Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Overview of the Analytic Sample


Figure 1 provides a high-level illustration of the approach used in our analyses.  The study population for this work consisted of Medicare FFS beneficiaries who were continuously enrolled in FFS Medicare Part A and Part B for 2004-2006, whose reason for eligibility was their age, and whose primary residence in 2005 was in one of three states: Florida, Oregon, or Texas.  As a result of our inclusion criteria, we excluded beneficiaries enrolled in a Medicare Advantage plan for any of the analyses period.  Claims data for the medical services received by individuals enrolled in a Medicare Advantage plan are not reported to Medicare, making it impossible to accurately create episodes of care for these individuals. We also excluded individuals who aged into Medicare over the time period of 2004-2006 or were eligible for Medicare due to end-stage renal disease. We did not exclude individuals who died during the time period as long as they met our other eligibility criteria.

The three states included in our analyses were selected in part because we sought states that 1) had a mix of urban and rural areas, 2) would facilitate an understanding of the issues associated with "snowbirds" who spend part of the year in a warm climate, and 3) had variation in the presence of long-term care hospitals to understand the effect their supply may have on the settings in which beneficiaries receive care. Furthermore, careful consideration was given to the geographic areas included in previous episodes of care work performed by MedPAC and Acumen, LLC (on behalf of CMS). - 

We used three years of claims data (2004-2006) for the construction of episodes of care. This provides a year of data as the primary period of focus and allows looking forward and backward to complete the episodes. We used Medicare Standard Analytic Files for inpatient (including those for acute care hospitals, long-term care hospitals, critical access hospitals, and inpatient rehabilitation facilities), skilled nursing facility, outpatient, home health agency, carrier (non-institutional providers including physicians, physician assistants, clinical social workers, nurse practitioners, independent clinical laboratories, ambulance providers, and stand-alone ambulatory surgical centers), durable medical equipment and hospice to construct the episodes of care. This project utilized 100 percent of the claims for Medicare FFS beneficiaries who resided in the three states within the specified time frame of the analysis. Thus, we included all of the claims for these Medicare beneficiaries, even if they receive some of their health care services in other states.

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