Post-Acute Care Episodes Expanded Analytic File. 3. Acute Hospital-Initiated Episodes

04/01/2011

Analyses of acute hospital-initiated episodes were based on the cross-sectional analytic sample described in Section 2. The analyses focused on understanding the types of cases with acute hospital-initiated episodes, the first site of PAC, and any differences that occur in the 3 years of data examined here. In addition, the analyses looked specifically at episode patterns, episode length, and episode payment under six different episode definitions. Overall, episode summary statistics are shown here for each of the 3 years of data, although only 2008 data are shown for the episode pattern and service-specific utilization under different episode definitions. The key findings from the analyses of acute hospital-initiated episodes are summarized below.

Table 3 summarizes the top 10 MS-DRGs for beneficiaries initiating a PAC episode with an acute hospitalization as well as the percentage of all PAC users with the MS-DRG. This table also provides data on the ranking of these same MS-DRGs in the earlier years of data included in our analysis. The most common MS-DRG among beneficiaries discharged to PAC is MS-DRG 470, "Major joint replacement or reattachment of lower extremity w/o MCC" (13.7 percent of PAC users in 2008). Other MS-DRGs in the top five include MS-DRG 194, "Simple pneumonia & pleurisy w CC"; MS-DRG 690, "Kidney & urinary tract infections w/o CC"; MS-DRG 065, "Intracranial hemorrhage or cerebral infarction w CC"; and MS-DRG 481, "Hip & femur procedures except major joint w CC." The top 10 MS-DRGs account for close to 30 percent of all PAC users in 2008. This analysis reveals that the top five MS-DRGs among PAC users have been consistent over the 3 years of data examined, 2006-2008.

Table 3. Top 10 MS-DRGs for Acute Hospital-Initiated Episodes for Beneficiaries Discharged to PAC
Rank
2008
Rank
2007
Rank
2006
MS-DRG N
2008
Percent
2008
Cumulative
Percent
2008
Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM143).
1 1 1 470: Major joint replacement or reattachment of lower extremity w/o MCC 90,434 13.7 13.7
2 2 2 065: Intracranial hemorrhage or cerebral infarction w CC 13,992   2.1 15.8
3 4 4 481: Hip & femur procedures except major joint w CC 13,704   2.1 17.9
4 3 3 194: Simple pneumonia & pleurisy w CC 13,064   2.0 19.9
5 5 5 690: Kidney & urinary tract infections w/o MCC 12,954   2.0 21.9
6 7 11 641: Nutritional & misc metabolic disorders w/o MCC   9,755   1.5 23.3
7 6 6 299: Peripheral vascular disorders w MCC   9,752   1.5 24.8
8 9 7 292: Heart failure & shock w CC   8,602   1.3 26.1
9 15 17 291: Heart failure & shock w MCC   8,561   1.3 27.4
10 12 14 552: Medical back problems w/o MCC   8,113   1.2 28.6

The proportion of beneficiaries with acute hospital-initiated episodes discharged to each site of PAC is shown in Table 4. The percentage of beneficiaries discharged to each PAC setting is similar across the 3 years of data, with the largest proportion of beneficiaries discharged to SNF (42.2 percent in 2008) and HHA (37.4 percent in 2008) and a smaller proportion discharged to LTCH (1.7 percent in 2008), IRF (8.6 percent in 2008), and therapy services (10.1 percent in 2008). These results indicate that there has been a slight decrease in the percentage of beneficiaries discharged to IRF and a slight increase in the percentage discharged to SNF over the period 2006-2008. This change is of particular note when looking at specific MS-DRGs. For example, 17.9 percent of beneficiaries in MS-DRG 470, "major joint replacement" were discharged to IRF in 2006, and this decreased to 12.2 percent of beneficiaries in this MS-DRG in 2008. The decrease is likely a result of the phase-in of the 60 percent rule in the IRF payment system—a rule that requires 60 percent of a provider's admissions meet certain classification criteria in order for the provider to be eligible for IRF payment.

Table 4. First Site of PAC, Acute Hospital-Initiated Episodes, Overall and for Top 5 MS-DRGs by Volume of PAC Users, 2006-2008
MS-DRG N %
Discharged to PAC
%
Discharged to LTCH
%
Discharged to IRF
%
Discharged to SNF
%
Discharged to HHA
%
Discharged to Therapy
Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM143, M3MM156).
All MS-DRGs 2008 659,549 38.7 1.7   8.6 42.2 37.4 10.1
470: Major joint replacement or reattachment of lower extremity w/o MCC   90,434 94.2 0.1 12.2 37.4 37.4 12.9
065: Intracranial hemorrhage or cerebral infarction w CC   13,992 75.0 1.2 37.0 36.8 17.3   7.7
481: Hip & femur procedures except major joint w CC   13,704 95.4 0.4 22.1 68.0   7.7   1.8
194: Simple pneumonia & pleurisy w CC   13,604 36.3 0.9   1.7 51.1 37.8   8.5
690: Kidney & urinary tract infections w/o MCC   12,954 43.9 0.4   1.7 58.3 28.9 10.7
All MS-DRGs 2007 661,958 37.9 1.7   8.9 42.2 37.1 10.0
470: Major joint replacement or reattachment of lower extremity w/o MCC   91,259 93.9 0.1 14.2 37.1 36.2 12.4
065: Intracranial hemorrhage or cerebral infarction w CC   14,433 75.1 1.3 36.7 38.1 16.4   7.4
481: Hip & femur procedures except major joint w CC   13,558 95.0 0.7 23.1 66.8   7.7   1.8
194: Simple pneumonia & pleurisy w CC   15,044 36.1 1.2   1.5 50.7 38.8   7.8
690: Kidney & urinary tract infections w/o MCC   13,704 43.9 0.4   1.8 59.8 28.0 10.1
All MS-DRGs 2006 667,784 37.1 1.8   9.7 42.1 36.4   9.9
470: Major joint replacement or reattachment of lower extremity w/o MCC   91,621 94.0 0.2 17.9 36.2 33.7 12.0
065: Intracranial hemorrhage or cerebral infarction w CC   15,459 74.7 1.6 35.5 39.0 16.3   7.5
481: Hip & femur procedures except major joint w CC   13,846 94.8 0.8 23.1 66.8   7.3   1.9
194: Simple pneumonia & pleurisy w CC   16,638 35.7 1.2   1.7 51.6 38.3   7.3
690: Kidney & urinary tract infections w/o MCC   13,724 43.3 0.5   1.8 60.8 27.3   9.7

Table 5 displays the top 30 episode patterns for beneficiaries with acute hospital-initiated episodes. Each letter in the sequence represents a type of service: A = acute hospital, S = SNF, H = HHA, I = IRF, L = LTCH, O = hospital outpatient therapy, and T = independent therapist. Note that a single letter may represent one claim or multiple claims of the same type. This episode pattern analysis was conducted on the 30-day variable-length episode definition to provide an understanding of the complete clinical trajectory of service use related to an index event. Analysis of episode patterns for beneficiaries with acute hospital-initiated episodes indicate that as expected, acute to HHA (AH) and acute to SNF (AS) are the most common episode patterns (36.8 percent of all PAC episodes in 2008), and that the top 30 episode patterns account for over 82 percent of all episode patterns for beneficiaries discharged to PAC. Given that a small proportion of beneficiaries use LTCH nationally, there is only one episode pattern in that top 30 that includes LTCH. The episode pattern acute to LTCH (AL) is the 26th most common episode pattern, and it is common to 0.5 percent of beneficiaries with acute hospital-initiated episodes.

Table 5. Episode Patterns: Acute Hospital-Initiated Episodes, 2008
Rank Episode Pattern N Percent Cumulative Percent
Note: Episode pattern is based on a 30-day variable episode definition. Each letter indicates a type of service use, but a single letter may represent one claim or multiple claims of the same type of service. A = acute hospital, S = SNF, H = HHA, I= IRF, L= LTCH, O = outpatient department therapy, T = independent therapist.
Source: RTI analysis of 2008 Medicare claims (M3MM157).
1 AH 150,850 22.9 22.9
2 AS   91,928 13.9 36.8
3 ASH   56,661   8.6 45.4
4 AO   34,141   5.2 50.6
5 AHA   24,512   3.7 54.3
6 AT   18,485   2.8 57.1
7 ASO   17,931   2.7 59.8
8 AIH   14,900   2.3 62.1
9 ASAS   14,687   2.2 64.3
10 AHO   14,655   2.2 66.5
11 AHT   14,467   2.2 68.7
12 ASA   13,841   2.1 70.8
13 AHAH     8,839   1.3 72.2
14 ASHO     6,632   1.0 73.2
15 ASHT     6,115   0.9 74.1
16 AIO     5,961   0.9 75.0
17 ASHA     5,221   0.8 75.8
18 AI     4,902   0.7 76.5
19 ASASH     4,446   0.7 77.2
20 AST     4,282   0.6 77.8
21 ASASA     3,453   0.5 78.4
22 ASASAS     3,353   0.5 78.9
23 AIHO     3,158   0.5 79.4
24 ASASO     3,135   0.5 79.8
25 AHAS     3,071   0.5 80.3
26 AL     3,004   0.5 80.8
27 AHAHA     2,488   0.4 81.1
28 AOA     2,482   0.4 81.5
29 AISH     2,337   0.4 81.9
30 AHASH     2,290   0.3 82.2

Summary statistics looking at index, PAC, and total episode payments, by episode definition are presented in Tables 6 to 9. Mean payments were calculated using three different methods—payments per service use, payments per PAC user, and payments per hospital discharge—to demonstrate the differences in mean payments across different beneficiary samples. These different calculations are described below.

  • Payments per service user indicate the mean Medicare payments for those beneficiaries who use the specific PAC service (average payments per SNF admission for those who had an SNF admission).
  • Payments per PAC user indicate the mean Medicare payments across all beneficiaries who use any PAC, regardless of whether or not they use a specific PAC service.
  • Payments per hospital discharge indicate the mean Medicare payments across all beneficiaries with an index acute hospital stay, regardless of whether they use a PAC service. Note that the per-hospital discharge calculations include rehospitalizations and a small amount of subsequent service use for beneficiaries not discharged to PAC from their acute hospital initiating event.

As also demonstrated in earlier work, episode length and payments differ significantly by episode definition. For example, in 2008, the mean PAC payment per PAC user under the longest episode definition, the 30-day variable-length episode definition, was $17,236 in 2008 compared with $10,651 under the episode definition that includes any claim initiating within 30 days after hospital discharge (Table 6). Payments per discharge, as opposed to payments per PAC user, depend on the proportion of beneficiaries discharged to PAC. Among beneficiaries with acute hospital-initiated episodes in 2008, 38.7 percent were discharged to PAC and the mean PAC payment per hospital discharge was $8,384 under the 30-day variable-length episode definition. Table 7 displays episode summary statistics for the top five MS-DRGs by volume of PAC users to demonstrate the differences in PAC utilization by MS-DRG and to demonstrate the differences in the per-PAC-user and per-discharge calculations by MS-DRG given differences in the proportion of beneficiaries discharged to PAC by MS-DRG. For example, for MS-DRG 470, the mean PAC payment per discharge and the mean payment per PAC user were very similar across episode definitions ($9,593 versus $10,067 for the 30-day variable episode) because 94.2 percent of beneficiaries in this MS-DRG are discharged to PAC. In contrast, only 36.3 percent of beneficiaries in MS-DRG 194 are discharged to PAC, and therefore there are significant differences in the per-PAC-user and per-hospital-discharge calculations for PAC payments ($7,072 versus $14,892 for the 30-day variable episode). In addition to summary statistics for PAC users, Table 8 also shows the mean length of stay associated with each of the episode definitions in each of the 3 years of data. In general, the patterns in episode length are consistent with the patterns we observe for payment, with significant variation in the PAC and total episode length depending on whether we look at a shorter fixed-length definition or a longer variable-length definition. These patterns were consistent across the 3 years of data examined.

Table 6. Episode Summary Statistics: Acute Hospital-Initiated Episodes, 2006-2008
Episode Definition Mean Index
Acute
Hospital
Payment
Per
Discharge1
Mean Index
Acute
Hospital
Physician
Payment Per
Discharge1,2
Mean
PAC
Payment Per
Discharge1,3
Mean
Episode
Payment Per
Discharge1,4
Mean Index
Acute
Hospital
Payment
Per PAC
User1,5
Mean Index
Acute
Hospital
Physician
Payment Per
PAC User2,5
Mean
PAC
Payment
Per PAC
User3,5
Mean
Episode
Payment
Per PAC
User5,5
  1. Index acute hospitalizations are defined as hospital admissions following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Note that per-hospital discharge calculations include use of acute and Post-Acute care services for beneficiaries who do not meet the criteria of PAC user (use of PAC services following discharge from an index acute hospitalization). This includes acute hospital readmissions for non-PAC users.
  2. Physician payment is defined as separately billable Part B physician services rendered during the index acute hospital stay.
  3. Post-Acute care includes Medicare payments for SNF, IRF, LTCH, HHA, and therapy. Note that acute hospital readmissions are also included in PAC payments for episode definitions A, C, and E.
  4. Episode payment includes the index acute hospital stay, PAC, physician services during the index acute hospital stay and during the PAC episode.
  5. PAC users are defined as beneficiaries discharged to SNF, IRF, LTCH, HHA, or therapy following discharge from an index acute hospitalization. An index acute hospitalization is defined as a hospital admission following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use.

Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM143, M3MM149, M3MM216, M3MM237).

2008 (N=659,549)
A. 30-Day Variable Episode $8,531 $1,172 $8,384 $18,847 $10,572 $1,524 $17,236 $30,827
B. 30-Day Variable Episode Excluding Acute Hospital Readmissions $8,531 $1,172 $3,511 $13,472 $10,572 $1,524   $9,075 $21,926
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge $8,531 $1,172 $5,252 $15,355 $10,572 $1,524 $10,651 $23,499
D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions $8,531 $1,172 $3,157 $13,048 $10,572 $1,524   $8,165 $20,838
E. 30-Day Fixed Following Hospital Discharge (prorated) $8,531 $1,172 $3,845 $13,948 $10,572 $1,524   $7,564 $20,412
F. 30-Day Fixed Following Hospital Discharge Excluding Acute Hospital Readmissions (prorated) $8,531 $1,172 $2,221 $12,113 $10,572 $1,524   $5,745 $18,418
2007 (N=661,958)
A. 30-Day Variable Episode $8,205 $1,161 $7,725 $17,807 $10,062 $1,524 $16,145 $29,156
B. 30-Day Variable Episode Excluding Acute Hospital Readmissions $8,205 $1,161 $3,259 $12,865 $10,062 $1,524   $8,596 $20,904
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge $8,205 $1,161 $4,905 $14,656 $10,062 $1,524 $10,100 $22,416
D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions $8,205 $1,161 $2,945 $12,489 $10,062 $1,524   $7,772 $19,918
E. 30-Day Fixed Following Hospital Discharge (prorated) $8,205 $1,161 $3,612 $13,363 $10,062 $1,524   $7,217 $19,533
F. 30-Day Fixed Following Hospital Discharge Excluding Acute Hospital Readmissions (prorated) $8,205 $1,161 $2,088 $11,632 $10,062 $1,524   $5,510 $17,656
2006 (N=667,784)
A. 30-Day Variable Episode $7,941 $1,127 $7,208 $16,953   $9,644 $1,482 $15,236 $27,720
B. 30-Day Variable Episode Excluding Acute Hospital Readmissions $7,941 $1,127 $3,045 $12,339   $9,644 $1,482   $8,200 $20,015
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge $7,941 $1,127 $4,617 $14,052   $9,644 $1,482   $9,604 $21,426
D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions $7,941 $1,127 $2,754 $11,991   $9,644 $1,482   $7,422 $19,086
E. 30-Day Fixed Following Hospital Discharge (prorated) $7,941 $1,127 $3,425 $12,860   $9,644 $1,482   $6,909 $18,731
F. 30-Day Fixed Following Hospital Discharge Excluding Acute Hospital Readmissions (prorated) $7,941 $1,127 $1,967 $11,203   $9,644 $1,482   $5,300 $16,964
Table 7. Episode Summary Statistics: Acute Hospital-Initiated Episodes, by MS-DRG for Top 5 MS-DRGs by Volume of PAC Users, 2008
Episode Definition Mean Index
Acute
Hospital
Payment
Per
Discharge1
Mean Index
Acute
Hospital
Physician
Payment Per
Discharge1,2
Mean
PAC
Payment Per
Discharge1,3
Mean
Episode
Payment Per
Discharge1,4
Mean
Index
Acute
Hospital
Payment
Per PAC
User1,5
Mean Index
Acute
Hospital
Physician
Payment Per
PAC User2,5
Mean
PAC
Payment
Per PAC
User3,5
Mean
Episode
Payment
Per PAC
User4,5
  1. Index acute hospitalizations are defined as hospital admissions following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Note that per-hospital discharge calculations include use of acute and Post-Acute care services for beneficiaries who do not meet the criteria of PAC user (use of PAC services following discharge from an index acute hospitalization). This includes acute hospital readmissions for non-PAC users.
  2. Physician payment is defined as separately billable Part B physician services rendered during the index acute hospital stay.
  3. Post-Acute care includes Medicare payments for SNF, IRF, LTCH, HHA, and therapy. Note that acute hospital readmissions are also included in PAC payments for episode definitions A, C, and E.
  4. Episode payment includes the index acute hospital stay, PAC, physician services during the index acute hospital stay and during the PAC episode.
  5. PAC users are defined as beneficiaries discharged to SNF, IRF, LTCH, HHA, or therapy following discharge from an index acute hospitalization. An index acute hospitalization is defined as a hospital admission following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use.

Source: RTI analysis of 2008 Medicare claims (M3MM143, M3MM149, M3MM237).

A. 30-day Variable Episode
470: Major joint replacement or reattachment of lower extremity w/o MCC $11,079 $1,484   $9,593 $22,802 $11,120 $1,505 $10,067 $23,365
065: Intracranial hemorrhage or cerebral infarction w CC   $6,392    $979 $21,822 $30,587   $6,401 $1,038 $28,034 $37,217
481: Hip & femur procedures except major joint w CC $10,295 $1,734 $24,434 $37,817 $10,296 $1,750 $25,465 $38,918
194: Simple pneumonia & pleurisy w CC   $5,347    $631   $7,072 $13,681   $5,471    $749 $14,892 $22,291
690: Kidney & urinary tract infections w/o MCC   $3,989    $513   $8,727 $13,859   $4,090    $586 $16,943 $22,712
B. 30-Day Variable Episode Excluding Acute Hospital Readmissions
470: Major joint replacement or reattachment of lower extremity w/o MCC $11,079 $1,484   $7,093 $20,079 $11,120 $1,505   $7,527 $20,601
065: Intracranial hemorrhage or cerebral infarction w CC   $6,392    $979 $13,849 $21,974   $6,401 $1,038 $18,460 $26,904
481: Hip & femur procedures except major joint w CC $10,295 $1,734 $16,900 $29,687 $10,296 $1,750 $17,719 $30,559
194: Simple pneumonia & pleurisy w CC   $5,347    $631   $2,710   $8,895   $5,471    $749   $7,458 $14,246
690: Kidney & urinary tract infections w/o MCC   $3,989    $513   $4,092   $8,814   $4,090    $586   $9,316 $14,494
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge
470: Major joint replacement or reattachment of lower extremity w/o MCC $11,079 $1,484   $7,335 $20,238 $11,120 $1,505   $7,701 $20,679
065: Intracranial hemorrhage or cerebral infarction w CC   $6,392    $979 $14,812 $22,960   $6,401 $1,038 $19,086 $27,484
481: Hip & femur procedures except major joint w CC $10,295 $1,734 $17,664 $30,413 $10,296 $1,750 $18,402 $31,193
194: Simple pneumonia & pleurisy w CC   $5,347    $631   $4,385 $10,711   $5,471    $749   $9,163 $15,977
690: Kidney & urinary tract infections w/o MCC   $3,989    $513   $5,418 $10,247   $4,090    $586 $10,453 $15,642
D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions
470: Major joint replacement or reattachment of lower extremity w/o MCC $11,079 $1,484   $6,437 $19,279 $11,120 $1,505   $6,831 $19,753
065: Intracranial hemorrhage or cerebral infarction w CC   $6,392    $979 $12,239 $20,191   $6,401 $1,038 $16,314 $24,528
481: Hip & femur procedures except major joint w CC $10,295 $1,734 $15,168 $27,749 $10,296 $1,750 $15,903 $28,528
194: Simple pneumonia & pleurisy w CC   $5,347    $631   $2,490   $8,631   $5,471    $749   $6,858 $13,527
690: Kidney & urinary tract infections w/o MCC   $3,989    $513   $3,684   $8,352   $4,090    $586   $8,400 $13,456
E. 30-Day Fixed Following Hospital Discharge (prorated)
470: Major joint replacement or reattachment of lower extremity w/o MCC $11,079 $1,484   $5,893 $18,796 $11,120 $1,505   $6,182 $19,160
065: Intracranial hemorrhage or cerebral infarction w CC   $6,392    $979 $10,520 $18,667   $6,401 $1,038 $13,496 $21,894
481: Hip & femur procedures except major joint w CC $10,295 $1,734 $11,567 $24,316 $10,296 $1,750 $12,047 $24,838
194: Simple pneumonia & pleurisy w CC   $5,347    $631   $3,112   $9,438   $5,471    $749   $6,235 $13,049
690: Kidney & urinary tract infections w/o MCC   $3,989    $513   $3,615   $8,444   $4,090    $586   $6,749 $11,938
F. 30-Day Fixed Following Hospital Discharge Excluding Acute Hospital Readmissions (prorated)
470: Major joint replacement or reattachment of lower extremity w/o MCC $11,079 $1,484   $5,173 $18,016 $11,120 $1,505   $5,490 $18,412
065: Intracranial hemorrhage or cerebral infarction w CC   $6,392    $979   $8,672 $16,624   $6,401 $1,038 $11,559 $19,773
481: Hip & femur procedures except major joint w CC $10,295 $1,734   $9,955 $22,536 $10,296 $1,750 $10,437 $23,062
194: Simple pneumonia & pleurisy w CC   $5,347    $631   $1,664   $7,805   $5,471    $749   $4,583 $11,252
690: Kidney & urinary tract infections w/o MCC   $3,989    $513   $2,353   $7,021   $4,090    $586   $5,364 $10,420
Table 8. Episode Length of Stay: Acute Hospital-Initiated Episodes, 2006-2008
Episode Definition N Percent of
Beneficiaries
Discharged to
PAC1
Mean
Index
Acute
Hospital
LOS2
(days)
Mean
Index
Acute
Hospital
Payment2
Mean PAC
LOS3
(days)
Mean PAC
Payment4
Mean
Episode
LOS5
(days)
Mean
Episode
Payment5
  1. PAC users are defined as beneficiaries discharged to SNF, IRF, LTCH, HHA, or therapy following discharge from an index acute hospitalization.
  2. An index acute hospitalization is defined as a hospital admission following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use.
  3. Post-Acute care length of stay is defined as the difference between the admission date on the first PAC episode claim and the discharge date on the last PAC episode claim. Note that for some beneficiaries there may be a gap in service use between the discharge date on the index acute hospital claim and the admission date on the first PAC episode claim.
  4. Post-Acute care includes Medicare payments for SNF, IRF, LTCH, HHA, and therapy. Note that acute hospital readmissions are also included in PAC payments for episode definitions A, C, and E.
  5. Episode length of stay is the difference between the admission date on the index acute hospital claim and the last episode claim. Episode payment includes the index acute hospital stay, PAC, physician services during the index acute hospital stay and during the PAC episode.

Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM143, M3MM149, M3MM237).

2008
A. 30-Day Variable Episode 659,549 38.7 6.2 $10,572 79.1 $17,236 87.3 $30,827
B. 30-Day Variable Episode Excluding Acute Hospital Readmissions 659,549 38.7 6.2 $10,572 56.4   $9,075 64.6 $21,926
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge 659,549 38.7 6.2 $10,572 40.6 $10,651 48.8 $23,499
D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions 659,549 38.7 6.2 $10,572 37.4   $8,165 45.6 $20,838
E. 30-Day Fixed Following Hospital Discharge (prorated) 659,549 38.7 6.2 $10,572 25.0   $7,564 33.2 $20,412
F. 30-Day Fixed Following Hospital Discharge Excluding Acute Hospital Readmissions (prorated) 659,549 38.7 6.2 $10,572 22.7   $5,745 30.9 $18,418
2007
A. 30-Day Variable Episode 661,958 37.9 6.3 $10,062 77.9 $16,145 86.2 $29,156
B. 30-Day Variable Episode Excluding Acute Hospital Readmissions 661,958 37.9 6.3 $10,062 55.8   $8,596 64.0 $20,904
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge 661,958 37.9 6.3 $10,062 41.2 $10,100 49.5 $22,416
D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions 661,958 37.9 6.3 $10,062 38.0   $7,772 46.2 $19,918
E. 30-Day Fixed Following Hospital Discharge (prorated) 661,958 37.9 6.3 $10,062 24.9   $7,217 33.2 $19,533
F. 30-Day Fixed Following Hospital Discharge Excluding Acute Hospital Readmissions (prorated) 661,958 37.9 6.3 $10,062 22.6   $5,510 30.9 $17,656
2006
A. 30-Day Variable Episode 667,784 37.1 6.4   $9,644 75.4 $15,236 83.8 $27,720
B. 30-Day Variable Episode Excluding Acute Hospital Readmissions 667,784 37.1 6.4   $9,644 53.2   $8,200 61.5 $20,015
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge 667,784 37.1 6.4   $9,644 39.2   $9,604 47.6 $21,426
D. 30-Day Fixed: Any Claim Starting Within 30 Days After Hospital Discharge Excluding Acute Hospital Readmissions 667,784 37.1 6.4   $9,644 36.1   $7,422 44.5 $19,086
E. 30-Day Fixed Following Hospital Discharge (prorated) 667,784 37.1 6.4   $9,644 24.7   $6,909 33.1 $18,731
F. 30-Day Fixed Following Hospital Discharge Excluding Acute Hospital Readmissions (prorated) 667,784 37.1 6.4   $9,644 22.4   $5,300 30.8 $16,964

The percentage of beneficiaries using specific PAC services also varies by episode definition as shown in Table 9 In this table, we report the percentage of beneficiaries using each type of service, the mean claim length of stay, mean payment per service user, mean payment per PAC user, and mean payment per hospital discharge for each of the six episode definitions examined. The results indicate that the percentage of beneficiaries using HHA and SNF services increases under longer episode definitions because these services may be used directly after discharge from an acute hospitalization or later in an episode of care such as following an LTCH or IRF admission. Use of LTCH and IRF services is less sensitive to episode definitions because these services most often occur directly following an acute hospitalization. Table 8 also demonstrates the differences in acute hospital readmission during an episode-by-episode definition. Under the episode definition including any claim starting within 30 days after hospital discharge, 14.8 percent of beneficiaries had a readmission during an episode, but this increases to 28.6 percent under a 30-day variable-length episode definition again indicating differences in service use and policy implications for different episode definitions.

Table 9. Service-Specific Episode Summary Statistics, Acute Hospital-Initiated Episodes, 2008
Service Use (N = 659,549) A.
30-Day
Variable
Episode
B.
30-Day
Variable
Episode
Excluding
Acute
Hospital
Readmissions
C.
30-Day Fixed:
Any Claim
Starting
Within 30
Days After
Hospital
Discharge
D.
30-Day Fixed:
Any Claim
Starting Within
30 Days After
Hospital
Discharge
Excluding Acute
Hospital
Readmissions
E.
30-Day Fixed:
Any Claim
Starting Within
30 Days After
Hospital
Discharge
(prorated)
F.
30-Day Fixed:
Any Claim Starting
Within 30 Days After
Hospital Discharge
Excluding Acute
Hospital
Readmissions
(prorated)
  1. "Per service user" indicates mean Medicare payments for those beneficiaries who use the specific PAC service.
  2. "Payments per PAC user" indicate the mean Medicare payments across all beneficiaries who use any PAC, regardless of whether or not they use a specific PAC service.
  3. "Payments per hospital discharge" indicate the mean Medicare payments across all beneficiaries with an index acute hospitalization, regardless of whether they use a PAC service. Note that per-hospital discharge calculations include acute hospital readmissions and a small amount of subsequent service use for beneficiaries not discharged to PAC from their acute hospital initiating event. Note that 13.3 percent of non-PAC users had an acute hospital readmission under episode definition A, and 13.2 percent had an acute hospital readmission under episode definition C and E.

Source: RTI analysis of 2008 Medicare claims (M3MM143, M3MM149, M3MM215).

HHA
Percent with Claim 60.7 57.1 52.2 51.3 52.2 51.3
Mean Visits 25.6 20.1 15.8 15.7 6.8 6.6
Mean Claim Length (days) 60.4 47.5 35.3 35.1 19.9 18.6
Mean Payment Per Service User1 $4,230 $3,429 $2,786 $2,768 $1,339 $1,304
Mean Payment Per PAC User2 $2,566 $1,958 $1,455 $1,420 $699 $669
Mean Payment Per Hospital Discharge3 $1,079 $759 $590 $549 $278 $259
SNF
Percent with Claim 48.2 44.5 45.3 44.2 45.3 44.2
Mean LOS (days) 39.3 30.3 32.3 29.4 19.8 18.9
Mean Payment Per Service User1 $13,646 $10,743 $11,476 $10,518 $7,495 $7,169
Mean Payment Per PAC User2 $6,575 $4,781 $5,204 $4,644 $3,399 $3,165
Mean Payment Per Hospital Discharge3 $2,703 $1,849 $2,085 $1,796 $1,348 $1,224
IRF
Percent with Claim 9.7 8.9 9.0 8.8 9.0 8.8
Mean LOS (days) 14.3 13.0 13.5 12.9 12.9 12.5
Mean Payment Per Service User1 $17,518 $15,922 $16,504 $15,825 $15,919 $15,378
Mean Payment Per PAC User2 $1,707 $1,410 $1,489 $1,387 $1,436 $1,348
Mean Payment Per Hospital Discharge3 $706 $545 $601 $536 $573 $521
LTCH
Percent with Claim 2.6 1.8 2.0 1.8 2.0 1.8
Mean LOS (days) 31.5 27.3 27.4 27.0 20.8 21.3
Mean Payment Per Service User1 $38,932 $35,069 $35,203 $34,861 $27,406 $28,144
Mean Payment Per PAC User2 $1,011 $634 $691 $621 $538 $501
Mean Payment Per Hospital Discharge3 $444 $245 $283 $240 $215 $194
Outpatient Department Therapy
Percent with Claim 20.3 17.0 11.5 11.4 11.5 11.4
Mean Payment Per Service User1 $1,410 $1,137 $628 $620 $363 $359
Mean Payment Per PAC User2 $286 $193 $72 $70 $42 $41
Mean Payment Per Hospital Discharge3 $117 $75 $29 $27 $16 $16
Independent Therapist
Percent with Claim 9.6 8.9 6.3 6.2 6.3 6.2
Mean Payment Per Service User1 $1,209 $1,125 $358 $358 $331 $330
Mean Payment Per PAC User2 $116 $100 $22 $22 $21 $20
Mean Payment Per Hospital Discharge3 $46 $39 $9 $9 $8 $8
Acute Hospital Readmission
Percent with Claim 28.3 14.8 14.8
Mean LOS (days) 11.3 7.4 6.0
Mean Payment Per Service User1 $17,561 $11,594 $9,652
Mean Payment Per PAC User2 $4,976 $1,718 $1,430
Mean Payment Per Hospital Discharge3 $3,288 $1,655 $1,407

The per-service-user, per-PAC-user, and per-hospital-discharge calculations highlight the sensitivity of these calculations to the episode definition selected and the population over which payments are averaged. This is demonstrated most clearly by examining the LTCH utilization. Under the episode definition including any claim starting within 30 days after hospital discharge, mean payment per beneficiary using LTCH is $35,203. When calculated per PAC user, the mean payment is $691, and when calculated per hospital discharge, the payment is $283. These sharp differences indicate the importance of understanding service use patterns in thinking about episode-based payment. This includes consideration of issues related to geography and provider supply in areas of the country with access to LTCHs compared with those without LTCHs in their area.

Physician service use is another topic of interest to episode bundling discussions. Use of physician services in the week prior to the episode initiating event, during the initiating event, and during the episode is presented in Table 10. To reveal more about differences in use prior to the start of an episode for different types of cases (for example, medical versus surgical), these data are presented both overall and for the top five MS-DRGs by volume of PAC users. Overall, 49.9 percent of beneficiaries with acute hospital-initiated episodes had at least one physician claim in the week prior to the start of an episode, although this finding varied from 34.5 percent for beneficiaries in MS-DRG 481, "hip & femur procedures," to 54.2 percent for beneficiaries in MS-DRG 470, "major joint replacement or reattachment of lower extremity." Total episode payments for physician services were higher for beneficiaries receiving surgical procedures and for beneficiaries with stroke compared with beneficiaries being treated for pneumonia or kidney and urinary tract infections.

Table 10. Physician Service Use, Acute Hospital-Initiated Episodes, by MS-DRG for Top 5 MS-DRGs by Volume of PAC Users, 2008
MS-DRG 7 Days
Prior to
Index
Acute
Hospitalization1
Index
Acute
Hospitalization1
A.
30-Day
Variable
Episode
B.
30-Day
Variable
Episode
Excluding
Acute
Hospital
Readmissions
C.
30-Day Fixed:
Any Claim
Starting Within
30 Days After
Hospital
Discharge
D.
30-Day Fixed:
Any Claim
Starting
Within 30
Days After
Hospital
Discharge
Excluding
Acute
Hospital
Readmissions
E.
30-Day
Fixed:
Any Claim
Starting
Within 30
Days After
Hospital
Discharge
(prorated)
F.
30-Day Fixed:
Any Claim
Starting Within
30 Days After
Hospital
Discharge
Excluding
Acute Hospital
Readmissions
(prorated)
  1. An "index acute hospitalization" is defined as a hospital admission following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use. Seven days prior to index acute hospitalization does not define the start of the episode.
  2. "Per service user" indicates mean Medicare payments for those beneficiaries who use physician services.
  3. "Payments per PAC user" indicate the mean Medicare payments across all beneficiaries who use any PAC, regardless of whether or not they use physician services.
  4. "Payments per hospital discharge" indicate the mean Medicare payments across all beneficiaries with an index acute hospital stay, regardless of whether they use a PAC service.
  5. Physician claims with dates of service falling between the admission date on an index acute hospitalization and the last date of episode were identified from the Medicare Carrier claims using physician specialty codes and the dollars associated with these services were included in episode payment calculations.

Source: RTI analysis of 2008 Medicare claims (M3MM216).

All MS-DRGs
Percent with Claim 49.9 98.6 98.9 98.9 98.9 98.8 98.9 98.8
Mean Payment Per Service User2 $207 $1,546 $3,052 $2,305 $2,302 $2,125 $2,302 $2,125
Mean Payment Per PAC User3 $103 $1,524 $3,019 $2,279 $2,275 $2,101 $2,275 $2,101
Mean Payment Per Hospital Discharge4 $107 $1,137 $1,931 $1,430 $1,572 $1,360 $1,572 $1,360
470: Major joint replacement or reattachment of lower extremity w/o MCC
Percent with Claim 54.2 98.9 99.0 99.7 99.0 99.0 99.0 99.0
Mean Payment Per Service User2 $156 $1,522 $2,200 $1,974 $1,877 $1,820 $3,104 $1,820
Mean Payment Per PAC User3 $85 $1,505 $2,178 $1,954 $1,858 $1,801 $1,858 $1,801
Mean Payment Per Hospital Discharge4 $83 $1,484 $2,130 $1,906 $1,824 $1,763 $1,824 $1,763
065: Intracranial hemorrhage or cerebral infarction w CC
Percent with Claim 37.0 98.2 98.4 98.4 98.4 98.3 98.4 98.3
Mean Payment Per Service User2 $217 $1,057 $2,827 $2,077 $2,030 $1,843 $2,030 $1,843
Mean Payment Per PAC User3 $80 $1,038 $2,782 $2,043 $1,997 $1,812 $1,997 $1,812
Mean Payment Per Hospital Discharge4 $81 $979 $2,373 $1,733 $1,756 $1,560 $1,756 $1,560
481: Hip & femur procedures except major joint w CC
Percent with Claim 34.5 98.8 99.0 99.0 98.9 98.9 98.9 98.9
Mean Payment Per Service User2 $181 $1,770 $3,189 $2,571 $2,522 $2,354 $2,522 $2,354
Mean Payment Per PAC User3 $62 $1,750 $3,157 $2,545 $2,496 $2,329 $2,496 $2,329
Mean Payment Per Hospital Discharge4 $62 $1,734 $3,089 $2,492 $2,455 $2,287 $2,455 $2,287
194: Simple pneumonia & pleurisy w CC
Percent with Claim 45.0 99.1 99.3 99.2 99.2 99.2 99.2 99.2
Mean Payment Per Service User2 $178 $756 $1,942 $1,328 $1,353 $1,207 $1,353 $1,207
Mean Payment Per PAC User3 $80 $749 $1,928 $1,318 $1,343 $1,198 $1,343 $1,198
Mean Payment Per Hospital Discharge4 $85 $631 $1,262 $838 $979 $794 $654 $794
690: Kidney & urinary tract infections w/o MCC
Percent with Claim 43.0 98.9 99.1 99.1 99.1 99.1 99.1 99.1
Mean Payment Per Service User2 $167 $593 $1,694 $1,098 $1,109 $975 $1,109 $975
Mean Payment Per PAC User3 $72 $586 $1,679 $1,864 $1,099 $966 $1,099 $966
Mean Payment Per Hospital Discharge4 $82 $513 $1,143 $734 $840 $679 $840 $679

 

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