Post-Acute Care Episodes Expanded Analytic File. 4.2 LTCH-Initiated Episodes

04/01/2011

Table 21 presents the frequency of the LTCH MS-DRG variable for beneficiaries with LTCH-initiated episodes, and Table 22 presents the frequency of the LTCH MS-DRG variable for beneficiaries initiating an episode of care in an acute hospital, but discharged to LTCH as their first site of PAC. These two tables indicate significant differences in the types of cases entering the LTCH from the community versus those who enter following discharge from an acute hospital. Most notably, the most common MS-DRG among beneficiaries with LTCH-initiated episodes is MS-DRG 885, "Psychoses," which was common to 13.5 percent of the LTCH community entrant sample in 2008. Other common MS-DRGs among community entrants included respiratory system diagnosis with ventilator support at 6.7 percent (MS-DRG 207), skin ulcers at 7.8 percent (MS-DRGs 592 and 593), and skin grafts at 6.1 percent (MS-DRGs 573 and 574). The relative frequency of these MS-DRGs was similar across the 3 years of data examined. In contrast, beneficiaries initiating an episode in an acute hospital and discharged to LTCH as their first site of PAC were more likely to have respiratory and medical diagnoses including MS-DRG 207 (14.2 percent of beneficiaries); MS-DRG 189, "pulmonary edema & respiratory failure" (7.8 percent of beneficiaries); and MS-DRG 871, "Septicemia w/o MV 96+ hours w MCC" (4.5 percent).

 

Table 21. Top 10 MS-DRGs for LTCH-Initiated Episodes, 2006-2008
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   1 885: Psychoses 672 13.5 13.5
  2   2   2 207: Respiratory system diagnosis w ventilator support 96+ hours 333   6.7 20.2
  3   5   6 189: Pulmonary edema & respiratory failure 204   4.1 24.3
  4   3   3 593: Skin ulcers w CC 196   3.9 28.3
  5   7   7 592: Skin ulcers w MCC 195   3.9 32.2
  6   6   8 573: Skin graft &/or debrid for skin ulcer or cellulitis w MCC 158   3.2 35.4
  7   4   4 574: Skin graft &/or debrid for skin ulcer or cellulitis w CC 142   2.9 38.3
  8   8   5 057: Degenerative nervous system disorders w/o MCC 136   2.7 41.0
  9 10   9 299: Peripheral vascular disorders w MCC 103   2.1 43.1
10 13 12 603: Cellulitis w/o MCC   84   1.7 44.8
Table 22. Top 10 MS-DRGs for Acute Hospital-Initiated Episodes, Beneficiaries Discharged to LTCH, 2008
Rank MS-DRG N Percent Cumulative
Percent
Source: RTI analysis of 2008 Medicare claims (M3MM143).
  1 207: Respiratory system diagnosis w ventilator support 96+ hours 1,628 14.2 14.2
  2 189: Pulmonary edema & respiratory failure    899   7.8 22.1
  3 871: Septicemia w/o MV 96+ hours w MCC    519   4.5 26.6
  4 949: Aftercare w CC/MCC    401   3.5 30.1
  5 177: Respiratory infections & inflammations w MCC    388   3.4 33.5
  6 208: Respiratory system diagnosis w ventilator support <96 hours    291   2.5 36.0
  7 193: Simple pneumonia & pleurisy w MCC    246   2.1 38.2
  8 945: Rehabilitation w CC/MCC    236   2.1 40.2
  9 190: Chronic obstructive pulmonary disease w MCC    223   1.9 42.2
10 057: Degenerative nervous system disorders w/o MCC    208   1.8 44.0

Table 23 and Table 24 describe the episode patterns for beneficiaries with LTCH-initiated episodes (Table 23) and beneficiaries with acute hospital-initiated episodes discharged to LTCH as their first site of PAC (Table 24). A higher proportion of beneficiaries used LTCH only in their episode among the community entrant sample (40.3 percent) compared with the acute hospital-initiated sample of beneficiaries discharged to LTCH (26.2 percent). More detail on the episode- and service-specific utilization between these two groups is presented in the next set of tables.

Table 23. Episode Patterns: LTCH-Initiated Episodes, 2008
Rank Episode Pattern N Percent Cumulative Percent
Note: Episode pattern is based on a 30-day variable episode definition. 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 L 2,002 40.3 40.3
2 LS    531 10.7 51.0
3 LH    425   8.6 59.6
4 LA    206   4.1 63.7
5 LO    132   2.7 66.4
6 LSO      92   1.9 68.2
7 LSA      90   1.8 70.0
8 LSH      79   1.6 71.6
9 LSAS      78   1.6 73.2
10 LHA      55   1.1 74.3
Table 24. Episode Patterns: Acute Hospital-Initiated Episodes, Beneficiaries Discharged to LTCH 2008
Rank Episode Pattern N Percent Cumulative Percent
Note: Episode pattern is based on a 30-day variable episode definition. 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 AL 3,004 26.2 26.2
2 ALH 1,352 11.8 38.0
3 ALS    872   7.6 45.6
4 ALA    643   5.6 51.3
5 ALSH    344   3.0 54.3
6 ALHA    281   2.5 56.7
7 ALSA    264   2.3 59.0
8 ALSAS    205   1.8 60.8
9 ALSO    183   1.6 62.4
10 ALO    158   1.4 63.8

Similar to the acute and HHA-initiated episodes, episode length and payments vary by each of the episode definitions (Table 25). Under episode definition C, any claim initiating within 30 days of discharge, the mean episode length of stay for beneficiaries with LTCH-initiated episodes is 57.8 days. In comparison, under the longer definition A, 30-day variable length, the mean episode length is 101.6 days. In Table 26, the total LTCH utilization per episode is shown for beneficiaries with acute hospital-initiated episodes discharged to LTCH and for beneficiaries with LTCH-initiated episodes. Though there was not much difference in the mean LTCH days per episode, the mean payments were higher for beneficiaries initiated their episodes in an acute hospital indicating that these beneficiaries are in higher weight MS-DRGs.

Table 25. Episode Summary Statistics: LTCH-Initiated Episodes, 2006-2008
Episode Definition N Mean
Initiating
Event LOS
(days)1
Mean
Initiating
Event
Payment1
Mean
Episode
LOS
(days) 2
Mean
Episode
Payment2
  1. An initiating event is defined as an LTCH claim following a 30-day period without acute, LTCH, SNF, IRF, or HHA service use.
  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 (M3MM143).

2008
A. 30-Day Variable Episode 4,967 26.7 $26,414 101.6 $46,633
B. 30-Day Variable Episode Excluding Acute Hospitalization 4,967 26.7 $26,414   70.9 $33,467
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 4,967 26.7 $26,414   57.8 $36,399
2007
A. 30-Day Variable Episode 4,587 28.0 $26,803   98.0 $45,447
B. 30-Day Variable Episode Excluding Acute Hospitalization 4,587 28.0 $26,803   81.3 $12,751
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 4,587 28.0 $26,803   58.5 $36,209
2006
A. 30-Day Variable Episode 4,821 27.9 $26,679   93.3 $42,851
B. 30-Day Variable Episode Excluding Acute Hospitalization 4,821 27.9 $26,679   65.5 $32,028
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 4,821 27.9 $26,679   55.7 $34,972
Table 26. LTCH Utilization, LTCH Initiated Episodes versus Beneficiaries With Acute Initiated Episodes Discharged to LTCH, 2006-2008
Episode Definition Mean LTCH
Length of
Stay
(days) per
LTCH
Initiated
Episode
Mean LTCH
Payment
per
Episode per LTCH
Initiated
Episode
Mean LTCH
Length of
Stay (days)
per Acute
Initiated
Episode
Discharged
to LTCH
Mean LTCH
Payment per
Episode per
Acute
Initiated
Episode
Discharged
to LTCH
  1. Length of stay 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 32.2 $31,549 31.2 $39,621
B. 30 Day Variable Episode Excluding Acute Hospitalization 28.6 $27,983 27.3 $35,291
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 29.1 $28,484 27.6 $35,784
2007
A. 30 Day Variable Episode 32.8 $31,429 31.5 $38,413
B. 30 Day Variable Episode Excluding Acute Hospitalization 29.4 $28,029 27.8 $34,536
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 29.9 $28,658 28.0 $34,920
2006
A. 30 Day Variable Episode 32.6 $30,998 31.8 $38,286
B. 30 Day Variable Episode Excluding Acute Hospitalization 29.4 $27,896 28.0 $34,526
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 29.9 $28,558 28.3 $34,957

In Table 27 and Table 28, we compare the service-specific utilization in the episode for beneficiaries initiating care in the LTCH (Table 27) to the utilization for beneficiaries who initiate care in an acute hospital-initiated episode and are discharged to LTCH (Table 28). Patterns of service-specific utilization do vary for these two samples, particularly when examining episode definition A, the 30-day variable-length episode. Beneficiaries with acute hospital-initiated episodes discharged to LTCH as their first setting of PAC have a higher proportion of service use of all types compared with the community-initiated entrants. For example, 38.6 percent of beneficiaries with acute hospital-initiated episodes discharged to LTCH used HHA during the episode compared with 24.1 percent among the LTCH community entrants; SNF utilization was 38.5 percent compared with 32.9 percent and acute hospitalizations was 42.7 percent compared with 29.5 percent. The differences in use during episodes between the community entrant and the acute hospital-initiated LTCH user likely reflect the types of cases in each group—the more complex medical conditions versus psychoses and skin cases, as demonstrated in Table 21 and Table 22. Use of physician services during episodes is presented in Table 29. Over 54 percent of beneficiaries with LTCH-initiated episodes have at least one physician claim in the week prior to the initiating event. Payments associated with physician services during LTCH-initiated episodes varied significantly by MS-DRG, with highest payments associated with beneficiaries in MS-DRG 207, "respirator system diagnosis w ventilator support 96+ hours," and MS-DRG 199, "pulmonary edema & respiratory failure," compared with far lower physician service payments for beneficiaries in MS-DRG 885, "psychoses."

Table 27. Service-Specific Episode Summary Statistics: LTCH-Initiated Episodes, 2008
Service Use (N = 4,967) A.
30-Day
Variable
Episode
B.
30-Day Variable
Episode
Excluding Acute
Hospitalization
C.
30-Day Fixed:
Any Claim
Starting Within
30 Days After
LTCH Discharge
  1. Service use for the initiating event is not included in this calculation. LTCH 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, M3MM213).

HHA
Percent with Claim 24.1 20.1 18.8
Mean Visits 59.1 44.7 22.7
Mean Claim Length (days) 137.4 105.6 48.2
Mean Payment Per Service User $7,958 $6,014 $3,188
SNF
Percent with Claim 32.9 28.1 29.3
Mean LOS (days) 56.2 43.3 43.0
Mean Payment Per Service User $16,599 $12,778 $12,861
IRF
Percent with Claim 3.5 2.3 2.6
Mean LOS (days) 18.8 17.8 17.8
Mean Payment Per Service User $21,804 $20,906 $21,303
LTCH (not including initiating event)1
Percent with Claim 13.3 4.9 6.7
Mean LOS (days) 40.6 37.7 35.2
Mean Payment Per Service User $38,469 $31,799 $30,881
Outpatient Department Therapy
Percent with Claim 13.5 8.9 6.0
Mean Payment Per Service User $2,602 $2,120 $1,140
Independent Therapist
Percent with Claim 1.3 1.0 0.7
Mean Payment Per Service User $1,362 $1,480 $415
Acute Hospitalization2
Percent with Claim 29.5 18.6
Mean LOS (days) 14.7 9.8
Mean Payment Per Service User $22,291 $15,69

Table 28. Service-Specific Episode Summary Statistics: Acute Hospital-Initiated Episodes, Beneficiaries Discharged to LTCH, 2008
Service Use (N = 11,454) A.
30-Day
Variable
Episode
B.
30-Day Variable
Episode Excluding
Acute
Hospitalization
C.
30-Day Fixed:
Any Claim Starting
Within 30 Days
After Acute
Hospital Discharge
  1. By definition, 100 percent of beneficiaries with acute initiated episodes discharged to LTCH have at least one LTCH claim in their episode. Note that 10.4 percent of beneficiaries in episode definition A, 0.9 percent in episode definition B, and 1.8 percent of beneficiaries in episode definition C have more than one LTCH 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 Claim 38.6 31.1 17.2
Mean Visits 51.3 36.6 21.6
Mean Claim Length (days) 113.7 81.0 44.9
Mean Payment Per Service User $7,499 $5,429 $3,325
SNF
Percent with Claim 38.5 30.5 18.0
Mean LOS (days) 57.0 41.7 40.1
Mean Payment Per Service User $19,550 $14,546 $14,002
IRF
Percent with Claim 8.0 5.9 4.0
Mean LOS (days) 20.0 18.2 17.5
Mean Payment Per Service User $21,776 $19,890 $19,862
LTCH
Percent with Claim1 100.0 100.0 100.0
Mean LOS (days) 31.2 27.3 27.6
Mean Payment Per Service User $39,621 $35,291 $35,784
Outpatient Department Therapy
Percent with Claim 14.5 8.2 1.4
Mean Payment Per Service User $2,467 $1,857 $582
Independent Therapist
Percent with Claim 1.7 1.0 0.1
Mean Payment Per Service User $1,218 $1,091 $171
Acute Hospitalization2
Percent with Claim 42.7 13.7
Mean LOS (days) 16.1 10.8
Mean Payment Per Service User $25,010 $19,878
Table 29. Physician Service Use, by MS-DRG and by Episode Definition: LTCH-Initiated Episodes, 2008
MS-DRG 7 Days
Prior to
Initiating
Event1
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
  1. An initiating event is defined as an LTCH 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.
All MS-DRGs
Percent with Claim 54.2 92.8 92.3 92.6
Mean Payment Per Service User $401 $4,306 $2,908 $3,084
885: Psychoses
Percent with Claim 56.5 96.4 96.4 96.4
Mean Payment Per Service User $174 $1,718 $1,523 $1,454
207: Respirator system diagnosis w ventilator support 96+ hours
Percent with Claim 42.6 85.3 84.4 85.3
Mean Payment Per Service User $820 $6,691 $4,638 $5,556
189: Pulmonary edema & respiratory failure
Percent with Claim 48.5 87.3 86.3 86.3
Mean Payment Per Service User $580 $6,596 $3,624 $4,084
593: Skin ulcers w CC
Percent with Claim 53.6 96.4 95.9 95.9
Mean Payment Per Service User $217 $3,665 $2,551 $2,559
592: Skin ulcers w MCC
Percent with Claim 50.8 97.9 97.9 97.9
Mean Payment Per Service User $269 $5,552 $3,432 $3,698

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