Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Footnotes

02/01/2009

1 Public Law 109-171, February 8, 2006

2 Public Law 110-275, July 15, 2008

3 Medicare severity diagnostic related groups

4 Prospective payment system

5 Relative value unit

6 Ambulatory payment classification

7 Electroconvulsive therapy

8 Healthcare common procedures coding system

9 Disproportionate share

10 Graduate medical education

11 Sustainable growth rate

12 Annual payment update

13 Resource utilization group

14 Home health resource group

15 Case-mix group

16 Medicare severity long term care diagnosis related groups

17 Rehabilitation, psychiatric and long term care

18 Hierarchical condition category

19 Prescription drug hierarchical condition category

20 Consumer price index for all urban consumers

21 Federal Employee Health Benefits

22 Medicaid statistical information system

23 Public Law 108-173, December 8, 2003.

24 Public Law 109-432, December 20, 2006.

25 Public Law 110-173, December 29, 2007.

26 P=Process, O=Outcome, E=Efficiency, IO=Intermediate Outcome, F=Functional, S=Structural, PE=Patient Experience

27 While the measure names are the same, the specifications of the individual measures may not be the same.

28 The ten conditions are colon cancer, non-small-cell lung cancer, mitral valve regurgitation, non-ischemic stage C congestive heart failure, ST segment elevated myocardial infarction, depression, diabetes mellitus type 2, knee replacement, hip replacement, and preventive care.

29 Provider identifiers used by Medicare, including Unique Provider Identification Numbers (UPINs), Provider Identification Numbers (PINs), and Tax Identifiers (TAXIDs) can be used by a provider group, and providers may have multiple identifiers.  These are being replaced by a new provider identifier, the National Provider Identifier, required since May 2007.

30 The two groupers were selected based on their use in analyses by MedPAC and ongoing CMS research. We did not compare them to each other or other existing groupers.

31 The conditions used in the MedPAC analyses include coronary artery disease, bacterial pneumonia, cerebrovascular disease, essential hypertension, congestive heart failure, urinary tract infections, diabetes (both type 1 & type 2), cholecystitis and cholelithiasis, prostate cancer, breast cancer, peptic ulcer disease, and sinusitis.

32 We did not evaluate the clinical validity of the two groupers, examine the logic that was used to define related services, or compare these groupers to other groupers not used in this project.

33 Standardized payments were reduced by the copayment amount for each service and excluded deductibles>

34 Primary care physicians were identified using their specialty code in Medicare claims. We included physicians with specialties internal medicine, family medicine, and hospitalists.

35 Currently, a single physician can bill under multiple tax identifiers, and those tax identifiers may represent "groups" of physicians.

36 The episodes of care were generated by Acumen, LLC using the specifications outlined here.

37 For Medstat, all chronic episode types have an associated clean period of 999 days.  Such diseases effectively have a 365-day clean period, because Medstat uses an annual cutoff for chronic episodes.  Thus, claims occurring one year apart should always be grouped to different episodes.  For this reason, and to make completeness statistics of chronic episode types more comparable between the two groupers, we use 365-day clean periods for these MEGs.

38 Diagnosis codes are not linked to services listed on institutional claims.  Additionally, 82% of IP claims, 70% of SNF claims, and 38% of HH claims have more than 4 codes, requiring the user to choose which four claims to include in the service record.

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