A large proportion of episodes involved care delivered in multiple states, suggesting potential challenges for care coordination and creating accountable groups of providers for an episode when they are not geographically proximate. Out-of-state care, particularly when not geographically promixate, could likely make it more difficult to coordinate the actions of providers and to then hold them jointly accountable for payment or quality within an episode--although this problem may diminish in the long run as providers adopt and use electronic information systems that can cross communicate. The rate with which multi-state care occurred varied across states and clinical conditions.
Out-of-state care occurs for various reasons. For example, beneficiaries may spend significant amounts of the year in different states (e.g., snowbirds), beneficiaries may live near state borders and they elect to receive care from providers in the bordering state, or beneficiaries may obtain care at referral centers (e.g., Mayo Clinic). The highest rate of cross-boarder care was for AMI-related episodes for beneficiaries in Oregon; 19 percent of all AMI-related episodes involved care in another state. The lowest rate was for diabetes-related episodes for beneficiaries in Texas; where three percent received some portion of their care in another state. For most conditions, Oregon beneficiaries were most likely to receive care in another state, and Texas beneficiaries were least likely. The frequency of multiple-state care also varied by condition, and was most common for AMI and breast cancer-related episodes. In episodes that involved out-of-state care, that care accounted for a large percentage of total payments for the episode (between 30 and 60 percent, varying by condition).