Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Number of Providers and Settings Involved in Episodes Related to Conditions

02/01/2009

Medicare beneficiaries received care for episodes related to the nine conditions of focus from a wide variety of providers and in numerous settings. Figure 14 presents the median number of providers delivering services during episodes related to each of the nine conditions. Providers were categorized as primary care physicians (specialties of family practice, internal medicine, general practice, geriatrics and genecology), specialists (all other physician specialties), and other providers (e.g., physical therapists, dieticians). We present only the information from ETGs as that produced by MEGs was not substantively different.


Figure 14. Median Number of Providers Involved in the Episode, ETGs

Median Number of Providers Involved in the Episode, ETGs

Figure 14 presents the median number of providers delivering services during episodes related to each of the nine conditions. Providers were categorized as primary care physicians (specialties of family practice, internal medicine, general practice, geriatrics and genecology), specialists (all other physician specialties), and other providers (e.g., physical therapists, dieticians). We present only the information from ETGs as that produced by MEGs was not substantively different.


Across most of the nine conditions we examined, we observe a median of one primary care physician involved in the management of the episode. For episodes related to breast cancer and low back pain, more than half of episodes did not include any primary care physicians. Only episodes related to AMI had a median number of primary care type physicians involved that was more than one.  Involvement of specialists varied more across the episodes related to the nine conditions, with AMI and hip fracture having the largest number of specialists involved (median of six and five, respectively), while episodes related to diabetes had the fewest (median less than one). Many of the episodes also involved other types of providers, most notably hip fracture (median of two). Larger numbers of providers involved in the treatment of an episode increases the likelihood that coordination challenges in the delivery of care will occur.

Figure 15. Median Number of Physicians Providing Services in Facility and Outpatient Settings, ETGs

Median Number of Physicians Providing Services in Facility and Outpatient Settings, ETGs

Figure 15 focuses only on physicians, shows the number of physicians delivering care in a facility (e.g. hospital, nursing home) versus the outpatient setting, which has implications for coordination of care. For ETG episodes related to some conditions, such as breast cancer, COPD, diabetes and low back pain, the majority of physicians are predominantly providing services in outpatient settings. For other conditions, such as AMI and hip fracture, the majority of physicians involved are providing care in facilities.


The number of physicians providing services during an episode only provides a partial picture of the potential complexity of an episode. Patients may flow between various health care settings and provider types, as shown in Figure 16, and Medicare has different performance measurement programs and payment systems for separate settings. In Figure 17, we show the number of settings involved in ETG episodes related to each of the nine clinical conditions of focus. There are nine settings captured by Figure 17: physician ambulatory services (i.e. services provided in the community), ambulatory surgical centers, hospital outpatient (includes the physician services delivered in hospital outpatient departments), inpatient acute care (including physician services), long-term care hospitals, inpatient rehabilitation facilities, skilled nursing homes, home health and hospice. Durable medical equipment (DME) and outpatient laboratory services are not included as separate settings for this figure. While there are some substantive differences in these results by the two episodes groupers, we present here only the results of ETGs for the purpose of simplicity. The results for MEGs are presented in the tables in the appendices.


Figure 16. Potential Patient Trajectories Through the Health Care System

Figure 16 shows the number of physicians providing services during an episode only provides a partial picture of the potential complexity of an episode. Patients may flow between various health care settings and provider types and Medicare has different performance measurement programs and payment systems for separate settings.


The number of settings involved in episodes varied both within a condition and between conditions. For example, while approximately 50 percent of ETG episodes related to low back pain involved only one setting, more than 50 percent of episodes related to hip fracture involved four or more settings. For cerebrovascular disease, over 20 percent of episodes fell into each of our four categories. The fraction of episodes involving just one setting ranged from 4.0 percent of AMI-related episodes to 50.6 percent of low back pain episodes. At the other end of the spectrum, the number of episodes involving at least four settings ranged from 4.4 percent for diabetes to 57.3 percent of hip fracture episodes. The large number of settings involved in a substantial portion of these episodes creates a number of complexities for aligning either performance measurement or financial incentives.


Figure 17. Number of Settings Involved in Episodes by Condition, ETGs

Figure 17 shows the number of settings involved in ETG episodes related to each of the nine clinical conditions of focus.


Figures 18-20 illustrate the different settings of care that patient with ETG episodes related to AMI, diabetes and hip fracture, respectively, "touch". Comparable information for the other conditions are provided in Appendix E. Also, in Appendix E we report the percentage of episodes related to the nine conditions for both groupers that involve each setting; these tables include DME and outpatient laboratories. In Figures 18-20, we categorize settings by ambulatory care (i.e. hospital outpatient, physician office, ambulatory surgical centers), acute inpatient care (hospital acute inpatient care), post-acute care (home health care, skilled nursing facilities, inpatient rehabilitation facilities, long-term care hospitals), and special populations (hospice). For each setting, we report in parentheses the percentage of episodes related to the condition that involve that setting. For example, 88.5 percent of episodes related to AMI involve the hospital outpatient setting (upper left portion of figure). As part of this analysis, we report the number of performance measures for the condition that are currently reported to Medicare for each setting below the percent of episodes involving the setting.  We also report at the bottom of each figure the most common combinations of settings that occur in episodes related to the condition. We focus on combinations that occur in more than 10 percent of episodes. We use this information to assess the extent to which the measures reported to Medicare for the condition align with the settings in which the care for episodes related to the condition is delivered and identify gaps in existing measures.

In addition to the condition specific-measures that are currently reported to Medicare for each patient of the settings of care, we recognize that there may be other measures that are potentially relevant to patients with each condition. For example, there will be a subset of AMI patients that will have a CABG performed in the hospital during the episode of care related to their AMI. For these patients, the CABG measures as well as the perioperative/surgical care measures would be relevant. Therefore, we address measures for other conditions that are potentially relevant for the condition of focus (e.g. AMI). Additionally, there are SNF, home health and PQRI prevention/screening measures that are not condition-specific that may be particularly relevant to patients with our conditions of focus. We indicate those measures that clinical experts at RAND believe may have particular relevance for each of the conditions in Tables 14 and 15.

Other Potentially Relevant Measures. There are number of measures that may apply to subsets of AMI patients.  These include CABG/Cardiac Surgery, Heart Failure, and Perioperative measures.  Additionally the PQRI measures calling for an electrocardiogram for non-traumatic chest pain or syncope may apply to patients with episodes of care related to AMI.


Figure 18. Settings Involved in ETG Episodes Related to AMI

Settings Involved in ETG Episodes Related to AMI

Figure 18 shows that nearly all (99.2%) patients with an AMI-related episode utilized an acute care hospital, 89 percent utilized the hospital outpatient department (which includes the emergency department), and 74 percent visited a physician office for that episode.-  Additionally, approximately 20 percent of patients utilized home health or a skilled nursing facility.-  There were three different combinations of settings that each accounted for more than 10 percent of the episodes related to AMI and these three combinations jointly accounted for 67 percent of the AMI-related episodes. The most common combination of settings involved acute care hospitals, hospital outpatient departments and physician office visits (41 percent of episodes). While there are nine clinical measures (listed in Table 12) reported for the hospital facility (and one for physicians in the hospital setting) and five measures for the emergency department, there is only one measure for care delivered in a physician office.-  The skilled nursing and home health measures are not condition specific and apply to all patients in those settings.


Table 12. Process and Outcome Measures Reported to CMS Applicable to AMI Patients

Measure Condition Measure Hospital
Inpatient
Hospital Outpatient/ED Physician
AMI Aspirin at Arrival X X X (inpatient)*
AMI Aspirin at discharge X    
AMI ACE-I or ARB for LVSD X    
AMI Adult smoking cessation advice/counseling X    
AMI Beta blocker at arrival X    
AMI Beta blocker prescribed at discharge X    
AMI Fibrinolytic medication received within 30

minutes of hospital arrival

X X  
AMI PCI received within 120 minutes of hospital arrival X    
AMI 30-day AMI mortality X    
AMI Median time to fibrinolysis   X  
AMI Median time to electrocardiogram   X  
AMI Median time to transfer for primary PCI   X  
CAD Beta blocker therapy for patients with prior MI     X
*This is a PQRI physician-level measure that would apply in a hospital setting

Nearly 90 percent of patients with an episode related to diabetes visited a physician office and 45 percent utilized the hospital outpatient department.  Only 15 percent had an acute care hospitalization related to the episode.  Additionally, 11 percent utilized home health care and 9 percent a skilled nursing facility.  Only two combinations of settings each accounted for more than 10 percent of the episodes; these two combinations accounted for 67 percent of all diabetes-related episodes in our sample. The most common combination involved only physician ambulatory services (41 percent of episodes related to diabetes). There are currently 10 measures reported to CMS for the physician office setting where the majority of the care for diabetes episodes is taking place; these measures are presented in Table 13. The skilled nursing and home health measures are not condition specific and apply to all patients in those settings.

Other Potentially Relevant Measures. The PQRI measure for wound care for patients with venous ulcers is also potentially relevant for individuals with diabetes.

Figure 19.  Settings Involved in ETG Episodes Related to Diabetes

Settings Involved in ETG Episodes Related to Diabetes

Figures 19 illustrates the different settings of care that patient with ETG episodes related to AMI, diabetes and hip fracture, respectively, "touch". Comparable information for the other conditions are provided in Appendix E. Also, in Appendix E we report the percentage of episodes related to the nine conditions for both groupers that involve each setting; these tables include DME and outpatient laboratories.

Measure Condition Measure Physician (Ambulatory)

Table 13.  Process and Outcome Measures Reported to CMS Applicable to Diabetes Patients

Diabetes Hemoglobin A1C poor control X
Diabetes LDL control X
Diabetes Blood pressure control X
Diabetes Dilated eye exam X
Diabetes Urine screening or medical attention for nephropathy X
Diabetes Foot exam X
Diabetes Foot and ankle care: neurological evaluation X
Diabetes Foot and ankle care: evaluation of footwear X
Diabetic Retinopathy Documentation of presence or absence of macular edema and level of severity of retinopathy X
Diabetic Retinopathy Communication with the physician managing ongoing diabetes care X

Over 90 percent of patients with an episode related to hip fracture utilized an acute care hospital, 85 percent utilized the hospital outpatient department (including the emergency department) and 65 percent visited a physician office related to the episode.  Additionally, 56 percent utilized a skilled nursing facility, 40 percent home health care 18 percent inpatient rehabilitation.  The three most common combinations of settings accounted for 41 percent of the hip fracture-related episodes in our sample. The most common combination of settings involved four settings (hospital acute inpatient, hospital outpatient, physician ambulatory services, and skilled nursing facility) and accounted for only 15.7 of episodes. There is currently only one condition-specific measure reported to CMS for hip fracture and that is for mortality in the acute care hospital setting. The skilled nursing and home health measures are not condition specific and apply to all patients in those settings.

Other Potentially Relevant Measures. As most patients who have a hip fracture will have surgery, the perioperative measures would apply as would the hospital inpatient Patient Safety Indicator for post operative wound dehiscence. Additionally, the PQRI osteoporosis measure calling for management following a fracture would likely apply.


Figure 20. Settings Involved in ETG Episodes Related to Hip Fracture

Settings Involved in ETG

Figures 20 illustrates the different settings of care that patient with ETG episodes related to AMI, diabetes and hip fracture, respectively, "touch". Comparable information for the other conditions are provided in Appendix E. Also, in Appendix E we report the percentage of episodes related to the nine conditions for both groupers that involve each setting; these tables include DME and outpatient laboratories.


Non Condition-Specific Measures. The PQRI prevention/screening measures and the Home Health and SNF measures are not condition-specific and are intended to be applied to all Medicare beneficiaries receiving care in those settings.  However, in Tables 14 and 15 we specify those measures that clinical experts at RAND determined to be the most applicable to the conditions of interest.

Table 14. Application of PQRI Prevention/Screening Measures to Conditions of Interest

Measures AMI Bacterial Pneumonia Breast-  Cancer Cerebro-vascular CHF COPD Diabetes Hip Fracture Low Back Pain
Medication reconciliation after discharge from inpatient setting X X X X X X X    
Advance care plan     X X X X      
Influenza vaccination for patients > 50 X X X X X X X    
Pneumonia vaccination for patients > 65   X X X X X X    
Screening mammography     X            
Colorectal cancer screening                  
Inquiry regarding tobacco use X     X X X X    
Advising smokers to quit X     X X X X    
Universal weight screening and follow-up   X     X X X    
Universal documentation and verification of current medications in the medical record X X   X X X X    
Pain assessment prior to initiation of patient treatment     X         X X
Screening for cognitive impairment       X          
Screening for clinical depression X   X X          
Screening and brief counseling for alcohol abuse                  
Endoscopy and polyp surveillance--interval in patients with history of adenomatous polyps                  
Elder maltreatment screen with follow-up plan       X       X  

Table 15. Application of SNF and Home Health Measures to Conditions of Interest

  Measures AMI Bacterial Pneumonia Breast-  Cancer Cerebro-vascular CHF COPD Diabetes Hip Fracture Low Back Pain
SNF
Long Stay:
Residents given influenza vaccination during the flu season   X              
Residents assessed and given pneumococcal vaccination   X              
Residents whose need for help with daily living activities has increased       X       X  
Residents who have moderate to severe pain     X       X X X
High risk residents who have pressure sores All
Low risk residents who have pressure sores All
Residents who were physically restrained All
Residents who are more depressed or anxious X     X         X
Residents who lose control of their bowels or bladder       X       X  
Residents who have had a catheter inserted and left in their bladder       X       X  
Residents who spent most of their time in a bed or in a chair       X X X   X  
Residents whose ability to move about and around their room got worse       X X X   X  
Residents with a urinary tract infection       X       X  
Residents who lost too much weight All
Short Stay:
Residents given influenza vaccination during the flu season   X              
Residents assessed and given pneumococcal vaccination   X              
Residents with delirium All
Residents who had moderate to severe pain     X       X X X
Residents with pressure sores All
Home Health
Improvement in ambulation/locomotion       X X X   X  
Improvement in bathing               X  
Improvement in transferring       X       X  
Improvement in management of oral medication All
Improvement in pain interfering with activity     X       X X X
Improvement in dyspnea         X X      
Improvement in urinary incontinence       X       X  
Improvement in the status of surgical wounds               X  
Patients requiring acute care hospitalization All
Patients requiring emergent care All
Patients requiring emergent care for wound infections             X X  
Patients discharged to the community All

The previous discussion of the settings involved in episodes of care highlighted the prominent position of hospital acute inpatient care for episodes related to AMI and hip fracture. While it is not surprising that multiple different physicians are involved in providing services during an episode, it would be easy to assume that acute inpatient care is provided in a single facility. However, this is not always the case, particularly for AMI patients. Seventeen percent of ETG episodes related to AMI involved more than one acute care hospital (table in Appendix E). This is likely due to patients being transferred from one hospital to another after they have been admitted or being readmitted during the course of the episode to a different hospital. This occurrence was much less frequently observed for the other conditions with less than two percent of episodes involving more than one acute care hospital.

Figure 21. Division of Standardized Payments across Care Settings, ETGs

Division of Standardized Payments across Care Settings, ETGs

Figure 21 shows how standardized payments for ETG episodes related to each of the nine conditions are divided across settings. Comparable information for MEG episodes is presented in the appendices. Substantial variation in the distribution of payments across settings and conditions is evident. For example, the percent of payments for acute inpatient care ranges from approximately six percent for total episode payments for diabetes, low back pain and breast cancer to 80 percent for episodes related to AMI.-  Similarly, while physician ambulatory services account for 63 percent of the episode payments for low back pain, they only account for approximately 3 percent of payments for AMI episode. Substantial variation exists for most of the other settings as well.

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