The pie charts in the previous section showing the distribution of payments for service use within episodes by service type indicate the significant role of physician services within episodes of PAC. The proportion of total episode payments accounted for by physician services varied only slightly across the medical DRG (DRG 089: Simple Pneumonia & Pleurisy Age >17) and the rehabilitative DRG (DRG: Major Joint Replacement or Reattachment of Lower Extremity) and also varied only slightly by severity level. In order to better understand the nature of physician service use, we examined the place of service associated with Part B physician claims using the Berenson-Eggers Type of Service (BETOS) codes on each of the Part B claims. The BETOS codes group HCPCS procedure codes into clinically meaningful categories.
We selected several BETOS categories to answer our questions of where these Part B physician services take place during post-acute episodes. These categories included office visits, hospital visits, nursing home visits, emergency room visits, home visits, inpatient consultations, and outpatient consultations. Note that the consultations were identified using HCPCS codes rather than BETOS codes because BETOS group inpatient and outpatient consultations into one category. Table 3-23 shows the number and proportion of beneficiaries using PAC with each type of visit, the mean number of units and the mean payments associated with visits in each category. In our 2006 episode sample overall, 90.2 percent of beneficiaries had a physician visit in a hospital. Over 68.0 percent had an inpatient consultation, 60.0 percent had an emergency room visit, and 55.0 percent had an office visit sometime during the episode of PAC. The highest payments were associated with physician hospital visits (over $1,100). Though beneficiaries in our sample all had an index acute hospital stay initiating an episode of care, some physician visits related to the hospital service may not be in the counts in the table.14 Note that over half of all beneficiaries had an office visit during their PAC episode indicating ongoing physician care subsequent to an acute hospitalization.
|All 2006 Episodes||N||Percent With Claim||Mean Units of Service||Mean Medicare Payments|
|SOURCE: RTI analysis of 2006 Medicare Claims 5% sample (MM2Y068).|
|Nursing Home Visits||45,847||42.0||5.6||$295|
|Emergency Room Visits||65,664||60.1||1.8||$175|
|2006 Episodes-Index DRG 089|
|Nursing Home Visits||2,136||45.7||4.8||$248|
|Emergency Room Visits||3,458||74.0||1.9||$171|
|2006 Episodes-Index DRG 544|
|Nursing Home Visits||5,024||32.9||4.6||$243|
|Emergency Room Visits||3,615||23.7||1.5||$142|