Examining Post Acute Care Relationships in an Integrated Hospital System. 3.7 Patterns of Use within an Episode

02/01/2009

Patterns of care during PAC episodes vary significantly depending on many factors including diagnoses, patient severity, and supply of services. One of the primary goals of this work has been to understand utilization of services within episodes of PAC. While the factors explaining use are explored further in the multivariate analyses, Tables 3-19 and 3-20 present patterns of episode utilization, and the corresponding episode lengths of stay and episode payments for these episode patterns, for both 2005 and 2006. Claims were sorted by date within an episode to create the patterns.

In both 2005 and 2006, approximately 75.0 percent of beneficiaries discharged to PAC had episode patterns from one of thirteen types of episodes. The most common type of episode was index acute hospital to home health (episode pattern=AH). Approximately 23.0 percent of beneficiaries discharged to PAC had this pattern of use. Another 17.0 percent were discharged directly from the index acute hospital to SNF (episode pattern=AS). A smaller proportion of beneficiaries had episode that included acute, SNF, and HHA (episode pattern=ASH; 8.0 percent), however these three episode types alone accounted for nearly 50.0 percent of all episode patterns among PAC users. Of these three episode patterns, ASH corresponded to the highest payments and longest episode length of stay. Compared to the AS episode pattern, AH had lower episode payments due to care in the home setting rather than an inpatient provider, but episode lengths of stay for AH episodes were longer compared to AS episodes due to the nature of home care services as delivered within 60.0-day episodes.

While the majority of beneficiaries have episodes of care with just one or two PAC settings, other beneficiaries have episodes of care with many settings of care. Readmissions to acute hospitals during episodes of care can increase PAC utilization and payments. Although not as common, some beneficiaries move in and out of the different types of providers before reaching the 60-day gap in service use that signals the end of a PAC episode. Patterns of use between 2005 and 2006, were very similar, however there was a slight increase in the proportion of beneficiaries with episode pattern AO (5.4 percent in 2005 vs. 6.0 percent in 2006) and a slight decrease in the proportion of beneficiaries with episode patterns of AIH (3.2 percent in 2005 vs. 2.8 percent in 2006). This result is consistent with analyses presented earlier demonstrating a decrease in the proportion of beneficiaries discharged to IRFs.

Table 3-19. PAC Transition Pattern Analysis Number of Beneficiaries, Episode Payments, and Episode Length of Stay for PAC Users, 2005
Episode Pattern1 Count (5% Sample) Percent of PAC Users (N=111,879) Cumulative Percent2 Mean Episode Payment Mean Episode Length of Stay (days)

NOTES:
1. A=Acute Hospital; H=HHA; I=IRF; L=LTCH; O=Outpatient Therapy; S=SNF.
2. 75.0 percent of PAC episodes are shown here.

SOURCE: RTI analysis of 2005 Medicare claims 5% sample (mmor167).

AH 25,916 23.2 23.2 $12,483 47.0
AS 19,676 17.6 40.8 16,952 43.0
ASH 8,500 7.6 48.3 21,150 75.5
AO 6,002 5.4 53.7 8,364 46.4
AHA 5,148 4.6 58.3 24,383 58.0
AIH 3,593 3.2 61.5 29,399 65.6
ASAS 2,944 2.6 64.2 31,922 79.3
AHO 2,820 2.5 66.7 13,729 87.7
ASA 2,268 2.0 68.7 26,548 48.1
ASO 2,002 1.8 70.5 18,336 87.2
AIO 1,869 1.7 72.2 25,285 77.3
AHAH 1,603 1.4 73.6 26,238 162.5
AI 1,585 1.4 75.0 24,274 17.5

 

Table 3-20. PAC Transition Pattern Analysis, Number of Beneficiaries, Episode Payments, and Episode Length of Stay for PAC Users, 2006
Episode Pattern1 Count (5% Sample) Percent of PAC Users (N=109,236) Cumulative Percent Mean Episode Payment Mean Episode Length of Stay

1. A=Acute Hospital; H=HHA; I=IRF; L=LTCH; O=Outpatient Therapy; S=SNF.

SOURCE: RTI analysis of 2006 Medicare claims 5% sample.

AH 25,238 23.1 23.1 $12,696 48.9
AS 18,714 17.1 40.2 17,930 44.2
ASH 8,474 7.8 48.0 22,208 76.4
AO 6,533 6.0 54.0 8,165 40.0
AHA 4,909 4.5 58.5 25,035 57.2
AIH 3,066 2.8 61.3 30,915 69.3
AHO 2,941 2.7 64.0 14,250 88.0
ASAS 2,934 2.7 66.7 33,346 81.7
ASA 2,092 1.9 68.6 28,106 47.2
ASO 1,993 1.8 70.4 18,805 87.1
AHAH 1,635 1.5 71.9 26,956 171.5
AIO 1,467 1.3 73.2 27,270 79.1
AI 1,382 1.3 74.5 25,330 17.4
Tables 3-21 and 3-22 demonstrate the patterns of PAC utilization during episodes of care for beneficiaries in DRGs 089 Simple Pneumonia & Pleurisy Age 17 > w CC and DRG 544 Major Joint Replacement or Reattachment of Lower Extremity in 2006. These two DRGs were chosen in order to understand differences in service use between beneficiaries in a medical versus rehabilitation DRG. The most common episode types for beneficiaries in DRG 089 were AS (26.1 percent) followed by AH (23.1 percent). IRF service use was not observed in the top episode patterns for beneficiaries in DRG 089. In contrast, the episode pattern AIH was among the top five for beneficiaries in DRG 544 due to the rehabilitative nature of treatment for beneficiaries in this DRG. However, the more frequent episode patterns for beneficiaries in DRG 544 were AH (23.0 percent) and ASH (13.0 percent).
Table 3-21. Patterns of PAC Use, DRG 089 Simple Pneumonia & Pleurisy Age >17 w/CC1, 2006
Episode Pattern2 Count (5% Sample) % of PAC Users (N=4,675) Cumulative Percent Mean Episode Payment Mean Episode Length of Stay

1. FY 2006 DRG titles were used in this analysis.
2. A=Acute Hospital; H=HHA; I=IRF; L=LTCH; O=Outpatient Therapy; S=SNF.

SOURCE: RTI analysis of 2006 Medicare claims 5% sample (MM2Y012).

AS 1,218 26.1 26.1 $14,018 40.5
AH 1,079 23.1 49.1 7,840 53.6
AO 343 7.3 56.5 5,579 31.7
AHA 240 5.1 61.6 18,434 59.8
ASH 236 5.0 66.7 15,965 72.7
ASAS 151 3.2 69.9 28,093 82.5
ASA 133 2.8 72.7 21,568 44.0
AHAH 76 1.6 74.4 21,350 200.1

 

Table 3-22. Patterns of PAC Use, DRG 544 Major Joint Replacement or Reattachment of Lower Extremity1, 2006
Episode Pattern2 Count (5% Sample) Percent of PAC Users (N=15,261) Cumulative Percent Mean Episode Payment Mean Episode Length of Stay

1. FY 2006 DRG titles were used in this analysis.
2. A=Acute Hospital; H=HHA; I=IRF; L=LTCH; O=Outpatient Therapy; S=SNF.

SOURCE: RTI analysis of 2006 Medicare claims 5% sample (MM2Y012).

AH 3,512 23.0 23.0 $13,591 33.0
ASH 1,988 13.0 36.0 20,475 56.8
AHO 1,410 9.2 45.3 14,324 78.7
AS 1,307 8.6 53.8 19,992 35.8
AIH 1,019 6.7 60.5 26,549 55.3
AO 918 6.0 66.5 10,818 51.9
ASO 732 4.8 71.3 16,853 71.5

Another way of examining PAC transitions is presented in Figures 3-2 and 3-3. Here we examine transfer patterns following acute hospital discharge. The majority of beneficiaries use only one or two post-acute services following discharge as we saw in the previous section, but some transfer multiple times between different types of settings or churn back and forth with acute hospital readmissions. The number of claims per episode varies depending on the beneficiary's first site of PAC.


Figure 3-2. PAC Transitions for Live Acute Hospital Discharges, Number and Percentage of Admissions, 2006

Figure 3-2   

Figure 3-2 is titled "PAC Transitions for Live Acute Hospital Discharges, Number and Percent of Admissions, 2006." This figure shows the post-acute care transitions for live acute hospital discharges in the 2006 post-acute episode file (Medicare claims 5% sample). This transition table shows the number and percent of beneficiaries discharged to each site of post-acute care. In 2006, there were 310,628 live hospital discharges. Of these live hospital discharges, 109,236 (35.2 percent) of beneficiaries went on to use post-acute care. Of the beneficiaries going on to post-acute care, 40,865 (37.4 percent) were discharged to HHA; 11,240 (10.3 percent) were discharged to IRF; 2,235 (2.0 percent) were discharged to LTCH; 9,968 (9.1 percent) were discharged to hospital outpatient therapy; and 44,929 (41.1 percent) were discharged to SNF. This figure continues to track the number and percent of beneficiaries discharged to subsequent sites of post-acute care. The post-acute episodes presented here are truncated at the fourth post-acute claim following hospital discharge.

NOTE: Post-acute episodes presented here are truncated at the fourth post-acute claim following acute hospital discharge.

SOURCE: RTI analysis of 2006 Medicare claims 5% sample (MM2Y094).


Figure 3-3 PAC Transitions for Live Acute Hospital Discharges, Mean Utilization and Medicare Payments, 2006

Figure 3-3

Figure 3-3 is titled "PAC Transitions for Live Acute Hospital Discharges, Mean Utilization and Medicare Payments, 2006." This figure shows the mean utilization and Medicare payments per setting for beneficiaries discharged to each post-acute care setting within their episode. The sample for this analysis was 109,236 beneficiaries using post-acute care in the 2006 (Medicare claims 5% sample). This transition table shows the mean utilization and payment per setting of care for beneficiaries discharged to each site of care. Utilization is measured in mean days for acute, IRF, SNF, and LTCH; mean visits for HHA, and mean units of service for hospital outpatient therapy. The mean length of stay and Medicare payments for index acute admissions was 6.8 days and $10,297. For beneficiaries discharged to HHA, mean HHA visits were 17.8 and mean Medicare payments for HHA were $2,760. For beneficiaries discharged to IRF, mean length of stay was 12.4 days and mean Medicare payment for the IRF stay was $14,660. For beneficiaries discharged to LTCH, mean length of stay was 28.8 days and mean Medicare payment for the LTCH stay was $35,917. For beneficiaries discharged to hospital outpatient therapy, mean use was 27.9 units of service and mean Medicare payment for hospital outpatient therapy was $847. For beneficiaries discharged to SNF, mean length of stay was 28.5 days and mean Medicare payment for the SNF stay was $8,759. This figure also shows the mean use and mean Medicare payment per site of care for beneficiaries discharged to subsequent sites of post-acute care during their episode. The post-acute episodes presented here are truncated at the fourth post-acute claim following hospital discharge.

NOTE: Post-acute episodes presented here are truncated at the fourth post acute claim following acute hospital discharge. The reported mean utilization and mean payment correspond to use at that level of care only, not to the entire episode. Utilization is measured as mean days for acute, IRF, LTCH, and SNF; mean visits for HHA; and mean units of service for outpatient therapy.

SOURCE: RTI analysis of 2006 Medicare claims 5% sample (MM2Y094).


The transition tables show the proportion of patients in each type of service and identify the percent using subsequent services of each type. As noted earlier, per our episode analysis 35.2 percent of live Medicare discharges from index acute hospital stays went on to use PAC in 2006. The largest proportion of beneficiaries was discharged to SNF (41.1 percent) or HHA (37.4 percent). Beneficiaries discharged to ambulatory settings, such as HHA or outpatient therapy are more likely to only use those PAC services. For example, 61.8 percent of beneficiaries discharged to HHAs and 65.6 percent of beneficiaries discharged to outpatient therapy use those services only. In contrast, beneficiaries using inpatient PAC are more likely to use at least one additional PAC service. According to our analysis of the 2006 episode data, 87.7 percent of beneficiaries discharged to IRFs and 74.9 percent of beneficiaries discharged to LTCHs go on to use other services during their post-acute episode.

PAC episodes appear to show a hierarchy in terms of service mix. Beneficiaries in institutional settings are most likely to use subsequent post-acute services. The most common discharge site for HHA, other than home or re-hospitalization is outpatient therapy (9.4 percent). Similarly, outpatient therapy cases are most likely to be discharged to HHA (8.1 percent) if not readmitted to an acute hospital (19.6 percent) or discharged home (using outpatient therapy only; 65.6 percent). SNF cases are most likely discharged to HHA (29.6 percent) or to outpatient therapy (6.4 percent) if not discharged home (41.7 percent) or readmitted to an acute hospital (21.9 percent). HHA is the most likely discharge destination for beneficiaries discharged from IRF (45.9 percent) and LTCH (25.4 percent) reflecting the ability of HHAs to provide follow-up therapy or nursing in the home following discharge.

Figure 3-3 presents the corresponding lengths of stay and payment for beneficiaries based on their patterns of PAC utilization. On average, beneficiaries discharged to post-acute care had acute index admissions of 6.8 days and Medicare payments of $10,297. Beneficiaries discharged to LTCH had LTCH stays averaging 28.8 days and Medicare payments of $35,917. Beneficiaries discharged to SNFs had similar length of stay in the SNFs as beneficiaries discharged to LTCHs (28.5 days), but had significantly lower payments for the stay ($8,759) reflecting the less intensive medical needs of patients discharged to this setting. Utilization for patients discharged to outpatient settings was measured in visits counts rather than days because these services occur with varying frequency over the course of a treatment period. Treatment in the outpatient setting was significantly less expensive in both outpatient therapy settings and HHAs compared to the inpatient settings.

Transition patterns differ by DRG. Figure 3-4 illustrates the transition patterns for beneficiaries who were hospitalized for DRG 089 Simple Pneumonia & Pleurisy Age > 17 with CC. Key differences between DRG 089 versus all DRGs generally are in the proportion of beneficiaries discharged to each of the subsequent discharge settings. Over 33.0 percent of beneficiaries in DRG 089 go on to use PAC services, but the majority of these beneficiaries go on to use HHAs (37.4 percent) or SNFs (47.3 percent). While over 10.0 percent of beneficiaries overall go on to use IRF services following discharge from the acute hospital, only 1.8 percent of beneficiaries in DRG 089 go on to use IRF following their index acute hospitalization. PAC episode lengths of stay and Medicare payments for beneficiaries in DRG 089 are less than for PAC episodes overall (Figure 3-5). The average pneumonia index acute admission was 6.2 days, and corresponding Medicare payments were $5,161 compared to 6.8 days and $10,297 dollars for beneficiaries overall.


Figure 3-4. PAC Transitions for Live Acute Hospital Discharges from DRG 089 Simple Pneumonia & Pleurisy Age > 17 with CC, Number and Percentage of Admissions, 2006

Figure 3-4

Figure 3-4 is titled "PAC Transitions for Live Acute Hospital Discharges from DRG 089 Simple Pneumonia and Pleurisy Age > 17 with CC, Number and Percentage of Admissions, 2006." This figure shows the post-acute care transitions for live acute hospital discharges in the 2006 post-acute episode file for beneficiaries in DRG 089 Simple Pneumonia & Pleurisy Age > 17 (Medicare claims 5% sample). This transition table shows the number and percent of beneficiaries discharged to each site of care. In 2006, there were 13,911 live hospital discharges in DRG 089. Of these live hospital discharges, 4,675 (33.6 percent) of beneficiaries went on to use post-acute care. Of the beneficiaries going on to post-acute care, 1,749 (37.4 percent) were discharged to HHA; 84 (1.8 percent) were discharged to IRF; 57 (1.2 percent) were discharged to LTCH; 573 (12.3 percent) were discharged to hospital outpatient therapy; and 2,212 (47.3 percent) were discharged to SNF. This figure continues to track the number and percent of beneficiaries discharged to subsequent sites of post-acute care. The post-acute episodes presented here are truncated at the fourth post-acute claim following hospital discharge.

NOTE: Post-acute episodes presented here are truncated at the fourth post acute claim following acute hospital discharge.

SOURCE: RTI analysis of 2006 Medicare claims 5% sample (MM2Y095).


Figure 3-5. PAC Transitions for Live Acute Hospital Discharges from DRG 089 Simple Pneumonia & Pleurisy Age > 17 with CC, Mean Utilization and Medicare Payment, 2006

Figure 3-5  

Figure 3-5 is titled "PAC Transitions for Live Acute Hospital Discharges from DRG 089 Simple Pneumonia and Pleurisy Age > 17 with CC, Mean Utilization and Medicare Payment, 2006." This figure shows the mean utilization and Medicare payments per setting for post-acute care transitions for beneficiaries in DRG 089 Simple Pneumonia & Pleurisy Age > 17. The sample for this analysis was 4,675 beneficiaries in DRG 089 using post-acute care in the 2006 (Medicare claims 5% sample). This transition table shows the mean utilization and payment per setting of care for beneficiaries discharged to each site of care. Utilization is measured in mean days for acute, IRF, SNF, and LTCH; mean visits for HHA, and mean units of service for hospital outpatient therapy. The mean length of stay and Medicare payment for index acute admissions was 6.2 days and $5,161. For beneficiaries discharged to HHA, mean HHA visits were 18.7 and mean Medicare payment for HHA was $2,722. For beneficiaries discharged to IRF, mean length of stay was 12.1 days and mean Medicare payment for the IRF stay was $14,285. For beneficiaries discharged to LTCH, mean length of stay was 21.5 days and mean Medicare payment for the LTCH stay was $28,091. For beneficiaries discharged to hospital outpatient therapy, mean use was 22.8 units of service and mean Medicare payment for hospital outpatient therapy was $669. For beneficiaries discharged to SNF, mean length of stay was 28.1 days and mean Medicare payment for the SNF stay was $8,150. This figure also shows the mean use and mean Medicare payment per site of care for beneficiaries discharged to subsequent sites of post-acute care during their episode. The post-acute episodes presented here are truncated at the fourth post-acute claim following hospital discharge.

NOTE: Post-acute episodes presented here are truncated at the fourth post acute claim following acute hospital discharge. The reported mean utilization and mean payment correspond to use at that level of care only, not to the entire episode. Utilization is measured as mean days for acute, IRF, LTCH, and SNF; mean visits for HHA; and mean units of service for outpatient therapy.

SOURCE: RTI analysis of 2006 Medicare claims 5% sample (MM2Y095).


Figure 3-6 shows transition patterns for the more rehabilitation-oriented hospital discharges in DRG 544 Major Joint Replacement or Reattachment of Lower Extremity. These cases are far more likely to be discharged to PAC in general. Over 87.0 percent of beneficiaries discharged from an index acute hospital admission in DRG 544 go on to use PAC services. Over 19.0 percent of these beneficiaries are discharged to an IRF setting compared with over 10.0 percent of beneficiaries across all DRGs. Beneficiaries discharged to IRFs had average IRF lengths of stay of 10.1 days and corresponding payments of $11,542 (Figure 3-7). Of the beneficiaries discharged to IRF, 88.0 percent go on to use other post-acute care services. The majority of these beneficiaries go on to use HHAs (52.2 percent) and hospital outpatient therapy (22.1 percent). Similar analyses were completed using the 2005 data and there was a notable decrease in the proportion discharged from index acute hospital to IRFs (25.7 percent in 2005 vs. 19.4 percent in 2006) and a corresponding increase in the proportion of beneficiaries discharged to HHAs (31.5 percent in 2005 vs. 35.7 percent in 2006), SNF (35.4 percent in 2005 vs. 37.2 percent in 2006), and outpatient therapy (6.9 percent in 2005 vs. 7.4 percent in 2006). As noted, this may be due to increased compliance with rules regarding the proportion of admissions to IRF settings required to fall within certain diagnoses.


Figure 3-6. PAC Transitions for Live Acute Hospital Discharges from DRG 544 Major Joint Replacement or Reattachment of Lower Extremity, Number and Percentage of Admissions, 2006

Figure 3-6

Figure 3-6 is titled "PAC Transitions for Live Acute Hospital Discharges from DRG 544 Major Joint Replacement or Reattachment of Lower Extremity, Number and Percentage of Admissions, 2006." This figure shows the post-acute care transitions for live acute hospital discharges in the 2006 post-acute episode file for beneficiaries in DRG 544 Major Joint Replacement or Reattachment of Lower Extremity (Medicare claims 5% sample). This transition table shows the number and percent of beneficiaries discharged to each site of care. In 2006, there were 17,475 live hospital discharges in DRG 544. Of these live hospital discharges, 15,261 (87.3 percent) of beneficiaries went on to use post-acute care. Of the beneficiaries going on to post-acute care, 5,442 (35.7 percent) were discharged to HHA; 2,963 (19.4 percent) were discharged to IRF; 50 (0.3 percent) were discharged to LTCH; 1,122 (7.4 percent) were discharged to hospital outpatient therapy; and 5,684 (37.2 percent) were discharged to SNF. This figure continues to track the number and percent of beneficiaries discharged to subsequent sites of post-acute care. The post-acute episodes presented here are truncated at the fourth post-acute claim following hospital discharge.

NOTE: Post-acute episodes presented here are truncated at the fourth post acute claim following acute hospital discharge.

SOURCE: RTI analysis of 2006 Medicare claims 5% sample (MM2Y095).


Figure 3-7. PAC Transitions for Live Acute Hospital Discharges from DRG 544 Major Joint Replacement or Reattachment of Lower Extremity, Mean Utilization and Medicare Payment, 2006

Figure 3-7

Figure 3-7 is titled "PAC Transitions for Live Acute Hospital Discharges from DRG 544 Major Joint Replacement or Reattachment of Lower Extremity, Mean Utilization and Medicare Payment, 2006." This figure shows the mean utilization and Medicare payments per setting for post-acute care transitions for beneficiaries in DRG 544 Major Joint Replacement or Reattachment of Lower Extremity. The sample for this analysis was 15,261 beneficiaries in DRG 544 using post-acute care in the 2006 (Medicare claims 5% sample). This transition table shows the mean utilization and payment per setting of care for beneficiaries discharged to each site of care. Utilization is measured in mean days for acute, IRF, SNF, and LTCH; mean visits for HHA, and mean units of service for hospital outpatient therapy. The mean length of stay and Medicare payment for index acute admissions was 4.2 days and $10,532. For beneficiaries discharged to HHA, mean HHA visits were 14.4 and mean Medicare payment for HHA were $3,120. For beneficiaries discharged to IRF, mean length of stay was 10.1 days and mean Medicare payment for the IRF stay was $11,542. For beneficiaries discharged to LTCH, mean length of stay was 22.1 days and mean Medicare payment for the LTCH stay was $23,122. For beneficiaries discharged to hospital outpatient therapy, mean use was 41.5 units of service and mean Medicare payment for hospital outpatient therapy was $882. For beneficiaries discharged to SNF, mean length of stay was 19.6 days and mean Medicare payment for the SNF stay was $6,985. This figure also shows the mean use and mean Medicare payment per site of care for beneficiaries discharged to subsequent sites of post-acute care during their episode. The post-acute episodes presented here are truncated at the fourth post-acute claim following hospital discharge.

NOTE: Post-acute episodes presented here are truncated at the fourth post acute claim following acute hospital discharge. The reported mean utilization and mean payment correspond to use at that level of care only, not to the entire episode. Utilization is measured as mean days for acute, IRF, LTCH, and SNF; mean visits for HHA; and mean units of service for outpatient therapy.

SOURCE: RTI analysis of 2006 Medicare claims 5% sample (MM2Y095).

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