Examining Post Acute Care Relationships in an Integrated Hospital System. 3.8.1 Part B Physician Service Utilization within Post-Acute Care Episodes

02/01/2009

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.

Table 3-23. Part B Claim Units of Service and Payments, by BETOS Place of Service, 2006
All 2006 Episodes N Percent With Claim Mean Units of Service Mean Medicare Payments
SOURCE: RTI analysis of 2006 Medicare Claims 5% sample (MM2Y068).
Office Visits 60,631 55.5 4.0 $198
Hospital Visits 98,482 90.2 20.8 $1,123
Nursing Home Visits 45,847 42.0 5.6 $295
Emergency Room Visits 65,664 60.1 1.8 $175
Home Visits 2,410 2.2 2.8 $237
Inpatient Consultations 75,220 68.9 3.1 $71
Outpatient Consultations 14,319 13.1 1.3 $157
2006 Episodes-Index DRG 089        
Office Visits 2,355 50.4 3.7 $189
Hospital Visits 4,570 97.8 16.4 $906
Nursing Home Visits 2,136 45.7 4.8 $248
Emergency Room Visits 3,458 74.0 1.9 $171
Home Visits 94 2.0 2.8 $241
Inpatient Consultations 2,520 53.9 2.8 $49
Outpatient Consultations 486 10.4 1.3 $153
2006 Episodes-Index DRG 544        
Office Visits 7,275 47.7 2.9 $134
Hospital Visits 10,794 70.7 10.4 $510
Nursing Home Visits 5,024 32.9 4.6 $243
Emergency Room Visits 3,615 23.7 1.5 $142
Home Visits 117 0.8 2.2 $181
Inpatient Consultations 8,483 55.6 2.0 $27
Outpatient Consultations 1,078 7.1 1.2 $137
The second two panels of the table allow for comparison of types of physician service use in a medical versus a rehabilitative DRG (DRG 089: Simple Pneumonia & Pleurisy versus DRG 544: Major Joint Replacement or Reattachment of Lower Extremity). The following differences in service use are noted. A higher proportion of beneficiaries in DRG 089 had hospital visits and emergency room visits (97.8 percent and 74.0 percent) compared with beneficiaries in DRG 544 (70.7 percent and 23.7 percent). These descriptive tables provide a straightforward look at service use within episodes and serve as a starting point to think more about the role of physician services in episodes of care. For example, other interesting analyses to perform on the physician claims include identifying when during the PAC episode these services occur and what types of specialists the beneficiaries see.

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