Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Implications of Beneficiaries with High Disease Burden

02/01/2009

To understand the extent to which episodes may differ for complex patients compared to less complex patients, we conducted a series of analyses using the number of episodes experienced by a beneficiary as a proxy for patient complexity. Beneficiaries were separated into three categories based on the number of ETG episodes they were assigned: up to 5 episodes (approximately 25 percent of beneficiaries), 6-11 episodes (approximately 50 percent of beneficiaries), and 12 or more episodes (approximately 25 percent of beneficiaries). In this section, we present selected results from these analyses.

Figure 26. Average Standardized Payment per Episode by Number of Episodes Experienced

Average Standardized Payment per Episode by Number of Episodes Experienced

Figure 26 shows there is in general a consistent relationship between the total number of ETG episodes experienced by a beneficiary and the average standardized payment per episode for episodes related to the condition of focus. The more episodes experienced by a beneficiary, the higher the standardized payments. There was one exception to this pattern for congestive heart failure, which was driven by a very high cost outlier with a small number of episodes.

Figure 27. Median Number of Providers per Episode by Number of Episodes Experienced

Median Number of Providers per Episode by Number of Episodes Experienced

Figure 27 shows that the greater the total number of ETG episodes experienced by a beneficiary, the more providers that tend to be involved in managing their care for a specific episode. This was largely driven by larger numbers of specialists involved when the beneficiary experiences many episodes. This larger number of providers involved doesn"t necessary translate into greater challenges attributing episodes to physicians, however.

Figure 28. Percent of Episodes Attributed to Physicians by Total Number of Episodes Experienced.

Percent of Episodes Attributed to Physicians by Total Number of Episodes Experienced.

Figure 28 shows the percent of episodes related to AMI, diabetes and hip fracture that could be attributed to a physician using the episode professional services cost plurality rule (single provider accounting for at least 30 percent of professional services costs). While the percent of episodes able to be attributed declined with increasing episodes experience by beneficiaries with AMIs, it actually increased slightly for beneficiaries with diabetes, and remained fairly stable for beneficiaries with hip fractures.

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