Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Extent to Which Beneficiaries' Care is for Episodes Related to Conditions of Focus

02/01/2009

Figures 9 and 10 show, on a per capita basis, how much of the care received by beneficiaries diagnosed with each of the nine conditions is for ETG episodes related to the condition.

Figure 9. Portion of Episodes Related to Condition, ETG

Figure 9 shows that related episodes make up a small fraction of all of the episodes experienced by beneficiaries with each of the nine conditions.

Figure 10. Portion of Standardized Payments for Episodes Related to Condition, ETGs

 

Figure 10 shows that, in general, related episodes comprise a greater portion of standardized payments than of total number of episodes. There is also substantial variation across the conditions both in the total standardized payment for care delivered to the beneficiaries and in the potion of payments that are for episodes related to the conditions. For example, for beneficiaries who experience an AMI, the care they received as part of the episodes related to the AMI accounts for approximately 50 percent of their total costs. In contrast, for beneficiaries diagnosed with diabetes, the care they received during their diabetes-related episodes accounts for less then 10 percent of their total costs.

Figure 11. Portion of Episodes Related to Condition, MEGs

Figures 11 shows comparable information for episodes created by MEGs. The results are substantively similar, so here we only discuss Figures 9 and 10

Figure 12. Portion of Standardized Payments for Episodes Related to Condition, MEGs

Figures 12 shows comparable information for episodes created by MEGs. The results are substantively similar, so here we only discuss Figures 9 and 10


To describe the unrelated episodes, Table 10 lists the average number of unrelated episodes for beneficiaries diagnosed with AMI, diabetes and hip fracture as well as the five most common unrelated episodes for each of the three conditions. Some of the unrelated episodes are very common across the three conditions, such as hypertension and fungal skin infection for ETGs, while for MEGs the commonalities were essential hypertension, and encounters for preventive health services.

Table 10. Common Episodes Experienced Not Related to Condition of Focus, Selected Conditions
  AMI Diabetes Hip Fracture
ETGs
Average # unrelated episodes per beneficiary 8.8 8.0 10.4
5 most common unrelated episodes: % of beneficiaries experiencing
Hypertension 63.1% 65.6% 67.3%
Congestive heart failure 53.7% Not in top 5 29.8%
Diabetes 34.5% Related to Diabetes Not in top 5
Cerebrovascular accident 22.2% Not in top 5 Not in top 5
Fungal skin infection 17.0% 19.3% 26.8%
Ischemic heart disease Related to AMI 37.7% 36.3%
Cataract Not in top 5 27.3% Not in top 5
Hyperlipidemia Not in top 5 23.2% Not in top 5
Infection of lower genitourinary system, not sexually transmitted Not in top 5 Not in top 5 26.7%
MEGs Average # unrelated episodes per beneficiary 8.1 7.5 8.6
5 most common unrelated episodes: % of beneficiaries experiencing
Coronary artery disease 62.3% 29.7% Not in top 5
Essential hypertension 51.3% 57.3% 53.0%
Encounter for preventive health services 32.4% 44.5% 33.7%
Congestive heart failure 32.2% Not in top 5 Not in top 5
Arrhythmias 21.0% Not in top 5 18.2%
Cataract Not in top 5 22.4% Not in top 5
Other inflammations and infections of skin and subcutaneous tissue Not in top 5 20.4% 22.9%
Urinary tract infections Not in top 5 Not in top 5 18.9%

The relatively small portion of care represented by the related episodes, together with the relative frequency of some of the unrelated episodes, suggests the complexities of defining what constitutes an episode of care and raises questions about how the tension between segmenting and "bundling" care could be balanced. Here we use beneficiaries diagnosed with AMI and the episodes created with ETGs to highlight this complexity and examine beneficiaries who experienced an AMI with the various combinations of vascular disease episodes of care shown in Figure 13.

Figure 13. Select Combinations of Vascular Disease Episodes

Select Combinations of Vascular Disease Episodes 

Figure 13 shows how we use beneficiaries diagnosed with AMI and the episodes created with ETGs to highlight this complexity and examine beneficiaries who experienced an AMI with the various combinations of vascular disease episodes of care shown.


We identified the ETGs' ischemic heart disease episodes as related to AMI diagnosis; no other ETG episodes were designated as related to AMI. Virtually all of the beneficiaries with a primary or secondary diagnosis of AMI in 2005 also had an ischemic heart disease episode. However, as shown in Table 11 below, only 13 percent of beneficiaries with AMI only had an ischemic heart disease episode (Patient 1). As shown in Table 9 above, 63 percent of the beneficiaries with AMI also had a hypertension episode. However, there were only 15 percent of beneficiaries with AMI who had only ischemic heart disease and hypertension episodes (Patient 2). As additional conditions that are prevalent in AMI patients are added, it represents a smaller, but still substantial portion of AMI patients. It is significant to note that as an AMI patient has additional vascular disease comorbidities that could "travel" together, not only are the total costs of caring for the patient affected, but the standardized payments for the ischemic heart disease episode increase substantially as well, as illustrated in the last row of Table 11.

Table 11. Select Combinations of ETG Episodes for Beneficiaries Diagnosed with AMI
Episode Combinations % of those Beneficiaries Diagnosed with AMI Standardized Payments for Ischemic Heart Disease Episode (AMI-related Episode) Total Standardized Payments for Beneficiaries with AMI
Patient 1: Only ischemic heart disease 13% $20,106 $26,885
Patient 2: Ischemic heart disease and hypertension 15% $21,834 $32,696
Patient 3: Ischemic heart disease, hypertension, and hyperlipidemia 7% $24,657 $32,264
Patient 4: Ischemic heart disease, hypertension, hyperlipidemia, cerebrovascular accident, congestive heart failure 2% $28,613 $61,322

 

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