Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Summary Statistics for Continuously Enrolled Beneficiaries

02/01/2009

To provide a sense of scale, Table 7 provides summary statistics on the number of Medicare beneficiaries residing in each of the three states in 2005 who were continuously enrolled in Medicare FFS, 2004-2006, the number of Medicare claims in 2005 for these beneficiaries and the total Medicare payments for these claims.  

Table 7. Summary Statistics for Continuously Enrolled Beneficiaries

State # of Beneficiaries # Medicare Claims in 2005 FFS Medicare Payments for 2005 Claims 2005 FFS Medicare Payments per Beneficiary
Florida 1,682,031 58,532,070 $14,096,159,338 $8,380
Oregon 222,691 5,623,819 $1,307,129,151 $5,870
Texas 1,596,950 48,959,417 $13,465,355,633 $8,432

Table 8 presents for both ETGs and MEGs the percent of 2005 claims the grouper did not assign to an episode and what these unassigned claims translated into in terms of the percent of 2005 Medicare FFS payments that were not assigned to an episode. We also present the total number of episodes created by the two groupers for the continuously enrolled Medicare beneficiaries in our study population and the average number of episodes per continuously enrolled beneficiary. We then show the percent of all episodes that were identified as being related to the nine conditions of focus in this project and the percent of Medicare payments the episodes related to the nine conditions represented.

State % Claims Not Assigned to an Episode % Payments Not Assigned to an Episode # of Episodes of Any Type Average Number of Episodes per Beneficiary % of Episodes Related to Conditions of Focus % of Medicare Payments for Episodes Related to Conditions of Focus

Table 8. Summary Statistics for Continuously Enrolled Beneficiaries

ETGs
Florida 9.6% 5.2% 12,773,401 8.0 13.1% 34.7%
Oregon 10.8% 4.5% 1,252,148 6.1 14.2% 34.0%
Texas 10.2% 5.2% 10,243,694 6.9 15.0% 37.2%
MEGs
Florida 12.9% 7.6% 13,474,905 8.4 13.3% 27.2%
Oregon 12.3% 5.3% 1,380,593 6.6 14.3% 27.8%
Texas 12.5% 5.5% 11,018,315 7.3 14.8% 31.2%

Both groupers assigned a high fraction of both claims and payments to an episode. Only approximately 10 percent and 12.5 percent of claims for ETGs and MEGs respectively were not assigned to an episode; these claims represented 4.5 percent to 7.6 percent of total Medicare payments made, depending on the state and specific grouper. The types of claims most frequently not assigned to an episode were durable medical equipment and laboratory tests. The vast majority of episodes created were deemed complete (approximately 97 percent for ETGs and 89 percent for MEGs). For purposes of this project an episode was deemed complete if it either began and ended in 2005 or began in 2004, with the necessary clean period for the specific episode observed, and ended in 2005.

A small portion of continuously enrolled Medicare FFS beneficiaries did not have any episodes, ranging from 4.2 percent ( Florida using MEGs) to 7.6 percent ( Oregon using ETGs). Most of these individuals did not have any claims. Individuals with at least one episode had an average of 6.1 ( Oregon) to 8.0 ( Florida) ETG episodes and 6.6 ( Oregon) to 8.4 ( Florida) MEG episodes. This variation in the number of episodes could partly be due to differences in practice styles across regions, which could trigger more episodes in one area than another. Another possibility is that the Medicare beneficiaries residing in Oregon may be healthier than those in Florida. The underlying reasons for variation in the number of episodes per enrollee is an area for future research.

Episodes identified as being related to the nine conditions of focus represented a relatively small portion of the total number of episodes (13.1 to 15.0 percent). They represented a substantially larger portion of Medicare payments, however, ranging from 27.2 percent to 37.2 percent of payments. While ETGs and MEGs captured very similar percentages of claims in episodes related to the conditions of focus, ETG episodes related to the conditions represented a larger portion of total Medicare payments than MEG episodes.

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