5 $6,747
  Home Health (Visits) 85 55.6 22.3 $3,078 1,255 52.5 24.5 $3,509 975 50.0 25.9 $3,864 81 45.0 20.0 $3,226
  IRF (Days) 2 1.3 13.0 $12,579 55 2.3 14.2 $17,222 64 3.3 15.5 $18,339 10 5.6 11.0 $13,969
  LTCH (Days) 1 0.7 8.0 $8,673 28 1.2 25.0 $27,436 51 2.6 24.8 $29,353 8 4.4 30.0 $49,630
  SNF (SNF) 70 45.8 33.1 $8,686 1,223 51.1 34.6 $9,877 1,112 57.0 35.4 $10,166 111 61.7 35.9 $10,510
  Hospital Outpatient Therapy (Services) 26 17.0 31.3 $858 526 22.0 27.4 $844 342 17.5 34.2 $1,082 29 16.1 30.6 $1,272
  Part B Therapy 6 3.9 - $210 77 3.2 - $248 60 3.1 - $303 7 3.9 - $184
  Part B Services (excluding Part B therapy) 152 99.3 - $1,664 2,378 99.4 - $2,092 1,943 99.6 - $2,821 178 98.9 - $3,771
  Durable Medical Equipment 41 26.8 - $340 967 40.4 - $599 810 41.5 - $613 75 41.7 - $593
  Hospice 2 1.3 - $1,976 20 0.8 - $2,473 28 1.4 - $1,127 4 2.2 - $2,876
  Acute Readmission (Days) 38 24.8 5.9 $10,369 683 28.6 10.0 $12,403 692 35.5 11.2 $13,604 66 36.7 12.1 $14,869

 

MS-DRG Severity of Illness Level4
DRG   No CCs (N=1,222) W/CCs (N=2,625) W/MCCs (N=828)
089 Simple Pneumonia & Pleurisy Age >17 w CC (N=4,675) N %
with
Claim
Mean
Use3
Mean
Payment3
N %
with
Claim
Mean
Use3
Mean
Payment3
N %
with
Claim
Mean
Use3
Mean
Payment3

1. Utilization is measured in days for acute, IRF, LTCH, and SNF; visits for HHA, and units of service for hospital outpatient therapy.
2. APR-DRG-level 1=Minor Severity; 2=Moderate Severity; 3=Major Severity; 4=Extreme Severity.
3. Note that mean use and mean payments are calculated per user of each service type.
4. Note that MS-DRG severity levels were assigned to 2006 DRGs. Results may differ in other years of data.

NOTE: *This is a row percent.

SOURCE: RTI analysis of 2006 Medicare Claims 5% sample (PSPA070 part 7).

  Total Episode (Index Admission + Part A + Part B Days) 1,222 26.1* 67.7 $17,525 2,625 56.1* 73.2 $20,517 828 17.7* 76.5 $24,701
  Index Admission (Days) 1,222 100 5.2 $4,941 2,625 100 6.2 $5,146 828 100 7.8 $5,534
  Home Health (Visits) 636 52.0 24.0 $3,376 1,379 52.5 24.7 $3,670 381 46.0 26.5 $3,902
  IRF (Days) 18 1.5 11.7 $14,350 82 3.1 15.4 $17,970 31 3.7 14.1 $17,867
  LTCH (Days) 12 1.0 22.3 $30,184 45 1.7 27.4 $31,096 31 3.7 22.9 $29,336
  SNF (SNF) 626 51.2 34.1 $9,689 1,396 53.2 34.6 $9,831 494 59.7 37.1 $10,871
  Hospital Outpatient Therapy (Services) 267 21.8 30.2 $842 501 19.1 28.5 $849 155 18.7 35.1 $1,440
  Part B Therapy 36 2.9 - $265 81 3.1 - $242 33 4.0 - $322
  Part B Services (excluding Part B therapy) 1,216 99.5 - $1,775 2,613 99.5 - $2,443 822 99.3 - $3,456
  Durable Medical Equipment 452 37.0 - $528 1,123 42.8 - $600 318 38.4 - $695
  Hospice 14 1.1 - $1,321 30 1.1 - $2,034 10 1.2 - $1,696
  Acute Readmission (Days) 351 28.7 8.9 $11,099 827 31.5 10.8 $13,455 301 36.4 11.6 $14,080

Post-Acute Care Episodes: DRG 089, By MS-DRG. In Table 3-17, we also present the same episode measures stratified by MS-DRG. In general, the trends observed regarding length of stay and Medicare payments are similar for both MS-DRG and APR-DRG severity groupings. The majority of beneficiaries with pneumonia are in the middle MS-DRG severity group with CCs (56.1 percent), and the smallest proportion are in the highest MS-DRG level MCC (17.7 percent). As we noted for the APR-DRG severity levels, in general, episode length of stay and payments rise with increasing MS-DRG severity levels. For example, pneumonia cases with no CCs have an average of post-acute episode length of stay of 67.7 days and Medicare payments of $17,525. In contrast, those in MS-DRG severity level MCC have episodes averaging 76.5 days in length and $24,701 in Medicare payments.

Post-Acute Care Episodes: DRG 544, By APR-DRG. As Table 3-18 shows, as a contrast to pneumonia cases, beneficiaries with DRG 544 (Major Joint and Limb Reattachment Procedures) have slightly lower APR-DRG severity, because most are in severity levels 1 (30.8 percent) and 2 (47.7 percent). In general, episode length of stay and payments rise with increasing APR-DRG severity. Joint and knee cases with APR-DRG severity of illness level 1 had an average of post-acute episode length of stay of 58.4 days and Medicare payments of $20,513. In contrast, those in APR-DRG severity level 4 had episodes averaging 99 days and $43,823.

These results also show that beneficiaries with joint and knee reattachment procedures who had acute readmissions after PAC are more likely to be in the higher APR-DRG levels, level 3 and 4, than patients using other PAC services. For example, 34.0 percent of the beneficiaries in severity level 4 had an acute readmission, compared with 10.0 percent in severity group 1. Another notable finding is that the percentage of joint and knee cases using outpatient therapy decreases with increasing APR-DRG severity levels (from 44.0 percent in the lowest severity level to 17.0 percent in the highest severity level).

Post-Acute Care Episodes: DRG 544, By MS-DRG. DRG 544 is a DRG that has only two levels of severity when grouped using MS-DRG. The highest severity level is those who have major CCs (MCCs) and the lowest is those do not have MCCs. As noted in Table 3-18, the vast majority of beneficiaries with joint and knee cases do not have MCCs (95.0 percent).

With the exception of claims for hospice and Part B therapy services, episode payments rise with increasing MS-DRG severity levels for knee and joint patients. The most notable rise was in Part B services (excluding Part B therapy), which had a mean payment per episode of $2,580 for those with no MCCs and of $4,366 for those with MCCs (higher severity). Furthermore, 70.0 percent of beneficiaries with no MCCs had home health visits, compared with 63.0 percent of beneficiaries with MCCs. Similarly, 37.0 percent of beneficiaries with no MCCs had hospital outpatient therapy, compared with 28.0 percent of beneficiaries with MCCs. It is likely that these more severe patients required more intensive services through IRF or SNF, given that the proportion using IRF or SNF increases dramatically between those with No MCCs and those with MCCs.

Table 3-18. Utilization1 and Payment, by Claim Type, APR-DRG Severity Index, and MS-DRG Severity Index, for DRG 544 Live Discharges, 2006
APR-DRG Severity of Illness Level2
DRG   1 (N=4,686) 2 (N=7,272) 3 (N=3,161) 4 (N=118)
544 Major Joint Replacement or Reattachment Procedures of Lower ESOURCE:xtremity (N= 15,237) N %
with
Claim
Mean
Use3
Mean
Payment3
N %
with
Claim
Mean
Use3
Mean
Payment3
N %
with
Claim
Mean
Use3
Mean
Payment3
N %
with
Claim
Mean
Use3
Mean
Payment3
  Total Episode (Index Admission + Part A + Part B Days) 4,686 30.8* 58.4 $20,513 7,272 47.7* 65.6 $24,466 3,161 20.7* 67.4 $27,223 118 0.8* 99.0 $43,823
  Index Admission (Days) 4,686 100 3.5 $10,362 7,272 100 4.1 $10,478 3,161 100 5.0 $10,764 118 100 12.5 $14,068
  Home Health (Visits) 3,278 70.0 15.9 $3,348 5,022 69.1 18.5 $3,630 2,259 71.5 19.6 $3,679 62 52.5 28.6 $5,001
  IRF (Days) 736 15.7 9.8 $11,347 1,545 21.2 10.8 $12,378 757 23.9 11.2 $12,735 40 33.9 13.2 $16,415
  LTCH (Days) 18 0.4 19.5 $17,756 33 0.5 31.6 $31,623 40 1.3 26.0 $29,834 8 6.8 19.4 $23,584
  SNF (SNF) 1,482 31.6 17.8 $6,535 3,047 41.9 24.8 $8,467 1,515 47.9 27.1 $9,190 72 61.0 48.9 $15,261
  Hospital Outpatient Therapy (Services) 2,063 44.0 49.5 $1,047 2,596 35.7 47.8 $1,054 828 26.2 44.8 $1,065 20 16.9 43.3 $980
  Part B Therapy 190 4.1 - $341 300 4.1 - $282 144 4.6 - $266 5 4.2 - $139
  Part B Services (excluding Part B therapy) 4,650 99.2 - $2,218 7,191 98.9 - $2,660 3,136 99.2 - $3,043 117 99.2 - $5,569
  Durable Medical Equipment 2,760 58.9 - $233 3,996 55.0 - $261 1,645 52.0 - $305 58 49.2 - $441
  Hospice 2 0.0 - $251 13 0.2 - $1,184 9 0.3 - $1,936 4 3.4 - $1,895
  Acute Readmission (Days) 444 9.5 6.4 $11,378 1,092 15.0 8.4 $13,292 593 18.8 8.7 $13,448 40 33.9 10.7 $13,798

 

MS-DRG Severity of Illness Level4
DRG   No MCCs (N=14,446) W/MCCs (N=815)
544 Major Joint Replacement or Reattachment Procedures of Lower Extremity (N=15,261) N %
with
Claim
Mean
Use3
Mean
Payment3
N %
with
Claim
Mean
Use3
Mean
Payment3

1. Utilization is measured in days for acute, IRF, LTCH, and SNF; visits for HHA, and units of service for hospital outpatient therapy.
2. APR-DRG-level 1=Minor Severity; 2=Moderate Severity; 3=Major Severity; 4=Extreme Severity.
3. Note that mean use and mean payments are calculated per user of each service type.
4. Note that MS-DRG severity levels were assigned to 2006 DRGs. Results may differ in other years of data.

NOTE: *This is a row percent.

SOURCE: RTI analysis of 2006 Medicare Claims 5% sample (PSPA070 part 7)

  Total Episode (Index Admission + Part A + Part B Days) 14,446 94.6* 62.9 $23,341 815 5.3* 84.8 $35,409
  Index Admission (Days) 14,446 100 4.0 $10,463 815 100 8.1 $11,761
  Home Health (Visits) 10,125 70.1 17.6 $3,530 514 63.1 24.7 $4,191
  IRF (Days) 2,848 19.7 10.6 $12,078 234 28.7 12.6 $14,781
  LTCH (Days) 72 0.5 26.4 $26,831 27 3.3 25.6 $30,124
  SNF (SNF) 5,688 39.4 23.0 $7,962 444 54.5 36.8 $12,070
  Hospital Outpatient Therapy (Services) 5,288 36.6 47.6 $1,040 227 27.9 55.5 $1,363
  Part B Therapy 591 4.1 - $300 48 5.9 - $232
  Part B Services (excluding Part B therapy) 14,431 99.9 - $2,580 808 99.1 - $4,366
  Durable Medical Equipment 8,031 55.6 - $253 436 53.5 - $426
  Hospice 19 0.1 - $1,468 9 1.1 - $1,446
  Acute Readmission (Days) 1,951 13.5 7.9 $12,683 225 27.6 10.4 $15,292

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