Post-Acute Care Episodes Expanded Analytic File. 4.1 HHA-Initiated Episodes

04/01/2011

Table 11 shows the distribution of cases for beneficiaries entering HHA without a prior acute hospitalization by diagnosis grouping as discussed in Section 2. There is no single, obvious way to classify home health community entrant episodes by diagnosis. While MS-DRGs have been developed for acute hospital and LTCH payment, HHA payment is based more on the services provided (nursing and therapy) rather than on the primary diagnosis for which the beneficiary is receiving care. RTI developed a grouping algorithm based on MDC and MS-DRG after running the MS-DRG grouper on all claims including HHA claims. These groupings are more highly aggregated than the MS-DRG but may provide an understanding of the broad types of cases entering HHA without a prior acute hospitalization. With this grouping approach, close to one quarter of HHA-initiated episodes are in an "other" condition grouping, but other large groupings include orthopedic minor medical, neurologic medical, and cardiovascular general, which account for a total of 40 percent of HHA-initiated episodes in 2008.

Table 11. Top 10 Condition Groupings: HHA-Initiated Episodes, 2006-2008
Rank
2008
Rank
2007
Rank
2006
Condition Grouping N
2008
Percent
2008
Cumulative
Percent
2008
Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM204).
1   1   1   Other, Medical 57,849 24.48 24.5
2   2   2   Orthopedic, Minor Medical 40,669 17.21 41.7
3   3   3   Neurologic, Medical 33,344 14.11 55.8
4   6   6   Cardiovascular, General 21,438   9.07 64.9
5   4   4   Integumentary, Medical 20,783   8.79 73.7
6   5   5   Endocrine, Medical 19,050   8.06 81.7
7   7   7   Cardiovascular, Cardiac Medical   9,429   3.99 85.7
8   8   8   Kidney & Urinary, Medical   6,909   2.92 88.6
9   10 11 Respiratory, COPD   6,075   2.57 91.2
10 9   9   Cardiovascular, Vascular Medical   5,522   2.34 93.5

In addition to looking at HHA episodes by condition grouping, RTI also examined the top 10 ICD-9 codes in the first position on HHA claims for beneficiaries with acute hospital-initiated episodes discharged to HHA and for beneficiaries with HHA-initiated episodes (Table 12) as well as the HHRG coded on HHA claims for these two groups of beneficiaries (Table 13). The results of these analyses indicate that the most common ICD-9 code for beneficiaries initiating care in an acute hospital was V54.81 "Aftercare following joint replacement" (11.5 percent) while the most common ICD-9 code for the HHA-initiated beneficiaries was V57.1 "Other physical therapy" (10.3 percent). In general, the top ICD-9 codes for the acute initiated episodes were for aftercare related to surgery whereas the top ICD-9 codes for the HHA-initiated episodes were for more chronic conditions such as hypertension, congestive heart failure, diabetes, and Alzheimer's. The top ten ICD-9 codes accounted for 43.6 percent of all episodes for beneficiaries initiating care in an acute hospital and discharged to HHA and 35.1 percent of all HHA-initiated episodes. The HHRG analysis also indicated some differences in these two populations. Based on the top 10 HHRGs in each group of beneficiaries, a higher proportion of beneficiaries initiating an episode in an acute hospital and discharged to HHA were in higher case-mix weight HHRGs indicating higher clinical severity, functional severity, and service severity compared to beneficiaries with HHA-initiated episodes. One of the top ten HHRGs for HHA-initiated episodes included 14-19 therapies while all others included 0-13 therapies. These results suggest a lower intensity, but chronic patient in the HHA-initiated episodes.

Table 12. Top 10 ICD-9 Codes (Primary) Coded on HHA Claims, Acute Hospital-Initiated Episodes for Beneficiaries Discharged to HHA and HHA-Initiated Episodes, 2008
Rank ICD-9 Code N Percent Cumulative
Percent
Source: RTI analysis of 2008 Medicare claims (M3MM256).
Acute Hospital-Initiated Episodes, Beneficiaries Discharged to HHA
1 V54.81: Aftercare following joint replacement 28,244 11.5 11.5
2 V57.1: Other physical therapy 14,552   5.9 17.4
3 428.0: Congestive heart failure, unspecified 13,116   5.3 22.7
4 V58.73: Aftercare following surgery of the circulatory system, NEC 12,439   5.0 27.7
5 486: Pneumonia, organism unspecified   7,841   3.2 30.9
6 491.21: Obstructive chronic bronchitis with (acute) exacerbation   7,252   2.9 33.8
7 V58.42: Aftercare following surgery for neoplasm   7,108   2.9 36.7
8 V58.78: Aftercare following surgery of the musculoskeletal system, NEC   6,388   2.6 39.3
9 V58.75: Aftercare following surgery of the teeth, oral cavity and digestive system   5,449   2.2 41.5
10 401.9: Essential hypertension, unspecified   5,224   2.1 43.6
HHA-Initiated Episodes
1 V57.1: Other physical therapy 24,218 10.3 10.3
2 401.9: Essential hypertension, unspecified 14,399   6.1 16.3
3 781.2: Abnormality of gait   9,312   3.9 20.3
4 250.00: Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled   8,534   3.6 23.9
5 428.0: Congestive heart failure, unspecified   5,652   2.4 26.3
6 250.02: Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled   5,388   2.3 28.6
7 728.87: Muscle weakness (generalized)   5,388   2.3 30.8
8 331.0: Alzheimer's disease   3,715   1.6 32.4
9 V57.89: Other specified rehabilitation procedure, Other (multiple training or therapy)   3,244   1.4 33.8
10 332.0: Paralysis agitans (Parkinson's disease)   3,119   1.3 35.1
Table 13. Top 10 HHRGs Coded on HHA Claims, Acute Hospital-Initiated Episodes for Beneficiaries Discharged to HHA and HHA-Initiated Episodes, 2008
Rank HHRG Case Mix Weight N Percent Cumulative
Percent
Source: RTI analysis of 2008 Medicare claims (M3MM257, M3MM258).
Acute Hospital-Initiated Episodes, Beneficiaries Discharged to HHA
1 1CGK: Early Episode, 0-13 therapies, Clinical Severity Level 3, Functional Severity Level 2,Service Severity Level 1 0.9896 24,521   9.9   9.9
2 1BFK: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 1,Service Severity Level 1 0.7335 19,884   8.1 18.0
3 1CFK: Early Episode, 0-13 therapies, Clinical Severity Level 3, Functional Severity Level 1,Service Severity Level 1 0.901   19,849   8.0 26.1
4 1BGK: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 2,Service Severity Level 1 0.8221 19,551   7.9 34.0
5 1AFK: Early Episode, 0-13 therapies, Clinical Severity Level 1, Functional Severity Level 1,Service Severity Level 1 0.5827 12,585   5.1 39.1
6 1AGK: Early Episode, 0-13 therapies, Clinical Severity Level 1, Functional Severity Level 2,Service Severity Level 1 0.6713   8,982   3.6 42.7
7 1BGM: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 2,Service Severity Level 3 1.2993   7,938   3.2 45.9
8 1BGP: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 2,Service Severity Level 5 1.69       7,005   2.8 48.8
9 1CHK: Early Episode, 0-13 therapies, Clinical Severity Level 3, Functional Severity Level 3,Service Severity Level 1 1.0733   6,742   2.7 51.5
10 1AGM: Early Episode, 0-13 therapies, Clinical Severity Level 1, Functional Severity Level 2,Service Severity Level 3 1.1485   6,466   2.6 54.1
HHA-Initiated Episodes
1 1CGK: Early Episode, 0-13 therapies, Clinical Severity Level 3, Functional Severity Level 2,Service Severity Level 1 0.9896 25,829 10.9 10.9
2 1CFK: Early Episode, 0-13 therapies, Clinical Severity Level 3, Functional Severity Level 1,Service Severity Level 1 0.901   21,635   9.2 20.1
3 1BFK: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 1,Service Severity Level 1 0.7335 15,057   6.4 26.5
4 1BGK: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 2,Service Severity Level 1 0.8221 14,876   6.3 32.8
5 1CHK: Early Episode, 0-13 therapies, Clinical Severity Level 3, Functional Severity Level 3,Service Severity Level 1 1.0733 11,522   4.9 37.6
6 1AFK: Early Episode, 0-13 therapies, Clinical Severity Level 1, Functional Severity Level 1,Service Severity Level 1 0.5827 10,317   4.4 42.0
7 1AGK: Early Episode, 0-13 therapies, Clinical Severity Level 1, Functional Severity Level 2,Service Severity Level 1 0.6713   6,361   2.7 44.7
8 1BGP: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 2,Service Severity Level 5 1.69       5,119   2.2 46.9
9 2BGK:Early Episode, 14-19 therapies, Clinical Severity Level 2, Functional Severity Level 3,Service Severity Level 1 0.8221   4,894   2.1 48.9
10 1BHK: Early Episode, 0-13 therapies, Clinical Severity Level 2, Functional Severity Level 3,Service Severity Level 1 0.9058   4,522   1.9 50.8

In Table 14, episode patterns for beneficiaries initiating care in HHA are shown. Over 70 percent of HHA community entrant beneficiaries have "HHA only" episodes and do not go on to use other PAC services. The second most frequent episode pattern is HHA to acute hospital (HA), which is common to 5.9 percent of the HHA community entrants. To learn more about the difference between HHA community entrants and beneficiaries with acute hospital-initiated episodes discharged to HHA as their first site of PAC, we ran an episode pattern analysis on the second set of beneficiaries as well (Table 15). A smaller proportion of beneficiaries in the acute hospital-initiated group use HHA only (61.2 percent), and a higher proportion of beneficiaries go on to use subsequent services—a pattern more clearly illustrated in the next set of tables.

Table 14. Episode Patterns: HHA-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 H 165,702 70.1 70.1
2 HA   14,033   5.9 76.1
3 HAH     8,681   3.7 79.7
4 HO     7,130   3.0 82.8
5 HAS     4,336   1.8 84.6
6 HT     4,293   1.8 86.4
7 HASH     3,099   1.3 87.7
8 HAHA     1,682   0.7 88.4
9 HOH     1,544   0.7 89.1
10 HAHAH     1,357   0.6 89.7
Table 15. Episode Patterns: Acute Hospital-Initiated Episodes, Beneficiaries Discharged to HHA, 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 (M3MM187).
1 AH 150,850 61.2 61.2
2 AHA   24,512   9.9 71.1
3 AHO   14,655   5.9 77.1
4 AHT   14,467   5.9 82.9
5 AHAH     8,839   3.6 86.5
6 AHAS     3,071   1.2 87.8
7 AHAHA     2,488   1.0 88.8
8 AHASH     2,290   0.9 89.7
9 AHAHAH     1,430   0.6 90.3
10 AHASA     1,060   0.4 90.7

Summary statistics for the HHA-initiated episodes are shown in Table 16 by year and episode definition. The mean number of visits in the initial index HHA claim is 16.8 visits, and this is consistent across the 3 years of data examined. As with the acute hospital-initiated episodes, episode length and payments are sensitive to the episode definition we look at. For example, under Episode Definition C (any claim initiating within 30 days following discharge from the initiating event), the mean episode length of stay is 64.0 days, but this increases to 113.1 days under the longer 30-day variable-length episode definition. Table 17 presents the difference in total HHA utilization for beneficiaries with acute-initiated episodes discharged to HHA and for beneficiaries with HHA-initiated episodes for 2006-2008. Beneficiaries with HHA initiated episodes have a higher number of HHA visits, more claim days in HHA, and higher HHA payments compared to beneficiaries with acute initiated episodes discharged to HHA.

Table 16. Episode Summary Statistics: HHA-Initiated Episodes, 2006-2008
Episode Definition N Mean
Visits
During
Initiating
Event1
Mean
Index
Claim
Length
(days)
Mean
Initiating
Event
Payment1
Mean
Episode
LOS
(days)2
Mean
Episode
Payment2
  1. 1. An "initiating event" is defined as an HHA claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use.
  2. 2. Episode length of stay is defined as the difference between the admission date on the first episode claim and the discharge date on the last episode claim. Episode payments include Medicare payments for SNF, IRF, LTCH, HHA, and therapy. Note that acute hospitalizations are also included in episode payments for episode definitions A and C.

Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM100, M3MM102, M3MM260).

2008
A. 30-Day Variable Episode 236,307 16.8 101.0 $2,779 113.1 $11,736
B. 30-Day Variable Episode Excluding Acute Hospitalization 236,307 16.8   83.7 $2,779   87.9   $4,966
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 236,307 16.8   59.4 $2,779   64.0   $6,446
2007
A. 30-Day Variable Episode 223,915 17.2   96.7 $2,690 108.9 $10,957
B. 30-Day Variable Episode Excluding Acute Hospitalization 223,915 17.2   80.2 $2,690   84.3   $4,773
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 223,915 17.2   57.6 $2,690   62.6   $6,155
2006
A. 30-Day Variable Episode 212,780 16.8 103.5 $2,555 116.0 $11,313
B. 30-Day Variable Episode Excluding Acute Hospitalization 212,780 16.8   82.2 $2,555   86.3   $4,678
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 212,780 16.8   56.4 $2,555   61.3   $5,924
Table 17. HHA Utilization, HHA Initiated Episodes versus Beneficiaries With Acute Hospital-Initiated Episodes Discharged to HHA, 2006-2008
Episode Definition Mean HHA
Visits per
HHA
Initiated
Episode
Mean HHA
Claim
Length
(days) per
HHA
Initiated
Episode
Mean HHA
Payment
per
Episode
per HHA
Initiated
Episode
Mean HHA
Visits per
Acute
Initiated
Episode
Discharged
to HHA
Mean HHA
Claim
Length
(days) per
Acute
Initiated
Episode
Discharged
to HHA
Mean HHA
Payment
per Episode
per Acute
Initiated
Episode
Discharged
to HHA
  1. Visit, claim length, and payments include index event plus subsequent service use in the episode.

Source: RTI Analysis of 2006, 2007, and 2008 Medicare Claims (M3MM260, M3MM261).

2008
A. 30 Day Variable Episode 64.7 101.0 $5,776 22.6 57.8 $3,697
B. 30 Day Variable Episode Excluding Acute Hospitalization 57.2   83.7 $4,777 17.9 45.7 $3,030
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 48.2   59.4 $3,675 14.8 34.9 $2,571
2007
A. 30 Day Variable Episode 65.2   96.7 $5,521 22.5 55.9 $3,462
B. 30 Day Variable Episode Excluding Acute Hospitalization 57.6   80.2 $4,597 18.0 44.4 $2,852
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 47.7   57.6 $3,530 14.9 34.5 $2,440
2006
A. 30 Day Variable Episode 68.0 103.5 $5,657 23.4 57.1 $3,416
B. 30 Day Variable Episode Excluding Acute Hospitalization 57.8   82.2 $4,504 18.1 44.0 $2,755
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 46.7   56.4 $3,321 14.8 34.2 $2,343

Table 18 and Table 19 show more clearly the service-specific utilization under different episode definitions for HHA community entrants (Table 18) and for beneficiaries initiating a PAC episode in an acute hospital but discharged to HHA for their first site of PAC (Table 19). In Table 18, we can see that 35.4 percent of beneficiaries with an HHA-initiated episode have more than one HHA claim in their care trajectory under the 30-day variable-length episode. Over 9 percent go on to use SNF, and 23.1 percent have an acute hospitalization under this same episode definition. Among those beneficiaries initiating care in an acute hospital but discharged to HHA as the first setting of PAC, a similar proportion of beneficiaries goes on to use SNF and have an acute hospitalization. Under the same episode definition, 7.3 percent of beneficiaries have an SNF claim and only a slightly higher proportion of beneficiaries have a rehospitalization (25.9 percent). In Table 20, we see the proportion of beneficiaries using physician services in the week prior to the start of an episode and during the episode. A higher proportion of beneficiaries with HHA-initiated episodes have at least one physician claim in the week prior to the start of the episodes, compared with beneficiaries with acute hospital-initiated episodes (57.2 percent and 49.9 percent, respectively).

Table 18. Service-Specific Episode Summary Statistics: HHA-Initiated Episodes, 2008
Service Use (N = 236,307) A.
30-Day
Variable
Episode
B.
30-Day Variable
Episode Excluding
Acute
Hospitalization
C.
30-Day Fixed:
Any Claim Starting
Within 30 Days After
Discharge from
Initiating Event
  1. Service use for the initiating event is not included in this calculation. HHA use following first claim reported here.
  2. Episode definition B excludes acute hospitalizations. Therefore values for acute hospitalization are missing for this episode definition.

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

HHA (not including initiating event)1
Percent with Claim 35.4 28.2 33.0
Mean Visits 64.0 53.9 18.5
Mean Claim Length (days) 166.4 148.1 51.6
Mean Payment Per Service User $8,465 $7,096 $2,711
SNF
Percent with Claim 9.3 0.4 5.6
Mean LOS (days) 47.8 40.0 36.3
Mean Payment Per Service User $16,517 $12,886 $12,863
IRF
Percent with Claim 1.5 0.2 0.8
Mean LOS (days) 16.2 14.2 14.9
Mean Payment Per Service User $19,238 $15,781 $17,772
LTCH
Percent with Claim 0.8 0.1 0.3
Mean LOS (days) 33.0 33.3 29.0
Mean Payment Per Service User $38,520 $31,122 $33,213
Outpatient Department Therapy
Percent with Claim 7.4 5.1 4.6
Mean Payment Per Service User $1,378 $1,141 $657
Independent Therapist
Percent with Claim 3.4 3.0 2.6
Mean Payment Per Service User $1,234 $1,181 $458
Acute Hospitalization2
Percent with Claim 23.1 16.7
Mean LOS (days) 10.7 7.3
Mean Payment Per Service User $15,850 $10,563
Table 19. Service-Specific Episode Summary Statistics: Acute Hospital-Initiated Episodes, Beneficiaries Discharged to HHA, 2008
Service Use (N = 246,595) A.
30-Day
Variable
Episode
B.
30-Day Variable
Episode Excluding
Acute
Hospitalizations
C.
30-Day Fixed:
Any Claim Starting
Within 30 Days After
Hospital Discharge
  1. By definition, 100 percent of beneficiaries with acute initiated episodes discharged to HHA have at least one HHA claim in their episode. Note that 18.9 percent of beneficiaries in episode definition A, 10.2 percent in episode definition B, and 1.6 percent of beneficiaries in episode definition C have more than one HHA claim in their PAC episode.
  2. Episode definition B excludes acute hospitalizations. Therefore values for acute hospitalization are missing for this episode definition.

Source: RTI analysis of 2008 Medicare claims (M3MM187).

HHA
Percent with Claim1 100.0 100.0 100.0
Mean Visits 22.6 17.9 14.8
Mean Claim Length (days) 57.8 45.7 34.9
Mean Payment Per Service User $3,697 $3,030 $2,571
SNF
Percent with Claim 7.3 0.7 2.8
Mean LOS (days) 39.7 30.5 26.4
Mean Payment Per Service User $14,135 $10,323 $9,679
IRF
Percent with Claim 1.3 0.1 0.4
Mean LOS (days) 15.3 12.9 12.9
Mean Payment Per Service User $19,184 $15,294 $16,065
LTCH
Percent with Claim 0.8 0.0 0.2
Mean LOS (days) 30.0 25.2 23.8
Mean Payment Per Service User $35,925 $26,896 $28,227
Outpatient Department Therapy
Percent with Claim 9.3 7.5 4.2
Mean Payment Per Service User $1,016 $881 $424
Independent Therapist
Percent with Claim 7.5 6.9 4.2
Mean Payment Per Service User $1,168 $1,124 $299
Acute Hospitalization2
Percent with Claim 25.9 14.0
Mean LOS (days) 11.4 7.1
Mean Payment Per Service User $18,205 $11,322
Table 20. Physician Service Use, by Condition Grouping and by Episode Definition: HHA-Initiated Episodes, 2008
Condition Grouping 7 Days Prior
to
Initiating
Event1
A.
30-Day
Variable
Episode
B.
30-Day Variable
Episode
Excluding Acute
Hospitalizations
C.
30-Day Fixed:
Any Claim Starting
Within 30 Days
After Hospital
Discharge
  1. An initiating event is defined as an HHA claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use.
  2. 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 Condition Groupings
Percent with Claim 57.2 83.0 81.8 82.3
Mean Payment Per Service User $259 $1,679 $1,018 $960
Other, Medical
Percent with Claim 60.2 78.8 77.5 78.3
Mean Payment Per Service User $349 $1,367 $842 $875
Orthopedic, Minor Medical
Percent with Claim 58.2 84.0 82.9 83.3
Mean Payment Per Service User $507 $1,431 $913 $825
Neurologic, Medical
Percent with Claim 51.7 82.6 81.4 81.7
Mean Payment Per Service User $488 $1,507 $903 $821
Cardiovascular, General
Percent with Claim 54.0 86.7 85.9 85.7
Mean Payment Per Service User $494 $1,532 $994 $816
Integumentary, Medical
Percent with Claim 57.9 83.0 81.5 82.2
Mean Payment Per Service User $629 $1,876 $1,024 $1,092

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