Post-Acute Care Episodes Expanded Analytic File. 4.3 IRF-Initiated Episodes

04/01/2011

The final set of community-initiated analyses presented is for beneficiaries entering IRF without a prior acute hospitalization. In Table 30 we show the proportion of cases of IRF-initiated episodes falling into the top 10 RICs. As discussed in Section 2, RICs are recorded on the IRF claims and represent 21 different types of conditions for which a beneficiary may be admitted to an IRF, for example, stroke, neurologic conditions, cardiac, pulmonary, spinal cord dysfunction, brain dysfunction, and amputation. Table 31 shows the proportion of beneficiaries with acute hospital-initiated episodes discharged to IRF as their first site of care by the RIC on the IRF claim as a comparison to the IRF community entrant. The most common RIC in both samples is stroke, although a higher proportion of the acute hospital-initiated sample is in this RIC compared with the community-initiated beneficiaries (21.3 percent versus 16.0 percent). A significantly higher proportion of beneficiaries are admitted for RIC 7 and RIC 8 (the lower extremity fracture and joint replacement RICs) in the acute hospital-initiated sample (37.5) compared with the community entrant sample (14.2 percent). The higher proportion of beneficiaries admitted to IRF directly from the community for neurologic conditions, pain, and amputation suggests that these patients may be more likely to be receiving care for an ongoing condition compared with beneficiaries with acute hospital-initiated episodes.

 

Table 30. Top 10 RICs, IRF-Initiated Episodes, 2006-2008
Rank
2008
Rank
2007
Rank
2006
RIC N
2008
Percent
2008
Cumulative
Percent
2008
Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM155).
  1   1   1 RIC 01: Stroke 1,917 16.0 16.0
  2   2   2 RIC 06: Neurological Conditions 1,875 15.7 31.7
  3   3   4 RIC 09: Other Orthopedic 1,648 13.8 45.5
  4   4   3 RIC 20: Miscellaneous 1,427 11.9 57.4
  5   5   5 RIC 07: Lower Extremity Fracture    994   8.3 65.7
  6   6   6 RIC 08: Lower Extremity Joint Replacement    710   5.9 71.7
  7   8   7 RIC 16: Pain Syndrome    445   3.7 75.4
  8   9   8 RIC 05: Spinal Cord Dysfunction, Non-Traumatic    441   3.7 79.1
  9   7   9 RIC 10: Amputation, Lower Extremity    376   3.1 82.2
10 11 11 RIC 02: Brain Dysfunction, Traumatic    373   3.1 85.4
Table 31. Top 10 RICs, Acute Hospital-Initiated Episodes, Beneficiaries Discharged to IRF, 2008
Rank RIC N Percent Cumulative Percent
Source: RTI analysis of 2008 Medicare claims (M3MM155).
  1 RIC 01: Stroke 12,010 21.3 21.3
  2 RIC 07: Lower Extremity Fracture 10,644 18.9 40.1
  3 RIC 08: Lower Extremity Joint Replacement 10,516 18.6 58.8
  4 RIC 20: Miscellaneous   4,921   8.7 67.5
  5 RIC 09: Other Orthopedic   3,463   6.1 73.6
  6 RIC 06: Neurological Conditions   3,248   5.8 79.4
  7 RIC 14: Cardiac   2,173   3.9 83.2
  8 RIC 03: Brain Dysfunction, Non-Traumatic   2,039   3.6 86.8
  9 RIC 05: Spinal Cord Dysfunction, Non-Traumatic   2,000   3.5 90.4
10 RIC 02: Brain Dysfunction, Traumatic   1,598   2.8 93.2

As observed in the other types of community entrants, a higher proportion of beneficiaries initiating care in an IRF use only IRF services in their episode (Table 32) compared with beneficiaries initiating their episode in acute hospitals and discharged to IRF as their first setting of PAC (Table 33) (24.3 percent versus 8.7 percent, respectively). A similar proportion of beneficiaries in each sample are discharged to HHA only following their episode, 22.6 percent among community-initiated episodes and 26.4 percent among beneficiaries initiating their episode in an acute hospital.

Table 32. Episode Patterns: IRF-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 I 2,910 24.3 24.3
2 IH 2,708 22.6 47.0
3 IO 1,220 10.2 57.2
4 IS    594   5.0 62.2
5 ISH    442   3.7 65.9
6 IHO    328   2.7 68.6
7 IT    214   1.8 70.4
8 IA    194   1.6 72.0
9 IHA    164   1.4 73.4
10 ISO    155   1.3 74.7
Table 33. Episode Patterns: Acute Hospital-Initiated Episodes, Beneficiaries Discharged to IRF, 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 AIH 14,900 26.4 26.4
2 AIO   5,961 10.6 37.0
3 AI   4,902   8.7 45.6
4 AIHO   3,158   5.6 51.2
5 AISH   2,337   4.1 55.4
6 AIHT   2,268   4.0 59.4
7 AIS   1,826   3.2 62.6
8 AIT   1,775   3.1 65.8
9 AIHA   1,410   2.5 68.3
10 AIA   1,114   2.0 70.3

Table 34 presents the IRF-initiated episode summary statistics per year of analysis and by episode definition. The mean episode length under episode definition C, any claim initiating within 30 days was 47.8 days, but this increased to 92.2 days under the longer 30-day variable-length episode definition. Patterns of use and payment per episode definition were similar across the years of data. In Table 35, the total IRF utilization per episode is shown for beneficiaries with acute hospital-initiated episodes discharged to IRF and for beneficiaries with IRF-initiated episodes. Across the episode definitions and years of data shown here, beneficiaries with IRF-initiated episodes had slightly longer mean episode length of stay, but slightly lower mean episode payments compared to beneficiaries with acute hospital-initiated episodes discharged to IRF.

Table 34. Summary Statistics: IRF-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 a IRF 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 11,956 13.0 $13,833 92.2 $27,563
B. 30-Day Variable Episode Excluding Acute Hospitalization 11,956 13.0 $13,833 67.1 $19,349
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 11,956 13.0 $13,833 47.8 $20,932
2007
A. 30-Day Variable Episode 11,564 13.2 $13,836 91.1 $26,734
B. 30-Day Variable Episode Excluding Acute Hospitalization 11,564 13.2 $13,836 66.9 $19,001
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 11,564 13.2 $13,836 48.3 $20,622
2006
A. 30-Day Variable Episode 11,936 13.2 $13,391 89.7 $25,486
B. 30-Day Variable Episode Excluding Acute Hospitalization 11,936 13.2 $13,391 63.5 $18,055
C. 30-Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 11,936 13.2 $13,391 46.4 $19,537
Table 35. IRF Utilization, IRF Initiated Episodes versus Beneficiaries With Acute Initiated Episodes Discharged to IRF, 2006-2008
Episode Definition Mean IRF
Length of
Stay
(days) per
IRF
Initiated
Episode
Mean IRF
Payment
per
Episode
per IRF
Initiated
Episode
Mean IRF
Length of Stay
(days) per
Acute
Initiated
Episode
Discharged to
IRF
Mean IRF
Payment per
Episode per
Acute
Initiated
Episode
Discharged to
IRF
  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 14.4 $15,436 14.1 $17,224
B. 30 Day Variable Episode Excluding Acute Hospitalization 13.3 $14,164 12.9 $15,836
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 13.7 $14,605 13.4 $16,453
2007
A. 30 day Variable Episode 14.5 $15,310 13.9 $16,850
B. 30 Day Variable Episode Excluding Acute Hospitalization 13.5 $14,113 12.8 $15,551
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 13.8 $14,539 13.2 $16,138
2006
A. 30 day Variable Episode 14.4 $14,795 13.5 $15,946
B. 30 Day Variable Episode Excluding Acute Hospitalization 13.4 $13,666 12.5 $14,763
C. 30 Day Fixed: Any Claim Starting Within 30 Days After Discharge from Initiating Event 13.8 $14,093 13.0 $15,291

In examining the service-specific utilization for IRF community entrants (Table 36) and for beneficiaries initiating their episodes in an acute hospital and discharged to IRF (Table 37), a higher proportion of beneficiaries with acute hospital-initiated episodes used HHA under the 30-day variable-length episode definition (62.7 percent compared with 48.1 percent) and had an acute hospitalization (29.3 percent compared with 22.9 percent), again demonstrating the likely differences in medical complexity between these two groups of beneficiaries. Physician service use for beneficiaries with IRF-initiated episodes is presented in Table 38. Of beneficiaries with IRF-initiated episodes, 65 percent had at least one physician claim in the week prior to the initiating event, and over 80 percent of beneficiaries with IRF-initiated episodes in RIC 09 (Other Orthopedic) had at least one physician claim prior to the start of the episode.

Table 36. Service-Specific Summary Statistics: IRF-Initiated Episodes, 2008
Service Use (N = 11,956) 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. IRF 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 48.1 42.6 40.0
Mean Visits 38.2 30.7 21.9
Mean Claim Length (days) 81.5 65.9 41.9
Mean Payment Per Service User $6,082 $5,007 $3,710
SNF
Percent with Claim 24.1 17.4 20.3
Mean LOS (days) 52.9 44.3 43.5
Mean Payment Per Service User $17,725 $14,755 $14,683
IRF (not including initiating event)1
Percent with Claim 7.8 2.0 4.4
Mean LOS (days) 17.8 15.9 15.6
Mean Payment Per Service User $20,537 $16,581 $17,490
LTCH
Percent with Claim 1.5 0.3 0.7
Mean LOS (days) 33.1 32.4 27.5
Mean Payment Per Service User $34,871 $28,617 $27,173
Outpatient Department Therapy
Percent with Claim 24.3 20.4 15.7
Mean Payment Per Service User $1,888 $1,544 $770
Independent Therapist
Percent with Claim 5.7 5.0 3.1
Mean Payment Per Service User $1,370 $1,240 $396
Acute Hospitalization2
Percent with Claim 22.9 13.7
Mean LOS (days) 11.5 7.8
Mean Payment Per Service User $16,910 $11,314
Table 37. Service-Specific Episode Summary Statistics: Acute Hospital-Initiated Episodes, Beneficiaries Discharged to IRF, 2008
Service Use (N = 56,439) A.
30-Day
Variable
Episode
B.
30-Day Variable
Episode Excluding
Acute
Hospitalization
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 IRF have at least one IRF claim in their episode. Note that 6.6 percent of beneficiaries in episode definition A, 0.5 percent in episode definition B, and 3.6 percent of beneficiaries in episode definition C have more than one IRF 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 62.7 55.2 49.6
Mean Visits 34.1 27.3 21.0
Mean Claim Length (days) 68.1 53.5 38.0
Mean Payment Per Service User $5,712 $4,714 $3,777
SNF
Percent with Claim 24.4 16.8 18.8
Mean LOS (days) 51.7 42.1 39.7
Mean Payment Per Service User $18,287 $15,016 $14,326
IRF
Percent with Claim1 100.0 100.0 100.0
Mean LOS (days) 14.1 12.9 13.4
Mean Payment Per Service User $17,224 $15,836 $16,453
LTCH
Percent with Claim 1.4 0.2 0.5
Mean LOS (days) 32.6 27.3 28.4
Mean Payment Per Service User $33,777 $27,479 $30,960
Outpatient Department Therapy
Percent with Claim 28.5 23.7 14.0
Mean Payment Per Service User $1,769 $1,484 $640
Independent Therapist
Percent with Claim 11.1 9.8 4.9
Mean Payment Per Service User $1,577 $1,496 $405
Acute Hospitalization2
Percent with Claim 29.3 14.7
Mean LOS (days) 11.5 7.9
Mean Payment Per Service User $17,801 $12,376
Table 38. Physician Service Use, by RIC and by Episode Definition: IRF-Initiated Episodes, 2008
RIC 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 IRF 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 (M3MM226).

All RICs
Percent with Claim 65.0 89.5 89.3 89.3
Mean Payment Per Service User $532 $2,172 $1,385 $1,433
RIC 1: Stroke
Percent with Claim 58.0 86.9 86.6 86.8
Mean Payment Per Service User $438 $2,400 $1,445 $1,448
RIC 06: Neurological Conditions
Percent with Claim 61.8 94.2 94.0 94.1
Mean Payment Per Service User $359 $2,237 $1,442 $1,459
RIC 09: Other Orthopedic
Percent with Claim 80.8 95.6 95.3 95.5
Mean Payment Per Service User $578 $1,990 $1,389 $1,431
RIC 20: Miscellaneous
Percent with Claim 70.5 93.6 93.4 93.5
Mean Payment Per Service User $411 $2,288 $1,327 $1,481
RIC 07: Lower Extremity Fracture
Percent with Claim 72.7 89.9 89.8 89.7
Mean Payment Per Service User $719 $2,228 $1,253 $1,292

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