Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Summary Statistics for Selected Conditions of Focus across the Three States

02/01/2009

As stated in the overview of our analyses, we sought to focus on conditions that are common among Medicare beneficiaries. Table 9 presents the number and percent of continuously enrolled Medicare FFS beneficiaries identified as having each of the conditions of focus using both primary and secondary diagnoses that appeared in the 2005 claims data. The selected conditions were fairly common among the continuously enrolled beneficiaries, with between 0.8 percent (bacterial pneumonia) and 17.7 percent (diabetes) experiencing each of the conditions. Three of the conditions were experienced by more than 10 percent of the beneficiaries: COPD, congestive heart failure and diabetes.

Table 9. Number and Percent of Beneficiaries with Conditions of Focus

Condition # of Continuously Enrolled FFS Beneficiaries with Condition % of Continuously Enrolled FFS Beneficiaries with Condition
AMI 37,464 1.1%
Bacterial Pneumonia 28,617 0.8%
Breast Cancer 55,129 1.6%
Cerebrovascular Disease 129,271 3.7%
COPD 364,691 10.4%
Congestive Heart Failure 513,000 14.7%
Diabetes 620,141 17.7%
Hip Fracture 35,576 1.0%
Low Back Pain 283,869 8.1%

 

Figure 2. Number of Conditions of Focus among Beneficiaries with at Least One Condition

Figure 2 shows the distribution of the nine conditions of interest in 2005 among the continuously enrolled Medicare beneficiaries. Two-thirds had only one of the conditions. Approximately a quarter had two of the conditions, while eight percent had three conditions. Two percent of beneficiaries with any of the conditions had at least four of the conditions, with the maximum being eight of the nine conditions.

While we used both primary and secondary diagnoses to identify the conditions of focus, the episode groupers use primary diagnoses on selected types of claims to trigger the creation of episodes.

Figure 3. Average Number of Related Episodes per Condition, ETGs

Figures 3 shows the average number of episodes related to the conditions experienced by beneficiaries identified as having each of the conditions for ETGs and MEGs, respectively.-  With both groupers, there were individuals we identified as having a condition who did not have an episode designated as being related to the condition. This occurred most frequently for congestive heart failure and COPD, where the condition was consistently used as a secondary diagnosis or appeared as a primary diagnosis on claims that did not trigger a new episode, such as durable medical equipment claims. There were instances where individuals with a condition had more than one episode related to the condition; this was most notable with back pain under MEGs. There were five MEG episodes we identified as being related to back pain (Appendix C). There were beneficiaries with back pain that experienced more than 1 of the 5 different episodes we identified as being related to back pain, while other beneficiaries experienced more than 1 of the same type of episode.

Figure 4. Average Number of Related Episodes per Condition, MEGs

Figure 4. Average Number of Related Episodes per Condition, MEGs

Figure 4 shows the average number of episodes related to the conditions experienced by beneficiaries identified as having each of the conditions for ETGs and MEGs, respectively.-  With both groupers, there were individuals we identified as having a condition who did not have an episode designated as being related to the condition. This occurred most frequently for congestive heart failure and COPD, where the condition was consistently used as a secondary diagnosis or appeared as a primary diagnosis on claims that did not trigger a new episode, such as durable medical equipment claims. There were instances where individuals with a condition had more than one episode related to the condition; this was most notable with back pain under MEGs. There were five MEG episodes we identified as being related to back pain (Appendix C). There were beneficiaries with back pain that experienced more than 1 of the 5 different episodes we identified as being related to back pain, while other beneficiaries experienced more than 1 of the same type of episode.

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