Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Medicare Measurement Efforts do not Address the Continuum of Care Delivered across an Entire Episode


Current health care quality measurement efforts focus on assessing care for individual indicators of performance for a patient with a specific clinical condition or set of risk factors at discrete points in time (e.g., percentage of patients with diabetes who received an HbA1c screening test or the percentage of women between the ages of 40-69 who received a mammogram). The measurement typically focuses on the actions of a single type of provider, such as the physician or the hospital, and emphasizes assessment of the provision of discrete services rather than the full spectrum of services within an episode for any given patient. 

The existing Medicare performance reporting systems with their discrete service indicator focus, do little to address the continuum of a patient’s care across provider settings or to create reinforcing incentives and joint accountabilities among providers for the care delivered to patients.  Only 10 clinical conditions are addressed by reporting programs for more than one setting. Three clinical conditions are included in programs for three settings: (1) acute myocardial infarction, (2) perioperative/surgical care, and (3) urinary incontinence.  Seven conditions are included in programs for two settings: (1) back pain, (2) community acquired pneumonia, (3) depression, (4) end stage renal disease, (5) heart failure, (6) pain, and (7) prevention. 

For the conditions addressed by more than one Medicare reporting program, the measures used do not fully permit the examination of the quality of care across a patient’s entire episode.  There is little overlap in the conditions covered across the reporting programs and there is a lack of coordination of measures across settings when there are measures for the same condition.  Across the various conditions, measures may address selected aspects of care in certain settings.  Important performance measurement gaps exist when considering measurement using an episode of care framework for assessment.  Key among the gaps are measures that directly assess care coordination or transitions of care from one setting to another—actions which are critical given that for most conditions, Medicare beneficiaries are being managed by multiple providers in multiple care settings.

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